Original Article

Year: 2016│Volume:4│Issue-1

Obituary to polio through tool of social mobilization- A cross-sectional study in Western Uttar Pradesh

M. Athar Ansari1, Ali Jafar Abedi2, Saira Mehnaz3

1MD, Professor, 2MD, DCH, Assistant Professor, 3MD, Assistant Professor

Department of Community Medicine, J.N. Medical College, A.M.U., Aligarh (U.P.)


Corresponding Author:

Prof. M. Athar Ansari, Department of Community Medicine,
J.N. Medical College, A.M.U., Aligarh (U.P.),
Pin-202002 Phone; +91-571-2720657 Mob: +91-9897267621


Abstract:

Background: Poliomyelitis (polio) is a highly infectious viral disease and mainly affects children under five years of age.Objective: The present cross-sectional study was conducted to assess the impact of social mobilization on families resistant to giving polio drops to their children.
Materials & Methods: One round of polio drop administration during September, 2014 was selected randomly. Medical interns were trained as social mobilizers by the UNICEF. The social mobilizers visited the households that refused to give polio drops to their children because of certain rumors and misguided beliefs. They tried to convince the family members that polio drops were safe and it did not hurt any religious and cultural sentiments.
Results:The total number of resistant families, identified during first day of house to house activity was 270. Out of these, 180 families were visited by Team ‘A’. Rest of the houses were covered by other agencies. A large number of houses 106 (58.8%) were converted to ‘P’ houses and 74 houses (41.1%) remained resistant after the activity of Team ‘A’. These resistant houses were again visited by Team ‘B’ members. Out of these 74 houses, polio drops were administered in 57 (77.0%) houses. However, after maximum efforts of both the teams, only 17 (9.4%) houses remained extremely resistant.
Conclusions: Large numbers of resistant families were converted to ‘P’ houses. However, some of the families remained resistant even after maximum efforts of the teams. These extremely resistant families might be the potent sources of polio infection in the community and they should be followed up strictly.
Key words: Polio round, Social mobilization, Post polio eradication, Resistant houses

Introduction

Poliomyelitis is a viral disease mostly affecting children that can paralyse them. It mainly affects children under five years of age. One in 200 infections leads to irreversible paralysis. Among those paralyzed, 5% to 10% die when their breathing muscles become immobilized.1 Globally, there were 359 cases of wild polio virus, reported in 2014 which included 340 and 19 polio cases in endemic and non-endemic countries respectively. Out of these cases, Pakistan reported maximum number of cases (306) followed by Afghanistan (28), Nigeria (06), and Somalia (05).2 Setbacks to polio eradication program started in 2002 when new cases steeply rose from 268 in 2001 to 1600 in 2002.3 In India, declining trend of polio cases has been noticed since 1998 setback occurred in 2002 and from 2006 to 2009 large number of cases have been reported.3 The last case (Rukhsar) of P1 polio virus in India was reported on 13th January 2011 in Howrah district of state of West Bengal.4 India’s name has been struck off from the list of endemic countries5 and finally “Polio Free India” certification was done on 27th March 2014.5It has been recommended that dose of IPV should be included by the end of 2015 as part of commitment of the countries declared polio free to the global polio endgame plan which aims to ensure a polio-free world by 2018.6

Initially, Pulse Polio Immunization Programme (PPI) enjoyed enormous success and popularity. There was an immense spirit of volunteerism throughout India, which resulted in successfully increasing the Oral Polio Vaccine (OPV) coverage from 85% in 1995 to 96.1% in 2000–2001.7 In 1999-2000, the Government of India stepped up the frequency of mass immunization from two national campaigns per year, which normally took place 4 to 6 weeks apart between December and January, to six. It also introduced a series of five Sub-National Immunization Days (SNID) with intensive vaccination of children in eight states where cases of paralytic polio were reported: Assam, Bihar, Gujarat, Madhya Pradesh (M.P.), Orissa, Rajasthan, Uttar Pradesh (U.P.) and West Bengal (W.B.) and the activity was renamed as Intensified Pulse Polio Immunization (IPPI).8 This was an effort to reach the remaining 3.9% children. These 3.9% or 5.3 million children were those eligible children, between 0-5 years of age, who either did not turn up at the booth or dropped out of the vaccination exercise.8 Without reaching these children it was not possible to eradicate the poliovirus from the country.

