Reaching Out to the Millions: A 5 Key Messages Rapid IEC Campaign During the COVID-19 Pandemic.

The ongoing COVID-19 pandemic has necessitated providing populations with simple and relevant, actionable informational messages for them to be informed on individual and community level measures to combat the pandemic. Distilling guidance from various sources into simple actionable message themes in a short time frame should be the hallmark of any rapid health promotion campaign. We developed and disseminated actionable Information, Education and Communication (IEC) messages on prevention and control during the ongoing COVID-19 pandemic by selecting five key message themes of prevention. A modified Delphi technique was used for the development process which was peer reviewed after consensus was generated. An online training model using specifically developed YouTube videos and Zoom Meetings was utilized to train Master Trainers and the further hierarchy reaching out to 6989 Community Resource Persons at the peripheral echelons. Conservatively the population reached out has been estimated to be more than 6 million (across 1.2 million households), over a two week period in April 2020. The implementing agency has created 300 videos in around 22 languages based on the 5 Key Messages, which are available online for universal access. A rapid IEC campaign that can be developed, designed and rolled out in a short span is required for emergency situations such as the ongoing pandemic. NGOs play an important role in reaching out relevant messages to the community, filling in the gaps by virtue of their relative systemic agility.

SARS-CoV-2, a newly discovered coronavirus, causes the disease COVID-19, which has resulted in an unprecedented pandemic requiring the full focus and commitment of governments, international organizations, healthcare workforce, civil society and general public at a global level. There has been a varied response across the world ranging from one extreme of total lockdown in India (barring essential services) to that of Sweden where life went on as usual apparently, except for precautions related to physical distancing. The Indian response has been considered one of the most stringent, scoring a perfect 100 on the Oxford COVID-19 Government Response Tracker, that tracks and compares governmental responses to the coronavirus outbreak globally.[1]

Undeniably, the best defence against any pandemic is a strong healthcare system. However, when even some of the best healthcare systems across the world have been found to be inadequate, the already overstretched Indian public health system would suggest that the dictum of “prevention is better than cure” be better adhered to, in safeguarding the vulnerable populations.

A large scale community based stratagem to control a pandemic type situation requires effective engagement from civil society and the general public, depending upon them having information about what they need to do and why in a language and at a level of simplicity that matches their language skills and health literacy. Health promotion is the most important component at the primary tier of the levels of prevention, and is the process of enabling people to increase control over, and to improve, their health. Health per se, is a positive concept emphasizing social and personal capabilities and health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to a more all encompassing well-being.[2]

The present report is based on the design and implementation of a health risk communication plan, customized for an Indian philanthropic organization, to convey the required information about the ongoing COVID pandemic to the community in the geographical footprint of their various projects across the country.

Material and Methods

In view of the restrictions imposed on movement even prior to the global ‘lockdown’, a modified Delphi technique[3,4] was adopted to develop five key messages as relevant to the ongoing COVID-19 pandemic. A peer group assessment was done of requirements for a large scale Information Education Communication (IEC) campaign. A WhatsApp group of 101 experienced doctors was accessed to obtain views on the perceived requirement to provide relevant IEC message themes at a population level. The messages shortlisted from the discussion generated were subsequently distilled further and inputs were sought on these from another WhatsApp group of 58 Medical College Faculty members. After deliberations, and moderated discussions, an abbreviated list of message themes was again circulated to sub-groups to be ranked in order of preference for inclusion in a population level campaign. The final five key messages were then extensively discussed further amongst a peer group of Specialists on multiple conference call sessions and the thematic messages developed and finalized in concordance with the updated WHO and Govt of India guidelines as relevant.

A pilot run of the key messages was conducted through an outreach campaign covering 250 villages in a state of India, covering a population of 2,50,000 people with a pre- implementation and post implementation representative cross sectional survey incorporated into the design.

For the roll out to the pan India ecosystem of the philanthropic organization, video learning modules were uploaded onto YouTube in a playlist and shared as pre-training material, with the target group of identified Master Trainers being graduates with a Bachelor’s degree at the minimum (in diverse fields). Training of these Master Trainers was conducted over Zoom Meeting sessions in a bilingual mode. The subsequent cascade of training involved the next tier of Mid Level Trainers, and thereafter Community Resource Persons (those who would be directly engaging with the community) across India. The Communications Team of the implementing agency developed SMS based messages, audio jingles and also short format videos in different regional dialects and languages involving local celebrities and public figures. Due to the ongoing lockdown in effect across the country, the community outreach action was restricted and low key, with most of the engagement being done through social media outreach and at the peripheral levels through small group interactive meetings with an emphasis on adequate ‘social’ (physical) distancing.

