Given the speed with which the pandemic progressed, the transmission route of the coronavirus SARS-CoV-2 that causes COVID-19, and the needed response measures, it was not always feasible to use face-to-face community-based behaviour change activities to promote hygiene-related practices needed to prevent coronavirus transmission. Instead, key COVID-19 preventative behaviours were communicated at international, national and local scales using remote methods, such as digital and mass media.
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This learning brief will summarise and explore key learnings about digital and mass media approaches utilized by the Hygiene & Behaviour Change Coalition (HBCC), local governments, NGOs, private sector partners and community groups responding to the COVID-19 pandemic in lower and middle-income countries (LMICs). This includes how partners participated in active and meaningful engagement with a broad range of stakeholders to develop social and behaviour change communication strategies, approaches and content; how formative research was used to inform these activities; to the use of audience segmentation to engage with and support specific groups, including populations who may be vulnerable; how communication approaches and content were developed and adapted to address pandemic and communication fatigue; how communication strategies were designed to deal with misinformation; and, how monitoring and evaluation (M&E) of digital and mass media activities supported adaptation and learning.
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Finally, we highlight key actions to improve future programming and recommendations for future pandemic preparedness and response.

Digital media refers to any form of media that uses electronic devices for distribution. Examples can include:

Mass media includes all forms of information communicated with large groups of people. There is no standard for how large the audience must be before communication becomes “mass” communication. Examples include:

Printed newspapers are still an important source of information in many regions of the world. Additionally, radio has an immense capacity for wider coverage and the ability to integrate a diverse range of programme forms. Globally, it remains the most widely consumed medium and an important source of information for both urban and rural communities, often reaching more rural and isolated communities than other forms of mass media.

During the initial response to the COVID-19 pandemic, social and behaviour change communication focused on the adoption of primary behaviours such as covering coughs and sneezes, handwashing with soap (HWWS), physical distancing, and later wearing a face mask or covering, to combat coronavirus transmission. Secondary behaviours that were promoted included cleaning and disinfecting frequently touched surfaces, isolating when feeling unwell and seeking medical advice, and seeking medical attention at the onset of severe COVID-19 symptoms. Communication content also focussed on helping people to cope with stress and the wider impacts of the COVID-19 response, and to cope with the infodemic including mitigating the sharing of mis/disinformation and rumours.

Responding to COVID-19 necessitated reaching as many people as quickly as possible with communication that could help populations understand what was happening, how to prevent coronavirus transmission, what to do if someone had symptoms that could be COVID-19, and response measures and how they might be impacted by them. The way in which the SARS-CoV-2 coronavirus was transmitted, the rate of transmission, the severity of COVID-19 and the accompanying infodemic created an urgent need to reach mass populations as quickly as possible. This was especially significant considering the nationwide lockdowns enforced in many countries that prohibited face-to-face interactions. Instead, posters, billboards, TV and radio advertisements, radio jingles, loudspeakers on cars, and social media, were used to help deliver information and social and behaviour change communication content.

COVID-19 response programmes possessed critical knowledge about the populations they were working with and were able to rapidly adapt and/or develop digital and mass media campaigns and content to respond to COVID-19. For example, hygiene messages on hand washing with soap (HWWS) were converted into videos, radio or TV adverts. Messages were adapted to different local contexts and examples include: handwashing for 20 seconds, and handwashing before entering shop/restaurant/public space.

To increase the uptake of primary behaviours, digital and mass media campaigns evolved to directly engage targeted populations, including children, youth, men, and women. These populations not only have varying degrees of access to different media but also consume media in different ways. For example, in India, women do less with their mobile phones than men and are more likely to have lower levels of digital literacy. The Calling All Women Project in India, used Interactive Voice Response (IVR) technology to make audio content accessible from any phone, therefore helping to overcome the literacy barrier.

Another example of how women were targeted and empowered through mobile technology to combat COVID-19, this time in Kenya, can be found here. In Kenya and Tanzania, Amref engage young people through illustrated comic stories and social media content that depicted heroes protecting their dreams, businesses, family, and health by adhering to public health measures which in turn would protect their loved ones from COVID-19.

