This paper is written on the Pulse Polio Immunization Programme in India. The details of the programme and history are also explained for a better understanding. The need for social mobilization for the success of the programme and how it has strategies have been devised and implemented. The programme was initiated for fighting against the potential dangers from polio and various methods were used for achieving the target that is to eradicate polio from India.
About the programme
Polio is a viral disease that spreads due to unclean conditions and improper sewage treatment. The infection is caused by a virus called as Poliovirus and attacks the digestive tract. Initially the patient feels flu like symptoms so people do not realize if it is the polio infection. Virus interrupts muscle signals, causing muscles to grow slack and weak and leads to paralyzing the person. In certain cases there is natural recovery of body, growing fresh nerve cells to replace the damaged ones. In other instances, permanent paralysis or disfigurement may result. It can be fatal also if the infection reaches the brain or lungs. So basically this disease needs to be prevented. As prevention is always better than cure in case of diseases and in the case of polio it is better to keep a check. So need for eradication of polio was felt by the government of India and in the year 1978 the vaccination against polio was initiated under the Expanded Programme on Immunization.
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By 1984 the coverage achieved was about 40% of all the infants. Three doses of Oral Polio Vaccine were given to them. Now in 1985 the Universal Immunization Programme was launched in phases with an aim of covering all the districts of India by 1990. In enactment to the World Health Assembly Resolution of 1988 as an extension to administration of routine OPV through the Universal Immunization Program, the Pulse Polio Immunization (PPI) Programme was launched in 1995-96 to cover all children below the age of three years by designating two National Immunisation Days (NIDs). The word PULSE stands for “Post-resuscitation and Initial Utility in Life saving Efforts”.
Since then the national immunisation days have been conducted successfully. In 1996-97 the target age group was increased from three years to five years to intensify the programme. All this effort resulted into decrease in the number of polio cases reported over the years. The vaccinations were given at fixed booths on two national immunization days during the winter season. The coverage was decent but still the polio transmission was active in most of the states during 1998-99. In 1999, this programme was intensified in order to meet the global deadline.To achieve the global goal of reaching zero incidence of polio by 2000 the government of India adopted a strategy to intensify the process. The strategy consisted of four nation-wide PPI rounds in the months of October, November, December 2000 and January 2001; followed by two sub-national rounds in 8 States of Assam, Bihar, Gujarat, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal and routine immunization, especially in the poor performing States. In the initial years even after a good coverage on an average around six percent children were being missed in the programme. Therefore in addition to the booth immunization, strategy was adopted to reach every child.
This house to house programme resulted in identification and vaccination 2.3 crore children who had never been vaccinated before. The global initiative to eradicate poliomyelitis by the end of the year 2000 is the largest international disease control effort ever. Most parts of the country have become polio free and widespread transmission is restricted only to the States of Bihar and Uttar Pradesh where 186 cases have been detected. India is still the largest polio endemic country in the world accounting for 20% of the cases reported globally during 2000 (till July 2000) mainly on account of the situation in Uttar Pradesh and Bihar.
The polio eradication programme in India has got a huge support of the Government of India and various strong efforts have been made to improve the quality of the programme and delivery of the services. Efforts are made to strengthen the supplementary immunization activities in the country. The outbreak was controlled and the disease curtailed in just two years from 1,600 cases in 159 districts in 2002, to 136 cases in 44 districts in 2004. The programme continued to build on these achievements and reduced the number of polio cases to the lowest level ever recorded in India. Initially this programme faced many challenges but firm steps were taken to overcome them. Various strategies were used to reach the most interior parts of the country where it was most difficult for the medical services to reach and many children were also not getting such benefits. The progress made since 2003 was most significant as the number of polio victims were declining year by year. This trend of success in achieving the target of eradicating polio got a shock in the year 2006 when the number of cases started rising alarmingly in western U.P and Bihar, posing the biggest threat to the realization of the goal of a polio free India. As per the Department of Family Welfare there was an increase in number of polio cases in India from three percent to 26 percent of the global cases. Maximum cases were reported from Uttar Pradesh and the muslim community had the maximum cases.
