Socioecological Challenges of Polio Supplementary Immunization Activities (SIAs) in the Asia-Pacific Region: A Systematic Review

"One of the strategic plans of the global polio elimination initiative (GPEI) is to generate vaccine acceptance by developing a better understanding of cultural and social barriers through social mobilization."

Human and environmental factors can influence the acceptance of individuals towards polio supplementary immunisation activities (SIAs), which are mass immunisation campaigns designed to increase immunisation coverage and make progress towards polio eradication. On the socioecological model (SEM), five multilevel factors influence a population's healthcare practice: intrapersonal (individual characteristic and behaviour), interpersonal (relationship between a family and its social networks), institutional (for example, a health institution and its workers), community (for example, risk perception on vaccine-preventable diseases), and policy (for example, providing a role in delivering healthcare access and service utilisation). This systematic review aimed to identify the challenges of polio SIAs based on the SEM approach, together with improvement strategies.

This systematic review method was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 review protocol. Relavant articles were searched from three databases (WOS, Scopus, and PubMed) from December 27 2021 until January 8 2022. The chosen primary articles were English language, open access, and published within 10 years (2012-2020) based on publication date. Thirty-three articles that fulfilled the inclusion criteria, but only 9 described some form of SIAs in their findings around the Asia region. Table 2 in the paper examines the articles included in the review based on the outcome measure, which mainly consists of SIA vaccination coverage, barriers, and challenges, as well as the intervention strategies.

The majority of the studies selected reported on post-vaccination coverage, summarising the evidence of polio SIAs in strengthening immunisation coverage. The majority of the considered literature showed a positive increment of immunisation coverage post SIA, except the finding seen in a quasi-experiment done in India in which the primary result showed no changes in immunisation coverage following SIA activities. The primary outcome for the present review study was consistent with a previous systematic review of 13 polio SIA studies across the African continent; the majority of those studies described a positive impact of the SIAs on polio vaccination coverage.

However, the studies revealed multifaceted challenges faced during SIAs, including at the following SEM levels:

• Intrapersonal and interpersonal - e.g., one mixed-method study identified an overall negative perception toward the SIA programme among surveyed parents. Among the 13% of respondents who did not participate in the SIAs, 73.9% refused due to fear of sterility, lack of faith in the polio vaccine, scepticism about vaccination programmes, and fear that the vaccine might contain religiously forbidden ingredients.
• Community - e.g., one study found negative social behaviour toward the polio SIA programme to be statistically significant with respect to the community's religion and educational background.
• Institutional - e.g., two studies touched on the weakness of the polio health surveillance and monitoring systems and the safety elements of healthcare workers, respectively. One of these articles showed that the data obtained from nonendemic middle-income and lower-income countries indicated no significant effect on polio vaccination coverage despite the intense numbers of SIA programmes, as they were planned based on a poor polio health surveillance system. The other article highlighted limitations associated with the manual handling of SIA monitoring processes, such as intensive resources, misreporting bias, and the risk of violence among healthcare workers. Workplace violence has also been reported, especially in places with poor security.
• Government policy - e.g., one study described challenges related to government policy, which reduced accessibility to routine vaccination services and SIA programme among preschools and primary school students during the COVID-19 pandemic era due to movement control orders.

Intervention strategies to address these barriers that were reported in the selected articles include:

• Institutional - e.g., one study reported the introduction of short message service (SMS) via mobile phone to monitor the coverage of vaccination post SIA activities instead of a manual monitoring system. Another described the improvement made for healthcare workers through intervention package that includes SIA training, supervision, and monitoring skills, which has helped improve safety during vaccination and developed skills on risk assessment for SIA.
• Community - e.g., a positive outcome was reported in one article, where the integration of community engagement into the polio SIA programme showed a significant increment in immunisation coverage. Other articles highlighted that the appointment of a third person as a community representative can help achieve desirable immunisation outcomes in difficult-to-reach or programmatically challenged places. This person can play a role in raising awareness about the SIA programme among communities. Meanwhile, another article mentioned that the selection of community mobilisers for the SIA programme was among the community members from Community Health Volunteers (KOSPEN), health advisory panel members, religious leaders, and goverment retirees.
• Government policy - e.g., one study discusses the SIA programme's use of smart partnership, utilising multiple strategies that involved collaboration with other stakeholders such as the Ministry of Education and other entities.

In reflecting on the findings, the researchers point to some strategies related to community mobilisation for SIAs, such as shifting from a campaign-focused approach to instead making investments in sustained trust and relationship building with communities, reviewing accomplishments using the Minimum Quality Standards and Indicators for Community Engagement, seeking opportunities for improving social mobilisation activities in outbreak settings, and including community engagement indicators in campaign preparedness dashboards to ensure social mobilisation activities are tracked against meaningful indicators.

The review calls for "a renewed focus on approaches to stakeholder engagement and political advocacy is a prerequisite to achieving eradication in both endemic and nonendemic countries through an effective mass vaccination campaign....In Pakistan, program success depends more on government political willingness or ownership of polio service delivery which requires systematic dialogue with the national and provincial leadership and other influential stakeholders."

In sum, the reported findings in each selected article suggest that the challenges during the SIA programme are diverse, ranging from the microlevel of interpersonal aspects up to the macrolevel of government policy. Advocating such an approach for synthesising research evidence through the SEM "needs to be spotlighted in the future so that the improvement strategies can be carried out." The researchers suggest that policymakers and healthcare providers can use the information from this evidence summary to strengthen existing policy and practice on polio SIAs, particularly during polio outbreaks.