NIGERIA

ADDRESSING COMMUNICATION CHALLENGES

POLIO COMMUNICATION

2011
SUMMARY REPORT

UNICEF Nigeria /2011/Morgan

UNICEF Nigeria /2011/Morgan

F A C T S

A N D

F I G U R E S
In January round, non-compliance as a reason for missed children was 27% and it finally reached 28% in September Immunization Plus Days.

As of November 25, 2011, Nigeria has recorded 43 cases of wild poliovirus (WPV) in eight States compared to 14 cases in seven States for the same period in 2010. Four (4) States of North Eastern part of Nigeria recorded 28 WPV cases. Kano has so far 14 WPV cases followed by Kebbi (8), Jigawa (6), Borno (5), Sokoto (5) and Yobe (3), whereas Katsina and Zamfara experienced one case each. Total number of circulating vaccine derived poliovirus (cVDPV2) is 25 in six States compared to 25 cases in eight States for the same period in 2010. Jigawa has the highest number of cVDPV cases (11) followed by Kano (9), Borno (2) and one in Katsina, Zamfara and Yobe States. In 2011, Nigeria conducted eight national and sub-national IPDs in January, February, March, May, June, July, September and November. There will be another Special Immunization Plus Days in 12 high-risk States in December. In line with the 21st Expert Review Committee (ERC) recommendations, Nigeria also conducted mop-up campaigns in the polio-affected States. The proportion of missed children during these campaigns has fluctuated. In January Immunization Plus Days, the percentage of missed children was 6% while in September it rose to 6.5% in the northern high-risk States. Non-compliance as a reason for missed children also showed a similar wavy trend.

Fig 1: Trend of missed children (MC) and non-compliance (NC) in 2011 IPDs.

THREE TIMES HIGHER THAN IN 2010

Nigeria continues to experience a surge of polio cases, following a dramatic reduction of cases in 2010. The country remains the only polio-endemic country in Africa. Significant progress has been achieved in Nigeria, with the number of cases collapsing by more than 95% in 2010. However, as of end of November, Nigeria recorded 43 cases of wild poliovirus compared to 14 cases in the same time period in 2010. In the first nine months of 2011, Nigeria has already reported more cases than in the whole of 2010. The States of Borno, Kano, Jigawa and Kebbi account for 85% of all cases nationally. Continued community resistance to the programme is profoundly impacting progress. Caregiver refusals, or non-compliance, to immunize their children still make up a significant proportion of the total number of children missed during campaigns, and refusals are on the rise in some highrisk States. This upsurge of polio cases is also due to higher number of under-immunized population groups and pockets of non-compliance in a few northern States. Routine immunization coverage remains below 80% nationally, with sub-optimal performance by northern States. Over the past months, Nigeria conducted a series of national and sub-national Immunisation Plus Days (IPDs) as well as mop-up campaigns in the polioaffected States. During mopping-up, vaccine is delivered house-to-house to children to ensure that all children are vaccinated. However, the proportion of missed children has shown a slightly increasing trend. Child absent was found as the main reason for missed children. According to Independent Monitoring data, one quarter of all missed children are missed due to refusal, with 68% of missed children due to child absent. The biggest challenges facing the Nigerian programme are to find ways to overcome the operational challenges, as well as the increasing numbers of missed children due to resistance. Experts opine that the eradication of polio from Nigeria in 2012 is feasible if all children under five years of age receive two drops of the oral polio vaccine during Immunization Plus Days campaigns and during routine immunization sessions at the health facility irrespective of their previous immunization status. Nigeria has made a lot of progress in reducing the number of polio cases in the country. More than ever before, the Federal Government, State Governments, Traditional and Religious Leaders and other Partners are committed to stopping polio completely in Nigeria by end of 2012. In September 2011, the Federal Government and the Nigeria Governors Forum signed a re-confirmation of the Abuja Commitments, pledging to reach at least 90 percent of children with polio vaccine with the goal of wiping out polio from the country and improve routine immunization. To achieve the target of Polio eradication requires multiple high quality rounds of Immunization Plus Days Campaigns that reach more than 90% of children under five in all villages.

