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Polio Communications Quarterly UpdateReport to the Independent Monitoring BoardJune 2011

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Contents

Introduction 5

Executive summary 7

Country updates

Afghanistan 11

India 15

Nigeria 19

Pakistan 23

Angola 27

Chad 31

DRC 35

Communication data profiles

Afghanistan 39

India 41

Nigeria 43

Pakistan 45

Angola 47

Chad 49

DRC 51

South Sudan 53

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The March report of the Independent Monitoring Board (IMB) expressed concern that “the GPEI’s focus on the sup-ply of vaccines remains greater than the focus on demand from parents, on understanding and working with the beliefs, structures and needs of communities.” This statement un-derscores the urgent need to strengthen work and focus in this key area if the goal of polio eradication is to be reached.

The past six months represents a period of unprecedented scale up of communication and social mobilization pro-grammes in support of polio eradication. Core staffing for polio communications has almost doubled or trebled in the eight priority countries since last year, and in some coun-tries, for example, in Pakistan, hundreds of social mobilizers are being hired to address social mobilization needs in the highest risk areas. This investment is perhaps long overdue, but now that scaling up is underway, one of the main chal-lenges is managing the high expectations that have inevita-bly been raised. It takes time for new teams to fit into their new roles and responsibilities and to learn the complexities of the social, political and economic contexts in which they find themselves. These are also among the most challeng-ing humanitarian situations to be found anywhere in the world.

Simultaneous with the development of human resource capacity has been the establishment of a new set of global communication indicators. Now teams are working towards building the necessary monitoring systems to collect the re-quired data both at national local level in key high-risk areas. This is no small task given that data-driven systems are not the norm in communication programmes. The indicators are also being tested for their relevance and ability to inform programme adjustments and management decisions. At the field level, systematically collecting social data using existing monitoring systems is not an easy task. Not all field staff are familiar with collecting, interpreting and recording social data, and in many cases where these variables are included in data collection tools, they are incompletely or inappropriately recorded. Frequently, it is clear that the importance of social data is not well understood. Even when it is collected, it is not systematically used to guide strategies and programme in-terventions. It is therefore critical to persuade key stakeholders of its importance, and to ensure it is perceived as a critical component to guide the development of national and subnational GPEI strategies.

In line with some specific points made in the IMB report, we share the view relating to the importance of strategic planning for high-risk groups. This is the main aim of strengthening communication data collection systems. UNICEF has appointed seven technical advisers at headquarters and regional offices to provide ongoing support to countries in all aspects of po-lio communications including strategic planning, data collection and monitoring. A number of rapid assessments are being conducted in the coming months to expand the foundation of evidence available to guide communication programmes.

As the country profiles in this report reveal, there is a need to improve monitoring forms in a number of countries. The sup-port of our key technical partners, particularly WHO and CDC, will be critical in order to make this an operational reality. The issue of refining and even adding to the current communication indicators, as well as ensuring independent verifica-tion, will be considered by the global communication partners in the next meeting.

IntroductionGLOBAL COMMUNICATION INDICATORS

The GPEI communication indicators are designed to help key stakeholders assess and monitor progress towards milestones outlined in the 2010-2012 Strategic Plan.

They provide insights into how well the high risk coun-tries are performing in the areas of communications and social mobilization, measuring performance against a core set of indicators and targets. A programme’s ability to collect and report on standard communications data is key to help guide or refine operational strategies, and to ensure that minimum standards are met.

Using insights and data from the field, this third report seeks to go below top-level management data, to explore areas of particular excellence and developing concern.

Of special note is the fact that the communication indica-tors were modified in the second quarter to incorporate suggestions made by the IMB in its March report. They now examine vaccination refusals more closely in order to capture and comprehend additional social reasons for missed children, beyond refusals. The presentation of indicators has changed to make their meaning clearer.

Finally, but no less important, is the caveat that despite well-defined indicator outcomes and targets, determina-tions of risk have a subjective component that permits judgment of overall risk. Despite meeting a milestone, work may still remain to meet the needs of the country-specific context; classification of risk has therefore been determined using both a quantitative as well as a qualita-tive lens.

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We have taken very seriously the challenge posed by the IMB to move from adopting a “bird’s eye view” to a “worm’s eye view” of realities on the ground. With a global programme of this scale, many creative approaches can be highlighted to present the diverse and innovative insights gleaned from the extensive fieldwork. It seems that the most valuable approach to do so in a concise report is to use the indicators to help the tell the story of how societies and caregivers perceive the Polio Eradication programme, and whether their commitment poses a risk to the success of eradication. We have aimed to do this by supplementing the indicator data with some of the social context and field level experience to explain ‘what’ is happening, in addition to ‘why.’

With respect to this report, we have amended the structure to provide both an overview of the indicators and more in-depth country vignettes that highlight specific successes and concerns. We do acknowledge some identified limitations in the data that is being collected, and we are addressing them. We are actively developing a specialized database for the indicators which was used to create the summary data profiles at the end of this report. We are simultaneously supporting the collection of more in-depth social data in our countries so that in time, each priority country has a system in place for collecting social data and monitoring trends. Finally, we have also developed a brief executive summary which summa-rizes the major communication challenges in the priority countries and areas requiring attention.

GLOBAL POLIOINFO

A specialized database has been developed for the GPEI global communication indicators using the DevInfo platform. An evolution of UNICEF’s ChildInfo database system, DevInfo is a powerful tool for organizing, analyzing and presenting data in a uniform and accessible way to facilitate comparisons within and across countries.

The presentation of data in a visual format – through mapping and compound indicator analysis – facilitates easy identifica-tion of correlations, problems and high risk areas. The ability to access the database – and subsequently the country data profiles - online in future will yield a powerful tool for engag-ing countries and partners in monitoring and understanding performance.

MANAGEMENT

Polio communication staff in place at field level (%)

PROCESS

100

Missed children due to refusal May Risk Assessment (Q2) Level of risk

100

Jan Mar May

No No No

Source: UNICEF monitoring

Mar May

40

4040

100

40

100

In place

Districts that received the funds (%)

Districts that received the funds (#)

In place

4

3

1

1

47

Districts targeted (#)

Jan

40 40

100

100

100

100

100

1

1

1

Source of information on polio campaigns Low

Area%

In placeTarget

Polio communication staff in place at country level (%)


Source: UNICEF monitoringSource: SIA Monitoring (PCA data) 2011

100

Source: Financial Monitoring data 2011

Afghanistan

Regions

Eastern Region

Western Region

South Eastern Region

Target

4

4

1

1

Afghanistan

Low

High

High

High

Polio communication staff in place at country levelPolio communication staff in place at field level

Social mobilization funds are available in high risk areas before SIA'sSocial data is systematically used for communication planning

Missed children due to refusalParents aware of campaign dates

Low

Low

Management

Process

Outcome

Social mobilization funds are available in high risk areas before SIA's

National and sub-national plans incorporate social data (Yes/No)

Provinces/ Districts

Mar Jun

Target

60 45

%In place

75

TargetIn place%

In place

4


%In place

100

100

100

JunArea

100

75

47

1

1

100

1

1

1

1

Southern Region 1

Mar

4 4

In place

4

1

1

Social data is systematically used for communication planning

GLOBAL COMMUNICATION INDICATORSAPRIL ‐ JUNE 2011

Afghanistan Global Communication IndicatorsApril - June 2011

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Executive Summary

What does the data say? Missed children: More work to be doneUnderstanding the reasons why children are missed during immunization campaigns is vital to improve cover-age and reach the most difficult to access. This data is potentially the most interesting and powerful resource to guide polio communication programmes. Hence we have chosen to present it as a “spotlight” in the country profiles that follow this introduction. High risk areas in Afghani-stan, DR Congo and Nigeria continue to miss over 10% of children during campaigns, also called supplementary immunisation activities (SIAs). Areas of Pakistan miss as many as 5-7%, and this does not take into account areas that are consistently inaccessible due to insecurity. India too must take care not to overlook complacency in the high risk states of UP and Bihar, as routine monitoring data (not independent monitoring) shows coverage slip-ping slightly since February, from 98% to 95% in Bihar, and from 93% to 92% in UP.

Understanding refusals and additional social barriers to vaccination

Reflecting on the bigger picture with re-spect to the reasons for missed children, refusal to vaccinate (also referred to as

‘non-compliance’) is not the main reason for missing children in any of the high priority countries. In fact, with the excep-tion of Nigeria and DRC where non-compliance is substantial (over 20% nationally since February), overt refusals on average represent less than 10% of all missed children in the other priority countries.

When refusals are combined with other demand-driven barriers to vaccination, however, social reasons appear to be responsible for approximately a quarter of all missed children in some countries.

In Afghanistan, while refusals have accounted for 3% of all missed children nation-wide since January, data revealed that “other reasons” for missed children - including if a child is newly born, sleeping or sick - account for 18% of all missed chil-dren during the same time period. Together, both of these categories account for 21% of missed children. West Bengal state, in India, shows similar data, where missed children due to refusals and sickness combined accounted for 24% of all missed children in April.

In Pakistan, refusals remain low nationwide (6%), but the current categorization of missed children in the Indepen-dent Monitoring forms makes it difficult to separate out the operational challenges from the underlying social, religious and political factors. We believe that even in ar-eas of Pakistan where the proportion of refusals among missed children is low, social reasons continue to hinder uptake of vaccination, and this is currently not being reflected in the data.

It is for this reason that for the indicator on ‘missed children’, countries have been given classifications of risk that may not seem to directly correspond with their levels of refusals. Some countries, like India and Pakistan, have low levels of refusal nationally, but elevated proportions in high

SOCIAL REASONS FOR MISSED CHILDRENWe have used the term “social reasons for missed chil-dren” frequently throughout this report. By this, we mean the cultural, religious, political and economic reasons that may contribute to a covert resistance to vaccinate. While overt refusal to vaccinate is a clear area of focus for communication efforts, other social reasons for missed children may be more of a barrier to immunization in some contexts, yet may not always be revealed in the current monitoring classifications and methods.

Caregivers refusing OPV - global (%)Feb - May 2011

Source: SIA monitoring data

Refusal to accept OPV0.2 - 5.05.1 - 10.010.1 - 24.0No data

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risk areas need urgent attention (e.g. West Bengal, Balochistan). For all countries, assessment against this indicator has taken into consideration refusals in high risk areas as well as additional social reasons for missed children.

In all countries, the partners should consider how monitoring classifications can better delineate between operational and social reasons for missed children. India is the only country that clearly distinguishes reasons for missed children as those that can be “converted” by communications efforts and those that are more reliant on improving the quality of operations. This approach helps the communications programme focus its efforts, monitor impact and manage expectations.

In addition to this, it is important for the partners to consider how “other reasons” of missed children can be expanded upon or revised in monitoring forms to better explain the reasons why children are missed. The “other reasons” category accounts for a significant proportion of missed children in many countries and could be concealing critical issues the pro-gramme is currently not focusing on.

Campaign awareness: Translating awareness into higher demand

Only India, Nigeria and DRC have reached the optimal target of at least 90% caregivers being aware of polio campaigns. Yet in these three countries, a high level of awareness leads to very different outcomes.

India enjoys an optimal mix of high awareness (90%) and low refusal levels (both overt and covert).

Nigeria and DRC, on the other hand, enjoy high levels of awareness, together with the highest rates of refusal.

This demonstrates the importance of digging deeper into additional cognitive variables that will help translate high awareness and knowl-edge into higher demand for OPV; such as risk perception and threat severity of polio, as well as efficacy of OPV. The programme in both Ni-geria and DRC face complex social contexts, where reasons for refusal are often woven into political statements, demand for other services, or cultural and religious beliefs. As India has shown, translating awareness into behaviour change in these environments will require intensive community engagement and trust. This takes time to accomplish.

Pakistan and Afghanistan have the lowest levels of campaign awareness, together with the highest proportions of chil-dren missed because they are not at home during the visit of the vaccination teams. In areas of insecurity or areas where women are not empowered to be the primary decision makers for vaccination, there may be a correlation between a lack of awareness and a lower probability of mothers opening their door to unknown visitors when vaccinators visit.

