Polio Project:

1. The ARCH ProjectApplied Research on Child HealthHarvard Institute for International Development (HIID) Polio Project: Missed Opportunities for Polio & Other Immunizations in Urban Poor Communities in West Africa

2. ARCH Polio Project: Research Components • Household survey of mothers • Qualitative research component targeting consumers & providers • Community profile: agents for social mobilization

3. The Studies...Table 1: Characteristics of the Study Sites

4. Numerical results by Team...Table 2: Percentage of eligible children vaccinated against polio

5. NID Figure

6. Additional findings…. • Methodological Issues: • Partnerships between researchers & program managers work • Periodic surveys of sub-populations with low immunization coverage to estimate progress toward the elimination of polio simple & inexpensive • Need to be sustained & developed to improve EPI & NIDs

7. General Conclusions • Methodological Issues • Partnerships between researchers & program managers has led to findings that will make the routine EPI & the NIDs more effective. • These working partnerships need to be sustained & developed in the years ahead.

8. Immunization Rates • Excellent progress with improved coverage through NIDs • More attention to sub-groups in next NID rounds • Tailor-made messages & approaches

9. Risk Factors • Unvaccinated children in NIDs different from families not participating in EPI or using modern health services. • Sub-groups of children with low immunization rates from middle class & poor neighborhoods: well-educated mothers as well as those with no education. • Careful thought needs to be given to the factors that lead to the exclusion of selected groups from the public health services.

10. Health Services • Instruct health staff to be more respectful of mothers, however ill-informed they may seem. • Ensure that a few key messages are clearly communicated to all mothers or guardians, such as: • NIDs are free • re-vaccination is recommended • one round is not enough • come this year even though you came last year

11. Communication & Social Mobilization • Good information & ready accessibility make a difference. • Offering low-cost or free services helped - but some are skeptical about the value of free services, especially if other similar services require payment.

12. Communication & Social Mobilization • Full participation of the community helps build ownership of the initiative. • Some prior contact with the health services means that people return for additional services later. Interventions to build confidence in the modern health services. • Many mothers heard indirectly from family members about NIDs, not through the radio or television. Local & informal methods of communication need to be encouraged.

13. Future Work • Alliances forged for this work could contribute further to the elimination of polio & the control of other infectious diseases if encouraged to do so. • Consider the needs of particular sub-populations.

14. Future Work • Develop the capacity to do competent social science research in the field. • The teams had most difficulty with the analysis of the qualitative materials & in conducting the “community profiles.” • Questionnaire design, sampling, coding & data entry skills

15. Future Work • Facilitate the capacity of mothers & health workers to recognize & distinguish particular diseases. • Develop effective & sustainable ways in which cases of disease can be reported to the health authorities for suitable response & follow-up.

16. NIDs vs. Routine EPI • Participation in NIDs was greater than with EPI • Percent of fully-vaccinated 1 year olds ranged between 51-69%. • Percent of children participating in both NIDs was greater than the percent fully vaccinated in all sites. • In Mali and Ghana, all four sites had at least 90% participation in both NIDs.

17. KUMASI - FGD with mothers • “Mobile teams and health workers are at our door step making it convenient” • “We expect the nurses to sometime congratulate us for looking after our child very well….so it will boost our morale, but they do not.” • "We, Muslim women, the nurses hate to see our faces at the hospitals. If given an option, a separate hospital should be built for women in the Zongo and should be manned by Muslim colleagues."

18. KUMASI - FGD with mothers • “Whatever medicine is vaccinated at any point in time, I do not know . All I know is to bring my child to the immunization center. If they tell us, it will stick in our minds.” • "They do not tell us what they collect money for when we come to the clinic. It is not always that you come around and the child is vaccinated… if the nurses have not gathered enough people, it means for that day your child will not be vaccinated."

