Enduring Outbreak

Defining an Enduring Outbreak

In the event of an Enduring Outbreak, we must escalate our response with additional measures to research, analyze, and address the outbreak's sustaining factors in order to properly address the response.

Enduring Outbreak Communications Strategy

The first step of addressing an Enduring Outbreak is conducting a systematic analysis of the root causes of the failure to interrupt polio transmission. Social, epidemiological, and campaign data and information should be aggregated and organized for analysis.

Key Steps of the Enduring Outbreak Communications Strategy

In Unsuccessful Areas:

• Identify failure points and root causes

• Redefine audiences to match the most at-risk populations

• Utilize the Enduring Outbreak Communications Planning Process to develop a communications strategy or revise your current strategy to address the barriers and audiences identified in steps one and two. See pp. XX for the Planning Process Diagram

In Successful Areas:

• Shift communications to promote the benefits of routine vaccination

• Concentrate on eliminating campaign fatigue

• Continue to test and refresh communications to optimize performance

Enduring Outbreak Communications Planning Process

The Polio Communications Planning Process outlines the steps and key decisions to make when developing communications. Each step has a corresponding component in this toolkit for reference.

For Enduring Outbreaks, the process begins with a deep analysis of the key issues affecting campaign performance in the preceding 12 months. Document the decisions you make and the information you use at each step. It will be a helpful reference and foundation for future planning.

Enduring Outbreak Barriers Analysis

Enduring Outbreak Analysis is a disciplined method of investigating and documenting the root causes of key barriers and failure points identified in the measurement and evaluation of previous campaign efforts. These root causes must be consistently addressed in order to reach every missed child.

The method, referred to as root-cause analysis, is an iterative, question-based technique for exploring the cause-effect relationships that underlie a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "why?" Each question forms the basis of the next question. Typically, a root cause will be revealed in five iterations.

Not all problems have a single root cause. If one wishes to uncover multiple root causes, the method must be repeated asking a different sequence of questions each time.

The key is to trace the chain of causality to a root cause that is connected to the original problem. When possible, the middle links in the chain should be supported by data, but field-based hypotheses are also viable (and can be subject for investigation through further research).

Typically, we think of root causes as barriers to achieving our desired behavioral objective. The root cause might be, for example, broken process (vaccinator morale) or an alterable behavior (mothers do not agree to vaccinate without consent of their husband), which can then be addressed directly to solve the original problem using customized communications.

Identifying Barriers and Their Root Causes

Identifying barriers and root causes in Enduring Outbreaks is the essential strategic task you must complete before designing a communications campaign. This section of the toolkit provides guidance and a method of analysis that will aid you in discovering, understanding, and solving key barriers that are sustaining the enduring outbreak.

In an enduring outbreak, the barriers to acceptance are likely to be specific to each community, culture, and region. They are also likely to be complex, with multiple causes that have individual, social, cultural, political, and environmental aspects. Because these barriers are likely to be both complex and unique, it is important to systematically understand them before exploring communications solutions.

FIRST: IDENTIFY THE PROBLEM

Diagnose the barriers using primary research conducted in the problem areas through the KAP model, using data collected during the previous period of the outbreak.

Barriers should be stated clearly in the form of a problem statement that contains the following elements:

• Where are children being missed?

• What is the problem?

• Who is the audience involved in the problem?

• What data has led to the diagnosis of the problem?

Here are some example barriers in the form of problem statements:

• Caregivers in high-risk communities are aware of polio (99% awareness) but do not know that the symptoms are incurable (70% believe symptoms are curable).

• Caregivers in rural communities deny access to health workers they see as outsiders (65% said the health worker who visited them was not from their community, 80% said the health worker was only somewhat trustworthy).

As a result of this analysis, you will generate a thorough understanding of the key barriers, what causes them, and the potential solutions.

[Side Bar reminder of the SEM levels]

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Using the Root Causes Identification Tool

The Root Causes Identification Tool will help you to document and visualize your analysis. The tool helps clarify the logical chain used to understand causes and any interdependencies between causes and barriers. Once the diagram is completed, it can serve as a quick reference for the issue you have identified through your research and analysis.

[CALL OUT] When completing barrier and root causes analyses, it is important to consider target audience mindset groups and types. Read the next sections to review the two types of mindset groups, as well as Caregiver and Influencer Audience Types.

[Side Bar]

REMEMBER

1. Be persistent in your analysis: don't stop asking "why?" too soon.

2. Consult subject matter experts when necessary; presenting them with the analysis and asking them to help can often uncover causes that could otherwise be missed.

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[CALLOUT] Choose and adapt creative communications to your specific problems and their root causes.

Enduring Outbreak Audience Analysis

Mindset Groups: Accepters and Rejecters

This section will help you understand the fundamental mindset groups and audience types that your communications should target during enduring outbreaks.

