In this resource we outline some of the reasons why all disease programmes need to build in mechanisms to allow adaptation. Whilst this resource has been produced with COVID-19, the principles can be applied to a range of infectious disease responses.

Adaptive programming can enable programmes to be more effective and responsive to local needs.

Adaptive programming improves existing programmes by modifying them as necessary in response to changing contexts. By adapting programmes to reflect the local realities, it is more likely that public health and water, sanitation and hygiene (WASH) programmes will remain relevant. Adaptive programming is especially important to consider when scaling up programmes to ensure they remain effective in achieving behaviour change for the target population. Therefore, adapting programmes throughout the course of their implementation is considered good practice. Adaptive programming is also important if you are undertaking advocacy or policy work.

The dynamic nature of disease transmission and the changing state of evidence requires constant adaptation.

Each country experiences infectious disease outbreaks differently, and as such, responses vary in different parts of the world and even within countries. For instance, some settings, cases and deaths due to COVID-19 are still on a steep rise, while others are seeing a decline. There are also many countries where the number of new cases stabilized or declined initially, but there was subsequent waves of cases and deaths. The graph below shows how transmission has varied across different continents.

Distribution of covid cases globally from January 2020 – October 2022. Source: The New York Times

The secondary economic and social impacts of COVID-19 will also vary by country and this The secondary economic and social impacts of COVID-19 have also varied by country, undeniably influencing policy decisions made by national governments. Throughout the pandemic, organisations have had to regularly adapt their programming because of these changes in transmission, policy and social perceptions.

As our understanding of a disease outbreak improves, prevention programmes have to adapt.

Between January and October 2020, more than 60,000 academic publications were written about COVID-19. The speed of our learning about this novel pathogen has been unprecedented and challenging for practitioners to keep up with.

Lit Covid data showing the number of academic publications about COVID-19 per week. Source: NCBI

Recommendations around prevention behaviours have changed over time in light of increased understanding about COVID-19. For example, in the early phase of the response, many countries were hesitant to recommend the use of masks among the general population. However, as our understanding of COVID-19 transmission improved and further research emerged, mask use was recommended by the WHO and has since been central to the COVID-19 response in most nations. In contrast, in the early stages of the pandemic, many countries were considering large-scale disinfectant spraying, but this has since ceased because it is unlikely to be efficacious and can pose safety risks. Other prevention behaviours like handwashing with soap and use of hand sanitisers were recommended early on, have been adopted globally and are still considered key to interrupting transmission. Accordingly, organisations have sometimes had to adapt their strategy and encourage additional behaviours among their target populations.

Adaptation is needed to move from the acute phase of response to longer-term action.

Disease programming needs to adapt as we transition from the acute, emergency response phase of programming to a more long-term response mode. For instance, as we enter this ‘living alongside COVID-19' stage, programming must pivot and consider sustainability and policy change. This will require us to:

  1. Close some of the gaps and inequities that result in some populations being disproportionately vulnerable to COVID-19: people who are clinically vulnerable (such as older people and people with pre-existing conditions), people who live and work in settings which put them at increased risk of exposure to COVID-19 (such as densely populated areas), people who are more likely to experience severe socio-economic secondary impacts (such as people living in poverty or working in the informal sector), people who lack access to WASH infrastructure, people who have reduced access to health care or critical services and crisis affected populations.

  2. Build resilience against future outbreaks and reduce the burden of chronic public health challenges like diarrhoeal diseases.

  3. Improve and sustain efficient public health response systems at the national, institutional and community levels.

  4. Continue efforts to achieve the WHO’s target of 100% vaccination coverage in health workers and adults, with a focus on reaching vulnerable groups. This includes delivering the 1st and 2nd booster vaccines and tackling vaccine hesitancy where applicable.

  5. Continue promoting non-pharmaceutical preventive measures, such as handwashing and mask usage, in areas experiencing outbreaks, or in vulnerable populations, such as camp-settings.

Adaptation is necessary to overcome ‘fatigue’ and keep programmes relevant.

When populations know the basics about transmission and prevention of the focal disease, it is important to change your approach to avoid disengagement. Without adaptive programming, there is a risk that the target population will get bored and may no longer consider programmes to be relevant to their lives and concerns. For example, Oxfam’s Community Perception Tracker documents community attitudes and concerns around COVID-19 in nine countries. They have found that many populations are tired of programmes that only give COVID-19 messages, because COVID-19 is only one of many issues they are facing. Ongoing, iterative adaptation is necessary along with the utilisation of innovative, evidence-based activities. It is important that organisations view behaviour change as a process rather than a one-off event. For inspiration in this regard, look to the private sector. Many big brands re-innovate their marketing approach regularly so as to ensure that there is constant interest and demand for their products. For example, Coca-Cola has maintained core aspects of their brand while releasing a new marketing campaign almost every year. See this paper for reflections on lessons learned during the West African Ebola crisis, including a section on avoiding message fatigue and confusion.

Adaptation to ensure programmes are inclusive.

Oftentimes, rapid response programming during the early phase of outbreaks may not be inclusive. However, with time, more data, and a better understanding of who is vulnerable, programmes can be adapted to address those earlier gaps. For instance, COVID-19 programmes and national strategies are now more commonly targeting specific sub-groups of the population who are at risk, through targeting older people and individuals with pre-existing health conditions for vaccine boosters, for example. There are now resources dedicated to mapping vulnerable populations providing more granular data to aid in response. In Kenya, the need for a more targeted COVID-19 response among at-risk populations has also spurred the creation of new indices to measure multiple dimensions of vulnerability (e.g. social, epidemiological) and inform programming. More diverse types of data are also needed to understand the perspectives of different population sub-groups and how the pandemic may have affected people in different ways. Working with groups that represent vulnerable groups (e.g. Organisations of Persons with Disabilities) can be key to developing successful and acceptable programme adaptations.

Programming also needs to tackle and confront any discrimination and stigmatisation that is observed during response efforts. The fear created by outbreaks can prompt people to blame minority groups as they search for explanations during these uncertain times. This can mean that people of certain ages, genders, religions, ethnicities, castes, socio-economic backgrounds or those who belong to certain professions, become unfairly stigmatised. Adaptive programming necessitates that response actors closely monitor messaging, images and approaches to ensure they are not inadvertently fuelling discrimination. For tips on de-stigmatising mpox communication, see this CDC page.

Keeping communities informed as you adapt

Communities should be informed about policy changes and changes in your programming, in order to allow them to make necessary changes in their lives. Information dissemination should be regular and concise in highlighting key milestones in the progression of the outbreak and the ripple effects in programming. For example, at the beginning of the pandemic in Zambia, the guideline was for those with COVID-19 symptoms to call a COVID-19 response hotline and not go to the public health facility. However, with time and after prevention and diagnosis measures were strengthened at the health facilities, people began using their local health facility for testing. These and other changes should be communicated in a timely manner and coordinating institutions should ensure messaging is consistent among themselves to avoid misinformation or unnecessary uncertainties.

Want to learn more about fostering a new generation of effective hygiene initiatives built on outbreak experience?

Editor's note

Author: Elli Leontsini, Peter Winch and Anika Jain
Reviewers: Tracy Morse, Helen Hamilton, Dan Jones, Sian White, Jenala Chipungu
Last update: 04.01.21

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