This was a serious issue as even after the Government was taking various measures to overcome this problem of polio but still due to various social mobilization issues some segments of the society were left behind. So in the year 2007 a state level committee of various highly learned and reputed muslim community leaders and scholars was formed. The formation of the committee was done to address various issues varying from myths, fallacies to resistance in the minority communities against the programme. The outcome of this mobilization effort was that about ninety percent of the myths associated with the pulse polio programme were done away with and the participation also increased. The efforts made were sustainable as more effective vaccinations were introduced. The volunteers carried out the task of mobilizing people by visiting every house and marking down the number of children below five years of age and giving them dosage. But later in 2007 more cases were observed of different type of polio infection. So more effective vaccines were introduced and the campaign was intensified to make the states as polio-free. The migrant families were also taken under the programme and proper vaccinations are given so that they do not become the carriers of polio. Most of the country by now is polio-free with the transmission only being restricted mainly to the states of Uttar Pradesh and Bihar. This being such a massive campaign needs full time commitment and strategies need to be updated timely to face the environmental uncertainties.
The success of the programme depends upon the level of awareness spread among people about the issue. It was a big challenge for Ministry of Health & Family Welfare to mobilize people and make them understand the threats posed by polio. Initially the vaccinations were given on two particular decided dates. Now to mobilize people and make them come to the vaccination booth was a tough task. The turn up of people was low initially due to various factors like religious myths, lack of trust, unavailability of time etc. So the ministry took various steps to curb these problems. A vast campaign was launched nationwide to mobilize people and spread awareness about the program. The most intensive print media campaign was chalked out for Pulse Polio Immunization. The campaign was made in a record time through a series of press Advertisements, 5 different posters and a single sheeter in English, Hindi and 11 regional languages. Press advertisements, audio-visual aids like radio, news channels, entertainment channels and newspapers in all regional languages were used as medium to spread awareness on Pulse Polio Immunization.
4.1 Print Media
The posters were made using mostly pictures showing infants and small children taking the polio drops to mobilize the mass. Notifications about the national immunization days and advertisements were regularly printed in various national and local newspapers.
4.2 Visual Aid
Advertisements were aired on the television many times in a day so that everyone is able to watch it. Celebrities like Amitabh Bachchan, Sachin Tendulkar and many other popular movie stars and cricketers were shown in the advertisements giving message to the people to come forward and participate in the immunization programme so that we all can together eradicate the disease from the country and have healthy children, healthy nation.
Doordarshan has been allocated 40 video spots for the Pulse-Polio Programme for production in Hindi as well as in the regional languages in the year 1995-96. In addition 12 audio spots and one on target free approach. Five 30 minute films dubbed in regional languages and various exhibitions are performed.
4.3 Public Health Centres
The doctors, nurses and medical staff also contribute in spreading awareness about the pulse polio campaign. The vaccines are made available to the people through the channel of the public health centres and the asha workers also visit each house and educate people about the possible threats from polio.
These promotional strategies were used by the ministry for social influence which results in an individual adopting the attitude advocated by the communicator. The process of social influence helps in linking the celebrity advertising with the mass even though there is hardly any interaction between the celebrity and the consumer. But still they help in the internalization process. The individuals adopt the behaviour being promoted as they view it as an honest and sincere behaviour on the part of celebrity. As these advertisements were used to mobilize the people and come forward to fight from the disease, so people also viewed it as a noble gesture. Public health programmes sometimes merely convey the information but at times fail to trigger the behavioural change in people.
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The motive behind the message cannot be achieved just by passing information. If the assumption that individual will change their behaviour as soon as they come to know about the potential danger from the disease does not result fruitful. Rather people just view it as just another piece of information. For positive and effective changes to occur people need to be motivated and educated properly about the ill effects of continuing with the ignorant attitude.
The behavioural changes cannot be forced but rather should be instigated. In the case of immunization, knowledge and information alone are not sufficient enough to lead to desired behavioural changes. The problem is in dilemma in occurrence of diseases. People have an impression that the disease may or may not occur and if the vaccines are given at the time of birth then they assume that the further doses are not necessary. In reality the immunization is very important for the infants till five years of age so that the chances of developing polio disease can be negated. The problem is that as individuals the need for preventive behaviour is not felt even if the need is recognized. In case of Pulse Polio the awareness was spread through advertisements in such a manner that directly affects the individual’s thought process and instigates them to adopt the changes.
