When Every Child Counts - Engaging the Underserved Communities for Polio Eradication in Uttar Pradesh, India

"Engagement is the key word, and is central to this focused intervention to enhance acceptance by the minority representing the missed targets, of the shared vision to rid India of polio."

India's underserved strategy, the focus of this United Nations Children's Fund (UNICEF) working paper, entails massive engagement of religious leaders, intellectuals, thinkers, doctors, teachers, and undergraduate students in the large public health movement to eradicate polio. As part of this strategy, partnership building works hand in hand with advocacy to create an enabling environment where opinions in favour of polio vaccination are generated to mitigate resistance to the vaccine. Interpersonal outreach is organised and directed at certain segments of communities, including Muslims, scheduled caste Hindus, scheduled tribes, and the economically poor, who are deprived of access to basic services; this which has molded a resistant attitude against the free polio vaccination service.

The strategy is so named because it aims to reach out to areas with families at high risk of wild poliovirus infection and with poor access to health, sanitation, and other basic services. Specifically, communities whose resentment against polio drops are largely an outcome of social exclusion, such as the paucity of support to their need for basic services. As of this writing, in Uttar Pradesh (UP), surveillance data show that Muslim children account for the highest number of cases of polio, and are most at risk of polio infection. Reaching these families and galvanising support from individuals among these communities on a relatively massive scale is thus the strategy's focus. A key feature is to identify major Muslim institutions to collaborate with UNICEF to undertake the following:

• Through the work of the District Task Forces, facilitate the inclusion of Muslim and other institutions with effective links to underserved communities in the planning, implementation, and monitoring of immunisation activities at district and block levels.
• Promote specific interventions to increase underserved communities' access to basic services.
• Enhance effective interpersonal communication between vaccinators, outreach teams, and all underserved communities.

Three Muslim universities, each with an extensive network of institutions - religious, academic, and professional - and those close to the grassroots have been engaged to conduct advocacy and outreach in western UP. Their work is built on that of the UNICEF Social Mobilization Network (SM Net), an interpersonal communication channel of community mobilisers to promote dialogue with families in high-risk, high-resistant areas, through a string of communication activities to enhance knowledge of the disease and the rationale for eradication, and above all, build trust. The network, which combines forces with the CORE group of international non-governmental organisations (NGOs), operates in synchrony with the Government of India - World Health Organization (WHO) National Polio Surveillance Project (NPSP) at state, district, and block levels.

High-risk and high-resistant communities are identified through active tracking of polio infection cases in villages or urban neighbourhoods. Intensive social and community outreach activities are planned jointly with a multitude of partners that constitute the District Task Force, led by the District Magistrate. The SM Net then carries out a series of actions 15 days before each vaccination round. These include courtyard meetings and mothers' meetings to enhance knowledge of polio and address concerns (e.g., of repeated doses or side effects). Day-long health camps to offer general curative care for children, routine immunisation, and preventive health counseling for parents are organised with major NGOs to draw mothers out of their houses with their toddlers. Meetings with influencers - respected figures such as Imams, teachers, medical doctors, and local activists - are arranged to enhance the quality of interaction with families, often, from door to door.

At the same time, UNICEF and Rotary, along with alumni of the Aligarh Muslim University (AMU) in UP, as well as the Chief Medical Officer of Aligarh, enlisted the support of AMU's Vice Chancellor, Mr. Naseem Ahmad, a highly respected Muslim intellectual and a senior Indian Administrative Services (IAS) Officer, to encourage families to participate in National Immunisation Days (NID)/Sub-National Immunisation Days (SNIDs). The Vice Chancellor issued an appeal to Muslim communities, allaying fear of polio drops as the cause of infertility in children, and affirming it as simply a vaccine to free India of polio. His statement lent weight to efforts by the SM Net and partners to persuade even more Muslim families to open doors during NID/SNIDs. Further, the Vice Chancellor, who was soon nicknamed "Mr. Naseem Polio", began to go around addressing thousands of Islamic followers in Friday sermons, including a well publicised meeting with Imams and Sheher Imams in the hardcore resistant district of Moradabad. Mr. Ahmad's visible pitch was a precursor to the underserved strategy launched by UNICEF and partners in 2003 to engage Muslim institutions in building and regaining Muslim families' confidence in polio vaccination.

