Anthrologica (Bedford); UNICEF (Chitnis, Webber, Dixon, Limwame, Elessawi, Obregon)
"The most frequently made recommendation was the integral use or involvement of the community."
In Liberia, as in the other most affected countries in West Africa, the Ebola epidemic led to a disruption in essential health services and resulted in low coverage of routine immunisation. In response, a national integrated polio, measles, and deworming campaign was implemented across Liberia, May 8-14, 2015. This article provides an overview of its community engagement and social mobilisation activities and reports the key findings of a rapid qualitative assessment conducted immediately after the campaign that focused on community perceptions of routine immunisation in the post-Ebola context.
The main challenge leading up to the May campaign was to rebuild confidence in the health system post-Ebola and to address concerns and fears about routine immunisation and the Ebola vaccine. The Ebola outbreak had coloured communities' perceptions of health workers and the services they provided, caused shifts in care-seeking practices and elevated distrust in local and national authority. Thus, a comprehensive social mobilisation and community engagement plan was developed by the Ministry of Health based on the communication strategy used during the Ebola response and drawing on lessons learned from previous immunisation campaigns. The aim was two-fold: to increase communities' understanding of the importance of routine immunisation and to raise awareness of the campaign by strengthening interpersonal communication about routine immunisation and the campaign through community engagement of social networks and house-to-house mobilisation, conducting high-level advocacy in the counties, using partners to raise the profile of measles and polio immunisations, and providing support in developing specific communication plans for communities.
In collaboration with the Ministry of Health and its Health Promotion Unit, the United Nations Children's Fund (UNICEF) provided technical leadership in rolling out the social mobilisation activities and through County Mobilization Coordinators (CMCs) and District Mobilization Coordinators (DMCs) coordinated the social mobilisation activities of partners at county and district levels. The network of CMCs and DMCs provided UNICEF coverage and oversight at county and district levels and ensured that the organisation could respond rapidly to emerging situations on the ground. Between the end of March and the start of the campaign in May, activities, which were designed to be well integrated, mutually reinforcing, and frequently repeated, included: training of trainers; mobilisation of chiefs and town criers; orientation of civil society organisations, religious leaders, and the traditional women's network; mass communication (through radio, printed press, posters and flyers, and parades); direct engagement activities, including door-to-door visits and community-based dialogues; and rapid polls through U-report, a free short message service (SMS)-based platform used to promote the campaign and seek feedback during and following its rollout.
Overall, UNICEF concluded that 229,031 house-to-house visits were conducted; 5,992 community leaders and 5,840 religious and traditional leaders were engaged and trained; 2,760 community meetings were held; 35,000 flyers, 5,678 posters, and 60 banners were printed and distributed; and 3 radio dramas were produced and aired over 67 radio stations. In total, 693,622 children (101%) received the oral polio vaccine (OPV), 596,545 (99%) received the measles vaccine, and 518,104 (99%) received the mebendazole tablet. UNICEF conducted exit interviews with caregivers presenting their child(ren) for immunisation across all 15 counties (n = 737). In response to the question "How did you hear this/these message/s [to get children under age 5 immunised]?," the most often cited sources of the information were (in decreasing order) Community Health Volunteer (CHV) or other health worker (72.8%, n = 516); health worker visited our house (56.7%, n = 402); poster, billboard, or flyer (55%, n = 390); radio (49.5%, n = 351); community meeting or community leader (46.5%, n = 33); town crier (44%, n = 312); and friends, neighbours, relatives (42.6%, n = 302).
Following the immunisation campaign, focus group discussions and interviews were conducted across 4 counties in Liberia (Montserrado, Nimba, Bong, and Margibi). Thematic analysis identified the barriers preventing and drivers leading to the utilisation of routine immunisation. Community members also made recommendations and forwarded community-based solutions to encourage engagement with future health interventions, including uptake in vaccination campaigns. These are included in the article, sometimes in the form of direct quotation from community members consulted as part of the research.
