Communication for Development Guidelines for Responding to Polio Events and Outbreaks Post Switch

In light of the fact that a fast, effective response to stop new polio outbreaks in previously polio-free countries is crucial to meet the Global Polio Eradication Initiative (GPEI)'s aim of global eradication, this document provides guidelines on communication for development (C4D) for Polio - a systematic, planned, and evidence-based strategic process that aims to promote positive and measurable social and behavioural change for maximum coverage of oral polio vaccine (OPV).

These guidelines are offered in this context: Countries and GPEI partners must stop transmission of poliovirus within 120 days of confirmation of any new outbreak, and the GPEI Standard Operating Procedures, or SOPs (see Related Summaries, below) recommend that supplemental immunisation activities (SIAs) be implemented within 14 days of identification of a poliovirus that requires an immunisation response. The outbreak response for circulating vaccine-derived polioviruses (cVDPVs) follows the same principles as for wild poliovirus (WPV). Editor's note: Starting in April 2016, the global polio eradication community switched from trivalent OPV (tOPV) to bivalent OPV (bOPV), removing OPV2 from immunisation programmes in an effort to eliminate the rare risks of vaccine-associated paralytic polio (VAPP) and cVDPV.

The Polio C4D response is based on the Social Ecological Model (SEM) developed and used by the United Nations Children's Fund (UNICEF) to understand and address norms that influence individual and collective behaviours, such as the acceptance or rejection of the polio vaccine and the vaccinator who delivers it. It relies on a foundation that social and behavioural change is rooted in local context, as well as the consultation and participation of children, families, communities, and networks. Rather than simply reaching out to individual caregivers with facts about polio and polio vaccination, the new polio strategy is specifically designed to address the dynamic perceptions and social norms that deter caregivers from vaccinating their children. Utilising a multi-faceted approach will help ensure that communities and decision-makers at local, national, and regional levels are engaged in dialogue toward promoting vaccination.

The polio outbreak communications strategy has 2 distinct phases:

1. Immediate Response Communications (IRC) - 24 hours to 1 month - where the goal is immediate mass response to communicate to the population about the outbreak, the planned response to the outbreak, and information about polio, the vaccine, and the health workers who will administer delivery of the vaccine. Within this phase, communications should be straightforward, clear, and elicit an urgent response from parents and the community at large.
2. Adaptive Phase Communications (APC) - begins 1-3 months after outbreak, depending on the local context - where communications will shift to more closely supporting the goal of reaching missed children. Communications will address social barriers and opportunities for promoting vaccination and will leverage these, respectively, through GPEI's communications and engagement approach. 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. The APC lasts until the outbreak is concluded.

The steps of each phase are explored in detail within this resource. A summary is below.

IRC involves:

