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:
What aspects of behaviour are you trying to change? - Before deciding on delivery channels, make sure that you have taken time to understand current behaviour and barriers to adopting preventative actions. Develop a ‘theory of change’ which outlines the specific aspects of behaviour that your programme hopes to change and how. Getting this clear will allow your organisation to determine whether your programme needs to be delivered in-person or remotely. However, it is also important to take into account local rules/preventive behaviours for your focal disease. For instance, if you are dealing with COVID-19, you would need to consider rules for gathering, physical distancing, and lock-downs.
Who are the population that you will be targeting and what are their needs, and preferences for information delivery - Define who your target participants are and where they are located. If you are targeting a large population or area, it may not be feasible to conduct household visits. Also consider the communication preferences of your population. For example, in some settings, populations may not want organisation staff to visit their household during outbreaks, whereas in other settings these may be necessary to build trust.
Consider language, literacy, and inclusivity - If you are living in a country where people speak a range of languages, this may make certain modes of programme delivery more challenging, time consuming and costly. Similarly, if a large proportion of your population have limited literacy, then this may preclude some communication approaches. In this case, you can consider using mostly images and simple text in your communication. Also consider using sign language interpreters for those who are deaf. It is also important to have messaging that is inclusive of older populations and people with disabilities, as well as minority and indigenous groups.
Access to technology - Many remote delivery channels rely on people having mobile devices or technologies. However, some households may not have access to mobile devices, computers, televisions, or radios, or the technology may not be equally accessible to everyone in the household. Consider whether your target population can be equitably reached through the delivery channel you intend to use, and if not, think about how you will reach those who may be excluded.
Cost - The delivery channels that rely on technology are typically cheaper for the number of people they are able to reach. When calculating the cost of conducting household visits, the cost of travel, training, and the amount of time that will be spent by going to each household will need to be considered. However, below we outline a few reasons why remote delivery channels may be less effective than in-person interactions.
Strengths and limitations of the three major delivery channels
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:
It’s harder to get people’s attention - Forms of non-personal communication like TV, radio or social media may not grab the full attention of audiences in the same way that in-person interactions do. To overcome this, try to think about how your content can stand out and be surprising. Try to maximise the opportunity for exposure by repeating messages as frequently as possible at different times of the day.
It may be harder for people to recall messages at critical moments - If working with mass media, it might be worth noting that there is normally a time gap between when people are exposed to the message and when they have the opportunity to practice the preventative behaviour. This time-gap means that behaviours may be easier to forget. To overcome this, keep messages simple and repeat them often.
Generic messages may be less persuasive - The use of mass media often requires you to broadcast messages to a whole region or nation in a standardised way. Standardised messaging can be seen as less interesting and persuasive as it may seem less relevant to a particular individual’s circumstances or context. To overcome this, try to share the stories of individuals and make content aspirational as well as practical. Additionally, use previous learning or formative research from your region to make the messaging context-specific.
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.
Source: BIDA Solusyon Facebook Page
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.
Mass media in general
Mass media in general
Digital communication in general
Online Group Chats
Online Group Chats
Interpersonal communication in general
Interpersonal communication in general
Table outlining the benefits and limitations of the three major delivery channels.
Source: Anika Jain
What should be considered when using mass media to communicate about outbreaks?
Radio as a delivery channel
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.
Here are some tips and considerations if using radio as a delivery channel:
Station mapping - Before beginning radio-based work, take time to understand radio station preferences in the country or region where you work so you can maximise your coverage. Ask about which stations are most listened to (in some cases this information may be publicly available), the times of the day when people normally tune in (probe on the age and gender of listeners), and people’s favourite radio personalities.
Try to incorporate a range of ‘voices’ - Challenging misinformation and getting people to adhere to preventative behaviours requires us to draw on a range of influential individuals. This may include public health experts, government leaders, local leaders, people who have had the focal disease and can draw on their direct experience, and people who have successfully adopted preventative actions despite contextual challenges. For example, in Nigeria, COVID-19 prevention messages were recorded by religious leaders from various regions and in Zambia, WaterAid created an online interactive radio report which allowed people to listen to how a community activist and community nurse are working to promote good hygiene to prevent COVID-19. Also consider bringing in people with disabilities or those from marginalised communities, to understand how they are being affected by the focal disease and how they perceive the virus.
