During outbreaks of infectious diseases, various measures are implemented. For instance, in the case of COVID-19, national lockdowns, physical distancing measures were introduced, creating unique challenges for community engagement. In this brief, we consider how community engagement can be adapted to suit restrictions. Hygiene promotion staff often play a key role in engaging and interacting with communities, so this brief is written with them in mind.
What is community engagement and how can it affect the work of organisations and governments during an outbreak?
Community engagement is a participatory process of communicating with, learning from and working with other people to find solutions for an issue affecting society.
During an outbreak, community engagement seeks to establish alliances around the common goal of protecting everyone to ensure:
The interventions adopted are practical and their social harms (such as disruptions to daily lives) are considered and mitigated;
Stakeholders take ownership of the interventions and work with the government in controlling the spread of the disease;
Disease control responses are effective and efficient.
For more information about the goals and principles of community engagement and risk communication and community engagement (RCCE), see Oxfam’s community engagement page, and an account from the International Rescue Committee, the 10-steps of RCCE from the Collective Service, and the Compendium of Hygiene Promotion in Emergencies. For an example of a disease-specific Risk Communication and Community Engagement (RCCE) Response Strategy, see the WHO’s policy brief on building trust through RCCE.
How is community engagement normally done?
To ensure information about the disease and response measures are discussed widely and to enable coordinated, community-level action on a large scale, community engagement initiatives typically pay close attention to:
Identifying community ‘gate-keepers’ or stakeholders to hold discussions with and through which information can be communicated;
The style of communication with each of the stakeholders and their communities;
The channels through which information is delivered and received.
Community engagement tends to work best when it is done on a continuous basis, through trusted authorities and in the form of a two-way dialogue, with at least some interactions done face-to-face. Each of these topics is discussed below.
1. Mapping the stakeholders to engage
The WHO and its partners emphasise that community engagement for an outbreak should build upon existing networks and past preparedness efforts. Public health authorities should identify and map the capacities of organisations, networks and stakeholders that can facilitate adoption of public health measures by the wider public. These efforts should be made at multiple levels, from national to local districts.
Stakeholders will differ according to the context, but may include local authorities, public and private institutions, community-based groups, as well as civil society organisations, such as faith-based organisations, advocacy networks, volunteer groups and organisations that fill gaps in essential state services and welfare provision (such as in informal urban settlements). Gaining a realistic understanding of existing socio-cultural and political structures and relationships is essential, to ensure that the stakeholders tasked with communicating and discussing information are trusted by local and diverse community members.
See the example below for a description of how stakeholders were identified in a region of Guinea during the West African Ebola outbreak.
Community engagement processes in the ethnic Kissi community of Guinea during the West African Ebola outbreak, as described by Wilkinson et al, 2017:
In ethnic Kissi regions of Guinea in 2014, Ebola response teams encountered distrust and resistance from local populations, which was contributing to an inability to control the spread of the Ebola virus. As a result, an anthropologist was asked to join the response to help understand and allay the tensions. One of her key findings was that the ‘community leaders’ whom various response teams had liaised with were considered illegitimate. Selection had been either through self-identification to teams, or assumed from their elite professional, civic or political associations which local people associated with abusive regimes. To identify more trustworthy individuals in the community whom response teams could work with, the anthropologist spent three days asking people who they would trust and nominate to speak on their behalf. From the long list of names collected, she identified 150 which came up frequently, spanning 26 villages. The list included: traditional practitioners, heads of the sacred forests, religious leaders (Christians and Muslims), circumcisers, village birth attendants, hunters, youth, returned migrants from the city, and elders. The response team held a workshop with these 150 people to discuss the response which ultimately lessened the resistance and initiated cooperation.
At each level and phase of engagement, special thought should also be given to how best to engage parts of the population who are at particular risk of the disease or who might be difficult to reach with information and services. This is because interventions may need to be adapted to meet different needs, capacities and levels of vulnerability of different stakeholder groups. For more information on groups who might be vulnerable to discrimination and exclusion, see our resources on older people and people with disabilities, gender, indigenous populations and minority groups.
Guidance for ensuring community engagement is inclusive of people who might be vulnerable to discrimination and exclusion, with examples of specific actions that can be taken, is available from the Regional Risk Communication and Community Engagement Working Group. Note that whilst the resource is specific to COVID-19, activities and principles can be applied to other disease responses.