However, the most backward and underserved communities with little or no access to mass media were probably not reached by these activities. It was also noted that communication between health specialist, national planners and community was poor. The rationale behind administering OPV drops to 0-5 year children through repeated doses over the years was poorly appreciated by the people.9 At the same time, in an effort to reach targets, use of force by the health workers in underserved areas added to the resentment against a ‘government sponsored programme’. Doubts were raised about government motives in repeated rounds. Doubts left unanswered led to rumors such as polio drops cause infertility, are useless and paralysis may occur in spite of its administration or it causes polio.8 People started shutting doors and hiding their children. They told lies and refused to have their children vaccinated, especially males.10 At this stage, resistance and rumors against OPV were widespread in the community. It became clear that the program could not succeed without participation of the community. Efforts were undertaken to break the barrier of resistance by social mobilization. An analysis of children affected in 2002, Aligarh revealed that these children were below 2 years of age, predominantly Muslim boys.11

The majority of cases (80%) were reported from Western Uttar Pradesh (UP), accounting for 60% of global cases.12 These cases were mostly confined to densely populated urban areas with poor civic amenities. Western Uttar Pradesh was the ‘world Epi-centre’ for polio in 2003.11 World Health Organization (WHO) and Government of India’s surveillance data showed that children in ‘high risk’ urban slums of Western UP were being consistently missed during NID or SNID and Routine Immunization sessions and they were primarily Muslims and It was estimated that 3.9% or 5.3 million eligible children were missed during the rounds.12,13

The Aligarh MuslimUniversity was approached by the UNICEF to work towards addressing the resistance in the underserved areas in partnership with UNICEF, Rotary International and District Administration.12 Role of Social Mobilization Network (SMNet) of UNICEF was to improve access and reduce family and community resistance to vaccination.14

Information, Education and Communication (IEC) activities were stepped up by multiple channels of communication, focused on reminding parents of the importance of vaccinating all children below 5 years of age, right from infancy, with TV spots, appeals by politicians and film stars.7,15

To reach these resistant pockets in community and to reduce the resistance, especially in more resistant Western UP including Aligarh, the underserved strategy was introduced and involved religious leaders, health personnel, opinion makers and other influential persons. They are instrumental in removing the misconception regarding polio drops, thereby reducing the resistance in the community especially Muslims. During the Friday prayer sermon, given by the high priest in the mosques, these rumors were clarified and rectified.13 Keeping in mind above facts, this study was undertaken to assess the impact of this social mobilization effort on resistance to the program.

Materials and Methods

This cross-sectional study was conducted in nine high risk urban areas of Aligarh, namely Indira Nagar, Banna Devi, K.K.Jain Clinic, Mehfooz Nagar, Upper Fort, Naurangabad, Jeevangarh, Begum Bagh and Ghantar Chowk where maximum number of resistant families were identified during polio rounds. Aligarh is a small district in the state of Uttar Pradesh, situated about 133 Km in south east of Delhi with an area of 5019 Sq Km and having a population of 3,673,849. The population of Aligarh city is 872,575 having an estimated 95,983 children in the age group of 0 to 5 years. Of these, 43% (37,5207 children) are living in nine high risk areas.16

To find out conversion rate by social mobilizers, out of 05 polio rounds conducted in Aligarh, one round of polio immunization campaign (September, 2014) was selected randomly for this study. Medical interns of the Aligarh University were trained as social mobilizers by the UNICEF, Rotary International trainers for carrying out Team ‘A’ and Team ‘B’ Activities. In every team, there was at least one female medical intern to play a vital role. Her presence made the accessibility to the houses easier because most of the male family members were laborers or working in small -scale industries and stayed away from home at the time of visit. Only female members of family were available. The Interns were trained keeping in mind the demographic, socio-economic, cultural and religious factors of the communities.

People were living in hard to reach areas, urban slums which were underserved. Training was also given to interns in such a way that they were capable of dealing with the local issues which are not directly related but they had indirect effect on social mobilization program. Sometimes the communities were resistant to polio drops not because of fear of sterility or other side-effects, but for other proxy grievances like electricity, water supply, roads and waste disposal etc.

