RESEARCH

 

Risk communication and community engagement -unlocking the key to South Africa's response to SARS-CoV-2

 

 

N Leburu^I; C Shilumani^II; C Bhengu^III; M Matlala^IV; P Maja^V; S Jimoh^VI; N Mayet^VII

^IBA, Dip Gen Nursing, Dip Midwifery; National Department of Health, Pretoria, South Africa
^IIBSc, MPH;The Centre for Communication Impact, Pretoria, South Africa
^IIIBA, BA (Hons), MA, Dip (Journ); National Department of Health, Pretoria, South Africa
^IVBIS (Hons), MSc; Clinton Health Access South Africa, Pretoria, South Africa
^VBA, BA (Hons), Cert Public Policy Admin; National Department of Health, Pretoria, South Africa
^VIBA, BA (Hons); National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
^VIIMB ChB, MPhil; National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: COVID-19 has changed the way that governments communicate and engage with citizens. In emergencies, effective communication must be immediate, grounded in science, transparent, easy to understand and in language-appropriate messaging delivered through multiple and varied platforms. For the South African (SA) COVID-19 response, the intent was to design an agile, locally relevant Risk Communication and Community Engagement (RCCE) strategy as the pandemic was unfolding and to constantly evaluate its implementation. Early involvement of communities in the formulation and direction of a risk communication plan is essential to its success
OBJECTIVE: To outline the significance of the RCCE's robust communication strategy during the COVID-19 response and the lessons learnt in executing the strategy
METHODS: This is a qualitative review of documents and reports generated and utilised by the RCCE Technical Working Group (TWG) and reflects the lessons learnt from discussions and multiple engagements at district, provincial and national levels. The review incorporates lessons learnt from international practice, resource documents from the World Health Organization (WHO), RCCE readiness and response to coronavirus disease, feedback from the Behavioural Science Ministerial Advisory Committee, input from the call centre, website and various established social media platforms
RESULTS: Communication and building trust with multiple stakeholders begin before an outbreak and is a prerequisite to facilitate the timeous flow of information, particularly in the context of a rapidly evolving outbreak of a new disease, where the scientific community does not immediately have all the answers. Initial COVID-19 messages were therefore filled with challenges that ranged from the lack of scientific and epidemiological information to rumours, conspiracy theories and misinformation. The findings validate that empowering communities to act, strengthening public trust and community participation using multiple channels as well as timely responses to rumours and misinformation are important drivers of COVID-19 communication efforts in SA. Communication efforts must be accelerated to translate science into locally relevant languages and the impact of interventions must be measured to appropriately direct limited resources. Conclusion. The risk communication strategy incorporated several key lessons that could be used to improve communication and inform future emergency response communication that is immediate, science-based, transparent, inclusive and encourages community participation

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COVID-19 has changed the way that governments communicate and engage with their citizens. The South African (SA) government and its partners moved from traditional communication methodology to 'winning hearts and minds' as a driving force behind the communication strategy intended to encourage early testing and health-seeking behaviour, to share the emerging science and intervention measures, to prevent the spread of the virus, to educate the public about the risks, symptoms and prevention practices, and to strengthen partner coordination.

A Risk Communication and Community Engagement (RCCE) Technical Working Group (TWG) was already in existence in February 2020 when news broke of an imminent virus outside China, and it was activated as part of the country's overall Incidence Management Team (IMT) tasked with response to the COVID-19 pandemic.

The Government's Communication and Information System (GCIS) leads and coordinates all government communication responses while the RCCE is led by the National Department of Health (NDoH) with the participation of bilateral, multilateral and non-governmental organisations (NGO) partners. The RCCE TWG was tasked with the role of leading COVID-19 communication as part of the country's National Emergency Preparedness Plan.

Guided by the International Health Regulations (IHR) established by the World Health Organization (WHO) in 2005 and updated for COVID-19 in 2020,^[1,2] the RCCE response to COVID-19 informs the health component of broader government communication activities under the COVID-19 Communication Command Centre.

