Training Module:�Demand Generation/Advocacy Communication and Social Mobilization (ACSM) for COVID-19 Vaccine

Intended audience for the training module

This training module is intended for progamme planners who are responsible for planning the demand generation/advocacy communication and social mobilization (ACSM) strategies and plans for COVID-19 vaccine introduction.

The slide deck includes content on key pillars of demand generation/ACSM.

Content can be extracted and customised as appropriate for various levels of stakeholders: 

• EPI managers
• Health workers
• Health education teams
• Vaccinators
• CSOs
• Social mobilisers etc

Learning objectives

At the end of the presentation, participants should be able to:

• Describe the purpose and importance of the Demand Generation/Advocacy Communication and Social Mobilization Interventions for COVID-19 vaccine introduction
• Understand key populations prioritized to receive COVID-19 vaccination 
• Describe the key components of Demand Generation Pillar for Country Readiness and Delivery for COVID-19 Vaccine introduction
• Understand the importance of social listening and have knowledge about standard tools for generating behavioral data
• Describe how to prepare and respond to possible AEFI related to COVID-19 vaccine
• Understand possible resistance behaviors to anticipate from the population and which SBCC tactics to implement to counter this (case studies)

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Purpose of demand generation interventions

Purpose of Demand Generation/ASCM interventions is to :�

• Generate demand for COVID-19 vaccine and encourage uptake of vaccines by eligible population
• Build community trust and confidence around vaccine
• Address public concerns regarding vaccine hesitancy and mistrust
• Encourage people to continue behaviors to prevent COVID-19 infection, even after vaccination

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Importance of robust plan for demand generation/ACSM plan

Countries should have a robust and well thought out plan for creating demand for the COVID-19 vaccine:

• To collect and use social data to inform the design and evaluation of demand-related interventions
• To manage misinformation and set up social listening and rumour tracking, if needed
• To provide evidence-based, accurate information to families and communities
• To engage communities in planning, designing, implementing and monitoring communication and social mobilization interventions informed by behavioural insights
• To listen to community feedback and address their concerns and questions 
• Communicate to public and media appropriately during possible crisis including AEFIs and address their concerns with empathy

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Prioritization of populations when vaccine supply is constrained 

Who will receive the vaccine first and why (countries will make the final decision):

Health Workers

Elderly 

(age cut off to be decided by countries)

Pre-existing conditions and immuno-compromised

Health workers are in direct contact with COVID-19 patients. If we do not protect them, they are at high risk of getting infected which may create a crisis in people receiving treatment for COVID-19 and other essential health services

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Data shows that the mortality among the elderly is highest. Vaccines will protect the elderly from severe illness and even death

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People with pre-existing condition such as hypertension, high blood pressure, diabetes, cancer and those who are immuno-compromised are a greater risk of infection and severe illness in case infected

SAGE:https://www.who.int/immunization/sage/meetings/2020/october/Session03_Roadmap_Prioritization_Covid-19_vaccine.pdf

Some aspects about the COVID-19 vaccine make communication different

Key messages on COVID-19 Vaccine

• Current evidence from Phase 3 trials indicates that COVID-19 vaccines can help to reduce severity of symptoms from coronavirus infection
•  COVAX Facility is working to ensure equitable access to COVID-19 vaccines for all countries. 
•  Manufacturing of vaccines is ramping up, but supplies are limited. 
• In Phase 1 of rollout, countries will get sufficient doses to cover 3% of their populations who are at highest risk WHO SAGE Allocation Framework https://www.who.int/immunization/sage/meetings/2020/october/Session03_Roadmap_Prioritization_Covid-19_vaccine.pdf
• According to the WHO SAGE Prioritisation Framework, health workers and essential care workers, elderly, people with chronic health conditions and (context-specific priority groups not already listed) will receive the vaccine in the first cohort.
• https://apps.who.int/iris/bitstream/handle/10665/334299/WHO-2019-nCoV-SAGE_Framework-Allocation_and_prioritization-2020.1-eng.pdf?ua=1

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It has to be noted that the countries will make the final decisions on prioritization of eligible population for COVID-19 vaccine

