Social determinants and polio 'endgame': a qualitative study in high risk districts of India.

Objectives: To understand the perceptions and likely determinants that facilitate or act as barriers in implementing additional strategies for polio eradication: (a) accelerated delivery of mOPV1 (monovalent polio vaccine type 1); (b) use of IPV (inactivated polio vaccine); and (c) provision of incentives.

Design: QUALITATIVE. Rapid appraisal procedures (RAP) were adopted to derive the reality by synthesizing multiple sources of information; search for opinions, motivations, behaviors and attitudes of key stakeholders within their organizational and socio-cultural matrix.

Setting: Two districts of Uttar Pradesh - Moradabad and J P Nagar.

Subjects: Total 244 interactions were conducted; 33 interviews and 4 focussed group discussions (FGD) conducted with providers; 33 mothers (<5 years) and 10 leaders were interviewed; 8 FGD were conducted with mothers of under-fives. Informal interactions (156) were also conducted with village pradhans, religious leaders, parents, businessmen, journalists (Hindi and Urdu media), mobilizers, vaccinators and supervisors.

Results: Providers expressed reservation regarding accelerated rounds of OPV; scientific rationale of accelerated rounds is not clear to parents and leaders. Although technical advantages of introducing IPV exist, issues of logistical difficulties and injection safety emerged strongly. Providers and communities indicated a clear 'no' to the cash incentives but argued for developmental issues. Resistance to the program has declined over time but still the program is perceived as the "government's need, not ours".

Conclusion: The polio eradication program is critically poised, an opportunity to intensify efforts for reducing inequities in health services and improve access of all children to the PHC services. Ongoing dialogue with local communities and strong political commitment would be essential to translate the technological innovations into a sustainable program.