Results

The five key message themes finalized and developed for the campaign are shown in Box 1. For the pilot run of the initiative, these were translated into Hindi (one of the most widely spoken Indian languages) and suitable training was given to 25 Cluster Coordinators in a specific geographic region of a large state of India. These individuals, further trained 250 ASHAs (Accredited Social Health Activists) who were then tasked to spread the relevant messages to the clusters of 1000 persons (approx.) that each ASHA was responsible for. However, due to the lockdown and imposition of restrictions due to the pandemic, the team had to forego the post implementation survey and the various large scale community activities that had been planned for the pilot phase.

The 5 Key Messages.

Subsequently, when work from home (WFH) became the norm due to the lockdown, it was thought of utilizing the pan India implementation network of a leading philanthropic agency to disseminate the pandemic-related health promotion messages in a local context.

The operational hierarchy of the campaign is given in Figure 1. 178 Master Trainers from across India were trained through three online Zoom Meeting sessions. In turn, they trained 251 Mid Level Trainers, who eventually oriented a further 6989 Community Resource Persons, who subsequently reached out to 1.2 million households across 21 States of India over a two week period in April 2020, estimated conservatively to reach out eventually, to more than 6 million people in total. The creative team of the agency has created almost 200 videos in around 22 languages, including rare dialects, which are all available for universal access on an online playlist. A diversified dissemination strategy was developed that spanned audio, video, animation videos, text messages, infographics, push notifications on apps such as ‘mKrishi’ and Interactive Voice Response Systems through ‘Gram Vaani’ (a technology platform). In a few states, community radio systems were also used.[5,6]

Figure 1.

Operational Hierarchy.

A central single point of contact was established for any queries or clarifications on technical matters. A system of feedback from the peripheral echelons of the campaign, resulted in release of three sets of Frequently Asked Questions (FAQs) which were again pushed to the periphery through email and WhatsApp with suitable translation to local languages.

Discussion

Sharing the right information with communities at large, is emerging as an important need in tackling public health emergency situations such as the ongoing COVID-19 pandemic. The non-availability of focused content in local dialects and regional languages is posing a big challenge to the Government and NGOs that are working overtime to spread awareness in the conventional IEC format. Conventional forms of communication such as inter personal communication, posters, handouts and wall paintings are not possible during lockdowns, making it more difficult to reach households. At this juncture in an evolving pandemic, it is utopian to expect implementation of a Behaviour Change Communication model for health promotion. Hence a rapid IEC campaign developed through the process as described in outline in this report is the most pragmatic way forward for replication across geographies and situations.

Earlier, risk communication used to be viewed simplistically as the mere dissemination of information about health risks and events, and guidance on how to modify behaviours to mitigate those risks. Social science evidence and new communication and media technologies have brought about a paradigm shift in the practice of health risk communication. This is now recognized to be a two-way and multi-directional communication engagement with affected populations so that they can take informed decisions to protect themselves.[7]

Internationally, some countries have produced extensive online and paper resources for public education. These have been made easily accessible, for example in the United Kingdom, where leaflets were also sent to every household for public education. Peyravi et al.[8] describe a comprehensive process in Iran for developing an understanding of informational needs and implementing a program to address these. However their approach is very different from the alacrity with which our group needed to address the rapidly evolving situation in India. The modification of group consensus development techniques (e-Delphi)[4] allowed for the five key messages to be developed in a relatively short time frame, given the urgency of the situation. Once the message themes were finalized, further sub-content was appended, as distilled from current Govt of India/WHO guidance on community and individual level prevention. These were developed as part of a health communication plan, and modelled on Behaviour Change Communication messaging.[9]

The health risk communication activity packaged as the 5 Key Messages platform had “Each One to Reach Many and Teach Many” as its guiding philosophy. To reach out to the people, requires an engagement with the frontline workers of the healthcare system, i.e the AAA troika (ASHA – Anganwadi Worker– Auxiliary Nurse Midwife). During the training sessions it was emphasized to all the Trainers to reach out and optimally involve these community based healthcare workers. Interpersonal communication using handheld tablets for individual sessions, and reaching out on telephone to societal influencers or key persons, was incorporated into the guidance instructions. The emphasis of the training sessions was for individuals to be kept central to the initiative. The approach is outlined in Box 2.