What motivates people to say yes to the polio vaccination during an enduring outbreak? For many, the decision is simple and made early on in the outbreak. Their awareness of how close they are to the poliovirus and what they can do to prevent it is sufficient for them to accept the vaccine for their children. These individuals are Accepters.

However, over the course of an Enduring Outbreak, repeated polio vaccine campaigns can test the patience and trust of caregivers. Therefore, it becomes very important to shift communications to focus on themes beyond just awareness.

Accepters in Enduring Outbreaks

The Acceptors in Enduring Outbreaks have accepted the vaccine multiple times. This means that initial vaccination efforts have succeeded in persuading them of the importance of the vaccine. Acceptors are sensitive to the threat that polio poses to their children, and they tend to trust authority figures when they request that their children continue taking the vaccine. Accepters in enduring outbreaks are more open to repeated vaccinations. They understand that they are necessary, but they walk a thin line of becoming Rejecters if they do not trust or believe in the need for continued vaccination.

Key Issue for Accepters

Fatigue is the key issue for Accepters in Enduring Outbreaks. The length of an Enduring Outbreak will lead to very high numbers of vaccination contacts with health workers as campaigns accumulate. This repeated exposure might erode trust and belief in the vaccine. We must address this risk with adaptive, strategic communications. For information about developing adaptive communications see Guiding Principle Three on pp. XX.

Rejecters in Enduring Outbreaks

The second mindset is Rejecters. In an Enduring Outbreak, passive or active Rejecters become the primary focus of analysis, strategy, and communications. While Rejecters are typically a minority of the at-risk population, they can cause suspicions about vaccination in communities that provide a supportive and cultural environment for their disbeliefs. This social dynamic, coupled with low vaccination and immunity status, provides an enabling environment for a polio outbreak to occur. Rejecters are defined by a reluctance to vaccinate their children during the initial outbreak and throughout the enduring outbreak. A rejecter may reject every time, or some of the time. They may reject overtly, or passively avoid vaccination or health workers. Their rejection has complex and intermingled root causes, and communications that work well with Accepters may not have the same effect on Rejecters. It is therefore very important to understand the root cause of why a caregiver is rejecting the vaccine

During any situation—outbreak, enduring outbreak, or maintenance, mindsets can be fluid: Accepters can become Rejecters if their perceptions change and Rejecters can become Accepters if their perceptions change. However, this change from acceptance to rejection is particularly acute in an enduring outbreak context due to multiple rounds of vaccination and the duration of the outbreak.

Key Issue for Rejecters

Moving from a place of rejection to acceptance is a difficult task that requires developing and sustaining trust and goodwill between health workers and the Rejecters. Throughout our communications, we emphasize this need. While mass media can provide an enabling environment to change perceptions, behavior change is most likely to emerge from interpersonal communication (IPC). See the Interpersonal Communications Section for guidance on IPC messages and approaches for Rejecters, pp XX .

Transient Audiences

Both Accepters and Rejecters may be "transient." That is to say they do not have a permanent home and are more difficult to reach. Where possible, with government assistance, child immunization should be made a prerequisite for travel and employment, regardless of where they are heading. In all other scenarios, transient populations must be reached with tailored communications.

With transient populations, we must consider the best ways we can reach and vaccinate them. Making this happen typically requires media at key transit points. It also depends heavily on interpersonal communications to succeed with an interaction that involves a caregiver who is typically rushed, unprepared, and perhaps unwilling to receive a health service at this time, particularly if they have received the same service multiple times before.

Additionally, the motivations for being transient should be leveraged to incentivize vaccination. These transient, potentially displaced individuals are a case of "strangers in a strange land," and we have the opportunity to resonate with them if our messages recognize their place of origin, their destination, or their purpose for traveling. Brand familiarity is an important source of trust that should be used in communications at transit points.

Key Factors for Transient Individuals

• Communications need to be tailored to reflect the transient audiences culture and country of origin.

  • If polio was an issue in their place of origin, synchronize messages and branding with place of origin and /or place of travel.

  • Identify and use spokespeople and sources they consider credible to build trust.

• Transient audiences may be less familiar with polio, so it is important introduce vaccination as a critical regional health issue.

• They may be less familiar with polio vaccination, so it is important to introduce vaccination as a critical regional social norm.

• Use appropriate medias channels, such as:

  • Booths at major transit locations

  • Mobile vans displaying communication materials

  • City buses

  • SMS and voice messaging services targeted to those who travel across borders, as well as other outdoor media in public spaces, such as railway stations, buses, bus stops, markets, dairy booths, banks, and schools

• If possible and when appropriate, bundle polio vaccination with other messages about desired health services.

• Utilize multipurpose communications, such as brochures that can be folded into small toys for children.

Audience Types: Caregivers and Influencers

There are two main categories of audiences in our communications: Caregivers and Influencers.

Caregivers

Caregivers are the family members who can make the decision to accept or reject vaccination for their children. The chart below outlines the role of caregivers in an Enduring Outbreak.

