Polio Communication Review India 2008 Phase 1: Uttar Pradesh, Varanasi Sub-region Report

This report details the findings of the consultant team sent to the Varanasi sub-region of Uttar Pradesh state in India to assess the status of the Social Mobilisation Network (SMNet) activities aimed at increasing coverage of polio immunisation among newborns in the Varanasi sub-region.

Strengths of the programme

Briefings and field visits identified a number of strengths of the programme. While this was not an exhaustive list, it summarises a number of areas in which the SMNet has solidified its activities.

1. The SMNet in the Varanasi sub-region has made progress on reducing XR households (unimmunised households) from approximately 6,000 XR households to about 1,000.
2. There is systematic and continuous registration/tracking of pregnant women (PW), frequent visits to homes of PW during the third trimester, and visits before supplementary immunisation activities (SIAs) to check on new births.
3. A special format is used to track newborns and their vaccination status. This form is used by all the A and B teams during SIAs.
4. Interpersonal communication (IPC) and counselling sessions are regularly held with families of PW on all aspects of delivery, neonatal care, and immunisation.
5. Many communication activities at the community level are already underway. Mohalla (street corner) meetings at night, when the weaver community men gather, has been identified and used as a very important forum to engage the community.
6. Many senior private practitioners and members of the Indian Medical Association (IMA) and Indian Academy of Pediatrics (IAP) have joined hands with the polio programme; they have personally visited XR homes and converted people into accepting polio drops. They have also issued appeals captured on video which are shown at night mohalla meetings.
7. All other techniques evolved and used by the SMNet for communicating with minority communities are being used - such as classes in madrasas (buildings used for teaching Islamic theology and religious law), frequent meetings with influencers, the issuing of appeals through local leaders, advocacy and vaccination during Urs (Indian celebration to commemorate the anniversary of the death of Khwaja Moinuddin Chishti), vaccination in marriage pandals (structures set up outside houses during weddings), write-ups of short success stories, dissemination of key data to local media, etc.
8. Normal planned communication activities are also in place, implemented and supervised by a very active United Nations Children's Fund (UNICEF) office and CORE SMNet teams.

Challenges faced

1. Varanasi City has had the highest number of refusal families regarding oral poliovirus vaccine (OPV) immunisation in India. This remains a challenge for the polio eradication effort.
2. Varanasi is a city of great contrasts. There is a vast minority community involved deeply in the weaving/trading business. The business is also largely controlled by this community. The upper and middle class in the minority community tends to resist PW registration and newborn/child vaccination for polio. This sends a negative message to the tens of thousands of economically poor workers and weavers involved in the business.
3. Open refusal to polio drops still exists amongst the Muslim communities, with many hidden myths, fears, and misperceptions about polio still holding strong in these communities.
4. A strongly held belief is the notion of not offering any external vaccination or medication to a newborn during the Sauri period (first 40 days of life). However, during field visits, the team also saw some progress being made in this area.
5. A very strict Purdah system and a total ban on newly delivered mothers stepping out of the house for a vaccination purpose is widely present. The team witnessed many young children, in the age group of 6-8 years, bringing newborns for routine immunisation (RI) sessions. Any communication or instructions to such young children really serves no purpose.
6. Extremely low birthweight babies, who are very vulnerable to infections and illnesses often resulting in death, are commonly seen in the districts visited in Varanasi. In many instances, newborn immunisation has been perceived as the cause of death, giving rise to fears and resistances to immunising newborns, including one case at the time of a field visit.
7. Poor sanitary conditions, inadequate health services (particularly in urban areas), frequent pregnancies, and high malnourishment all act as deterrents to the polio programme.

Key issues and opportunities

High number of newborns missed due to being born in maternal grandparents' house

Problem: One very common phenomenon in India is that many PW do not deliver in their own homes where the husband and in-laws are present, but, instead, go to their own maternal homes to deliver. This is particularly true of first pregnancies, and, in many cases, during the second pregnancy also. It is widely accepted that the young woman would feel more at home when her own mother is around, as she would need a lot of care after the delivery. The implication is that the post-delivery period means extra work for family members, and that the maternal family should bear the burden of all this extra work.

