Outbreak

Defining an Outbreak

When a new polio outbreak occurs, it is critical to maximize vaccine coverage within the affected region as quickly as possible to control the virus and minimize its spread. We define an outbreak as one or more cases of polio in an area that has been polio-free for at least 6 months. The critical factor in an outbreak is the presence of a critical mass of vulnerable children who must be swiftly vaccinated before the virus can spread.

Outbreak Communications Strategy

The polio outbreak communications strategy has two distinct phases: Immediate Response Communications Phase and Adaptive Communications Phase

Immediate Response Communications (IRC)

Immediate Response Communications address the beginning of an outbreak and are focused on building (or rebuilding) caregivers’ critical awareness. At the beginning of an outbreak, the goal is immediate mass response to communicate to the population about the outbreak, the planned response to the outbreak, information about polio and the vaccine, and the health workers who will administer delivery of the vaccine.

Within the immediate response phase, communications should be straightforward and clear. The primary goal is to raise awareness of the outbreak, the disease, the vaccine, vaccination dates, and the response to a threshold of at least 90% awareness as quickly as possible.

Key Actions for IRC

News of an outbreak will create an immediate sense of crisis and an enhanced perception of threat for a short period of time. During this time the audience is particularly sensitive to communications that are related to the crisis, both correct and incorrect. Communicating the importance, safety, and efficacy of vaccination from the onset will dispel potential campaign-threatening rumors.

• Analyze existing, target audience, relevant Knowledge, Attitudes, and Practices (KAP), data regarding vaccines, immunization service, and polio to guide message development.
• Analyze the media landscape to identify how to quickly reach the most people as possible within the target population.
• Inform the target population about polio, the vaccine, and the health workers who will provide support to vulnerable children.
• Activate social and community mobilizers in the highest risk areas.
• Frame the vaccination effort and health workers as heroic and mission-driven to create a supportive environment for the campaign.

After the initial response, remember to:

• Collect observations and data on campaign performance.
• Conduct disaggregated KAPs to assess community acceptance and understanding of the polio program.
• Analyze the KAPS studies for refusals and access issues, and investigate to identify the key issues underlying barriers to immunization.

Adaptive Phase Communications (APC)

Adaptive Phase Communications begins once the awareness threshold has been achieved and involves identifying and addressing both communications barriers and successes.

In part, APC is about adapting communications to address the specific barriers that impede or limit vaccine coverage within the affected region. Uncovering these barriers requires research and analysis of caregivers and their knowledge, attitudes, and practices about polio that should be conducted as IRC progresses. As barriers are identified, new communications will be required to address them.

APC additionally involves identifying and capitalizing on the successes of previous communications. If specific elements and messages were proven effective in the initial stages of your communications, consider building off of them to maintain success and address emerging barriers

The APC lasts until the outbreak is concluded.

Key Actions for APC

• Identify population unreached or under-reached by previous communications.
• Retarget and refine communications to said populations.
• Shift communications to address the root causes of refusals and access issues, as identified through KAPS data.
• Begin targeting and addressing harmful social perceptions and norms.
• Identify and capitalize on previous communication successes.
• Close the loop by creating means for caregivers of missed and absent children to get in touch with UNICEF/other parties directly in order to get the vaccine.
• Shift from an emphasis on the individual consequences of polio to the importance of communal protection and social action.
• Continue to support social and communal mobilization, engage communities, and evolve IPC messages to align with mass communications and vice versa.

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. Follow the steps, beginning with Audiences & Regions, to systematically plan the communications necessary for your scenario. 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 Analysis

Mindsets: Accepters and Rejecters

This section of the toolkit will help you understand the fundamental mindsets and audience types that your communications should target.

We will begin with mindsets. What motivates people to say yes to the polio vaccination? For many, the decision is simple—awareness of how close they are to catching polio and what they can do to prevent it is sufficient for them to accept the vaccine. We call these individuals, Accepters.

Accepters

In all countries of the world, accepters constitute the vast majority of people. The decision to vaccinate is simple because they are predisposed to accept vaccines and vaccination is a matter of common sense. This means that initial communications do not need to persuade that vaccination is necessary—they already believe it. Instead, communications can focus on creating awareness of polio and the immunization campaigns.