Chad is showing national awareness of polio campaigns at 84% but in some areas, including the capital city of N’djamena and districts in the Lac region, awareness is worryingly low, at only 65%. It is in these areas also where the highest pro-portions of children are missed. In Angola national awareness is at 83% for the last round, but levels fluctuate between campaign rounds and within geographic areas, perhaps indicating inconsistent quality of awareness raising efforts. In Sudan, awareness almost meets the target of 90%, but has slipped from 94% in the last round in 2010.

Sources of information: Establishing targets and monitoring efficacy

As countries have not yet established concrete targets for this indicator to reflect successful implementation of the commu-

nication strategy, this data must be approached with some caution. In Angola the main source of information on polio campaigns is currently mass media, which reflects the relative investment of resources in this intervention area. However, interpersonal communication (IPC) as a main source of information has doubled since February and it is not completely clear what interventions have contributed to this substantial increase. In Pakistan too, the main source of information is

Caregivers’ awareness of polio campaignsFebruary - May 2011 (most recent available data for all countries)


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mass media. This is in spite of the fact that there is currently very little mass media investment by UNICEF, partners, or the Government in support of po-lio campaigns. IPC has yet to make a significant mark as a source of informa-tion in areas beyond FATA, which means the new strategy is not yet universally showing impact. However, the relative popularity and influence of Lady Health Workers suggests that the polio pro-gramme should consider opportunities to tap into this network as an additional resource for social mobilization.

In India, the intensive social mobiliza-tion strategy has proven highly effec-tive. Community organizations such as the Anganwadi Workers (AWW) and Social Mobilization Network (SMNet) may be the factors that maintain high social commitment in UP and Bihar. Over 50,000 AWW workers routinely accompany polio workers in Bihar and mobilize local populations while also collecting information about the number of families refusing vaccine. The SMNet, operating in Uttar Pradesh, has over 5,000 community organizers who assist immunization teams and track immuni-zation progress in their catchment areas. Because these workers come from the communities they serve, they have a better understanding of, and credibility among, these populations. It has taken intensive and highly focused work for over seven years to achieve the near universal social commitment we see in these two states today. In West Bengal, by contrast, only 4.7% of people get their information through interpersonal communication despite having 1700 health workers in the field working on social mobilisation. Although this is a substan-tial increase from the 0.5% reported in January, we can conclude that recent investments in increasing the number of field workers has not yet yielded sufficient results.

Nigeria is another excellent example of the polio communication strategy functioning well with the main source of infor-mation about polio campaigns coming through social mobilization, thus reflecting the strategic investments in this area over several years. DRC has the highest IPC figures among the 8 priority countries, with a staggering 97% of caregiv-ers receiving their information through this method. But DRC, too, has high levels of refusal. In order to yield the desired outcomes in social commitment in both these countries the extensive IPC efforts need to be targeted more substantively to address the highly localized reasons for refusal to vaccinate.

The partners in Afghanistan have made commendable progress since the last quarter in including this indicator as part of routine SIA monitoring. In just two campaign rounds, IPC shows an increasing trend in areas where communication activi-ties are taking place. Still, mass media dominates as the main source of information. In a context where social reasons account for almost a quarter of all missed children, more intensive IPC will be critical to overcome these barriers.

Communication risk assessment has been determined using these indicators and targets. In some instances (indicated by a *), the indicator and target has been revised since the last quarterly update to incorporate the IMB’s suggestions. Further revisions will be discussed at the upcoming global communication partner’s meeting.

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Using data: Substantial challenges remain

For communication interventions to be ef-fective, it is important to continuously em-ploy social data to guide planning. At the

same time, the concept of social data is causing some confusion in the field, where inexperienced teams do not always know what kind of data is needed, how to collect it, or how to use it to guide programmes. These indicators will continue to be problematic until greater technical capacity is developed at national and sub national level. For example, many countries self-report that all communication plans are informed by social data. Deeper probing reveals a lack of appropri-ate social data, a lack of in-depth analysis of the data, or a lack of systematic utilization of the data. In some cases, where data exists and is incorporated into plans, the plans remain static. Coordination meetings do not demonstrate that discus-sions have reviewed recent data, indicating the programmes may not be monitoring and responding dynamically enough to emerging social trends. It is for this reason that some countries may appear to deserve a “low” risk assessment classifi-cation based solely on progress against the core indicator, which captures whether or not “national and sub-national plans incorporate social data.” However, in an attempt to make this indicator more sensitive to field realities, we have built in additional indicators behind it that help to determine if these data are actually used to guide programme implementation.

The wording and meaning of this indicator has been slightly revised and expanded in this quarterly update to reflect the systematic use of data for communication planning. The further revision of how this indicator is phrased and monitored will be an important topic of discussion in the upcoming global communication partners meeting.

Capacity: Staff and skills are required

All polio-affected countries have scaled up their human resource capacity in the past six months, and in most cases the new teams are starting to lay the foundations

for stronger programmes, but more time will still be required to show results. Many of the priority countries continue to face recruitment challenges. For example, in security compromised areas like DR Congo, it is difficult to attract staff and consequently only 40% of staff at the national and approximately a quarter at provincial level are in place. Similar chal-lenges confront Pakistan with only 56% capacity at federal level, 60% at province level and 40% at Union Council level in place. In Pakistan, recent plans to scale up have caused performance in this area to look like it has decreased due to an increase in the staffing denominator, but in fact recruitment has progressed. The UNICEF country office has hired a specialised contractor to oversee field recruitment and ensure that the necessary staff are in place by the fourth quarter of 2011. In Nigeria, social mobilization capacity in high risk Local Government Areas (LGAs) and concerns about funding to sustain staff for the longer term are challenging polio communication operations there.

This indicator is somewhat incomplete, as it does not capture the critical necessity of ensuring not only that staff are in place, but that they have the right skills to get the job done. In many countries, communication staff are new to polio eradi-cation, and new to the countries they are working in. Orienting them to their context and to the particular complexities of polio eradication, including the more rigorous evidence-based approach required to achieve the goal, will continue to be a work in progress.

Funding: Disbursement to the field is still a challenge

Reporting on financial resources has improved over the past quarter in all countries except Angola, where no data

is available as the government is supporting polio communication interventions. In general, campaigns are being support-ed by communication interventions in all countries, but serious concerns are flagged in Pakistan where only 40% of High Risk Areas received funds on time, and in South Sudan where only 50% of funds were received on time. Consequently, urgent improvements are needed in this area.

The remainder of the report provides additional information for each high priority country, highlighting successes and best practices from the field. Data profiles appended as an annex show the overall communication risk assessment for each country, and detailed progress against each indicator.

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The contextAfghanistan has reported six wild poliovirus cases so far this year compared to eleven cases during the same period • last year. The date of onset for the most recent case was 8 May.

More than two years have passed since the country’s last reported WPV type 3 case in April 2009. All six type 1 cases • reported this year are from the high risk Southern region.

Polio virus circulation in Afghanistan is sustained due to the persistent transmission within the 13 high risk districts.•

Communicating polioA national communication strategy is in place for 2010 – 2011, but this is currently being revised following more systematic generation of communication data and a new UNICEF team in place. Government commitment is positive and engaged through national and regional coordination mechanisms and meetings. They are now keen to take the lead, and are be-coming increasingly pro-active, particularly around the planning of communication interventions. UNICEF along with GPEI partners welcomes this trend and would like to see them engaged in more visible advocacy events. An advocacy plan for 2011 is being developed as a part of the revised communications strategy.

The communication objectivesTo increase caregiver awareness about polio campaigns to at least 80%.•

To reduce the proportion of missed children due to social reasons (refusal, newborn, sick or sleeping) to less than • 10%.

To ensure the development and implementation of evidence based communication plans in all high risk districts and • clusters.

Spotlight on missed childrenAfghanistan’s GPEI milestone for 2010 was to cover at least 90% of children during a minimum of four supplementary immunization activities in the 13 high risk districts. Citing coverage figures for accessible areas only, three of the 13 High Risk Districts achieved coverage above 90% in the January 2011 campaign; by May, six districts had met this target. How-ever, some districts have demonstrated extremely low levels of coverage, even in accessible areas, such as Shwaikalot, which reported only 20% coverage in the May campaign. In Trinkot, coverage declined from 86% to 70% between March and May. The sharp fluctuation in coverage rates is due primarily to security con-cerns that obstruct access to entire districts or selected clusters. Frequent staff turnover, which affects the quality of implementation and supervision of campaign activities, also adversely affects coverage.

Why are we missing children? So far in 2011, nearly a quarter of missed children can be attributed to social rea-sons based on available data. Refusals (usually for religious or political reasons) are a challenge, but comprised an average of only 4% of all missed children in high risk districts since January. During the same period, “other reasons” (includ-ing if a child is newborn, sleeping or sick) were responsible for approximately 20% of missed children. Similarly, in May 2011, refusals comprised 3% of missed children, and “other reasons” 19% (see graph, right). Further explora-tion is needed to ascertain if the high proportion of children missed due to “other reasons” is a result of lack of knowledge or low perceived need for the vaccine or if it indicates ‘covert refusals’.

Afghanistan


Reasons for missed children HRAs (%)May 2011

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Digging deeperThe 2009 Knowledge, Attitudes and Practices (KAP) study undertaken in four provinces revealed no overt refusals or concerns about OPV safety. However, only one of the sampled provinces (Kandahar) was in the Southern Region, so it is difficult to generalize results to all the high risk districts.

Nonetheless, the study revealed that knowledge of polio is generally quite low: 74% of the 440 respondents had heard of polio, but only 39% could correctly identify paralysis as a sign of the disease. A mere 19% of respondents correctly stated that polio is not curable.

Limited knowledge about polio, coupled with the fact that most people think it is curable, could explain why mothers may not feel it necessary to wake a sleep-ing child for vaccination. Tradition-bound families also believe that babies should not be exposed to the out-doors before their 40th day of life, which means vacci-nating newborns is difficult without gaining access into the homes of these children – a barrier that faces the all-male vaccination teams common in Afghanistan.

Campaign awareness Campaign awareness levels are extremely low in Afghanistan. On average, only 60% of caregivers are aware of campaigns before they take place. Aware-ness levels grew slightly between March and May in areas where communication activities were taking place, from 59% to 63% and are higher in intervention areas than non-intervention areas. However, overall awareness is clearly inadequate and remains far be-low the identified minimum target of 80%.

Moving into actionMass media, primarily radio, remains the largest source of information on campaigns. UNICEF and partners have supported the development of standard radio and TV spots that announce the campaigns and communicate the importance of polio immunization. Additional spots with targeted messages addressing “other reasons” for missed children - such as sick or sleeping children - will be developed prior to future campaigns. These messages will stress vaccine safety during illness and the importance of repeated doses and the need to wake up sleeping children when teams visit the household.

Posters are currently considered unreliable as a com-munication tool to announce the campaigns and cre-ate visibility because they are not distributed widely or in a timely manner at district level. UNICEF is now trying to ensure all posters reach district level at least one week before a campaign to improve their effectiveness.

In the high risk areas of the Southern Region, community mobilizers have been deployed as part of a government-led Po-lio Communication Network (PCN) which receives technical guidance from UNICEF and other partners working on polio communication. Before each campaign, the network engages key community influencers such as community elders, mul-lahs, teachers and community health workers in order to mobilize communities for polio vaccination. Supervision of this network has increased over the last few months, with the result that interpersonal communication is becoming the main source of information on polio in these regions and this is beginning to show a more positive influence on coverage rates. However, there continue to be some intrinsic shortcomings to this approach because all of these influencers are males in a society where male-female interaction is restricted by social norms.

Source: Post-campaign Assessment data

Sources of information in HRAs (%)March - May 2011

Source: Post-campaign Assessment data

Caregivers aware of polio campaigns (%)March - May 2011

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The way forwardSecurity constraints, limited access to women and lack of female vaccinators present the major challenges to polio com-munication activities as well as the overall polio eradication programme in Afghanistan.

