Table 2.

Barriers to Polio Program Success

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%)

^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)

^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