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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 27
| Issue : 1 | Page : 1-13 |
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Evaluating nongovernmental organization–led community mobilizers in health promotion, immunization campaigns, and acute flaccid paralysis surveillance: a systematic review of the evidence
Muktar A Gadanya1, Chihurumnanya Alo2, Amina A Umar1, Kabiru A Ahmad3, Tolulope Afolaranmi4, Davies Adeloye5, Rayyan M Garba1, Bashir Dabo6
1 Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano State, Nigeria
2 Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
3 Federal Medical Center, Birnin Kudu, Jigawa State, Nigeria
4 Department of Community Medicine, University of Jos, Plateau State, Nigeria
5 Centre for Global Health, Usher Institute, University of Edinburgh, Scotland, United Kingdom
6 College of Public Health, University of South Florida, Tampa, FL, United States of America
| Date of Submission | 02-Feb-2021 |
| Date of Decision | 18-Apr-2021 |
| Date of Acceptance | 18-May-2021 |
| Date of Web Publication | 3-Dec-2021 |
Correspondence Address:
Muktar A Gadanya
Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano State.
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.IJMH_5_21
Community mobilization, partnership, and surveillance are regarded as key elements in various polio eradication activities. Several nongovernmental organizations have led community mobilizers (CMs) in different aspects of the polio eradication campaigns, and their effectiveness shows mixed findings. This study systematically reviewed the literature on the role of CMs in polio eradication activities. Literature searches were conducted using a combination of key words to find relevant published studies up to 30 November 2020. The 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist addressing the various components of systematic review was adhered to. A total of 1627 articles were identified by the search, with 65 articles passing the title/abstract and full text reviews, and with four additional articles obtained from references of articles included (making a total of 69 articles). Of these 69 articles involved in the review, 24 (five reviews and 19 original articles) focused largely and explicitly on CMs and were included in the full review. The rest (45) discussed CMs in a broader context, hence they were summarized based on part 1 of the data extraction form only.The findings of the review indicated that although CMs’ instrumental role in health promotion and supporting immunization is consistent for all the reviewed studies, their role in acute flaccid paralysis (AFP) case detection is limited. The role of CMs, other actors in community-based surveillance, and health education needs to be further strengthened, particularly in high-risk communities where routine immunization and AFP surveillance are much needed. Keywords: Acute flaccid paralysis, community mobilization, community mobilizers, polio and systematic review
How to cite this article:
Gadanya MA, Alo C, Umar AA, Ahmad KA, Afolaranmi T, Adeloye D, Garba RM, Dabo B. Evaluating nongovernmental organization–led community mobilizers in health promotion, immunization campaigns, and acute flaccid paralysis surveillance: a systematic review of the evidence. Int J Med Health Dev 2022;27:1-13 |
How to cite this URL:
Gadanya MA, Alo C, Umar AA, Ahmad KA, Afolaranmi T, Adeloye D, Garba RM, Dabo B. Evaluating nongovernmental organization–led community mobilizers in health promotion, immunization campaigns, and acute flaccid paralysis surveillance: a systematic review of the evidence. Int J Med Health Dev [serial online] 2022 [cited 2023 Feb 8];27:1-13. Available from: https://www.ijmhdev.com/text.asp?2022/27/1/1/331727 |
| Introduction | |  |
The Global Polio Eradication Initiative (GPEI) has made substantial progress toward the attainment of a poliomyelitis-free world since its inauguration at the World Health Assembly (WHA) in 1988, but challenges still remain.[1] Since then, the WHA has urged polio endemic states to engage local leadership and members of the community in the remaining polio-affected populations to ensure acceptance of polio eradication interventions.[1] This initiative requires community mobilization, partnership, and effective surveillance systems to guide polio programmatic action.[2],[3],[4]
The community mobilizers (CMs) have been regarded as valuable tools in strengthening routine immunization for polio and other vaccine preventable diseases, conducting supplementary immunization and mop-up vaccination for successful polio eradication campaigns,[5],[6],[7] and in acute flaccid paralysis (AFP) surveillance.[8] A CM is an active community member who is well respected and conducts house-to-house surveillance. They are expected to be responsible for documentation, and they support pre-, during, and post-implementation activities.[9] Individual reports from different countries have been published on the role that CMs play in various activities related to polio eradication, including routine immunization, particularly in endemic, hard-to-reach, resistant, or security-challenged areas.[1],[4],[6],[8],[10] However, to our knowledge, no systematic review of these findings has been published.