Limited availability of social data - and questionable quality of the data that does exist - compounds implementation chal-lenges and makes it difficult to direct communication interventions in the most strategic way. Where monitoring data exists on social reasons for missed children, the figures fluctuate so much from one round to the next, that it is difficult to under-stand if they reflect dynamics occurring in the field or if they are a result of limitations in data quality. UNICEF and partners are in the process of implementing a KAP study in 2011 with the aim of having the results available by the end of the year. In the short-term, while teams are being asked to analyze the reasons for refusal of polio vaccine in more detail, there is also a need to explore and follow up on the reasons for missed children in the “other” categories in order to get a better overview on the barriers to vaccination of these children. Human resources and capacity are an additional constraint.

The Polio Communication Network lacks clear ownership and effective management of its efforts. Short-term government contracts for personnel make it difficult to retain and build capacity. Further, many communication staff working in high risk clusters face frequent transfers, which limits continuity of activities and the ability of these individuals to establish trust and rapport with the community.

The newly established UNICEF communications team is in the process of reviewing all human resources and assess-ing training needs for communication in the field. Post-campaign reviews being systematically conducted following each campaign round have successfully identified additional areas of concern that will need attention. These include the need for communication skills training for national and regional professionals; development of management and supervisory skills for provincial and district level teams; and more systematic use of social data for communication planning at district and cluster level.

A lack of mobility among women and limited TV ownership among lower socio-economic groups make it unsurprising that the 2009 KAP study identified the most effective com-munications media to be community interaction, radio and vaccine teams, respectively.

Engaging mothers for polio vaccinationThe Polio Communication Network (PCN) conducts a range of communication interventions that include house to house visits, community gatherings, and mosque an-nouncements. In Afghanistan, gaining access to women presents one of the major barriers to community engage-ment. The lack of female vaccinators in the PCN is a shortcoming of the programme, as male teams cannot enter a household unless a male is present. This practice makes it difficult to fully engage with mothers who may not be aware of the importance of her child receiving vac-cination.

In 2008, UNICEF established an initiative known as “Women’s Courtyards” in the Eastern region of Afghani-stan to address these culturaly sensitive communication barriers. In clusters where coverage rates are low, female community health workers create a women’s discussion forum within household courtyards. During these sessions, these female health workers meet groups of moth-ers and caregivers including sisters or grandmothers of young children to inform them of immunization dates and explain the importance of vacination. This initiative has not only improved the programme’s ability to engage with women, but also increased the number of female vaccinators, supervisors and field monitors.

Unfortunately, insecurity and cultural barriers have limited the wide replication of women’s courtyards in the Southern Region.However, the programme is currently exploring ways in which this initiative can be employed to increase women’s enagagement and encourage more women to participate in vaccination efforts in the South-ern Region.

Women’s Courtyards, above in Jalalabad, are being considered for expansion into the Southern Region.

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The contextIndia is closer to achieving polio eradication than ever, having reported only one case of wild poliovirus type 1 in How-• rah, West Bengal, on 13 January this year.

The endemic states of Uttar Pradesh (UP) and Bihar have made historic progress with no cases reported in UP since • November 2009 and no cases reported in Bihar since January 2010.

Complacency must be avoided in UP and Bihar, ensuring that children continue to take multiple doses at every pos-• sible opportunity even as cases disappear. In West Bengal, pockets of refusal present risks to the programme and threaten progress.

Communicating polioIndia is about to launch a new communication campaign which should re-ignite fresh enthusiasm for polio at a time when recent success could be threatened by complacency. The highly personalised campaign will target parents in all high risk areas. For the first time, high-risk groups are also being placed as a primary audience for communication messages, with an emphasis on vaccinating migrants and mobile populations. At the community level, the campaign will also engage par-ents in the 107 highest risk blocks in promoting four key behaviours that reduce risk factors for polio and improve overall child health (seeking routine immunization, ensuring exclusive breastfeeding, seeking treatment for diarrhea with ORS and Zinc, and regular hand-washing with soap).

The communication objectivesTo sustain and increase high levels of community and political ownership for the Polio Eradication Programme. •

To reduce the proportion of missed children in high risk areas, focusing on the highest risk groups (underserved mi-• norities, nomads, slum-dwellers, brick kiln and construction workers, etc.).

To reduce the risk of polio in the 107 highest risk blocks of UP and Bihar by promoting four additional protective be-• haviours.

To respond immediately to any outbreak in the non-endemic states, and ensure communication mechanisms are • urgently established.

Where are children being missed in India? Overall, coverage rates in India remain extremely high, with over 98% cover-age in UP and Bihar since February . Coverage in West Bengal is consis-tently lower, with 94.8% coverage since February.

If polio transmission is to be interrupted in India this year there is no room for complacency. While coverage rates and immunity levels remain extremely high in Uttar Pradesh and Bihar, gaps remain in the outbreak areas of West Bengal, particularly among under-served and highly populated pockets in and around Kolkata.

Spotlight on missed childrenIndia is the only country that has classified its data on missed children into those that can be ‘converted’ by communication interventions and those

India

Reasons for missed children - UP (%) April 2011


16

that are more reliant on improving the quality of operations. The ‘convertible’ categories identify children who are missed either because parents overtly refused the vaccine or manifestations that may indicate a more ‘covert’ refusal. Parents citing that the child was sick, or saying that the child was not at home during the campaign and failure to vaccinate these children despite multiple revisits by the vaccination teams may be indicators of covert refusals. Available data suggests that ’convertible’ or social reasons for missed children have been limited to 10-12% of all missed children in UP over the last year. In Bihar, these reasons account for less than 2% of missed children.

In West Bengal, the proportion of children missed due to convert-ible reasons is substantially higher, with children missed due to sickness and refusal accounting for almost a quarter of all missed children during the last round of the emergency response cam-paigns. And although percentages of missed children have been declining since January, convertible categories of missed children have been consistently rising – from a combined figure of 17% in January to 24% in April. This is concerning and requires careful monitoring.

The principal reason for missed children in India however, is population mobility. Eighty-eight per cent of missed children in UP, and 98% in Bihar are missed simply because they are on extended travel out of their home district or state at the time of the campaigns.

Why are we missing children?Understanding refusalsRefusals remain at an all-time low in India, with rates of 1.3% among all missed children in UP and .02% in Bihar during

the last round. Large numbers of clustered refusals - a significant challenge in UP even when overall percent-ages have been low - have also declined. Agra is the only remaining district in UP with high numbers of clustered refusals, estimated at 276 households in April. However, this is a substantial decline from 1000 house-holds with reported refusals in January. This decline is due to a combination of efforts including increased staffing, additional media workshops, and a renewed effort to engage imams and religious influen-cers in the problem areas.

Of most significance and concern for the programme are the on-going pockets of resistance in and around Kolkata, close to the only case reported this year. These populations are made up of tailors and agriculturalists, most of whom come from the minority Muslim popula-tion.

Refusals in West Bengal generally manifest either through overt refusal of the vaccine, or through an

increasing trend of children being reported as sick. Reasons for overt refusal include frustration with government authori-ties related to the lack of development in particular communities; beliefs that Islam does not support immunization; or, that polio vaccine is being administered to sterilize their children and control population.

Reaching high risk groupsHistorically migration has been perceived as more of an operational challenge. However, the communications programme has been working to gain social insights into migration patterns and populations, so that these high-risk groups can be reached effectively with information and vaccination services.

Children of brick kiln workers remain one of the most vulnerable groups to miss out on regular polio vaccination.

Caregivers refusing OPV (%)January - April 2011

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The 2010 KAP study showed that high risk groups (nomads, slum dwellers and migrant laborers) have almost universal awareness of polio including the fact that multiple doses are required to ensure immunity (about 90% in UP and Bihar). However, only 65% felt that missing a dose of OPV was potentially harmful to a child. In addition, there appears to be some confusion about why so many doses are needed among high-risk groups and the general population.

Because the campaign has focused so intensively on a house to house approach, groups that are not at home may not know where to get the vaccine if they are outside their normal environment or if they miss a visit by the vaccination team. Only 53% of high-risk groups were aware of a polio booth in their area, compared to 93% of parents in the general popu-lation in high risk areas. This is due to limited communication interventions targeting these populations in the past, as well as the fact that polio booths are less frequently placed in temporary slum areas, brick kilns or nomadic settlements. In-creasing vaccination among high-risk groups, therefore, must rely on a mix of interventions designed to increase demand for the vaccine, as well as extending vaccine supply among these populations through appropriate outreach efforts.

Campaign AwarenessThe level of campaign awareness differs according to the data source used. The 2010 KAP study showed that 98% of parents in the two endemic states were aware of polio campaigns. Similarly, campaign monitoring also shows high rates of awareness, with 90% of parents in Bihar aware of the campaigns. Monitoring of campaign awareness has just recently been introduced in UP and West Bengal, so data for these two states will be available during the next quarter.

Over 70% of parents in UP cited the Social Mobilization Network as the primary source of information on polio in the 2010 KAP Study. In Bihar, using data from the same source, anganwadi workers were cited as the primary source of informa-tion by 69% of parents, reflecting the extensive training and utilization of anganwadi workers as community mobilizers in Bihar. Although March 2011 monitoring data shows anganwadi workers to be the primary source of information for only 20% of the population, this may not truly reflect declining performance of the programme. Because the anganwadi work-ers visit households throughout the month, they are the primary source of information on polio, but not necessarily for campaign dates. Campaign dates are usually disseminated first through mass media and posters. This data reflects the importance of combining an emphasis on interpersonal communication (IPC) as well as mass media as per the polio com-munication strategy in India.

In West Bengal, following the reported case in January, an emergency outbreak response was initiated. Given that this was outside the two traditional endemic states, the programme lacked the capacity and the network on the ground to ensure a rapid communication response. Partnerships with NGO’s and civil society groups were rapidly forged, provid-ing support to the emergency campaigns. It has taken several months to shift NGOs from working for only a few days between the campaigns to working full-time during the month. Results of this intensified work are beginning to show, with 5% of caregivers in West Bengal now reporting NGO workers as a primary source of information. This is still very low, but substantially higher than the 0.5% reported in January, a result of a scale up from 600 field volunteers to more than 1700. This underscores the intensity of investment required for a scale up of IPC activities.

Moving into actionUP and BiharInterventions targeting high-risk groups rely on a mix of mass media and interpersonal communication. Newly developed TV and radio spots feature messages aimed at high risk groups, encouraging vaccination “wherever you may be”, and di-recting parents to transit booths positioned at railway stations, bus terminals and roads. In Bihar for example, polio videos are continuously played on the LCDs of 29 train stations, aimed to raise awareness about the importance of vaccination, and mobilize parents to the railway booths.

At the community level, high-risk groups are tracked through a network of informers that report to the Social Mobilization Network (SMNet) on population movements. SMNet staff then visit the households to discuss polio and other health is-sues, and provide the names of eligible children to vaccination teams to ensure every last child is listed on microplans and immunized during campaign rounds.

To mitigate the risk of cross-border infection, transit kiosks have been established along known border crossing points between India and Nepal. Banners are draped along the border in both Hindi and Nepali. Polio messages are broadcast across 238 PA systems and personally conveyed through 2,254 transit mobilizers in May. Nepali journalists will join their Indian counterparts for a cross-border media workshop in June.

18

West BengalIn West Bengal, partnerships with the medical community are being strengthened to tackle resistance. Doctors carry great credibility in India, and the programme is enlisting them to act as local influencers to help communicate the benefits of OPV. The Indian Medical Association and West Bengal Department of Paediatrics have combined efforts to produce public advertisements promoting safety and efficacy of OPV, even when a child is sick.

In areas where NGO workers have scaled up their activi-ties, refusals are beginning to show a decline. In Ma-heshtela, one of the highest-risk areas in West Bengal, parents refusing citing sickness of the child (XS) has fallen by 84% from February to May (to 459 houses), while overt refusal (XR) has fallen by 46% (to 1106 houses) in the same period. While this is encouraging progress, much more work is still needed, as the quality of communication interventions is still inconsistent and performance varies from one month to another.