Change in Strategy
When in 2000 the cases of polio started coming up at a fast pace then the Government had to change the vaccines and introduce better quality products. As due to the new polio cases in the states of Uttar Pradesh and Bihar people’s trust on the vaccines got shaken. So as per the suggestions from the World Health Organization the quality of the vaccines was improved.
Some more challenges
Several districts in western Uttar Pradesh consist of Muslim population with good numbers of Muslims in rural areas. Similar were the scenario in the cities like Moradabad, Rampur, Bareilly and Badaun. Since the early 2000s confirmed cases of polio in India have been increasingly and disproportionately amongst Muslim children and by 2007 Muslim children accounted for 94% of confirmed cases. The explanation given for this pattern was that the Muslim children are less likely than others to receive the polio drops. In response to this a very high-profile public awareness campaign – the “underserved strategy” was initiated which included various celebrities, community leaders and local volunteers which spread the awareness messages in the polio hot spots. Muslims in western UP were known to be alienated from Bharatiya Janata Party governments at the state and national levels until 2004, but prominent Islamic institutions gave their support and madrasas hosted pulse polio teams.
The cases of polio are rising and most of those identified with wild polio are Muslims who already have had many doses of vaccine. Hence more of the similar vaccinations were not going to solve the problem. The need of the hour is to recognise that polio cannot be eradicated, and that planning must move towards a routine immunisation programme that covers all children against all communicable and preventable diseases. This process requires a reallocation of resources away from the high profile but ultimately barren pulse polio initiative into revitalising the public health services of Uttar Pradesh and Bihar. Investing more money is not going to solve the problems they face, but more money will certainly help. The pulse polio activities are organized on a monthly basis to cover all the children.
It was observed that some of the major reasons for non-acceptance of PPI were lack of information, illness of the child, absence of the child on the “PPI day”, lack of faith in immunization and fear of adverse reaction. There was manpower shortage in form of volunteers from community were responsible for lower coverage at booths in many places. Lack of community participation, poor community mobilization and untrained vaccinators were responsible for low coverage.
Some steps taken
For polio eradication deployment of additional personnel to high risk areas is required and for enhanced social mobilization efforts targeted at reaching population groups missed during previous rounds, use of mobile teams to vaccinate children at transit points and on moving trains, and increased engagement and accountability of political leaders and of health staff at all levels required to be implemented. “Communities where social mobilization activities are conducted are consistently less likely to refuse OPV, more likely to attend booths and more likely to report positive attitudes towards OPV and higher perception of polio risk, compared with families in communities without these activities, hence contributing to lower incidence. In four high-risk districts of Uttar Pradesh where social mobilization activities were conducted, the number of wild poliovirus cases dropped from 116 to 49 and there was a significant increase in booth coverage between 50 and 57%, compared with 19- 35% at district level.” (Source: An article by Patricia Jeffery, Roger Jeffery)
There are ways in which we can increase the booth attendance. Puppet/theatre shows, video vans and other folk media activities held in more than 3500 villages in Uttar Pradesh, contributed to a 20% increase in booth attendance.
Television and radio are the main source of information for polio round. In present study among booth service utilizers, health worker or anganwadi worker and television were main source of information for pulse polio round. The principal agency responsible for disseminating information about PPI was identified to be the multipurpose health workers during house to house activity, few unimmunised children were found. The reasons are children not at home at time of visit of health team, parents were not at home, not aware of polio round or they were too busy. Polio eradication activities in India have provided successful operational models for elimination of transmission in many other areas of the world.
Special campaigns were launched for social mobilization for Pulse Polio Immunization (PPI) Programme. Social mobilization for the Pulse Polio Immunization Programme has been marked as highly successful by various agencies those who have assessed the programme.
For any health programme to be successful various factors are taken into consideration and the success in also measured based on those factors only. Still there is a need for imparting more knowledge to the weaker section of the society who are illiterate and bound with many taboos.
When this campaign is exercised and participated by everyone then only it will be possible to eradicate it globally.
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