Core Group Polio Project: Angola Baseline Report

This report covers a Core Group Polio Project (CGPP) team baseline assessment held in July 2008  in order to better understand specific barriers to polio immunisation in Angola. CGPP activities in Angola are funded through a United States Agency for International Development (USAID) grant that began in October 2007, and will end in September 2012. The baseline activities were funded with a World Vision-US contribution.

Over the last 10 years, the CORE Group, in partnership with the United Nations Children's Fund (UNICEF), Rotary, and the governments of India, Nepal, Ethiopia, and Angola, has worked to reduce the burden of polio by mobilising local and hard to reach communities through routine immunisation campaigns and vaccination services. Common barriers to immunisation in these countries include things like a lack of awareness regarding vaccination, poor surveillance capacity, and a belief that vaccinations can be harmful to children.

To address a major polio outbreak - over 1,000 cases - in Angola in 2001, the original CORE Group project began organising volunteers and now encompasses volunteer tracking of defaulters, use of community maps in detailed sub-district level microplanning, and active case searching among local leaders and healers. The CGPP-Angola coordinates the work of 5 US-based private voluntary organisation (PVO) partners and many local partners to reach 3,781,072 children under the age of fifteen each year.

This baseline assessment consisted of a household survey with questions pertaining directly to vaccination history, beliefs, and practices relating to vaccination, and awareness of CGPP activities. The sample was selected using the 30-cluster methodology to select clusters distributed across CGPP catchment areas nationwide. Simultaneously, the project conducted a review of the CORE Polio Eradication Initiative (PEI) using an external local evaluator for a series of semi-structured interviews with stakeholders, while a CGPP staff member conducted semi-structured interviews with PVO partner staff. As stated here, "while the primary purpose of these interviews was to assess the CORE PEI, they yielded some results with implications for the CGPP, and thus a summary of the major findings is included here....The PEI established its primary strategy as the establishment of community-based networks of lay workers trained in the recognition of and appropriate response to acute flaccid paralysis (AFP). Called activistas or volontarios (volunteers), these lay workers in the community paid visits to households with children under fifteen as well as to community leaders to raise awareness of AFP symptoms and encourage communities to report cases to the local health post. In the event of SIAs [supplemental immunisation activities], the volunteers also visited homes to encourage mothers to vaccinate their children."

Communication-related work of the CORE PEI is summarised as follows: "...The primary focus of the PEI in Angola was initially to improve surveillance while supporting any supplemental immunization activities that occurred...Due to the evidence of continued transmission [and following a period of civil war and reconstruction], PEI activities in later years came to incorporate more active support for SIAs. Volunteers began conducting more heath education talks on the importance of child immunization and focusing on encouraging mothers to vaccinate during home visits. Some PVOs also incorporated street theater and work with church groups in order to support SIAs....In addition, throughout its history, the PEI in Angola incorporated support to local, provincial and national ministry of health personnel in its project activities. Locally, PVOs provided logistical support such as transport and use of telecommunications equipment to local health posts to aid in case investigation, stool sample collection and campaign logistics. Nationally and provincially PVO staff and secretariat staff participated in microplanning of vaccination campaigns...The project pursued strengthening partnerships at both the national and local levels, attending Interagency Coordinating Committee meetings and other technical events, hosting PVO coordination and skills building events, recruiting church and other community leaders into vaccination and surveillance education activities and integrating the polio volunteer network into local formal and traditional governance structures. The project’s community education activities ranged from one-on-one health promotion at home visits and health education talks to street theatre and puppet shows. In addition, the PVO polio staff supported the local MOH [Ministry of Health] system through providing logistics support, participating in microplanning, and conducting supervisory visits covering surveillance and cold chain review."

The results showed coverage rates of 62% receiving four doses of vaccine with a dropout rate of 21% and 77% coverage in the July 2008 National Immunisation Day (NID). Data showed lower rates in areas with no CGPP programming. As for knowledge and attitudes surveyed, "[r]esistance among the population appears to be present but data collected in this survey do not identify the specific nature of mothers concerns." Stakeholder interviews with the non-governmental organisations (NGOs), bilateral, and international organisations showed a desire to expand the CGPP activities; and PVO partners also reported a high level of satisfaction with the CGPP’s activities, including an enhancement in quality due to standardisation of training and approach and several local variations between PVOs in social mobilisation tactics, including songs, mobilising schools and youth groups to spread the polio message, presenting polio messages at neighbourhood meetings, and recruiting traditional healers as volontarios (volunteers).

Among the recommendations are the following:

1. "Additional data gathering and analysis...”, particularly focused on resistance to vaccinate or to continue vaccinating.
   
2. “Programmatic measures
   

• Address low rate of children reached in vaccination campaigns by improving the quality of SIAs through intensive microplanning at district-level and below with CGPP and MOH staff together. Place particular emphasis on using community maps and registers to identify every child under five during house-to-house vaccination. Consider seeking mechanism to support the MOH in training vaccinators.
  
• Continue implementing defaulter tracing to improve the rate completion of at least seven doses of OPV [oral polio vaccine] in 1st year of life. Place particular emphasis on using community maps and registers to identify every child under five immediately at birth.
  
• Explore reasons for higher-than-expected resistance to vaccination among mothers. Conduct qualitative research possible including a Doer-Non-Doer or positive deviance analysis regarding barriers to and beliefs about immunisation.
  
• Renewed emphasis on awareness of acute flaccid paralysis (AFP) among caregivers and community leaders, in response to low levels of recognition of AFP symptoms in the community. Focus on raising mothers’ awareness of AFP symptoms and strengthening link between community leaders, including traditional healers, and the formal surveillance system.
  
• Some CGPP areas still have surveillance failures, and only one of the stakeholder interviewed perceived surveillance as an important contribution of the project. In addition a survey of district and sub-district MOH workers conducted simultaneously (data not shown) revealed a perception that the CGPP’s performance in providing both logistical and supervisory support for AFP surveillance. Conduct systematic surveillance supervisory visits at district and sub-district level with PVO staff, secretariat staff and national stakeholder representatives."

CORE Group members in Angola  include:

• Africare
  
• Catholic Relief Services
  
• Save the Children
  
• Salvation Army World Service Office
  
• World Vision