Think of ways to engage listeners and make radio more participative - Radio does not have to be a one way mode of information sharing. Try to use a mix of the formats mentioned above to keep content interesting and dynamic. Call-in shows can be particularly engaging, however if you are planning a call-in session, it’s important to have people who are able to answer people’s questions and challenge misinformation. In Rwanda, WaterAid worked with school children to develop radio dramas which reflect their local experiences during the COVID-19 outbreak. In Burkina Faso, Development Media International worked to develop catchy radio spots by first conducting surveys among the local population to target COVID-19. During the West African ebola crisis, BBC Media Action aired a radio drama called Mr Plan, which built listeners confidence and capacity to respond to the outbreak. Radio was also key in reducing childhood diarrhoea in Ethiopia.
Partner with and develop the capacity of local radio stations - You may need to conduct some initial advocacy and capacity building work to help radio stations understand the critical role they play within the COVID-19 response. For example, the WHO trained radio presenters in Burkina Faso on effective communication practices during the COVID-19 pandemic. BBC Media Action partnered with a volunteer-led radio station in Kenya to air PSAs during a cholera outbreak. This webinar provides an overview of the media’s critical role during the COVID-19 pandemic and BBC Media Action have also developed this guide for effective reporting and media use. Note that whilst the aforementioned guidelines are COVID-19 specific, principles and activities can be applied to responses to other outbreaks.
Television as a delivery channel
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.
Here are some tips and considerations if using television as a delivery channel:
Many considerations for TV are similar to those of radio – it is worth conducting a mapping exercise to understand TV audiences and television show preferences. It is worth incorporating COVID-19 content into a range of formats from news and TV dramas, to reality TV shows and children’s animations. TV affords the opportunity to show audiences how to practice COVID-19 preventative behaviours in settings that mirror their own. For example, in Zambia John Snow Inc, developed a mini-series that depicts realistic scenarios of people applying COVID-19 preventative behaviours, despite the challenges this presents in their context. In Nigeria, the government decided to share stories of COVID-19 cases at the early stage of the pandemic, to help convey that COVID-19 is real and can affect all Nigerians. In 2022, USAID and UNICEF partnered with an Indian film maker to launch an “edutainment” TV series which weaves in messages around vaccine promotion and appropriate preventive behaviours post-pandemic and is aired on a national in India. In this case study from Kenya, puppet edutainment programmes were disseminated via TV and radio, to inform children about COVID-19 and in Kyrgyz Republic, the World Bank launched a national communication campaign, which included airing a clip of children washing their hands correctly several times a day. Whilst these examples relate to COVID-19. TV has also been an effective channel for other health challenges, such as cholera and fecal sludge management, wherein BBC Media Action launched a TV drama series to promote correct behaviours.
Source: Hygiene Hub
Social media as a delivery channel
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).
Here are some tips and considerations if using social media as a delivery channel:
Develop content that can be delivered in a range of formats - Try to develop posts that utilise questions or polls, photos, graphics, and videos. As an example, Pan American Health Organization (PAHO) developed a multitude of social media cards with clear messages and graphics on a variety of COVID-19 topics.
Staff social media initiatives sufficiently - Make sure to allocate sufficient staff to your social media work to ensure that your organization can properly interact and respond to your target audience. This may include moderating and removing offensive or inaccurate content.
Develop a plan for engaging people in your content - At a relatively low cost, some social media platforms provide the opportunity to do paid or promoted posts. These can be useful for reaching large audiences. However, there are other ways of grabbing people’s attention on social media. For example, WaterAid Eswatini engaged a local comedy troupe to share COVID-19 prevention messages. The comedy element of videos like this helped to draw more people to their COVID-19 content. UNICEF also run their Goodwill Ambassador Campaign where they share social media content of celebrities supporting various causes, such as cholera.
Differentiate your posts from misinformation - Many rumours or misinformation often start on social media. It's important to think about how your content may be perceived and to actively differentiate your posts from other misinformation shared on social media. This might include stating the source of where information comes from, using consistent colours or branding, including multiple perspectives and opinions, fact-checking and correcting common misunderstandings and depicting situations which reflect the local situation. A study conducted during the COVID-19 pandemic also showed that if you remind people to think critically about the information they are receiving then they will be more likely to distinguish between accurate and fake information.
Make social media sharing participatory - Think of ways that your population can create and share content based on their experiences of outbreaks. For example, the WHO began a #SafeHands Challenge on social media during the COVID-19 pandemic. This encouraged people to record videos of them washing their hands. Strategies like this are effective because they help to normalise and celebrate preventative behaviours. The Vietnamese Health Ministry created a COVID-19 video and song recommending proper hygiene behaviours and limiting contact with crowds. This song and its messaging also became part of a popular TikTok handwashing dance challenge. Similar approaches have been taken for other public health challenges, for instance, UNICEF launched a #VaccinesWork campaign in 2019 to address hesitancy towards childhood immunisation programmes.