UNICEF Nigeria /2011/Morgan

UNICEF Nigeria /2011/Morgan

P R O G R E S S
Sustained high awareness of polio immunization
According to independent monitoring data, the level of prior awareness of caregivers about polio campaigns is 98% in all rounds of 2011. According to the September 2011 IPD independent monitoring data, 45% of the caregivers were informed about IPDs by town announcers followed by radio/TV (23%) and traditional/religious leaders (19%). IPD data also revealed that about 75-80% of the decision to immunize the child was taken either by the father or the mother. Consequently, community dialogues involving men and compound meetings with women have been intensified so that caregivers high awareness level can be effectively turned into a positive decision about polio immunization by caregivers. Nationally, the level of awareness about polio immunization has increased from 65% (2009 KAP) to 75% (2010 KAP) with a wide variation among States (25% in Kano to 94% in Bauchi). The milestone target is to bring the awareness level to 85% by the end of 2011. Effort is underway to increase awareness through community dialogues, compound and town hall meetings, Majigi film shows, the use of IEC materials and mass media.

Reduced proportion of noncompliance

Communication activities to address non-compliance have produced promising results. The proportion of missed children due to non-compliance has declined in comparison to 2010. In 2010 non-compliance as a reason for missed children ranges from 47% (2010 January IPD) to 35% (2010 November IPD) in high risk States where as it came down to 27% in January 2011 and 28% in September 2011 IPDs. However, the number of non-compliant wards varies greatly from round to round and is difficult to predict.

Involvement of community in PEI

UNICEF piloted few community-based communication initiatives in three northern States. Neighbor to Neighbor (N2N) in Sokoto, Dattawa & Abokai (Respected elderly women and youth) in Zamfara and Household Adoption Strategy in Kebbi States showed encouraging results by reducing missed children and non-compliance through active community participation. The 22nd Expert Review Committee meeting recommended scale-up of participatory and community-based communication initiatives. UNICEF is now rapidly scaling up communitybased communication initiatives in three priority States. The main objective is to reduce the percentage of missed children during IPDs through targeted interventions to generate demand for and acceptance of Oral Polio Vaccine in Kano, Sokoto and Kebbi States. This project is funded by the Bill and Melinda Gates Foundation.

Decreased immunity gap

The proportion of zero doses NP-AFP cases at national level fell from 3% in 2010 to 2% in 2011. As of 18 November 2011, Borno has more than 12% zero dose children followed by Kano (7%), and Katsina (5%). Three high-risk States namely Gombe, Jigawa and Yobe have 0% zero dose children. Nationally, 22% children among NP-AFP cases received <4 doses of OPV. Progress has been achieved nationally in 2011 where 78% of the NP-AFP children have >3 doses which was 68% in 2010. However, four States Borno (61%), Kano (63%), Yobe (64) and Sokoto (68%) have lower coverage.

Implementation of intensified ward communication strategy

Intensified Ward Communication Strategy was implemented vigorously in 2011 as recommended by 21st ERC and was found to be effective. While 86 wards were identified as very high risk in January IPDs, only 59 remained high risk in September round. This indicates that evidence-based communication planning at ward and LGA level has produced promising results. However, States like Borno, Kano, Jigawa and Yobe still have high number of LGAs with persistent noncompliance (>300 households). As Nigeria approaches the last phase of polio eradication, data driven communication activities and interventions which empower communities to take action will be of high importance to reduce missed children and non-compliance.
UNICEF Nigeria /2011/Morgan

The objective of the intensified ward communication strategy is to reduce the percentage of missed children due to noncompliance of more than10% in the targeted wards through intensified communication activities. Selection of the high-risk wards is based on the following criteria: with more than 20% missed children and more than 30% non-compliance with more than 50% missed children, presence of WPV or cVDPV in the last six months

