Maintenance

Defining the Maintenance Scenario

After an outbreak has closed, or after an endemic country has been declared polio-free, a country (or in some cases, an area within a country) has entered the Maintenance Scenario. In Maintenance, there are two key objectives: maintain high rates of immunity and vaccination coverage, and transition from a focus on polio to the bigger issue of child health, with an emphasis on showing and depicting child health-seeking behaviors as good, normal, responsible, and uncontroversial. These objectives are interrelated and should be pursued simultaneously.

Maintenance Communications Strategy

Objective 1: Maintain high OPV coverage rates

Although the outbreak has concluded, we want to ensure that immunity remains high. It is likely that there are still individuals who have never been vaccinated. High vaccination rates must be maintained to:

1. Prevent non-symptomatic carriers from inciting a new outbreak

2. Protect individuals who, for medical reasons, could not be vaccinated

3. Prevent the spread of vaccine-derived polio

4. Protect the population against importations that may occur from countries or areas with continued transmission

In a Maintenance Scenario, caregivers, influencers and health workers may not be aware that threats still exist and therefore may become complacent and fatigued by ongoing campaigns. To combat complacency and fatigue, remind caregivers that taking all vaccines is ordinary, routine, and responsible for the decline of children's diseases in their area. Make sure caregivers know when, where, and how to get vaccinations and other health services that are being provided.

Focus on supporting immunization days and campaigns with clear messages that deliver the essential information to caregivers (the "when, where, how, and what" for each campaign) and follow up on these communications with surveys measuring their effect.

Objective 2: Transition from Polio to Health, and establish supportive norms and habits

The infrastructure and capacity put in place to respond to a polio outbreak creates an opportunity to improve overall child health – and particularly immunization - during the maintenance phase by leveraging polio vaccination success to extend to similar caregiver behavior for routine immunization and other health practices.

The first step to transitioning from polio to health is establishing a clear baseline for data on knowledge, attitude, and practice (KAP) factors regarding vaccination, routine immunization, and other key childcare issues. In particular, caregivers should view health workers, routine vaccination, and the basic tenets of child health care positively, and they should openly support these attitudes and practices within their community (for more information, please see the Guiding Principles). If there are gaps in these attitudes and practices, or on linking demand with service delivery, this should be the focus of the communications strategy and campaign.

The key steps to transitioning from Polio to Health are as follows:

1. Establish a baseline for caregiver attitudes and practices about broader immunization and child health through KAP studies.

   1. Focus on these four key elements:

      1. Accurate knowledge

      2. Positive attitudes

      3. Supportive practices

      4. Evidence that community members openly talk about child health and immunization

2. With partners, identify opportunities for improvement concerning knowledge, attitudes, and practices as well as ensuring that service delivery meets community demands.

3. Analyze each opportunity using the SEM model to discover the solutions and catalysts for each opportunity.

4. Craft communications using the toolkit and appropriate creative concepts.

5. Test, refine, and optimize communications.

Maintenance Communications Planning Process

The Maintenance 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 Maintenance, the process begins with an analysis of the conditions (knowledge, attitudes, practices, and social norms) that create a supportive environment for maintaining high vaccination coverage rates, based on the SEM model. Document the decisions you make and the information you use at each step. It will be a helpful reference and foundation for future planning.

Audience Mindset Groups and Types

Mindset Groups: Accepters and Rejecters

This section of the toolkit will help you understand how to address the fundamental mindset groups and audience types that your communications should target during maintenance scenarios.

Within the Maintenance Scenario and after an outbreak has been closed, Rejecters will have been minimized as a source of risk due to the effect of herd immunity. The focus should return to Accepters and to maintaining this group's compliance to repeated vaccination. Without an active outbreak in progress, it is more important to maintain the positive and supportive attitudes and practices that Accepters are open to by monitoring and addressing the risks posed by the barriers listed on page X.

Accepters in Maintenance Scenarios

In Maintenance Scenarios, we want Accepters to share their mindset openly with other members of their community. By openly discussing vaccination and the health workers, Accepters help us make it clear that the majority of people agree with repeated vaccination.