In short, the campaign was found to be a success. Coverage rates were high, and all participants in the rapid qualitative assessment (including those who had not presented their child) had knowledge of the campaign, confirming a high level of awareness due to social mobilisation activities, direct and indirect communication, and wide publicity. Of the caregivers who had not presented their child, none mentioned financial barriers or issues of inaccessibility; rather, they explained their actions as a positive choice to avoid vaccination services - a choice made in the context of Ebola (whether they had experienced Ebola directly or indirectly). The vaccine itself and the provision of the vaccination service were the dominant barriers - there was fear and suspicion communities continued to experience in relation to Ebola, as well as negative perceptions resulting from the Partnership for Research on Ebola Vaccines in Liberia (PREVAIL) Ebola vaccine trial. There was a particularly strong and widespread narrative that suggested that the measles and polio campaign was a cover for targeting the country's children.
The community engagement instilled a sense of trust in both the vaccine and the vaccine campaign, and communities repeatedly confirmed that it was this that had led them to accept the vaccines. Positive drivers of immunisation uptake also included receiving the vaccine from a known and trusted source and confidence in who was giving the key messages about the campaign and through which information channels. Several respondents explained that general Community Health Volunteers (gCHVs) or "those in yellow T-shirts" had visited their communities prior to the campaign. The majority of respondents trusted the gCHVs and mobilisers and emphasised the need for interactions and prolonged engagement. As one community leader in Bong explained, "They said it was what we had taken before, that we should not be afraid. Our fellow black men encouraged us, my brothers can't hold anything back, we know them."
Many respondents heard about the campaign on the radio, and most regarded this as a reliable and trusted source of information (as also reflected in the Knowledge Attitudes and Practices [KAP] surveys and U-report data). In addition to direct community engagement (by gCHVs, social mobilisers, health workers, and other stakeholders) and indirect engagement via the radio, a small number of respondents explained that the local town crier had also made announcements about the campaign, and one community leader recounted that there was a community meeting, "but attendance was poor." Mothers in one focus group in Monrovia discussed mobile dramas as being an effective way of raising awareness and providing information. No participant mentioned the banners, posters, flyers, or frequently asked questions sheets as a source of information.
In terms of community recommendations for future interventions, respondents stressed the need for communities to be active participants in an intervention rather than being conceived as passive recipients of a service delivered by outsiders. Efforts to incorporate known community members (in addition to community leaders) in social mobilisation activities were embraced. The involvement of mothers was particularly emphasised. Participants noted a high degree of trust between mothers due to shared experience and maternal responsibilities and in terms of "bearing witness";a mother in Margibi concluded, "I saw a woman in the market who was not going to take her child, but I went to speak to her and showed her my child and encouraged her to carry and take the child."
With regard to different modes of community engagement, no mention was made of mobile or SMS communication channels that could provide an immediate feedback mechanism. Rather, participants stressed their preference for interpersonal or face-to-face dialogue. In one focus group discussion in Nimba, a mother asserted, "We want somebody to come here first to educate us, and then we can ask questions." The CMCs confirmed that communities were confident in asking questions and expressing their concerns during social mobilisation activities. With regard to social mobilisation activities, communities suggested that they should start earlier and go longer and that they should be ramped up during a campaign. This last point was also recommended by the CMCs who emphasised the importance of community engagement prior to, during, and after a campaign. Communities requested that social mobilisation and health education activities happen in the evenings and on weekends rather than during the working day so that everybody ("whole families") could be engaged. Several participants also stressed the need to leave the towns and villages and go to the farms to do effective mobilisation.
In conclusion: "the reintroduction of routine services across West Africa, particularly at a community level, must take into consideration the multitude of changes Ebola brought about. Extended community engagement, health promotion, and risk communication must mitigate the challenges faced, proactively encourage utilization and in so doing, ensure that communities are at the center of future policy and programing."
Journal of Health Communication: International Perspectives Volume 22, 2017 - Issue sup1: The Communication and Community Engagement Response to Ebola, 2014–2015: Evidence and Lessons for Future Global Health Crises. Image credit: (c) UNICEF Liberia/S. Grile