Looking Back and Planning Ahead: Examining Global Best Practices in Communication for Inactivated Polio Vaccination Introduction in Rwanda

"This article provides insights into the critical role that communication efforts have played and will continue to play in polio eradication worldwide."

This article combines research from secondary and primary sources on country experiences in polio vaccination and from the polio vaccination programme in Rwanda. As articulated by the Global Polio Eradication Initiative (GPEI) in the Polio Eradication and Endgame Strategic Plan 2013-2018 (see Related Summaries, below), the next big programmatic push relies on strengthening global routine immunisation systems and replacing oral polio vaccination (OPV) with inactivated polio vaccination (IPV). Secondary data included a review of 20 global articles published from 2004 to 2014 (inclusive) that describe and analyse communication efforts for polio eradication and highlight best practices in communication approaches to address polio. The primary research consisted of qualitative and participatory data gathered from various stakeholders (84 individuals) in two rural sites in Rwanda through focus group discussions, in-depth interviews, and transect walks with community mapping. According to the researchers, this provides a specific example of formative research for understanding polio eradication communication approaches that can be considered by other countries for introducing IPV within their routine immunisation schedules. (It is important to mention at the outset that Rwanda has achieved much higher trust in vaccination and in the government as a whole and has been successful in achieving higher vaccination coverage than many other countries.)

Results from the secondary analysis
In terms of strategic approaches, interventions most commonly leveraged community-based approaches (n = 11), capacity-building efforts (n = 8), and interpersonal approaches (n = 6). In addition, 8 articles reported the use of more than one approach to meet the intervention's objectives. Two articles reported positive, unintended policy-level consequences from their interventions. Behaviour change communication (BCC) and social marketing were described in specific articles. Furthermore, manuscripts from India, Nigeria, and Pakistan showcased the instrumental role of social mobilisation efforts, specifically through Muslim clerics, in promoting vaccine coverage, especially during supplemental immunisation activities (SIAs). Key lessons from the literature reviewed suggest that community participation, advocacy, and leadership are critical to overcoming individual- and structural-level barriers. In addition, social mobilisation, which involves a combination of top-down and bottom-up efforts with interpersonal communication (dialogue and engagement) serving as a key component, is a complex and dynamic process and that it is critical to tailor efforts to local contexts. A final strategic approach that emerged from the review was the reliance on lay community health workers (CHWs) in immunisation efforts, especially for identifying missed children and reaching marginalised or hard-to reach groups.

Results from the primary analysis
Three specific channels emerged as critical in the Rwanda context:

1. Interpersonal communication and counseling (IPC/C) - The specific IPC/C components mentioned by participants included several categories: (i) training for various community-based healthcare providers and for other relevant nonhealth professionals - Of specific importance was counseling training designed to "improve their ability and efficacy to communicate with pregnant women, mothers with children, fathers, and parents in general." The primary data revealed uneven knowledge among healthcare providers regarding the current polio vaccination schedule and possible contraindications of the polio vaccine. (ii) counseling for parental caregivers by community-based providers, specifically mobilisers and community health workers (CHWs), on the changes to the routine Expanded Program on Immunization (EPI) schedule, why these changes are important, and how such changes would affect caregivers. (iii) word-of-mouth communication, within social networks, which emerged as the preferred form of communication about polio vaccination. The participants proposed change agents and cross-network connectors who would allow information to flow within and between networks and diffuse through the social system over time. Some potential change agents and connectors in Rwanda are: CHWs, community mobilisers, leaders (religious, chiefs, social welfare), and representatives of the village chief. In addition, there were several mentions of the role that neighbours could play in talking to one another about immunisation.
2. Community and social mobilisation - "Vaccination is not a taboo topic requiring confidential and individualized counseling and participants across the board mentioned the importance of meetings as a way to communicate messages." It is important to select meeting locations that evoke a sense of place for community members. Data from the transect walk in Ruhango, for example, drew attention to an avocado tree where babies were weighed and community meetings typically took place. This could make for a prime location to hold meetings and disseminate key messages on the inclusion of IPV and gradual withdrawal of OPV. IPV information could also be integrated into announcements made through use of megaphones, for example. The key idea expressed across stakeholders was that: "the community members can all be abahwituzi (a Rwandan word for someone who awakens the community)".
3. Mediated communication - Radio emerged as the most viable form; battery-operated radios were commonly used. The importance of an integrated strategy where radio messages reinforced and were reinforced by other information was mentioned. Caregivers did not mention TV as a viable channel, and key influentials mentioned that they do not have access to TV because of lack of electricity. The providers displayed some awareness but no utilisation of existing SMS services for sending texts regarding missed vaccinations or adverse events. In terms of print material, one key point made by both service providers and influentials was that any materials should be visual and/or pictorial so as to appeal to a largely non-literate audience. Another was that posters depicting severe cases of vaccine-preventable diseases should be prominently displayed in healthcare settings to remind people about the importance of vaccinations.

Findings from this primary and secondary research highlight the importance of identifying multichannel and multiaudience approaches to polio eradication that cut across different levels of the social ecological model. The Rwanda data emphasises the use of social network approaches that allow for identification of individuals who can act as message multipliers and motivators within specific communities to help families make a seamless switch from OPV to IPV. The success of several previous polio interventions in the literature was linked to communication efforts that engaged local community leaders and lay health workers (e.g., CHWs). This finding is of specific relevance in the Rwandan context, where there is a national CHW network in whom there is deep trust. "With adequate training and supportive supervision, they can serve as the link between caregivers and the healthcare system using a social network approach."

Findings further emphasise the importance of evidence-based and audience-centred communication programming. Monitoring polio vaccination uptake through simple yet comprehensive recordkeeping processes emerged in the literature as a key component of success in polio eradication, especially when ensuring that hard-to-reach and disadvantaged populations were reached. A current low-tech but important monitoring tool that is widely implemented in Rwanda (and in other countries) is vaccination cards. These cards are used by the health providers to track vaccination uptake and follow-through, and serve as reminders to families to follow the vaccination schedules in a manner appropriate for parents and caregivers with low levels of literacy. One methodological challenge noted in the literature review was the lack of preintervention data to measure programme impact. The desk review uncovered some interesting uses of research methods. For example, one study used street intercept surveys to find mothers and children and screen for vaccination status. Another intervention designed to reach nomads in Chad used existing migration patterns to identify a point-of-intervention.

The planned addition of IPV builds on normative behaviour across all sectors of society for children to receive full immunisation on schedule. In addition to the widespread acceptability of vaccinations throughout Rwanda, a broader trust in healthcare system and medical science was also widely seen, which can be leveraged into a rapid uptake of IPV. "In the context of positive social norms, communication messages in Rwanda could emphasize that transitions are always for the better and are based on new evidence of what works best to protect children’s health. Rather than explain or justify complex Global Polio Eradication Initiative plans for stepwise phase-out, a more basic message would be that progress in prevention requires flexibility, and that uptake of the newest recommendations is a benefit of living in a country with strong health sector investments."

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.