Key Factors for Accepters

• Accepters tend to trust authority figures and healthcare providers, including our health workers.
• Accepters are sensitive to the threat that polio poses to their children.
• Accepters understand the need to vaccinate their children, and are receptive to polio communications
• 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

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.

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 just awareness over time.

Rejecters

The second mindset is Rejecters. Rejecters are typically a minority of the at-risk population, but they often cluster in communities that provide a supportive social and cultural environment for their disbeliefs and suspicions about vaccination.

Rejecters as individuals do not pose a substantial threat to eradication. However, a cluster of rejecters in areas of low population immunity and high virus susceptibility can be a breeding ground for the virus. In some cases, rejecters can be a small number of individuals who have a broad and strategic influence over our target population. Thus, it is important not only to know whom the rejecters are, but also to understand which rejecters are strategically important to focus on.

They are defined by a reluctance to vaccinate their children, or a propensity to discourage vaccination of other children, a behavior that has complex and intermingled root causes. It is unlikely to be successful with Rejecters. A different approach will be needed for this group.

Key Factors for Rejecters

• The decision to vaccinate is complicated and risky. Rejecters may be influenced by uncertainty and rumors about the benefits and dangers of polio vaccine.
• They may be more challenged to satisfy basic needs, such as food, water, shelter, power security, and safety, and they may prioritize these over vaccination, especially after repeated campaigns.
• They may be prohibited from getting the vaccine by local social and cultural norms.
• They may not perceive their family members, neighbors, community leaders, religious leaders, or other influencers to be in support of vaccination children against polio.
• In extreme circumstances, they may be witnesses to acts of violence from others within their community over the vaccine.
• Low literacy and education rates may impede communications from effectively educating them about polio, and may also support rumors or other alternative explanations that are harmful.
• They may heed traditional, cultural, or religious understandings of medicine over scientific understandings. This may mean that the concept of preventative medical care, including vaccines, must be explained differently to resonate.
• They may actively distrust the institutions, organizations, and individuals that polio communications come from, including their national government, Ministry of health, and UNICEF, WHO, or other international organizations.
• They may have an established habit of only seeking medical care after something is painful or obviously wrong, and they may not have the notion or understanding of incurable, yet preventable diseases like polio.
• Their refusal may be outright, or it may be disguised through a falsely reported absence of their child.

The Rejecter’s Journey

Rejecter journeys tend to be specific to the local conditions and require a tailored, adaptive approach to communications and media channels.

For example, mass communications that are successful in reaching the majority in a given population may not lead individuals to seriously consider vaccination because they belong to a specific subcultural community, and the communications fail to resonate with their specific cultural values.

Within any polio outbreak, rejecter journeys can become a source of increasing risk as response efforts continue to go on, especially as vaccination fatigue can cause formerly accepting individuals to reject as well, potentially reducing the base of accepters and increasing those who reject.

Considerations for Transient Individuals

Transient Audiences

Both acceptors 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. Read the chart below to understand the roles of caregivers.

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 the outbreak communications effort. These charts are derived from the C4D SEM framework, but focus specifically on audiences that can directly influence the caregiver.

Situational and Attitudinal Barriers

There are two primary categories where vaccination compliance breaks down. The first is situational, meaning there is an externalized challenge to overcome, such as lack of awareness, or a complicated security environment. The second is attitudinal, when challenge is internalized on the part of the caregiver, and requires a nuanced approach to motivate behavior.

Situational Barriers

Situational barriers can often be addressed by exposing the audience to the right information through mass communications and Interpersonal Communication efforts. The recommended campaigns and immediate response creative examples are concepts to be adapted to the cultural and social specifics of your target audience.

Awareness

Establishing general, universal awareness of the outbreak and the risk it comprises to children is the first barrier that must be overcome in any scenario. Ideally, this will be accomplished in advance of vaccination campaigns. For the segment of the population that already supports vaccination in general, awareness may be the only necessary barrier to address. Consider the following awareness variables when developing communications:

• Awareness and understanding of the disease and ability to name/identify symptoms
• Awareness of the presence of an outbreak, and the heightened risk to children in the area
• Awareness of the vaccine, and the need for multiple doses for full protection if taking drops
• Awareness of the campaign, and when the health workers will be visiting homes
• Awareness of herd immunity and the impact that individual decisions to vaccinate have on the health of the entire community’s children

Access

Access issues have multiple possible causes that can be addressed through a combination of mass media campaigns and IPC communications.