The use of digital and mass media channels was also critical in addressing disparities between urban and rural populations. For example, in many countries in rural areas, radio continues to be the more accessible and engaged with communication channel – access to TV, digital and print media is often much more limited and sometimes not accessible at all, and lower literacy levels mean a greater reliance on audio and image-based communication formats. In Nepal, WaterAid used other ways to target hard-to-reach populations and employed a technique known as ‘miking’ using loudspeakers and microphones to promote key COVID-19 preventative behaviour messages in remote rural areas (Image 2).

As the pandemic progressed, COVID-19 data and social science research highlighted the need for communication content and campaigns to engage with and support specific populations who might be more vulnerable to COVID-19. This included people with disabilities (PWDs), older adults and immunocompromised people.

While the focus on digital and mass media communication campaigns fluctuated during the pandemic as countries came in and out of lockdowns and COVID-19 vaccines were developed and rolled out, the process for developing impactful campaigns remained the same—building and relying on partnerships across sectors, including governments, INGOs and CSOs, creative agencies, artists, community and religious leaders, media experts and practitioners, and behaviour change specialists.

Active and meaningful engagement with a broad range of stakeholders to encourage partnerships, collaboration, and sector coordination for more effective social and behaviour change communication.

Partnerships and collaboration across organisations, sectors and nations, including between government and non-government entities are crucial in a large-scale public health response. Strong working relationships help build a stable foundation from which impactful digital and mass media campaigns can be quickly implemented during times of crisis. Establishing and maintaining trust and cooperation between government entities, UN agencies, NGO, CSO and media and communication partners can help navigate approval processes more quickly. Government engagement also fosters ownership and encourages sustainability, but it is important to be sensitive to the context and unique leadership styles of different governments to ensure successful engagement and relationship building. It is equally important to work closely and collaboratively with local organisations and networks (e.g., community-based organisations, youth groups, school committees, women’s rights and gender equality groups, people with disability groups etc.) and other key stakeholders outside of the public health and WASH sectors, in particular, media and communication organisations and practitioners. This collaboration helps ensure that media and communication content and campaigns are relevant and possible for different populations and contexts and can be sensitive to and mitigate secondary impacts of a public health response.

In Kenya, Uganda and Tanzania, Amref set up a coalition of partners from different working streams including a media committee (digital and mass media partners). This committee supported the development of campaign materials that were disseminated through radio and TV as well as digital channels, including social media (Facebook and Instagram). Innovative digital approaches included the use of public youth champions, public Wi-Fi advertising, social media influencing, and edutainment formats e.g., comic books, and puppetry (Image 3). This approach showed the value of engaging a variety of partners and public-private engagements to adopt innovative methods to maximise reach and engagement.

Before starting a new or adapting a pre-existing programme, actively and meaningfully engage with local stakeholders (including media), and government and non-government organisations to find ways of aiding the design, implementation, evaluation and adaptation of social and behaviour change communication strategies and activities.

Use a range of research methods to inform social and behaviour change strategies, approaches and content.

Formative research is typically carried out in advance of programme design and used to inform programmes to ensure they are adapted to the context and help address the needs and priorities of the local populations. Research is often repeated thoughted the programme and can also facilitate learning and adaption of approaches throughout the response.

Formative research comprises a range of quantitative and qualitative data collection methods that are carried out to understand current practices, perceptions, and factors that enable or limit behaviours (see Table 1 for a list of potential formative research methods).

Table 1. Examples of formative research methods that can be used to inform programming

In the context of a pandemic such as COVID-19, formative research had to be adapted, streamlined, and expedited. In this situation, rapid assessments and situational analysis were carried out to provide more information. Many organisations harnessed existing data and research instead of primary formative research, whilst others successfully overcame barriers to conduct formative research (Case study 1).

Other NGOs also conducted a range of formative research across settings such as household surveys, KIIs, IDIs, and FGDs. These examples include:

COVID-19 hindered standard formative research approaches as in-person data collection was no longer feasible. Subsequently, organisations had to adopt new data collection methods which were adapted to adhere to COVID-19 guidelines and crucially, timelines were expedited due to the nature of the pandemic as an evolving crisis (Case study 2).

A range of platforms were employed to aid remote data collection including:

Remote data collection methods should be considered for use in the context of future pandemics or emergency situations. Specifically, there should be a focus on adaption to build resiliency in research during future outbreaks. You can find more information about remote data collection methods here.

