2021 National Emergency Action Plan - Polio Eradication Initiative, Afghanistan

"Strategic communication continues to play a critical role in polio eradication in Afghanistan."

In 2020, the Afghanistan Polio Eradication Initiative (PEI) had to adapt the operations according to varying state of security and access while responding to twin outbreaks of wild poliovirus type 1 (WPV-1) and circulating vaccine-derived poliovirus type 2 (cVDPV-2). The programme also had to adjust its planning and implementation processes as per the unprecedented situation of the COVID-19 pandemic. From the National Emergency Operation Center (NEOC), Afghanistan, this document represents an update to the National Emergency Action Plan (NEAP) as developed and continually revised by the PEI.

The NEAP was updated for 2021 using a bottom-up consultative approach. The regional EOCs consulted and brainstormed with the provincial and district teams on identifying current challenges, interventions implemented, and key lessons learned in 2020. Based on the deliberations, the group outlined 12 objectives for 2021 (see page 24 of the report), made adjustments to the current strategies and activities, and set forth plans for new interventions that aim to address the remaining challenges. (The summary below will focus on the communication elements of the NEAP 2021.)

Having outlined the epidemiological situation - basically, the number of cases and infected districts have been on the rise since 2018 - the report looks at progress on the objectives set out in the NEAP 2020 (see Related Summaries, below):

• Two out of the eight objectives were met - e.g., to maintain a scenario-based approach to rapidly adjust to any possible/anticipated access and programmatic situations;
• Five were partially met - e.g., to improve community acceptance and demand for vaccination and address vaccine refusals through effective and locally appropriate communication strategies;
• ...and yet the one main objective of stopping ongoing WPV-1 transmission in the South and East regions was not met. The programme has identified the following significant challenges/risks to stopping polio transmission in Afghanistan:
  1. Inaccessibility and inability to perform house-to-house campaigns - Challenges include: very few health facilities in some districts, difficult terrain, long distances, and lack of motivation among communities to walk extended distances for only polio vaccination. Notably, there has been no significant improvement in the access situation (due to anti-government elements - AGE) since late 2019, and more than 35% of the children aged less than five years in the country cannot be reached with the oral polio vaccine (OPV) through house-to-house campaigns. Importantly, in 2020, more than 50% of the target population in the South and West Regions could not be reached through house-to-house campaigns.
  2. Sub-optimal campaign quality - The programme suffers from compromised-quality supplementary immunisation activities (SIAs) - both in accessible and AGE areas - due largely to management and accountability issues.
  3. Refusals - Per the PEI, clustering of refusals in the South and Southeast regions is potentially contributing to already-diluted population immunity due to campaign quality and inaccessibility. The key reasons for refusals continue to be religious objection, campaign fatigue, concerns over contents of the vaccine, and lack of other health and development services, particularly in the marginalised and underserved communities in the South Region. Reports also indicate that use of non-local staff, involvement of young male volunteers, and lack of female vaccinators/social mobilisers add to the challenges around community acceptance for polio vaccine. These issues are exacerbated by community fatigue, multiple door knocks, insufficient staff capacity, and low staff motivation.
  4. High population mobility - Continued cross-border population movement between Pakistan and Afghanistan due strong socio-cultural ties, as well as trade and commercial reasons, constitutes a significant challenge for the programme.
  5. Chronically low routine immunisation coverage in the polio high-risk provinces - Reaching newborns is an operational and communication challenge, with factors like the cultural practice of keeping newborns inside the house for 40 days from birth complicating efforts.
  6. Continued COVID-19 pandemic - Afghanistan is planning for the roll out of COVID-19 vaccine during the course of 2021. The polio programme will have to adjust its activities and strategies as per the evolving polio and COVID-19 epidemiology as well as interventions for the two initiatives.

Despite multiple challenges faced by the polio programme in 2020, the PEI continued its efforts to address vaccine acceptance issues through a wide variety of community engagement and social mobilisation activities. The percentage of refusals has significantly decreased in Kandahar city and Dand in 2020 from 5.2% in January 2020 to 2.5% in January 2021, mainly to a cluster-level approach and a combination of community engagement interventions and improvement in female engagement in the vaccination teams (more than 65% in Kandahar city as of December 2020).

In addition, engagement with health workers, influencers, local authorities, community and religious leaders, and women's associations was undertaken as part of the community mapping to maximise the results of community networks. Meanwhile, polio-branded promotional materials were provided to at-risk communities to enhance their vaccine uptake and promote other relevant health practices such as hygiene. Other targeted community dialogue sessions for mobilisation of community members due to polio outbreaks in those areas were also executed to address any vaccine acceptance issues in a timely manner.

Furthermore, national Islamic Advisory Group (IAG) members have been actively engaging other government partnerships such as Ministry of Haj and Auqaf and Ministry of Education across Afghanistan. Training of national IAG (NIAG) provincial focal points and religious scholars/mullahs was conducted at the national level focusing on vaccination, child health from Islamic perspective, interpersonal communication skills for polio, and routine immunisation promotion. This strategy will continue in 2021.

