Bringing Behavioral Change through Inter Personal Interaction with Refusal Families for Improving the Polio Immunization Coverage in Uttar Pradesh, India

With funding from the United States Agency for International Development (USAID), the CORE Group Polio Project (CGPP) is a multi-country, multi-partner initiative providing on-the-ground technical guidance and support to strengthen host country efforts to eradicate polio. CGPP-India operates in India through 3 private voluntary organistions, one of which is Adventist Development and Relief Agency - India (ADRA India), a humanitarian organisation with a mission to work with people in poverty and distress to create just and positive change.

To strengthen the polio immunisation programme, the polio campaign booth day strategy was introduced. When many community members missed the booth day, the polio programme developed the door-to-door strategy. However, this approach had weaknesses: This was a one-way flow of communication, with community workers acting like "messengers" only. There was a lack of training in communication. What resulted was a "chasing" behaviour pattern showing persitent follow-up without a proper strategy. The community become suspicious, having heard rumours that polio vaccine causes impotency and seeing fatwas against polio drops. This led to a huge resistance in 2002: Refusal families were not willing to talk to the mobilisers, and there was stiff resistance to polio immunisation.

When thousands of families said "NO" to the vaccinator, CGPP recognised the need for a change in the communication strategy. They had to rethink and review concern (refusal families), to understand the gaps, and to introduce the GATHER approach: Greets the mother, Asks and assesses, Together talks and listens, Helps in identifying difficulty, Explains to the mother, and Recommends and re-visits. More than 5,000 community mobilisers were deployed in resistant areas by Social Mobilisation Network (SMNet) partners. Community mobilisers were selected from the same community - more acceptance from the community. They were oriented and trained, and their capacity was built.

This prepared the community mobilisers to support vaccination decisions through one-on-one interaction (with mother, with family) and group meetings (mothers' meetings, meetings with influential people). They were able to identify the causes of refusal: ignorance, myths and traditional beliefs, adverse effects, refusal by male members, bad experience at local health facility, negative propaganda. They could understand the stages of behaviour change: from aware to contemplation to preparation to action to maintenance. They introduced simple and effective tools, such as use of indigenous games for communication (snakes & ladder game, turmeric mud & water game, stick game, and glass & water game), behaviour charts and other print materials, and use of films.

The scenario changed due to strategic communication, as illustrated by a figure on slide 20 with the average number of refusing houses at the end of supplementary immunisation activity (SIA) campaigns in districts covered by CGPP India, October 2007 - September 2017.

ADRA India credits India's success in eliminating polio from the country to the strong commitment and partnership between the Government of India, the World Health Organization (WHO), CORE, Rotary, the United Nations Children's Fund (UNICEF), and other international agencies and key polio implementing partners.

Final notes: Gaining the confidence of the community is important, and identifying the current behaviour of the audience is the key to achieve desired behavioural change.

Editor's note: The above is a summary of a presentation delivered by Shilpi Das and Vivekananda Biswas at Shifting Norms, Changing Behaviour, Amplifying Voice: What Works? The 2018 International Social and Behavior Change Communication (SBCC) Summit featuring Entertainment Education, held April 16-20 2018 in Nusa Dua, Indonesia.

Click here to access the 23-slide presentation in PDF format.