2. Communication style and approach
During outbreaks, public health authorities prioritise sharing informative, life-saving and actionable information in real-time to enable stakeholders to design effective control strategies and to enable people at risk of disease to adopt protective health behaviours. Authorities also need to recognise how the quality of information they provide and the style through which public health messages are communicated can motivate or alienate stakeholders and the public and affect public health behaviours.
Behaviour change specialists have explained that this is because of the role information plays in promoting trust:
“people will cooperate to achieve common goals if they feel like they are part of a shared communal effort, and if they believe the people leading this effort are part of the same ‘community of circumstance’ and are acting legitimately on their behalf [...] If people feel that they are not given enough information to allow them to undertake these difficult actions, or that their agency, choice, or control over their lives is undermined, then their sense of cohesion with the leaders and organisations providing guidance will be compromised. As a result, public health directives are more likely to be resented and inadequately applied or even ignored.”
In the table below, they recommend key communication strategies that can enhance community engagement. This includes transparency, continuous interaction, practicality and respect for difference:
Table 1. Communication strategies to enhance community engagement and cooperation. Source: Yardley et al (2020)
Though advice needs to be tailored for different contexts, the principles of communicating about disease control should be consistent and coordinated. People have a greater level of trust in consistent information which they see featured in multiple sources or channels, whatever these may be. However, the same is true of misinformation, which can gain traction and credibility as it circulates. For information on identifying and addressing false information, see these resources by the Social Science in Humanitarian Action Platform and the CDAC Network.
Care should also be taken to ensure information is communicated in the languages preferred by different parts of the population.
An effective way to ensure that information is responsive to people’s needs and concerns is by listening to and collecting feedback on the information that is disseminated, so that it can be tailored to meet community needs, which may change over time.
3. Channels of communication
To be effective, we know that community action and behaviour change programmes need to interact with populations on multiple occasions, over an extended period of time. This is because populations have a range of other priorities, behaviour change takes time and populations may only be motivated to act after hearing and comprehending messages numerous times and through a range of sources. Read more about the principles of behaviour change here and here. Public health authorities also need to reach multiple parts of a population. For all of these reasons, public health campaigns tend to adopt multiple channels of communication.
In the public health response to Ebola in the Democratic Republic of Congo (DRC) in 2018, community engagement happened through the following channels:
The media: Including mass media (such as news, radio and journalists), social media (Facebook, WhatsApp), and traditional media (mobile community theatre)
Influencers: Mainly authorities and community representatives, including elders
Community networks: Face-to-face communication by existing organisations to their members through small group and community-wide meetings, house-to-house visits, and discussions following theatre and video projections in public spaces.
When selecting delivery channels for community engagement, consider the following:
Reach: Which delivery channels are available to the majority of people within your population? If you are considering using mass media, you might also want to pay attention to which stations people tune into and at what times. If you are working in an area where people have access to social media and the internet, find out the websites and social media sites that are most commonly used and trusted, and how they are used within the culture.
Accessibility: While overall reach is important, it is necessary to also consider which delivery channels are most appropriate for different sections of the population. Women and girls, older people, people with disabilities, people living in rural areas, and other vulnerable marginalised groups, are all likely to be harder to reach through most delivery channels. To overcome these challenges, it may be necessary to actively engage these populations to identify their preferences and tailor materials to their needs. For an example of COVID-19 RCCE resources, see this document from UNICEF which provides guidance on RCCE for people with disabilities and this document from IFRC which provides guidance on engaging and communicating with older people.
Trustworthiness: Which communication channels or individuals do people trust, respect or find influential? Exploring this with communities may challenge common assumptions about what constitutes reliable public health information. For example, a recent study among Rohingya refugees living in Bangladesh found that trusted sources of information during outbreaks included trained community leaders, such as imams and women’s group leaders. Information from these sources was preferred over health and aid workers who are not always seen as trustworthy and are sometimes misunderstood. Refugees also trusted members of the Rohingya diaspora rather than public health information shared by local news services as Bangladeshi and Burmese news services were seen to stigmatise refugees and even legitimise violence against them. Community leaders were also engaged in this case study from the COVID-19 response in Indonesia.