ADDRESSING CHALLENGES
It is 10.00 a.m. at the health facility of Dawakin Tofa, one of the villages in Kano State with several polio cases this year. Outside of the health facility, a group of women health educators, community mobilisers and vaccinators are preparing to start a house-to-house polio immunization mop-up activity to reach every last child. Among this group, Ms. Hafsat, vaccinator, and her team were assigned to cover a remote village of Yansalmo, where block resistance to polio immunization by the community is still persisting. Why is the polio vaccine given round after round when there is no health care nor clean water in our village? There are so many other diseases like malaria, cholera and meningitis that kill our children; drugs are either unavailable and we cannot afford to buy them, a representative of the village asked when the team arrived. In Kano State, continued community resistance to the polio eradication programme is profoundly impacting progress. Caregiver refusals, or non-compliance, to immunize their children still make up a significant proportion of the total number of children missed during campaigns, and refusals are on the rise in some high-risk areas. According to the latest data analysis, non-compliance accounts for more than four (4) out of ten (10) of missed children in Kano State and in ten (10) Local Government Areas (LGAs), non-compliance accounts for fifty percent (50%) of missed children. It is difficult to convince families under these circumstances, especially when they are facing multiple deprivations. But, through compound meetings and community dialogues, we were finally able to convince villagers to accept the oral polio vaccine. We have been successful in turning around their resistance by increasing their threat perception of polio, Ms. Hafsat said. To address the issue of resistance to polio immunization, local government and polio eradication partners organize regular community dialogues with the support of traditional leaders. In fact, according to the latest data analysis, almost eight out of ten of resolved non-compliance cases were due to traditional leaders interventions. UNICEF also initiated an interpersonal communication training to strengthen the capacity of health educators, supervisors and ward focal persons to convince communities to be immunized against polio. By the end of the year, all these actors - in the States of Kano, Kebbi, Zamfara and Sokoto which account for the majority of all cases nationally - will be trained. Piloted in Kano State, these training sessions will be followed by a cascade training aiming to target all actors at community levels. Media professionals have joined communication efforts to raise awareness around polio issues in some high risks States. Through the Journalists against Polio networks, radio programs with appropriate messages and healthrelated FAQs are periodically on air for mass awareness. Journalists are playing and have to play an important role in communication for social and behavior change. This is why we decided to join our forces and support polio eradication initiative in Nigeria, said Sani Zango, chairman of the Journalists against Polio network in Kano State With all the challenges we are facing, we just have to do more to eradicate this disease, and the most important contribution is to strengthen the health system to improve Routine Immunization coverage Ms. Hafsat concluded. Several pilot projects which have engaged and empowered community volunteers in the efforts to reduce missed children and non-compliance have also shown encouraging results in Nigeria. With the support of Bill and Melinda Gates Foundation, UNICEF is planning to scale up these volunteer community mobilizer initiatives in three priority States as recommended by the 22nd Expert Review Committee. This project will contribute to reducing the percentage of missed children during IPDs through targeted interventions to generate demand for and acceptance of Oral Polio Vaccine in Kano, Sokoto and Kebbi States. Over 900 settlement level volunteer mobilizers will be recruited, trained and deployed in these settlements where refusals have been a persistent problem, says Tommi Laulajainen, UNICEF Chief of Polio Communication. Nigeria continues to experience a surge of polio cases, following a dramatic reduction of cases in 2010. As of November 25, Nigeria recorded 43 cases of wild poliovirus compared to 14 cases in the same time period in 2010. In the first nine months of 2011, Nigeria has already reported more cases than in the whole of 2010. This upsurge of polio cases is also due to higher number of under-immunized population groups and pockets of non-compliance in a few northern States. Routine immunization coverage remains below 80% nationally, with sub-optimal performance by northern States. The country remains the only polio-endemic country in Africa. A national and state level raise awareness and advocacy campaign Polio-Free Torch campaign - was recently launched in the country to reinforce advocacy efforts and to mobilize wide support from a variety of stakeholders at all levels for the last lap of the polio eradication efforts in the country.