The way forwardMaintaining heightened national commitment to the goal of polio eradication, continuing to focus on high risk groups, and reducing overt and covert resistance in West Bengal are the main communication priorities critical for continued success in India. Preparedness measures to ensure a rapid response in the event of any outbreaks outside UP, Bihar and West Bengal are also being put in place.

New social data planned for 2011 will continue to shed light on behaviours and attitudes of high-risk groups, which will further inform the communication campaign, aimed for launch in the next few months.

The emergency response in West Bengal has stretched available social mobilization funding in India. Identifying re-sources to sustain the scale-up will be critical to intensification of activities in West Bengal as well as consolidating the programme in UP and Bihar and inching towards a polio-free India.

A UNICEF social mobilizer in Howrah, West Bengal, speaks to resistant Muslim fathers and quotes an advertisement by the Indian Medical As-sociation and West Bengal Department of Pediatrics that promotes polio vaccination.

19

The contextNigeria has witnessed a surge of wild poliovirus (WPV) cases in early 2011, following a dramatic 95% reduction of • cases in 2010.

As of 22 June 2011 Nigeria reported a total of 15 WPVs (10 type 1, 5 type 3), triple the number of cases since this • time last year.

Most of the WPV and circulating vaccine-derived poliovirus (cVDPV) cases were detected in the north western and • north eastern parts of the country.

In particular, Borno, Sokoto and Kebbi are facing an alarming situation with eleven WPV and two cVDPV2 cases in • 2011, accounting for approximately 75% of new cases.

Communicating polioAlthough refusals are still high, they are starting to decline. The Intensified Ward Communication Strategy - a highly localized evidence-based communications planning and action approach – is believed to be playing a key role. It uses social data to engage communities and target messages to address specific reasons for non-compliance, including low polio threat perception or doubts about OPV safety and efficacy. In the longer-term, concerns over ensuring adequate resources to sustain polio communication capacity, particularly staffing, may be challenging and could pose a threat to the programme. This must be addressed, if the eradication goal is to be reached.

The communication objectivesTo ensure high-level visibility to national policy makers, associations and partners, through implementing the Abuja • commitments along with improved coordination

To increase community demand for polio vaccination and routine immunization•

To engage national media to profile polio and immunization as a national health priority•

To improve the capacity of front-line communication workers through interpersonal skills training and reward mecha-• nisms

To support sustained engagement of Traditional Leaders to reduce missed children, including engagement of Koranic • schools and local private sector partners

Spotlight on missed childrenThe worrying surge of new polio cases in 2011 may be due to the growing immunity gap in persistently underserved com-munity groups, as well as the small but stubborn pockets of refusals in a few northern states, e.g., Borno, Kebbi, Jigawa, Kano, Zamfara, Sokoto and Yobe. While national polio coverage rates remain consistent from an average of 94% to 93% since the last quarter, the immunity level is rising, with 82% of children having more than 3 doses of OPV, compared to 76% in 2010 according to non-polio AFP data. Routine immunization coverage also remains below 80% nationwide, with even lower coverage in the northern states.

Why are we missing children?Non-compliance still makes up a considerable proportion of all missed children, but it has been on the decline, dropping from 29% in January to 22% in May. This drop coincides with implementation of the “Intensified Ward Communication Strategy”, suggesting that the evidence-based communication planning at Ward and LGA level is bearing results. The new

Nigeria

20

approach isolates high risk wards based on campaign performance in-dicators and prescribes a package of communication interventions that rely heavily on interpersonal contacts. This strategy receives planning, implementation and monitoring support from the federal team, but rely upon Local Government Area (LGA) level teams for implementation.

Despite the declining trend in refusals, states like Borno, Kano, and Yobe continue to face extremely high proportion of refusals (over 26% of all missed children) and large numbers of LGAs with persistent clustering of non-compliant households (over 300 in some areas). Re-fusal rates in Zamfara have remained consistent at 16% of all missed children since January.

Understanding refusalsAccording to March data, the main reasons for non-compliance are “no reason” (23%), “no felt need” (23%), and “too many rounds”- (12%). When combined with “no caregiver consent” (13%), it accounts for another quarter. Interestingly “religious” (9%) and “political” (5%) reasons for refusals appear less significant. A more in-depth analysis will be required to understand what this really means and how communication interventions need to be adjusted.

In addition, overt refusals are not the only threat to missing children. Sixty eight percent of missed children are reported to be due to “child absent”, of which a proportion may be a reflection of covert refusal and may be combined with other operational factors.

Digging deeper

It is important for the communications effort to convince caregivers that OPV is critical for their children’s health, and also to provide them with the basic knowledge of campaign dates and vaccine eligibility so that children will be kept at home and available when the vaccination teams visit their homes. However, more focus is also needed to expand the reach of special teams and ensure that they are dispatched to immunize children at playgrounds, markets, social events, and in other areas where they might be during campaign activities. Often, “child not available” simply means that the children are playing with their friends in the neighborhood and could be reached with a bit more effort. In this complex environment, communications and operations need to work together to maximize vaccination opportunities and address both the supply and demand side barriers.

Campaign awarenessAlmost all caregivers are aware of polio campaigns in advance of the campaigns. Campaign awareness is 98% on average, both in high risk and non-high risk states.

Since January 2011, information conveyed through inter-personal communication has increased nationally from 35% to 42% on average, making it the lead source of in-formation on campaign dates in all areas. IPC as the main source of information is substantially greater in high risk areas (HRAs), at 49%, compared to 31% in non HRAs, (see graph) where focused community engagement is be-ing carried out, further demonstrating the positive effect of the Intensified Ward Communication Strategy.

Caregivers aware of polio campaigns in HRAs (%)January- March 2011

“Many people offer no real explanation for refusing even if teams actually bother to ask why. They often simply ignore the question until the team goes away.” - STOP team volunteer


Nigerian caregivers refusing OPVMarch 2011.


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Going beyond awarenessIt is clear from the continued high non-compliance rates, however, that although awareness of campaign dates is neces-sary, it cannot increase vaccination coverage on its own without the other forms of persuasion.

Parents who refuse the vaccine often express a low-felt need for the vaccine, and see little value in repeated doses. In some cases, non-compliance has little to do with perceptions about the polio programme itself, but is used as a tool to le-verage access to other health services, as demonstrated by one community in Zamfara (see panel). This is why UNICEF has intensified the scale and substance of community dialogues and meetings in high risk states, aiming to transform high levels of knowledge and awareness into greater programme commitment and acceptance of OPV.

Moving into actionIn high risk states, teams are carrying out a series of targeted communication interventions during the campaigns, and since last May, communication activities were initiated between rounds to ensure a more consistent presence in these areas. About 95% of communication plans are now making use of social data, and the impact is starting to show. The package of interventions may include community dialogues led by traditional leaders (see panel), compound meetings with women led by women’s groups, Majigi film showings with structured dialogue, town crier involvement and campaign “flag offs”’ intended to mobilize entire communities to support campaigns. Increasingly, efforts are being made to engage faith-based mobilizers and members from state associations of polio victims in behavior change and mobilization efforts.

March SIA monitoring data also revealed that 52% of the decisions for immunization were taken by fathers, whereas only 31% were taken by the mothers.

To further engage and empower women to understand the importance for vaccinating their children, FOMWAN (a coalition of Muslim women’s organizations) and other women’s groups have been working in five very high risk states to organize compound meetings and Majigi shows specifically targeted at women. UNICEF is also addressing the limited IPC skills of vaccinators and town criers through enhanced training and materials. Development of a new set of Information, Educa-tion and Communication (IEC) materials in local languages is under way to make community and compound meetings more effective.

The way forwardThere are strong indications that persistent non-compliance in high risk areas is starting to decrease as a result of the Intensified Ward Communication Strategy, but it is clear that Nigeria’s challenges must be tackled through multiple ap-proaches. While interpersonal approaches are making headway in building trust and actively engaging communities, higher level advocacy and visibility is key for generating renewed commitment for polio eradication goals among state and local level officials at this critical time.

In order to support ongoing face-to-face efforts, the National Social Mobilisation Working Group will launch a mass media campaign by September to increase programme visibility. Messages delivered by local champions and advocates will be

Caregivers’ main source of information in HRAs (%)January - March 2011

Caregivers’ main source of information in non-HRAs (%)January - March 2011

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systematically broadcast on TV and radio. This is in response to results from the 2010 Knowledge, Attitudes and Practices (KAP) study showed electronic media to be the most trusted source of polio information.

Finally it is important to note that the lack of sufficient funding is affecting the communication programme’s ability to recruit and retain long-term human resources to develop and carry out plans. At the national and zonal level, the programme faces long-term funding shortages for many key positions. At the state and LGA level, funding constraints are preventing the recruitment of the full cadre of field staff required to implement the programme, with only two thirds of the required communication staff in place. While immediate funding has been secured to keep people in positions, the longer term funding situation remains insecure and unpredictable.

“We will collaborate!”

Community dialogues resolve vaccine rejection in Bungudu LGA, Zamfara

Gidan Mallamai settlement is a hard to reach area 23 miles away from Bungudu metropolitan area, accessible by a small, dirt road, littered with pot-holes. This community rejected oral polio vaccine en masse in the last two immuni-zation rounds, despite multiple town announce-ments. The polio vaccination teams, it seems, had failed to convince caregivers about the safety of OPV.

The District Head of these settlements, Alhaji Garba Umar, was finally approached and a community dialogue was scheduled involving all fathers within Gidan Mallamai.

During the community dialogue, teams begin to understand that in fact, it was the non-distribu-tion of promised mosquito nets that led to the block rejection, leaving more than 130 children unvaccinated.

A salient feature of community dialogues is the local leaders who are also key influencers. They have a deep impact on the minds and hearts of their people and if properly and adequately sensitized, can play a key role in achieving the goal of reaching all eligible children with vaccination.

“At the start, I was not fully sensitized on how to answer questions by the caregivers and to tell them why polio vaccina-tion was critical for their children. We now realize our role in taking all health interventions to our communities. I find myself empowered enough to convince caregivers on my own,“ says Alhaji Garba Umar.

After the community dialogue with fathers, the female State Health Educator along with the UNICEF consultant enters the women’s compound to address a group of thirty women.

“We rejected the polio vaccine before, but now we will collaborate. We will collaborate!,” shout the women in one voice after a brief dialogue with the State Health Educator.

Community dialogues focus on decreasing non-compliance in Zamfara State

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The contextTransmission of type-1 wild poliovirus continues in at least four provinces, with 51 new cases reported in 23 districts • and agencies within FATA/KP, Balochistan, Sindh and Gilgit Baltistan.

Since November 2010, no type-3 cases have been reported nationwide. The province of Punjab, home to 60% of • Pakistan’s population, has also been polio-free for more than 6 months, though virus has recently been identified through environmental sampling.

Operational challenges in insecure areas are a major obstacle. In addition, even in accessible areas, such as in • Sindh, poor campaign quality and limited coverage of communication interventions continue to be major barriers to success.

Communicating polioThe crafting of a new national communication strategy is a key opportunity to generate momentum and excitement for the President’s Plan. In addition to reenergizing mass media approaches, it involves a massive scaling up of social mobilizers in high risk areas at district, Union Council and community levels. They will engage some of the most persistently high-risk communities, and tackle stubborn pockets of resistance, which continue to threaten polio eradication efforts.

The communication objectivesTo communicate the aims of the President’s Plan•

To engage the population, the key decision makers, and the media, actively in polio eradication•

To mobilize civil society to play an active role, particularly in mobilizing communities at high risk•

To reduce refusals, and to engage high risk groups with data driven communication and social mobilization strategies •

Spotlight on missed childrenAlthough campaigns reportedly reach the vast majority of eligible children in Pakistan in acces-sible areas, the most commonly cited reason for non-vaccination is child absence when the vacci-nation team visits. A deeper understanding of the reason for absence is urgently required to help tease out whether this is an operational or a com-munications problem, or a combination of both.

Data shows that the highest proportion of missed children is in FATA, where insecurity is the major challenge. However, in terms of sheer numbers, the most missed children in accessible areas are in Sindh, with between 173,000 to 260,695 chil-dren who go unprotected during each SIA.

