USAID (Ogden & Shimp), Academy for Educational Development (Waisbord), The Communication Initiative (Thomas)

"As avian influenza and other emerging diseases threaten developing countries, the role of communication in disease control is becoming more prominent and recognized. Incorporating communication into the development of policies and practices for disease control is essential for conveying appropriate actions, providing information on related-issues such as quarantine or travel restrictions, addressing real versus perceived risk of disease and improving personal preparedness. In the absence of well-managed communication efforts, negative economic consequences, public panic, inappropriate actions, and ongoing disease circulation can result..."

This 31-page paper was presented at the October 2006 World Congress on Communication for Development (WCCD), an event organised by the World Bank, the Food and Agriculture Organization (FAO) of the United Nations, and The Communication Initiative (The CI). While exploring communication strategies, challenges, and ways forward in the context of polio and the Polio Eradication Initiative (PEI) in particular, the paper is a review of - and call to action to support - the use of communication approaches in a variety of disease control programmes (e.g., epidemics or disease outbreaks such as avian flu (bird flu) or severe acute respiratory syndrome - SARS). It outlines the evolution and most significant advances in developing evidence-based approaches for communication within the context of a global disease control and eradication initiative.

The core premise of this paper is that communication strategies such as advocacy, social mobilisation (SM), media engagement, and interpersonal communications are crucial to effective disease control - and must be emphasised at every stage of the control process, from the very start. To provide context for this claim, the authors begin with an Introduction that includes a comparison of communication efforts to eradicate polio with other diseases such as smallpox. The landscape has changed since smallpox was conquered in the late 1970s, the authors explain; among the factors communication practitioners have been challenged to consider are:

• Smallpox eradication veterans recall that "nobody said no" to smallpox vaccination, in part because the idea of community empowerment was only gradually entering the thinking and practice of international development. More recently, however, demands for participation and equality are antithetical to top-down eradication programmes; democratisation and decentralisation pose both new challenges and new opportunities, which are detailed here.
• Major technology changes have also resulted in communication challenges for the PEI that smallpox eradication did not face. Today, information and communication technologies (ICTs) such as the internet and satellite television offer many "opportunities" to promote negative opinion and circulate rumours beyond local boundaries. However, these new ICTs also provide positive opportunities to extend the reach of accurate and supportive messages, if a good media management plan is in place.

The authors move on to explore the historical development of polio communication in depth. In short, in the early phases of the PEI (i.e. in the mid-1980s) the role of communication was to provide basic information about schedules and places where the Oral Polio Vaccine (OPV) would be administered through posters and other media, and to conduct focused SM efforts during National Immunization Days (NIDs). As the PEI expanded, regionally, in the 1990s, organisers realised that tapping into existing demand was not enough; communication had to be more pro-active and integrated with service delivery. The process of this evolution, which grew to incorporate efforts to contribute to both supply and demand factors using advocacy, SM, and information, education and communication (IEC) activities, is explored in depth here. The authors discuss various challenges that have affected the shape of this process. For example, "Many epidemiologists dismissed communication as a 'soft science', criticizing communication officers for not producing measurements of social mobilization or data on the impact of communication activities. Their perennial question has been: How do we know and measure what communication does?" (However, the authors also stress that "Improvements in data would help to make the case for increased communication support and acknowledgement but will not necessarily transform entrenched hierarchies and institutional cultures.")

In a section of the document titled "Theoretical and Methodological Basis and Developments in Polio Eradication Communication", the authors explain that communication for polio eradication draws on an accelerated United Nations Children's Fund (UNICEF)-developed ACADA (assessment, communication, analysis, design and action) planning model, the P Process developed by Johns Hopkins University, and other applied theories on communication and behaviour change. The authors argue that, while in most situations, communication efforts that draw on such approaches cannot alone raise immunisation coverage, in concert with other immunisation components they play an important role in assuring every child receives a complete immunisation series before his or her first birthday as well as boosting simultaneous immunity across large geographic areas. The authors make the case for this claim - in part by citing country polio communication examples from the 2005 Technical Advisory Group (TAG) Meeting on Communication for Polio Eradication in Yaoundé, Cameroon, where some of the progress achieved thus far was documented using an evidence-based approach. Examples are provided from India, Pakistan, Nigeria, Egypt, and Benin.

Along these lines, the authors contend that efforts to strengthen evidence-based communication strategies for polio eradication - and other eradication programmes, which also have shorter timeframes and focus on quick bursts of action, rather than daily behaviour change - can be bolstered by real-time data using a combination of detailed, case-based surveillance, independent monitoring of immunisation campaigns, social mapping, and rapid survey techniques. These methodologies (described in more detail within the document) have apparently proven to be more effective in guiding communication decisions than have traditional knowledge, attitudes and practices (KAP) studies and other common approaches to measuring and modifying communication strategies.

Based on a reflection of the above-summarised history and challenges, key lessons include:

• In the case of epidemics or disease outbreaks, communication experts should be part of any outbreak investigation and response team.
• Sustaining fresh messages and motivation for a programme such as polio eradication is difficult and requires a multi-disciplinarily approach and the active involvement of communication experts, epidemiologists and civil society.
• Flexibility to react to a rapidly changing environment is paramount, yet one that large international organisations or Ministries of Health are not fully prepared for.
• Measurement of achievement and impact of communication activities, through key indicators and a data collection system, also needs to be integrated within the health strategy.
• For donors and policy-makers it is important to factor in the communication needs of immunisation and disease control programs and continue to champion this area for resources, skilled personnel, analytic integrity, and professionalism.