If the goal of polio eradication is to be achieved, the program strategy should be acceptable to everyone concerned without harassment and hesitation. In this context, it will be imperative that the determinants of underlying social resistance in the endemic pockets of Uttar Pradesh and Bihar are systematically analyzed. This is particularly critical when younger age groups need to be repeatedly immunized at short intervals to achieve optimal immunity. The present study was designed to gain an understanding of the phenomenon of social resistance/reluctance and rumours against pulse polio campaign in two highly endemic districts of western Uttar Pradesh, namely Moradabad and Jyotiba Phule Nagar (JP Nagar).

One primary health center (PHC) was selected in each identified block for in-depth interviews (IDI) and focus group discussions (FGDs). IDIs were held with different levels of providers, mothers of under-5 children, and community leaders (religious, social and political). Special emphasis was placed on interviewing leaders from different religious groups, influential business persons and political leaders. FGDs were held for female health workers (Auxiliary Nurse Midwives), vaccinators, mobilizers (community-based functionaries of NGOs/UNICEF), and mothers of under-5 children in the identified PHCs. To complement IDIs and FGDs, a total of 156 non-formal interactions with local leaders, Hindi/Urdu journalists, businessmen, mobilizers, vaccinators, supervisors, and parents of children from marginalized Muslim and Hindu communities were also conducted. Profile and number of stakeholders interviewed and FGDs conducted in each of the two districts is reported in Table I and II. None of the clients or providers who were approached for in-depth interviews refused to participate. Observations were also recorded during the field work on a National Immunization Day (NID).

Table I



Number of Stakeholders Interviewed and FGDs Conducted in Each District 

TABLE II



Profile and Number of Stakeholders Participating in Non-formal Interactions 

Attempt was made to search for opinions, motivations and perceptions of key stakeholders from the district, PHC and community levels. IDIs, FGDs, and non-formal interactions including observations were used in the study to make an assessment of reality by synthesizing multiple sources of information. Based on our previous work on polio eradication programs in India(11-13), systematic reviews and other published qualitative research studies on polio eradication, guides for FGDs and tools for in-depth interviews were developed.

All FGDs were audio recorded and handwritten verbatim notes were later supplemented by transcripts of audio tapes, before final translation into English. Interviews were not audio taped; instead they were recorded verbatim by research assistants. All interactions were held in the locally spoken and understood language – Hindustani, and the investigators were familiar with the local dialect, customs and culture. The in-depth interviews lasted for 30-50 minutes. The duration of FGDs ranged from eighty minutes to two hours. FGD of providers consisted of 8-10 respondents, while FGDs of community members ranged from 9-13 members. Issues explored in FGDs included problems and constraints of the pulse polio program, reasons for not accessing some/all pulse rounds, response of the administration towards defaulters, perceptions/reasons of specific groups (e.g. geographically isolated, specific caste or religious groups) who did not immunize their children with oral polio vaccines, and details of rumors/boycott of pulse rounds by any group(s). The non-formal interactions attempted to explore, capture and triangulate some sensitive domains of information. Notes were, however, made of non-formal interactions; the decision to include their perceptions was on the basis of consensus arrived among the investigators that they were internally consistent with findings from in-depth interviews and FGDs.

Qualitative data were analyzed in a stepwise manner: free listing of responses, domain formation, coding, and analysis. Data were analyzed separately for each category of stakeholder and then re-analyzed to assess similarities and differences in perceptions across stakeholders. The triangulation was done at two levels – across methods and across respondents. The consistency indicating towards a substantive significance (the way it is used in qualitative data) was explored.

Concept identification began with the first set of interviews with district level providers. Data collection was alternated with analysis. Open coding was initially done by opening up the text of the interactions and subjecting them to intensive scrutiny, asking the question ‘what is going on here’? Detailed line-by-line microanalysis was done. Phenomena were identified from the interactions during interviews and FGDs, and analysis of stakeholder perceptions. Properties and dimensions of the phenomena were also identified, giving it specificity(17). Data was weaved around phenomena by axial coding. Thus, the major categories of phenomena began to emerge from the data. Finally selective coding was done for construction of core categories. We reached a point in both the districts when information seemed repetitive, and assured that the data saturation was achieved. Memo writing was done by handwritten notes. The theory finally arrived at went beyond mere reconstruction of events, it was a co-construction between researchers and participants(18). The model arrived at was reflective of practical situations and the structural conditions that led to these problems(19).