Pakistan

These informed Pashto-speaking mothers have brought their children to a local health center, where they will be vaccinated. Reaching out to Pashto-speaking communities will be critical to increasing coverage among high risk groups.

Karachi, the capital of Sindh, is now the only mega-city in the world where polio is endemic.

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Why are we missing children?The communication partners are trying to better understand why children are being missed in Pakistan. The current Independent Monitoring forms makes it difficult to separate out the operational challenges from the underlying social, religious and political factors.

For example, a child missed due to “child absent,” could sim-ply mean that the child was not at home when the vaccina-tion team visited. However it could also hide a covert refusal, for example if the parents don’t admit that the child is there. In such cases it’s critical to dig deeper into the underlying reasons for non-vaccination.

Although refusals amount to only a very small percentage of the total children missed (6% on average), clusters of refus-als can present a much more serious problem for the pro-gramme if they are not urgently addressed.

For example, although Nowshera reported a zero-refusal rate at district level in May using independent monitoring data. However, deeper analysis uncovers a significant number of clusters where households refused en masse (see map).

Signs of progressAlthough areas such as Balochistan and Sindh continue to record refusal rates that are above the national av-erage, some progress is being made. For example in Balochistan, refusals have declined from an alarming 23% in January down to 11% in May. During the same period, the Balochistan district commissioners and local security forces have taken greater responsibility for polio eradica-tion activities, adopting more intensive community inter-ventions to reduce refusals at district level, in line with the guidelines in the National Emergency Action Plan.

Digging deeper But despite progress, the high rate of refusal in the border area with Afghanistan is still a concern, and linkages need to be ex-plored further. Spin Boldak, one of Afghanistan’s13 high risk dis-tricts on the border with Baluchistan, has been consistently report-ing the highest rates of refusal in the country: an alarming 47% in December that declined to 17% since January 2011.

Balochistan is strongly linked to Afghanistan’s southern districts by geography (see map) as well as strong social and cultural ties. A highly mobile population travels frequently between these areas, and research shows that refusals are largely based on safety concerns about OPV, combined with anti-Western sentiments and religious beliefs.

Ongoing virus transmission in Sindh, Balochistan and high risk districts of Afghanistan underscores the need to develop a focused communication strategy to reach high risk groups in these ar-

Caregivers refusing OPV (%)January - May 2011

Refusals in Nowshera district (FATA)May 2011

Data source: Refusal log book by DHCSO

The highest proportion of refusals is consistently on the Pakistan-Afghanistan border (May 2011 data).

Caregivers’ refusal of OPV


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eas. To date, 84% of wild polio virus cases in Pakistan in 2011 have been reported in the highly mobile Pashto-speaking population. A better understanding of the social patterns and links between these communities living on opposite sides of the border will strengthen the design and implementation of communication activities. A rapid qualitative assessment is currently underway to better understand what’s working and what’s not in terms of reaching these high risk groups. Data will be available by September 2011.

Campaign awarenessIt is important to be reminded that not all communication challenges are complex. The areas with highest refusal rates, in Balochistan and Sindh, also record the lowest levels of awareness of campaigns, as well as the highest percentages of children “not available” when the vaccination teams visit. If lack of campaign awareness is a significant factor in the child not being home when the teams visit, then this could be relatively easy to address.

In insecure areas like Balochistan and FATA, if caretakers are not aware of campaign dates, it is less likely that they will open their door to unknown visi-tors. Therefore every opportunity must be made to ensure that caretakers open the door when a vaccination team arrives. Ironically, awareness levels are highest in FATA, where immunization access is most compromised by insecurity, yet even there awareness levels are showing decline, a trend that must urgently be reversed.

Moving into ActionPakistan is currently scaling up its mass media strategy to publicize cam-paign dates more widely across the country through TV and radio to address the issues of low general awareness. The number of social mobilization workers at Union Council and community levels will also be substantially increased so that the team’s arrival dates - specific to each locality based on the microplan - can be communicated to families, who will be encouraged to keep children at home on these days.

Encouragingly since January 2011, the new communication strategy has influenced a shift in the main sources of information about campaign dates in FATA. As a result, interpersonal communication (IPC) has risen from 4% to 48%, and mass media from 22% to 40% as acknowledged information sources. This can be attributed, in part, to increased efforts to build trust with religious and tribal leaders though Jirga’s, or community dialogues (see box on next page).

COMNet

A new 3-tiered social mobilization network, will assign 100 District Health Communication Support Officers (DHC-SO) to the 33 highest risk districts; 72 of these positions are already filled. These district level staff will support and assist the District Task Force in planning and implementing district-wide communica-tion and social mobilization activities, and supervise and coordinate the work of 400 newly-established Union Coun-cil Communications Officers (UCO’s). The UCO’s will be placed in 270 Union Councils at highest risk for persistent transmission, refusal clusters and nomadic/mobile populations. Half will fo-cus on engaging the general population, and the other half will focus exclusively on high risk populations. The existing 82 social mobilizers at community level will nearly double to 160, for deployment in areas of persistent refusal, and where the most intense, focused mobilization is required.

Caregivers’ main source of information - FATAJanuary - May 2011

Caregivers aware of polio campaigns (%)March and May 2011

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The way forwardThe dual ability to halt transmission in non-high risk areas and deliver intensive high-quality campaigns in the highest risk districts is vital if transmission if Pakistan is to interrupt transmission. Effective communications and social mobilization are key. Priorities include raising awareness of key issues, such as the effectiveness and safety of OPV and campaign dates, as well as raising community demand levels for the vaccine. Recruiting fully qualified communication specialists to serve in some of the most challenging and security compromised areas will be a critical element for success.

Community dialogue fosters social change

In Urmar Mera, Peshawar district, local Imam Maulana Humayun refused to immunize his children. Despite typically high accep-tance rates, the entire village followed the Imam’s example and refused immunization. A Jirga, or meeting of religious and tribal leaders, was held at which the Imam was able to express his concerns. Attending Inter-religious Council on Health (IRCH) workers engaged the group in dialogue on the value of immu-nization in light of Islamic teaching, and they shared numerous fatwas already issued in favor of vaccination. They also invited the Imam to inaugurate the next immunization round, to which he agreed, immunizing his daughter before the entire village. He fol-lowed with a speech expressing his satisfaction that the vaccine was both safe and effective. After the Imam answered further questions, the community took the step of requesting routine im-munization services.

A Jirga with religious and tribal leaders held in FATA offers an op-portunity to discuss concerns about polio vaccination and enables elders to participate more actively in the programme.

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Angola

The contextThe total number of cases for 2011 remains four, compared to ten for the same period last year. •

Circulation of an imported wild poliovirus has persisted for more than 12 months. •

Transmission is highly concentrated in the Luanda-Benguela corridor along the Atlantic coast. •

Localized communication planning, guided by social data and adequate technical capacity are the key priorities to • improve the polio communication effort here.

Communicating polioA communication strategy has been drafted at the national level, combining mass media with the use of interpersonal net-works, including religious institutions and Sobas (traditional ruling bodies). However, a number of constraints such as low staff capacity and inadequacies in the availability of social data and monitoring mechanisms have limited the implementa-tion of this strategy.

The communication objectivesRaise national awareness about the importance of polio eradication and create demand through information, advo-• cacy and social marketing strategies.

Contribute to strengthening the demand for routine immunization in the 164 municipalities.•

Promote and advocate actions to strengthen sanitation, hand washing, hygiene, water and food as key supportive • measures for the eradication of poliomyelitis in Angola.

Spotlight on missed childrenIndependent post-campaign monitoring identified an average of 8% of missed children nationwide following the April 2011 campaign. Luanda has consistently higher rates of missed children estimated at about 10%, but many provinces have shown improved coverage in the last few months. This is due to a number of reasons, including increased involvement by administrative and political authorities and increased local planning, as opposed to the centralized approach that had been taking place during the previous years. Timely financing of local operations and coordinated support by the govern-ment and partners has also contributed to better implementation of campaigns.

Why are we missing children?Refusal to vaccinate is not a significant barrier to immunization in Angola, where the average rate of refusal among missed children has been about 3% nationwide from February to April 2011. In areas where refusal proportions seem very high (Lunda Norte, Lunda Sul), the total number of missed children are very small. Thus, the high proportion of refusals in these areas is not a cause for major concern.

The major causes of non-vaccination derived from independent monitoring data are ‘absent children’ (39%), ‘no vaccination teams visiting households’ (32%), and ‘other’ reasons (27%). Although ‘no vaccination teams visiting households’ is clearly an op-erational shortcoming in campaign implementation, the categories ‘absent children’ and ‘other’ reasons need to be further unpacked and understood to determine if they are due to social reasons - and consequently resolvable through appropriate com-munication - or are due to operational shortcomings.

Reasons for missed children (%)April 2011


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Low motivationThe quality of the campaigns is largely determined by the motivation of staff at all levels, but particularly the volunteer community vaccinators. Vaccinators and mobilizers are not paid, so it is difficult to regulate systematic standards of qual-ity and ensure accountability. Houses are inconsistently visited or visited at times inconvenient for the families or when children are likely to be outside their home. This, coupled with the fact that these houses are seldom revisited, results in a large number of missed children. Although low staff motivation is currently not seen as a priority area for polio communica-tions per se, it has an impact on how the communication programme is implemented since in most areas, the vaccinators serve as the mobilizers.

Reaching high risk groupsAnother key gap that affects the design of polio communication interventions is the inability to identify children who are most likely to be missed during campaigns. While greater community participation is now seen through increased num-bers of vaccinators, these individuals are volunteers and are usually students and young people. The volunteers change frequently from round to round, which leads to a lack of continuity and experience among field staff, in addition to a lack of in-depth knowledge about communities among the vaccinators and mobilizers. Social mapping is also not utilized and consequently high risk groups are not identified either through innate, or empirical, methods.

Campaign awarenessAwareness of campaign dates is moderately high, at 83% nationally, with higher knowledge in Luanda (90%), but very low knowledge in the high risk province of Benguala (which has slipped drastically from 92% in February to 63% in April).

Interpersonal communication as a major source of information has more than doubled in the country since February, but this is essentially due to progress in Lunda Norte, where there is high government commitment and visibility, as well as active mobilization undertaken by social mobilizers and vaccinators.

In Luanda, where awareness is highest, communication through interpersonal communication methods is low – at 8% in April. Mass media is the overwhelming source of information here, due largely to a successful TV and radio campaign implemented by the government and partners.

Moving into actionThe polio partners have been advocating with government to take measures to improve the quality of vaccinator’s and mobilizer’s performance, which is critical for both operational and communication activities. Provincial and local leaders have been encouraged to improve the recruitment process in selecting field staff, and to provide training opportunities and materials for them once they have been recruited. Communication training has been incorporated into the vaccinator train-ing curriculum. This may have contributed to the national increase in interpersonal communication (IPC) as a main source of information. The increased selection of volunteers from within communities has also led to increased retention of staff from one round to the next.

Caregivers aware of polio campaigns (%)February - April 2011

Caregivers’ main source of informationFebruary – April 2011

29

Renewed ties have also been established with church and traditional leaders through a church alliance covenant. Churches are used to help organize ad-ditional vaccination efforts during congregations or events. While these activi-ties can potentially have a great impact, they are often organized with little advance planning and monitoring.

A majority of the funds for communication activities are provided by the gov-ernment and this is indeed commendable. However, there have been chal-lenges in timely disbursement of these funds to the peripheral levels. Recent anecdotal evidence suggests that funds to cover the operational and social mobilization activities for campaigns are now being disbursed to the districts on time. But no formal report has been provided by the Government, although the Coordinating Committee has requested it.

The way forwardLack of social data is perhaps one of the most significant constraints within the polio communication programme in Angola. Little, if any, social data is currently available, meaning the programme is potentially working “blind” in the design of strategies, messages, and interventions. The lack of data impacts not only the overall strategy and identification of high risk groups, but also limits the programme’s basic ability to identify all the potential social reasons and de-mand side barriers for missed children during campaigns.

