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External Factors

Political, economic, social, technological, legal, and other environmental factors

Social

Communities are non-accepting and/or resistant to the intervention

• Vaccine hesitancy

• Community fatigue given repeated campaigns, misaligned priorities

• Lack of information

Economic

Insufficient revenue sources

• Limited economic resources

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

Technological

Slow or limited advances of technologies used in implementing program activities

• Technological and infrastructural challenges affecting vaccine supply and surveillance

Other

Challenges related to physical and human geography

• Geographical inaccessibility

• Population migration

Process of activities

How activities were implemented

Executing

Failing to carry out activities according to plan

• Lack of accountability mechanisms

• Environmental disruptions to program implementation

• IPV supply challenges

Engaging

Difficulty attracting and involving appropriate stakeholders in implementation

• Difficulty identifying appropriate stakeholders to engage given diverse administrative structures, cultural norms

• Community mistrust

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

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

Characteristics of individuals

Characteristics of individuals within an organization involved in polio eradication activities

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

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

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

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

Organizational characteristics

Factors related to the organization(s) supporting implementation

Structure

The age, social architecture, and size of an organization led to challenges

• Shifting structure of global partnership

• Understaffing and shifting roles of staff

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

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

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

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

Program characteristics

Activities conducted to enable implementation, including technologies adopted

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

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

Relative Advantage

Perception that there was another, better approach

• Concern that polio program is run in parallel to (and at expense of) routine immunization

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

Trialability

No ability to test on a small scale and reverse course if warranted

• Perception of polio program asÌýtoo big to fail even in the face of coordination and implementation failure affecting certain activities

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

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

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