In Uttar Pradesh, India, CMs were credited with achieving higher-than-expected community participation in polio immunization activities, a dropout rate of less than 7%, and increased booth coverage in the mobilized communities.[5],[11] Similar roles were also found in the Bombay slum of Malavani, India, where diphtheria-pertussis-tetanus (DPT) follow-up increased from 67% to 78% and the incidence of paralytic polio decreased between 1980 and 1987.[10] Similar findings were reported in Karachi, Pakistan.[12]
In Africa, after the major polio outbreak in Ethiopia in the year 2000, CORE Group Polio Project (CGPP)–led CMs were credited for successfully linking the mobile dispersed populations with the formal healthcare system. This resulted in the country’s increase in AFP case detection rate from 0.7% in 2000 to 2.8% in 2010.[13] In the same vein, while investigating the drivers of routine immunization in Africa, La Fond et al. found that community volunteer groups, among other factors, were responsible for a 15% average increase in the DPT3/Penta3 coverage between 2006 and 2010 in the selected countries of Ethiopia, Cameroon, and Ghana.[14] There were similar findings in Somalia[15] and Nigeria.[16],[17]
Some areas in Nigeria were known to be highly resistant against immunization activities and to occasionally harass or attack immunization teams. These areas were successfully tamed through the use of CMs in immunization campaigns.[18] For instance, in an immunization-resistant community in Nigeria, a World Health Organization (WHO)–led CM group involving mainly youth groups resulted in a significant decrease in the proportion of missing children from 7% in 2007 to 2% in 2015. Similarly, the number of noncompliant households in the community decreased after the intervention.[18],[19]
With billions of dollars expended on polio eradication, even a single case of Wild Polio Virus (WPV) can lead to a setback for the enormous success achieved at huge material and human costs. This study aims at systematically reviewing the literature on the effectiveness of nongovernmental organization (NGO)–led CMs to increase social mobilization to promote health messages, immunization campaign participation, routine immunization, and improve AFP case detection.
| Materials and Methods | | |
Data sources and search strategy
A wide-ranging literature search was conducted on electronic databases by a public health information specialist with experience in conducting systematic literature search. A combination of keywords that reflect CMs and polio eradication and routine immunization was employed in the searches. The terms for the systematic search were adaptations from the validated filters for online version of Index Medicus produced by the United States’ Library of Medicine (PubMed) (Shojania and Bero)[20] and an Elsevier database of research articles and related works (EMBASE) (Wilczynski and Haynes)[21] and were parallel-reviewed again by another expert. Duplicates were identified and removed from the list of retrieved articles before conducting title and abstract screening on a spreadsheet. This study included studies published in the English language up to 30 November 2020. The complete search terms are provided in Appendix 1. 
Study selection
Eligibility criteria and screening
The identified articles sourced from PubMed, Scopus, EMBASE, African Journals Online (Ajol), WHO, and United Nations Children Funds (UNICEF) websites were screened based on the agreed inclusion and exclusion criteria. The criteria for inclusion were: (i) studies with any of the quantitative, qualitative, and/or mixed methods; and (ii) studies with a focus on CMs in the context of the polio eradication initiative and routine immunization.
Articles that had no explicit mention of CMs or community mobilization were excluded.
Two reviewers screened all titles, findings were compared, and disagreements were resolved by a consensus-based discussion on the guidelines of Furlan, et al.,[22] with persisting disagreements resolved by a third, more experienced reviewer.
The full texts of articles involved in the review were sourced and subjected to another screening to ensure that they met the inclusion criteria. Totally, 1627 articles were identified by the search, with 65 articles passing the title/abstract and full text reviews, and with four additional articles added from the references of articles included (making a total of 69 articles). Of these 69 articles involved in the review, 24 (four review and 19 original articles) focused largely and explicitly on CMs and were included in the full review. The rest (45) discussed CMs in a broader context, hence they were summarized based on part 1 of the data extraction form only.
