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Learning Briefs – Pakistan Polio Communication February 2021
BUILDING TRUST
Learning Brief 1
CONTEXT
The large majority of Pakistan’s population willingly vaccinate their
children, participate regularly in supplementary immunisation
activities (SIAs), and believe in the effectiveness and safety of the
polio vaccine. However, trust varies over time, across the country,
and amongst different groups. It can be lost easily and is difficult to
rebuild. In some communities, trust is so low that parents make
little effort to ensure children are available during campaigns (or
even hide them), directly refuse the vaccine, or intimidate frontline
workers (FLWs) to falsify vaccination, leading some children to be Bottlenecks and Gaps
finger-marked when they have not been vaccinated. Even in
communities where vaccination rates are high, gaps in knowledge, Local context is everything.
changes in risk perception, or frustration with frequent rounds can
• South Khyber Pakhtunkhwa (KP)’s history of
leave caregivers more susceptible to believing destructive rumours
insecurity and legacy of destroyed infrastructure, limited
or diminish their enthusiasm for the polio programme. Due to such
complexities, gaining and sustaining trust is not a one-off activity. social services, economic disruption, widespread public
distrust of outsiders, and few skilled medical personnel and
teachers makes it a unique and difficult place to build trust.
This history is compounded by high levels of poverty, low
Public trust in vaccines and immunization levels of literacy, and pent-up demand for healthcare services
well beyond polio.
programs is a dynamic and changing
• In other areas, illicit activities or families without
phenomenon. - The Vaccine Book proper documentation create further reasons to distrust
outsiders. Conservative religious groups cast doubt on the
polio programme’s agenda or consistency with Islamic law,
Recent polls have found that 95% are positive about vaccination
“posh” neighbourhoods can view FLWs and campaigns as
and 96% trust polio workers which corresponds to earlier data
beneath their status, nomadic groups can be suspicious of
that found that 98% (outside the Federally Administered Tribal
outsiders, and the underserved can use rejection of polio
Areas - FATA) and 86% (inside FATA) believed polio drops
vaccine as leverage in struggles for other services.
were good or somewhat good, and 99% (non-FATA) and 95%
(FATA) said they had received drops in the previous round. • In many communities, suspicions have led to
However, trust is not a fixed or permanent state. Continued politicisation, culminating in targeted attacks on staff, bans
exposure to rumours and/or community frustration from on campaigns, and multiple and widely accepted rumours
neighbours or influential people can change people’s attitudes. that the programme represents an international agenda that
As seen in the fallout from the events of April 22, 2019 the 'slow seeks to do harm or is not halal.
drip' of frustration and rumour can create environments prone to
crises. As far back as 2014 research pointed to this danger with • Much, though not all, of this suspicion is
12% (non-FATA) and 33% (FATA) having heard and believed concentrated in areas where the dominant language and
destructive rumours. culture is Pashtun.
• Building trust will require ownership of the
programme not only on the part of Pashtun and other
underserved and marginalised communities but also by posh
neighbourhoods and a representative group of allies from
across Pakistani society.
Learning Briefs – Pakistan Polio Communication February 2021
Lessons: The Nigeria Boycott
In 2003, the political and religious leaders of Kano, Zamfara, and Kaduna
states of northern Nigeria began a boycott of polio vaccination. They argued
that the vaccine was contaminated with anti-fertility, HIV, and/or cancerous
agents and was part of a western anti-Muslim agenda. The boycott wasn’t the
result of a single event or pronouncement but, rather, was the culmination of a
series of events and the discourse around them, including the terrorist attacks of
September 11, 2001, the Iraq war, a recent drug trial scandal, and political
distrust between Northern Nigeria and the federal Nigerian government. The
resultant loss of trust in the polio programme reached from the highest levels of
political, religious, and traditional leadership to the doorsteps of villages across
northern Nigeria. Turning the tide on this situation took several years and cost
the Global Polio Eradication Initiative (GPEI) an estimated US$500 million.
Key Lessons: Recovery from an erosion of trust is neither easy nor quick.
Rebuilding trust required a multi-layered and sustained approach that included
advocating with senior political and religious leaders, developing and “Recovery from an erosion of
sustaining relationships to engage traditional leaders, working with polio
survivors who could make the value of vaccination understood through
trust is neither easy nor quick
personal experience, and responding to community suspicion and concern by … most importantly, it
changing immunisation practises and building social mobilisation capacity. involved extensive dialogue
Perhaps most importantly, it involved extensive dialogue with key influencers
at all levels led by trusted people. This was the case for the most senior with key influencers at all
leadership and the caregiver at the door. The approach involved changes in levels led by trusted people
programme operations, such as adding incentives during campaigns and
assuring people the vaccine would be sourced from a Muslim country, and also …”
in programme communication by engaging influential advocates at all levels
and developing new media campaigns.
