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Table 2 Barriers to Polio Program Success

From: Synthesis and translation of research and innovations from polio eradication (STRIPE): initial findings from a global mixed methods study

CFIR Domain Barrier Definition Illustrative examples All survey responses,
N = 9714
n1 (% of N)a
n2 (% of n1)b
External Factors Political, economic, social, technological, legal, and other environmental factors   3826 (39.4%)
Social Communities are non-accepting and/or resistant to the intervention • Vaccine hesitancy
• Community fatigue given repeated campaigns, misaligned priorities
• Lack of information
1695 (44.3%)
Economic Insufficient revenue sources • Limited economic resources 1170 (30.6%)
Political Policymaker disinterest or resistance, limited windows of opportunity within the political climate, political structure non-conducive to coordinated action • Low political will
• Insecurity and conflict
1115 (29.1%)
Technological Slow or limited advances of technologies used in implementing program activities • Technological and infrastructural challenges affecting vaccine supply and surveillance 626 (16.4%)
Other Challenges related to physical and human geography • Geographical inaccessibility
• Population migration
817 (21.4.0%)
Process of activities How activities were implemented   2144 (22.1%)
Executing Failing to carry out activities according to plan • Lack of accountability mechanisms
• Environmental disruptions to program implementation
• IPV supply challenges
1213 (56.6%)
Engaging Difficulty attracting and involving appropriate stakeholders in implementation • Difficulty identifying appropriate stakeholders to engage given diverse administrative structures, cultural norms
• Community mistrust
915 (42.7%)
Reflecting & Evaluating Difficulty monitoring program progress and quality, including lack of regular debriefing about progress and experience • Lack of supervision
• Lack of formal processes for analyzing monitoring data and adapting plans accordingly
803 (37.5%)
Planning Implementation schemes/methods not planned in advance, or poor quality of such methods • Poor quality enumeration
• Difficulty in planning large-scale changes, e.g. the switch from tOPV to bOPV
758 (35.4%)
Characteristics of individuals Characteristics of individuals within an organization involved in polio eradication activities   1773 (18.3%)
Knowledge Knowledge and beliefs about the activity - individuals did not have positive attitude toward the program, were unfamiliar with facts, truths and principles related to the intervention • Misconceptions about the vaccine and its effects
• Lack of awareness of vaccine benefits
1121 (63.2%)
Stage of Change How likely (or not) the individual is to provide skilled, enthusiastic and sustained support of the program throughout the different stages of implementation • Health worker fatigue resulting from campaign/vaccine fatigue from the communities 566 (31.9%)
Perception of organization Poor perception of the organization and degree of commitment to the organization • Temporary status of some frontline workers affecting commitment to organizational goal 419 (23.6%)
Self-efficacy Lack of belief in one’s own abilities to execute required courses of action • Health workers’ lack of understanding of the program, what’s expected of them 394 (22.2%)
Organizational characteristics Factors related to the organization(s) supporting implementation   1076 (11.1%)
Structure The age, social architecture, and size of an organization led to challenges • Shifting structure of global partnership
• Understaffing and shifting roles of staff
236 (21.9%)
Networks The nature and quality of formal and informal communication within an organization led to challenges • Limited communication channels between extension workers, program leads
• Challenges related to dissemination of strategy from central to peripheral level, including securing buy-in
439 (40.8%)
Culture The norms, values, and operating assumptions of an organization led to challenges • Priorities dictated by managers
• Limited voice given to field workers to propose adaptations
349 (32.4%)
Implementation Climate Limited capacity for change, the receptivity of the team to the proposed intervention, the relative priority of project, organizational goals, incentive and rewards, etc. led to challenges • Lack of consensus on program strategy
• Waning prioritization of polio among some stakeholders
398 (37.0%)
Implementation Readiness Lack of leadership engagement, limited available resources and poor access to knowledge and information led to challenges • IPV shortage
• Chronic underfunding of the health system
469 (43.6%)
Program characteristics Activities conducted to enable implementation, including technologies adopted   895 (9.2%)
Intervention Source Perception of whether the intervention was developed internally or externally led to challenges • Imbalance between global and national priorities
• Community distrust of western intervention
276 (30.8%)
Evidence Perception of the quality and validity of the evidence did not support belief that the intervention would have the desired outcomes • Concerns about relative effectiveness of OPV and IPV 302 (33.7%)
Relative Advantage Perception that there was another, better approach • Concern that polio program is run in parallel to (and at expense of) routine immunization 200 (22.3%)
Adaptability The activity was not adapted, tailored or refined to meet local needs • Lack of understanding of community norms to guide adaptation of implementation activities 361 (40.3%)
Trialability No ability to test on a small scale and reverse course if warranted • Perception of polio program as too big to fail even in the face of coordination and implementation failure affecting certain activities 101 (11.3%)
Complexity Perceived difficulty of implementation reflected by its duration, scope, radicalness, disruptiveness, centrality, intricacy, and number of steps required • Difficulty sustaining the cold chain in hard-to-reach areas
• Health worker and community fatigue
284 (31.7%)
Design Quality & Packaging Difficulty arising from how the intervention is bundled, presented, and assembled • Challenges related to use of injectable vaccine (IPV)
• Vaccine wastage due to how IPV and OPV were packaged, especially in hard-to-reach areas
162 (18.1%)
Cost Cost of intervention and its implementation, including investment, supply, and opportunity costs • Difficulty financing program functions previously supported by donors
• High cost of implementation in hard-to-reach areas
252 (28.2%)
  1. aEach respondent was allowed to choose all relevant domains that contributed as barriers to polio program goals. Hence, the sum of all responses, n1 (9,714) is greater than sample size for all survey respondents (3659)
  2. bWithin each domain, respondents were similarly allowed to choose all relevant categories that contributed as barriers to polio program goals, e.g. for the external factor domain, each respondent selected multiple categories under that domain such that the sum of all category-specific responses (n2) is greater than n1 (3,826) for that domain