Influencers

Influencers consist of the key individuals who exert an influence on the caregivers at the different levels of the SEM model. They can include the elders, religious and community leaders, political figures, and other members of society.

It can be useful to target, address, and engage secondary audiences that influence caregivers. The following charts outline the influencer audience types and common profiles to provide an overview of how they can be included in enduring outbreak communications. These charts are derived from the SEM C4D model, but focused specifically on audiences that can directly influence the caregiver.

Interpersonal Engagement & Key Messages

Mass media tactics are an effective and crucial element of any program, but where they fail, interpersonal communication tactics can succeed. Mass media elements are unidirectional and are unable to adapt to the audiences needs and concerns in the moment. Interpersonal communication on the other hand, is dynamic; it can be tailored to the individual's specific needs and can effectively address caregiver-specific barriers.

The following themes represent complex barriers that mass media tactics may fail to overcome. Within the themes are interpersonal-based solutions and key messages that should be delivered by a health worker or social mobilizer. Importantly, these themes should be incorporated into all frontline health worker trainings.

THEME ONE: Repeated Campaigns

Problem

• We visit them so often and don't build acceptance into a strong enough habit.

• People become frustrated after X visits and don't understand the necessity of the visits. The reason that polio continues to be a threat hasn't been communicated to them adequately.

Solution

• Empathize with their frustration before explaining the reason behind repeated campaigns in a neutral way.

• Listen to their response.

• Emphasize the importance of doing this together without being pushy or disrespectful.

• Explain that other members of the community are also vaccinating their children and that many children are vaccinated each day to keep the whole community safe.

Message to the Caregiver

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I can see how you'd feel this way. I felt this way, too, but I found that it's a good thing that we continue to protect our children against polio together. It turns out that for polio to stop making our children ill, we must continue to vaccinate. This will protect our children until the virus is no longer detected in local water, where it can live and keep infecting new unvaccinated children for almost six months. That's why we keep bringing the vaccine, and it turns out to be good for your child to continue taking it as a precaution. If we all work together to protect everyone, we can eliminate the disease entirely. Please help us, and please help your friends and family understand this.

Influencer Message (We are assuming we will only engage influencers who personally support the vaccine)

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the influencer.

• How many times will we come? We will keep going until polio is gone from here. We know we can do it because we've removed it completely from many other countries in the world and in most parts of our country. It turns out that for polio to be stopped entirely, we must continue to protect our children until the virus is no longer detected in local water, where it can live and keep infecting newborns and unvaccinated children for almost six months between active cases. Until it's completely gone, every new child is at risk, and polio can easily come back into our community through a vulnerable child. That's why we must come so often. If we all work together to protect everyone, we can eliminate the disease entirely. Please help us, and please help your friends and family understand this.

THEME TWO: Belief that vaccine is unsafe

Problem

• We have frequently communicated the safety of the vaccine, so a persistent belief that the vaccine is unsafe indicates that our message was not received, not trusted if it was received, or that a rumor is creating enough uncertainty to make normal safety messages ineffective.

Solution

• Empathize with their concerns to defuse negative emotions they may have surrounding the vaccine, especially fear, uncertainty, and doubt.

• Reframe the issue of safety to the immediate and familiar reference point of the local community. Famous leaders and celebrities who work with polio vaccine can also be helpful occasionally.

• Listen to their response.

• Emphasize the importance of doing this together, without being pushy or disrespectful.

• If necessary, offer to take some of the vaccine itself, to show that it is only helpful, not harmful.

Caregiver Message

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I can see how you would feel this way. I've felt this way, too, with the children in my family. But then I found out that it is actually completely safe, and I've never seen any child get ill from taking the vaccine. The worst thing that can happen is a slight fever, which is normal and a sign that body is using the vaccine to become immune to polio.

• We've been giving the vaccine for years in this [community/village/neighborhood/city/area], and all of the children are fine. If you think about it, you already know so many people who take it whenever we come by, and they don't have any problems. You probably know most of them very well, too, your [community leaders] and [religious leaders] have also given their children this exact vaccine, and they are perfectly healthy. That's because we all know that it is completely safe. We're fortunate that there is such an easy way to prevent this disease. It is a wonderful thing.

• Giving the vaccine doesn't just protect your children, it actually will help us completely stop polio from harming the children in our community. If you'd like, I can take some of the vaccine right now with your child. It's only helpful, there's no risk at all to anyone from taking it.

Influencer Message (We are assuming we will only engage influencers who personally support the vaccine)

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the influencer.

• How many people in your community have taken vaccines, including you and your family? And no one has ever gotten sick because they are perfectly safe. Taking them is just normal. And when we give them to all our children, we can protect all of our families and the entire community from disease. We're fortunate that there is such an easy way to prevent this disease. It is a wonderful thing.