The Individual Focused Framework.

The modern era is an age of instant communication and social messaging. WhatsApp, Facebook, TikTok, Twitter and a horde of other messaging and social media apps come either preloaded or can be easily downloaded on smartphones. The risks of propagation of unscientific information and opportunistic use of the crisis to spread harmful propaganda aimed at creating division and hatred also needs to be kept in perspective. Hence regular updates by the Government using television, social media and other methods of communication are essential. The public needs to be kept informed about various issues and the scientific rationale behind them, including but not limited to the biology of the disease and its evolving symptomatology, and actions required to be taken for prevention and control. In addition, a legal clampdown on those who generate or circulate ‘fake news’ and unscientific information is also essential.

The Government with its vast and impersonal machinery in a developing country has substantial challenges in reaching out to the grassroots community, through a rapid IEC campaign. In such a situation, NGOs and philanthropic agencies can be utilized to play a vital role, in reaching curated information to the people of the nation, such as the 5 Key Messages campaign. The professional communications team of the implementing philanthropic agency developed messaging content by involving local celebrities and public figures to ensure effective reach to the target audience(s), thus keeping the flavour local, with the content being universally applicable.

Due to the lockdown which was in effect across the country, the ‘in person’ community outreach action of the described campaign was restricted and low key, with most of the engagement being done through social media engagement and interpersonal communication through mobile phones. The Community Resource Persons have acted as ‘Change Agents’ and the ‘Network Effect’ has been optimally deployed to exponentially disseminate the key messages.

The COVID-19 pandemic has taught the world the importance of rapidly deployed and focused IEC campaigns. Campaigns such as the present 5 Key Messages for freedom from the coronavirus (‘Paanch Kadam, Corona Mukt Jeevan’ i.e Five Steps to a Corona free Life) with its focus on hand hygiene, respiratory etiquette and physical distancing require to be conceptualized, peer reviewed and launched within a short span of time to be effective and timely. These campaigns need to utilize all available and accessible forms of media, from mass media to social media, and by virtue of the requirement to be regionally relevant, have to have flexibility and a degree of autonomy. This can only be achieved by ‘keeping it simple’. Hence, while we are still grappling with the present pandemic, we must think about how to be better prepared to prevent or deal with the next pandemic by positioning information strategies and preparing for community resilience.

One of the major barriers for effective access to health care services is lack of credible information. Although every National Health Program has an integrated health education component, this remains one of the lower priority areas. At present, IEC for most programs is conducted at the District level through the frontline workers such as the ASHA, who accord low priority to these IEC activities as they are already overwhelmed by their other responsibilities and are often inadequately trained and oriented. Given the scenario of a constraint of resources in developing countries, regionally relevant mass education may be the best possible approach to disseminate IEC messages aimed at increasing knowledge, improving skills and influencing adoption of desired behaviour changes.

There is a ‘felt need’ to use innovative approaches to disseminate health related information in a manner appropriate for the community and culture of the region, via a community centric approach rather than the current health system centric approach. The present governmental focus to develop IEC materials in the form of posters, pamphlets, flip charts etc needs to be transformed in line with the changing sociocultural milieu and expanded to include harnessing the power of the social media. Political electoral success has been achieved in adapting to the ‘new normal’ of social media, so why not apply the same learning to conveying credible health information to the people?

There is significant overlap of IEC issues for multiple health programs such as those related to water, sanitation, and hygiene (WASH), diarrhoeas, vector-borne diseases, tuberculosis and, now, COVID-19. Most of them require promotion of personal hygiene, sanitation, healthy environment, physical distancing and hand hygiene. In view of this, there is a need for integration of the IEC components of all National Health Programs which would allow pooling and better utilization of existing human as well as material resources. However such personnel would need to be retrained through focused skill development and training courses which align with this proposed integrated approach for Health Promotion which would also align the country with the requirements of the Astana Declaration and the earlier Shanghai Declaration.[10,11]

• Wash your hands frequently!

• Follow respiratory etiquette

• Practice Social (physical) Distancing

• Believe only in “Correct” sources of information

• Early recognition and referral for fevers

Inform the individual about the key message themes in an easy to understand, locally contextual manner, with no technical details.

Motivate individuals to adopt the key behaviours being conveyed by focusing on the individual, his family and his community, and working on these subsets individually and collectively.

Guide into action, i.e show the individual how he can adopt the behaviours that he was informed about. It can be done through demonstration and explanation.