For example, independent monitoring forms in Angola attribute “other” rea-sons for missed children to mean a lack of campaign awareness on the part of the child’s mother or caregiver. However, a mother’s lack of awareness is not a sufficient reason to explain why children are missed. It is not clear whether the mother’s lack of awareness of the campaign resulted in her not opening the door for vaccinators when they visited or if it resulted in her not being home when the vaccinators visited or if it resulted in her overtly refusing vaccine for her children. It is strongly recommended that the partners reconsider how they collect and interpret data in the “other” sub-category of missed children.

A rapid assessment to understand who the highest risk groups are must be urgently conducted and feed into the national strategy. Data should be collected with sufficient sensitivity at district and sub-district level, in order to guide the develop-ment of social maps and localized plans.

These activities, together with improved recruitment, training and motivation of vaccinators could contribute to vastly im-proved and more strategic communication interventions in Angola.

A baby receives a dose of oral polio vaccine at the Vila da Paz Health Centre in Cacuaco Municipality, on the outskirts of Luanda, the capital.

31

The contextChad now has the highest number of reported polio cases of any country in the world in 2011. At the time of this re-• port, Chad has 78 confirmed wild poliovirus cases (75 type-1 and 3 type- 3), all genetically linked to Nigerian strains.

Transmission is widespread, despite 11 Supplementary Immunization Activities in the past 12 months.•

Frequent cross border travel with Nigeria and other neighboring countries puts Chad at continued risk for re-impor-• tation of wild polio virus. With the ongoing outbreak, Chad presents a major threat to other countries, particularly its neighbors.

Communicating polioPoor quality campaign activities continue to lead to large pockets of missed children and therefore low population im-munity to polio virus. Village chiefs are key to the success of polio communication and social mobilization, but they are currently conducting these activities with little or no training. Innovative ways of improving the visibility of the programme are desperately needed. Efforts are being made to intensify interpersonal communications at grass roots levels by forging partnerships with local associations, NGOs and religious entities to engage parents, particularly in districts with high refus-als. New media partnerships are being forged to intensify radio and television messages. Telephone companies are also sending campaign messages to 1.2 million users by SMS.

The communication objectivesIncrease the percentage of caregivers aware of dates in advance of polio campaigns to more than 85% in 13 high risk • districts

Reduce the number of children not vaccinated due to child absence in high risk areas •

Contribute to reducing the number of children missed due to teams not visiting•

Monitor and reduce refusal rates •

Spotlight on missed childrenOperationally, Chad faces immense challenges in all areas of the programme including in surveillance and in the delivery of vaccine. The most recent type-3 cases in Eastern Chad are genetically linked to a case 18 months earlier, pointing to significant gaps in timely detection of cases. In addition, routine immunization coverage is very low, estimated at 10% fully immunized children according to the 2010 Multi Indicator Cluster Survey (MICS). Further, access to health care services is limited due to poor infrastructure, geographic and financial barriers and compounded by insecurity in many parts of the country.

Approximately 11% of children are missed nationwide following polio cam-paigns, with higher figures in Hadjer Lamis (as high as 14% in the March campaign), Salamat (22%, March SIA) and N’Djamena (with consistently high rates of 26% and 22% in February and March). With this kind of poor perfor-mance in even the relatively easy to access capital city, it is clearly an uphill battle to stop wild poliovirus transmission in the country.

Chad

Source: SIA monitoring

Parents refusing OPV in ChadFebruary 2011


32

Why are we missing children?According to available data, ‘Child not available’ and ‘no team visiting’ remain the main reasons for missed children in Chad. In the April sub-national polio campaigns, which missed around 6% of children, approximately 70% of these were due to child absence, with only 4% of children missed due to refusal.

Although refusal of vaccine is not a widespread problem in Chad, there are areas where it needs to be addressed. Re-fusals do play a more significant role in Logone Oriental, Chari Baguirmi, and in some parts of urban N’Djamena. Dur-ing a Social Research Evaluation assessment in the region of Logone Occidental, respondents reported that children are missed during campaigns mostly because parents do not understand the importance of immunization, and many do not know the dates of the campaigns, thus sending children out for chores or for play. This results in the children being ‘absent’ from the home when the teams visit. In addition to low awareness of polio eradication efforts, circulating rumors about polio vaccination result in misconceptions regarding the vaccine including beliefs that the vaccine may be harmful to their children.

Active refusalsAvailable data show major fluctuations in refusals in various provinces. The most consistent and substantial threat of refusals is in the capital city of N’Djamena, where recent wild poliovirus cases have been detected. Although refusals have declined from 26% of all missed children in the January SIAs to only 8% in March, additional communication indicators continue to be low here (e.g. awareness), indicating continued challenges of communication even in urban areas.

Low motivationVaccinator performance is another factor in missing children. Poor behavior and scruffy appearance, as well as reports that they are in a hurry to finish the job and consequently do not immunize all children when they visit houses are some of the explanations for poor perfor-mance If children are not home when they arrive, teams are unlikely to revisit, explaining the high rates of children missed to “child unavailable” (over 60% in most regions during the last campaign).

Campaign awarenessThe lack of a mass media infrastructure, combined with a largely illiterate, traditional rural population, mean that it is a challenge to raise awareness and persuade communi-ties to immunize their children in Chad.

Although national awareness is tentatively reported at 84%, trend data will be important to demonstrate real and consistent progress in this area. Progress has also not

been consistent across all areas. In LAC Region, Bol District, where there is less media access, only 45% of parents were aware of campaigns prior to vaccinators arriving at their house in May. With similar awareness figures in other high risk areas, it is not surprising that there is a high proportion of missed children and that most children are missed due to children not being at home when vaccinators visited their household.

Signs of progressWhile awareness levels need improvement, they are not low everywhere. In Batha, for example, awareness was 98% in February; in Dar Sila awareness was 88% for the same month. As a result of more targeted messages and improved campaign materials, polio eradication is beginning to achieve greater vis-ibility and reach in select areas.

© U

NIC

EF

Cha

d/20

11/E

stev

e

Caregivers’ awareness and missed children (%)February 2011

33

Moving into actionEfforts to reach out to inter-sectoral line ministries and civic organizations have resulted in several innovative partnerships. Public buses now carry polio messages as they travel along major and minor roadways. Through partnerships with two major cell phone operators, Tigo and Airtel, it has been possible to reach cell phone subscribers with text messages that inform them of campaign dates and the need to immunize their children. These text messages are reported as the second most cited source of information in some high risk areas of the south, according to independent monitoring data.

In May, an open-air concert on behalf of the GPEI and featuring key Chadian celebrities drew an audi-ence of over 5,000 attendees and received exten-sive media coverage and help to spread the word on polio eradication activities (see panel, right).

Radio jingles have also been aired through local stations prior to campaigns.

The Chad polio team has helped local administra-tive and health authorities to develop 18 Regional Communication Plans based on available cam-paign and social data. They are now refining strate-gies for specific populations including nomads, populations at high risk or populations in difficult to access areas and those living in N’Djamena.

At the regional level, the capacity in communication has recently been scaled up. There are 26 social mobilization con-sultants in place performing polio communication functions. These social mobilizers are managed by five international im-munization officers. The next step would be to reinforce capacity at the grass roots level by better utilization of community agents and other civil society structures. Partnerships with local organizations such as the Chadian Red Cross, the Scouts and Guides of Chad, CELIAF (a women’s association), and religious leaders/entities have been forged to promote house to house mobilization. This should help raise awareness and knowledge levels in the high risk areas.

The way forwardAs stipulated in the Emergency Plan, the programme is working to achieve the following results:

Increase immunization coverage by at least 10% in 32 high-risk health districts•

Reduce the proportion of unvaccinated children during SIAs in monitored districts to less than 10%•

Increase the proportion of parents informed before each campaign from 80% to over 85%•

The social mobilization sub-committee has recommended the following key activities to increase the level of awareness of parents:

Organize official launches of each campaign at the national and regional levels •

Redefine key messages for the campaign •

Intensify mass media coverage and large public events•

Build capacity of journalists and other media managers on EPI, polio immunization and AFP surveillance•

Intensify the supervision of field teams and ensure that community mobilization is integrated in the daily evaluations of • the 32 high risk health districts

“Two drops, that’s all!”Chadian artists sing about Polio

Some of Chad’s most prominent artists came together last month for ‘Deux Gouttes’, a concert held in the capital to raise aware-ness about polio and increase the visibility of the country’s polio immunization campaign.

‘Deux Gouttes’ – or ‘Two Drops’ – refers to the dose of oral polio vaccine that can help prevent this dangerous childhood disease.

Throughout the concert, representatives of UNICEF, the Govern-ment of Chad, the World Health Organization and the Chadian Red Cross, as well as the performers themselves, informed the audience about the state of the epidemic. They also stressed the critical importance of immunizing all children under the age of five.

Approximately 9,000 people of all ages attended the concert, which took place in Fest’Afrika, the largest public events venue in N’Djamena. Audience members sang and danced to a line-up of artists representing Chad’s rich cultural and musical diversity.

The artists also performed ‘Deux Gouttes, Stop Polio’, a song composed specially for the concert. As vocalist Audrey Linda Shey sang, directly addressing mothers in the crowd: “If we’re going to kick polio out of Chad, dear moms, open the doors of your house to vaccinating agents. Two drops, that’s all, stop polio!”

34

Better mechanisms are urgently needed to evaluate campaigns, and to avoid repeated date changes, delays in transfer of funds for operational costs, and inadequate follow up in addressing known gaps identified during previous campaigns. Bottlenecks in releasing funds from the central and regional levels must be urgently addressed.

Currently, UNICEF and its partners still lack sufficient human and financial resources to scale up communication activities.

35

Democratic Republic of Congo

The contextDRC has reported 56 type 1 cases this year, almost all of which are in the western provinces neighboring Angola and • Congo Brazzaville. Kinshasa, Bandundu, and Bas Congo has reported 95% of all cases in the country

Despite multiple campaigns this year, and improved awareness, the poliovirus continues to spread in at least four • provinces. Only Kasai Occidental seems to have stabilized.

Refusals remain high at an average of 16%, but have the ability to sporadically increase due to political and develop-• mental issues. Increased localized ownership, planning and engagement is urgently needed to solidify support for the programme

Communicating polioDRC’s humanitarian emergency presents significant challenges for communicating about polio. Continued insecurity in many areas, on-going population movements and displacement, and diverse social groups mean tailored solutions are required at local levels. Social mobilizers are creating high levels of awareness about polio campaigns, but are unable to engage with communities in much depth due to lack of capacity and highly centralized planning systems that don’t facilitate local planning. Social mapping followed by targeted interventions aimed at resistant communities and influential opinion leaders has led to substantial declines in refusal rates in some areas. This kind of community engagement needs urgent scale-up in order to tackle the complex challenges in DRC.

The communication objectivesReduce refusals to less than 5% of all missed children in high risk areas•

Increase campaign awareness levels to over 90% nationally and in high risk areas•

Communication microplans are developed in 2/3 of high risk health zones and incorporate social data•

Political, traditional and religious leaders – particularly those opposing OPV – demonstrate support for the programme • and for polio vaccination in general

Spotlight on missed childrenWhile administrative data continues to report consistently high vaccination rates, independent monitoring shows an aver-age of 93% coverage during the first four months of 2011. More children are being missed in Katanga and Equateur, where geographic access is a challenge. Access constraints led to almost half of Equateur’s population (48%) being missed during the April round. Moreover, OPV coverage through routine immunisation remains low and estimated at 58% according to the 2010 Multi indicator Cluster Survey (UNICEF). While the National Emergency plan rightly focuses on strengthening routine immunization in addition to SIA’s, improving campaign quality will be essential for virus interruption this year.

Why are we missing children?The main reason for missing children in DRC is because the child is not available when vaccinators visit. “Other” rea-sons are the second highest reason for children being missed. This needs to be further unpacked as it is not clear if this characterizes a social or operational reason for non-vaccination. Refusals in DRC are high, at a national average of 16%, with extremely high rates of up to 29% in Kinshasa. Religious beliefs frequently contribute to refusal, but politically fuelled rumors have been on the rise since February, and can lead to dramatic spikes in refusals.