• Some people seem to worry that the vaccine is unsafe. That's okay; it's good to worry about your children and their health. We want them to know that it is safe, and that nothing bad ever happens to the children to whom we give the vaccine. They can see the proof: We have given it to children in the community before, and those children are perfectly healthy and polio-free. We hope that you will help us by talking to your family, friends, neighbors, [and community/religious following if applicable], about how safe the vaccine is and how they actually do know so many people who have taken it.

THEME THREE: Campaign Mistrust

Problem

• The polio program is ubiquitous, and campaigns are frequent. More individuals experience contact with the campaign than experience contact with polio or its symptoms. The comparative rareness of the disease means that the cause of the vaccination activities is not always known and immediate to individuals on a firsthand basis. Instead, they must learn about it through communications and their community, rather than firsthand observation.

• The poor information environment leads to natural skepticism and distrust of official narratives, especially when they do not explain their origins, agendas, and owners in detail.

• Regional insecurity and instability exacerbate trust issues by making skepticism and suspicion rational and normal.

• Rumors and competing explanations are entertained and accepted when they are both unchallenged and emotionally satisfying.

• Beliefs about corruption may have a basis in fact, giving additional credibility to rumors and mistrust. This will be especially true if the government has a history of censorship and control of news, journalism, and mass media within the region. In some cases, this effect is so extreme that foreign and international sources of information might be more credible than local and domestic sources.

• Providing the correct information is only one part of the solution to correcting misbeliefs and rumors.

• By itself, information is often insufficient when mistrust is prevalent.

• Trust begins with the credibility of the source, not the correctness of the information. A skeptical individual will carefully consider the source before deciding to trust the information itself.

• Multiple factors influence the perception of credibility:

  • Is the source known to the individual (e.g., a well-known and trusted brand, company, or individual) or unknown?

  • Does the source have firsthand, special, or eyewitness knowledge of the information that is being communicated?

  • Does the information have sufficient detail?

  • Would it have been difficult to manipulate or distort the information?

• Simply denying rumors and contradictions is inadequate, as the lack of trust means the new information is not credible, whether correct or not.

Solution

The information provided via IPC must reframe the campaigns as trustworthy, using information that is credible coming directly from a health worker or social mobilizer. Make the right introduction. The health worker/social mobilizer must introduce himself or herself, explain who they are, where they are from, and who they know in common with the caregiver within the community. If the health worker has an ID card, he or she should show the card. This establishes their personal trustworthiness and credibility and gives the caregiver a sense of control, as they will be able to verify the health worker/social mobilizer's credibility through someone they trust.

• Convey that the campaign is the standard approach to polio outbreaks and has been implemented safely in the past and in other countries.

• Emphasize that this information was acquired personally through access the health worker/social mobilizer had during training.

• Emphasize that the people behind the program are known and trusted by the health worker/social mobilizer.

Caregiver Message

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I understand what you're saying, but that's not the truth. These campaigns are actually completely ordinary, and the way we do them here is similar to how they have been conducted everywhere else in the world. We actually use similar training and the same vaccine - I've seen all of this myself when I started helping with the campaigns by talking to parents about polio and vaccination against polio. The campaigns have been the same for decades because they work. It's all very ordinary. You can ask any of us - we've all seen the same thing during our training and when we go and get the vaccines. For everyone who works on these campaigns, it's a job and a big effort. But we know it's worth it because together, we can protect children. We're here to help, and with your help we can ensure that both your children, the children in this community, and children across the world are protected from polio.

Influencer Message

• Introduction to influencer, including name, role, and origin, and who they know in the area who would be known to the influencer.

• Some people seem worried that the polio campaigns aren't just about vaccinating children against polio, and they are confused. They think there is something else going on. That's not the truth, though. The truth is that the campaigns are just completely ordinary. I know, as I've seen that we use the same training and methods that older campaigns in other countries have used. It's almost exactly the same, everywhere. That's because it works; it's a difficult and big effort to vaccinate all of the children in our area, so we need to be really organized and consistent. As long as we keep going, we'll keep getting closer to completely protecting our children against polio, forever. And once that happens, we can stop the campaigns. It's as simple as that.

THEME FOUR: Belief that vaccine is ineffective

Problem

• OPV needs multiple does for maximum efficacy. In ideal scenarios, three doses are effective. Variable conditions in the field require many more doses, depending on the strength of the child's immune system.

Solution

• Ask caregivers why they believe the vaccine is ineffective.

• Empathize with the caregiver to defuse any tensions that disagreement with their belief may cause.

• Explain that the vaccine is effective, but that every child is different and that some children need less and most children need more vaccine to be fully protected, which is why some people believe the vaccine is ineffective.

• If the caregiver doesn't understand how vaccines are effective in general, use simple metaphors to explain the notion of preventing illness.

• If the caregiver cannot be persuaded, ask them for their trust and willingness to give the vaccine as just a precaution.

Caregiver Message

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I understand how you feel, and I thought about that, too. But then I found out that the vaccine is more effective taken more times, and you have to give it as many times as you can to get the best protection. That's why we come by so frequently.

