India Polio Communication Review, Phase 1 - 2008

In December 2007 the India Expert Advisory Group (IEAG) recommended that a review of polio communication be conducted in 2008. A plan was developed to conduct a 2-phased review process involving 10 consultants who would review identified communication issues in a number of high-risk areas in Uttar Pradesh and Bihar states. The first phase of polio communication reviews was completed in 6 sub-regions of Uttar Pradesh (Meerut, Varanasi, and Bareilly) and Bihar (Darbhanga, Khagaria, and Patna) in September 2008. The second phase is set to be conducted in December 2008, focusing on follow-up on the recommendations from Phase 1.

Phase 1 Report:

Ten external communication experts conducted reviews on specific themes in each sub-region. During the review, the teams visited 50 villages and urban areas of 11 districts in the 2 states. Consultants used various qualitative research methods such as in-depth interviews, focus group discussions, and one-on-one meetings to examine the issues. The teams reported overall high levels of commitment and motivation towards the programme at all levels, and generally found the quality of communication work to be of a high standard. They also appreciated the evident partnership and coordination among various partners.

In total, 45 specific, time-bound, and measurable recommendations are currently being acted upon to improve programme performance in 6 sub-regions of Uttar Pradesh and Bihar. Based on context-specific analysis, the recommendations are highly localised, with practical applications – such as specific approaches to improving newborn coverage in Varanasi through the mapping of private nursing homes. Other recommendations are related to leveraging existing health systems, such as in Meerut, where the team has suggested special immunisation campaigns on certain days among populations known to be migrating back into the sub-region from neighbouring non-endemic states.

Through a participatory process, the review teams worked with the health department and polio partners at the sub-regional and district level to identify key actions with time-bound outcomes and to clearly define milestones to be achieved by December 2008. In December, the second phase of the review process will begin. One person from each of the review teams will re-visit the same 6 sub-regions to analyse the progress of implementation of the recommendations, and to arrive at a consensus for further action points to be followed through the low season of polio virus transmission. Progress reported by December will be presented at the meeting of the IEAG scheduled for mid-December 2008.

Observations:

This process of sub-regional reviews has been appreciated for its relevance to the current epidemiological conditions of the polio programme in India. Improvements in communication, as with operations, are now incremental and context-specific. This review process contributed to helping local teams re-examine their approach to very specific issues and resulted in recommendations that are likely to be implemented because of their relevance to that area. However, it remains to be seen whether the recommendations themselves still have the specificity required to make a difference to outcomes and whether the recommendations or approaches tried are transferable to other sub-regions facing similar issues but where the context may be different. The approach was also highly participatory, and communication staff and other polio partners felt encouraged by the intensive interaction with external consultants. At the same time, this process was time-consuming and labour-intensive, with considerable pressure due to the complex logistical arrangements required, making this process difficult to implement on a wider scale.

Key Issues and Recommendations:

1) Team One

Theme: Missed children due to migration

Sub-region Meerut, Uttar Pradesh

Migration is the main cause of missing children in the sub-region, especially in the district of Muzaffarnagar. As per data from tally sheets and community mobilisation coordinator (CMC) registers, most remaining X houses are categorised as XV (child out of village) or XL (house locked). Migrant families usually go to Haryana, Punjab, and Rajasthan to work in brick kilns.

There are two major issues identified in the report:

A. Immunisation of children during migration.

B. Immunisation of children when families return to their homes.

Recommendations:

A. Immunisation of children during migration.

• Increased interaction and counselling with families to ensure that they carry immunisation cards with them while out of the state so that immunisation opportunities are noted.
• Facilitate information-sharing about the migrant families between districts and states.
• Strengthen routine immunisation.
• Mapping of all brick kilns in the area.
• Increased involvement and sensitisation of brick kiln owners in the polio programme.

B. Immunisation of children when families return to their homes.

• Identification and mapping of blocks with high migration rates.
• Special immunisation sessions during the months when migrant families return.
• Special interpersonal communication (IPC) with families to ensure coverage of all children.

2) Team Two

Theme: Access to newborns for birth dose oral poliovirus vaccine (OPV)

Sub-region: Varanasi, Uttar Pradesh

Data from CMC registers showed that this sub-region was less likely to immunise newborns with OPV between rounds than other sub-regions in Uttar Pradesh. This is partly due to deficiencies in the close monitoring of when and where newborns are actually delivered (i.e., the number of pregnant women is higher than the number of newborns immunised). Evidently, while the tracking of pregnant women in CMC areas is good, converting this into immunisation outcomes at birth remains a problem.

The review team identified the following issues:

• High numbers of newborns missed due to being born in the maternal grandparents' house.
• Newborns missed due to refusal/sickness.
• Missed opportunity of newborn immunisation in absence of supplementation immunisation activity (SIA)/routine immunisation (RI) (i.e., newborn immunisation gap).
• Lack of immunisation at private clinics/nursing homes, which do not have basic and/or adequate immunisation infrastructure.
• Missed opportunities for educating mothers when they gather for RI.
• Lack of community awareness on the importance of: care of pregnant women, institutional delivery, newborn immunisation, polio eradication in general, etc.
  