36

Understanding refusalsReligious beliefs are often cited as a reason for refusal in DRC. On the surface, concerns seem to be about fears of multiple doses weakening children, OPV causing sterilization, or a general belief that only God - not vaccine - can protect children from disease. But deeper analysis is required to understand the true reasons behind refusals in some com-munities.

While religious beliefs undoubtedly play a prominent role in some care-giver’s refusal to vaccinate, rumours are sometimes fuelled by religious leaders who have other motives for discrediting the vaccine. In Katan-ga, for example - where refusals are consistently above 10% - the dis-trict of Kalemi has had persistent clusters of refusal for several rounds. Here, religious leaders and clusters of households banded together to resist polio vaccination, citing various different reasons. Deeper probing revealed that refusals were organized as a collective demonstration of dissatisfaction with political and social developments in the region.

In the nearby province of Bandundu, where refusals have also been consistently high and rising (from 11% in April to 17% in May), a vet-erinary vaccination campaign took place at the same time as the polio campaign, which led to burgeoning rumours that the same vaccine was being used in both campaigns (e.g. “the same vaccine is used for both people and chickens.”). It is not clear if these were genuine concerns or rumours fuelled to discredit existing political leaders. In these circumstances, the ability to dig deeper and understand the real cause of refusal is critical to converting refusals. This is difficult in areas where community engagement approaches are not in place to debunk myths.

Campaign awarenessCaregiver awareness of polio campaigns has been fairly consistent, hovering around 83% for the last few months. Preliminary May data shows a rise for the first time to 91%, but this needs to be confirmed following official data publi-cation.

Interpersonal communication is reported as the main source of information by a staggering 97% of caregivers; the high-est figure reported among the 8 priority countries. This is largely due to information provided by town criers, who are effective at announcing the campaign dates, but do not nec-essarily engage parents in dialogue. The social mobilization committee members – those organizing activities on the ground – are unpaid volunteers who are minimally reim-bursed for expenses and lack technical capacity. Limited mobility due to difficult terrain and lack of adequate vehicles (that comply with UN security standards) especially in Kasi Occidental further inhibits community engagement. Thus, while the high awareness figures are undoubtedly positive, the achievement should be levelled with an understanding of the ground realities which may explain such high levels of awareness and commensurately high levels of refusals.

Moving into actionIn response to a sharp increase in refusals after the February SNID, a series of communication interventions were car-ried out to engage religious groups in stronghold areas of resistance. Most notable is a social mapping of refusals in the Kalemi district, mentioned above. All religious groups were identified, together with high risk populations living in the area. In-depth meetings were held with all the groups, and their concerns documented and discussed in detail over the course of several weeks.

This resulted in 7 of 9 resistant religious groups accepting vaccination, with some even signing “petitions of engagement”

Data source: Independent monitoring

Caregivers’ main source of information (%)January - April 2011

Data source: Independent monitoring

Congolese caregivers refusing OPVApril 2011


37

that documented their commitment to advocating for OPV vaccination amongst their religious followers. Similar activities are now being implemented in Bas Congol, Kasai Orientale, Bandundo, Kinshasa and Sud-Kivu to tackle persistent refusals in these areas.

The five big religious entities in the country have also estab-lished a formal partnership with UNICEF, and have enlisted their leaders to promote polio vaccination. In the April NIDs, the church represented a main source of information for 17% of families, the 4th biggest source of information after mobilizers, radio and vaccinators.

A further challenge faced by the polio communication teams in DRC was the change in the target age group to be vaccinated. As a result of the 2010 ourbreak in the neighbouring Republic of Congo which affected older age groups, the entire popula-tion was targeted in the affected areas rather than the usual practice of targeting children aged below five years during polio campaigns. Similarly, older cases were reported in certain pockets in DRC, e.g., Kinshasa. This led to campaigns targeting the entire populations in these areas and consequently communication messages had to be adapted to ensure high demand for these campaigns.

Four press conferences with the Minister of Health and GPEI partners were held this quarter, and special TV reports have frequently featured notable figures being vaccinated in order to instill trust and confidence in the vaccine.

Media communication has been designed to respond to the enduring rumours and explain the need for frequent cam-paigns. Interviews with polio victims have been aired nationally in order to maintain heightened risk perception.

The way forwardThe kind of community engagement on-going in Kalemie is vital, but scaling this up will be a challenge. DRC has a cen-tralized communication planning structure, which constrains opportunities to respond to specific local issues. Provincial plans call for uniform activities and standardized communication resources, which often do not correspond to, or address, needs on the ground. High risk areas are identified at health zone and health area level, which serve upwards of 30,000 people, and social characteristics are not considered when establishing criteria for these high risk areas. Micro-level plan-ning and implementation that takes into account the varied social groups of the country – many of whom have opposing belief systems - will be critical in order to tackle the highly localized challenges in this vast and diverse country.

In order to maximize local planning, it will be important to understand who and where the chronically missed children are, and what behavioural and social barriers prevent them from being reached. The lack of empirical data available to ex-plain the diverse social practices and beliefs in DRC is another area that requires urgent attention. Plans are in place to conduct a rapid assessment exploring reasons for missed children during polio SIA’s. In addition to this, a KAP or other in-depth social study is urgently needed.

Lack of capacity in the area of monitoring and evaluation is now being addressed. In addition, additional communication staff is being recruited at the sub national level to further enhance polio communication capacity.

Following social mapping in Kalemie district, refusals among all missed children dropped from 59% in February to 16.7% in April.

A mass media campaign featuring notable national and international figures receiving vaccination has been implemented to promote adult vaccination and instil trust in the safety of OPV

39

AfghanistanGlobal Communication IndicatorsApril - June 2011

MANAGEMENT


PROCESS

100


100

Jan Mar May

No No No


Mar May

40

4040

100

40

100

In place



In place

4

3

1

1

47


Jan

40 40

100

100

100

100

100

1

1

1


Area%

In placeTarget



Source: UNICEF monitoringSource: SIA Monitoring (PCA data) 2011

100


Afghanistan

Regions

Eastern Region

Western Region

South Eastern Region

Target

4

4

1

1

Afghanistan

Low

High

High

High




Low

Low

Management

Process

Outcome



Provinces/ Districts

Mar Jun

Target

60 45

%In place

75

TargetIn place%

In place

4


%In place

100

100

100

JunArea

100

75

47

1

1

100

1

1

1

1

Southern Region 1

Mar

4 4

In place

4

1

1



40

OUTCOME

Parents aware of campaign dates (%)

43

Source: *KAP 2010 / **PCA data

Mass media Health service worker Interpersonal source

Afghanistan 36 71 65 13 41 37 - 41

Area *Jan **Mar **May

Missed children due to refusal (%)May

2

3

*Jan **Mar **May *Jan **Mar **May

Source of information on polio campaigns (%)

Source: Post Campaign Assessment data 2011

28

23

13

9

3

5

11

16

66

81

5

15

Kandahar City

Spin Boldak

Panjwayee

Maiwand

5

10

16

20

7

8

15

15

5

11

14

13

Source: SIA Monitoring (PCA data) 2011

Percentage of missed ChildrenMayMarJanArea

Afghanistan

HRAs (Southern Region)

Area Jan Mar4 3

5 5

4

9

8

10

7

13

Source: Post Campaign Assessment data 2011

May

Afghanistan

Reasons for missed children (%)

Shah Wali Kot

Bust (Lashkar Gah)

Nada ali

Nawzad

Musaqala

Sangin

Dehrawod

Trinkot

Shahid hassas

Source: SIA Monitoring (PCA data) 2011

6

6

29

26

13

5

5

5 0

5

Trinkot

Shahid hassas

0

5

14

10

0

0

0

2

0

13

120

24

11

0.2

1

1

12

22

22

4

8

Nawzad

Musaqala

Sangin

Dehrawod

5

0

4

1

17

0

0

17

0

1

7

0

0

2

1

14

0

4

14

0

2

1

Afghanistan

HRAs (Southern Region)

Kandahar City

Spin Boldak

Panjwayee

Maiwand

Shah Wali Kot

Bust (Lashkar Gah)

Nada ali

Refusal to accept OPV,

2

Noteam/team did not visit,

31

Child not available, 51

Other reasons, 16

59.362.7

59.3 56.7

0

20

40

60

80

100

Mar May Mar MayHRAs with

communications inputHRAs without

communications input

National data

41

Global Communication IndicatorsApril - June 2011

India

MANAGEMENT


PROCESS


Missed children due to refusal Apr Risk Assessment (Q2) Level of risk

Source: UNICEF monitoringSource: SIA Monitoring 2011

86


Delhi

Bihar

West Bengal

Target

14

7

7

-

In place


In place

12


In place

Mar

6

6

1

7

UP


64

India

Low

Moderate

Moderate

Low




Low

Low

Management

Process

Outcome


Area

100

Jan

Yes

5224

%In place



Bihar

UP

JunArea Mar

Source: UNICEF monitoring 2011

May

64

- 1

63

100

5330

7

14

6

1468

5500

1021 70

95

12

1778

63

100

86

94

6

-

Jan

100

63

100

86

West Bengal 783 780 99 1778

32753

Mar May

Yes Yes

100

Source: UNICEF monitoring 2011



63

%In place

94

Mar Jun

Target%

In place Target

86

100

34638

5686

Target In place%

In place


42

OUTCOME


Source: *KAP 2010 / **SMNet monitoring data / ***NPSP Booth data


-

-

West Bengal 11.6 13.1 - 36.6 36.2 - 8.1 10 -

Bihar 48.3 42.0 - 69.1 19.6 - 29.9 4.0

UP 54.4 - - 30.0 - - 70.0 -

Source: SIA Monitoring data 2011


1.8

1.7

0.3

4.8

Area Jan Mar May

-

-

-

-6 9

India

Jan Mar May Jan Mar May

Bihar

West Bengal

Area Mar AprIndia 1.10 1.09

UP 1.88 1.29

West Bengal

1.5

1.7

0.4

5.3

Source: Independent Monitoring data 2011

Source: SIA Monitoring data 2011

Percentage of missed ChildrenMayAprMarArea

-

UP


Source: SMNet data*/ KAP 2010**


Bihar

West BengalUttar Pradesh

April

India

-

-

- Bihar 0.04 0.02

Refusal to

acceptOPV, 1

Child Sick, 3

Child not

home, 8

House Locked,

13

Child out of

Village, 75

9890

9589

98

0

20

40

60

80

100

Jan-Feb Mar Jan-Feb Mar Jan-Feb Mar

Bihar CMC Areas* Bihar Non CMC Areas* UP CMC Areas**

Refusal to accept

OPV, 0.02

Child not home, 0.29

House Locked,

28.9

Otherreasons,

0.45Child out of Village, 70.3

Refusal to

acceptOPV, 9

Child Sick, 15

Child not

home, 21

House Locked,

55

* *

*

** **

** *

*

****

43


MANAGEMENT

Polio communication staff in place at field level (%)Polio communication staff in place at country level (%)JunArea Mar

%In place

Mar Jun

Target

Nigeria

Moderate

Low

High

Low




Low

Low

Management

Process

Outcome


Area%

In placeTarget

Source: UNICEF monitoringSource: SIA monitoring data 2011

Target In placeIn place In place%

In place%

In place TargetIn place


PROCESS




HR LGAs90

98

86157

58


84

12

100


Source: UNICEF financial monitoring and reporting matrix

Nigeria

States

157

58


72


Jan

12 12

100

142

58

86 72 8490141

57

100

Jan Mar May

Yes Yes Yes

Feb Mar

12

1212

100


Source: Reporting matrix of UNICEF SocMob consultatant

Nigeria

44

OUTCOME

Parents aware of campaign dates (%) Reasons for missed children (%)

Source: SIA monitoring data 2011

Mar

Nigeria

-


Percentage of missed ChildrenMayMarFebArea Area Feb Mar

Nigeria (HR States) 25 2277


-Nigeria (HR States)


