Understanding Barriers to Polio Eradication in Uttar Pradesh: Final Report

This 88-page document describes the motivation behind, methodology of, and results from a study that was carried out in 3 districts of Uttar Pradesh, India in an attempt to understand why efforts to eradicate polio in that country have not been successful. In particular, the study aims to explore the very local-level contexts within which communities interact with the polio programme, which has been implemented by the Government of India with support from UNICEF, the World Health Organization (WHO), the Centers for Disease Control & Prevention (CDC), Rotary, the World Bank and other international partners.

The study, which involved a total of 867 households with children between 0 and 5 years of age, used largely qualitative methods to understand the specific socio-cultural contexts which result in non-acceptance of and resistance to the oral polio vaccine (OPV). These methods included focus groups discussions, in-depth interviews, family discussions and problem solving group discussions. The findings are divided into the following categories:

• Childhood morbidity and health-seeking behaviour - In sum, disease causation is explained simultaneously through the domains of "folk etiology" (including religion), and biomedical notions of germs, communicability and contagion. These diverse notions co-exist, but are not static and are continually being reshaped and hence may be described as "fragmented". The emerging practices of medical pluralism are evident not only in relation to disease causation but also through simultaneous accessing of various kinds of healers, and practices of seeking care and cure. The general experience with government health services is described as being of poor quality, and characterised by apathy of the health staff, discrimination based on caste and religion, and corruption and inaccessibility.
• Status of routine immunisation - In sum, the immunisation status of 0-5-year-old children is very poor, with a small percentage of children of 0-1 being fully immunised. The low level of coverage is as much an outcome of poor delivery of services as of the low social demand for services. People here have a very poor understanding of the importance of vaccines, how vaccines work, and specific vaccine-preventable diseases. Rumours about side effects and adverse reactions due to vaccines/injections have resulted in a general fear and rejection of all vaccines.
• Perceptions and practices concerning the polio programme - In sum, there is widespread awareness of polio, though there are differing perspectives on what causes the disease, and hence a questioning of the logic of vaccination. The various agents of service delivery and motivators - e.g., for the frequent polio vaccination rounds - are not perceived as credible for various reasons, leading to strategies of avoidance, resistance and negotiation. Reasons for resistance and non-acceptance of the polio vaccine (which is spreading among the urban and educated classes as well), is due to many reasons, including:
  1. failure of the agents of delivery to communicate effectively and accurately the logic of eradication, the need for repeated vaccination, the biomedical logic of how vaccines work in the human body, and accurate information on specific diseases against which different vaccines protect the body
  2. the failure to adequately involve local leaders (both religious and political) in the planning and implementation of the programme
  3. dispersion of fragments of biomedical information that question vaccination, or specific aspects of the polio programme, coupled with media reports about vaccine-related side effects and adverse reactions
  4. lack of credibility of social mobilisers among the community, due in part to a perception of their appointment as unfair and corrupt.

Following detailed sharing of specific results, the paper goes on to suggest strategic directions for overcoming barriers to increase OPV coverage in areas with high levels of unreached children - with the caveat that specifics need to be worked out in relation to the local contexts within which the programme will operate and in collaboration with district-level implementers. ("The rationale for this approach stems from our research findings which indicates that no single factor can explain why people accept, refuse or resist polio vaccination."):

1. To address the "dispersion of fragments of biomedical knowledge which are mediated by local knowledge and experiences," it is necessary to develop a comprehensive communication strategy that is able to deliver accurate information through credible agents at the local level.
2. To address the "unifocal nature of the programme coupled with its intensity, which sends out wrong signals about the intention of the programme," it is necessary to deliver quality child health services, as also other health services, using existing governmental and non-governmental resources at the local level through mechanisms that are sustainable.
3. To address the fact that "social mobilisers at all levels, but specifically the community level, are not adequately trained," it is necessary to develop a more comprehensive training of trainers programme that functions on a paedagogy of praxis-based dynamic learning so that it is continual and also rapidly responsive at the local level.
4. To address the "growing fatigue among service providers and the community because of the intensity of the programme, frustration that the goal of eradication is becoming elusive, and the sense among local leaders and the community that they are not full partners in the programme," it is necessary to enhance the scope of community participation in the planning, setting of immediate and long term goals of the programme, and establish mechanisms for greater mutual accountability between and among service providers and community members.

Communication strategies also figure prominently in the specific suggestions shared by participating community members, social mobilisers, and government health functionaries for ways forward. To cite only a few examples, research participants stressed the importance of village-level involvement in terms of planning and implementation, as well as several ideas for increasing polio awareness in the community, including: offering baby shows, games, and cultural melas; inviting well-known personalities; use radio for information and awareness; carrying out specific campaigns to counter rumours; and involving local leaders, cooperatives, schools, and non-governmental organisations (NGOs) in awareness programmes.

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