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Components of Demand Generation Pillar for Country Readiness and Delivery for COVID-19 Vaccine introduction

Community feedback

Identification of key influential people

Social Profiling

Social and Digital Listening

PLANNING PHASE

Planning and coordination

Data for Action

Behavioral and social data

Stakeholder engagement

Crisis communications preparedness

Monitoring Framework

Establishment of a coordination mechanism

Include crisis communication in planning phase

Develop M&E framework in planning phase

Development of costed plan

Collaboration with CSOs/CBOS/PVt sectors who work with priority population

Components of demand generation pillar for country readiness and delivery for COVID-19 vaccine introduction

Capacity building: IPC skills of health workers, orientation to media, stakeholders

Production, pre-testing and dissemination of culturally appropriate communication material

Behaviourally Informed Communication

Advocacy

Mass media and Social media campaign

Social Mobilization

Continuation of RCCE

Partnerships: journalists, CSOs, Medical associations, others

Misinformation management

Community engagement

IMPLEMENTATION PHASE

Supervision and monitoring and evaluation

Initial Steps for Country Planning

• Check if behavioural and social data is available which can inform the communication strategy
• Is there a social listening or rumour tracking mechanism in place-if not can the country establish it?
• Establish or reactivate the coordination mechanism-it could be ACSM committee or the existing RCCE coordination platform could be mobilized
• Establish a system for approval of communication strategy/approaches and content
• Identify who the stakeholders will be for the phase-wise introduction of COVID-19 vaccine and for identifying innovative ways of reaching priority population

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Health workers: HWs at all levels (medical doctors, nurses, vaccinators, community health workers) are recipients of vaccination as well as communicators 

• Through health system structures: communication content can be part of the training; short videos could be developed with key messages on benefit of vaccine, doses, possible side effects if any etc. 
• Through professional nursing and medical councils and community health workers can be reached through community level training and interpersonal communication

Elderly population: Mass media, mobilization of CSOs to reach house to house, mobilization of men's groups, youth groups as these structures can reach elderly male population

• Mobilise women's groups where they exist & female health workers to reach female elderly population
• Wherever available, reach out to long term care facilities to reach elderly populations

People with pre-existing condition: 

• Through community volunteers to reach house to house and encourage them to take the vaccination. 
• Use social media and mainstream media-dedicated content and talk shows in mass media on the importance for people with these conditions to be vaccinated

Important to be aware of gender dimensions in communication-many female HWs are in the frontline-they will need to be reached both as recipients of vaccines but also as communicators, how do we reach emales with pre-existing condition?

Examples of possible channels of communication to reach priority populations 

Coordination

• Government led multi-sectoral coordination mechanism could be established or activated at national and sub-national level, NITAGs
• Existing RCCE taskforces or Advocacy Communication and Social Mobilization taskforces can be mobilized
• The coordination body will be responsible for planning, providing guidance for implementation, monitoring and reporting of ACSM interventions
• The same coordination mechanism or a sub-group within it can be mobilized for managing crisis communication
• Better coordination will help leveraging resources, avoiding duplication and maximizing communication efforts to reach priority population

Behavioural and Social Data (BeSD): �Listening to people and communities

Surveillance data

Programme data

Who?

Where?

Why?

Behavioural and social data

Zero-dose, delayed

under-vaccinated

Vaccine supply, wastage, policies, legislation

Disease burden

Barriers and drivers per population group

Understanding what drives vaccination uptake and triangulating these insights with other programme data will enable programmes to:

• Identify and address influences on behaviour: reduce negative, enhance beneficial
• Target and evaluate strategies in specific contexts
• Examine trends over time
• Better plan for what’s ahead

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Objectives of the BeSD tools

Boost the availability, quality, and use of local and global data on acceptance and uptake of COVID-19 vaccines

• Support assessments of the drivers of vaccination to inform planning
• Inform the design and evaluation of targeted interventions:
• Match interventions to diagnosed drivers or barriers to uptake
• Identify measures for tracking of outcomes
• Evaluate, adjust interventions, implement, monitor…. for continuous improvement
• Track comparable trends over time at a subnational, national, and global level
• Contribute to national, regional, and global reporting processes

🡪 Better targeted, cost-effective and impactful strategies

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What tools are available?