Figure 1 Community Empowerment Reinforcing Approaches
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Learning Briefs – Pakistan Polio Communication February 2021
Lessons: India’s Influencers
In the mid-2000s, India's polio programme was being held back
by misinformation that led elders and local leaders to discourage
participation in immunisation programmes. Analysis revealed
the concentration of these issues in Muslim communities that
also had high rates of un- and under-immunised children. India
had already developed a social and behaviour change “Different influencers to
communication (SBCC) strategy focused on identifying and
involving community members who had social, political, and
reach different
economic influence and were viewed as sources of credible populations … Sustain
information. However, the lower levels of coverage amongst over time … no substitute
Muslims were an indication that India’s SBCC influencer for local knowledge …
strategy was not reaching this large and underserved minority
identification of the who
group. This recognition led to the engagement of Muslim
communities to better understand the issues they faced and the and why?”
concerns they held. This new understanding formed the basis for
identifying, engaging, and supporting influencers they trusted to
Ways Forward
respond to those concerns. Trust is not a new concept or area of focus for Pakistan
or the GPEI as a whole, but it can be a tricky one to
Key Lessons:
understand, measure, and achieve. It is important to
• Different types of influencers are needed to reach begin with a framework to help define the areas trust-
different populations, even within the same community. building should focus on and the principles it needs to be
built on. If, for instance, we look at UNICEF’s 2013
• This work needs to be sustained over time, and framework in the appendix, the dimensions and
influencers need to be supported with training, resources, principles outlined can help clarify the focus of trust-
recognition, and regular engagement with the programme. building initiatives and the approaches required to
develop relationships between the community and polio
• There is no substitute for local knowledge in the
identification of local influencers, and, where the programme programme that are strong enough to achieve eradication
has FLWs, these personnel can be a great resource in identifying levels of vaccination. The issues that drive distrust and
and supporting those local advocates. therefore the responses will be different for different
communities, so the approach needs to be flexible, led by
• Influencers are one part of a trust-building strategy and well-resourced, supported, and confident FLWs and
need to be integrated into other elements such as training, influencers, developed through dialogue with
support materials, identification of the “who?” and “why?” of communities and their leaders, and promoted publically
resistance, mobilisation activities, media campaigns, and by a range of influential partners and individuals.
continued tracking of resistance and its reasons within subsets of
communities. The framework for communication describes a shift from
a health belief model that emphasises risk perception to
one that focuses on building social norms that reinforce
and encourage polio vaccination. Behavioural Insights
and nudge theory are to be used within the mass media
campaign Vaccinate to Eradicate, and community
empowerment approaches are to be used in high-risk
local areas implemented in a 5-step process shown in the
diagramme above – Inform, Consult, Involve,
Collaborate, Empower. This will be done through long-
term SBCC interventions that will operate in a sustained
way between vaccination campaigns. Differentiated local
strategies will focus on approaches tailored to high-risk
underserved communities.
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Learning Briefs – Pakistan Polio Communication February 2021
Ways Forward continued
Pakistan is presently developing or refining a number of interrelated programme
responses that deal with the above issues by:
• Better understanding the communities where polio circulation is most
entrenched through research;
• Responding to refusals through a reinvigorated influencer programme
that pays more attention to their selection and support;
• Strengthening knowledge of local concerns and issues through
participatory challenge mapping and engagement of FLWs;
• Building deeper partnerships with carefully chosen allies across Pakistani
society;
Sources
• Developing new media initiatives that support and enhance trust in the “The Vaccine Book” : Heidi J. Larson and
programme, its workers, and the vaccine; Seth Mnookin. “Trust and Confidence in
Vaccines: Tales of Three Vaccines, Lessons
• Using social media in increasingly sophisticated ways to respond to for Others”, in The Vaccine Book, Second
rumours and support FLWs; and Edition, ed. Barry R. Bloom and Paul-Henri
Lambert (Academic Press, 2016), p. 529.
• Providing FLWs, community members, and local advocates with better DOI: 10.1016/B978-0-12-802174-3.00027-8
support, resources, and training. “Recent polls”: - Assessment of Mass
Media Campaign of Polio Eradication
Each of these areas is a critical pillar to regaining trust, and each must function Initiative, August 2020
in ways that reinforce the work of the others.
“2014 polling data”: - Harvard Opinion
Appendix: Measures and Framework Research Polling (HORP)
“The Nigeria Boycott”: Ayodele Samuel
UNICEF 2013 Framework for Trust Building: Polio Communications
Jegede (2007), “What Led to the Nigerian
Quarterly Update: Trust
Boycott of the Polio Vaccination
Campaign?” PLoS Medicine 4(3): e73
Trust needs to be built along three dimensions: in the programme as a whole; in https://doi.org/10.1371/journal.pmed.0040
FLWs, and; in the oral polio vaccine (OPV) itself. 07 3
Four principles: “India’s Influencers”: Dewy R., Mahendra
V.S., Morry C., Venth A., Solomon R.,
1. Honesty - The programme's objectives and the methods it uses to Awale J., and Choudhary M.K. (2018).
achieve them must be transparent and understood by everyone. “Influencing Change: Engaging Influencers
Building Trust”. In Influencing Change:
2. Competence - People must perceive the programme, its workers, and Documentation of Core Group's
Engagement in India's Polio Eradication
the vaccine as technically sound. Programme. India: CORE Group.
3. Morality - Vaccination must be carried out in ways that are seen as “Tricky one to understand, measure, and
principled and in alignment with local standards; the vaccine itself must be seen achieve”: Heidi J. Larson, Richard M.
as halal; and the people who serve as the face of the programme must behave in Clarke, Caitlin Jarrett, Elisabeth
accordance with local norms. Eckersberger, Zachary Levine, Will S.
Schulz, and Pauline Paterson (2018),
4. Genuine concern for children - The people who promote and offer the “Measuring Trust in Vaccination: A
vaccine must demonstrate an authentic commitment to the well-being of Systematic Review,” Human Vaccines &
Immunotherapeutics, 14:7, 1599-1609, DOI:
10.1080/21645515.2018.1459252
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