Online group chats as a delivery channel
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 are some tips and considerations if using online group chats as a delivery channel:
Develop content that can be delivered in a range of formats, including written content, photos, graphics and short videos.
If you are setting up a new online group chat, make sure it has a clear goal or purpose based on a) who is eligible to be a part of the group, b) how you would like people to use the group (e.g. ask questions, share ideas or experiences) and c) what types of content should not be shared.
Carefully consider whether to publish the links to groups chats as this may expose the group to hackers who may post offensive content and may undermine the legitimacy and trust in the group.
Carefully consider how frequently you post in the group. Some people may leave if posts are too frequent.
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 as a delivery channel
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.
Here are some tips and considerations if using phone messages as a delivery channel:
Decide which format/s are most appropriate for your context - Your decision should factor in things such as literacy, mobile access and the type of mobile phone that people typically have (basic phone vs smartphone). Also consider what you would like to achieve through sharing phone based messages. IVR allows for more creativity for engaging populations. For example, a COVID-19 campaign in Cambodia used IVR to ask users how they would behave in different scenarios, and in India, IVR was used to capture and share real experiences from communities. IVR has also been used by UNICEF to tackle ebola and cholera.
Design messages based on behavioural theory - Information alone is often not sufficient to change behaviour. When developing the content of phone-based messages, try to think about how these can be shaped by behavioural theory. For example, think about how phone-based messages can be informative but also allude to social norms, aspirations, common barriers, planning and intention, and rewarding people for doing the right thing. For instance, this mask intervention included text messages which either targeted altruism or self-protection. This list of key behaviour change principles in relation to COVID-19 might be useful in developing more creative phone messages, while this blog summarises key lessons from the Behavioural Insights team who used SMS messages to reach audiences in the UK. Similar approaches have been adopted in other infectious disease responses, such as the ebola response, where the Red Cross launched a system which provided information on treatment and preventive measures in response to text messages.
Think about how to position messages as legitimate - Some previous work on phone-based messaging has suggested that messages may be more effective if they are seen to come from a character or persona rather than a general messaging service. For example, in a study in Bangladesh, they used the persona of a friendly medical professional to encourage preventive behaviours during a cholera outbreak and found that this was acceptable and seen as credible. In India they used an audio recorded message from a Nobel laureate to persuade people to seek care if they had COVID-19 symptoms and found that this was much more persuasive than standard government guidance.
Adapt and develop messages over time - Try to engage people through multiple messages spread across time. Where possible, make sure that messages are iterative and reflect major concerns at that stage of the pandemic. If you are able to establish two-way interactions via your messaging platform, consider trying to personalise or tailor messages to the individual (or to a group of individuals).
Build on formats that already exist - Lots of organisations have shared text and audio messages for outbreak prevention. For example, during the COVID-19 pandemic, the WHO produced an SMS message library of messages that can be translated and adapted to deliver by SMS or audio message. UNESCO also produced some examples of audio recordings to combat misinformation about COVID-19.
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.
What should be considered when using interpersonal communication to communicate about outbreaks?
House-hold level visits as a delivery channel
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.
Here are some tips and considerations if using household-level visits as a delivery channel:
Train delivery teams properly on the key messages to be delivered and the plan for activities. One way to do this is to develop an instruction manual for hygiene promotion teams.
Try to avoid content that is only focused on education or information sharing.
Pilot your proposed activities with a small number of households first and seek their opinions on the process and how it could be improved. Improve the activities accordingly.
Develop a list of common questions and answers about the focal disease that can be given to frontline staff so they are able to answer questions from the community with clear, factual and updated information. You may need to revise this list at the end of each week.
Plan for team meetings where staff share experiences and learn from each other about what is working or not working. Adapt your programming based on this.
Consider whether you may need to visit households more than once as this may be more likely to influence behaviour.
Key Stakeholders as a delivery channel
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.
Here are some tips and considerations if using key stakeholders as a delivery channel:
Consider who you are involving and how this individual or group may be perceived locally (i.e. just because someone is a village leader it doesn’t necessarily mean they are liked or trusted)
Consider whether remuneration should be provided if substantial work is being asked of individuals, but be cautious of setting up precedents that may be hard for other actors to follow
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