Recommendations:

• Intensify visits to pregnant women who are likely to deliver in their parental house in order to increase likelihood of acceptance for OPV (ongoing assessment, education, and counselling).
• Identify areas with low RI coverage and organise special immunisation sessions to cover all newborns with the help of CMCs in that area.
• Map all private nursing homes that offer delivery facilities and prepare an action plan with the local government to support immunisation services in those facilities.
• Refresher training of CMCs and block mobilisation coordinators (BMCs) on use of adult learning methods and care of pregnant women and newborns.
• Specific IPC sessions with mothers who come for immunisation of their children at RI sites.
• Information, education, and communication (IEC) material to be displayed at RI sites.

3) Team Three

Theme: Underserved strategy and ensuring support from influencers

Sub-region: Bareilly, Uttar Pradesh

The review team visited 2 districts in the sub-region: Bareilly and Badaun. The Bareilly sub-region has a significant Muslim underserved population. The United Nations Children's Fund (UNICEF) and CORE are implementing a specific intervention to reach this underserved population. The focus of the review team was to assess the effectiveness of the underserved strategy and to suggest measures to strengthen it.

The team identified the following issues during the field work:

• A higher percentage of missed children in Badaun.
• Lack of involvement and sustainability of "good" influencers.
• Lack of capacity of CMCs.
• Lack of relevance of IEC material according to local needs.
• High frequency of rounds, which poses a communication challenge.
• While there is no significant refusal to OPV, limited refusal is evident in some pockets due to lack of civic amenities.
• Partners' meetings which include all partners not being held on regular basis.

Recommendations:

• Strengthen underserved strategy staffing, capacity, and competency through rationalisation of staffing numbers and workloads and refresher training of social mobilisation network (SMNet) members.
• Strengthen planning and coordination through regular meetings of partners, joint work-planning, and sharing of data.
• Sustain and increase the effectiveness of influencers through correct identification, involvement of local health workers as influencers, and appropriate rewards and recognition for "good" influencers.
• Include Hindu underserved communities in the strategy by conducting an analysis of Hindu underserved communities and designing appropriate activities for them.

4) Team Four

Theme: Community mobilisation in Kosi river, Patna with CMCs

Sub-region: Khagaria and Patna, Bihar

The review team visited 2 sub-regions: Kosi river areas of Khagaria and urban areas of Patna districts. In the Kosi river area, the team examined the process used by community-based interventions to reach inaccessible and missed children, while in urban areas of Patna district, the team analysed the underserved strategy to address resistance and vaccine avoidance in underserved communities. The issues in both areas are different; therefore, the team has prepared different recommendations for each area.

Kosi River Area

Key issues:

• Lack of qualitative data on IEC activities and influencers' involvement.
• Lack of awareness about the need for repeated rounds.
• Lack of proper tracking of end-use of IEC material.
• Absence of performance tracking of Panchyati Raj Institution members (PRIs) and influencers.
• Absence of professional supervision of CMCs' activities by BMCs.
• Need to improve the tracking of missed children by enumerating based on numbers of children 0 to 5 years old.

Recommendations:

• Introduce a format designed to track the use of IEC and IPC material for effective utilisation of tools.
• Introduce an IPC tool for use by anganwadi workers (AWWs) at anaganwadi centres (AWCs), focusing on repeat rounds in order to increase awareness of the rationale behind repeat rounds.
• Put in place a format designed to track activities performed by PRIs and influencers against activities assigned to identify good performers.
• To improve the quality of meetings, put in place a format to track social mobilisation meetings with indicators including attendance, agenda, questions raised/resolved, and resolution adopted.
• Build the capacity of BMCs in the areas of monitoring and analysis.
• Insist on compliance with accurate completion of all inputs required by the communication plan format for better implementation of the communication plan.
• Begin enumeration, based on actual numbers of children 0 to 5 years old in the region, in order to track all missed children.

Urban Areas of Patna District

Key issues:

• Persistent resistance in some pockets.
• Fear of impotency and lack of health services (the major causes of resistance).
• Good monitoring and reporting system, but data are not being analysed at the sub-regional level.
• No IEC materials available in Urdu.

Recommendations:

• Undertake influencer performance analysis for each round and track it across time to identify good performers.
• Put in place a format to track social mobilisation meetings with indicators - including attendance, agenda, questions raised/replied, and resolution adopted.
• Build the capacity of BMCs and district unit coordinator (DUC) in monitoring and analytical skills.
• Install special health camps in underserved areas to provide much-needed health services and to tackle resistance.
• Hold refresher training of CMCs in improved IPC skills to tackle hardcore resistance.
• Ensure IEC materials are available in Urdu.

5) Team Five

Theme: Integrated Child Development Services (ICDS) mobilisation and team performance

Sub-region: Darbhanga, Bihar

The review team visited Darbhanga sub-region to examine the involvement of ICDS with the polio eradication programme. The team identified the following issues and recommendations to improve the involvement of ICDS.

Key issues:

• The programme is working well, with a high level of motivation and commitment at all levels.
• The inclusion of many partners has strengthened the programme.
• Refusal is still a key issue in urban areas.
• Community ownership of the polio eradication programme is limited.
• Maintaining current levels of motivation among workers is a major challenge.

Recommendations:

• Arrange identity cards for AWW.
• Continue to intensify training and capacity building of anganwadi workers.
• Ensure availability of IEC material for AWW to be used during family visits and group meetings.
• Strengthen the network with inclusion of non-governmental organisations (NGOs) and self-help groups (SHGs).
• Involve medical students and trainees of Darbhanga medical college in monitoring and supervision.

Click here to download the full report as a Word document.