Since the first case was reported in SA, the RCCE TWG developed a range of guidance documents, namely Risk Communication and Community Engagement Preparedness and Response Strategy and Plan, and the Social Behaviour Change Community (SBCC) strategy.^[3] In addition, the RCCE TWG developed reporting tools, systems and created networks across all levels of society to ensure effective COVID-19 communication response in the country.

The strategy and tools were constantly reviewed as to their effectiveness in SA. Promoting adherence to the recommended non-pharmaceutical interventions remained a global and a national challenge as COVID-19 fatigue challenged sustained behavioural change. In this paper, we outline the significance of the RCCE's robust communication strategy during the COVID-19 response, reflect on what has changed in the way we communicate and engage with stakeholders, and how these changes can be used to inform future RCCE planning and implementation.

 

Methods

In an emergency, the need for speed means that a lot happens quite quickly with less time to develop accurate strategies and plans before implementation.^[4] The present study followed a qualitative research methodology, characterised by the review of key RCCE documents and other local and international literature (Table 1) relevant to the RCCE during emergencies to identify lessons learnt that could be used to further refine our strategies and inform planning for similar emergency situations.

Data collected from the review of RCCE documents informed the interpretations of our findings and framing of our conclusions and recommendations.

The intent was to design an agile, locally relevant RCCE strategy as the pandemic unfolded and to constantly evaluate its implementation.

 

Results

The findings of lessons learnt are categorised into six broad themes.

Transparent communication

The IHR 2005^[11 indicates that 'it is critical to communicate to the public what is known about the outbreak, what is unknown, what is being done, and actions to be taken regularly'. The RCCE TWG sought to communicate news, issues, and updates on COVID-19 in a transparent manner. We found that honest communication remained at the heart of all communication led by political leaders at both national and provincial levels. This finding is supported by Forman et al.^[5] in their lessons learned from the management of the coronavirus epidemic. One of the hardest challenges for communicators has been the lack of epidemiological and scientific knowledge as COVID-19 was a relatively new virus with very little known initially and with rapidly evolving, sometimes conflicting and incoherent information (e.g. at an early stage, there was no need for masks and later they were enforced through the Disaster Management Act with the type of masks from surgical to cloth masks being contested). The issue of fogging and spray tunnels had no scientific basis and the debate about the use of ivermectin continues to rage as the science unfolds.

The approach of the RCCE T WG and communicators was to be honest when there was not sufficient information available related to some aspects of COVID-19 and to follow the scientific and epidemiological studies as they were published and communicate as and when accurate information became available. The RCCE plan was structured to guide communicators as per established protocols including COVID-19 daily media updates and development of messages by simplifying clinical, scientific, and epidemiological information, aligning messaging to the Ministerial Advisory Committee (MAC) recommendations with ad hoc representation of RCCE on the MAC and reinforcing messages delivered by the President, Minister of Health, and Inter-Ministerial Committee. RCCE TWG partners, such as the National Institute for Communicable Diseases (NICD), a division of the National Health Laboratory Service, South African Red Cross and others supporting the NDoH in promoting transparent sharing of information through frequent media briefings, media interviews that tapped into the expertise of the NICD and other scientists, targeted communications campaigns, and providing up-to-date clinical guidance, training, and technical resources to health workers.

Empowering communities to act

The first nationwide lockdown tested how functions were discharged on RCCE. The restrictions on travel as well as the need for physical distancing meant it was not feasible to implement the routine method of community engagement activities contained in the RCCE plan. In July 2020, the restrictions had been relaxed to an extent and the RCCE TWG developed a SBCC strategy'³¹ that emphasised community action.

The IHR 2005 requires that 'preparedness and response activities are conducted in a participatory, community-based way that is informed and continually optimised according to community feedback to detect and respond to concerns, rumours and misinformation'. The use of community action groups comprising existing community health workers (CHWs) and other existing cadres at the community level to disseminate COVID-19 messages became central to the COVID-19 SBCC strategy's community action pillar, where addressing community-level barriers to widespread adoption and maintenance of non-pharmaceutical interventions was prioritised. While protective personal equipment provision is outside the scope of RCCE activities, partner support was key in investing resources in generating an enabling environment for adherence through the distribution of masks and sanitisers in supported communities.