Vaccinators were not the part of the team but they moved with the teams and vaccinated the children in resistant families. Sunday was the booth day on every polio round where families were supposed to bring their children to booth for vaccination. Most of the time attendance at booth was low due to the anticipation that the vaccinators would come on Monday at their door step to vaccinate their children.

On Monday vaccinators identified the resistant families refusing vaccination with polio drops. In the daily evening meeting at the district hospital, list of the resistant families were made and handed over to community mobilization coordinator (CMC) of the concerned area for next day activity. Team ‘A’ activity started on Tuesday and continued for four days. Team ‘A’ was accompanied by the CMC who took the team of interns to resistant houses. Trained members of the Team ‘A’ first greeted the families, took note of their grievances and asked about any apprehension regarding polio drops. They tried to counsel the families and answered their doubts. They imparted correct health education in a friendly atmosphere to these resistant families and tried to convince them that polio drops did not have any side effect and it did not cause sterility.

After convincing them, polio drops were given to their children. Sometimes the family pretended that child was sick. The interns, then examined the children and if found sick, gave them medicine which they carried with them. The seriously ill children were referred to nearby health centers, district hospital and medical college. These sick children were vaccinated on subsequent days.

During house to house Team ‘A’ activity, most of the resistant or ‘XR’ houses were converted to ‘P’ houses where polio drops were administered to children. However, during this activity, few resistant families were identified who refused to give polio drops to their children even after exhaustive and skilful social mobilization activity carried out by Team ‘A’ members. For these more resistant families Team ‘B’ activity was carried out 2 to 3 days after the completion of Team ‘A’ activity. Numbers of Team ‘B’ were reduced due to less number of resistant houses. Composition of Team ‘B’ was based on feedback received from the CMC and medical officer regarding performance of the Team ‘A’.

All efforts were made to convince these families by the team members but in some of the families, medical interns and other social mobilizers could not succeed. These were extremely resistant families which constituted the vulnerable group posing threat to the children in the community. Appropriate ethical clearance for the study was obtained from the Institutional Ethical Committee of J.N. Medical College, Aligarh Muslim University, Aligarh (India). Data were collected, collated and analyzed using SPSS 20.

Result

Total number of resistant houses, identified on first day of house to house activity was 270 which included sick children (XS) and purely resistant houses (XR). Practically these houses were considered as resistant as most of the families pretend that child was sick. It included 199 houses of sick children, and 71 resistant houses without any apparent reason of denying the polio drops. Out of these, 180 families (66.7%) were visited by Team ‘A’. Rest of the houses were covered by other agencies. A large number of houses 106 (58.8%) were converted to ‘P’ houses (houses where children had polio vaccination). After 3 days of Team ‘A’ activity, 74 houses (41.1%) remained resistant and these were most resistant houses. (Table-1)

Table 1: Conversion during Team ‘A’ Activity



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XR: Resistant family other than sick child
XS: Sick child

All the 74 most resistant houses were visited by Team ‘B’ volunteers. After prolonged counseling and motivation, family members of 57 houses (77.0%) allowed administering polio drops to their children. However, Team ‘B’ failed to give polio drops in 17 (23.0%) houses and these were seen as extremely resistant houses. It included 10 sick children and 07 resistant families where apparent reason of resistance was not known. Conversion rate was higher in sick children (80.8%) than other type of resistance (68.2%). (Table-2)

Table 2: Conversion during Team ‘B’ Activity



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Table-3 summarizes the result of Team ‘A’ and Team ‘B’ activities in nine high-risk areas. Out of 270 resistant houses, identified during house-to-house activity, 180 houses were visited by both the teams. Out of these 180 resistant houses, 163 (90.6%) houses were converted to ‘P’ houses by the workers of Team ‘A’ and Team ‘B’. Only 17 (9.4%) houses were remained resistant after putting across all efforts. These houses were notified and list was given to higher authorities for further action at their end.

