Evidence-Based Engagement of the Somali Pastoralists of the Horn of Africa in Polio Immunization: Overview of Tracking, Cross-Border, Operations, and Communication Strategies

Building on the experience of the 2013-2014 wild poliovirus (WPV) outbreak in the Horn of Africa, this study examines applied strategies that helped to engage pastoralists of the Somali cluster (Somalia, Somali Region of Ethiopia, and North-East Kenya) in supplementary immunisation activities (SIAs). Aimed at being applicable to other public health interventions, the study synthesises knowledge about Somali pastoralism in the Horn of Africa and explains the approaches used for tracking nomadic groups and creating dialogue, as well as building trust, to enable better vaccination opportunities for pastoralist children. This research provides practical recommendations to public health practitioners who are facing the challenge of reaching pastoralist populations with health services.

The paper explores pastoralism in the Somali cluster, including the communication patterns among these pastoralists. In light of the fact that the 2000-2006 adult literacy rate stood at 37.8%, news is usually passed orally by traveling relatives, which fits the nomadic pastoralist way of life given the historically limited availability of contemporary communication or media channels. Radio is widely considered to be the most powerful medium of mass communication. Given the well-functioning mobile network infrastructure in Somalia, cell phones are also increasingly common among pastoralists and are used, for example, to share information about livestock market prices, weather, remittances, pasture availability, and water sources.

As the researchers explain, people in the Horn of Africa are displaced for numerous reasons that push them to move, including: conflict and violence; persecution; repression; abuse of human rights; environmental conditions such as water scarcity, food insecurity, drought, environmental degradation, famine and natural disasters; and poverty and the failure of economic development to secure viable livelihoods. The region is one of the major refugee producing and hosting regions in the world. Nomadic pastoralists, although mobile by nature, can also become displaced due to conflict and natural reasons, such as droughts, and become so-called pastoralist internally displaced people. Delivering even basic health services, such as immunisation, to these mobile groups presents a significant challenge for the governments of the countries, humanitarian agencies, and non-governmental organisations (NGOs). In the scenario of the 2013–2014 polio outbreak, where the virus spread and sustained circulation in the pastoralist areas of Puntland and the Somali region of Ethiopia, reaching pastoralists with immunisation became a most urgent imperative.

Global Polio Eradication Initiative (GPEI) partners in the Horn of Africa led a series of research projects that informed the development of special strategies to engage and reach pastoralists in the region. In sum, engagement with pastoralist populations required a thorough understanding of: their classification (e.g., nomadic-pastoralists, agro-pastoralists) and power structures; the spatial and temporal dimensions of their movement patterns; their beliefs and values; how to establish trust through respectful dialogue; and the services they found most relevant. On the basis of this deeper knowledge of the Somali pastoralists in the Horn of Africa, GPEI partners rolled out the following strategies:

• Nomadic tracking through a 3-pronged strategy: (i) enlisting already known pastoralist groups through local government and partners engaged in animal vaccination, (ii) establishment of an extensive network of informants at community level that will stay in contact and engage with clan elders, and (iii) cross-notification of the enlisted nomadic groups once they move to a new place, where programme stakeholders at district level inform each other of arriving and departing groups. In 2015, there were 3,323 social mobilisers and 153 district and regional communication managers contributing to tracking pastoralist movement and engaging with clans in Somalia.
• Planning and inclusion of pastoralist settlements in campaign planning through involving them in microplans, which include social maps to guide vaccinators and social mobilisers to every household (including often-omitted pastoralist settlements, rendering them invisible to the programme). More than 200 new settlements were identified and planned for in Somalia in 2014. Similarly, in the vast pastoralist area of the Somali region of Ethiopia, there was a 675% increase: from 240 to 1,620 identified new pastoralist settlements. More than 30% of nomadic children were missed in 2014, which was reduced to less than 20% in 2015, following the revision of microplans.
• Engagement of clan leaders by leveraging the trust nomadic pastoralists held for the Food and Agriculture Organization (FAO)'s animal health project. Ministry of Health local representatives made the first contact and informed clan leaders about the polio outbreak and available vaccination opportunities. The relation was then transferred over to a dedicated network of social mobilisers and field staff from the same locality, who were trained in interpersonal communication (IPC) methods. Between 2014 and 2015, contacts had been made with 868 clan leaders in Somaliland, 303 in Puntland, and 935 in the South Central Zone with the aim to create better vaccination opportunities for pastoralist children.
• Cross-border collaboration at the local level and especially at major crossing points where the majority of migration occurred. (Pastoralists rarely recognise international borders, and perceived availability of better services on the other side of the border could trigger localised irregular or unexpected migration flows.) For example, one polio partner, the CORE Group Polio Project, had built strong relationships with local NGOs and has been using those relations to create and support cross-border health committees along the frontiers of Ethiopia, Kenya, Somalia, South Sudan, and Uganda. Thirty nine cross-border meetings were held in the region, resulting in better understanding of the migration flows and better micro planning along the border areas, leading to validation of information, establishment of vaccination sites at crossing points, and common approaches to branding and communication messaging.
• Mapping of water points and livestock markets as an entry point into pastoralist communities. On the basis of this knowledge, activities were developed that included engagements with the Dilaah (broker) and Mallaal (assistant broker), who are in charge of trade- and market-related information, which are sent to the most remote pastoralist communities. Educational activities were also conducted at these sites aimed at creating awareness and health opportunities for pastoralist children.
• Pastoralist-focused communication products. Although there were few printed communication products specifically for Somali pastoralists of the Horn of Africa because of their predominantly oral communication culture, in Ethiopia, Kenya, and Somalia, health education kits and pictorial aids were produced about polio, routine immunisation, and other preventive health behaviours. The products featured traditional Somali settings, including camels, livestock, and pastoralist housing to be culturally appropriate. Similarly, radio content related to ongoing polio programmes also included pastoralist topics of interest to draw more pastoralist audiences. Tarpaulins, which pastoralists traditionally use to weatherproof their mobile houses, were branded with polio vaccination imagery and distributed as promotional items.
• Joint human-animal vaccination campaigns in 5 pastoralist districts of Puntland, Somalia. Over a period of 30 days in the second half of 2014, 20 social mobilisers and vaccination teams, accompanied by local community elders, traveled to administer polio and measles doses to pastoralist children, using animal vaccination campaigns as a vehicle to deliver health services. Children received 26,393 polio and 23,099 measles doses; of these children, 34% were immunised against polio for the first time ever.
• Establishment of permanent transit vaccination points. By August 2014, 611 permanent transit vaccination points had been established in the Horn of Africa to capture children on the move; in sum, 592,548 were vaccinated at these sites. Three hundred of these transit points were located in Somalia, with many of them located at the crossing points used by various mobile populations; it stands to reason that many of them were pastoralists.

The proportion of children who had never been vaccinated against polio in the overall incidence of children reported with nonpolio acute flaccid paralysis (APF) in Somalia was used as an outcome measure before and after the interventions. Results demonstrate that the proportion of these zero-dose children was reduced from 44.6% to 19.5% between 2014 and 2015.

Although these results suggest that polio vaccination status of nomadic children substantially improved after the rollout of special strategies focused on pastoralists, challenges associated with greater focus on pastoralists include: significantly higher cost per child reached; substantial time, human, and financial resources required for tracking and engaging with nomadic groups; limited epidemiological and social data that disaggregate pastoralists as a group; and lack of other programmes (except in the animal vaccination sector), which means that interventions are often a first point of contact for nomadic groups with health services. Furthermore, "scaling-up programs for pastoralists truly requires a paradigm shift in organizational culture and thinking, where considerable dedication, resources, and political will are necessary to operationalize this equity agenda. Although the know-how is available, these requirements could represent a larger challenge in availing better development opportunities for pastoralist populations."

Editor's note: This paper has been published as part of a United States Agency for International Development (USAID)-funded initiative to increase the number of peer-reviewed papers on routine and polio communication and to ensure that academics from a range of countries, including those facing the greatest polio and routine immunisation challenges, are supported in getting their research peer reviewed, published, and widely disseminated through The CI and the new journal Global Health Communication.