• Survey (approx. 30 questions), quantitative tool targeted to either:
• Health workers
• Adults

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• Interview guides, qualitative tool targeted to either:
• Health workers
• Adults

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• A guidebook, to support local adaptation, testing, and use of tools, including:
• Adaptation for different needs/settings (campaigns, facility-based, rapid…)
• Data gathering, analysis and use, triangulated with other programme data
• Framework and decision-trees for translation of findings into action

What domains are assessed?

• Thinking and feeling
• Social processes
• Motivation
• Practical factors

How can the tools be used?

Tools are modular and designed to easily integrate with existing activities

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PLANNING:

• Either or both the survey and interview guides may be used
• Tools can be adapted to local needs, languages, and target populations:
• Integrated into existing mechanisms for data collection
• Used alone, across a country or for specific target populations
• Can be used across different methods: surveys, rapid assessments, polls, etc.

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DATA GATHERING AND ANALYSIS:

• Data gathering on paper or electronically (e.g. ODK)
• Set up for triangulation and analysis with other programme data

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USING DATA FOR ACTION:

• Frameworks and tools available to guide use of findings for future planning and M&E

How can the data be used to intervene?

• Once findings have been analysed and the team has identified problem areas where indicators do not meet expectations, these problem areas can be matched up to interventions

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• Evidence-Based Interventions for HCW and Older Adults
• Evidence-based interventions to increase demand for COVID-19 vaccines are available in table format for healthcare workers, older adults, and adults with pre-existing conditions
• Interventions fall under broad categories:
• Educational campaign, on-site vaccination, incentives, free/affordable vaccine, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion

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• If there are multiple interventions to choose from with similar feasibility, going for the intervention with high likely impact and high strength of evidence is best

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Social Listening

• Resistance and distrust are common in epidemics and are often driven by a population’s fears of government control and intrusion.
• “We’re not just fighting an epidemic; we’re fighting an infodemic. Fake news spreads faster and more easily than this virus and is just as dangerous." – Tedros, WHO Director-General.
• The spread of COVID-19 has been accompanied by a massive proliferation of vaccine-related mis- and disinformation.
• This may be undermining public trust in routine immunization and in new COVID-19 vaccines.
• This must be addressed by an integrated national strategy that coordinates social listening and analytics and assessment with digital engagement initiatives.

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Social Listening: Key guiding principles

• A social listening system should integrate media, social media, novel digital sources (eg U-Report), and even offline sources of data and insights.
• It is important to develop a country-level communications ecosystem assessment to understand what the relevant conversations and disinformation narratives are, where they are located (eg social media networks and communities, media, real-world communities), who is influencing those conversations (trusted voices, vaccine advocates), who is developing and disseminating the disinformation, etc.
• Monitoring needs to be transformed into actionable insights. A social analyst/infodemiologist is responsible for the monitoring, situational insights (regular reports), and monitoring and evaluation of interventions. Disinformation needs to be verified and evaluated for potential impact.
• Both online and offline RCCE and communications and advocacy actions should be informed by, and inform, social listening and analytics.
• Content should be grounded in current behavioural and social insights, including inoculation against misinformation (pre-bunking), and rapid tested for efficacy and safety.
• Systematic monitoring and evaluation should enable continuous recalibration of RCCE actions.

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Social Listening: Key Recommendations

• Countries should develop a national vaccine misinformation management strategy, that is integrated into the vaccine demand and communications plan.
• A social listening system should integrate media, social media, novel digital sources (eg U-Report), and even offline sources of data and insights.
• Data should be compiled and analysed, and recommendations produced by a social analyst/infodemiologist. This multi-disciplinary competency may need to be developed.
• Develop and test content and interventions based on behavioural insights, tailor to context, evaluate impact.
• Any strategy should mobilise and coordinate the actions of all partners to ensure impact.