General Factors for Accepters in Maintenance Scenarios

• Accepters are sensitive to the threat that polio and other diseases pose to their children.

• They understand the value of vaccination and will generally get it if easily available.

• Accepters tend to trust authority figures and healthcare providers, including our health workers.

• Although accepters tend to be more open to repeated vaccinations if they understand the necessity of them, the frustration from repeated campaigns could change their mind if handled poorly, causing them to become rejecters.

The Accepter's Journey

The Accepter's Journey is characterized by brevity and lack of resistance across the stages that facilitate the health workers'performance at the moment of contact. Awareness, Resonance, and Consideration occur simultaneously, as messages around immunization align to their existing opinions.

[Side Bar] 
Remember, over time, repeated polio vaccine campaigns can begin to test the patience of even the most sympathetic Accepter, and so it becomes important to shift communications to focus on themes beyond awareness only over time.
[end Side Bar]

Rejecters in Maintenance Scenarios

The second mindset is Rejecters. Maintenance Scenarios can tolerate small numbers of Rejecters because of the herd immunity effects that mass immunization provides. If the rejecters are widely dispersed, they do not need to be specifically targeted and addressed, as the threat they pose will be minimal.

If a notable concentration of Rejecters emerges in a single area, over time a critical mass of vulnerable children might be established. The preconditions for an outbreak could therefore occur. Develop microplans to monitor campaign performance and identify potentially dangerous concentrations of missed children and Rejecters.

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

  • 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 types 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 Maintenance situations.

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 the Maintenance Scenario. These charts are derived from the SEM C4D model, but focused specifically on audiences that can directly influence the caregiver.

Addressing Barriers in Maintenance Scenarios

In a Maintenance Scenario, the barriers are different than those in Outbreaks and Enduring Outbreaks. They are informed by the overall strategic goal of stabilizing a high rate of vaccine coverage by establishing childhood vaccination as an ordinary and routine behavior for caregivers.

The biggest risk after the conclusion of an outbreak is passive or active non-compliance due to complacency. Caregivers might no longer feel at risk and might be experiencing fatigue after multiple rounds of vaccination during the outbreak. As a result, they might believe there is no longer a need to continually vaccinate their children.

The primary barrier categories for caregivers in a maintenance scenario are attitudinal, behavioral, and logistical in nature. Focus on addressing and eliminating issues at each of these levels to maintain polio-free communities and to begin to broaden vaccination efforts to general health concerns. Below are a series of questions to help you understand some probable barriers in the Maintenance stage, followed by guidance on how to address the barriers.

Logistical Barriers

Questions:

• Is routine polio vaccination available?
• Is routine polio vaccination convenient?
• Do caregivers perceive it as convenient?
• Do they know when and where they can get routine polio vaccination services?

Guidance:

When a behavior becomes routine and ordinary, logistical frictions can become the primary barrier. If caregivers do not widely find vaccination to be convenient, accessible, and easy, then they will not get it, even if they otherwise support it. It is important to ensure service delivery and operations are adequately prepared and attended to throughout the vaccination program. Furthermore, regularly monitor awareness of these factors and discuss findings with partners who are responsible for ensuring adequate and accessible service. Identify and act on opportunities to affirm that vaccination is very convenient and directly provide caregivers with the information they need to get it.

Attitudinal Barriers

Questions:

• Do caregivers report strongly supporting routine vaccination, including polio?
• Do they view vaccination as an ordinary, normal, and important thing to do for everyone?
• Do they perceive health workers as trustworthy, admirable, and compassionate?

Guidance:

Widespread, continued support for vaccination at the individual level is necessary for maintaining high coverage rates. Ensuring that caregivers perceive health workers positively is a crucial precursor for shifting campaign efforts to general health initiatives.

Identify and act on opportunities to affirm and reaffirm that vaccination is good and is the right thing to do for everyone. If necessary, remind caregivers that by failing to participate in routine vaccination, they are putting their children – and those of their community – at risk. Furthermore, continue to refresh and utilize communications that create a positive, admirable image around health workers.

