There were an estimated 350,000 cases of wild poliovirus in 1988 . In dramatic contrast, the total number of wild polio cases in all of 2009 has dropped to 1604; the global total number of 2010 wild polio cases is 618 as of 24 August 2010 . Four countries are endemic for wild polio: Afghanistan, India, Nigeria and Pakistan . As of 24 August 2010, there have been 30 reported cases of wild poliovirus in India compared to 236 during the same period in 2009 . Almost all wild polio cases in India are from high-risk districts in western Uttar Pradesh and central Bihar . The most recent primary strategy to interrupt transmission of wild poliovirus in India is to improve supplemental immunization activities (SIAs or mass campaigns) and routine immunization coverage in 107 high-risk blocks of western Uttar Pradesh and central Bihar . It is widely acknowledged that grass roots social mobilization efforts are needed to reach underserved populations during SIAs and to combat rumors against polio vaccination [5–7]. The CORE Group is a US-based organization made up of health professionals, working for a variety of non-governmental organizations, who collaborate on international health and development programs . In 1999, the United States Agency for International Development (USAID) launched the CORE Group Polio Project (now known as CGPP) in six countries, including India. The CGPP harnesses and synchronizes the efforts of a coalition of US-based Private Voluntary Organizations (PVOs) and their in-country offices, as well as non-governmental organization (NGOs) partners to support the polio eradication effort by providing both social mobilization and detailed local planning for vaccination services. The CGPP focuses on targeting the most inaccessible populations, whether due to cultural or physical barriers to access. The project reaches these populations by systematic enumeration and tracking of children less than five years, and through highly targeted social mobilization strategies that rely on direct personal communication with families and with informal and formal community leaders.
In India, the CGPP works in ten districts of the state of Uttar Pradesh (UP) through a consortium of the following PVOs: Adventist Development & Relief Agency (ADRA) India, Project Concern International (PCI) and Catholic Relief Services (CRS), as well as their local NGO partners. The CGPP India has a Secretariat providing coordination and technical and managerial support to field staff. The CGPP 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 CORE, 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 doing the following: 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.
Organization Of The Social Mobilization Network (SM Net)
Formed in 2003, the Social Mobilization Network (SM Net) in Uttar Pradesh, India comprises the CORE Group Polio Project (CGPP), Unicef, the National Polio Surveillance Project, and Rotary International. CGPP and UNICEF implement synchronized social mobilization activities using community level workers called community mobilization coordinators (CMCs). The SM Net developed the behavior-change communication materials, training materials, supervision structure and pay scale with uniform guidelines; these are implemented consistently across CGPP and Unicef areas. Over time, the SM Net has standardized field staff positions and functions, expanded and refined the data collected by the CMCs and incorporated increasingly focused behavior-change communication techniques.
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 urban area, and keeps records of the immunization status of all 0-5 year children in those households. During SIA (Supplementary Immunization Activity) rounds, CMCs assist vaccinators in setting up vaccination booths, organize groups of child mobilizers (Bulawwa tollies) and arrange for mosque and/or temple announcements. CMCs also do the following: accompany vaccinator teams to all the houses; work to convince families with an unvaccinated child (called an 'X' household) to allow their child to be vaccinated (converting an 'X' household to 'P' (denoting a house where all eligible children are vaccinated against polio); and, accompany persons of influence (influencers) during follow-up activities.
In between the SIA Rounds, the CMC carries out activities aimed at increasing OPV coverage. S/he visits houses, talking to mothers and other caregivers, dispelling their doubts or rumors about the vaccine. S/he holds mothers meetings to discuss their children's health and explains prevention and management of common illnesses. One of the most interesting activities that s/he conducts is harnessing the potential of schoolchildren. S/he conducts 'Polio classes' at schools in her/his area. In these classes, she 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) who mobilize mothers to bring their children to the booths during SIAs.
In India, the Block is the smallest administrative unit and is made up of 100-150 villages. Within the SM Net, 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. The BMC reports to the District Mobilization Coordinator. H/she is responsible for the following activities: capacity building of all CMCs through training; data collection and collation by CMCs; building partnerships with the Medical officer in charge of the Block Primary Health Center and other stakeholders; ensuring that routine immunizations are conducted in hard to reach areas; conducting inter-personal communications (IPC) sessions; participating in their block task force and other related meetings; organizing health camps; and, monitoring CMC vaccination booths and house-to-house vaccination visits.