19. KUMASI - FGD with mothers • “When the nurses come, they should not only vaccinate the children they should also vaccinate the mothers as well so that we will have the strength to look after the children.” • “We have a lot of things on our minds, so we forget to bring the child for drops.” • “Any information you give us, we will listen.” • Most mothers in the FGD preferred evening after supper to go to the clinic.

20. In Depth with one Health Personnel • Volunteers are few for NIDs • T-shirts should be an integral part of the remuneration…..volunteers were very happy and it helped in identifying volunteers. It contributed to the success of the program. • More vehicles must be provided

21. In Depth with one Health Personnel • Important to tell people one month before NID so they will not forget. • Training was emphasized • Money or lunch and refreshments for staff….because the work is very tedious.

22. ACCRA • Women were confused when it came to the number of doses a child needs • "including polio it makes nine…I injected him only six….including yellow fever it is seven….the diseases are six and so each one has its injection"

23. Risks and Dangers of Vaccines • After probing, the women strongly expressed that the vaccination is important • “There is no one who should not be vaccinated.” • “Whether the child is sick or not, it is very important.”

24. Cost and Other Obstacles • Why mothers do not vaccinate the children: • Laziness • "many times, it is laziness you know" • Business or job • "those mothers put their jobs before anything" • No food supplements • "at first they used to give food supplements to give to their children, but now they do not., so they do not come” • "it is not necessary to bring the child because the child is not given food"

25. The groups were divided on the question of costs... • "if she wakes up in the morning, the money to even eat is a problem so the C200 is a problem" • "as for the weighing, the government has to make it free for nursing mothers….the thing is that, in this world we know that all the fingers are not equal" • Some agreed "mothers have to pay a token for the services"

26. Previous Experience • All the women had vaccinated children before; asked about ways it can be improved: • "waiting hall was too small” • "because we combine with pregnant women, it makes us uncomfortable, so if we have our own place…” • "we want a fan; place is small and there is heat it makes the children cry so much” • "staff normally angry too quickly or frequently” • (too much work for ) "they are already annoyed before we come".

27. Information • There seemed to be disagreement amongst the group regarding information or lack of that the mothers do not understand. • “Do not know the benefits.” • “If somebody says she does not understand this weighing, she is lying because if you watch the way they show it on TV. It will come to your mind, that yes, I have to take my child.” • “They keep talking about it on the radio if even you are in the village they talk about it. How much more in the city??”

28. Information • “Everywhere they say it. Even Ampadu has made a song , this polio song, so everybody knows. So, if someone says this weighing they have not heard, then that person is not in Ghana.” • “Explain to us and tell us may be in this month, it is this and that, that you will come and inject.” • “We will plead that you explain things to us.” • “The way the other mothers dress to weighing, she does not have the same thing to bring so she does not want to come.”

29. Reasons for Non-Attendance • Long waiting time • “Nurses came late and because of many people and so mixed up the cards, and trying to pick their friends and favorites to attend first.” • Majority of mothers mentioned food supplement, "they should be re-introduced again which will encourage mother to participate in immunization program. • Some disagreed and said, "we must help them to help us"

30. Perceptions of Polio and Willingness to Report • Most of the women knew the purpose of the NID • "the government want to eradicate this disease so that it doesn’t affect the child" • "it is important that the child is given because it protects the child from disease"

31. Sources of information and channels for community mobilization • All mothers mentioned a number of sources including radio, information vans, posters, Muslims announced in the mosque, volunteers go from house to house, family members and people living on the same compound… • “sometimes Pozo Hayes sings on the television” • Some said the medicine has expired and they have brought it to kill the children that the medicines has expired from another country • "I heard something like that"

32. Why Children aren’t being Immunized • Some women explained that most mothers come for the polio or NID but not for the immunization. • Most mothers did not understand why they do not go to the NID • "if they charge money, then you can say you don't have money, but it is free and you don't take your child then its your own problem” • Repeatedly, mothers said it is laziness.