• It really depends on your child, and every child is a little different, especially when it comes to health. Some never seem to get sick, even when they are newborns, and some seem to always need more help fighting off fevers and illnesses. The vaccine works the same way, but it's okay because it's safe to take it many times. Everyone needs at least three doses to be protected, but many children need as many as five or even more, especially if they tend to get sick a lot. In any case, with any child, it's safest to take it every time we are here.

• Vaccines protect children by helping their bodies recognize and fight diseases before they become sick. It's like any other danger, really -- you have to be able to recognize it ahead of time or you'll be in trouble. An unvaccinated child is like a bus driver without headlights -- how can they avoid crashing when they can't see the road ahead? It's better to be smart and protect them against the dangers ahead of time.

• As you can imagine, it's hard to vaccinate everyone in an entire village, let alone a big city or the entire country. But we've been successful, and we've protected so many children by doing this all together; when it comes to diseases and illnesses, we're all fighting them together. The vaccine becomes so much more effective once everyone has them because it becomes harder for polio to find unprotected children to pass through.

• Since there's no risk here, I can take a few drops right now. If you want to watch, they are totally safe. May we give them to your child just to be safe? Because that's the funny thing about vaccines: when they work, disease is prevented, so it's worth being safe and taking them.

• To ensure the vaccine works as best as it possibly can, your child needs to be strong enough to fight infections. Wash hands with soap to prevent diarrhea, get your full routine immunization to ensure he/she is protected from all other diseases, and feed him good, nutritious food, together with breastfeeding.

Influencer Message

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the influencer.

• Has anyone you've mentioned that they think the polio vaccine just doesn't work? What did they say? Why do you think they feel that way?

• The polio vaccine actually does work, but sometimes children who are a little weaker need more doses to be fully protected, so sometimes people believe that it simply doesn't work. I can see why they would come to that conclusion. It actually can take many doses to give complete protection, which is why we come here so often. It's not worth the risk of catching polio when taking the vaccine is so easy and so safe.

• It really depends on the child, and every child is a little different, especially when it comes to health. Some never seem to get sick, even when they are newborns, and some seem to always need more help fighting off fevers and illnesses; it's the same with the vaccine, so to be safe, we need your help. Please talk with your friends, neighbors, and family, and tell them we are happy to talk to them and to listen to them about their concerns. It's okay to have questions about medicines for children, and we want to help.

• How might we get better at talking to people in your community about the vaccine's effectiveness?

THEME SIX: Children are not available (absent, newborn, sick, sleeping)

Problem

• The cause for the unavailability needs to be understood on an individual basis in order to give the correct response and, on a collective basis, to understand whether there is a broader pattern of unavailability that requires an additional intervention to address, beyond one-to-one IPC communications.

• It is also possible that claims of child unavailability are a "soft" refusal of the vaccine, made with the intent of avoiding direct confrontation.

  • If so, ignoring this desire to avoid confrontation communicates a lack of empathy for the caregiver, which may harden their refusal into outright rejection.

  • At the same time, simply taking their word for it may further incentivize "soft" refusals within a community or area, if it becomes known that these kinds of refusals will go unchallenged.

  • Further complicating matters, the truthfulness of a claim of unavailability may be difficult or impossible to discern in the moment.

Solution

• Gently probe into the issue to see if the caregiver is willing to explain further, and ask them to suggest a time that would work for them to create a sense of reciprocity within your conversation.

• Inform them that they and their children have the right to the vaccine, which is being provided free of charge, and that they are missing their chances to receive it when their children are unavailable.

• If regional security allows, provide the caregiver with further information on when health workers will visit, as well as alternative places and ways (health camps and other healthcare facilities) to get the vaccine.

• Ask them to talk to their neighbors about the vaccine and the days the health workers are coming as well.

Caregiver Message

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I'm sorry to hear that your children aren't around. It's all right, we will be returning [insert date] to try again. You and your children have the right to these vaccines, free of charge, so it's important that we find a time when they can get them. Otherwise, they won't be getting what is fair for them, and what they need to protect them – and your family – from polio. May I ask where they are and why they couldn't be here to get their vaccines?

• Is there anything we can do to help? Is there a better time for us to come?

• Would you be willing to discuss this with your family, friends, and neighbors? We want everyone to know his or her rights, and we want everyone to take advantage of this service, which is being provided at no charge.

• In general, when do you think we should come when we can provide healthcare and services?

Influencer Message

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the caregiver.

• Some of the parents in your area have been telling us their children aren't around when we come with vaccines for polio. We worry they don't understand that they and their children have a right to these medicines, and that they are going to miss their chance because it isn't clear when they need to be home to get them. Would you be willing to talk to your community about this and let them know that they need to have their children there so they can receive what is rightfully theirs?

• We are also open to coming by at different times, if it would be more convenient for some parents. When do you think would be the best time?

THEME SEVEN: Belief that polio is curable

Problem

• These experiences, whether firsthand or hearsay from trusted sources, provide a credible basis for the incorrect belief to caregivers that cannot be refuted simply.