Where negative attitudinal perceptions are based on inadequate service or poor health worker performance, communications should focus on improving the interpersonal skills of frontline staff. Only then can broader communications credibly depict a positive and admirable image around health workers. Remember, the objective of our strategy is to build trust and communicate authenticity. What we communicate must be as closely aligned to the operational reality as possible.

Behavioral Barriers

Questions:

• Do caregivers accept the vaccination whenever it is offered?
• Do caregivers often talk to one another about their support for vaccination?
• Do families speak amongst themselves about their support for vaccination?

Guidance:

Support for vaccination must also result in action, and so the actual behavior of caregivers when it comes to vaccination is important. If they tend to accept vaccination whenever it is offered, or, ideally, seek it out, it reveals that vaccination is becoming a routine and normal pattern of behavior. Caregivers should also hear supportive information for vaccines from each other, in addition to our communications.

Use data to inform caregivers about the high rates of acceptance in order to firmly establish acceptance as a normal behavior. Identify and act on opportunities to show people discussing vaccination with each other positively to firmly establish the act of openly supporting vaccination as a normal behavior.

TARGET AND ADDRESS HARMFUL SOCIAL PERCEPTIONS AND NORMS WITH COMPELLING COUNTER-NARRATIVES

The attitudes, perceptions, beliefs, and behavioral norms of social groups influence how their members behave. When uncertain, people turn to the behaviors of others as an example of how to behave. If we make sure that caregivers are aware of how broadly accepted vaccination is, they will be more likely to seek it as part of routine care for their children. Implement communications that establish this by explicitly addressing social norms to create positive and supportive behaviors.

KEY POINTS:

1. Target a specific behavior to be influenced by a social norm (vaccinator access to children in the home, for example).

2. Communicate a new, desired descriptive norm to the audience to increase awareness of what is normal behavior.

   • "98% of the people in [COMMUNITY A] let vaccinators inside to protect their children against polio."

3. Apply injunctive norms to the message whenever applicable.

   • "Everyone lets vaccinators inside because it is the right/honorable thing to do."

4. Negative injunctions can have greater salience than positive injunctions and should be considered when feasible:

   • "Saying no when the vaccinators come by is wrong because it places all children in our neighborhood/tribe/family at risk."

5. Create compelling counter-narratives that juxtapose cultural qualities against each other to shift public perceptions of rejecters.

   • "Only foolish and unwise people don't vaccinate their kids."

WHEN SUPPORTING SPECIFIC IMMUNIZATION CAMPAIGNS (E.G., A NATIONAL IMMUNIZATION DAY), EXAMINE COMMUNICATIONS FOR OPPORTUNITIES TO PORTRAY HEALTH WORKERS POSITIVELY AND HUMANELY, WITH AN EMPHASIS ON TRUSTWORTHINESS.

For more information, please refer to the Global Strategy and Guiding Principle One.

MOVING FROM POLIO TO HEALTH

SHIFT FROM EMPHASIS ON POLIO TO CREATING DEMAND FOR OTHER HEALTH SERVICES AND SUPPORT

Our normal approach to polio communications emphasizes information about the disease and the vaccine, with a goal of causing people to fear polio and desire the vaccine for protection. This focus on threat perception does not need to be used in the Maintenance Scenario, especially where basic living conditions are challenging and caregivers prioritize meeting their basic needs over other concerns that are not present in their day-to-day life.

Health camps or clinics – where they are available – provide an opportunity to tap into people's desire for basic necessities and healthcare. They create an opportunity to bundle vaccines with other services.

KEY POINTS:

1. Present polio vaccination as part of a "basket" or "bundle" of services, headlined by the services we can offer that are most in demand in the area, especially water and other urgent necessities and emergency care.

2. If the health camp approach is available, advertise health camps as new, and emphasis their newness and the improvement they represent over previous service to create demand for them.

   • Create social proof in advance by communicating the intent of the majority of people who visit the camps, even if inexact or imperfect measurement of this intent exists.