Data extraction
The following data sets from the agreed-upon full publications were extracted using a pretested extraction form: (i) general characteristics of the review, including country, subnational focus, funders, implementers, aim and nature of the intervention(s), study type, and presence and/or absence of controls; and (ii) review summary, comprising the specific intervention/research objectives of and the major findings and general characteristics of the article.
The extraction sheet also has two parts: (i) the article’s general characteristics and summary of findings, and (ii) specifics of funders, implementers, and outcomes for specific objectives.
Data analysis
Data were extracted using the described framework and recorded on a Microsoft Excel spreadsheet. The findings were combined on a component-by-component basis to aid theme identification and description.
Findings were reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Liberati, et al.).[23] However, the findings could not be presented quantitatively and summary measures based on calculations were not possible due to the wide disparity of the reporting strategies and outcomes of the studies reviewed.
| Results | | |
Search results
The database search yielded 1625 articles (from PubMed, Scopus, EMBASE, and WHO Global Health regional databases) that were potentially relevant to the systematic review. After the title/abstract review, 84 articles were selected for a full text review, after which 19 more were excluded.
Of the remaining 65 reports [Figure 1], 24 articles (five review and 19 original articles) satisfied the secondary inclusion criteria, that is focused largely and explicitly on CMs or community mobilization and were included in the full review. The rest (41) did not meet the criteria, hence they were summarized based on part 1 of the data extraction form only, together with four additional articles added from the references of articles included. | Figure 1: Flowchart of the article selection process. CM = community mobilize
Click here to view |
Most of the reviewed articles on the contributions of CMs to polio eradication were conducted in India, Nigeria, and Pakistan. Some studies were exclusive to certain countries, whereas others were a part of multicountry investigation, as shown in [Table 1]. | Table 1: Setting of the 24 articles with exclusive/primary focus on community mobilizers
Click here to view |
Details of the studies’ contexts and findings are provided in Tables 2–4.
| Discussion | | |
This systematic review used the available literature to point the various mechanisms through which CMs participated, with an implication for ways to enhance their roles and integration into health systems [Tables 2]. It also shows their dynamic roles in various polio eradication and routine immunization strategies at different geographical settings [Table 3][Table 4][Table 5][Table 6]. | Table 2: Summary of the CMs’ roles in polio eradication activities and routine immunization
Click here to view |
The promotion of health messages by CMs decreased resistance to polio vaccine uptake in the high-risk districts of India and Chile and increased community awareness about poliomyelitis.[8],[41]
Other studies describing the relationship between CMs and immunization promotion for both immunization campaigns and routine immunization have found similar results.[17],[42],[43],[44],[45],[46]
In Afghanistan, studies wherein community-based healthcare professionals worked with community volunteers increased childhood vaccination coverage rates for the basic vaccines.[47] Cutts found that urban immunization programs require intersectoral collaboration to mobilize community members and community structures to vaccinate eligible children and their mothers.[44] They also showed the benefits of community mobilization to identify and refer eligible people for vaccination.
The polio birth dose is an important entry step for routine immunization and it can help to strengthen trust in safety of the vaccine; other services that the healthcare system can provide and community mobilization are shown to be essential for ensuring polio birth dose vaccination.[45] Proactive engagement with the community by CMs, such as door-to-door immunization services, has improved DPT and polio primary vaccination.[17] In addition, the selection of well-integrated CMs and proper training is a vital component in improving vaccination rates.[46]
Although CMs have consistently been shown to have beneficial effects on supporting routine immunization services,[42],[43],[44],[48],[49] their roles in AFP case detection reported mixed findings. Lack of proper training and supervision were the most cited reasons for the poor performance of AFP surveillance systems. In another study, it was found that the limitations of community volunteers and health extension workers in detecting cases of AFP were due to lack of knowledge of the formal case definition.[39] Low literacy and lack of adequate supervision of the community volunteers led to less effective surveillance systems. Training CMs on case definition and the elements of community-based surveillance (CBS) will improve the ability of community volunteers and health extension workers to detect and report cases of AFP.[40],[50],[51],[52]
Another barrier in establishing successful CBS systems is security. Research examined a broad range of strategies in the unstable states of Adamawa, Borno, and Yobe in Nigeria where the security challenges have led to the killing of health workers, destruction of health facilities, and displacement of large populations.[34] They conducted a retrospective review of AFP surveillance between 2009 and 2014, using the AFP database at the WHO, Nigeria country office. They also reviewed the reports of surveillance activities conducted in these states to identify strategies that were implemented to improve polio surveillance. They identified the annual training of surveillance officers, an increase in the number of community informants, and media-based messaging (via radio and television) to sensitize the public to the importance of surveillance as the key strategies to strengthen case detection.