UNICEF Nigeria /2011/Morgan

C H A L L E N G E S
Lack of commitment of health workers
In principle, health workers need to be in the forefront and spearheading the polio eradication effort in Nigeria. However, the contribution of the health workers in communication activity has been found very minimal and that may indicate lack of commitment from them. In 2011, the contribution of health workers as a source of information and influencer has been found below 5% in all rounds. Interpersonal Communication (IPC) skills training as part of the IPDs training packages was found to be ineffective. Knowledge of health workers about polio, the vaccine efficacy and safety is poor. Health workers also hardly make efforts to resolve non-compliance and track child absence. Considering the importance of involving health workers in a more effective manner, UNICEF has started IPC Skills training in high-risk States. Training of trainers on IPC Skills has already been completed in Kano and Sokoto and by December, in two other States.

2011 national election and security situation

With the 2011 national and state level elections, the government at different levels gave its priority and focus on the election campaigns for a certain period. Likewise, the mass media was also preoccupied for extended period of time by election coverage. Tracking of the implementation of Abuja commitments (Governors and LGA Chairmen involvement in IPDs) shows a downward trend with the new faces of leaders at national, State and LGA levels. However, it is expected that the ongoing advocacy efforts and Polio-Free Torch campaign will increase the commitment level of Governors and LGA chairmen in the high risk States. The August 26, 2011 bomb attack at the UN House in Abuja was also a big blow to the normal functioning of UNICEF and other partners like WHO. Several staff of UNICEF and WHO died in that incident and many were injured. The situation was very stressful and still there are threats of more bomb blasts. However, UNICEF was able to rapidly recover from this incident with renewed commitment to polio eradication in Nigeria. States like Borno, Bauchi, Yobe, Kaduna and Plateau also have faced repeated outbursts of violence in 2011. Sectarian carnage erupted a number of times this year in Plateau, Kaduna and Bauchi while abduction, bombing and killings have become common in Borno.

POLIO-FREE TORCH

AWARENESS AND ADVOCACY CAMPAIGN

The Federal Government of Nigeria with the support of the Polio Eradication Initiative partners launched a new communication campaign on September 24th, 2011, entitled Polio Free Torch Campaign. Supported by the Nigerian Olympic Committee (NOC) and a number of Nigerian Olympians, this campaign is designed to overcome resistance to polio immunisation and to mobilize wide support from a variety of stakeholders at national and State levels for the last lap of the polio eradication efforts in Nigeria.

This is a war. Not a war on killing people, but a war for the survival of people
His Royal Highness, The Emir of Kano State, Nigeria

The Polio- free Torch will serve as a reminder to all Nigerians that a healthy Nigerian child can grow up to be an Olympian and win laurels for the country, said the Vice-President of the Federal Republic of Nigeria, Namadi Sambo, on behalf of the President, Goodluck Jonathan. As the world heads for the London 2012 Olympic Games, the Polio Free Torch illustrates the determination of the Nigerian Polio Eradication Initiative to make the year 2012 the last year that Nigeria witnesses a case of Polio. The campaign kickoff at the federal level has already initiated a series of State level launches in the Northern States which are still considered at very high risk from the wild polio virus. Olympic Icons in each State carried the Polio Free Torch during a public Polio Rally to sensitize the public and engage their support. In Niger State, the Governor commits to release funds for polio eradication programmes in the state until the end of the year. He also instructed all local government chairmen to rise up to the task of eradicating polio from the State. In Kano, one of the highest risks States in the country, the torch campaign serves as a symbol of renewing the commitments of all the main stakeholders. The State tour joined by Nigerian Olympians featured lighting of the torch by the Governor to symbolize the States commitment to eradicate polio by the London 2012 Olympics. Governors decorate a number of key influencers as Polio Ambassadors with the Polio free lapels. We are racing against time with the global goal of eradicating polio from the world by 2012. UNICEF believes that partnerships and collaborative relationships with all stakeholders at all levels are critical to deliver results for children and to ensure that not a single Nigerian child will be victimized by this crippling disease, said Dr. Suomi Sakai, UNICEF Representative in Nigeria. Private sector companies have also expressed their interest to support this special advocacy campaign. Flash IT Solutions is among the corporate companies responding to the call for support issued by PEI partners, by designing and hosting free of charge a dedicated website for the campaign. The telecommunication company, Visafone, also supported the campaign by financing print advertisement in the newspapers.