Prioritise formative research at the beginning and undertake regular research to understand who is being impacted by your content and how to enable programmes to use the results effectively and efficiently to inform and adapt activities.

Deliver segmented social and behaviour change communication activities to help engage with and support groups who might be more vulnerable to exclusion, stigma and discrimination.

Segmentation aims to align messages, delivery channels, products and services with the needs and preferences of an intended audience to maximise the impact of a behaviour change intervention and programme. The process divides a target population into sub-groups that are perceived to have similar characteristics and differences from other sub-groups. A digital and mass media audience may be segmented by demographics or into specific groups or contexts which might be more vulnerable, for example. As hygiene and behaviour change campaigns develop, it is important to tailor messaging and delivery channels to maximise reach throughout the population. For example, not all people own a TV, so it is not possible to reach the entire targeted population with TV adverts. Similarly, different groups of people get information from various sources and media channels. Someone of a certain age or living in a particular context may favour a channel that is different to the general population, so it is important to reinforce the same behaviours through the use of multiple channels.

Examples of segmentation in digital and mass media campaigns might include identifying and diversifying campaigns by the following:

Mass and social media assets utilised by WaterAid initially used influential personalities such as celebrities, WASH ambassadors, community leaders, comedians, athletes, and music artists. For example, the ‘Power of 5’ campaign implemented by WaterAid initially used five key athletes promoting key behaviours and then expanded to use five powerful women, five inspirational national leaders and the Deaf Society, and proved extremely successful and well-received, reaching over 7.5 million people in Zambia (Image 5). As time passed, promotional materials were tailored to each context and within certain populations. To reach more remote and rural populations, radio campaigns were created which included skits, talk shows, panel discussions with experts and representatives from PWD groups, jingles, public service announcements (PSAs), dramas, call-in programmes, and competitions.

This type of communication also allowed for two-way communication, with people expressing opinions and asking questions — a key method in targeting misinformation. In Nepal, to further maximise reach to target populations living in more remote areas, ‘miking’ hygiene promotion methods were employed. This involved driving mobile trucks with billboards, celebrities, pictorials and loudspeakers with recorded audio scripts through remote and rural regions. The use of multiple channels and the inclusion of influential and trusted people in the community was key to expanding and maximising the reach of hygiene promotion campaigns and building trust with the audience.

Promotion of hygiene messages through the use of social media, particularly TikTok, is a relatively novel approach that has proven extremely successful in engaging young populations. Social media also allows for real-time feedback via likes, shares and comments sections, informing timing of posts and style of delivery. For example in Kenya, Amref were able to respond to a complaint about poor access to handwashing stations on a social media post by sharing locations of local options.

In an ever-changing setting, it was important to be flexible and adapt messages to the local context. In Uganda, PSI used a variety of delivery channels to increase reach among populations. Social media platforms such as Instagram, Facebook, and Twitter were employed to target youths, and campaigns combined Ebola awareness and prevention messaging, whilst IVR was used to target older adults (Image 7). Recorded SMS messages on COVID-19 and Ebola awareness and prevention (in response to an Ebola outbreak in Uganda) were developed and broadcast to target mobile phone users through a 1-6-1 IVR platform (an automated, toll-free information service that the public can call to access information on key topics) and the caller-to-listeners conversion rate was measured to calculate reach.

There was also a need to focus on how content and approaches could be adapted to maximise reach for groups and contexts which might be more vulnerable, through adapting behaviour change messaging. For instance, in Kenya, PSI adapted adverts to include sign language and used radio and local mass media by broadcasting audio from information centres and vans. WaterAid produced assets that included sign language and highlighted people with different disabilities that were used in multiple country programmes.

SESAME campaigns in India targeted parents and caregivers across the country on Facebook, Instagram, Twitter and YouTube. Its content focused on promoting key hygiene behaviours by depicting a variety of settings, such as low-resource handwashing facilities and a combination of video, graphic and game-focused content featuring the Muppets and friends which were used to ensure content variation and keep the campaign messaging fresh. The content was produced in different languages and dialects and included accessibility-focused content, such as sign language, for maximum reach.

