Author: Ellen Coates, February 8 2017 - The 2014/2015 polio outbreak in Lao People’s Democratic Republic [Laos] resulted in two deaths and paralysis of a small group of children and adults. All cases and positive contacts were from the Hmong ethnic minority group, which has traditionally had a tense relationship with the Lao government characterized by a lack of trust on both sides. The Hmong community, where outbreaks of other vaccine preventable diseases in the recent past were also concentrated, had both limited access to, and limited willingness to access health services that in Lao are provided primarily by government-run clinics. During a social investigation conducted in 2015, Hmong parents and caregivers often indicated that they didn't know about polio or the vaccination campaigns, didn't trust the government services or the vaccine quality, and/or weren't comfortable with the health service personnel, most of whom were not Hmong speakers. Parents also tended to prioritize their work, i.e. providing for their families, and so were unwilling to leave the rice paddies or plantations where most worked to either participate in a campaign or to take care of a child suffering from post-vaccination fever or illness.

In an environment with a notable lack of NGOs, which typically provide the community-based approaches and access to hard-to-reach communities that Ministry of Health [MOH] services often struggle with, the Lao government and particularly the MOH achieved significant success in addressing the communications and other challenges that in many cases national strategies provide lip service to but don't address. The Lao MOH, in partnership with UNICEF and WHO, found ways to pragmatically operationalize those aspects of its national outbreak response strategy, taking concrete steps to address local needs including those of the Hmong. They also maintained flexibility that allowed rapid responses to the emergency itself, Outbreak Response Assessment (OBRA) team recommendations, and emerging information.

The MOH deployed Hmong staff to the outbreak and high-risk villages to meet with local leaders and community members to build awareness and answer questions. Because of the agricultural work that keeps many community members away from home/village during the day, the meetings were held in the evening, and teams often spent the night in the villages in order to meet with the communities for a second night to answer remaining questions. This was a time-intensive approach, to be sure, requiring that members of the minority or otherwise underserved community who visit the villages be trained MOH staff with the stature to command both respect and some decision-making authority. The MOH also adjusted polio campaign approaches to better reach the plantations and rice fields where many Hmong (and other minority migrant workers) stay for extended periods. A poster showing a Hmong member of the Lao Parliament giving polio vaccine drops to an infant was also produced and widely distributed.

With support from UNICEF, a set of USBs with polio messages were recorded in five languages including Lao (the official language) and the major minority languages such as Hmong. The USBs were distributed to villages nationwide, along with loudspeakers and other equipment to ensure that the announcements could be played before and during campaigns (daily announcements are common in the villages, but not all had the technology to broadcast messages from USBs). Based on feedback from several campaigns, during the rainy season hiatus the messages were redesigned from a lecture format to a dialogue between parents and a health worker, adjusted to answer additional frequently asked questions, and rerecorded in the same set of languages using more user-friendly technology. These were again distributed to all villages, beginning with the most high-risk ones.

Health education manuals covering polio, immunization, and key child health messages in flip chart form with images for the public on one side and cues for the providers on the other were also designed, again with significant UNICEF support. While the flip charts were based on the models widely used all over the world, the polio partners in Lao invested significant time in widespread field testing of messages and images to ensure both understanding and cultural acceptability among Hmong and the other key minority groups that are very different linguistically and culturally from the Lao majority.

Improved quality of immunization services and polio vaccination campaigns, along with communications efforts that contributed to overcoming lack of awareness and distrust among the Hmong population, have strengthened immunization coverage through increased participation in polio vaccination campaigns. Findings from the second external OBRA, conducted in May 2016, indicated that the Lao government and its partners had achieved notable success in overcoming challenges to universal participation in vaccination services and improving coverage during supplemental immunization activities (SIAs). In particular, awareness of and participation in the campaigns, trust in the vaccine and vaccination services, and willingness to prioritize accessing vaccination services all improved within the Hmong population. These and other investments in ending the outbreak contributed to a shift from distrust of the vaccine and vaccination services among the Hmong to the 2nd and 3rd OBRA team's findings (in May and August 2016) that families were seeking out immunization services, coming in from the rice fields and other distant worksites to participate in campaigns, and looking for the vaccinators if they had left the fixed posts.

Image caption/credit: A local villager at a computer, broadcasting the campaign messages recorded on a USB - Ellen Coates

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