• Although the disease is not curable, children do sometimes recover from the symptoms, and it is natural for people to assume that the care they received at the time caused the recovery, implying that polio is curable.

• Caregivers may believe that polio is curable, especially if they have seen someone exhibit key symptoms from which they recovered while receiving care.

Solution

• Empathize with the caregiver and gently probe them about their belief that polio is curable and the reasons they believe it.

• If their belief is based on anecdotes of recoveries from polio, do not tell them they are wrong, or that the stories they have heard are false. Instead, express amazement and gratitude for the miraculous recovery of those children.

• Explain that it takes a miracle to recover from polio, and that the care they've received actually isn't the source.

• Within that context, we should all hope for miracles for the sick, but it's far better to take action and protect children through vaccination, instead of leaving it to chance.

• If they simply hold erroneous beliefs, provide correct information without disagreeing with them directly or telling them that they are wrong.

Caregiver Message

• ntroduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• That's interesting that you think that polio is curable. I want to understand more. Can you tell me why you think that?

• [If beliefs are based on anecdotes of recovery] That is amazing, and we should all be thankful for such a miraculous recovery. Thank you for sharing that story with me. I wish that all children could be so blessed. If they were, then I would not need to do this work, and I could turn toward other things. Unfortunately, many are not so lucky, and it's far safer to vaccinate children and give them certain protection, than to risk their paralysis by hoping and praying for a miracle. That's why we must be vigilant.

• [Otherwise] I understand how you feel, and I thought about that, too. But then I found out that only some children are lucky enough to recover from those effects of the disease and that home remedies and other medicines don't work reliably. It's pretty much a miracle when it happens. I wish that all children could be so blessed. If they were, then I would not need to do this work, and I could turn toward other things. Unfortunately, many are not so lucky, and it's far safer to vaccinate children and give them certain protection, than to risk their paralysis by hoping and praying for a miracle. That's why we must be vigilant.

Influencer Message

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the influencer.

• Has anyone you've spoken to said that they think polio is curable? What did they say? Why do you think they feel that way?

• I understand why someone would feel that way, and it's good to be hopeful. But the truth is that only some children recover from the symptoms, and home remedies and medicines simply don't work. It's pretty much a miracle when a child makes a good recovery, and we would be truly lucky if it happened more often. Unfortunately, many are not so lucky, and it's far safer to vaccinate children and give them certainty in their protection against polio, than to risk their paralysis by hoping and praying for a miracle.

• Together, I hope we can spread this message: don't rely on miracles when there's a safer way. Vaccinate your children.

• Please, talk to your friends, neighbors, and community about this, and please let us know how we can help spread the truth about polio.

THEME EIGHT: CVDPV

Problem

• If this occurs AND there are enough unvaccinated children within the area, it is possible that an outbreak will occur.

• As poliovirus declines in threat, the circulating version of the virus that is derived from oral polio vaccine is a potential source of outbreaks as it mutates in the wild.

Solution

• CVDPV outbreaks are addressed in exactly the same manner as other outbreaks, and sufficient coverage of children is the key to solving them. As such, there is no need to actively communicate about CVDPV specifically, unless knowledge of CVDPV is a specific source of refusals and people begin to believe that the vaccine is unsafe because of it.

• In such a case, it must be emphasized that CVDPV is only a threat to children who have not been vaccinated, and that properly vaccinating children multiple times affords them complete protection against all polioviruses, including CVDPV.

Caregiver Message

• Introduction to caregiver, including name, role, and origin and who they know in the area who would be known to the caregiver.

• I can see how you would feel this way. I've felt this way too, with the children in my family. But then I found out that it is actually completely safe, and I've never seen any child get seriously ill from taking the vaccine. The worst thing that can happen is a slight fever, which is normal and a sign that the body is using the vaccine to become immune to polio.

• We've been giving the vaccine for years in this [community/village/neighborhood/city/area], and all of the children are fine. If you think about it, you already know so many people who take it whenever we come by, and they don't have any problems. You probably know most of them very well, too. Your [community leaders] and [religious leaders] have also given their children this exact vaccine, and they are perfectly healthy. That's because we all know that it is completely safe. We're fortunate that there is such an easy way to prevent this disease. It is a wonderful thing.

• Giving the vaccine doesn't just protect your children, it will actually help us completely stop polio from harming the children in our community. If you'd like, I can take some of the vaccine right now with your child. It's only helpful, there's no risk at all to anyone from taking it.

Influencer Message

• Introduction to influencer, including name, role, and origin and who they know in the area who would be known to the influencer.

• How many people in your community have taken vaccines, including you and your family? And no one has ever gotten sick because they are perfectly safe. Taking them is just normal. And when we give them to all our children, we can protect all of our families and the entire community from disease. We're fortunate that there is such an easy way to prevent this disease. It is a wonderful thing.