     • For example, "80% of people said they want to bring their kids to the health camp within the first two days they are available."

   • Position the camp in all communications, including media, as an improvement to the community.

   • Rapidly follow up with both pleased and angry visitors to the camp, to ensure that services meet or exceed expectations and that positive word of mouth about the camps spreads quickly.

Creative Concepts

There are three conceptual territories to use as a basis for creating mass communications. Each looks at health workers and children's health from a slightly different perspective and can be tailored to address particular issues more directly.

• Best Amongst All

• We Are Intertwined

• Strangers No More

In the Maintenance Scenario, Best Amongst All aims to demonstrate the commitment and care of the health workforce. It is a ‘feel good' campaign that highlights the role that health workers have in protecting children, helping to maintain high morale and trust with families and communities. 

The We Are Intertwined campaign may be used to communicate the supportive norms, values, and messages to foster continued vaccination leading to collective action and community protection. This may be especially useful in settings where there may be waning acknowledgment or supportive norms for vaccination. 

Lastly, Strangers No More is appropriate for communications that directly support building trust for the frontline health workers who are leading vaccination or other health efforts. This campaign can be useful in settings where the health workers are unfamiliar or have low trust from target populations

"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.

In a maintenance scenario, through celebrating the recent achievement of establishing a polio free country, the Best Amongst Us concept can be used to promote broader health and other immunization goals.

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 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. 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.

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.

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

Once an outbreak has been closed and the shift to maintenance has occurred, the purpose of the communications and media touch points must shift as well. During the Maintenance Scenario, the media efforts should be used to support the ongoing vaccination effort as well as the transition to the broader health offerings that would be available. Just as the message would shift from crisis, to optimism, to hope, the media channel selection should match this approach.

As the crisis period wanes, and no cases have been reported for a number of months, the media communications would provide more of a consistent voice around continued vaccination efforts and routine vaccination or other bundled health services more broadly. Media decisions should be based on a review of how media channels performed before and after the outbreak. When reviewing media channel performance, also consider what publicity the program has received up to this point and how it has assisted or hindered the program's progress. The media channels deployed would be similar to those used to build ongoing support of any local or national brand that wants to remain relevant and important to the general population.

Questions to answer when shifting to a Maintenance approach:

• Are our target audiences the same for maintenance as they were for outbreak? Are we targeting a broader group of people now, or a more focused sub-section?

• What channels are best served to provide updates and alerts for scheduled health camps and routine vaccination campaigns?

• What channels are most connected to consistency and normalcy in a given community? Soap operas, both radio and TV, news and newspapers, and social media could all apply.

• Does entertainment play a role in a more hopeful and positive connection to the ongoing vaccination effort?

• What media channels were potentially overused during the outbreak and should therefore be avoided?

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

• What is the appropriate frequency for media – continuous so that effort remains top-of-mind, or only to promote the vaccination camps of campaigns?

• How much to "place-based" materials drive local vaccination campaign engagement and receptivity? Billboards, banners and flyers could all play a role in local efforts.

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:
   • Awareness

     • Awareness of polio

     • Awareness of the vaccine

     • Awareness of where and how to get vaccinate

     • Awareness of the campaign

       • Brand recall

       • Message recall

       • TV impressions

       • Radio impressions

     • Resonance

       • Perception of polio as likely and serious

       • Understanding importance of polio vaccination

       • Perception of OPV as safe and effective

       • Understanding of herd immunity

       • Communal perceptions of polio vaccine

     • Consideration

       • Intent to vaccinate

       • Perception of health worker as part of community

       • Perception of health worker as trustworthy

       • Perception of health worker as competent

       • Perception of health worker as honest and moral

     • Vaccination

       • Reasons for missed children

       • Missed children

       • Number of successful vaccinations

     • Repeat Vaccination

       • Intent to vaccinate again

       • Vaccination coverage

       • Contact efficiency

       • Repeat vaccination success

     • Social Mobilization and Advocacy

       • Influencer Advocacy

       • 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, and 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 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, and 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