In 1988, the estimated number of wild poliovirus in 1988 was 350,000 . However, by the end of 2010, the total number of wild polio cases fell to 1288 . As of 7 June 2011, the total number of 2011 wild polio cases worldwide was 195 and there was only one (1) reported case of wild poliovirus in India compared to 43 and 741 in all of 2010 and 2009, respectively [2–4]. Although India interrupted transmission of wild poliovirus in 2012, India remains at risk of an importation of wild poliovirus from neighboring Pakistan, similar to the recent importation in China—a country polio free since 1994 .
The majority of wild polio cases in India have been in the states of Uttar Pradesh and Bihar . The strategy to interrupt transmission of wild poliovirus in India is to conduct frequent supplemental immunization activities (SIAs or mass campaigns) in high-risk districts and blocks. The high frequency of campaigns is designed to overcome “high immunity thresholds,” meaning that an extremely high percent of the population needs to have immunity in order to interrupt transmission . During an SIA, oral polio vaccine (OPV) is given to all children in the target group of 0–5 years as a part of the polio eradication program. The yearly frequency of SIAs in India may vary from 4–12 and the scope can range from a district to an entire state up to the entire country. Grassroots social mobilization efforts, including those of the CORE Group and SM Net, have been effective in reaching underserved populations during SIAs and combating rumors against polio vaccination in India [7–10].
The CORE Group is a US-based organization made up of health professionals, working for a variety of non-governmental organizations, to collaborate on international health and development programs . In India, the CORE Group Polio Project (CGPP), with funding from the US Agency for International Development (USAID), works in ten districts of the state of Uttar Pradesh (UP) through a consortium of the following PVOs: Adventist Development & Relief Agency (ADRA) India, PCI and Catholic Relief Services (CRS), as well as their local NGO partners.a The CGPP in India has an extensive network of 1,325 Community Mobilization Coordinators (CMCs) who conduct social mobilization activities for behavior change related to polio vaccination. These CMCs are a part of the Social Mobilization Network (SM Net) in India that includes CGPP, UNICEF, Rotary, and the Indian Government’s and WHO’s National Polio Surveillance Project (NPSP). The SM Net was formed in UP in 2003 to support polio eradication efforts there by: identifying high-risk areas and working with underserved communities in planning, implementing and monitoring social mobilization and other immunization activities in those high-risk areas. The three-tier network of community mobilizers (community level, block level, and district level) does the main work of the SM Net.
The Community Mobilization Coordinator (CMC) interacts with families and community members at the village level. As the backbone of the SM Net, s/he is assigned responsibility for mobilizing about 500 households in either a rural or an urban area.S/he keeps records of the immunization status of all children less than five years of age in those households. CMC areas are groups of communities within a block where the SM Net deploys CMCs. The SM Net selects these communities for additional social mobilization efforts based on past communication-related and operational challenges for immunizing children. Most of the CMCs are deployed in areas designated as High Risk Areas (HRAs). Jointly with key partners (Unicef, MOH and CGPP), NPSP defines the criteria for HRAs; these criteria are reviewed periodically and modified. The most recent criteria for HRAs take into account the following information: the number of wild polio virus (P1) cases during low transmission seasons since 2003; the presence of High Risk Groups (Slum dwellers/Nomads); the number of cases last two years with polio-like symptoms; if 40% or more of the population is Muslim; and, the percent of households that have unvaccinated children (X houses). Once a community is identified as an HRA, the SM Net arranges for CMCs to work there. A CMC has to be 18 years or more, preferably female and from the same community. The partnership periodically revises the areas designated as an HRA. All CMCs are paid a monthly honorarium of Rs. 1600 (about $30-35).
During SIA (Supplementary Immunization Activity) rounds, CMCs do the following: assist vaccinators in setting up vaccination booths; organize groups of child mobilizers (Bullawa tollies); help arrange for mosque and/or temple announcements, rallies, interpersonal communication meetings, and meetings with influential people. CMCs also accompany vaccinator teams to homes with children under five years of age, work to convince families with an unvaccinated child (called an ‘X’ household) to allow their child to be vaccinated (called converting an ‘X’ household to ‘P’, with ‘P’ denoting a house where all eligible children are vaccinated against polio), and accompany persons of influence (influencers) during home visits. Conversion of ‘X’ households to ‘P’ is measured during each SIA round. The Block Mobilization Coordinator (BMC) oversees social mobilization activities during (and in between) SIA rounds through supervision and mentoring of the CMCs working in the block. A description of key social mobilization activities of the CGPP and the SM Net is provided below.
One of the most interesting activities that CMCs conduct harnesses the potential of schoolchildren. S/he conducts ‘polio classes’ at schools in her/his area promoting hand washing and cleanliness in a fun way. In these classes, s/he also uses various methods to get the children interested in becoming a part of the polio campaign---from poetry and painting competitions on the polio theme to rallies. A few children are then selected to come together as ‘Bullawa Tollies’ (Literal translation = Calling gangs). These children (ages between 5 and 12 years) visit homes throughout the neighborhood during booth activities, not only persuading mothers to have their infants taken to booths for immunization but also to bring the babies themselves and be rewarded with small token gifts.
Mosque and temple announcements
These announcements remind families about the SIA date and increase program credibility when delivered to a religious congregation. Most places of worship now have a PA system and this amplifies the reach of the message. The CMC contacts the mosque/temple priest and asks him to deliver the messages and thus participate in the program.
CMCs approach schools about recruiting children to participate in rallies held the day before the SIA. During the rallies, children spread the word about the SIA. The go around their village carrying placards that show date and making verbal announcements.
The purpose of “Influencers Meetings” is for CMCs to obtain the cooperation of influential persons such as, community leaders, religious leaders, practitioners of alternate medicine including “quacks” or illegitimate practioners, ration dealers, shopkeepers, etc. Through demonstrating their support for polio vaccination efforts, influencers can help gain community support for the CMCs and act as a credible communication channel for the community. Ideally, the CMCs use the meetings to convince influencers to visit homes with the CMCs during SIA rounds. The influencers assist the CMCs to allay fears of families who are reluctant to vaccinate their children for various reasons (e.g., illness of child, fear that child is too young for vaccination, fear of sickness resulting from vaccination, etc.). CMCs also use these meetings to convince religious leaders to make encouraging SIA announcements from mosques and temples prior to the campaigns. These persons’ participation is voluntary.
Interpersonal communication (IPC) meetings
The individual-focused activity performed by CMCs in between SIA rounds is Interpersonal Communication (IPC) Meetings with mothers and caregivers, especially with those who express resistance to vaccination. The purpose of IPC Meetings is to address misconceptions, rumors and fear through face to face dialogue. During IPC Meetings, the CMC shares information about polio: how the virus is transmitted, and how transmission can be prevented. S/he promotes routine immunization as well as immunization during each mass immunization campaign.
In this paper, we explore the reasons vaccination outcomes were found to be better in CMC areas than in non-CMC areas, as described in Weiss et al. (2011) . We explore which social mobilization activities predict better or worse performance in CMC areas as compared to Non-CMC areas. The purpose is to identify which social mobilization should be continued and which ones should not. Much effort and many resources are being used to carry out social mobilization activities in support of polio eradication. Information that can help program managers rationalize which should be continued, among many social mobilization activities, will help improve the cost-effectiveness of polio eradication efforts.