• Some people seem to worry that the vaccine is unsafe. That's okay; it's good to worry about your children and their health. We want them to know that it is safe and that nothing bad ever happens to the children to whom we give the vaccine. They can see the proof: we have given it to children in the community before, and those children are perfectly healthy and polio-free. We hope that you will help us by talking to your family, friends, neighbors, [and community/religious following if applicable] about how safe the vaccine is and how they actually do know so many people who have taken it.

Creative Concepts

There are three conceptual territories to use as a basis for creating mass communications in Enduring Outbreaks. Each looks at health workers and children's health from a slightly different perspective and can be tailored to address particular issues more directly. Which campaign you would choose will depend largely on the audience barriers that you have identified.

1. We Are All Intertwined

2. Strangers No More

3. Best Amongst All

We Are All Intertwined

The core of this concept is the idea that immunization and children's health are shared community obligations and that the community remains strong only if every child is protected. Drawing inspiration from the rich tradition of textiles in many of the at-risk regions, it takes the metaphor of community as fabric and uses it to illustrate our interconnectedness, and the superior value of a collective gain. And it depicts the positive behavior of immunization support and acceptance.

In other media, the metaphor is extended by showing other kinds of interrelationships and connectivity such as a truck driver who is connected to others through his travel, or a brick worker connecting bricks to build a strong foundation for a home. In these stories, we also have the ability to depict the vaccinator in a very positive heroic light so as to remove any barriers to acceptance and access. The goal is to socially normalize immunization by emphasizing the collective responsibility to vaccinate every child for the good of all children.

Selection checklist

1. General appeal for the importance of immunization

2. Overcome fatigue from perception of too many immunization campaigns

3. Overcome anti-vaccination sentiments

4. Encourage sense of responsibility and community

Strangers No More

Knowing something about someone—their hometown, tribal, or religious affiliation or even just their name—changes how you feel about them and how you behave with them. If you look at health workers solely through their role, you will be less likely to listen to them than if you have a bit of context. This concept creates a context of trust around the health workers by humanizing them. In mass media, we meet them through their background and interests and then pivot to their roles as health workers.

This extends all the way through IPC training by asking our health workers to first introduce themselves ("Hello! My name is Baharwar. I am from Lorilai. How are you?") before engaging on the subject of inquiring about the children. This concept is specifically designed to change the general perception of the health workers, though the IPC techniques are universally applicable regardless of conceptual area.

Selection checklist

1. Overcome failure at point of service due to lack of trust

2. Caregivers believe that vaccinators are "outsiders" and not part of the community.

Best Amongst All

"Best amongst all are those who are chosen for the most difficult tasks." In many areas, the health workers face especially arduous conditions, from extreme geographic remoteness, to security challenges, and more. In those cases, depicting the health workers through the lens of the importance and dignity of necessary work lets us shape how people see them and how they see themselves and their work.

This concept was created with the frontier areas of Pakistan in mind, but could easily apply to anywhere that acknowledging the challenges they face might apply, such as northern Nigeria, Syria, Iraq, the Ukraine, etc.

Selection checklist

1. Overcome lack of respect in the health workers

2. Target areas with challenging security environments

3. Campaign fatigue or additional trust issues

Communications Planning Worksheet

The Communications Planning Worksheet contains the key questions necessary to plan a strategic communications campaign. By answering each of the questions, you will identify and refine your communications strategy. After completion, the worksheet serves as a point of reference for communications throughout campaign development and through coordination with partners, including creative and communications agencies, and the development of new IPC messaging.

The worksheet's sections correspond with sections of the toolkit, and more information and analysis about each of the section's focus area can be found there.

Media Channel Selection in Enduring Outbreaks

After the initial immediate response effort to simply alert and create awareness of the polio outbreak, the media strategy needs to shift to address the barriers that are allowing the outbreak to continue. Media decisions should be based on the situation in the affected regions and the collective analysis of how media channels have performed before the outbreak and since the beginning of the outbreak. When reviewing media channel performance, also consider what publicity the program has received and how it has assisted or hindered the program's progress. This will determine whether your media strategy should adopt a high or low visibility approach.

By using the Root Causes Identification Tool and the Communications Planning Worksheet, you should have already identified the barriers that remain and determined how best to address them with messaging and a general idea of media channels. The next step is to identify which specific media channels are most effective in getting caregivers to either allow vaccinators in the home or take their children to the clinics or camps where vaccination occurs.

Answer the following questions to determine changes to media channel planning in an Enduring Outbreak:

• What channels were most effective in changing behavior over the last 6 to 12 months? Have you done any survey or focus group work to determine this?

• Which channels showed the quickest "wear-out" (i.e., failure to resonate or engage the audience)? Did the messaging no longer resonate with caregivers because of the message or the media channel?

• Are some channels better for reaching rural targets? Urban targets?

• Which channels are more cost-effective to use than others? Radio versus TV?

• What kind of earned media and/or publicity is the campaign receiving, and what actions can be taken to utilize or improve earned publicity?

