Polio Communication Review - India 2008: Bihar, Patna Report

This report details the findings of the polio consultant team sent to Patna City to review community mobilisation, vaccine avoidance, and resistance in urban areas of Patna, India. The team focused on community involvement, Xr (households missed because they refused immunisation) conversion, and influencer movement with vaccinator teams via:

1. Analysis of community mobilisation coordinator (CMC)-level supplemental immunisation activity (SIA) data.
2. Meetings with identified converted Xr, non-converted Xr, and Xo (child out of home) families.
3. Analysis of supervisor reports.
4. Meeting with key influencers (Mosque Imam/Madarsa in charge, etc.).

The team began with briefings from the United Nations Children's Fund (UNICEF) and partners from the Patna Urban district. The team held in-depth meetings with polio programme staff and key influencers in Patna City, Gulzarbagh, and Rajendranagar. Household discussions were conducted at the doorstep and in the homes of several "hard core" Xr and Xo households.

The team was asked to review a set of indicators and gauged progress against the following:

1. Percentage of teams with influencer assigned.
2. Percentage of teams with influencer moving with them.
3. Percentage of influencers replaced after 1, 2, 3 SIAs (as an indication of quality of the influencer, assuming that poor influencers are replaced and that quality in terms of community familiarity is developed through an enduring presence).
4. Percentage Xr remaining in influencer versus non-influencer areas.
5. Percentage of community members who can name influencers.
6. Percentage of converted Xr households who claim influencer had an impact on their decision to accept oral polio vaccine (OPV).
7. Inter-round phase: how often do supervisor and influencer meetings occur (every 2, 3, 4, 5+ rounds).
8. Stakeholders' meetings planned and held: Imam, Moazzin/Mutawalli, Madarsa mdohtamim/Mazar.

The team identified the following key issues:

The CMC deployment is relatively new and is functioning very well, considering its newness.

• The structure is in place;
• Influencers have been identified and are moving with teams;
• Between-round meetings and household visits are being carried out at an increasing rate; and
• X generation (the number of missed households generated in a particular round of vaccination) and X remaining (the missed households after the round, including return visits to those households) are decreasing in CMC areas (478 Xr households (HH) generated and 257 remaining in April 2008 and 423 Xr HH generated and 195 remaining in July).

However, as in all-new programmes, there are gaps to fill and refinements to make to improve upon these strong beginnings. The team feels these fall into the following main areas:

1. Improving reporting and tracking of influencer performance and impact data. Influencers are critical to the success of the programme in further reducing the numbers of X generation and X remaining households and building a solid and ongoing base of support for polio immunisation in the community. It is therefore important to pay special attention to their performance and impact by tracking and analysing these indicators over time.
2. Tracking outcomes for communication plan activities. Communication plan activities are presently planned with dates, descriptions, and expected outcomes; however, the actual outcome of these activities is not tracked beyond whether they happened or not. This leaves a gap in terms of understanding the quality of these activities: what was discussed, what was the agenda, were there decisions or agreements reached, is follow up required, etc. The team does not want to suggest adding a lot of extra reporting, but, rather, that simple indicators tracking the outcome of relevant activities on each CMC's communication plan be tracked.
3. Creating polio-branded information, education, and communication (IEC) materials in Urdu. There is a gap in polio-branded materials designed to reach the underserved that should be filled.
4. Deepening interpersonal communication (IPC) training for block mobilisation coordinators (BMCs), block underserved coordinators (BUCs), and CMCs and adding extra support for visits to "hard-core" resistant households. Many of the remaining Xr households are now classified as "hard-core" refusals. These households are particularly resistant to conversion; many have been visited by BMCs, BUCs, CMCs, and more than one influencer - without effect. Dealing with such persistent refusal can be difficult, and high-level IPC skills are required. It is considered important to ensure that ongoing and possibly specialised training is provided to enable BMCs, BUCs, CMCs, and some influencers to appropriately deal with such households. Beyond this it may be necessary to establish specialised teams with carefully chosen influencers to visit these households.
5. Linking the programme to activities such as health camps in order to associate it with efforts to improve access to health services. Refusals were often associated with a lack of health services. Initiatives like health camps, which reach out to underserved communities with free health services including immunisation, are one way of visibly providing at least occasional access to improved levels of service. Closely associating the BMCs, BUCs, and CMCs with such initiatives and encouraging that they happen as frequently as possible may be a way to break some of the resistance associated with lack of health services for the underserved.
6. Developing a better understanding of the growth of Xo households. The question of the increase of Xo households was raised during presentations to the team during the Patna briefing. The team was unable to analyse this question but found that Xo households are becoming an increasing problem and can be as difficult to convert as refusal households. Given the potential for this to become a major source of X remaining households, the team feels it should be a priority to analyse the reasons for households becoming Xo and developing particular strategies to deal with this issue. 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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