Ability to promote two-way interaction: During outbreaks, populations are often curious to learn more about the disease and, understandably, are likely to have lots of questions in relation to the information they receive. When information is shared in a didactic manner that does not encourage questioning or two-way discussion, it can be met with resentment. This is one of the key advantages of house-to-house visits - participants can ask hygiene promoters questions, raise concerns and devise solutions on the spot. However, many other delivery channels offer opportunities to create discussion and to provide feedback on the response to authorities. The CDAC network offers useful guidance on mechanisms to seek feedback from communities and address complaints. Based on learning from the West African Ebola epidemic, community feedback to Ebola interventions in DRC were actively monitored and characterised in terms of community receptivity, reluctance, refusal or resistance, so that strategies could be adjusted accordingly. For an example of effective two-way interaction, see this case study on BBC Media Action’s work in Somalia. The organisation used a diverse range of methods to co-produce public service announcements which were delivered via radio, TV and social media, as well as launching a mentoring programme for journalists and radio producers. Crucially, BBC Media Action and partner radio stations gathered feedback through social media and call-ins, shaping content.
Remember that in many locations, information about appropriate delivery channels already exists. Make sure to utilise these existing resources. Here is an example of a document mapping delivery channel preferences in Lebanon.
In what ways does community engagement need to be adapted for a disease outbreak response?
“the organisational challenge of epidemic control is always intensive [...] Community engagement is usually done painstakingly and in person [...to balance the need] to do things fast and at scale while also ensuring control measures are contextually appropriate.” Source: Annie Wilkinson
As indicated in the above description of community engagement, face-to-face communication with stakeholders and the public is typically a large part of the intensive and painstaking work done to bring epidemics under control. However, physical distancing requirements associated with some outbreaks, such as COVID-19 or Ebola, means that many of the interactions that would normally happen in person now need to be minimised. Below we outline some general principles for community engagement during outbreaks.
Develop a phased approach to your response. During the early stages of the outbreak, and as cases decline, it might be possible to do some in person activities, such as house-to-house visits or work within small neighbourhood groups (where physical distancing can be maintained). In many countries, these one-to-one interactions are highly valued and seen as the preferred mode of communication by communities. However, at the peak of the outbreak, these in-person interactions may need to cease to protect staff and communities. We suggest developing a staged approach to your programme according to the WHO response levels. This would require making plans for how you would adapt your programme at different stages of the response.
Avoid all large group gatherings. Depending on the transmission route, hygiene promotion and community engagement activities should not include bringing together large groups of people.
Encourage staff to lead by example. See our article about measures that hygiene promoters can take in order to maintain physical distancing.
Build community networks. Once key local stakeholders and trusted individuals have been identified, find ways of establishing communication networks with these people should in-person communication become infeasible. Make sure to use the ‘window of opportunity’ before the outbreak becomes too serious to establish these networks.
Continue to learn from communities and adapt to their needs. Formative research and opportunities to learn from communities about their needs and priorities is recognised as being a key part of good programming. This process will now be more challenging to conduct during outbreaks but is no less critical.
Develop or support local action plans. Globally we have seen communities mobilise to support each other during disease outbreaks, such as the COVID-19 pandemic. Find ways that your organisation can encourage and support community level action.
Actively seek out the voices of groups who might be vulnerable to exclusion and discrimination. These groups may be particularly hard to reach at this time. In particular, working with older people, either in leadership positions or as experienced elders, will be challenging as they could experience severe complications of disease if the disease is transmitted to them during community engagement activities. Separate and more intensive initiatives may need to be implemented to include these groups.
Invest in training frontline staff. Hygiene promoter roles and other roles which require a high degree of community engagement also require diverse skills and sufficient training. Hygiene promoters should be trained on the focal disease and be given a list of common questions and answers they are likely to encounter. This list should be updated to reflect emerging concerns. Hygiene promoters should also know what is within the responsibilities of their role and what is beyond it. For example, as non-medical professionals, they should not make medical judgements or speak about topics that they are unsure of, but rather should refer people to appropriate health services or other information sources as needed. In this case study from Yemen, community outreach members were trained to deliver health promotion activities during the COVID-19 response.
Ensure messaging is coordinated. To avoid creating confusion or conflicting messaging, ensure messages that your organisation adopts are in line with the broad principles being disseminated by national governments and/or the WHO.
Practical ideas for engaging communities at a safe distance
In this section we share some examples of innovative ways that organisations have done community engagement during recent outbreaks. Note that whilst the majority of examples relate to COVID-19, principles and activities can be applied to other disease responses.
Learning from communities:
Conduct rapid assessments to understand perceptions and behaviours. Formative research is an important first step in designing outbreak control programmes that are acceptable and effective. Often the pressure and constraints of delivering programmes in outbreaks means that this step is omitted or compromised, resulting in programmes that may not be well accepted. Conducting assessments of behaviours and perceptions does not need to be time consuming. The WHO have developed a simple rapid assessment survey for COVID-19 which can be done in person or over the phone. The Wash’Em Rapid Assessments Tools are qualitative tools designed for use in outbreaks to understand hygiene behaviours and design appropriate hand hygiene interventions.
