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The Importance of Context: Different Situations, Different Strategies

Here, Svea Closser explores communication strategies across different risk contexts. (Step 4.16)
SVEA CLOSSER: So first, let’s talk about context. In order to be effective, health communications need to be tailored. So in the next few slides, we’ll see how UNICEF has designed strategies to tailor communication to the epidemiologic profile of a given country. So when you think about the Polio Eradication Initiative in 2020, there are a couple different kinds of epidemiological contexts. One of them is where polio is endemic, meaning where transmission has never been interrupted, or where there’s been an outbreak that has continued for more than six months. And this is a particularly challenging communications context, because people in these areas may have been hearing polio messages for the last 20 years.
And at least early on, and a lot of those messages may have talked about the imminence of eradication, and when it didn’t happen, people may be less likely to listen to polio messaging. So let’s look at the key messages that you might want to promote in a setting like this.
First, you have to think about the challenges. There may be fatigue and mistrust, due to repeated messaging and repeated campaigns. So, for example, in Afghanistan, and Pakistan, northern Nigeria, which are the really endemic places that had been going on for a long time in polio, you may have over 10 campaigns a year, with communications campaigns going around these vaccination campaigns, and this could have been happening for the last 20 years. People might have stopped listening. Second, one of the issues with these areas, and often one of the factors leading into the fact that they still have polio transmission, there may be large numbers of mobile populations that may not be immunized.
So these are often really tough to reach populations, refugees, pastoralists, people who are outside the reach of the standard communications messaging system. They may not have television, for example, so you may have to think about different ways to reach them. Third, and this is UNICEF’s language, there may be traditional or cultural views biasing caregivers against vaccines. As an anthropologist, I tend to think that no view about vaccines is ever traditional, people have not had vaccines for that long. So any ideas about vaccines are inherently modern. But the point here, is that there may be narratives about vaccines that people are talking about collectively, that may not line up with the communications objectives we want to.
There may be regional insecurity or instability, which, as we’ve discussed throughout this course, makes all kinds of things very difficult, including communications. Communities may have really pressing issues. If they’re in the context of a war zone, the messaging about polio immunization is unlikely to make it to the top of their minds, and the same is true of health workers. Finally, there is a very difficult communication challenge around a vaccine-derived poliovirus. So, as we’ve discussed, vaccine-derived poliovirus is circulating poliovirus that came from a vaccine virus. Now, the way to prevent this, is actually to vaccinate, but that’s a very complicated communications challenge. People may have heard that polio came from a vaccine.
That may make them more worried about giving the vaccine to their children. And the messaging that the way you prevent vaccine-derived polio is through vaccination, it’s a somewhat counterintuitive message that is difficult to communicate, effectively. So, given all these challenges, you may want to take a moment and think about what are some possible communication strategies you might use. Feel free to pause the video if you’d like to do that, and think about what are some ways you could overcome these very real challenges. So here are UNICEF’s strategies, and I think they’re really excellent. The first thing that they say, is you have to empathize with people’s frustrations. You can’t just pretend they don’t exist, you can’t lecture to them.
You have to realize that these frustrations are real, that people have been– are tired, perhaps, of polio activities, for very rational reasons. And listening to them, empathizing with those frustrations, is a very important starting place. Along with that, it’s important to think about explaining why the program is operating the way it is. Why is there the need for these repeated doses? Why is it that we feel the vaccines are, in fact, safe? You want to emphasize the need for the well-being of our children, that this is our collective responsibility, and perhaps, that this is part of the global push for eradication, that this isn’t just an issue of this one community. It’s a global issue.
Now, as you do this, you want to have these messages synchronized, across platforms and people. So, UNICEF talks about having social media, local influencers, and religious leaders, all getting the same messages as you might be getting from mass media, for example. That’s really important for increasing trust and reinforcing the messages. If the messages are different in different channels, it can confuse people. You may also have targeted communications at transit points from populations on the move. So, for some of those pastoralists, or refugee populations we talked about earlier, you might have messages on mobile vans, city buses or railways.
So you can think about getting those populations with communications, you may want to rely on SMS and voice messaging for those who may have mobile phones. You may want tailored messages for different groups of people. So some groups of people are accepting the vaccine, others may be rejecting it. You may have transient populations, or people who are on the move. There may be caregivers, there may be influencers, there’s health workers. These are all different groups of people with different engagements with polio eradication, and they may need messages tailored to them, in order for them to hear it the best. For example, to keep workers motivated, you might want messages focused on empathy and service.
So, an example that UNICEF has, is, quote, “you’re fighting the good fight. Keep protecting and vaccinating our children to eliminate polio.” That’s a great message for a health worker. Obviously, you wouldn’t necessarily give that message to a religious leader. You might. But you want to think about tailoring your messages to your audience. For an influencer, or a religious leader, you might say, help eliminate polio by talking to parents about the safety, efficacy, and simplicity of the polio vaccine. And as these ideas suggest, it’s really important to use interpersonal communications, not just mass media, especially in a setting where people are really tired of repeated messaging. Having interpersonal communication from someone they trust, is going to be really key.
So, it’s that interpersonal communication that’s going to be used to address concerns or myths, and to build trust. For the mass media, all you can really rely on it to do is to raise awareness, to let parents know when campaigns are coming up, and to make immunization, hopefully, socially normal. But it’s that interpersonal communication that you need in order to actually address things like refusals. It’s very difficult to do that through mass media. And you’re doing all of this, you also have to continuously refine, refresh your messaging, that you’re not just rolling out the same ads again and again and again. So, as you can see, all this is quite complex, and that’s just a strategy for one setting.
