Annual Report 2014: Polio Eradication Initiative, Afghanistan

"Polio program is now at a cross roads to...achieve the objective of stopping the circulation of wild polio virus in Afghanistan....In order to do so all polio partners have started working hand in hand with communities and all influential layers of society in order to reach out to all children of under-5 years of age to assure the vaccination." - Dr. Ferozuddin Feroz, Minister of Public Health

From the Expanded Program on Immunization (EPI), Ministry of Public Health, Afghanistan, this report narrates the epidemiological situation with regard to polio, the status of supplementary immunisation activities (SIAs), acute flaccid paralysis (AFP) surveillance, and communication activities implemented in 2014 and planned for 2015. As reported here, 2014 was full of challenges; the number of cases and infected districts doubled (to 28 cases and 19 infected districts) compared to the previous year, and chronically missed children continued to be problem - both in accessible and hard-to-reach, security-compromised areas.

It is noted that communication and social mobilisation activities were conducted at national and regional levels, with focus on low-performing districts (LPDs). Communication has shifted focus from raising awareness to community demand and ownership through community elders, mullahs, and teachers in the selected LPDs. "Engaging religious authorities was an important community-level activity of social mobilizers. District Communications Officers facilitated over 4,200 Mosque announcements mostly aired on Fridays....More than 3,550 community meetings were held in Kandahar and Helmand involving elders, teachers, and mullahs. Sensitization and orientation sessions were held targeting religious leaders, mullahs, community representatives and only in Kandahar a total of 14,880 people were included while in Helmand it was over 9,000."

The polio eradication service delivery structure in Afghanistan is outlined, as is the polio virus epidemiology in that country. The report describes the key programme areas of the National Emergency Action Plan (NEAP) during 2014 - interventions that were described as strengthened by high-level political commitment, ownership, and oversight and translated down to sub-national levels with a sense of urgency and quality. The NEAP also focuses on reaching children in LPDs and conflict/security-affected areas, which has involved communication approaches such as local-level access negotiation through access negotiators from within the communities and training on interpersonal communication (IPC), which is integrated into lesson plans to focus on missed children. Close to 12,000 PEI frontline workers (including vaccinators and social mobilisers) participated in training sessions on IPC skills in 2014. The World Health Organization (WHO) has introduced half day IPC training for all vaccinators and supervisors in the eastern region. Over 10,000 attended training on delivering key messages on routine immunisation (RI) and the risk factors for polio. These trainings included more time for role playing during training (30 minutes to 60 minutes for vaccinators). As a result of these and other activities (as described in the report), the overall proportion of missed children in the country was reduced from 8% in 2012 to 6% in October 2013 and to 5% in October 2014. Also described here are specific efforts to ensure campaign quality by strengthening monitoring. For example, Lot Quality Assurance Sampling (LQAS) is based on providing real-time data; a system has been developed in which each surveyor uses specially programmed mobile phones linked to a main server to transmit real-time data immediately from the field.

Along the lines of data, the AFP surveillance system is described in depth, including the management approach in conflict-affected areas. "Overall AFP surveillance in Afghanistan has maintained all the global quality indicators.

As indicated here, a vital component of the polio eradication campaign is a multi-pronged communication strategy led by the United Nations Children's Fund (UNICEF) that creates demand for vaccinations by reaching out to relevant audiences, leaders, and influencers through a wide range of communication mediums. Several outreach and advocacy processes are running in parallel throughout the country, with a particular emphasis on LPDs in the south, southeast, and east regions, which have been home to the largest number of confirmed polio cases. The aim of these efforts is to make communities and caregivers aware of the dangers of polio, to increase public health knowledge on preventing polio through vaccination, and in general to stimulate greater demand for life-saving vaccinations. The main components include:

• Mass media to educate and mobilise community participation - Produced in 2013 by UNICEF in collaboration with an Afghan media production company, nearly 1,500 radio ads per month were broadcast on 5 national channels and 12 local channels with coverage areas reaching LPDs. Five different TV ads, nearly 500 per month, were also run. These were broadcast on 6 national and 3 local channels. The most widely broadcast ad, lasting about 55 seconds, features a boy who cannot play football (soccer) because he has polio. The second most broadcast ad, also lasting about 55 seconds, features a mullah who prays with followers and afterwards meets with parents concerned about the safety of the vaccine. Speaking into the camera, he reassures parents that polio vaccinations are religiously correct. Three other ads feature a father, a mother, and a teacher. For each National Immunization Day (NID) and Sub National Immunization Day (SNID), UNICEF prepared targeted media plans. Radio and TV stations that broadcast in areas where the rate of missing children was higher were ones where more air time was bought. Yet, aside from these targeted efforts, "[p]olio was mainly covered, when as it was covered at all, as an event. This was usually an article or clip about the beginning of a vaccination campaign. Polio as a health concern was or news about outbreaks in Afghanistan never merited a news story in any of Afghanistan's leading print, TV, radio, or online new sources....As we move into 2015 steps are being taken to change this. Contracts with BBC Media Action and collaborations with Voice of America [VOA] are moving forward that will ensure that polio and other public health concerns become more mainstreamed news features. Additionally, both BBC Afghan Service and VOA broadcast in Pashto using shortwave radio. Their core listenership overlaps closely with regions considered LPDs."
• Door-to-door distribution of information, education, and communication (IEC) material - Altogether, about 20,250 banners, 291,000 posters, and over 3 million leaflets/flyers were distributed in 2014. The slogan of these products was "Polio Is My Responsibility". Surveys designed by UNICEF and undertaken by social mobilisers indicate that these items helped increase public awareness of polio from 30% to 35% in the southern region, where most of these products were handed out. Measures have been taken to update and improve these materials. Also, instead of one uniform leaflet, vaccinators and social mobilisers will begin distributing numerous leaflets containing information on different facets of polio awareness.
• Vigorous grassroots outreach through an Immunization Communication Network (ICN) - These numbered about 4,870, including 4,059 social mobilisers. These are the people who went door-to-door, speaking with community leaders and parents, dispelling incorrect ideas about vaccinations, identifying homes with young children, and strengthening demand for other child health services. In 2014, this cadre of part-time workers supported 36 SIAs (NIDs, SNIDs, and Short Interval Additional Dose (SIADs)/Case Responses) and inactivated polio vaccine (IPV) campaigns in 44 prioritised LPDs. Post-campaign surveys in the southern region reveal that about 61% of parents indicated that their leading source of information about the polio campaign was social mobilisers. New technology is playing an important role in supporting the ICN network. An ongoing pilot that was begun in June 2014 connects ICN staff in the southern region via text messages to an unstructured, private group chat. Its objective is to facilitate real-time communication and coordination in remote areas in order to improve working conditions and the efficiency of staff in the field. Since the launch of PolioChat, about 12,000 text messages from 400 unique chats have been sent between 40 staff working in polio communications. About 60% of the chats are reports about campaign preparations and activities, meaning that peers share their activities (like holding training, speaking with the governor, hearing about a measles case, or addressing an access issue). "UNICEF Afghanistan is the first country office in the world to establish an SMS group chat service for the PEI social mobiliser network. The accomplishment is all the greater because many of those chatting are based in volatile areas where combatant groups operate."

Based on post-campaign assessment (PCA) monitoring in high-priority polio campaign districts, awareness levels of polio among caregivers increased from 56% in 2011 to 84% in 2014.

Some key challenges remain, including the low literacy rates of social mobilisers, the need for better designed IEC materials, greater coordination with non-governmental organisations (NGOs) and partners providing RI, and the need for more women social mobilisers. Despite efforts to hire a larger cohort of frontline female social mobilisers, only about 14% are women (strong cultural biases against women undertaking roles in the public sphere deter many women from work outside of the home). Furthermore, the ICN networks are only employed during campaigns and therefore do not engage in follow-up of missed children and refusals. "This remains a missed opportunity." Suggestions are offered looking forward. For example, an issue that became more evident during 2014 is the effectiveness of the range of trainings that are conducted for the PEI programme. "Training is largely approached as a deliverable and an end in itself. Trainings for all levels of personnel within PEI give little attention to the actual learning that occurs. Specifically, more attention is required to achieving cognitive and behavioural change resulting from training. This has immediate implications on curriculum, methodology, appropriate learning environments, and follow-up supervision and support to trainees." It is suggested that the PEI communication network be used to increase community demand and ownership for RI.

Specific plans for 2015 are laid out. For instance, there will be a strategic communication focus to ensure that caregivers and community leaders have trust in and demand for public health services, particularly in inaccessible or security-compromised areas. "[P]olio needs to become something discussed by everyday people and the goal of eradication has to be seen as a collective national goal. It will require awareness and enthusiasm at the grassroots level and active engagement with local media so that it remains a multi-faceted news story. Media engagement in LPDs will be particularly important, both as a source of information on when vaccination campaigns occur but also news about polio, its causes and consequences of contracting the disease. An effort will be made to reinforce positive impressions of vaccinators, social mobilizers and community health workers. Three separate but linked and necessary methods for communications engagement will be deployed: 1) expanding the range and quality of materials that vaccinators and social mobilizers offer caregivers when they arrive at the front door. 2) Creating a new, broad and varied 'paid media' content outreach strategy that engages national and more targeted regional audiences. This will include TV and radio but also phone voice mail messaging that will alert caregivers at the district level about vaccination campaigns, and 3) vastly enhancing 'earned media' outreach in ways that build public awareness about polio and cultivates a national movement to eradicate the disease." To cite another example, the plan in 2015 includes developing links with community health workers (CHWs) and engaging them for social mobilisation with the strategic intent to use PEI resources to support both polio communication and, subsequently, broader public health education and promotion.

Editor's note, August 31 2017: This document is no longer available online.