For immunisation purposes this is a definite challenge, as the woman is really lost to the local health and SMNet teams who know her well due to their frequent visits and interactions with the family. If there is no SMNet at the other end, the baby often misses the birth dose polio during the A teams' visit to the house during the SIA, particularly due to cultural beliefs associated with the Sauri period, sicknesses, and refusals due to other reasons. If there is no SIA, the chances of the baby getting immunised becomes even bleaker, as RI sessions are held at fixed places and not at home.

Many ideas were explored as to how this particular problem can be overcome and ensure that the PW who move for delivery can still be tracked for care, delivery, and immunisation purposes. One of the ideas suggested was that a referral slip would be given by the health system and the PW would keep it as a record for health personnel to see in the district to which they may have moved. However, given the current state of the health delivery systems and the lack of knowledge and general awareness in the population, the team, including the local SMNet, felt that the idea of a referral slip would really serve no great purpose in ensuring that birth dose OPV is given to the baby.

Many newborns missed due to refusal/sickness

Problem: In about 15-20% of cases there is a straightforward refusal from families. The community mobilisation coordinator (CMC) has reached the house, and the A / B teams reach the houses of these newborns, but the parents/family members are not ready to immunise the child. This is partly due to the belief that newborns should not be vaccinated for 40 days – although this figure varies anywhere from 12-14 days to 1 month to 40 days. This is a part cultural/part religious belief and has no scientific validity. Nevertheless, numerous families still do believe it; therefore, new ways of identifying and convincing them have to be found.

On the other hand, sometimes familes refuse to vaccinate a child who is genuinely sick. While mild illness is not a contraindication for administering birth dose OPV, many babies are born with extremely low birth weights and die within a few days of birth. A birth dose OPV administered to such a sick child may in fact trigger a spurious connection between the vaccine and the infant death.

Missed opportunity of newborn immunisation in absence of SIA/RI (newborn immunisation gap)

Problem: Women in India are delivering babies all the time. Even as these words are written at least 20 babies are born every minute, many of them at home or in small clinics which may not have immunisation services. In any particular village, RI sessions happen only once a month. In urban areas, if there are health posts, then immunisation sessions take place. Otherwise, facilities for regular preventive services are few and far between in urban areas. Similarly, not all areas have SIA all the time. They are held at least a month apart. In such situations, the babies being born at a given time may miss all those immunisation opportunities and will have to wait for one to two months before any service becomes available. How do the teams reach these babies within days of their being born?

Lack of immunisation at private clinics/nursing homes which do not have basic and/or adequate immunisation infrastructure

Problem: In urban areas where the government health infrastructure is limited, many families prefer to take a pregnant woman to a private clinic for delivery. There are hundreds of big, medium, and small hospitals and clinics all over Varanasi and other towns of the sub-region. The big private hospitals have excellent infrastructure and cold chain facilities. After delivery, the hospital immunises the baby before discharging the mother and baby. The medium hospitals do not have such good cold chain facilities but they still may immunise the child before discharge. The smaller clinics and delivery places just do not have any kind of facility. They do not immunise the babies and just let the family go after delivery.

Government hospitals lack sense of urgency regarding polio programme and accord little priority

Problem: The team visited the district hospital in Varanasi, which they deemed a fairly well run institution. On visiting the women's wing, the team found that there was a dedicated labour ward and a general ward for women who have just delivered or are about to deliver. A neonatal resuscitation and intensive care area was not operational, as there was a power outage. Discussions with the superintendent of the women's wing revealed that, while vaccinations are given to neonates before discharge from the hospital, if BCG (the tuberculosis vaccine) is not available, even polio drops are not given. Furthermore, government hospitals do not "own" the polio programme, which is just one more programme among many. Thus, the urgency and passion with which the programme is run is hardly felt in government health facilities where deliveries take place or sick neonates may be admitted. The doctors on duty have never been really oriented to the programme and are barely aware of the importance of polio eradication or the particular roles they could play in supporting the programme.

