Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE): Initial Findings from a Global Mixed Methods Study

"Widespread uptake of key public health lessons, based on both positive and negative experiences, do[es] not occur passively but require[s] active strategies to package and communicate such lessons to potential adopters."

Several efforts have been made to document the lessons learned from the Global Polio Eradication Initiative (GPEI) and polio eradication activities broadly. These efforts have sought to articulate and disseminate insights from a worldwide push that has contributed to a decrease in the global incidence of polio by 99%. The public goods that have resulted could be relevant for advancing population health, especially in the many low- and middle-income countries (LMICs) in which those public goods were created. Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is an effort to systematically synthesise lessons learned from different levels of the polio eradication experience across geographies, organisations, and work streams and to apply them to future lifesaving initiatives. The STRIPE project involves 4 key phases: knowledge mapping, synthesis, packaging, and dissemination and uptake. This paper describes 2 of the main methods under the knowledge mapping activities, the survey and key informant interviews, and presents initial findings drawn across global, national, and sub-national levels.

As this paper explains, the STRIPE project included partners from focus countries representing various GPEI context typologies and contexts: Afghanistan, Bangladesh, the Democratic Republic of Congo (DRC), Ethiopia, India, Indonesia, and Nigeria. To guide the project, a high-level technical advisory committee (TAC) was formed that includes individuals representing GPEI core partners (the World Health Organization (WHO), United Nations International Children's Fund (UNICEF), Centers for Disease Control and Prevention (CDC), the Bill and Melinda Gates Foundation (BMGF), and Rotary International), ministries of health in LMICs, non-governmental organisations (NGOs), faculty from schools of public health in LMICs and high-income countries, and other relevant agencies.

The knowledge mapping activities utilised a sequential explanatory mixed-methods design. A tacit knowledge survey was conducted online at the global level, and at national and sub-national levels in all focus countries between August 2018 and December 2019, with the global survey remaining open through April 2019. The survey tool was developed based on the Consolidated Framework for Implementation Research (CFIR), the Organizational Social Context framework, and the socioecological model. It collected information from 3,955 unique respondents (3,659 completed the survey) on contextual factors that were key barriers and facilitators of the polio eradication activities and the level where barriers originated from (global, national, sub-national). Key informant interviews (KIIs) were administered to a nested sample of survey respondents to further explore implementation challenges of polio eradication activities, strategies for addressing these challenges, and their intended and unintended outcomes across the levels of the socioecological framework.

Among the implementation barriers and strategies for addressing them found in the research are:

External factors were the most frequently cited barriers to implementation in the survey (39.3% of all barriers). Among these:

• Social factors accounted for the majority (44.3%). The importance of the social environment to programme success was echoed in the KIIs, who most commonly cited low vaccine demand - an issue that manifested at both the individual and community levels to hinder the success of the polio programme. KII respondents described the need to address low levels of awareness of immunisation services and its benefits, particularly among communities that lived outside the formal system, and cited vaccine hesitancy as a major reason for low vaccine demand and one of the biggest threats to programme success. In some places, vaccine hesitancy was due to a general mistrust of government programs based on historical antecedence and this affected vaccination efforts more broadly, including refusal of non-polio vaccines. In other places, the vaccine hesitancy was specific to the uptake of the oral polio vaccine (OPV) due to fatigue and concern over repeated campaigns and house-to-house vaccination, and a perception of misalignment of health priorities by community stakeholders. Other manifestations of OPV hesitancy across different contexts included lack of awareness, concern over multiple doses, fear that vaccines could cause infertility, fear that vaccines contained HIV, and concern that vaccines were "non-halal" in some communities.
  • Strategies used to address these social barriers include, at the community level, identifying and preparing champions and early adopters. Religious, community, and local leaders served as "gatekeepers" between implementers and the community who encouraged vaccination within their communities and thus facilitated programme implementation. Increasing awareness of the population, including dispelling concerns about vaccination, also relied on individual-level appeals via social mobilisation activities. Across contexts, health workers and/or community volunteers were trained in information, education, and communication (IEC) tactics and deployed as outreach staff to promote the polio programme and to follow up with hesitant families. This strategy was viewed as effective for increasing polio vaccine demand across countries, so long as both messengers and messages were tailored to the local context. Unfortunately, in some countries, these strategies were developed only after issues of vaccine hesitancy threatened the eradication goal.
• Economic and political factors were the next major external factors that were indicated as barriers to success from the survey, 30.6% and 29.2% respectively. Economic and political factors also emerged from the KIIs. For example, economically deprived communities were suspicious of the polio community that emphasised polio eradication goals while basic livelihood issues were neglected, and this contributed to mistrust. Political factors discussed by respondents included low political will and lack of polio programme ownership in-country, political favoritism, and insecurity and conflict. In conflict-affected and insecure areas, respondents recounted repeated disruptions to service delivery as a result of conflict and described lack of accessibility and concerns over health worker safety as persistent barriers to implementation.
  • Strategies to address these economic and political barriers include: working to involve stakeholders and workers in the implementation effort, undertaking high-level advocacy (being careful not to engage stakeholders who might politicise vaccination activities), and using satellite imagery and community informants to assess coverage gaps and identify cases.