Review and/or map communication and information chains. In many communities there will be individuals with a mobile phone or a radio – they could become key information providers when physical access becomes limited. Remember to assess who has access to what information and how trusted they are, especially by groups who are more vulnerable to discrimination and exclusion.
Share all insights about community perceptions to allow for programme improvement across the sector. If each organisation establishes independent learning and accountability mechanisms, this can create confusion. In Afghanistan, BBC Media Action conducted 300 telephone interviews with the general population each month, to understand community needs and barriers, as well as perceptions around COVID-19. This feedback was translated into monthly ‘Community Voice’ reports which were shared with local actors, particularly humanitarian workers. The findings also shaped the content of weekly radio programmes.
Set up mechanisms to continue to learn from populations over time. Perceptions are likely to change over the course of the outbreak, so it’s important to identify ways of continuing to learn from populations over time. For example, during the Ebola outbreak in DRC, Oxfam tested a Community Perception Tracker (CPT). This involved Oxfam’s teams using mobile devices to systematically record timely qualitative information on perceptions, fears, questions and concerns that people had. This information was regularly analysed alongside epidemiological data and provided key trends across different locations, age and gender groups. Programme teams used these trends to adapt their activities according to needs and preferences of affected communities. The data was also shared with external coordination platforms to advocate for the inclusion of people’s voices. The CPT mechanism was also employed during the COVID-19 pandemic in Venezuela, to gain an understanding of communities insights and concerns. Feedback highlighted that returnees were experiencing social discrimination and Oxfam was able to respond with community interventions to promote inclusion. The tool also proved effective during the COVID-19 response in Zimbabwe by ACF and in Lebanon by Oxfam.
Involve local community stakeholders in decision-making and message creation. Invite local community stakeholders, such as small business holders, public transport representatives and WASH service providers to join national and district response teams, to ensure their perspectives are reflected in decisions that are made and messages that are adopted.
Community perception tracker. Source: Oxfam
Using communication channels creatively:
Radio call-in shows allowing communities to connect with local experts. Radio also has the ability to create the impression of a large shared community. Call-in shows can help break down barriers across geographies and between different levels of society. Some examples of how radio is being used creatively at this time are available here. UNHCR has developed this useful resource for creative radio-based communication.
Radio dramas incorporating COVID 19 messages. Radio dramas, when developed locally and creatively, can be a powerful way of changing behaviours during an epidemic through narratives that local communities can relate to. In Rwanda, Wateraid has been developing a radio drama which has now been adapted to incorporate coronavirus messages. While in many settings, in-person communal listening groups are often used to help people digest and discuss radio content, such gatherings would need to be reduced or suspended during the COVID-19 outbreak.
Telephone call centres and hotlines. IFRC has developed some practical guidance on setting up phone hotlines including examples from how this was used in Sierra Leone during the Ebola outbreak. ACF are currently running phone hotlines in Jordan and Iraq with staff members sharing information and learning from communities. The safety of these communication channels can be improved if staff and guests can avoid having to travel to recording studios and call centres, with as much work as possible done from their homes or at a safe distance from others.
Image above: A slide from an IFRC training course on COVID-19 risk communication and community engagement (RCCE) – showing how their programmes are being adapted. Source: IFRC
Image above: An ACF staff member in Iraq makes calls to past and present program participants to share messages about COVID-19. Calls are made from home to minimise risk to staff. Source: ACF
SMS, voice-based messages and chat services. During the outbreaks, many organisations make use of voice or SMS based information sharing services. There are also ways of making these services more interactive. For instance, UNHCR has developed guidance on key things to consider for two-way SMS services and chatbots. This webinar about a study during a cholera outbreak in Bangladesh demonstrated that messaging can be a very effective way of changing behaviour during outbreaks. Viamo also provided a range of creative mobile phone based technologies to address COVID-19. For example, in Nepal they encouraged people to record their own stories and experiences and share them on hotlines. In Burkina Faso, they facilitated a poetry slam about COVID-19. They also worked with Wanji Games to provide interactive audio games that are appropriate in areas where people do not have smartphones. The WHO also operates a WhatsApp system to respond to categories of common questions on COVID-19 through private messages.
