Health Communication: Polio Lessons

This report emerges from a March 13 2009 gathering of health communicators, practitioners, researchers, and policymakers convened to identify and discuss key lessons from polio communication practice for the field of health communication. Co-organised by the United States Agency for International Development (USAID), The Communication Initiative (The CI), The George Washington University (GWU), and The American Public Health Association (APHA), the meeting featured presentations based on initial findings of research to be published later in the year in the Journal of Health Communication. The day provided an overview of the use of communication in the effort to eradicate polio, insight into the frontline experience of polio workers, analysis of how field and surveillance data have been used to inform and plan communication intervention, an exploration of the role of social mobilisation and community involvement, case studies on social mobilisation interventions, and dialogue on the advocacy efforts that have kept polio on the global funding and policy agenda. Each presentation was followed by an opportunity for reflection and dialogue from all present, and these discussions are also summarised within the report (though not noted here below).

Opening comments of this meeting identified the key foundation for the gathering: as a public health initiative driven by the need to reach the proverbial last child, polio's pursuit of universal coverage can provide lessons to other healthcare initiatives. This is particularly true in the area of communication. New tools (e.g., insecticide treated nets, vaccines, and directly observed treatment, short-course (DOTS) to treat tuberculosis) work only as well as they are being used, and misunderstandings and rumours can derail efforts. Much depends upon people and on their ability to adapt and respond to unfolding and unpredictable situations. In developing communication-based programmes, there is a great deal to learn from the polio household-to-household experience.

Session 1: The polio communication experience

Ellyn Ogden, USAID's Worldwide Polio Eradication Coordinator, began with an overview of the global polio situation, citing current case numbers and endemic countries. [Click here to access a related PowerPoint presentation]. She began by showing a series of pictures to remind us that each "case" of paralytic polio is a child who could die or be disfigured or paralysed. Ogden then went on to identify crucial communication strategies for eradication. One key strategy is through routine immunisation where children in endemic countries are brought to health care providers to receive 4 doses of polio vaccine before their first birthday. However, in many countries where the health care system is not functioning well enough to provide this kind of service, polio treatment has had to rely on massive communication campaign efforts in which clinics, hospitals, and booths are supplemented by an army of vaccinators recruited from every corner of the country to literally knock on every door and immunise every child under 5. Polio is the only public health initiative that has utilised this tactic. The interaction that takes place on the doorstep is critical, and relies to a great extent on trust. Other strategies are designed to meet challenges associated with reaching mobile populations, including those moving across borders and nomadic children.

Ogden highlighted some of the communication strategies used to build demand:

• Mass media. Local broadcasters and celebrities can and do help by disseminating information via radio, television, etc. Working with journalists and editors to encourage positive or neutral stories is an important strategy.
• Interpersonal communication (IPC). This includes polio survivors telling their stories, health workers answering questions, trained mobilisers reassuring parents, and vaccinators encouraging caregivers to vaccinate every child.
• Getting leaders involved. When community leaders speak in favour of vaccinations or publicly administer vaccines, people take notice.
• Information, education, and communication (IEC). Posters, leaflets, and billboards are often branded with messages that are recognisable across countries and that feature consistent colours.

Next, Tim Brookes, author of The End of Polio? Behind the Scenes of the Campaign to Vaccinate Every Child on the Planet (with Omar A. Khan, M.D.), presented "Why is the polio communication experience important? The polio experience, lessons and opportunities for public health." His remarks were based on ten days spent in Pakistan researching his book in 2006. In many of the economically poorest and least-developed countries where the polio battles are being fought, there are issues more pressing than polio. The complicating factor, Brookes explained, is that the simple act of relaying basic polio messages can result in problems for the people on the front lines. As messages are interpreted by communities and individuals, the intended meaning can be lost or reinterpreted.  Furthermore, cultural, socio-economic, gender, religious, and other differences create opportunities for differing reactions and responses. Thus, dealing with such complexity is most important where it is greatest - at the level of the vaccinator team. Brookes underscored the importance of recruitment and training. Every vaccinator must have skills for effective and, at times, advanced IPC.

Session 2: Key lessons for health communication

Lora Shimp, MPH, of Immunizationbasics spoke next about "Using data to guide action in polio health communications." [Click here to access a related PowerPoint presentation]. Shimp focused on the following themes: involving NGOs, mapping the catchment area, identifying community partners, and determining the best mobilisers.

Shimp focused first on India, noting that where there is on-the-ground good tracking there is a better understanding of the overall situation (e.g., why children are being missed), better targeting of campaign resources, and the ability to look at trends over time.