Limited use of adult learning methods/principles by CMCs in critical houses and in other group activities like mothers' meetings, meetings with minority community leaders, other community groups, etc.

Problem: Although the CMCs have received a lot of training in which they have been guided in using IPC tools and adult learning principles, the teams observed that very few of these principles are used in turn by the CMCs in their own interaction with families and community groups. The approach is paedantic, with limited interactive question/answer opportunities. This information-giving style limits the ability of participants to understand and own the basic elements of the polio eradication effort, and makes them more vulnerable to rumours, misinformation, and other issues that may lead to refusals.

Missed opportunities for educating mothers when they gather for RI

Problem: While CMCs are constantly in touch with the families, some messages and actions are still not getting across. For example, at many RI sessions the team observed the following: mothers are not carrying their immunisation cards; they are not quite sure about how to care for children after immunisation; they are not aware of dosage of simple medicines like paracetamol given in cases where the baby develops a fever; and they have no knowledge whatsoever about how important it is to keep a baby warm. Also, the sessions turn out to be quite chaotic and unproductive for communication. The RI sessions are, therefore, lost opportunities for intimate communication and reinforcement of key child health messages, including vaccination-related messages.

The auxiliary nurse midwife (ANM), her helper, and the CMC are busy at the session; therefore, extra human resources are needed at every session.

Lack of knowledge and experience amongst CMCs to pick up danger signs in a sick child so as to avoid untoward incidents

Problem: While the team was in Varanasi, there was an incident in which a newborn was immunised and then died a few hours later. While initial investigations by the medical team assigned by the community mobilisation officer (CMO) concluded that the death was not really connected to polio vaccination at all, it sparked a big uproar locally which could have had severe impact on the ongoing RI sessions/A team activities. The media also picked up the story and gave it a lot of coverage.

The team feels that it is important to train the CMCs to be able to assess if the baby is really ill, and to check out the birth conditions (like extreme low birth weight, delivering doctors' advice and observations, etc.). While the CMCs may tend to use illness as an excuse for not bringing the newborns for immunisation, with good supervision by the BMCs this tendency can be controlled

Lack of community awareness about the importance of care of pregnant women, institutional delivery, newborn immunisation, the comprehensive effort required for polio eradication, etc.

Problem: The way families, men, and communities look at pregnancy, PW, and childbirth is still steeped in myth, religion, and ignorance. The average family size ranges anywhere from 5-10 children. Birth is believed to be God's gift and will; thus, the woman is seen as having a duty to bear children - no matter how emaciated she is or her previous children are.

The communities also have limited information about vaccinations. They understand that the polio vaccination is all about not getting the polio disease by which children get disabled. However, concepts such as the importance of continuously immunising one's child and thereby protecting one's child from wild poliovirus and building viral immunity are difficult to understand and perhaps have not been adequately explained to communities. There are many families who have no active resistance to polio vaccination, but have begun to take it lightly. They miss rounds nonchalantly: "We will give it the next time around when it happens," or "we just gave it at the beginning of this month," and so on. Families are certainly not aware of the importance of vaccinating newborns and its significance for polio eradication efforts. There are also a number of taboos about immunising newborns and many misconceptions are floating around about the polio vaccine, including confusing polio with other diseases that affect children's extremities (as illustrated by a local newspaper report).

New young mothers and families lack knowledge on basic newborn care (warmth, cleanliness, correct breastfeeding, sickness signs, and when to seek help)

Problem: The conditions in which newborns are kept and cared for are related to both poverty and lack of knowledge; this issue is connected to birth dose OPV. With a little more knowledge and correct information, mothers are likely to improve the hygiene, cleanliness, and feeding practices needed for caring for neonates. This will greatly improve the chances of survival of newborns and act as a motivator for polio vaccination, ensuring better survival of the baby. Often illness and poor conditions cause infant mortality, but families may attribute it to polio vaccination, thereby causing great harm to the programme and eradication prospects.

The team made several recommendations after consultation with district and state level polio staff and partners, which can be found in the report.

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