• Epidemiological and social investigation - undertaken between the Ministry of Health (MOH), UNICEF, and the World Health Organization (WHO) with the goal of rapidly assessing the management, operational, and social environment in the area affected by the virus. If feasible, a review of existing data of knowledge, attitudes, practices, and behaviour (KAPB) surveys, or a rapid assessment, will take place in parallel to learn about the social norms that can affect vaccination.
• Media response in a polio outbreak context - Monitoring and engaging with different forms of media is critical from the onset of the case; media can pick up the confirmation of polio virus and disseminate it in an unproductive manner if not well-managed. Ensure that the polio programme and UNICEF have spokespeople identified who have the capacity to work with media, who send the right message about ownership and the "public face" of the response, and who are media-trained.
• Understanding the communication landscape - Collect information on: media consumption patterns (TV, radio, press, outdoor, transit, social media, magazines, etc.); highly viewed/listened-to programmes and channels; influential media personnel who are "public social leaders" and can help the polio cause; available social mobilisation committees at national and subnational levels; available community engagement networks in the country, especially in high-risk areas, as well as their readiness and capacity to be deployed, etc.
• Coordination of communication interventions - Creating or reinvigorating a national communication or social mobilisation taskforce is critical, starting with the early days of the outbreak. External communications and social mobilisation should be joined up and undertaken through a cohesive strategic approach.
• Communication for development within the national outbreak response plan - The SOPs require deploying a GPEI team as soon as an outbreak is confirmed in any country to initiate the development of a comprehensive plan that includes C4D, including the following components:
• Communication objectives and indicators - While it will be important to indicate expected changes in KAPB, it is equally important to link the communication objectives to the programme indicators the full campaign response aims to achieve (e.g., percent of districts where interpersonal (IPC) training for social mobilisers and vaccinators has been conducted during the last 2 months.
  1. Audience analysis - segment the audience into primary and secondary groups. The audience analysis should also include a list of stakeholders or people who can be mobilised to support the programme, or with whom it is important to advocate to get their support. It is also vital to analyse the barriers that can block triggering the vaccination decision by the intended audience. In the context of polio outbreaks, the intended audience may fall under one of the following categories: (i) acceptors; (ii) vulnerable acceptors; (iii) rejectors; or (iv) transient.
  2. Developing key messages and materials - Existing relevant materials should be the first place to start. Some can be reproduced, with modifications to adapt to the new outbreak event. Should new materials be needed, they should adhere to these 3 principles: (i) understand and leverage social perceptions, norms, and beliefs related to polio and polio vaccination. (ii) humanise health workers by emphasising their social and emotional depth. (iii) continuously refine communications to maintain authenticity and credibility for the intended audience(s).
  3. Strategic channel mix and activities in polio outbreak - Various communication channels should be used, but the communication channels most often used in outbreak contexts include: mass media, IPC through community outreach networks, community folk media, and information, education, and communication (IEC) materials. Lists of different C4D activities that could be undertaken in both IRC and APC phases are included. Continuous discussion with community members after the vaccination process is vital to reinforce norms supportive of vaccination. A comprehensive training package for frontline workers (FLWs) is available to improve vaccinations capacity, especially for IPC.
  4. Monitoring and evaluation - Typical indicators include process indicators, such as the number of communication media materials produced and disseminated (posters, flip charts, TV/radio spots, etc.) and/or the number of training workshops conducted (training of trainers (TOT), peer education, etc.).
  5. Managing the plan - There are 2 categories for budgeting communication and social mobilisation activities: (i) campaign social mobilisation (activities specifically planned and undertaken around National Immunization Days (NIDs) and Sub-National Immunization Days (SNIDs) or Supplementary Immunization Activity Days (SIADS) and (ii) ongoing communication activities.
• Surge support to communication interventions - The GPEI will follow a 2-phase surge process: (i) Rapid Response Phase (Rapid Response Team - Team A): Within 72 hours of the outbreak notification, the GPEI surges pre-identified, trained, and experienced professionals with multiple expertise for deployment of up to 1 month. (ii) Surge Response Phase (Surge Team - Team B): Within 3 weeks of the outbreak notification, the GPEI makes available, consistent with the outbreak grade, a multidisciplinary and trained surge team and additional surge staff as needed.

In the APC phase, monitoring of results, and modification of interventions accordingly, is critical to effectively reach children. This involves collecting observations and data on campaign performance, conducting disaggregated analysis to assess community acceptance and understanding of the polio programme, and analysing root causes for refusals and access issues and identifying key issues underlying barriers to immunisation.

Three to 6 months post-outbreak and beyond, the emphasis is on closing the outbreak and maintaining success. Continuing to focus on SIA quality, strengthening surveillance, and reaching missed children is critical. Meanwhile, supporting routine immunisation (RI) will be the backbone to maintaining the interruption of virus transmission, so the outbreak response plans should indicate how RI services will be promoted. This should include the training of FLWs, production and dissemination of IEC materials, and monitoring of services. A plan should be made to integrate polio assets that were specially recruited to support polio activities into the health programme. It is equally important to develop preparedness plans that can mitigate the risk of future outbreaks. Finally, it is important to document the achievements and lessons learned from social mobilisation, advocacy, and media and partnership activities at the national, provincial, and district levels. Use of photos, anecdotes, testimonials, press reports and media coverage is critical to maintain national political support and generate donor interest in continuing to support health and immunisation programmes.

Annex 1 provides a methodology for a special investigation tool to identify reasons for missed children. Annex 2 focuses on the "rhythm of business for pre Team 1 to Team B". Annex 3 offers terms of reference for C4D Team B.