A multi-disciplinary team comprising of program evaluation experts, health social scientists, anthropologists, public health specialists and epidemiologists constituted the study team. All the team members have participated in several polio eradication program reviews since 1997 and were trained in qualitative research methods(11-13) in these districts and were familiar with local cultural milieu. Health workers and mobilizers from local communities also facilitated the interactions.

Five investigators undertook the field work, conducted interviews (formal and non-formal) and FGDs. They were assisted by four research assistants. One investigator conducted quality assurance visits during data collection. The entire team participated in preparation of tools, data analysis and finalizing the report.

This study has attempted to analyze the phenomena that lead to the social resistance and contextualize the situations in which rumors spread. The nature and content of rumors have also been analyzed. While there were indications on the possible sources of some of the rumors, in the limited scope and the design of the study it was not possible to track the sources. While the source (reported) and content of rumors had strong religious association, the authors were sensitive to the fact that such issues were not just of religion but of marginalized communities in general, and intense politicization had further complicated the situation. There were no differences in the two districts, and between study blocks, which were contiguous.

A systematic pattern of rumors, religious edicts, and suspicion to oral polio vaccine was observed among the poorest of Muslim families (especially Quraishis/Ansaris/Saifis) in urban/peri-urban areas like Sarai Pukhta in Moradabad city and Sarai Tareen in Sambhal, and with less intensity, in some rural clusters of Dingarpur and Ratupura. There were instances of sporadic reluctance among marginalized Hindu families (especially Sainis/Khadgavanshis) as well. However, this seldom translated into a significant or lasting resistance in spite of reporting occasional incidents of coercion at the individual family level. The health workers were largely Hindus and represented the face of the state to the Muslim communities. Overcoming reluctance/resistance among Muslims was reported by health workers (Hindus) to be a far more difficult task. Reports of coercion by the administration came from marginalised Hindu communities, including Dalits. There were occasional reports of ‘reverse coercion’ (triangulated through both provider and client interactions) from Muslim majority areas where the health workers were forcibly asked to mark their children as immunised (an indelible ink-mark on their fingers) without giving vaccine. The process of generation and dissemination of rumours leading to resistance to the polio vaccine consisted of a series of inter-related phenomena (Box 1 and 2).

Box 1 Emerging Model of Rumors and Resistance to Pulse Polio Campaign

Box 2 Rumors and resistance: Representative quotes

The model presents a set of necessary conditions for the rumors to be generated and spread. However, it was important to explore and attempt to explain how these phenomena are sustained. The content of rumors appeared to represent different concerns of Muslim communities (Table III). They also indicated that in the current geo-political environment, health behavior of communities might be influenced by unrelated non-health events. We present a set of additional conditions that have probably been responsible for sustaining social resistance in these districts for a considerable length of time.

TABLE III



Nature and Content of Rumors

Among the marginalized Muslims, the elite of their community often appeared to have little credibility - and even a professional or a well-to-do businessman was considered a part of the elite. The middle class that could have acted as an interface - and a critical section determining the behavior of the community, was largely missing. Level of cynicism was so high in some of the extremely marginalized sections of minority that they even considered civil society as an intruder. Metro-based minority institutions were perceived as the Muslim mask of Western influence. IEC (Information, Education and Communication) attempts by Muslim celebrities and metro-based Islamic institutions were seen with suspicion, and were unlikely to have the desired impact.

"If you really want to do something, you will have to involve volunteers from Qureshis and Ansaris. See, there is no middle class in Muslims. Ordinary Musalman says that well-to-do people in their community have a double face. You keep on depending on Jamia-Shabana etc. … nothing will happen. They don’t even listen to me." [Artisans’ Union Leader, Moradabad]

"Celebrities don’t mean anything in this place. Poor people don’t have any faith in the educated section of their own community. Educated and rich people are seen as westernized and untrustworthy." [Urdu Journalist, Sarai Pukhta - echoed by several Community Stakeholders]

The poorest of the poor and the rich behaved similarly while evading SIAs. Both of them defeated pulse polio rounds in their own ways. However, the rich got their children’s routine immunization (RI) through private practitioners while the children of poor households were often left out of even the RI as they were primarily dependent on weak public health services. This probably was one of the most critical reasons for the apparent difference in the incidence of WPV and other vaccine preventable diseases (VPDs) among the two strata.

"People in Budh Vihar and Sarai Pukhta behave similarly on pulse days. Both of them avoid polio drops. However, the rich go to private practitioners for routine immunization. The poor are neither going for routine immunization nor receiving pulse polio drops" [Provider, Moradabad City - echoed by several Providers]

The state of public health services in these districts was poor. Indeed many respondents expressed their dissatisfaction at the lack of primary health care services. PHC medical officers voiced their frustration about their inability to deliver routine services on account the frequent SIA rounds. The question "why only polio?" while delivery of routine health services remained dismal, was uppermost in the minds of the community.

