Facilitators and Barriers to Community Engagement in the Global Polio Eradication Initiative - A Mixed Methods Study
Affiliation
Johns Hopkins Bloomberg School of Public Health (Agrawal, Neel, Alonge); Addis Ababa University (Deresse); The Bill and Melinda Gates Foundation (Gerber)
Date
Summary
"Understanding and executing strategies to engage communities in a program process is critical to recognize the nuances that can streamline the uptake of an evidence-based program within communities and fulfil the objective of the program."
Over the years of implementation, the Global Polio Eradication Initiative (GPEI) transitioned to engage more with communities via its community engagement (CE) strategies, which improved its understanding of the importance of buy-in from end users. The impact of the use of CE, a blend of concepts and approaches based on mutual respect and inclusion to achieve shared goals and visions among diverse actors at the community level, is typically studied from the beneficiaries' perspective. In contrast, this paper highlights the contributors and challenges to the implementation of the GPEI's CE initiatives from an implementer's perspective. The study took a mixed-methods approach to analyse data collected from the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project, which conducted an online survey and hosted key informant interviews with individuals who had been engaged with the GPEI programme from 1988 onwards in seven focus countries: Afghanistan, Bangladesh, the Democratic Republic of Congo (DRC), Ethiopia, India, Indonesia, and Nigeria.
An analysis of data limited to individuals (32%, N = 3,659) who were primarily involved in CE activities revealed that around 24% were frontline healthcare workers, 21% were supervisors, and 8% were surveillance officers. Self-reported CE activities covered diverse strategies, including strategies to build trust and ownership within the communities, mobilise community members for action, reach high-risk or hard-to-reach populations, engage prominent figures and faith leaders, seek participation of marginalised populations, challenge stereotypes and social hierarchies, and address misinformation, myths, and fears around vaccinations.
Based on the Consolidated Framework for Implementation Research that guided the development of the survey tool, the facilitators and barriers to CE activities were segregated as internally or externally facing. Internally facing characteristics that were drivers of success mainly contributed to the implementation process of the CE programme (38.7%), including discussions, real-time learning and feedback, task shifting, and sharing resources among collaborators. In addition, the personal characteristics of the individuals implementing the CE activities within an implementing organisation (such as work ethic, commitment to the cause) facilitated the success of CE activities, according to 25.3% of the respondents.
Respondents also identified social context (50.9%), political climate (23.4%), and financial forces (10.9%) external to their implementing organisations as factors that led to the overall success of the CE effort. On the other hand, some of these factors could be barriers as well. For instance, 48.9% of the individuals reported that the communities themselves (external environment) were a barrier to enacting CE activities. The perception of communities towards the polio programme and related field activities was a major challenge (50.8%). Some communities were resistant or non-accepting of the polio vaccine, which translated to pushback and suspicion of related CE activities, especially in low-resource communities. Socioeconomic inequities (poverty, limited economic opportunities, and low education status) combined with personal religious beliefs, disinformation and misinformation about vaccinations, and the influence from spiritual healers and alternate medicine practitioners negatively impacted the uptake of CE activities in some of these low-resource communities.
Conflict was a deterrent in the initial efforts at CE activities in different settings, as implementation processes were not able to embrace the contextual and cultural nuances of the community. There was backlash in the form of distrust and struggle in carrying out planned activities, as well as violence towards frontline healthcare workers and vaccinators. However, by working closely with local partners with deep understanding of the communities, political and influential support, and timely adjustments to the programme, CE activities were able to go a long way in creating awareness and importance of polio interventions. India's experience with mistrust among communities about the use and implications of the polio vaccine and strategies developed by the programme, such as engaging school children and teachers as immunisation champions or mobilising community members to be volunteer influencers, are some examples of leveraging the communities to achieve success for a programme.
Recruitment of local people for teams has been instrumental in tackling the issue of vaccine refusal, according to a respondent from Afghanistan. The strategy involved training Malik (local community elders) and the staff of clinics such as community health workers (CHWs) to conduct community awareness activities. Team members are recommended by local elders, so they are from the community; they have relatives there and are trusted by families. Messages are also provided through TVs and mosques.
Feedback from the individuals involved in engaging with communities reiterated the importance of collaborating with local governments and leaders, high-profile residents and religious influencers in crafting the implementation strategy of the programme. Their support in raising awareness and helping fight rumours around polio and vaccinations in general was necessary to have more communities comply with the vaccination programme. Some respondents suggested engagement of community members in the planning and execution of activities on the ground to provide the communities with ownership and control of the campaign.
Respondents also highlighted the collateral benefits of CE activities. For example, in some countries, like Afghanistan, where experiential evidence from the field had shown that social norms were against women working as vaccinators, especially in rural areas, female members of the community that were employed as frontline workers. These women were given access to households and could make sure all children were getting immunised while gaining employment. The awareness programmes and health education activities conducted to raise awareness within communities were found to have sparked an interest in youth to focus on science and biology. The mobilisation programmes also improved literacy of local communities in health services delivery, access, and basic hygiene.
In conclusion, CE "has become an integral component of program implementation and plays a unique and important role in the success of a program....The nuances recognized from a program as large scale as the Global Polio Eradication Initiative can support and preempt the thinking and strategizing around barriers to community engagement for other similar programs that aim to reduce mortality and morbidity within communities due to communicable and non-communicable diseases."