Another recommendation from the literature to improve AFP surveillance is mass media messaging to entire communities, not only to CMs.[39],[51] It was found that only about one-fifth of the studied sample in Nigeria were aware of the AFP surveillance system/activities and only 6.6% could give a correct definition of the meaning of AFP surveillance.[53]
There has been some success with building effective community-based AFP surveillance. This study examined the introduction of CBS of AFP by the CGPP in Ethiopia. The system was created from a partnership between Ethiopian and U.S.-based NGOs. The CGPP supported volunteers in capacity building regarding AFP and in facilitating case reporting. Volunteers additionally conducted active AFP searches, visiting community leaders who were likely to know of AFP cases. The researchers found a near doubling of AFP reporting in project areas since the implementation of CBS, according to key informant interviews with stakeholders.[13]
The literature on community mobilization for polio eradication indicates that CMs can be used to successfully improve vaccination rates, educate, and engage communities about polio and AFP. However, the literature is still fairly limited. For examining the success of CMs in health messaging for polio eradication, only two papers fit the inclusion criteria. Although other papers explored the impact of CMs on promoting health messages, they did not meet the rigorous scientific requirements to apply their findings to program strategies. There needs to be more rigorous examination of the impact of CMs on polio eradication. Understandably, these studies are not easy to conduct as polio eradication campaigns are now mostly concerned with marginalized and isolated subpopulations. However, their findings can have an impact outside of polio eradication campaigns, indicating how to best engage with these communities to improve health outcomes.
| Conclusions | | |
This review shows that CMs positively support social mobilization activities for the promotion of health messages, immunization campaign participation, and routine immunization; they have also remained a valuable tool for effective AFP case detection, reporting, and overall surveillance strategies in their respective communities for successful polio eradication program and routine immunization. Although there seem to be consistent findings in all the reviewed studies regarding their role in promotion of health messages, immunization campaign participation, and routine immunization, their effectiveness in AFP case detection is relatively limited because of the need for more training and low literacy level among significant proportion of CMs. It is evident that increasing the CMs’ ability to identify AFP is necessary and should extend beyond just CMs to the general community through mass media.
Based on the findings of this review, it is recommended that CMs require adequate supervision and support to improve theirs and the community’s ability to contribute to routine immunization and polio eradication initiatives and activities, notably through community participation and CBS. The CMs need sufficient and continual training on all aspects of their work, related to routine immunization and ongoing activities with the GPEI with special emphasis on AFP case detection. Studies in this review showed that their low formal education on case definitions of AFP contributed to underperformance in AFP case detection relative to other tasks in polio eradication and routine immunization. The CMs’ role should be expanded to work with other formally engaged actors in the GPEI, with increasing engagement in routine immunization and other aspects of health care as the GPEI enters its final stages. Identification and capacity building by hiring additional CMs should be cognizant of the limitations and experiences of the currently trained CMs. In addition, CMs and other actors in CBS need to be further motivated through capacity building and special recognition, especially in all high-risk communities.
With the burden of AFP and WPV on regional and global decline, it should be remembered that humongous material and human resources were expended on polio eradication and even a single case of WPV can lead to a setback for the enormous success achieved at huge costs and with extraordinarily large opportunity costs to other health and human development activities. Every effort needed to globally eradicate polio needs to be sustained.[84]
Acknowledgements
The authors acknowledge Drs. R. Ibrahim, A. Sari, U. M. Ibrahim, and F. S. Dankishiya for their help during the process of writing this article.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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