COMMUNITY MOBILIZERS NETWORK

TARGETED INTERVENTIONS TO GENERATE DEMAND FOR AND ACCEPTANCE OF ORAL POLIO VACCINE
Several pilot projects which have engaged and empowered community volunteers in the efforts to reduce missed children and non-compliance have shown encouraging results in Nigeria. In October 2011, 22nd Expert Review Committee recommendations clearly emphasize the need to strengthen community empowerment through up scaling community based innovative approaches following intensified ward communication strategy (IWCS). Some community based innovative strategies were piloted at High Risk settlements at various polio endemic States. Case studies were submitted with before and after the intervention data analysis, and some very positive trends of reduction in non-compliance and missed children were noticed. Over 900 settlement level volunteer mobilizers With the support of Bill and Melinda Gates Foundation, UNICEF is starting to scale up these volunteer community mobilizer initiatives in three priority States as recommended by the 22nd Expert Review Committee. This project will contribute to reducing the percentage of missed children during Immunization Plus Days through targeted interventions to generate demand for and acceptance of Oral Polio Vaccine in Kano, Sokoto and Kebbi States. All high risks LGAs, Wards and Settlements will be identified. Over 900 settlement level volunteer mobilizers will be recruited, trained and deployed in these settlements where refusals have been a persistent problem: 557 settlements in Kano, 200 in Kebbi and 200 in Sokoto. Through this extensive Social Mobilization efforts and increased House-to-House behavior change communication, Polio Eradication Initiative aims to achieve the goal of immunizing missed children and making Nigeria Polio Free.

Neighbour to Neighbour communication approach to reduce non compliance

Makwabci to Makwabci (Neighbour to Neighbour) aims to reduce non compliance and child absent in high risk settlements. Neighbour to Neighbour is a community-based approach delivered by volunteers and strengthens community ownership and action for addressing local health issues with special focus on Routine Immunization and polio eradication. Volunteers serve as champions for their neighbours, families and friends. The purpose of volunteers is to conduct informal conversations with their neighbours in community settings. Volunteer training was designed to provide key facts about aims of this project, polio updates/risk, Routine Immunization, Wild Polio Virus, Polio Eradication Initiative, Oral Polio Vaccine, sanitation and hygiene. Volunteers conduct individual conversations with their neighbours. Reasons given for holding individual conversations were to encourage open conversations, as people are more likely to query rumours and vocalise doubts on a one-to-one basis, expectations of groups include pluses.

House-to-house mop-up at the village of Kashirmo in Kano State Nigeria /2011/Morgan UNICEF
Hafsat, the vaccinator, uses her interpersonal skills to engage with a nervous mother clutching her child close to her. She explains about prevention of childhood diseases and the importance of Routine Immunization to the mother who draws closer, listens and looks carefully at the picture of the child with polio. Hafsat shares more pictures and information on vaccinepreventable diseases and a quick lesson on health hygiene and sanitation and care of her baby. The mothers face is transformed with a smile as she vaccinates her child with oral polio vaccine. Hafsat is confident that this mother has understood the importance of giving her child the oral polio vaccine drops. Before she steps out of the household, she explains where and when to take her child to the health facility for Routine Immunization.

FOR MORE INFORMATION, PLEASE CONTACT

Tommi Mika Laulajainen Chief of Communication (Polio) +234 706 401 9646 tmlaulajainen@unicef.org UNICEF Nigeria Country Office www.poliofreenigeria.com Facebook page: Polio Free Nigeria

UNICEF Nigeria /2011/Mendes