PEI contends that the use of mass media and social media engagement has been successful in reaching large audiences, especially when influencers have been profiled. The Afghanistan digital engagement strategy that included the launch of the polio website and social media platforms such as Facebook, Twitter, Instagram, and YouTube had a wide reach that was most effective during the COVID-19 response period. Since the launch of the Facebook page in late 2019, an average of 5 million social media users are reached monthly. The digital engagement activities reportedly helped to reach some inaccessible areas and ensure that those communities are consistently receiving polio messages. Other innovations such as use of WhatsApp was also introduced and used by community mobilisers to disseminate key messages within various communities while also tracking rumours and providing appropriate information on the spot.

The report summarises the main communication approaches planned for 2021 NEAP and the suggested strategic shifts, including:

• The continuation of the COVID-19 pandemic and the impact on community engagement activities and possible public fear of infection requires listening and responding to community concerns and continuing to reassure the public through messages and different communication images in relation to COVID-19 safety, in addition to equipping frontline workers (FLWs) with all protective measures.
• The strategic communication programme will need to solidify its base of social evidence through reliable quantitative assessments (e.g., community knowledge and attitudes and trends for refusals) to inform medium- and longer-term strategic decisions. In the meantime, the programme should deepen its understanding of community concerns and possible confounding factors that directly and indirectly influence decisions of caregivers.
• A special communication strategy tailored for the South and South East to overcome existing challenges of access and refusal will be developed. The plan will detail how urban areas and cities such as Kandahar would be reached vs. other inaccessible areas.
• A comprehensive strategic approach for engagement with religious leaders at all levels in and outside Afghanistan will be important to initiate to build influencers' support for the programme, especially in the South.
• The introduction of the novel OPV2 (nOPV2) vaccine will be an important milestone in 2021 and requires that special communication preparedness measures be in place; these measures could influence the scope of other activities to be undertaken. Additionally, the potential use of nOPV2 vaccine (to address wide spread of cVDPV2) will require the development of a crisis communication plan and an advocacy and communication strategy to ensure political buy-in and community acceptance.
• The interdependence and synchronisation among different arms of the communication programme, including crisis and risk communication, advocacy, partnerships, and community engagement, will be crucial to effectively reach desired results in an efficient way.

Pages 44-48 of the report detail the core communication strategies and interventions that are planned for 2021. Lists are provided in the areas of:

• Regional communication plans - e.g., develop new cross border communication materials in coordination with the Pakistan team to ensure synchronised communication materials are displayed at the border;
• Mass media - e.g., create edutainment media products such as mini radio dramas or short videos for social media platforms to engage the community on a variety of issues, including polio and routine immunisation, to influence refusals and instill vaccination as an important behaviour and community practice (social norm);
• Digital engagement - e.g., use state-of-the-art software to analyse social media trends, identify traffic, track rumours and their origin, and design appropriate messages to counter them;
• Crisis communication - e.g., train national and regional EOCs on crisis management;
• Partnerships and advocacy interventions - e.g., continue to build the capacity of journalists to better understand polio and vaccines through media orientation sessions, and enhance their reporting skills on polio and health-related issues;
• Community engagement - e.g., work with elderly women ("grandmothers") who have influence over families, conduct question-and-answer sessions for women's groups, engage polio survivors in community events, conduct polio awareness interventions with Madrasas, among others;
• Religious leaders initiative - e.g., engage with local mullahs to increase awareness and influence vaccination in the communities;
• Communication interventions in inaccessible areas - e.g., develop communication materials tailored to the local audience in consultation with the local leadership;
• Polio communication coordination for efficiency and effectiveness - e.g., ensure that one United Nations Children's Fund (UNICEF) national polio communication staff member is permanently present in the national EOC;
• Training and capacity building - e.g., champion distinguished workers and promote females' participation, such as through World Polio Day events that honour FLWs' efforts and sacrifices; and
• Initiatives under the IAG - e.g., engage at least one faith-based non-governmental organisation (NGO) to support IAG activities in polio eradication and child health.

The report also outlines plans in other areas, such as identification, mapping, and coverage of high-risk mobile populations, and monitoring of various types, including monitoring and evaluation (M&E) of communication. For example, the National EOC M&E working group (WG), with the support of the communication working group (CWG) will define key performance indicators and develop monitoring plan for the SIAs' demand generation activities. Based on this, for example, evaluation of Immunization and Communication Network (ICN) performance in accessible areas like Kandahar City against core SIA outcomes (coverage, missed children, refusals, change in acceptance) will be included in the M&E annual plan. The WG will also develop operational measures to assess community trust in the programme and to assess impact of media/social media messages on household perceptions.

In conclusion: "The programme will continue to monitor the evolving COVID-19 situation in the country and make necessary adjustments and take required mitigating measures to optimally implement the NEAP 2021 strategies and approaches."