Undoubtedly, the biggest challenge was referenced by the WHO's Director-General as 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'.^[6] With the overwhelming abundance of information, the RCCE sought to communicate and explain changes in messaging in a timely manner, ensuring that community perspectives informed new and revised messaging. There were multiple fake messages, and these were quelled by the President by indicating early in the pandemic that fake news will be dealt with within the ambit of the law. The RCCE team was on constant alert and verified and stamped all fake news even though coming from apparently 'reputable sources'. This sign of credibility also allowed for a more literate audience as the public were engaged on methods they could use to discern between factual, credible messaging v. harmful rumours.

Strengthening public trust and community participation

The IHR of 2005 advises that 'Responsive, empathic, transparent and consistent messaging in local languages through trusted channels of communication, using community-based networks and key influencers and building capacity of local entities, is essential to establish authority and trust'. To build trust in our COVID-19 messages, our political principals communicated regularly and updated SA on the COVID-19 response. Health workers and essential workers participated in the fight against COVID-19 by sharing their personal stories, facilitated through the Centre for Communication Impact.^[7] These were stories of how they handled and/or survived COVID-19, inspiring hope in SA at a time of national stress of facing increasing illness and death. These stories of sacrifice and facing death amidst a deadly virus that had no cure, sent strong messages of hope and solidarity to the communities.

RCCE TWG members dispatched mobile multimedia broadcaster vehicles equipped with a built-in sound system and high-definition LED screen displays on three sides to share public health messages through video and sound in all provinces focusing on high-burdened districts. This public communication initiative incorporated an awareness and education campaign alongside the truck with dedicated ground support teams. CHWs, social mobilisers and volunteers onsite educated communities and distributed information material. This provided opportunities for health workers to do social listening to address misinformation.

Using multiple communication channels to disseminate information

Communication is effective when it is interactive. The RCCE TWG used multiple platforms to communicate COVID-19 messages. This included social media platforms, billboards, posters, infographies, pamphlets and animations, which were translated into all SA languages and shared nationally in all settings including businesses, malls, bus and taxi ranks, train stations and highways. Most importantly, the RCCE TWG mounted a COVID-19 radio campaign that reached SA with messages through a network of 55 community radio stations in all nine provinces. Through this radio campaign, over eight million SA people were reached with COVID-19 messages. Scientists across the country utilised multiple platforms to share the latest information and the research being conducted in vaccine effectiveness, new variants and vaccine roll-out plans.

Another radio programme, Sikhaba iCOVID, led by RCCE partners, communicated messages on COVID-19 at the regional level with a strong focus on survivors of COVID-19 sharing their stories.

In addition, two community radio stations were selected for focused interaction to gain an understanding of the knowledge, attitudes, perceptions and behaviours towards COVID-19 from community residents. Insights collected from these two radio stations informed messaging and interventions that were rolled out in the two communities. These interventions were radio-focused and community-based, and included handwashing demonstrations, COVID-19 awareness Training of the Trainers sessions, informal business COVID-19 compliance spot checks, taxi rank activations, radio adverts and a radio drama aimed at addressing the misconceptions of COVID-19 and knowledge gaps that were identified in the studies. Community agents (n=918) trained included CHWs, community activists, traditional practitioners, church delegates and high school learners. The stakeholders were initially trained on COVID-19 awareness through a course adopted from Médecins Sans Frontières. Some of the organisations that were trained went on to train 777 more people in their communities.

A set of data-free WhatsApp services targeting different cohorts of the population were launched early in the pandemic. These digital tools have connected the health system to over 6 million citizens and health workers, empowering officials with the information they needed to make informed and effective decisions.^[8] Additional features included a risk assessment tool that helped the public assess risk, allowing early detection, mapping and efficient management of health cases and resources. A separate service was launched targeting health workers of all cadres, which provided psychosocial support and up-to-date information for health workers on the frontline.^[9] A COVID-19 hotline number 0800 029 999 was also well publicised, where communities could obtain information and ask questions. Questions and answers were generated from the call centre and these informed further refinements of COVID-19 messages. Daily media updates on the number of COVID-19 cases, new cases, active cases, deaths, case fatality rate, tests conducted, recoveries and recovery rates were published on multiple platforms. As the vaccination programme was being rolled out, the total number of people vaccinated formed part of the daily updates.