The District Mobilization Coordinator (DMC) is in charge of social mobilization activities in all the CORE blocks of the district. S/He is responsible for the following activities: compilation of all block level data that are sent to the Secretariat; training; participation in District Task Force meetings; developing the joint SM Net District Communication Plan; building strong partnerships with the district government officials and other stakeholders; and, ensuring routine immunization sessions are conducted in hard to reach areas. During SIAs, the DMC monitors the quality of vaccination activities at CMC vaccination booths and during house-to-house visits. In addition, h/she updates records about the SIA and provides feedback to the Chief Medical officer, and medical officers in charge of the health centers. The District Underserved Coordinator (DUC) is in charge of planning and implementation of activities in underserved areas in the district, such as liaison with religious leaders and religious institutes and ensuring mosque announcements. The Sub Regional Coordinator (SRC) is an employee of one of the CGPP partner organizations and oversees activities in multiple districts. S/He collaborates with local government departments, non-governmental organizations, religious institutions, and other polio partners.
CMC areas are villages where the SM Net deploys CMCs. The SM Net selects these villages for additional social mobilization efforts based on past communication 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 acute flaccid paralysis cases that were compatible with polio in last two years; if 40% or more of the population is Muslim; and, the percent of households that have unvaccinated children (X houses). Once an area 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.
How vaccination is done during SIAs in SM Net CMC areas
Vaccination during SIAs in SM Net areas is conducted in the following way. On Day 1 of the SIA, almost always a Sunday, fixed booths are set up where the vaccination teams are stationed. The team consists of three persons, and the third person is hired from the same community to mobilize children from houses. In CMC areas, CMCs accompany team members and mobilize children by making bulawwa tollies of older children from the same neighborhood (as described above). From Day 2 through Day 5 or 6, vaccination teams, called A Teams, visit about a hundred households each day to document vaccination of all eligible children. Once the vaccination team has visited all assigned households on a particular day, they count the number of households that have not had all eligible children vaccinated. These are called "X" households. The vaccination team then revisits all the "X" households to vaccinate children. The CMC accompanies the vaccination team during visits to "X" households and uses various methods to convince families to vaccinate all eligible children. If an "X" household allows all eligible children to be vaccinated, then we say that an "X" household has been converted to "P." For example, if a family refuses to allow their child to receive vaccine, the CMC may arrange for an influential person in the community to come and speak with the family and encourage vaccination. This ends the A Team effort on a particular day for the team's assigned households. There might remain a number of "X" households, however, in the section of households that the A Team passed through that day.
On the day after the A Team has passed through a section of houses, another team, called B teams, visits the households still labeled "X" after the A Team's efforts. This is the last chance during the SIA to vaccinate eligible children in "X" households through B team activities. The CMC accompanies B team members and visits all "X" houses remaining after A team to communicate to the families, the importance of OPV, and also, if required, to arrange influencer's visit. At the end of the B team activities, there might still remain a number of "X" households.
The Indian Academy of Pediatrics (IAP) has praised the efforts of SMNet in western UP for reducing the number of "X" houses during house to house immunization, increased booth coverage, and led to a reduction in 'resistant' households . The IAP additionally encouraged the SM Net to continue its social mobilization efforts in UP. This is important because social resistance to polio vaccine remains a key barrier to eradication in western UP [9, 10]. As the social mobilization efforts of the SM Net in western UP continue, it would be useful to more rigorously evaluate the outcomes of these efforts. While the IAP cites some evidence (above) of improved vaccination outcomes, the question arises about the value-added of the SM Net efforts: Does having a CMC provide any advantage in achieving vaccination outcomes? In the Patna Region of the State of Bihar, there is a report that vaccination outcomes in areas with CMCs are improving faster than in areas without CMCs . In this paper we examine the evidence for the value-added of the SM Net in western UP.
In this paper, we examine the performance of the SM Net efforts in the CGPP districts only. We assume that performance in Unicef areas is similar because the CMC personnel structure is used in Unicef areas is the same as in CGPP areas; however, it is possible that there are differences. The objective of this study is to learn if vaccination outcomes in SM Net areas are as good or better than in non-SM Net areas within the CGPP program. We will compare vaccination efforts in areas within a block that have CMCs with non-CMC areas in the same block.