Facilitators and Barriers of Infectious Diseases Surveillance Activities: Lessons from the Global Polio Eradication Initiative - A Mixed-Methods Study

"Surveillance programmes should be designed with inputs from local communities and frontline implementers."

Since the Global Polio Eradication Initiative (GPEI) was launched in 1988, surveillance has been one of the key strategies for interrupting the transmission of poliovirus and tracking progress. Implementation process, which ranges from planning to engagement, execution, and evaluation, is recognised as a major determining factor for the success of any intervention. For instance, successful surveillance depends on detailed planning of the entire process, including the engagement of individuals with the right knowledge, perception, and self-efficacy. This study reports challenges and factors associated with successful polio surveillance from the perspectives of 802 persons involved in the implementation of surveillance activities under the GPEI at the global level and in seven low- and middle-income countries (LMICs).

This cross-sectional study used data from the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project, which aimed to apply implementation science methods to document lessons learned from GPEI. The study population included funders, managers, policymakers, researchers, and frontline field implementers who have spent 12 or more continuous months working on surveillance activities under the GPEI in Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, and/or Nigeria. The main explanatory variables in the survey were the three main challenges (barriers) in the implementation of surveillance activities: (i) organisational challenges: factors relating to characteristics of the organisation supporting the polio eradication programme, (ii) GPEI programme challenges: challenges relating to specific activities used towards eradicating polio, and (iii) external challenges: those relating to the impact of political, economic, social, technological, or environmental settings.

Of the 802 participants, 511 (63.72%) reported the process of implementing surveillance as a factor for successful surveillance, and 291 (36.28%) reported otherwise. For example, according to a subnational surveillance officer from the qualitative analysis, process activities identified as factors for successful surveillance included "the setting up of community-based surveillance which involved community informants within their cells or villages, health workers and effective collaboration between community teams and district officials in disease detection, reporting, investigation, feedback and outbreak response". Regular training, financial incentives, and routine progress meetings were additional internal contributors to successful surveillance described by respondents.

Overall, participants who reported challenges relating to GPEI programme characteristics had 50% lower odds of reporting implementation process as a factor for successful surveillance (adjusted odds ratio (AOR): 0.50, 95% confidence interval (CI): 0.29 to 0.85). Challenges were mainly perceptions of external intervention source (i.e., surveillance perceived as "foreign" to local communities) and the complexity of surveillance processes (i.e., surveillance requiring several intricate steps). As an example of the former, a district surveillance officer remarked that "parents were sometimes not supportive, some thought polio was not their priority, they were skeptical to release their child's faecal samples, so we not only had to continue educating them but also gave out small incentives to encourage them to participate".

Those who reported organisational challenges were almost two times more likely to report implementation process as a factor for successful surveillance (AOR: 1.89, 95% CI: 1.07 to 3.31) overall, and over threefolds (AOR: 3.32, 95% CI: 1.14 to 9.66) at the national level.

In reflecting on the findings, the researchers note that the expansion of surveillance focal sites beyond health facilities to include community surveillance is one of the factors for successful surveillance. Community-based polio surveillance programmes in Ethiopia that focused on acute flaccid paralysis (AFP) detection among remote and migratory populations (CORE Group Polio Project) contributed to increasing the non-polio AFP detection nationally, an indication of effective polio surveillance.

Along the lines of community involvement, the researchers stress that surveillance "should account for the peculiarity of each region/level through the engagement of community leaders and relevant stakeholders. This will enhance the quality of study design, identification of context-specific challenges, development of tailored programmes and ultimately promotion of programme adoption and success....[Furthermore, the] findings highlight the need for well-structured organisations to lead surveillance programmes. The organisation's work climate and culture need to be conducive to the learning, growth, productivity and innovative spirit of employees involved in surveillance activities."

In conclusion: "Programme characteristics may have impeded the process of conducting surveillance under the GPEI, while organisational characteristics may have facilitated the process. Future surveillance programmes should be designed with inputs from local communities and frontline implementers."