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Empowering Health Workers: What is the role of vaccinators in communicating about COVID-19 Vaccination?

• Advocate for COVID-19 vaccination as an early recipient of the vaccine, vaccinator, and trusted source of health information to the community
• Share information and facts about COVID-19 vaccine with the community
• The importance of COVID-19 vaccination for controlling the epidemic
• Priority groups to receive COVID-19
• Where and when to get COVID-19 vaccination
• The safety of COVID-19 vaccination
• Common minor side-effects from vaccination and what to do in case of side effects
• Who else in their community is a source of information on COVID-19 vaccination
• Organize communication activities through use of data available in the facility microplan 
• Respond to community concerns with understanding and empathy

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Capacity building: Basic concepts for communication and vaccination

• Communication: is the art and technique of using words and visuals effectively to share information or ideas-could be one way (e.g., though posters, TV, radio) or two way (face to face)
• Interpersonal communication (IPC) – a process by which two or more people share information, ideas, and feelings, includes verbal and non-verbal interaction
• Empathy – the ability to understand and share the feelings of another 
• Empathy helps us to treat people with respect and kindness, regardless of their background, social position or attitude. 
• Showing empathy makes clients more likely to feel comfortable raising questions or concerns.
• Human centered approach – Keeping people at the center when designing and implementing programs
• Demand for immunization – the actions of individuals and communities to seek, support, and/or advocate for vaccines and immunization services
• Vaccine hesitancy – delay in acceptance or refusal of vaccines despite availability of vaccine services

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Why is IPC important? How can it be used? 

IPC can be used to:

• Understand the client's experiences and perspectives by asking questions and listening
• Provide simple clear, practical information about who will receive the vaccine, why and where
• Respond to clients' questions and concerns with empathy and contribute to reduced refusals
• Develop trust in vaccination
• Acknowledge local challenges and show respect for customs and culture
• Encourage acceptance and uptake of COVID-19 vaccine

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IPC techniques

• Welcome the client warmly
• Listen actively and respectfully with empathy
• Keep key messages simple 
• Encourage them to express their ideas and feelings 
• Use culturally appropriate visual aids to support your message
• Summarize at the end and request the client's commitment to vaccinate

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Good IPC helps create and maintain a relationship of respect and trust between health workers, families, and communities. 

How can frontline workers communicate effectively about COVID-19 vaccination?

• Adapt your communication based on client risk group and their attitude or perspective towards the COVID-19 vaccine. 
• Align communication and key messages with the client risk group. For example: 

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How can frontline workers communicate effectively about COVID-19 vaccination?

• Align communication and key messages with client attitude or perspective towards the COVID-19 vaccine. For example: 

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Community Engagement

• Community engagement and accountability should be at the center of COVID-19 vaccine strategies
• Key people who are responsible for CE are frontline workers: Community Health Workers, Lady health workers, Community health volunteers, social mobilizers of CSOs or Government
• Community trust is key to ensure vaccine uptake and buy-in.
• To build trust, it is important to understand how communities perceive the disease and what are their main questions, doubts, and fears around vaccines, generally, and towards COVID-19 vaccine, more specifically.
• Community engagement is expected to support the buy-in and uptake from communities and individuals of COVID-19 vaccine

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Steps to Community Engagement

• Assess and collect social data: Social profiling and community rapid assessments are key to understand perceptions towards vaccines, hesitant groups, communication channels etc
• Coordinate community level activities to avoid duplication
• Define objectives
• Identify local actors and influencers
• Advocacy at local level
• Develop action plan with community’s engagement-microplan should include community engagement activities
• Implement planned activities
• Establish a community feedback mechanism
• Monitoring

Refer to community Engagement guidance for details

Crisis communication

• When a new vaccine is being introduced, people will have concerns about safety of vaccines, there will be rumours, fake news circulating
• There may be adverse events following immunization-most of the time coincidental and not related to vaccine-but in rare cases may be linked to vaccines
• Having a robust crisis communication plan is critical to ensure that rumours and misinformation can be mitigated and addressed on real time

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Steps for Crisis Communication