"OPDs get shut. CHC has staff, but additional PHCs may have problems. Give medicines today and then . . . after six days. People are already troubled with one month cycle (rounds of pulse polio)." [District Level Provider]

There was intense grassroot politicization of the issue. Leaders, especially in minority areas, had more than one stand/front on the issue, and they used them depending upon the addressee. Attention overload had tutored most of the stakeholders, including parents, in diverse ways. Even a non-utilizer client was likely to be aware about ‘what is politically correct/safe to say’, regardless of the ground reality. Evidence available ‘on the record’ was vulnerable to miss some highly significant aspects of the truth.

"This place is visited by so many people that everyone knows what to say and what not to say. If you are an outsider and move with a notepad, no one will speak the truth." [Practitioner of Indigenous System of Medicine, Sarai Pukhta - echoed by several Community Stakeholders]

"Politicians speak in two languages – so people have also learnt that. If you really want to know what’s going on …. stop taking interviews and engage people in heart-to-heart conversation." [Urdu Journalist, Sarai Pukhta]

Linking acceptance of the vaccine to developmental issues was becoming increasingly common. These issues, ranged from supply of essential goods in public distribution shops to construction of roads and bridges, and were raised by both Hindus and Muslims. As a rural Muslim mother put it, "Polio is your concern, not mine"– the program was thus perceived as the "government’s need". The acceptance of the vaccine was being used to negotiate with the state machinery for developmental issues including road construction, basic sanitation, donations, loans, and even licences.

"They have understood that it is our need – not theirs. So they are twisting our arms to get things done. They also use their children as captive in this bargain. They want us to make roads, clean garbage, arrange for arms license etc. This has created numerous difficulties for our day to day working." [Provider, Thakurdwara - echoed by several Providers]

"Every week you people (read outsiders) are at their doorstep. Anyone will use this situation to his advantage. By keeping the children inside on polio day, poor people are increasing their bargaining power. You just forget about them for one or two rounds . . . the resistance will decrease." [Community Leader-Muslim, Sarai Pukhta]

Immediate needs such as food, security and employment are likely to take priority over other nationally and internationally set goals and programs, when scarce resources find competing interests(24). The developmental issues used as a bargaining point should be seen in this light. It raises a fundamental concern of felt needs versus epidemiological needs, and it demonstrates that the top-down vertical approach is ill-equipped to address the plethora of local political, social and economic conditions. On one hand, this calls for reforms in the choice of programs that address local health priorities; on the other, program managers have to engage in advocacy (to a reasonable extent) to articulate developmental needs and aspirations of local communities. The field of development communication can make a meaningful contribution in this regard.

The methodological approach adopted in this study was useful to deconstruct some of the phenomena linked to the resistance/reluctance observed during polio eradication campaign in endemic districts of North India. In the given context, we faced the challenge of coping with an unstructured reality(27). While it is impossible to begin research with no preconceptions, this exercise was conducted with ‘a more rather than less open mind’(28). There is a bias in social research in favoring ‘underdogs’ and drawing attention to social inequities(29). We drew upon ‘Other’(30) while addressing class differentials within the same (minority) religion to distinguish between parental/group responses to routine immunization and SIAs. Our explanation may be a partial one, with limited explanatory power. The strength of this work lies in its attempt in unravelling social determinants in WPV endemic districts where social mobilization strategies have changed almost as frequently as technical strategies, none of them relying on credible evidence. The present model needs to be validated in other locations with similarly placed societies and program situations.

Lastly, we need to re-examine the scope of the concept of ‘social resistance’. Does it include ‘cultural resistance’ by default? Or we need to be little more discreet about these two seemingly distinct phenomena? Science places certain realities that cannot be understood or addressed without liberating ourselves from our training of political correctness. The endemic resistance against polio eradication program, witnessed in this study, refused to be totally explained by socioeconomic marginalization alone. Contents of some of the rumors indicated that the phenomenon had a distinct share of cultural resistance as well.

Contributors: RD, SC and NKA: Concept, design, acquisition of data, analysis, interpretation and writing of manuscript; KKG, VA and SR: Conception, design, acquisition of data and analysis; and LS and S: analysis and critical revision of manuscript.

Funding: South East Asian Regional Office, World Health Organization, New Delhi, India.

Competing interests: None stated.