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      Conflict, community, and collaboration: shared implementation barriers and strategies in two polio endemic countries

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          Afghanistan and Nigeria are two of the three remaining polio endemic countries. While these two countries have unique sociocultural characteristics, they share major polio risk factors. This paper describes the countries’ shared contexts and highlights important lessons on implementing polio eradication activities among hard-to-reach populations relevant for future global health programs.


          A grey literature review of the Global Polio Eradication Initiative (GPEI) followed by an online survey was conducted in both countries. The survey was targeted to individuals who have been involved continuously in polio eradication activities for 12 months or more since 1988. A sub-set of respondents from the survey was recruited for key-informant interviews (KII). The survey and KIIs were conducted between September 2018–April 2019. A cross-case comparison analysis was conducted to describe shared implementation challenges, strategies, and unintended consequences of polio eradication activities across these contexts.


          Five hundred thirteen and nine hundred twenty-one surveys were completed in Afghanistan and Nigeria respectively; 28 KIIs were conducted in Afghanistan and 29 in Nigeria. Major polio eradication activities in both countries include house-to-house campaigns, cross-border stations, outreach to mobile populations, and surveillance. Common barriers to these activities in both countries include civil unrest and conflict; competing political agendas; and vaccine refusal, fatigue, and mistrust, all of which are all bases for describing hard-to-reach populations. Both countries employed strategies to engage community leadership, political and religious groups through advocacy visits, and recruited community members to participate in program activities to address misconceptions and distrust. Recruitment of female workers has been necessary for accessing women and children in conservative communities. Synergy with other health programs has been valuable; health workers have improved knowledge of the communities they serve which is applicable to other initiatives.


          The power of community engagement at all levels (from leadership to membership) cannot be overstated, particularly in countries facing civil unrest and insecurity. Workforce motivation, community fatigue and mistrust, political priorities, and conflict are intricately interrelated. Community needs should be holistically assessed and addressed;programs must invest in the needs of health workers who engage in these long-term health programs, particularly in unsafe areas, to alleviate demotivation and fatigue.

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                Author and article information

                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                18 December 2020
                18 December 2020
                : 20
                Issue : Suppl 4 Issue sponsor : Publication of this supplement was funded by the Bill & Melinda Gates Foundation (OPP1178578, Teaching Global Health Leaders about the Lessons Learned from Polio Eradication). The articles have undergone the journal's standard peer review process for supplements. The Supplement Editor declares that they have no competing interests.
                [1 ]GRID grid.9582.6, ISNI 0000 0004 1794 5983, University of Ibadan College of Medicine, ; Ibadan, Nigeria
                [2 ]Global Innovations Consultancy Services, Kabul, Afghanistan
                [3 ]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Department of International Health, , Johns Hopkins Bloomberg School of Public Health, ; 615 N Wolfe St., Baltimore, MD USA
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: OPP1178578
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                © The Author(s) 2020

                Public health

                polio, endemic, conflict, vaccine hesitancy, mistrust, community engagement


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