In Somalia, BBC Media Action radio programmes sought to emphasise how the coronavirus and COVID-19 were spread, and how to manage traditional practices whilst following prevention measures. Audience segmentation enabled the team to target populations who might be more at risk of developing severe COVID-19, such as older people and people with disabilities, and people who were more vulnerable, such as internally displaced people.

Audience segmentation is essential for developing social and behaviour change communication strategies, activities and content to ensure programmes and campaigns engage with people through the channels they already use, and to meet the needs of both mass audiences as well specific populations and groups who may be particularly vulnerable (e.g. migrants, refugees and people who have been internally displaced, women and girls, and people with disabilities, older adults and clinically vulnerable individuals).

A media and communication social and behaviour change strategy and plan that includes regular research and reviews is needed from the start to mitigate and/or limit communication fatigue and for maximum engagement.

A key challenge in the later phases of the COVID-19 response has been the shift of attention from COVID-19 towards other pressing issues, with many countries lifting public health restrictions. Consequently, there is a misconception that COVID-19 is no longer a risk and messaging on masks and physical distancing are no longer resonating with communities.

Oxfam employed the use of a Community Perception Tracker- an approach that uses a mobile tool that enables staff to capture, analyse and understand perceptions of communities during disease outbreaks. They found many populations grew tired of continuously hearing COVID-19 messages and content as COVID-19 was one of many issues they were facing. To address communication fatigue, it is crucial to adapt media and communication content to keep communities engaged and encourage the continued practice of key behaviours.

Examples of ways in which social and behaviour change communication activities and content can mitigate and limit pandemic and communication fatigue in digital and mass media campaigns include:

Contests or challenges to motivate and incentivise people to do good work in their community were employed by Amref and proved successful. Amref adapted messages and content to include the latest trends and incorporate catchy, child-friendly content through using comic books and social media influencers in their digital campaigns targeting youth groups. Social media influencers also organised competitions encouraging targeted audiences to take part and win prizes. These interventions were targeted to certain high-risk locations.

WaterAid created a range of motivational assets to avoid campaign saturation, reduce fatigue and continuously reinforce the behaviours. These used a range of delivery channels including videos and TV jingles, with songs proving to be a successful and entertaining way to repeat a core message in a way that people remembered. Longer segments such as TV adverts and radio dramas were also developed and were useful in delivering messaging on promoting key behaviours and their importance. Entertaining and engaging social media posts and billboards used celebrities, community leaders, WASH ambassadors and local leaders in different sectors. WaterAid noted that one-off exposure was not enough and a higher reach with repeated frequency using multiple channels, targeting multiple target groups, was key to reinforcing behaviours and reducing campaign fatigue.

In Turkey, the WHO country office carried out Twitter polls asking respondents specific questions about actions they are taking to protect their health. This encouraged people to reflect on their own behaviours and environments and served as a reminder of the ongoing relevant behaviour change messages to align with.

Ensure digital and mass media communication strategies and content are sensitive to current trends and priorities through regular research, to limit communication fatigue and adapt content and strategies to include up-to-date, nuanced content which is tailored to different groups and engages more people in innovative ways.

Effectively challenging mis- and disinformation and rumours related to COVID-19 requires understanding why people believe in and share misinformation and a variety of communication approaches and channels.

As a novel virus, there were many unknowns about COVID-19 initially. This resulted in an information vacuum that contributed to the spread of misinformation, disinformation and rumour. The provision of high-quality and up-to-date information during health crises is crucial to the adherence of health advice and recommendations. Health communication through digital and mass media needs to understand what drives misconceptions, mis- and disinformation and rumour in different contexts, populations and on different communication channels and help address those drivers as well as directly addressing widely shared misinformation. This also involves helping people to build the skills they need to fact check information for themselves.

Formative research carried out by BBC Media Action in Somalia identified misconceptions about COVID-19 and beliefs about how infectious diseases are spread as a central challenge. Misconceptions included that there was a separate strain in Somalia, the inability of the coronavirus to survive in a hot climate and the belief that the coronavirus did not affect Muslims. BBC Media Action addressed these misconceptions by developing PSAs and programme content that included interviews featuring people who understood and could clearly counter misconceptions and communicate the facts that the audiences trusted and believed including health experts and religious leaders as well as Somali nationals who had had COVID-19. PSAs also shared where people could get more information that would be factually accurate and up to date. Follow-up evaluations found that more people who were reached by their programming were able to identify false statements about COVID-19 compared to those who did not access the content (Image 8).