Absence

Absence of children is often addressed through a follow-up visit, but persistent absences can become a significant problem in communities, especially when caregivers are not made aware of the impending campaigns in advance.

Transience

Transience can also present access issues that must be addressed through tactics specific to the transient audience (see page 13).

Attitudinal Barriers

Attitudinal barriers primarily apply to rejecters. These barriers stem from a rejecters mindset to:

• Doubt the safety, efficacy, and necessity of the polio vaccination
• Assume that others in the community are anti-vaccination
• Doubt the credibility and motive of health workers

These barriers are often fueled by individual perceptions of community norms. Therefore communications addressing attitudinal barriers need to alter the audience’s negative perception around polio vaccination.

Attitudinal barriers may also stem from campaign fatigue. As campaigns progress, fatigue from repeated vaccinations becomes an increasingly likely cause of refusals, especially after the third or fourth vaccination. The necessity of repeated vaccinations may not be apparent, especially if the outbreak is waning. To address this, the importance of communal vigilance should be stressed, with the need to protect all children continuously until the region is polio free. For more information regarding communal vigilance please refer to the Attitudinal Barries section (page 26).

Media Channel Selection

Different media channels play different roles in communications. For example, television and radio spot advertisements work well to raise awareness about an issue, while newspaper articles can provide more in-depth information about a topic. When planning your communications, you should identify your intended population’s preferred channels and media use, as well as their capacity for passing on information within their social networks.

Information and communication technologies (ICTs), including social media, are effective for spreading messages in real-time to members of the population if have access to the means for receiving social media messages, for reinforcing messages, for enhancing service delivery, and for building social networks that can be activated to mobilize communities. The two-way or reciprocal nature of digital or ICT platforms allows for rich feedback loops and dynamic engagement of members/populations in dialogue, empowering them as active participants in the discussion rather than passive recipients of messages. Each type of communication channel has benefits and drawbacks for conveying certain types of messages to specified populations.

It is important to consider:

• The intended population you want to reach:
  • Does your intended population have access to the channel?
  • Will the channel reach your intended population?
  • Does the channel allow for feedback from the population?
  • Are the channels perceived as trusted sources of information about your issue?
• The message(s) you want to deliver:
  • Is the channel appropriate for the type of message you want to deliver (e.g., visual, oral, simple, complex)?
• The channel reach:
  • Does the channel cover enough area to expose your intended population to the messages?
• Timeliness of the channel:
  • Does the channel allow the intended population to receive the messages whenever they want (e.g., via text message or a Web site) or on a set schedule (e.g., a radio advertisement)?
• Cost of using the channel:
  • Does the C4D program have the resources to utilize certain channels?
  • What is the cost-effectiveness of the channel(s) being considered?
• Synergies with other program activities:
  • Does the channel reinforce messages for other program activities?
  • Does the channel encourage the population to engage in dialogue?
  • Do the messages motivate the population to seek/demand rights and services?

Source: UNICEF, MNCHN Guide Model 2: http://www.unicef.org/cbsc/index_65738.html IX. Measurement, Monitoring and Evaluation

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

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

Develop evaluation indicators: Indicators should reflect variables that are included in, or affect, the caregiver’s choice to vaccinate their child. It may be helpful to consider the stages of the caregiver’s journey to develop indicators. 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 heard immunity
• Communal perceptions of polio vaccine

Consideration

• Intent to vaccinate

Health Worker Contact

• Perception of health worker as part of community
• Perception of health worker as honest and moral
• Perception of health worker as competent

Vaccination

• Number of successful vaccinations

Repeat Vaccination

• Intent to vaccinate again
• Vaccination coverage
• Contact efficiency
• Repeat vaccination success

Social Mobilization and Advocacy

• Peer to peer communication
• Peer advocacy
• Net promoter score (vaccinated and vaccinators)

Create the tools that program staff will use to conduct monitoring activities. For example:

• Observation checklists
• Weekly viewer discussion groups
• Weekly brief survey questionnaires
• Quarterly rounds of Rapid Audience Assessment surveys
• Quarterly focus group discussions
• Knowledge Attitudes and Practices Studies (KAPS)

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.

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.

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.

Write a report on the findings from the evaluation study:

• Communicating evaluation 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.

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