In July 2003, UNICEF identified 9 districts for the initial phase, to introduce the underserved strategy in Saharanpur, Muzaffarnagar, Meerut, Baghpat, Moradabad, Bijnor, Bulandshar, Ghaziabad, and Aligarh districts (See Annex A). In doing so it entered into partnership agreements with the AMU, Jamia Millia Islamia (JMI), and Jamia Hamdard to plan, implement and monitor strategic interventions at the district, block, and settlement levels. The partnership signifies a systematic rather than ad hoc, need-based approach to engaging Muslim institutions in the polio vaccination drive. The 3 institutions activate a host of alumni, influential Islamic scholars and thinkers, eminent persons, students, volunteers, and local networks to foster larger changes in opinions about polio. Alliance with these institutions also paves the way for UNICEF to build new ties with other institutions for the SM Net. The nurturing of trust has spawned a further network of partners comprising groups and individuals, to work around local neighbourood and communicate with families at their doorstep. The strategy with its spin-offs allows UNICEF to cooperate with more than 200 local institutions and groups in some 20 districts across UP to promote polio vaccination.

This working paper describes in depth the process of engaging "movers and shakers in the intellectual and religious world". Communication activities carried out with each of the 3 partners are detailed. To cite only one example from the collaboration with JMI, or the National Islamic University: The systematic engagement of the underserved, in this case, takes the form of knowledge and education of intermediaries: the religious leaders and teachers who are bridges to families on a daily basis, and in places where resistance can be hidden and undetectable. The first task was to devise an advocacy booklet designed to reach these intermediaries, elucidating health in the context of Islam (chapter 1), public health in terms of epidemic-prone diseases (chapter 2), and the meaning of participation in polio eradication campaign, followed by a Questions and Answers section as well as a full routine immunisation schedule on the back page. Various verses of the Koran are quoted to elicit parents' sense of responsibility for their children's health. The advocacy booklet is used for a series of sensitisation, brainstorming, and planning workshops to engage religious leaders in the polio eradication programme. The participants - Imams, teachers, and other local influential figures – are asked to prepare a plan of action during the workshop that details their specific roles and responsibilities with clear time-lines. The plan carries both short-and long-range objectives: polio eradication in the immediate future and improved health of Muslim children over time. Immediate activities include: (i) Developing Islamic-oriented polio communication materials; (ii) issuing of appeals, letters, background materials, and talking points for religious and community leaders; (iii) organising regional/sub-regional meetings to sensitise families; and (iv) setting up task force to coordinate block-level mobilisation of partners and influencers.

As detailed in section 5 of the paper, the series of intense interventions over the months produced visible changes - as reflected, for example, in the conversion rate and the contribution to the reduction of immunity gap. To cite only one figure included in the document: The number of Muslim children insufficiently vaccinated decreased from 29% in 2002 to 5% in 2004, and among Hindu children, from 14% to 2% over the same period.

"The process of engaging the Muslim communities to change mindsets and behaviours has brought the needs and rights of the underserved to the fore, on how a global goal can fail when a small minority does not participate fully in the programme." According to the paper, the combination of advocacy, social mobilisation, and behaviour change communication approaches has yielded several lessons:

1. The involvement of religious leaders, eminent persons, and medical authorities, including Unani physicians, in the neighbourhood effectively brings authority to bear on resistant attitudes that are founded on rumours.
2. Opinion changes through local interactions with resistant families are sustainable only when buttressed by similar opinion changes in the macro or larger environment, especially through the engagement of religious leaders whose viewpoints matter greatly to followers.
3. The introduction of health services has tentatively bridged the need of preventive and curative care for children of these communities, and helped change parents' attitudes towards polio immunisation.
4. Contributions of individuals such as the Unani physicians and religious figures, whether in their daily interactions with the community or during the rounds, are vital to linking the polio eradication goal to the grassroots.
5. The JMI network's involvement in microplanning and coordination with other polio partners in communities on outreach activities is increasingly recognised by the district health department as valuable. The appeals and statements secured from important Islamic centres such as Darul Uloom and Miftaul Uloom Deoband have proven helpful to changing behaviours of the reluctant Muslim underserved families. The advocacy booklet it prepared was also critical to opening doors to more Muslim institutions and opinion makers to enlist further support.

The results demonstrate that polio eradication is attainable with improved outreach to underserved communities and that the process is not halted by what is commonly misunderstood as a Muslim issue but rather, the need for focused advocacy, social, and community mobilisation, as well as interpersonal communication interventions. "Trust building through those enjoying credibility among the resistant households, seeking out the right communicators for neighbourhood outreach, facilitating door-to-door persuasion with detailed micro-planning, and thorough mapping of families in neighbourhoods that are oft a hybrid of ethnic groups are groundwork that represents no easy path. But it is the type of actions that must be taken in order to achieve change, to ferret out and vaccinate the last child....With a host of religious leaders and influential Muslim figures now on board, the challenge ahead is to maintain the momentum until polio is eradicated."