Delivery channels are the means by which organisations can reach, engage and inform people within communities. Disease outbreaks force response actors to think differently about the way information is communicated and how programs are delivered, especially since in-person programming is not always safe and appropriate. Behaviour change projects for infectious disease prevention need to be designed with appropriate behavioural techniques and delivery channels and this will depend on the characteristics of your population and the particular setting or context where your organisation is working. It is very likely that multiple delivery channels will be needed to reach the entire population. While it is important to think carefully about the selection of delivery channels, it is even more important to dedicate time and energy to thinking through the content that will be delivered via the chosen delivery channels – it is this content that is key for changing behaviour. This resource from the World Health Organization (WHO) provides a framework for delivering effective communications and this resource provides advice on engaging populations in low resource settings. Note that whilst the latter is focused on COVID-19, principles and activities can be applied to other diseases.

One of the key decisions organisations must make is whether to use in-person communication or remote delivery channels. Consider the following when making this decision:

There are three main types of delivery channels that can be utilized for communication: mass media, digital communication, and interpersonal communication. Within these main types of delivery channels, there are multiple ways that information can be disseminated. Mass media campaigns utilize mediums such as radio and television, to reach large numbers of people in a short period of time. Digital communications rely on the use of electronic means to relay information through platforms, such as social media, group chats and phone messaging. Interpersonal communications can take place in the form of household-level visits and are likely to have a much smaller reach than the other types of delivery channels.

When utilising mass media or other technology-based formats, consider how the following points may influence the effectiveness of your programme:

To overcome some of these limitations mentioned above, it's useful to always utilise more than one delivery channel. For example, the Phillipine Department of Health created a multimedia behaviour change campaign called BIDA Solusyon (Be The Solution) that includes radio commercials, television commercials and social media outreach on Facebook. By combining these three mediums, they are more likely to reach more of the population. See this BBC Media Action Somalia case study for another example of effective communication via multiple delivery channels for the COVID-19 response.

The table below shows the benefits and limitations of the various types of delivery channels that can be used to reach people at a community level. Each of these are discussed in more detail in the subsequent sections.

Radio can be used to communicate in many different ways, including via radio dramas, public service announcements, panel discussions, call-in discussions, competitions, news content, feature pieces, or story-telling. Radio is typically more cost-effective than other mass media options (e.g. much cheaper than TV) and is often more widely accessible in LMIC settings.

Other benefits of radio are that it allows for some two-way interaction (e.g. with people calling in to express their opinions), it is often regarded as a legitimate source of information, it allows for standardised messaging (e.g. recorded content can be aired multiple times with no compromise on quality of delivery) and can be used to reach remote populations. In some cases, key messages are communicated within communities via ‘miking,’ by using loudspeakers on tuk tuks or vehicles to reach parts of the population that may not receive important information otherwise.

Because radio content is typically broadcast to a large region or across the nation, this limits the ability to tailor content to specific audiences or contexts. In most countries there are multiple radio stations of varying popularity across the country, meaning that your organisation may have to work with multiple radio stations to achieve sufficient reach.

Similar to radio, television can be used to deliver content in a variety of ways. This may include content delivered as TV dramas, public service announcements, panel discussions, news content, feature pieces, and commercials. Television is usually seen as a legitimate source of information and its content is typically more believable because it combines video and audio content. The mix of audio and video allows television broadcasts to be used more creatively than other media formats and longer-format content is possible because people typically watch TV for extended periods of time.

Some of the drawbacks of using television are that it limits the opportunity for community dialogue (except through pre-recorded interviews and events), it is expensive, and it has a limited reach in many countries, especially in low income settings. Similar to radio, there is a limited ability to tailor TV content to specific audiences or contexts, access to televisions varies a lot by country, geography and wealth, and your organisation may need to work with multiple television stations to achieve sufficient reach.