Next, let’s look at a different context, an outbreak setting. So this is a case where polio had been gone for a long time, but now there’s an outbreak. When a new polio outbreak occurs, you want communications focused on ending the outbreak as quickly as possible. So the challenges in outbreak settings, as UNICEF points out, are somewhat different than the ones you have in endemic settings. In contrast to being tired of hearing about polio, there may actually be a lack of awareness. People may not know that there is a polio outbreak. There may still be rumors and resistance in a situation like this, and caregivers may not be that motivated to vaccinate their children.
On the other hand, it’s common that leaders with a political agenda may be using the polio outbreak to meet their own goals. So there would be all kinds of narratives about a polio outbreak, that were really sort of unrelated to the outbreak itself, and more about people using the outbreak to make political points. So you can think about this, probably, in almost any outbreak that you’ve experienced in your own country. Any outbreak that gets a lot of press coverage, political leaders are often trying to spin it in various ways, and polio outbreaks are no exception. Finally, a challenge can be that under the pressure of an outbreak, there can be a lot of staff hired very quickly.
They may not be well paid, they may not be well trained, they may not be well motivated, they may not be the best people to be communicating polio messages in the most sophisticated way. So, as you did with the previous section, you may want to pause the video, and think about, given these challenges, what are some strategies you might use in this situation? So here are UNICEF’s recommendations. Break communications in outbreak settings into two phases. The first phase is an immediate response, where you want straightforward, clear communication, talking about the outbreak, what’s happening, talking about the vaccine, and where it’s being given. You want these messages to be consistent. You want to train community and social mobilizers.
So, again, this person to person communication is really important. Not just mass media, but you want people trained to deliver these messages in person, while using mass media as a backup, to give people background information, and to help create urgency to get immunized. So, during this first phase, the audience is particularly sensitive to communications related to the crisis, and you can think about this in any disease outbreak. When it’s new, people are much more attuned to it, and much more likely to listen to information about it. So you have a window here to communicate things like the important safety and efficacy of vaccination.
Once this initial time period has passed, we move into what UNICEF calls phase 2, or an adaptive response, which is a little more of a long term issue. So, at this point, you may have barriers arising, you may know what some problems are, and you may need to adapt your communication to address those specific barriers or problems. You may need to shift your communication away from these messages around, look, there’s an outbreak, here’s when we’re doing our vaccination campaign, to thinking more deeply about the root causes of why kids might be being missed. You may want to have more messages about the importance of communal protection, and social action.
So, in an outbreak, you can see that the communications needs are slightly different, and the challenges are slightly different than you see in an endemic setting, and that’s before we even get in to specifics of the political situation in a given place. So context is extremely important when thinking about a communications strategy. Finally, there’s another context that UNICEF has developed guidelines for, and that’s areas that are polio-free. So this is actually kind of challenging, because in a polio-free setting, as long as there’s polio anywhere in the world, you still need to maintain vaccination coverage. But, if there hasn’t been polio in an area for 15 years, parents may not be that concerned about it.
So the challenges in polio-free settings, are that people may not be that worried about polio, and may not be really seeking out vaccination for their kids as much, because it doesn’t seem like a big issue to them, because it hasn’t been around for a long time. There may be, on the health system side, delays or shortages in service delivery, because the health workers may not feel that polio vaccination is really that critical. And finally, there may be community members who are leveraging the success of polio to demand other health services. We’re going to get into this issue in quite a bit of depth in a moment, so we’ll come back to this.
Given this, can you think for a minute about the strategies you might use in this kind of scenario? And again, feel free to pause the video. So UNICEF strategies in these sort of settings, are that you want to maintain high vaccination rates by promoting the importance of continued vaccinations, and in a simple, understandable way, telling people that high rates of vaccination are really important, and that they’re normal. That this protects individuals, who for medical or other reasons, could not be vaccinated, that it prevents the spread of vaccine-derived polio– again, that’s a complicated communications message that has to be done carefully. And that this may protect their children against importations that occur from countries or areas with continued transmission.
And you can think about transitioning from polio to child health, that the messaging shouldn’t be just around polio, which may not be very relevant to parents, but it should be about child health, more broadly. That messaging should focus on developing accurate knowledge, and positive attitudes toward child health, more broadly. In fact, I would argue this is actually important across endemic outbreak and polio-free settings, for reasons we’ll get into in the next section. So communications messages in these settings might talk about vaccination as one of many things you would do to promote good child health.
So the point here is that, in each setting, you need to think about where parents are coming from, what their concerns may be, and you tailor your communications to address those concerns. So we’ve here broken it down in the way UNICEF does, between endemic settings, outbreak settings, and polio-free settings. That makes a lot of sense. But within each of these settings, things are yet more complicated. There’s different political groups, there’s different groups of parents from different backgrounds, who may have different thoughts or ideas about the vaccine, and all of these have to be addressed in really targeted ways for successful communication about vaccination.
So, on the surface, while communication about vaccination may seem simple, it becomes very complex to do well. And context, and understanding context, is key to that.

Svea Closser, MPH, PhD Bloomberg School of Public Health, Johns Hopkins University, USA

After watching this lecture, review your response to What do you think are some possible communication strategies?. Did any of your suggestions match up with those mentioned in the lecture?

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