• Coordination: establish a small core team, which will be responsible for coordinating/managing crisis communication
• Develop a communication tree so that people know exactly who to communicate to in case of crisis and what actions to take.
• Social listening: Systematically monitor social and mainstream media to assess any negative rumours or concerns from public regarding vaccination. Analyse public perception towards covid vaccine.
• Urgent and real time response: Address rumours/fake news/ misinformation and disinformation real time as much as possible. Negate negative news by either blocking or removing the content and by posting post positive content
• Identification of spokespersons and training: identify spokespersons for national and sub-national levels and train them on crisis communication in various scenarios. Make sure that crisis communication is included in training content at all levels-with clearly described responsibilities of all cadres of health workers and social mobilizers.

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Steps for Crisis Communication

• Develop simple standard operating procedures for managing crisis communication. Develop frequently asked questions and fact sheets for spokespersons.
• Develop partnership and work closely with media and have contact numbers of media persons who can be called upon immediately in case of a crisis
• Build trust among public about the vaccine by undertaking robust social mobilization and communication activities.
• Communicating with affected population: In case of AEFI-be transparent with public-be honest, empathetic but do not give false promises. Tell them what is being done by the Government in terms of investigation into the case.

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Crisis communication: Role of social mobilizers in crisis communication and AEFI

• Reassure populations that the vaccine is safe and is given to protect people from COVID 19
• Ask the vaccinator to explain to people being vaccinated what could be minor side effects and wat should be done in case of side effects
• If you see that a person has fallen seriously ill after vaccination, refer to the vaccinator immediately
• As a social mobiliser, do not talk the media yourself if they approach you regarding the case-your role is to refer to the right person as they would have full information on what has happened and what needs to be done

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Crisis Communication: Role of the vaccinator in crisis communication and AEFI

• Reassure clients that the vaccine is given to protect them from COVID-19 and explain:
• Why the vaccination is given, benefits and safety of the vaccine, possible side effects and what to do 
• If you see that a person recently vaccinated has fallen seriously ill after vaccination: 
• Immediately start treatment, refer to the appropriate health centre as needed
• Gather details about the health problem, timing of health problem and timing of receipt of COVID-19 vaccine. Contact supervisor with details.
• As a vaccinator, do not speak to the media if they approach you regarding an AEFI case
• Your role is to refer the media to the AEFI focal point, who will have better information on what has happened and what needs to be done
• Let the community know about the investigation being carried out by the government 
• Show compassion to the community and family but do not give incorrect/false information
• Inform the community that you will share follow-up information at a specific date/time
• If no additional information is available, maintain communication with the community members and provide them a new follow-up time

Role of the supervisor in crisis communication and AEFI

• Communicate to the AEFI committee and crisis communication spokesperson immediately is you have heard any rumours or an AEFI incident
• Communicate to the vaccinator/ focal points that they should refer all concerns from either public or media regarding the COVID 19 vaccine to you so that you can immediately communicate to relevant persons as necessary
• If it is a rumour with minor concerns on side effects explain to communities that:
• The vaccine is safe and is given to protect people from corona virus infection
• Common side effects of COVID-19 vaccination are redness and soreness at the injection site, mild fever and body aches. Side effects usually improve within XX hours/days after vaccination.
• If a person has fallen seriously ill after vaccination, the vaccinator would have an AEFI kit and should use it immediately as per the training they have received
• In your role as a superviser, do not talk the media yourself if they approach you regarding the case-your role is to refer to the district spokesperson as he/she is the right person with full information on what has happened and what needs to be done

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Monitoring and reporting

• Develop simple monitoring indicators as part of the communication plan
• Include the monitoring questions into the monitoring checklist to be used by supervisors who go to monitor the COVID 19 vaccine introduction
• Make sure that questions on demand generation are integrated into the post evaluation survey of new vaccine introduction
• When reporting on COVID-19 vaccine introduction, include content on demand generation component also.

Resources:

• Demand planning template and guidance
• BeSD user guidebook, survey tools and qualitative interview guides
• HW training module
• Community engagement guidance
• Health worker job aids
• Social listening guidance
• FAQs and fact sheets