Over the years of implementation, the Global Polio Eradication Initiative (GPEI) transitioned to engage more with communities via its community engagement (CE) strategies, which improved its understanding of the importance of buy-in from end users. The impact of the use of CE, a blend of concepts and approaches based on mutual respect and inclusion to achieve shared goals and visions among diverse actors at the community level, is typically studied from the beneficiaries' perspective. In contrast, this paper highlights the contributors and challenges to the implementation of the GPEI's CE initiatives from an implementer's perspective. The study took a mixed-methods approach to analyse data collected from the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project, which conducted an online survey and hosted key informant interviews with individuals who had been engaged with the GPEI programme from 1988 onwards in seven focus countries: Afghanistan, Bangladesh, the Democratic Republic of Congo (DRC), Ethiopia, India, Indonesia, and Nigeria.
An analysis of data limited to individuals (32%, N = 3,659) who were primarily involved in CE activities revealed that around 24% were frontline healthcare workers, 21% were supervisors, and 8% were surveillance officers. Self-reported CE activities covered diverse strategies, including strategies to build trust and ownership within the communities, mobilise community members for action, reach high-risk or hard-to-reach populations, engage prominent figures and faith leaders, seek participation of marginalised populations, challenge stereotypes and social hierarchies, and address misinformation, myths, and fears around vaccinations.
Based on the Consolidated Framework for Implementation Research that guided the development of the survey tool, the facilitators and barriers to CE activities were segregated as internally or externally facing. Internally facing characteristics that were drivers of success mainly contributed to the implementation process of the CE programme (38.7%), including discussions, real-time learning and feedback, task shifting, and sharing resources among collaborators. In addition, the personal characteristics of the individuals implementing the CE activities within an implementing organisation (such as work ethic, commitment to the cause) facilitated the success of CE activities, according to 25.3% of the respondents.
Respondents also identified social context (50.9%), political climate (23.4%), and financial forces (10.9%) external to their implementing organisations as factors that led to the overall success of the CE effort. On the other hand, some of these factors could be barriers as well. For instance, 48.9% of the individuals reported that the communities themselves (external environment) were a barrier to enacting CE activities. The perception of communities towards the polio programme and related field activities was a major challenge (50.8%). Some communities were resistant or non-accepting of the polio vaccine, which translated to pushback and suspicion of related CE activities, especially in low-resource communities. Socioeconomic inequities (poverty, limited economic opportunities, and low education status) combined with personal religious beliefs, disinformation and misinformation about vaccinations, and the influence from spiritual healers and alternate medicine practitioners negatively impacted the uptake of CE activities in some of these low-resource communities.
Conflict was a deterrent in the initial efforts at CE activities in different settings, as implementation processes were not able to embrace the contextual and cultural nuances of the community. There was backlash in the form of distrust and struggle in carrying out planned activities, as well as violence towards frontline healthcare workers and vaccinators. However, by working closely with local partners with deep understanding of the communities, political and influential support, and timely adjustments to the programme, CE activities were able to go a long way in creating awareness and importance of polio interventions. India's experience with mistrust among communities about the use and implications of the polio vaccine and strategies developed by the programme, such as engaging school children and teachers as immunisation champions or mobilising community members to be volunteer influencers, are some examples of leveraging the communities to achieve success for a programme.
Recruitment of local people for teams has been instrumental in tackling the issue of vaccine refusal, according to a respondent from Afghanistan. The strategy involved training Malik (local community elders) and the staff of clinics such as community health workers (CHWs) to conduct community awareness activities. Team members are recommended by local elders, so they are from the community; they have relatives there and are trusted by families. Messages are also provided through TVs and mosques.
Feedback from the individuals involved in engaging with communities reiterated the importance of collaborating with local governments and leaders, high-profile residents and religious influencers in crafting the implementation strategy of the programme. Their support in raising awareness and helping fight rumours around polio and vaccinations in general was necessary to have more communities comply with the vaccination programme. Some respondents suggested engagement of community members in the planning and execution of activities on the ground to provide the communities with ownership and control of the campaign.
Respondents also highlighted the collateral benefits of CE activities. For example, in some countries, like Afghanistan, where experiential evidence from the field had shown that social norms were against women working as vaccinators, especially in rural areas, female members of the community that were employed as frontline workers. These women were given access to households and could make sure all children were getting immunised while gaining employment. The awareness programmes and health education activities conducted to raise awareness within communities were found to have sparked an interest in youth to focus on science and biology. The mobilisation programmes also improved literacy of local communities in health services delivery, access, and basic hygiene.
In conclusion, CE "has become an integral component of program implementation and plays a unique and important role in the success of a program....The nuances recognized from a program as large scale as the Global Polio Eradication Initiative can support and preempt the thinking and strategizing around barriers to community engagement for other similar programs that aim to reduce mortality and morbidity within communities due to communicable and non-communicable diseases."
Source
PLOS Glob Public Health 3(4): e0001643. https://doi.org/10.1371/journal.pgph.0001643. Image credit: ©UNICEF Ethiopia/2015/Getachew via Flickr (CC BY-NC-ND 2.0)
- Log in to post comments