Alirajpur COVID-19 Vaccine Community Outreach:

Project Summary

My association with Alirajpur, India’s least literate district in the state of Madhya Pradesh, began in February 2020, when my father’s public service job saw him posted to the district’s administration. As the COVID-19 pandemic reached India, and the country headed into lockdown by March 2020, I made the decision to join my father in the district, continuing my education remotely. Living with my father, I became aware of the unique opportunity I had to gain insight into policy implementation and constraints on the ground, especially as the government moved forward with pandemic containment and relief. My interest in policy and impact assessment guided my goals as I began listening, reading and writing about the policy structure in Alirajpur. Ingratiating myself with local officials, I began by gaining information on containment immediately after the announcement of the lockdown in India, in late March 2020. Owing to some impressive on-ground implementation of policy, made possible by the Panchayati Raj system of localized governance, Alirajpur managed a staggering six infections in the lockdown period from March 2020 to September 2020, despite being the least literate district in the country.

As the Government of India parallelly monitored vaccine development and set up infrastructure for inoculation, I closely followed communications to anticipate the impact in Alirajpur. Having identified the communication gaps in on-ground implementation of previously designed lockdown policy, I began working on an app ‘Apna Alirajpur’ (‘Our Alirajpur’), to best relay government communication and reassurances to the local population. When the vaccination drive began on 16th January 2021, I began accessing my network to gain a greater understanding of the situation at the grass-roots level and accordingly create a plan of action. Having identified two-way communication between government and citizens as the key implementation gap, I focused on creating material and initiatives that would help improve it.

1. Preparation

I began the community outreach by familiarizing myself with the Government of India’s (GOI) communication strategy, which gave detailed suggestions for community programs. Simultaneously, I made a list of community leaders and officials based on Alirajpur’s demographics who I would need to contact in order to gain a better understanding of the troubles with implementation. This is documented below:

 

Person Role
Patel Traditional Village Headman – a non-elected post, but highly influential
Sarpanch Elected Head of Village Panchayat – seen as the defacto leader of community
Kotwar Specially appointed local government officers who are a part of the community
Tadvi Local shaman, known to practice traditional medicine, specializing in exorcisms
Shastri The religious leader of the Hindu community
Shahar Kaji The district level head of the Muslim community
Sadar Head of local mosques
Imam Religious figure presiding over mosque sermons

Table 1: List of influential leaders in Alirajpur with their designations’

Upon contacting the Zilla Panhcayat, Alirajpur’s district council, I was able to gather details about the ongoing vaccine effort. Around 15,000 vaccine doses were expected to arrive in Alirajpur to vaccinate 6,500 healthcare and 1,000 frontline workers as a part of the first phase of vaccination. In preparation, the Panchayat had identified 23 potential centers for vaccination, of which 15 were operational as of February 10, 2021.

Image 1: GOI mandated requirements for vaccination centers; Source: Ministry of Health and Family Planning

The government had also mandated the presence of the following officers at each vaccination center:

Vaccination Officer 1 (police personnel): In-charge for pre-checking registration status of beneficiary and photo ID verification before entering the waiting room/area, ensuring selected entry to the vaccination session, and assisting in making queues/crowd management.

Vaccination Officer 2 (Health/ICDS/other government department employee e.g. election model): In-charge of authenticating documents in the Co-WIN system.

Vaccination Officer 3 and 4 (IEC/communication ICDS/other government department e.g. election model): In-charge of crowd management, ensuring 30-minute wait, monitoring for any AEFI symptoms, guiding non-registered beneficiaries.

Vaccinator Officer (Doctors (MBBS/BDS/AYUSH), Staff Nurse, Pharmacist, ANM, LHV): In-charge of vaccinating the beneficiaries. Anyone authorized to give injection may be considered as potential vaccinator.

Based on these requirements of staff and venue, the Panchayat had limited itself to using hospitals, CHC (Community Health Centre) and PHC (Primary Health Centers) as venues.

Image 2: Meeting with officials at the Panchayat office in Alirajpur

My meeting at the Panchayat made me aware of the requirement of a translator for the rest of the outreach project. While, like much of India, most people in Alirajpur understood some Hindi, the prevailing language was Bhili. I immediately contacted a local government school and met with teacher Mrs. Sangeeta Bhavsaar, who agreed to help me translate for the community outreach. I compiled an itinerary to coincide with the first phase of inoculations and began working on key forms of outreach.

