Audiences are at the heart of all of our work - and reaching them effectively and at scale has never been as critical as during the global pandemic.

To design any project or programme we need to understand where people are starting from: what do they know?  What difficulties are they facing?  What information is missing?  Who do they trust?  What attitudes do they hold?  

A crisis makes this information all the more important - and in the case of the pandemic, even more difficult to gather. Our work in humanitarian situations helps other aid agencies strengthen their understanding of audiences to support their own humanitarian response, as we have been doing in Cox’s Bazar and Afghanistan.

Last year, at the height of the pandemic, we were commissioned by World Health Organization to develop a , enabling them to collect timely insights into people’s changing needs, to help ensure that WHO country offices’ COVID-19 response and service delivery is reflecting these.

We designed a methodology and research tool to collect quantitative and qualitative data, and piloted it in Nigeria and Zambia to ensure that it was suitable to embed data in the overall COVID-19 response.  

Design amid challenges

We designed the tool to ensure that there was flexibility in the research method, given changing restrictions related to the pandemic. We created a quantitative survey questionnaire that could be conducted remotely by mobile phone or face-to-face, to understand social and behaviour change around COVID-19, as well as a method to conduct further exploratory qualitative research  to understand issues that came up in the quantitative survey more fully.

It wasn’t easy to conduct research remotely. In Nigeria, for instance, enumerators encountered challenges including poor phone connectivity, and hesitancy, unwillingness and mistrust from participants. In some cases, enumerators were accused of being scammers, given the prevalence of scam calls in the country; some respondents simply hung up. Some interviews also had to be conducted very late at night to accommodate respondents’ availability. And in Zambia, load-shedding led to power cuts, requiring us to make appointments  in advance to ensure the respondents’ phones could be charged in preparation.

In both countries, face-to-face interviews were also conducted to ensure that we collected data from the most vulnerable people, who were less comfortable being interviewed by mobile phone. 

A woman is interviewed for qualitative research in Nigeria. Credit: 主播大秀 Media Action Nigeria

Back in March 2020, everyone was worried about what would happen when the COVID-19 pandemic reached the Rohingya refugee camps in Cox’s Bazar. It is one of the most densely populated parts of the world, with challenging sanitation and limited health care resources; live in tarpaulin shelters on unstable slopes and up to 12 inhabitants share each shelter.

Experts warned that up to 98% of the population would be infected during the first year and, without effective intervention, the hospital’s 340 beds would be full to bursting within 2-5 months.

By late March, Bangladesh authorities had restricted movement in and out of the camps, and on 8 April the Bangladesh government imposed a lockdown banning all travel into and out of the district. But in May, COVID-19 was confirmed in two Rohingya refugees and 10 Bangladeshis living nearby.

Looking back, we now know the situation was not as catastrophic as anticipated; cases in the camps remained , even as they rose across the country.

Research demonstrates some success

Why this happened is difficult to explain. But our research has demonstrated one success: the level of awareness among the Rohingya population about COVID-19, driven by sustained work by several agencies including the Common Service for Community Engagement and Accountability, led by 主播大秀 Media Action, which has been supporting Rohingya people and host communities to cope with COVID-19.

We carried out a face-to-face survey in January 2021, among nearly 2,700 Rohingya refugees and more than 1,000 people in adjacent host communities, to provide robust data on access to information and accountability in the camps. We measured the reach of our Common Service communication materials in these communities, and explored the association between exposure to this content and specific outcomes.

We found that almost two-thirds of the Rohingya population felt quite well-informed or well-informed about COVID-19, and Rohingya women felt more informed than men - 65% compared to 55%. More than 70% of Rohingya people could accurately identify COVID-19 symptoms, and said they felt well- informed about how to protect themselves. And a majority of people surveyed knew how to keep themselves safe: washing their hands with soap, which they said they didn’t do before but had been doing since the pandemic; wearing masks in public; keeping distance from people and avoiding crowds.

