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A Social Norm Strategy for Polio Eradication in Pakistan Susan Roe, UNICEF ROSA / Kathmandu, Nepal

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Now A Much More Localized Problem

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Global Efforts = Continued Progress GPEI Goals: By end 2011: Cessation of transmission in at least 2 out of 4 endemic countries; and, By end 2012: Cessation of all WPV transmission!

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Pakistan Epidemiology - Challenges From 2011 cases / data: 71% cases below 2 years of age 77% Cases Pashto Speaking (89% of Karachi cases) 23% of the polio cases from 'refusal' families 88% cases living in Multiple Family Dwelling Vaccination status (based on recall): 31% no OPV dose 73% no routine OPV dose

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An Innovative Approach Needed for Engagement with HRGs From WPV Cases 2009 - 2012 Pashto speakers: 73% Have lower knowledge and risk perception regarding disease (factual beliefs / personal normative beliefs e.g. attitudes - individual); Yet concerns / lack of knowledge about OPV safety are largest among Pashtuns (with rumors of infertility / sterility also highest in this group); Are more likely to chronically refuse than other groups; and, Among all 2011 refusal cases (47) or 89% were Pashto-speakers mostly clustered in / around Balochistan. *KAP 2012

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Refusal A Social Norm? Consider Social Dimensions What do other community members do or say? (Empirical Expectations) My neighbors dont accept and told me that this vaccine is brought from America and contains family planning medicine. What do people in the community expect from me or others? (Normative Expectations) My mother-in-law does not allow taking of the drops. She says that her children remained safe without them, so yours will be fine. Are there consequences for not complying? (Normative Expectations) These drops are not accepted by our household (e.g. husbands) and if we raise the issue we could be kicked out of our home if we dare say something. Or perhaps - What do I do based on actions of others (but not caring what they think)? A Descriptive Norm?! Need for further research and investigation!!!

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Challenges Associated with Existing Polio Structure Top down multi-level structure; Perceived as externally / internationally driven; Focus: individual behavior (acceptance), coverage and prevalence numbers; Delivered door-to-door - isolates / privatizes action - casts community as receivers; Messaging primarily one-way announcing campaign dates and promoting readiness to receive; Fails to address other issues (intensive focused on eradication but some linkage to RI - convergence); and, Credibility, motivation and geo-political dimensions highly contentious (Western conspiracy, drone attacks vs. immunization, fake campaigns to locate Bin Laden).

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Existing Communication / Social Mobilization Strategies Message development - demand creation, addressing incorrect factual beliefs and shifting attitudes (Individual); Enlistment of multiple relevant network members / influentials as part of process and to enhance credibility and trust (Social) ; Introduction of new relevant network - Com Net (in HRDs) to forge linkages with communities for engagement and interaction (Social); Recruitment of HR group members / women as part of network and build capacity (Social);

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Existing Communication / Social Mobilization Strategies Specific HRG strategies reach out to marginalized populations (festivals and religious gatherings information provision (Individual); New mass media campaign (How Far Would You Go?) to activate stakeholders across levels & increase visibility (Individual); Enlistment of celebrity and culturally relevant advocates to promote polio for the wider population (localized ownership - Individual); Continued work with media to promote relevance, benefits and success at local level (visibility, local ownership / support - Individual).

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Further Considerations Data related to factual beliefs and personal normative beliefs (attitudes) available through past research initiatives; Resistance to the vaccine may be affected / influenced / motivated by social expectations; Will require more investigation / research into Empirical and Normative expectations; In addition to survey tools use of in-depth interviews and focus group discussions can also be applied.

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Sample Empirical Questions: Do your neighbors accept polio drops every time they are offered? Why or why not? Do your leaders encourage you to immunize your child and that polio drops are safe and cause no harm? Does your family members (husbands / mother in laws) welcome polio vaccinators when they come to your door? Does your community encourage one another to support social mobilization around OPV and to accept drops when they are offered each and every time? Sample Normative Questions: Do you feel that your neighbors think that you ought to accept polio drops every time they are offered? What happens to a member of the Pashtun community who accepts polio drops when others feel that he / she shouldnt? Do you think that your neighbors believe you and others in the community should accept OPV because it is beneficial for the whole community? What would your community do or say about someone who accepted polio drops when others disagree or feel they should be refused?

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Desired Outcomes Polio acceptance / demand creation at care-giver and household level (PB - Individual); Positive attitudes around vaccine acceptance and service seeking behavior (PNB - Individual); Demand and acceptance for polio drops demonstrated and promoted by others (EE - S); Create expectation that community / relevant network expects others to demand and accept OPV each and every time it is offered (NE - S). To do this in addition to existing strategies - need to introduce new social norm around polio acceptance within the HRG (e.g. Pashtun) community.

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Review data / conduct additional research related to further learning and next steps addressing social expectations; Revisit existing messages and strengthen interdependent dimensions / social normative perspectives; Use collective meetings (facilitated by Com Net and relevant network members or leaders) for values deliberation and unpacking scripts related to good parenting, child health and social identity; Use triggering to explore issue of social dilemma and for addressing incorrect factual beliefs / rumors; Restructure existing networks through blending of Com Net and traditional leaders in support of organized diffusion; Use traditional gatherings or religious festivals as a mechanism for bringing polio discourse more out into the open while building credibility and trust; Proposed Way Forward

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Use of pledges or public affirmation of commitment to new polio acceptance norm (building visibility, confidence and trust); Consider use of symbolic, collective immunization events to signal shift to new norm, build confidence and solidify internal motivation (also ensure acceptance when H2H rounds commence); Sustain and prevent slippage through continued engagement with local Com Net workers and social mobilizers / vaccinators from local community; Continue / build on existing polio social mobilization activities in support of organized diffusion to sustain and reinforce (other partners and media to expand reach and spread); Promote harmonization of social and moral norms around immunization and gather evidence to negotiate with officials regarding timing / severity of proposed legislation; Explore possibility for replication especially along migration routes, cross border or at end point destinations; and, Celebrate win win situation with community, leaders, GoP, PEI partners as related to implications for county, regional and global eradication.

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Potential Risks /Additional Challenges Time / effort required for additional research / analysis for new data related to expectations; Community dialogue / discussion needs skilled facilitation capacity?; Sensitivity of specific group being targeted / singled out; Visibility of collection immunization could also be mis- understood or perceived as sensitive (and backfire with other groups / media); Limited time (GPEI goals) for implementation / process!

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Many Thanks for Kind Attention!