A randomised control trial by Winters et al. looked at approaches to debunking highly prevalent health information using audio dramas delivered by WhatsApp in Sierra Leone. One group of episodes shared through the messaging application explicitly cited and discussed misinformation around the topic which was subsequently debunked in the episode. Other dramas focused on the correct information and both dramas made sure to include the cultural context and language. Results showed that both methods reduced misinformation, improved knowledge and increased protective practices. Additionally, learning from WaterAid highlighted that the use of trusted context-relevant characters, such as local and trusted people, was effective in addressing misinformation and promoting positive behaviours.

COVID-19 hotlines and call centres set up by Oxfam in Somaliland provided a 24/7 service where callers could have two-way conversations with health professionals specially recruited for the programme (Image 9). They were able to engage on common topics of misinformation and it allowed both rural and urban populations, regardless of their literacy level or internet access, to benefit from accurate information and tailored answers to their questions.

To tackle the issue of misinformation for future public health emergencies and pandemics, preparedness activities need to include understanding what and who drives misinformation and misconceptions about different health issues (historical as well as present day issues) amongst different populations and groups; understand what harms vs. what builds trust in information, and focus on what is relevant to the community. A combination of mitigation and countering misconceptions and misinformation approaches is needed, as well offering scientifically accurate information and helping build broader digital and media literacy skills.

Connect with experts in infodemic management and managing information disorder now to build capacity and strategies for mitigating and responding to misinformation early in future public health emergencies.

Monitoring and evaluation is a key component of delivering effective digital and mass media campaigns.

M&E is a critical component of hygiene promotion campaigns using digital and mass media methods. It is important to collect accurate, up-to-date, disaggregated data for monitoring trends, informing programming and adaption of interventions. Monitoring is crucial in assessing whether digital and mass media campaigns are working and reaching targeted populations. M&E of digital and mass media can encompass some of the following aspects:

The shift towards remote data collection created challenges for obtaining quality data which could inform programming. Partners reported that their monitoring processes were simplified to focus on collecting numerical indicators to summarise reach and self-reported perceptions and behaviours. Surveys conducted via phone or SMS were kept short to maintain the attention of the respondents, but this also led to data that was not nuanced enough to act upon in some cases. Other more in-depth tools are sometimes needed. IVR surveys were commonly used early on in the pandemic; however, response rates were low and short-answer responses were not useful in informing programmatic decisions. The use of social media to conduct polls or promote surveys was more efficient in collecting large amounts of data, however, this approach was biased in terms of who participated, and it was difficult to draw links between the respondents and the population living in the targeted areas.

It was also more challenging to measure the effectiveness of programming and whilst some partners found ways to monitor the reach of their messages, through social media analytics or media monitoring, it was more challenging to gauge the impact of hygiene messages on behaviour. Given that access to communities change frequently in an evolving pandemic such as COVID-19, it is helpful to have multiple indicators and methods to measure the same behaviour. Strengthening M&E systems is crucial and there is a need to support routine monitoring and build resilience against future outbreaks. More information about approaches to strengthening M&E can be found here.

M&E is key in ascertaining whether campaigns are reaching the desired population and having the desired effect. Collect disaggregated data to ensure specific populations e.g. IDPs or women are being reached.

This learning brief was written by Fatima Ahmed who is part of the Hygiene Hub. Valuable inputs were also provided by Lauren D’Mello-Guyett (LSHTM), Jenny Lamb (LSHTM), India Hotopf (LSHTM) and Genevieve Hutchinson (BBC Media Action).

Published on June 22, 2023

The COVID-19 Hygiene Hub is housed at the London School of Hygiene and Tropical Medicine (LSHTM) and developed in partnership with Centre for Affordable Water and Sanitation Technology (CAWST) and Wash’Em. hygienehub.info

Ahmed, Fatima; (2023) Digital and mass media approaches to support hygiene and vaccine uptake during the COVID-19 pandemic. London School of Hygiene and Tropical Medicine, London, UK. DOI: https://doi.org/10.17037/PUBS.04670143. Link here.

The Hygiene Hub is funded by the Foreign, Commonwealth and Development Office (FCDO).

This project was made possible by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s official policies.