Social media are web-based or application-based platforms that allow their users to create and share content, leading to the development of social networks. Some examples of social media networks are Facebook, Twitter, Instagram, YouTube, TikTok, Snapchat,LinkedIn and video conferencing programmes, such as Zoom. The strengths of using social media as a delivery channel is that it is cheap, it can allow for a two-way dialogue (e.g. via comments and likes), it is easy to track and reach engagement (especially with the use of social media analytics, hashtags and the number of views), and it allows for different types of content (i.e. photos, articles, videos). Studies have shown that platforms like YouTube have a huge potential to reach and engage people during outbreaks. In this study, a Dutch social media influencer collaborated with a national paper to launch a campaign on YouTube, where he interviewed a renowned virologist on the importance of COVID-19 preventive behaviours.

This case study from Kenya utilised a range of social media platforms, including Facebook, Instagram and Twitter. YouTube was used to disseminate a video of well-known stars teaching people how to correctly wash their hands and promoting a UNICEF platform, in order to tackle ebola and cholera. Video conferencing programmes, such as Zoom and Google Meet, are also instrumental during infectious disease outbreaks, providing a platform for delivering remote activities. For instance, this intervention study in Jordan delivered virtual coaching sessions on handwashing and mask use over Zoom.

The challenges of using social media are that it can be difficult to regulate or moderate and it may only be useful in reaching certain parts of the population (such as people who have access to the internet or smart phones, suggesting it may not be a good option for the rural population, especially in low income settings).

Online group chats are platforms by which groups of people can exchange messages with one another. Some examples of group chats are WhatsApp, GroupMe and Facebook messenger. Online groups are great for two-way information sharing, they are useful for communicating within an established social network and are quite highly trusted by users since the information comes from people they know. Online group chats can be leveraged by implementers and health care workers as a platform for communities to share best practices and keep up to date about rapidly changing information and regulations.

The down sides of using group chats are that it is very difficult to regulate and moderate, it is not possible to track how information is shared, it is difficult to distinguish between your content and other misinformation and that existing groups are normally closed to other users.

Here is some information on how to send information to several contacts in WhatsApp. The WHO partnered with WhatsApp to communicate news and information about COVID-19 in multiple languages on a large scale where users could opt-in to receive messages. Facebook allows you to send private messages and automated responses through Facebook Pages. During previous outbreaks, such as the Ebola outbreak in West Africa, the BBC used WhatsApp as an effective way of sharing information. In early 2020 during the COVID-19 pandemic, the community of Bergamo in Italy launched ‘Superbergamo’, an initiative where volunteers delivered medicine and food to clinically vulnerable populations, with WhatsApp and Facebook groups being central to coordination.

Phone messaging can be used in a variety of ways to deliver outbreak related messages to mobile phones. You can send short text messages via short message service (SMS) or text messages with multimedia content via multimedia messaging service (MMS). Interactive voice response (IVR) is a type of technology that allows users to interact with a computer-operated system through voice or the use of the keypad, and audio messages can be delivered to mobile devices as calls.

Phone messaging can be delivered via a number of modalities. For example, your organisation could partner with a mobile phone provider to disseminate messages in bulk, alternatively you could take a more organisation-led approach by sending messages to a known list of contacts from prior programming. Phone messages are a relatively cheap way of reaching a lot of people and it is relatively easy to send multiple messages over a period of time, allowing for repeated engagement.

However, if people did not actively sign up to receive the messages, or if they are sent too frequently, people can easily find them annoying, uninteresting and may not even open the messages. Most phone messaging is relatively one-way, however IVR and other techniques can enable more dynamic engagement.

There are also equity issues with using mobile phone messaging, since access to phones can vary by geography, gender and age. Text messages are likely to be less effective in areas with low literacy and it can be challenging to convey more detailed or nuanced information by text or short audio messages. In some low income settings, people may have to pay to receive messages and if so, they may be reluctant to do so given the widespread economic impacts that disease outbreaks can have.

Alternatively, mobile applications could be employed; for instance, in this case study from Kenya, Amref launched an app to enable remote training of community health volunteers to aid COVID-19 prevention.