Monitoring rumours and misinformation

With WHO labelling COVID-19 as an infodemic,^[6] the team soon realised that the RCCE TWG was faced with an uphill task as rumours, conspiracy theories and misinformation were undermining communication efforts and adversely affecting public trust. With support from the Johns Hopkins Centre for Communication Programs, Centre for Communication Impact supported RCCE TWG to develop the District Health Information System (DHIS) as a rumour-monitoring system. This system was handed over to the NDoH to manage and form part of the regular reporting for the department. After this, a full social listening mechanism was developed led by the NDoH. Through this mechanism, rumours, conspiracy theories, public perceptions and other forms of misinformation were collected on a weekly basis. This was transitioned to the social listening mechanism where rumours and misinformation are collected and translated into a weekly report along with responses that are informed by science with support from scientists and technical experts in health and COVID-19^[10] The RCCE TWG believes that these tools will be useful in monitoring rumours and misinformation related to tuberculosis (TB) and HIV, as well as other diseases, in the future.

Capacity to deliver

The capacity to deliver on a complex, rapidly changing landscape of communication where social media messaging quickly fills a space requires the capacity to field messages and to respond to messages continuously. To deliver effectively, the government implemented the Integrated District Development Approach in all 52 districts to coordinate and accelerate the COVID-19 response. Multiple partners had to be brought on board to assist, call centres had to be established and staff trained on providing universal messages.

 

Conclusions and recommendations

Based on our findings, there are a multitude of factors to consider when developing and implementing ongoing and future RCCE strategies.

Emergency communication should be led by the government at national level with the support of health partners, experts, special committees, communities and civil society. Continuous transparency and coordinated efforts are key to building rapport and instilling trust and confidence at a time when citizens are uncertain and anxious.

Establishing channels that allow frequent, two-way feedback between national, provincial and district level RCCE teams holds multiple benefits, including allowing for interventions that support expedited cross-learning between provincial teams, while providing provincial and district level teams access to technical support through partner participation and ensuring that a bottom-up approach is followed at the national level.

The decisions are informed and guided by data, especially in the context of the needs, issues and perceptions that arise at a community level. The response should be inclusive of all vulnerable and marginalised groups, and their support can be rallied through simplified communication.

Effective communication alone is not sufficient for encouraging social behaviour change during disease outbreaks - compliance activities should complement the messaging. Integrated communication that includes health promotion, CHWs and environmental health interventions are encouraged to ensure that messaging is complemented with on-the-ground surveillance of adherence to preventative measures in public spaces.

RCCE structures should invest in novel content creation approaches to ensure that the public are continuously captivated as the repeat of the content may exacerbate non-compliance, further contributing to community transmission and pandemic fatigue.

Emergency response communication activities should include continuous monitoring of preferred communication channels, mobile device penetration rates, access to data and mainstream information channels.

Future plans should include measuring and monitoring the impact of infodemics during health emergencies by standardising taxonomies and classifications.

Declaration. None.

Acknowledgements. None.

Author contributions. SJ, NM, MM and CS conceptualised the study. NL, CB, MM, CS and SJ contributed sections to the manuscript. CS and PM reviewed the manuscript. All authors approved the final version of the manuscript for publication.

Funding. None.

Conflicts of interest. None.

 

References

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10. South Africa COVID-19 and vaccine social listening report. https://sacoronavirus.b-cdn.net/wp-content/uploads/2021/10/Collated-Social-Listening-Report-7-Oct-2021.pdf (accessed 19 October 2021).         [ Links ]

 

 

Correspondence:
N Leburu
nombulelo.leburu@health.gov.za

Accepted 3 November 2021