Internal barriers, with proposed strategies, included:

• 22.2% of barriers related to the process by which activities were implemented; of those process-related barriers, a majority (56.7%) fell under issues with executing (ability to carry out activities according to plan). The KIIs suggested a strong link between external and internal barriers to implementation. To that end, some of the strategies discussed for addressing external barriers, including ongoing stakeholders' engagement and political advocacy, were also successfully applied to issues related to executing the programme. Other strategies to address these issues were multifaceted and included addressing issues around specific health system inputs, as well as improving management processes.
• Challenges related to programme evaluating, reflecting, and planning included, for example, lack of monitoring and evaluation tools, structures, and processes. The KIIs illuminated how these challenges were related to information systems and data quality, as well as management and governance issues. Strategies to address these issues included, for example: developing mechanisms for feedback, monitoring, and evaluation; holding regular planning/brainstorming sessions; and working with health staff at the sub-national level to create detailed micro-plans that put special populations, inaccessible groups, and hesitant communities at the centre of implementation plans - a tactic that proved critical for ensuring delivery to hard-to-reach populations.

Individual, organisational, and programme characteristics accounted for the remainder of barriers to implementation indicated in the survey, as indicated by 18.1%, 11.1%, and 9.3% of identified barriers, respectively. These categories covered a broad array of barriers, but included issues related to knowledge and beliefs (individual), poor implementation readiness (organisational), and limited programme adaptability (programme characteristics). (From the survey, inability to adapt, tailor, or refine the programme to meet local needs was the most commonly cited challenge related to the polio programme itself (40.2%), and reflects both policy- and organisational-level constraints. A sample strategy: use of information and communication strategies such as tailored messaging and creating narratives that resonate with community values at the individual level in order to increase individuals' knowledge about the polio programme and to resolve issues of distrust and fear held by household decision-makers. "By their nature, however, not all strategies developed to address barriers could be universally applied, and indeed, many were specific to the social and political norms of a locality."

STRIPE notes that the GPEI developed a core set of implementation strategies to address these barriers, including: strategies for social engagement and mobilisation (e.g., coordinating information and communication at individual and community levels); strategic advocacy at various policy levels; and other health systems strategies such as incentivising health workers, strengthening data and surveillance systems, and establishing emergency operational centres for rapid decision-making. The degree of success of these various strategies depended on the organisational and individual capacities in the different contexts where polio programmes were implemented.

The paper's authors note that the STRIPE study findings align closely with the conclusions of other studies or reports that have examined global polio eradication efforts. However, the STRIPE study particularly prioritised the view of frontline workers at the national and sub-national levels, which they say yielded findings that have been less described in the literature - e.g., the significant impact of misconceptions about polio vaccine and the lack of awareness of its benefits among certain frontline workers, their temporary working status, and how these affected specific organisational objectives and the overall polio programme goals.

Recommendations based on STRIPE's analysis of the GPEI experience that could guide future global health programmes:

1. Recognise issues related to external factors earlier on, and actively strategise around them on a continuous basis and throughout the life of the programme.
2. Conduct careful pre-programme analysis of the broader political, social, and economic contexts to identify both threats and opportunities to successful programme implementation.
3. Consider the following core principles for implementing complex public health programmes: conducting ongoing stakeholder engagement based upon mutual respect, coordinating efforts to build political will and accountability over different phases of the programme and at different socioecological levels, systematically adaptating service delivery activities to local contexts, and establishing sound planning, management, and monitoring and evaluation practices that measure implementation outcomes (e.g., acceptability of the various key activities with different stakeholders) in addition to endpoint outcomes (e.g., vaccine coverage under the polio programme). "It is especially important to identify and work through 'gatekeepers' at the community level from the outset of any implementation effort, understand how and when to engage these 'gatekeepers,' know the target population and risk factors, and assess ongoing population movement and dynamic changes to the population risk profiles."
4. Give adequate attention to participatory approaches that can facilitate implementation processes across socioecological levels, especially at national and sub-national levels. These approaches could involve: participatory planning to align polio eradication goals with other health system objectives at national and sub-national levels and accommodate local knowledge of the context and priorities of community members and frontline health workers; participatory research to understand barriers and identify contextually appropriate solutions to collective goals of the polio programme, health system objectives, and community priorities; and participatory actions to co-own implementation processes among various stakeholders.
5. Make efforts to build social capital, which may address factors outside of the intervention delivery and that may control behaviours and choices at individual and community levels.

A concluding thought: "The implementation of various polio eradication initiatives, including the GPEI, provides important lessons for implementing future lifesaving programs and health systems strengthening activities globally. Understanding the implementing context of any program is critical for identifying both threats and opportunities to program implementation. Systematic efforts to unpack contextual factors, target strategies to perceived barriers, and understand the readiness of recipient communities and health systems should be prioritized before implementation."