In Nigeria, Shimp explained, the process of mapping out non-compliant households and identifying missing children is beginning. The next step is determining the nuances specific to certain blocks with "non-compliant" households.

Shimp next spoke of the polio eradication effort in the Democratic Republic of the Congo (DRC). From 2002-2006, transmission of WPV was temporarily interrupted; however, this could not be maintained due, in large part, to the country's lack of both health care infrastructure and baseline and health-related social data.

Amongst Shimp's recommendations for going forward was a focus on garnering financing for good communication. Communication indicators (e.g., percent reduction in "missed" children) must be refined and standardised, in part by involving epidemiology and child health technicians in communication monitoring and supervision. According to Shimp, data trend analysis is key, along with a level of sensitivity and specificity in the collection of nuanced, actionable data.

Dr. Bill Weiss (Research Associate, Johns Hopkins Bloomberg School of Public Health, and Technical Advisor, CORE Polio Partners Project) next presented "SMNetwork/India: Activities and Achievements." [Click here to access a related PowerPoint presentation]. The focus of this presentation was on the polio eradication effort in India, where the Social Mobilisation Network (SMNet) is doing its work. Weiss described the structure of SMNet's work, the current size of the network, and the main responsibilities of the community mobilisation coordinators (CMCs).

Recognising that certain communities had a disproportionately higher incidence of polio (Muslim and urban economically poor populations, for example), SMNet developed a "UP Underserved Strategy", to engage Uttar Pradesh's population through massive networking and intensive engagement with Muslim and urban leaders. A key strategy has been creating posters and other IEC materials that are standardised in an effort to foster brand visibility. It appears that these efforts have paid off; in 2000, 70% of polio cases were occurring among Muslim children; in 2008, the percentage had dropped to less than 40%. Weiss shared additional data indicating the influence of SMNet's communication work. For instance, looking at the average numbers of children immunised at fixed site booths in CMC versus non-CMC areas, Weiss found that CMC areas were getting double the number coming to the booths (reaching approximately 60% of the population as compared to 40% in non-CMC areas). This pattern, he said, is repeated in every district. Furthermore, over time, the percentage of newborns getting birth dose is increasing; Weiss linked this shift to intensive efforts to track newborns.

The next presentation was a joint one: Dr. Silvio Waisbord, Assistant Professor of Media and Public Affairs at The George Washington University and Dr. Rafael Obregon, Director of Communication and Development Studies at Ohio University, discussed "The complexity of social mobilization in health communication: Top-down and bottom-up experiences in polio eradication." [Click here to access a related PowerPoint presentation]. Waisbord and Obregon highlighted a "tension" between what they call "pragmatist" and "activist" meanings of social mobilisation (SM). Assessing the levels of complexity of SM and its effects on health communication practice in the Polio Eradication Initiative (PEI) context could, they say, lend rich lessons for other practitioners working on other health issues.

The activist conception is one typically associated with a "bottom-up" approach; concepts of participation and empowerment are central, as communities themselves express demands, define goals, and make key decisions. The engagement of communities has intrinsic value that goes beyond the strengthening of health services. In contrast, when SM is conceived in a pragmatist sense, involving communities is a means to an end. The question is, if SM is construed as a strategy necessary to overcome systemic weaknesses, deliver services, and raise funding, how is "activist" SM possible in the context of global initiatives like the PEI? The two understandings of SM can co-exist; the question is, how?

Data reveal that SM activities have made important contributions to the programme. On the measure of pragmatic SM - where the key notion is how different resources are used at local/community levels to achieve programme goals - the polio experience shows the impact of local actors' participation in service delivery and communication, and in changing attitudes and behaviours. Often, in conducting vaccination activities, SMs are providing other kinds of rehabilitation or education services. Data show that going beyond polio in this way creates a more enabling environment.

Discussion shifted to activist SM related to opposition to PEI, where SM can refer to contentious action to challenge global goals - even those that go beyond polio. There are 2 forms of oppositional SM: political protest, which is open defiance of polio eradication efforts (as seen in northern Nigeria in 2003), and passive resistance, which is a rejection of vaccination teams due to lack of understanding about multiple rounds, etc. Study of oppositional SM reveals that it is dangerous to assume that global goals are unanimously adopted by communities worldwide. Additionally, SM around PEI can be a platform for expression of deep-seated conflict and resentment going far beyond vaccination.