A vital role in informing about COVID-19

Our communication initiatives played a vital role in informing people about COVID-19, particularly for women who, because of traditional community values, are often secluded from public life with limited access to media. We found that 40% of Rohingya people had high levels of knowledge about COVID-19 – 47% among women, and 33% among men. This may be because trusted NGO staff and volunteers had been particularly effective at reaching Rohingya women through listening groups, door-to-door visits and women-friendly spaces, many of them using communication tools and techniques we have provided.

This is particularly important because we found that, unlike their host communities, the Rohingya people in the camps have limited access to mass media, and receive most of their information through these face-to-face communications interventions: meetings with NGO staff and volunteers, loud-speaker announcements, and communication materials made available at listening groups, food distribution points, health facilities and information hubs. We found that people who attend these places, and are exposed to this content, have greater knowledge about COVID-19.

This is a testament to all agencies who have been working tirelessly to communicate with the community throughout the pandemic. The Common Service project played a vital role in creating and sharing communication materials, now available on our for anyone to use.

At the onset of the pandemic, we produced more than 60 communication tools () designed to improve communication, awareness and knowledge of COVID-19 for the Rohingya and host communities, and for health workers themselves.

Following requests from the World Health Organization and other health-focused agencies, we produced videos to train frontline health workers on infection prevention and control. Several agencies also used our audio recordings for community health volunteers. Later in 2020, we produced dozens more tools in response to agency and sector requests: community-facing materials on COVID-19 awareness, prevention, and mitigation, and tip sheets for new protocols for food distribution, the re-opening of registration, the principles of case management, child protection and immunisation.

Our survey data found that 75% of the Rohingya community said they had seen or heard at least five pieces of Common Service content. And, vitally, those who had accessed our content were 1.6 times as likely to have greater knowledge about COVID-19 than those who hadn’t.

"People did not want to believe Covid is a real thing, so they [Common Service] made some videos. Imams were shown using masks in the video and it used habits and quotations from the Quran – this makes people take it seriously. This worked well. That really resonated with the community,” said a field-level practitioner in the Rohingya response.

Our researchers found community members liked the content because it was made for them, in their language; it was easy to understand; they could relate to the characters and the camp setting; and it was in line with their values.

The next deadly wave

In Cox’s Bazar, the pandemic is far from over. Since April this year, Bangladesh has again been under tough COVID-19 restrictions, following another wave of infections and the spread of the ‘Delta’ variant in neighbouring countries. Cases are also rising in the camps at a higher rate than before.

Once again, we know we need to redouble our efforts to communicate with this isolated community, living in a confined space and left out of the information shared by mass media in the region. If our research has shown us one thing, it is that with a targeted communication strategy, trustworthy, relevant, and engaging content can help save lives - even from a deadly virus.

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Arif Al Mamun is 主播大秀 Media Action's Head of Research in Bangladesh. Read more insights and impact from our Common Service project on our website.

The world’s hopes for a vaccine for COVID-19 cannot be overstated.

A vaccine will help prevent new infections, and more than that, it will help businesses and schools in hard-hit countries get back to normal. Vast amounts of money have been invested in finding a vaccine and media reports update us regularly on the progress of over 200 candidate vaccines under evaluation.

There is also important work on ensuring equitable access once a vaccine is available, and some mention of concern about vaccine hesitancy – the delay in acceptance or refusal of vaccines even when vaccine services are available. Public health officials recognise vaccine hesitancy and refusal is a problem, but there is little evidence that countries around the world have plans to address it. 

The vaccine hesitancy problem 

Even before the COVID-19 crisis, the WHO declared vaccination hesitancy one of the Top 10 threats to global health in 2019. At that time, the world saw spikes in vaccine-preventable diseases – for the measles, mumps and rubella vaccine slipped by 10 per cent. In reference to COVID-19, the WHO Director of the Department of Immunization, Vaccines and Biologicals, Katherine O’Brien, “We don’t have a vaccine yet and already there is an anti-vaccination voice on it.”

While many see a COVID-19 vaccine as the main route to restoring social and economic normalcy, a small minority of doubters could scupper the massive global effort to discover a vaccine and roll it out effectively.