Involve respected local leaders, local artists and celebrities in information sharing. In some settings, engaging celebrities that people already relate to and identify with, can be a powerful way of promoting action. Having artists work together to create entertaining but informative songs or jingles can work well to unify a campaign message. Here are some examples of this being done in Zambia, Bangladesh and Ghana. Similarly, in many cultures, religious leaders are looked to in times of uncertainty and are likely to be influential in outbreaks. Engaging Imams, priests and other religious leaders can be important during outbreaks too; for instance, faith-based organisations have played multiple roles in the response to COVID-19. For example, religious organisations have been asked to examine how they can implement physical distancing measures in their activities such as by reducing in-person religious gatherings, responding to the social, spiritual and safety needs of their members that may be impacted by disease control measures, and presenting information about COVID-19 in the context of shared values and honoured traditions.
Community support networks. In many countries, communities organise to support each other during an outbreak. For example, in the United Kingdom, UK Mutual Aid helped to coordinate and support the establishment of thousands of local volunteer groups to support older people, other groups who might be vulnerable to exclusion and discrimination and those who are self-isolating by delivering food and connecting people to a range of services during the COVID-19 crisis. Their website has a range of resources to support the establishment of these kinds of groups in other settings. In some settings, a ‘traffic light’ system, involving placing coloured cards in windows can be used to communicate when people are in need of support – again, this idea is simple to replicate in low and middle income settings. In South Sudan, the UNHCR mobilised secondary school students in their scholarship programme to work with community health workers and leaders to safely disseminate COVID-19 messages door-to-door in refugee camps. Social messaging services like WhatsApp can be a great way to connect community groups. Some international organisations such as World Vision International use online training courses to equip their outreach workers worldwide to share COVID-19 information. Upon graduation, these people are added to very large organisational WhatsApp networks to receive new messages and circulate them among their communities.
Disease outbreak information in a range of accessible formats. WaterAid created materials which incorporate sign language to ensure people with hearing impairments are not missing out on key information.
Additional resources on Community Engagement
Tips for engaging populations in low resource settings – A co-created and dynamic document sharing general principles and case studies from a range of settings.
Community Engagement Hub hosted by British Red Cross – which provides a detailed number of guides, tools, and training materials focused on community engagement.
Oxfam’s An Introduction to Community Engagement in WASH – provides an overview of what community engagement is, the guiding principles in WASH and measurement of CE.
Oxfam’s guide for frontline staff – Full of simple ideas for hygiene promoters and other community-facing staff to use during their day to day activities at this time.
Social Science in Action – Lessons learned from 2014-2016 Ebola Outbreak in Guinea: A review of RCCE related publications – this summary is structured across 6 response pillars: a) contact tracing, b) Ebola treatment centres, c) safe and dignified burials, d) vaccination, e) infection prevention and control, and f) risk communication/community engagement.
GOAL’s guide on facilitating Community-led Action - This is an adapted guide for COVD-19 response explaining a step-by-step process for community mobilisers.
Holding the line: communities as first responders to COVID-19 and emerging health threats – UNAIDs report highlighting the role of community-led organisations in the COVID-19 response.
Community Engagement at a Distance – A guidance note from BBC Media Action explaining how programmes can be adapted to continue to engage people during COVID-19 response.
RCCE Action Plan Guidance – Developed by IFRC, WHO and UNICEF, this document provides general guidance for developing a risk communication and community engagement strategy with a simple template to follow.
Collective Communication and Community Engagement in Humanitarian Action – General guidance on engaging communities during crises.
Community Engagement Hub – A collection of resources from IFRC covering effective use of different delivery channels, accountability to populations and ways of assessing perceptions.
RCCE Toolkit – includes links to a range of resources for developing and implementing RCCE work.
UNICEF’s RCCE Guidance – Provides an overview of key principles with links to other useful resources.
Guidance on accountability to populations – Guidance from UNICEF about suggested ways of establishing accountability mechanisms to allow communities to provide feedback on COVID-19 response programmes.
Community Engagement in WASH Emergencies: Understanding barriers and enablers based on action research from Bangladesh and the Democratic Republic of Congo (DRC) – presents findings from building trust in emergencies and the enablers/barriers to meaningful community engagement.
Compendium of Hygiene Promotion in Emergencies – Comprehensive guideline developed by The German WASH Network, IFRC, Global WASH Cluster and Sustainable Sanitation Alliance and published in 2022.
WHO COVID-19 policy brief: Building trust through risk communication and community engagement – Provides key advice from the WHO, along with useful resource
Hygiene Hub case study from Uganda – Reflects on the experience of taking a collaborative approach to learning about RCCE with refugees and host communities.