• Is there a need to use more "interruptive" media such as stunts or live events versus paid media?

• What is the role of ICT channels to allow for social media impact beyond paid media?

• Can popular culture in the form of music, entertainment, or celebrities be a media channel to reach a broader or perhaps less-interested audience?

• If the outbreak has not been closed because of specific geographical targets, can targeted micro-media efforts be used? This could also include communities that are separate from the general population for other reasons as well (languages, tribal areas, religious sects, etc.).

Measurement, Monitoring, and Evaluation

Monitoring Your Campaign

Monitoring, also referred to as process evaluation, is the routine (day-to-day) tracking of activities and deliverables to ensure that the campaign is proceeding as planned.

Monitoring can:

• Uncover problems or deviations from the campaign

• Provide information for improved decision-making

• Measure behavior changes

If necessary, adjustments to message, materials, or activities can be made in a timely manner.

Key Monitoring Action Steps

1. Prepare an operational plan: Describe the information that will be collected, from which source(s), by whom, by what dates, and at what cost. Be mindful of ethical practices of ensuring the privacy and security of information regarding program participants.

2. Develop evaluation indicators: Indicators should reflect variables that are included in, or effect, the caregiver's choice to vaccinate their child. It may be helpful to consider the stages of the caregiver's journey. For example:

   1. Awareness

      1. Awareness of polio

      2. Awareness of the vaccine

      3. Awareness of where and how to get vaccinate

      4. Awareness of the campaign

         1. Brand recall

         2. Message recall

         3. TV impressions

         4. Radio impressions

   2. Resonance

      1. Perception of polio as likely and serious

      2. Understanding importance of polio vaccination

      3. Perception of OPV as safe and effective

      4. Understanding of herd immunity

      5. Communal perceptions of polio vaccine

   3. Consideration

      1. Intent to vaccinate

   4. Health Worker Contact

      1. Perception of health worker as trustworthy

      2. Perception of health worker as competent

      3. Perception of health worker as honest and moral

      4. Perception of health worker as part of community

   5. Vaccination

      1. Reasons for missed children

      2. Missed children

      3. Number of successful vaccinations

   6. Repeat Vaccination

      1. Intent to vaccinate again

      2. Vaccination coverage

      3. Contact efficiency

      4. Repeat vaccination success

   7. Social Mobilization and Advocacy

      1. Influencer Advocacy

      2. Peer advocacy

3. Develop monitoring data collection templates: Create or adapt the tools that program staff will use to conduct monitoring activities. For example:

   • Independent Monitoring forms, adapting the Global Guidelines and Forms

   • Campaign Observation checklists

   • Weekly viewer discussion groups

   • Weekly brief survey questionnaires, using RapidPro or other technology if available

   • Quarterly rounds of Rapid Audience Assessment surveys

   • Quarterly focus group discussions

   • Knowledge Attitudes and Practices Studies (KAP) using Harvard Polling questionnaire and methods, if appropriate

4. Develop a monitoring data analysis plan: Describe what information will be analyzed, how, by whom, and by what dates. It is helpful to create dummy tables for the data analysis.

5. Develop monitoring reporting templates: Create easy-to-use reporting forms that are mindful of the time it will take to complete and read. The format should be concise so that the information can be readily interpreted and acted upon.

6. Develop a mechanism for using monitoring reports to support on-going program activities: Create a process for reviewing monitoring reports, discussing them with staff, partners, and stakeholders as necessary, delegating tasks to address any issue that are detected through the monitoring activities. This may be done through Communication Taskforces or other forums.

7. Write a report on the findings from the monitoring after each campaign or quarter: Communicating monitoring results effectively is critical if they are to be used for advocacy and re-planning. The narrative should be supported by graphics and illustrations to help the reader understand the findings. Translate the report into local languages as necessary to ensure the data reaches all critical stakeholders, particularly those who are implementing strategies at sub-national levels.

8. Disseminate Results: Share and discuss evaluation results with relevant partners, donors, all stakeholders, communities, and program/study participants as appropriate. Program staff should seek out opportunities to convey evaluation results via briefings, websites, e-mail, bulletins,Listservs, press releases, journal articles, conference presentations, and other appropriate forums. In order for the findings to be most useful, you should make sure that they are communicated using formats that fit the needs of the recipients.

Data Collection Methods

There are many methods for collecting quantitative and qualitative data. The method(s) selected for an evaluation will depend on (1) the purpose of the evaluation, (2) the users of the evaluation, (3) the resources available to conduct the evaluation, (4) the accessibility of study participants, (5) the type of information (e.g., generalizable or descriptive), and (6) the relative advantages or disadvantages of the method(s). All evaluations should aim to use mixed methods, that is, a combination of quantitative and qualitative methods in order to capture multiple facets of the program outcomes/impacts, and to be able to triangulate the findings.

Source: UNICEF, MNCHN Guide Model 2: http://www.unicef.org/cbsc/index_65738.html