There are studies, mostly in the US, that show a lack of confidence in a COVID-19 vaccine. A May 2020 Associated Press-NORC Center for Public Affairs Research found that 31% of Americans were unsure if they’d get vaccinated against COVID-19, with another one in five saying they would refuse the COVID-19 vaccine outright. These acceptance figures are a moving target as the science around the virus progresses and is shared, and people’s personal experience of the impact of COVID-19 is felt.

There is urgent need to get in front of this challenge – before a vaccine becomes available. Experts have called the need to improve public health communication and health literacy as the number one recommendation out of six for and response.

However, historically, health communication is to achieve maximum effect. 

Analysis from Gavi, the Vaccine Alliance, for example, finds that spending on creating demand for vaccines, and for broader social and behaviour change communication, between 2011 and 2015, represented just 1.2% of the money it dispersed.

Solutions exist - where is the will?

What those of us working in health communication know is that well-designed efforts can increase uptake of vaccines. Academics and communication practitioners know what works and what doesn’t, gleaned from experience from , routine immunisation, Ebola trials and  more broadly.

At a recent on “infodemiology” (the science of managing 'infodemics'), epidemiologist and Yale Institute for Global Health Director Saad Omar summarised key lessons around what works in addressing health misinformation, which is essential in addressing the persistence of anti-vaccine information. These are:

1) do not affirm a misperception,

2) avoid lingering on the myth,

3) connect to people’s values,

4) account for the anticipatory behaviour,

5) focus on narratives, and

6) avoid false assurances.

These align with those of others who work in the field of . A recent Johns Hopkins University sets out similar recommendations, emphasising the need to understand and inform the public and gain their confidence in vaccines early in the process.

Yet despite these recommendations, we are not seeing explicit investment in vaccine education in places where refusal of a COVID-19 vaccine is a possibility. There is also little data available outside the US on which geographic areas or communities may be resistant to a COVID-19 vaccine, which would help inform areas of immediate focus. (The , analysing five years of global vaccine confidence trends and including implications for new COVID-19 vaccines, is likely to aid in this effort).

The role of health communication

主播大秀 Media Action has over 20 years’ experience in health communication -- the practice of using a range of approaches, including mass media and other information communication technologies, social mobilisation and interpersonal communication, to improve health outcomes. This experience includes working on vaccine acceptance and in global heath emergencies.

And at this moment we are researching, producing and disseminating content on COVID-19 in more than 50 languages reaching tens of millions of people around the world. This content ranges from in-depth TV and radio discussion programmes featuring experts, to using narrative storytelling to tackle the more nuanced angles of the behavioural drivers that impact COVID-19 risk. We are also on how to report on COVID-19. All of this research and reach can be leveraged to address the vaccine uptake challenge immediately. 

Highlights from our work

As part of a Unicef intervention to mitigate the spread of poliovirus in Somalia, which re-emerged in 2013, we produced a rapid mass media response aimed at increasing the demand for the vaccine.

主播大秀 Media Action developed a 42-episode Somali-language radio programme called ‘Drops for Life.’ Broadcast on the 主播大秀 Somali Service, the programme was designed to prepare the ground for the arrival of the mobile polio vaccinators. It allowed people to digest relevant information in advance of the vaccination campaigns and made them more amenable to inviting polio vaccinators into their homes. It incorporated audience feedback and personal stories, and provided a space for them to ask questions to allay their fears.

The programme also addressed specific concerns around vaccination safety, which contributed to a history of attacks on health workers and low uptake.

Audiences placed high levels of trust in information gained from the programme, both because of the credibility attributed to the 主播大秀, and because it featured trusted individuals, such as doctors and sheikhs. The programme also built the capacity of vaccinators and health workers and enhanced the public’s trust in them. These factors – use of trusted media platforms and community members, appropriately timed and grounded in local realities, helped to quash the major barriers to vaccine uptake.