Using household-level visits as a delivery channel involves staff (such as frontline hygiene promotion staff) travelling to each household to share information, have discussions, or undertake behaviour change activities. You should decide on whether this method is appropriate for your context based on the extent of community-level transmission, government guidelines and your organisation’s risk assessment. All in-person work involves higher levels of risk than mass media or other remote ways of communicating with your population. If you choose to utilize household-level visits, it is important to make sure appropriate safety measures are put in place. The changing dynamic of infectious disease outbreaks may mean that even if house-to-house visits are safe to do now, they may become unsafe later, so it is best for them to be combined with other delivery channels. For instance, in this case study in Colombia, digital media was employed whilst cases were primarily in urban settings and radio was used in rural settings. They also used interpersonal communication to collaborate with indigenous community leaders.

The benefits of household-level visits are that they can be personalised to the household and are often more engaging. More than any other mode of communication, it enables proper dialogue and can be easily changed or adapted at minimal cost. Typically, in-person visits allow organisations to address a broader range of determinants of behaviour (e.g. you can help families make changes to their physical environment so that behaviours are enabled).

The effectiveness and quality of in-person interactions are very dependent on the capacity of staff. Good interpersonal programming therefore requires lots of training and ongoing support which can be time consuming. In-person work during outbreaks is likely to be most effective and feasible if it focuses on particular regions or populations that are likely to be at high risk or who are particularly hard to reach, as it is not normally feasible at national level.

Key stakeholders are people, groups or organizations within a community that have some influence, are normally involved in information sharing, or who come in contact with many other people (e.g. village leaders, religious leaders, bus drivers, health workers, school teachers, celebrities). These key stakeholders are always important to engage in your programming, however key stakeholders can also be trained to become frontline COVID-19 prevention actors. Key stakeholders may also contribute to the work you are doing through other delivery channels.

The benefits of working with key stakeholders are similar to doing in-person work in general – they can be personalised and engaging, they enable proper dialogue, and can be easily changed or adapted. During outbreaks, there are several other key benefits of working with key stakeholders to deliver prevention programmes. In contexts with movement restrictions, working with community-level actors is much safer than getting staff from an organisation to travel to and from communities on a daily basis. Engagement at the community-level through the use of key stakeholders can also target populations that may otherwise not be reached by other delivery channels. For example, WaterAid Pakistan used female community resource persons (CRPs) to conduct household visits in rural communities to ensure information reached women during the COVID-19 pandemic. If selected well, key-stakeholders are likely to be known and trusted voices in the community, and they are likely to be similar to the target population and therefore seem more legitimate or better able to speak to their circumstances. For this reason, engaging these individuals can be particularly useful in trying to establish new social norms around preventative behaviours. Working via key stakeholders may also enable two-way learning and the collaborative improvement of programmes, this in turn may contribute to building longer-term capacity and resilience within communities.

Working via key stakeholders is not always easy. It can be difficult and time-consuming to identify appropriate individuals to deliver your message, to establish these partnerships, and to encourage people to undertake prevention work among their other priorities/responsibilities. It can also be challenging to provide quality control and support for their work if this is being done remotely.

The WHO has recommendations on how to work with religious leaders and faith-based communities to promote COVID-19 prevention behaviours. This example from World Vision in Afghanistan shows this in practice. In Sudan, a network of thousands of youth volunteers (previously primarily working on sexual and reproductive health) have been mobilised to conduct household level visits around COVID-19. There are also multiple global examples of celebrities becoming engaged in COVID-19 prevention work. For example, the Indian government decided to use a famous Bollywood actor to promote their messages, while the Tanzanian Government utilised government representatives and music stars to help convey COVID-19 information. Note that whilst the guidelines and examples are related to COVID-19, principles and activities can be applied to other disease responses.

Author: Anika Jain

Review: Katie Greenland, Lara Kontos and Kondwani Chidziwisano
Version date: 23.09.20

​