Initially deciding on using posters to communicate the importance of vaccinations, I created the following flyer in the local language under the guidance of the district’s COVID Vaccination Officer, Dr. Narendra Bhaydia. The flyer not only provides information about the benefits of inoculation but also addresses concerns around the safety of the vaccines and its associated symptoms/side-effects. It also reminds the reader to continue following COVID-19 protocols, including wearing a mask and maintaining social distancing, even after getting vaccinated.

Image 3: COVID-19 Vaccine General Information Flyer

However, I recognized that Alirajpur’s low literacy rate meant that most of the target audience were unable to read these posters, which proved to be largely ineffective as a tool. Thus, I chose to focus on the oral; deciding on traditional ‘baithaks’ (discussion circles), poems and songs as mediums to effectively convey information.

Image 4: With key collaborator and translator, Mrs. Sangeeta Bhavsaar at a ‘Baithak’ at Harasvaat Village

Starting with the poem, I knew I wanted to stress on the importance of vaccination, without understating the continued usage of pandemic hygiene, social distancing and mask-wearing. To that effect, Mrs. Bhavsaar and I devised the following poem in the local language.

मुखडा़— टीको लगाड़ने छे रे भाय टीको लगाड़ने छे। सुब काजे कोरोना न टीको लगाड़ने छे।

We must all get vaccinated, my friend. We must get vaccinated.

1/ टीकों लगाडी़ न हमु कोरोना न भोगाड़णु छे। कोरोना न भोगाडी़ न अमु टोणकाय राखणु छे।

Once vaccinated, we must rid ourselves of Corona and become healthy.

2/ कोरोना न टीकों घोणों फायदा वालों छे रे। आपणु काजे कोरोना न खिलाफ लोड़ने न जुर आपसे।

The Corona vaccine is effective, it will give us the power to fight against the virus.

3/ आपणी वारी आवे ते टीकों जोरुरी लगाड़ जु। टीकों बी लगाडो़ मूई मा मास्क बी लगाडो़ रे।

When our turn comes, we must definitely get the vaccine. We must get the vaccine

and wear our masks.

4/ मोयना भोरी मा दुई टीका लागसे। पेल टीकों लगाऊ बीस आठ दाहडा़ मा दिसरो।

We will get 2 vaccines, the second will be 28 days after the first shot.

5/ दूई माणस्या न वीच दूई हाथु न छेटी राख रे। थुडी़ थुडी़ वार मा आखा दाहडा़ हा धुवू रे।

And even then, we’ll continue to keep distance and regularly wash hands!

We also worked on converting the poem into a song, in line with the local folk-music beat. Sung by Mrs. Bhavsaar in the local language (Bhili), and composed in a small make-shift recording studio in Chandpur Village, the song can be found at: https://soundcloud.com/rudra-saigal/tika-lganu-che-lets-get-vaccinated

I also adapted the idea of a ‘Chai pe Charcha’ (Tete-a-tete, usually over tea), popularized by Indian Prime Minister Narendra Modi. Taking advantage of the socializing atmosphere around tea shops, I decided on organizing chats based on this site of live Indian politics; these events came to be the central component of the outreach campaign.

Additionally, I reached out to the aforementioned community leaders (Table 1), convincing them to organize batches of community representatives and willing townsfolk for conversations. The legitimacy provided by the village Sarpanch helped greatly, and I was able to persuade all the leaders I had listed. Having successfully planned for my outreach, I began meeting batches of people from 16th January, 2021.

2. Outreach and Observations from the ground

In tandem with the government’s vaccination drive, I began organizing batch meetings and ‘Chai pe Charcha’ events from 16th January 2021. As of February 10, 2021, I have successfully organized Chai pe Charcha events in the following villages in the district:

  1. Harasvaat
  2. Akola
  3. Palasda
  4. Chandpur
  5. Chichal Guda
  6. Lakhankot
  7. Seja
  8. Thod Sindhi
  9. Richhvi Holi Falia
  10. Jhandoli
  11. Pujara
  12. Laxmini
  13. Dungar Gaon
  14. Guda

Image 5: Local participants at a ‘Chai pe Charcha’ event organized in late January

Through each of the events I attempted to keep a similar structure of talking for 5-10 minutes and allowing for questions for 20 minutes. However, over the first three days of outreach I made a few observations that I incorporated into future meetings and outreach plans. These are delineated below:

  • Womenfolk preferred separate, smaller meeting groups than the batches I had organized. While they seemed comfortable in interacting with me (perhaps owing to my ‘outsider’ status), they seemed uncomfortable in large groups of mixed company where they had to be careful about social norms.
  • While the government had anticipated Vaccine Eagerness (an over anticipation of the dose as a simple end to the pandemic) and Vaccine Hesitancy (Mistrust of the vaccination process) in their communication booklet, what I noticed amongst many people in Alirajpur was a third, non-mentioned category of ‘Vaccine Indifference’. While there was widespread hesitancy, many of the people I interacted with also seemed to think that COVID was a “rich person’s” disease and thus the vaccine was wasted on towns like Alirajpur.
  • There was a generalized mistrust of non-traditional medicine in the town, with people suspecting such campaigns as poisonings, placebo and even non-consensual mass sterilization drives.
  • Patron-client bonds continued to run deep in Alirajpur, with non-elected community leaders like Patels and Sardars holding great sway over the public mood.
  • While people were aware of the vaccine as an abstract cure, they were unaware of how it would be beneficial to them. This could be attributed to lack of literacy, owing to which word of mouth was the biggest source of news and opinions.

Images 6 and 7: Women gather at the smaller, more exclusive meeting we began organizing to encourage female participation at Laxmini (top) and Chandpur (bottom) Villages

I also noticed a general lack of engagement with the positive impact of vaccines. In order to adjust the outreach to these challenges, I decided to start tailor make initiatives to the sociological demographics of specific villages. I began creating distinct women-centric seating and even planning women-friendly and women-dominant meets (it was never women-only, as certain families in Alirajpur have norms against leaving women unaccompanied and would send brothers/husbands/brothers-in-law). Some villages had designated ‘Mahila Mandals’ (Women Groups), who were happy to help organize larger participation.

I also began contacting the community leaders of the villages ahead of the meetings, asking them to join me during the meetings, extending their patronage over the vaccine outreach, and helping in translating the dialogue in the local language.

Additionally, I began asking for the previously mentioned COVID song to be played around the village in lead up to the event and at the event itself. This provided basic information on the vaccine in an interactive way, and allowed people to be prepared with questions and concerns that engaged with the issue. This provided an alternative source of information to word of mouth and increased participation tremendously.

Envisioning long term impact, I also reworked the “Apna Alirajpur” app, where I uploaded expert’s (doctors and other medical personnel) answers to frequently asked questions.

In order to overcome the general lack of literacy, I have also begun identifying ‘group leaders’ who are literate and own a smart phone. These tagged individuals collect questions as they appear and upload them onto the app, also notifying the community when an answer is posted.

Image 8: Increased footfall and participation in Seja Village following participation of the local Patel

Despite significant improvements following these changes, the mistrust towards non-traditional medicine continued to pose a problem. Villagers had elaborate stories of how vaccines had caused draught, ill-luck and death in other villages or amongst relatives. One man even told me that a vaccine shot for him had caused the death of all the chicken he reared one year! The association of modern medicine in general and vaccines in particular as something of an unknown entity was compounded by these stories that seemed to reinforce the ‘vaccine indifference’ I had previously noted.

To counter this, I began showing videos of doctors and medical staff receiving the vaccine in weeks prior. I also encouraged the Sarpanch to pledge that he would record receiving his vaccination and upload it onto the Apna Alirajpur app; group leaders would then share the video with their batches. Via this process, I hope to initiate more positive associations with vaccine than those that currently exist.

Images 9 and 10: Question time at ‘Chai pe Charcha’ events in Guda (top) and Akola (bottom) Village in early February 2021

3. Conclusion

As I have gone through the process of community outreach in Alirajpur, the importance of detailed policy briefs that include civil society has become increasingly clear. There exists a huge gap between policy and implementation, owing to the chasm between theoretical and ground-level realities. Despite efficient decentralization that gets people to obey the law (as it successfully did during the COVID-19 lockdowns), there is a huge lacuna in terms of understanding the law.

To fix the massive communication gap between the government and the citizens, there is an immediate need for creative policy execution that acknowledges the knowledge divide in India and acts on it by consulting local stakeholders at the grassroot level. Moreover, since community leaders, religious leaders and traditional healers continue to hold a tremendous amount of influence in townships like Alirajpur, even when unelected, it is essential that they be mobilized as sources of correct knowledge and understanding in ensuring active implementation of government policy.