In Nigeria, we worked with mass media combined with community outreach to help overcome the personal and social barriers to vaccine uptake, especially for people in the Northern states where vaccine-preventable diseases, particularly polio, have been a higher risk. We recorded our popular Hausa-language radio drama in front of a live audience in rural and semi-urban communities, then followed the recordings with discussions with vaccinators and health workers, to provide communities with direct answers to questions about routine immunisation and polio vaccination.

that our audiences knew more about how polio is transmitted and prevented, and took action following vaccinator visits, compared to those who didn’t participate. Evidence also suggested that radio interventions helped to debunk misinformation and harmful myths around the polio vaccine, and that the drama was used as a tool to challenge vaccine refusal within families and beyond. This work finished in 2019, the same year Nigeria was declared “polio free”. 

We need to act now

Vulnerable countries urgently need a plan to address the risk of vaccine refusal, starting with investing in research that can isolate where and among whom the risk is likely to be highest. Health departments need support to as they prepare for a COVID-19 vaccine, by conducting this research and creating spaces and content that help answer people’s questions and address their fears. Let us draw on the vast experience of the health communication field to support the responsible, community-focused roll-out of national coronavirus vaccination programmes.

What we say and do now will impact how successful we will be in halting the spread of COVID-19.

On March 20, the World Health Organization announced its latest tactic in its fight against COVID-19 – a new on the popular Facebook-owned messaging app, WhatsApp. Users simply sign up to the service by sending a ‘hi’ message to one of seven Swiss phone numbers – one for each of the seven languages offered. It replies by asking subscribers to select from a list of information options ranging from the latest COVID-19 numbers to myth busters.

With 2 billion users, WhatsApp is an ideal channel for the WHO to communicate trusted health information to people around the world – not least because the messaging app has also become a – covering how it spreads, symptoms, false cures and conspiracy theories. With over 5 billion mobile phones users globally, this service meets people where they already look for information. And with information about the virus changing daily, a health alert from a reliable source is needed now more than ever.

This is not the first time WhatsApp has been used during a global health emergency. In 2014, 主播大秀 News created an Ebola service on WhatsApp in English and French, which at its height had over 25,000 subscribers, most of whom were in West Africa where Ebola was most prevalent. Here at the 主播大秀’s international charity, we also created a Krio-language version in Sierra Leone at that time, which gained 14,000 subscribers.

Advances in technology mean the WHO service has in some ways improved upon the 主播大秀 experience. Unlike the WHO’s informational bot service, the 主播大秀 services allowed subscribers to send messages to the news and charity teams running the services – which were read by humans, rather than generating automated responses. Having people text or record their questions back to the 主播大秀 provided a window into what ordinary people were talking about, what questions they had and what rumours were going around. This helped inform how best to respond to the needs and questions of those facing Ebola in their communities. But this feature presented a huge challenge of managing an incredibly high volume of messages – a prospect which would be untenable for the WHO’s service. It is reported to have racked up .

Learning from Ebola
There are lessons that the WHO can take from the 主播大秀 messaging app experience.

At the height of the Ebola crisis, the 主播大秀 provided content about three times a day: much of it information from the WHO, the Centers for Disease Control and UNICEF. WHO’s Health Alert, by contrast, is demand-driven. Users ping the service to request the latest information from the original option list, rather than messages being pushed out at regular intervals. Some may consider this a considerate approach to avoid unwanted spam. But if I’ve been busy for a couple of days and not had a chance to ask the alert what I want to know, it stays silent. Sending me what I need to know each day would keep me better informed.

The appeal of WhatsApp lies in its full potential – including audio and visual messages, which are particularly useful for users with low literacy levels. The 主播大秀’s content included images, text and audio clips (video was avoided to reduce the burden on data). 主播大秀 Media Action’s Krio version even included a serialized Ebola radio drama.

But the WHO content is still text-heavy and not yet share-worthy; even its emojis are hard to locate or interpret. It feels more likely to appeal to educated officials than to a general audience.

WHO Health Alert welcome message and content example

Indian government's MyGov Corona Helpdesk WhatsApp