Table: 3 Conversion during Team ‘A’ & ‘B’ Activity



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Picture 1: Interaction with a resistant family during social mobilization



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Discussion:

Though India has achieved elimination status in 2005, many districts & blocks still lag behind. Knowledge & favourable attitude of all sections of population towards this most stigmatised disease are required to eliminate leprosy as a public health problem. To explore knowledge & perceptions about leprosy among different social groups including local common people, FGD was conducted in both high & low prevalent districts in West Bengal. Health workers participating in FDG have shown good knowledge and favourable attitude toward leprosy in both high & low prevalent districts. Similar finding was seen in a study done in Satara district of Maharastha revealing that more than 88.31% MPWs had good knowledge about leprosy and NLEP activities under national leprosy eradication programme.6 ASHA workers who have been involved in bringing out suspected leprosy cases from their villages for diagnosis, treatment & follow up2 were found to have inadequate knowledge about the disease. Verma & Rao in their study found that only 3-6% of the ASHA workers in the NRHM had taken an active interest in leprosy8
Teachers from high prevalent districts were found to exhibit better knowledge compared to their counterparts from low prevalent districts. Panchayet representatives from both high & low prevalent districts have poor understanding as well as motivation towards leprosy. Villagers participating in FDG representing the common people have shown poor perception and high stigma toward the disease. Similarly, a study reflected the poor awareness and negative attitudes towards leprosy in leprosy colony dwellers and urban slum dwellers in South District of Delhi4

In a qualitative study undertaken in the Kanchipuram district of Tamil Nadu in South India, respondents including patients, healthcare providers, policymakers and community leaders referred to problems arising from both health system and behavioral factors.7 A study conducted in urban slum of Kolkata showed that a majority had some knowledge of leprosy but hardly knew early signs or symptoms or where to get proper diagnosis and treatment. Glaring gaps were noticed between knowledge and practice of slum population regarding leprosy.9 Similarly in rural Tamilnadu family member’s knowledge about different aspect of leprosy varied from 37% to 82%.5 Another study conducted in Delhi showed inadequate knowledge of the respodents.10
In the current study, stigma was found to be prevalent not only among common people, but equally among people representatives also; teachers and workers attached to health system were not totally free from this problem. Different studies conducted in different states of India & outside of it expressed similar concern.3,4,10,11,12,13,14 In urban slum of Delhi, myths and belief such as “leprosy can occur spontaneously”, “due to past sins”, “curse of God” and “hereditary were still prevalent in the study subjects 4 In brazil, Hansen’s disease is treated as a case of impurity. Some of the patients used to hide the disease from neighbours and co-workers for fear of their reactions. Feeling like annoyance, silence, stigma, and aversion were found to contribute to the failure of treatment, noted by a poor adherence to the therapies.3 In another study conducted in Kolkata among adolescents showed the role of social stigma in hiding, delay in starting of MDT & defaulting11

All community-based rehabilitation workers in South Africa rightly commented that social stigma was a stumbling block to leprosy elimination as expressed in the following comments, “The leprosy patient rejects his/herself first by shying away from people and sitting at corners in gatherings, followed by the family and the community”.12

The factors associated with higher stigma were found to be illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat13 As a consequence of both enacted and perceived stigma, a person over a long period of time develops a self-stigma or internalized stigma, thus lowering self esteem & respect.

Conclusion:

From Focus Group Discussion, the findings came out that most of the panchayet representatives & villagers had poor knowledge & adverse attitudes towards leprosy, whereas ASHA workers who were supposed to spread awareness in the village were found to have inadequate knowledge about the disease. Stigma about the leprosy was still prevalent among groups with inter group & intra-group variation. With the community involvement at all stages of a programme, from planning to evaluation, proper reorientation & adequate training of front line workers, removing enacted & perceived stigma among people through proven IEC, we can address the problem to reach the desired goal.

Acknowledgment: We gratefully acknowledge the financial support made by the Indian Council of Medical Research, New Delhi for this research work. We are indebted to Dr. Vishwa Mohan Katoch, Director General, ICMR for his contribution to conduct this study. We are equally thankful to the Department of Health & Family Welfare, Government of West Bengal for providing data regarding leprosy patients under treatment, and Participants of FGDs for their cooperation.

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