The polio experience also underlines the importance of viewing IPC as a process of dialogue and engagement, not just a matter of convincing people to change behaviours. There has been a shift in the global programmes' perception of communication represented by the increasing use of community dialogue, the engagement of religious/political leaders, and other IPC-centred strategies employed over the past several years. More data are needed as to why IPC, in particular, has proven effective in reducing resistance, but there is substantial data to demonstrate that it has.

In conclusion, Waisbord and Obregon stressed that SM should not be approached as a top-down information strategy. Results can't be predicted because participation sets in motion uncertain dynamics and demands. It is crucial to take local needs into consideration rather than seeing them as a reaction.

In her presentation "Global advocacy: language and reality", Judith Kaufmann (Consultant, former (retired) Director of State Department's Office of International Health) shared findings from her research project, which is still in its early stages. Conducting interviews with people in funding organisations and a review of advocacy statements from polio partners and media stories have led her to begin identifying which advocacy messages, forums, epidemiologic pictures or other "triggers/buttons" resonate with donors and lead to funding decisions or secondary advocacy efforts. The hypothesis guiding her research breaks the global polio advocacy into several periods, the most recent of which is characterised by the sense that - as the achievement of eradication bogs down - the PEI is "too big to fail" and the world cannot walk away from so much investment over so many years, especially not when eradication is so close.

As part of her effort to understand how best to show the effect of polio advocacy messaging, and demonstrate what worked (is a link to funding decision the best or only method?), Kaufmann posed a series of research questions to the audience.

Session 3: Reflections on the day from a decision-maker perspective:

• Dr. Linda Venczel, Bill and Melinda Gates Foundation: Looking back at the effort to eradicate polio over the last 30 years, including actions in Latin America, Dr. Venczel traced polio eradication's evolution from a very top-down approach to a real effort to go to the community level and establish mobilisation. Breaking eradication into realistic goals and smaller steps that indicate success is an option. Transparency about the programme is important. Refraining from circling exact dates on a calendar may be more credible in the long run. In terms of building strong partnerships that keep people engaged, Venczel pointed to the symbolism of Muslim countries getting involved.
• Dr. Dan Salmon, National Vaccine Program Office, US Department of Health and Human Services: Salmon noted similarities between his work in the United States (US) and the polio experiences discussed today. As the fear shifts from the disease to the vaccine, clusters of resistance develop and outbreaks are possible. In the US, most parents are worried about autism, asthma, obesity - not infectious diseases; polio is similarly de-emphasised in other countries facing a host of other problems. It is crucial to craft communication strategies proactively and to consider who are the most credible messengers.
•  Dr. Elizabeth Fox, Senior Technical Advisor, USAID: The PEI has seen an evolution from a directive, information-based, top-down model to one where participation and SM have crucial roles. Key health communication lessons have been particular to the eradication effort: a) Although polio has become a rare event, the need to vaccinate continues and surveillance is crucial. When encouraging people to be on the lookout for things that they frequently will not be able to find, communication/messaging and measuring success becomes tricky. b) Polio has revealed the two faces of SM. On one side, it is manipulatory but effective; on the other, it is a negotiation. The polio experience has raised questions about communication messaging regarding other issues, such as normative change around sexual practices and HIV/AIDS. c) The PEI has taught us to redefine success by identifying smaller steps or different steps. d) This experience has led to reflection on the practice of using positive incentives rather than negative incentives in advocacy. 
• Paul Mitchell, Manager of the World Bank Development Communication Division: Mitchell thought that perhaps we can learn from Rotary and its success with sustaining constant advocacy efforts. If polio eradication is not catching on, we must explore how to link polio eradication to other outcomes that people can see and that may be tied to them. For example, the hand washing campaign in Vietnam just wouldn't catch on. Only when it was linked to avian flu did the message "stick". On the flip side, much wisdom from polio communication can be applied to other health sectors: Communication is evidence-driven and linked to the work itself; communication is contextual, and ever-evolving; what is important is how people receive information and what they do with it (and not the tools themselves); paying attention to politics is critical; participation and two-way communication are key.
  

A discussion and end-of-day reflections followed, led and then summarised by Ellyn Ogden., who encouraged the building of innovative communication strategies in a way that is measurable, systematic, and sustainable. According to Ogden, we need to keep our volunteers and social mobilisers motivated and armed with new, sophisticated communication tools and lessons learned from other programmes and efforts.

The Communication Initiative's Executive Director, Warren Feek, closed with a summary of the various tensions that must be managed in the various contexts of polio communication.