22

No team/team did not visit,

10Child not available,

68

Other reasons,

0

National data

9897 97

98

80

100

Feb Mar Feb Mar

HR states Non HR states

26 29 -

29 38 -

19 16 -

19 - -

13 9 -

- 1 -

21 15 -

30 29 -

33 32 -

Jigawa

Kaduna

Kano

Katsina

Kebbi

Plateau

Sokoto

Yobe

Zamfara

6

7

6

-

-

-

-

-

-

-

-

-

-

- Borno 21 26


Katsina

Kebbi

Plateau

Sokoto

Yobe

Zamfara

-

-

Bauchi

Borno

FCT

Gombe

5

5

8

10

-

14

5

Bauchi 41 26

FCT

5

4

-

3



3

4

4

-

4

5

6

5

-

-

4

4

Jigawa

Kaduna

Kano

Area Nov-Jan Feb Mar

-

-

-

-

5 -

Gombe - 22

Nov-Jan Feb Mar Nov-Jan Feb Mar

44 49

National 22 17 20 7 5 6 35 43

31



Non High Risk Areas 23 15 24 8 8 12 32 30

42

49High Risk Areas 17 18 17 3 3 3

45


Pakistan

MANAGEMENT


PROCESS





High Risk Districts

High Risk Areas (UCs)

JunArea

100

100

100

560

2

1

33

82

2

1

2

2

FATA 1

Source of information on polio campaigns Moderate

Area%

In placeTarget

Mar

3


15

%In place

71

Mar Jun

Target

74

-

71

%In place

96

-

Target

67

33

60

Pakistan

High

High

Moderate

High




High

High

Management

Process

Outcome

Source: UNICEF monitoringSource: PCM Coverage data 2011

100


Islamabad

Balochistan

Khyber Pakhtunwa

Punjab

Sindh

Target

6

2

1

1

In place


%In place


-

In placeIn place

6

2

1

3

3

6

May

Yes

20


1


Mar May

5

2

In place

2

1

1

10

40

Jan Mar

No Yes

71


Jan

5 5

67

100

100

100

50

3

0

0

1



46

OUTCOME


Source: KAP 2010/ Post campaign monitoring data *


Source: PCM Social Mobilization data 2011

May

Pakistan

Source: PCM Coverage data 2011


3

5

7 FATA

3

4

6

4

1

4

3 1

Percentage of missed ChildrenMayMarJanArea

4

Mar5

16

Pakistan

Jan Mar * May *



4

4

7

3

2

4

2

3

Balochistan

FATA

Khyber Pakhtunwa

Punjab

Sindh

Pakistan 7

Balochistan 23


6

11

2

5

2

8

4 5

Punjab 4 2

Sindh 7 7

Area Jan

Khyber Pakhtunwa

Jan Mar * May *Pakistan 29 - - 24 - - 7 - -

Area Jan Mar * May *

10

FATA 22 17 40 21 10 8 4 32 48

Balochistan 33 27 24 20 24 21 7 10

Khyber Pakhtunwa 22 - - 21 - - 4 -

12


Sindh 38 25 27 39 17 16 6 18

-

Punjab 29 - - 18 - - 10 - -


6


37


Other reasons, 6

National data

5143

7469

5046

52 5349 49

5853

0

20

40

60

80

100

Mar May Mar May Mar May Mar May Mar May Mar May

Balochistan FATA Sindh DHSCODistricts

NONDHSCODistricts

Pakistan

47


Angola

MANAGEMENT


PROCESS




821 100

%In place

100

-

-

%In place

-

-

TargetIn placeIn place

2

2

Luanda

Benguela

JunArea

100

100

10366

821

100

Lunda Norte 2

Mar

8

2

Source: PAV microplan

Mar Jun

Target

-

100

Angola

High

High

Low

Moderate




Low

Low

Management

Process

Outcome

8


Area%

In placeTarget

-

Source: PAV microplan


100

Luanda

Benguela

Lunda Sul

Target

8

2

2

2

100 10366


-

2

215 215

- -

100

100

100 2

JanNational and sub-national plans incorporate social data (Yes/No)

- - - 89 89

Source:


Lunda Norte

Lunda Sul

- - -

100


Mar May

-

--

Districts that received the funds (%) -

In placeIn place

8

2

2

2


-

%In place

-

Jan Mar May

No No No


48

OUTCOME



Apr

Angola

6

10

8 Benguela 1 0

5 4

4 3

3

0

Source: Independent monitoring data 2011

6

9

Percentage of missed ChildrenAprMarFebArea Feb Mar

7

Missed children due to refusal (%)Apr

7

6

2

Source: SIA monitoring data 2011 * Actual number of missed children due to refusal is extremely low.

2

0


Area

Lunda Norte

Feb Mar Apr

Luanda

Benguela

Lunda Norte

Lunda Sul

Angola

Luanda

2

3

2

Angola

Lunda Sul 4 21*

7

36

Area Feb Mar Apr

13

57*

5 4

Angola 47 41 43 17 25 30 15 36

Feb Mar Apr


4

8

Benguela 35 37 34 20 31 27 20 35 38

Luanda 80 77 75 11 35 27 8 11

-

Lunda Norte 59 56 54 13 19 41 15 34



32

Lunda Sul 48 0 0 31 - - 26 -


2


32

Child not available,

39

Other reasons,

27

National data

88 90

76

63

74 71

82 83

0

20

40

60

80

100

Mar Apr Mar Apr Mar Apr Mar Apr

Luanda Benguela Lunda Norte Angola

49


MANAGEMENT

Polio communication staff in place at field level (%)Polio communication staff in place at country level (%)JunArea Mar

%In place

Mar Jun

Target%

In place TargetIn place

Chad

High

Moderate

Low

Moderate




High

High

Management

Process

Outcome

Source of information on polio campaigns High

Area%

In placeTarget

Source: UNICEF monitoringSource: SIA monitoring data

Target In placeIn place In place%

In place


PROCESS




Regional100 --


-120 52 43.3-

Districts that received the funds (#) 8

100


Source: Financial monitoring data 2011

Chad 21


21 -


Mar

13 8

-

100

Jan Mar May

- - -

Source:

Apr May

22

2213

100

Chad

50

OUTCOME

Parents aware of campaign dates (%) Feb

No data


Source: SIA Monitoring 2011

Chad

Percentage of missed ChildrenMayAprMarArea

Source:

Missed children due to refusal (%)AprArea Feb Mar

78

79

98

78

88

81

64

68

66

80

84

77

80

71

80

71

81

0 20 40 60 80 100

National

Barh El Gazal

Batha

Chari Baguirmi

Dar Sila

Guera

Hadjer Lamis

Kanem

Lac

Logone Occidental

Mandoul

Mayo Kebbi Est

Moyen Chari

N'Djamena

Ouaddai

Tandjile

Wadi Fira

-

5---

9--------

-------02

0-10-3-

0.46

-

----

2870-0

2858-2

108--

--------

---115-16

-13

-

96--

--

---

-


ChadBarh El GazalBathaChari BaguirmiDar SilaGueraHadjer LamisKanemLacLogone Occidental

- ChadBarh El GazalBatha

-- 31011

Mandoul

7-8

102214

-1010

-------74

-

Mayo Kebbi EstMayo Kebbi OuestMoyen ChariN'DjamenaOuaddai

KanemLacLogone OccidentalLogone OrientalMandoul

722

Logone Oriental

1017

5--

May

Chari BaguirmiDar SilaGueraHadjer Lamis

Mayo Kebbi EstMayo Kebbi OuestMoyen ChariN'DjamenaOuaddaiSalamatTandjileWadi Fira



SalamatTandjileWadi Fira

422

-11

713

-

Source: KAP 2010


Chad 26 - - - - - - -

Area Feb Mar May Feb Mar May Feb Mar

51


Democratic Republic of Congo

MANAGEMENT


PROCESS





High Risk Districts

JunArea

100

100

15

Mar

5

19


%In place

33

Target

5 5

%In place

100

Target

5


In place

Democratic Republic of the Congo

Moderate

Moderate

High

Low




High

High

Management

Process

Outcome


Area Mar Jun

2

100




Kinshasa

Provinces

Target

2

5

In place


In place

2

5

40


Jan

7 2

26

2

In place

5

%In place

%In placeTarget

82

Jan Mar May

- No Yes


Mar May

11

97

100



52

OUTCOME


Source: Social Mobilization data 2011

Apr

Democratic Republic of the Congo

48

7

3 Western Kasai 9 10

Source: WHO Independent Monitoring 2011


Percentage of missed ChildrenAprMarFebArea

9

3

7

Kinshasa

Western Kasai

Eastern Kasai

Bandundu

Orientale

-

-

-

-

-

-

-

5

11

12

14

10South Kivu

59

-

9

-

Equateur 13 -

Kinshasa - 16

19

Eastern Kasai

Mar

Bas Congo

Katanga

Maniema

North Kivu



-

Bas Congo

Katanga

Maniema

North Kivu

South Kivu

7

-

-

-

-

-

-

19

12

11

7

Jan-Feb Apr Jan-Feb Apr

Missed children due to refusal (%)Apr

9

30

3

12

11

9

- -

Bandundu 23 -

Orientale - -

-

Area Feb


Mass media Health service worker Interpersonal sourceJan-Feb Apr

Dem.Rep.Congo 33 45 5 19 87 97

Area

Dem.Rep.Congo 7 - 10 Dem.Rep.Congo 27 - 16

-

Equateur -

12

5

-

-

24

12

-

3

-

7


16


11


Other reasons,

18

National data

878887

9753

8495

929393

6693

8490

979594

9083

7981

8983

91

0 20 40 60 80 100

AprMayApr

MayApr

MayApr

MayApr

MayApr

MayApr

MayApr

MayApr

MayApr

MayApr

MayApr

May

Katanga

Bas Congo

Bandundu

Eastern Kasai

Western Kasai

Kinshasas

Equateur

Maniema

Dem. Rep. Congo

Orientale

South Kivu

North Kivu

53


South Sudan

MANAGEMENT


PROCESS





Districts or HRA's

JunArea

100

100

N/A

Mar

2

10


%In place

N/A

Target

N/A N/A

%In place

N/A

Target

N/A


In place

South Sudan

High

High

Low

Moderate




Low

Low

Management

Process

Outcome


Area Mar Jun

6

60


South Sudan

Source: UNICEF monitoringSource: WHO PCE data 2011


National

States

Target

2

10

In place


In place

2

10

100


Feb

10 10

100

2

In place

10

%In place

%In placeTarget

-

Jan Mar June

N/A Yes No


Mar May

-

-4

40

Missed children due to refusal Feb Risk Assessment (Q2) Level of risk


54

OUTCOME


-Warrap - 24 - - 38 - - 39

-EES - 18 - - - - - 42 -NBeG - 5 - - 7 - - 75

- 30 - - 34 -Jonglei - 20 - - 37 - - 20 -

-

-----

NBeG - 8EES - 6Warrap - -


Source: WHO SIA Monitoring data 2011

Feb

--

- WBeG - 5

------

WES - 14Jonglei -

CES

Source: WHO SIA PCE data 2011

Source: WHO PCE data 2011

Percentage of missed ChildrenMayFebJanArea

--

Lakes

WBeGUpper NileUnity

WES - 4Jonglei - 9NBeG - 4EES -

Area Jan FebSouth Sudan - 5Lakes - 9

Upper Nile

65

1235

Source: WHO PCE data 2011


--

---

7Warrap - 3CES - 7

4

- 3

-

Area Jan Feb May


--

---

- 1Unity - 1

South Sudan

Jan Feb May Jan Feb MaySouth Sudan - 25 - - 32 - - 25 -

-

CES - 61 - - 27 - - 17 -

Lakes - 23 - - 26 - - 18WES - 24

-WBeG - 9 - - 40 - - 25

-

Source: WHO PCE Data 2011


Unity - 35 - - 25 - - 26

-Upper Nile - 29 - - 4 - - 25


5


26


Other reasons, 26

National data

8784

9592

988685

6399

919190

9587

9190

10096

8987

9487

0 20 40 60 80 100 120

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Dec

Feb

Lakes

WES

Jonglei

NBeG

EES

Warrap

CES

WBeG

Upper Nile

Unity

South Sudan

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