Step 1. Set up a communications task force and appoint a national focal person

While many governments have assigned political responsibility and created high-level committees on the COVID-19 response, these tend to concentrate on urgent matters such as provision of care, supplies and testing. Promotion of daily domestic practices such as handwashing is often seen as lower in priority, but still requires an urgent and specific focus, since such measures are the only effective way to prevent infection in the absence of a vaccine. While existing public health promotion teams will have been mobilised, it can be useful to reinforce them through the designation of a National Focal Person with sole responsibility for pandemic behaviour change planning. Their role is to champion and coordinate national communications activities. The chosen national focal person will need technical experience in communications, marketing, cross-sectoral coordination and public health, and combine this with personal qualities of energy, persistence, open-mindedness, a problem-solving focus, communications and networking skills and motivational leadership.6 Her/his role is to assure a joined-up approach to national communications across all channels and by all partners (as far as is possible in an emergency). He or she may be seated in the Ministry of Health (MoH) but must coordinate across the full range of ministries and cabinet offices that contribute to the response. Aside from technical leadership, the focal person will need to be able to lead the national effort, bringing together all key stakeholders around a step-by-step strategy and a unifying brand.

The national focal person will need the support of a small, agile, action-oriented, task force to execute the communications strategy. This task force should draw on local skills and resources, but could include the MoH’s health promotion unit, private sector representatives, media, behavioural scientists and/or creative and communications specialists and, ideally, one or more members of the target audiences. The task force should not replace, but complement, existing coordinating structures, for example, under the cabinet or the United Nations, and seek to amplify their ability to mobilise expertise, reach and resources under national leadership. An example is the Swaach Bharat Mission which successfully transformed sanitation provision across India by using a task-force, results-oriented, approach; co-opting young, energetic staff to mobilise activity within the bureaucracy of a busy line Ministry.6

Step 2. Mobilise resources, including from the private sector

Financial and human resources are being mobilised globally towards COVID-19 prevention. National governments have the mandate to ensure that these are harnessed towards the Government’s agreed goals, that efforts complement each other and that they use evidence-based approaches. Governments can source funds from national budgets, from loans and donations, by switching existing programmes towards the pandemic response and/or by approaching Industry. Some portions of loans and donations are usually dedicated for public communication, which, if not planned strategically, will be reallocated. Countries with well-thought-out communications strategies often find themselves at the head of the queue when applying to banks, multilateral and unilateral donors and granting foundations. The better a country, task force or focal point can organise and articulate what is being asked for, the more, and faster, resources will be forthcoming. For example, funders are seeing disproportionate numbers of applications from countries such as Bangladesh and Pakistan, which have a lot of experience in communications planning.

Governments are generally used to seeking the support of external agencies such as the development banks, the bilateral donors and the international non-governmental organisations. However, in the current context, mobilising finance may be less of a problem than mobilising human capital. A sophisticated communications campaign needs the support of experts in behaviour, in content development, in media buying, planning and influencing and in monitoring outputs so as to gauge impact. Industry has special skills in this respect. While governments may expect that companies will want to make donations of products such as soap, industry can make a more valuable contribution to the prevention effort—their particular ability in marketing to consumers (behaviour change, by another name). Companies are competing to join the COVID-19 response, and are keen to gain government approval for their efforts, both because it increases their reach and enhances their legitimacy in the social field.9

Industry has particular skills and capacities that are invaluable for national communications campaigns. They understand the need for unification around a single ‘brand’ (in this case the national COVID-19 brand—see step 7, below) and how to create such a thing. They have access to professional creative companies and individuals who can craft messages and bring them to life, ensuring that the content of messaging is not just informational, but surprising, motivating and feasible.8 10 In other words, ensuring that it is not just the right message that is being diffused but that the message is right.11 For example, most current COVID-19 communications efforts are still entirely focused on the provision of information, yet it is doubtful that information alone is sufficient to change behaviour.1

Industry also understands media planning, through being able to model how far resources invested in different channels will allow messages to reach a specific set of the target population, and to monitor the reach and effectiveness of their activities. Increasingly, they also understand how to manage communications output, not just through traditional channels such as TV and radio, but via digital and social media as well. In many countries, industry may be the only institutions set up to communicate at the scale that is required in the current crisis. For these reasons, the government team should enlist business help as early as possible. Ministers can begin the process by directly calling on national Chief Executive Officers for help, ideally asking for some delegation of staff time for communications planning purposes.

Government public health authorities may be unused to dealing with private sector players. The national focal person needs to be able to liaise with and speak the language of business, to respect the speed at which business moves (eg, to engage them only in focused meetings to make quick decisions, rather than in prolonged national committee debates), and to recognise that the private sector is competitive, so companies may not collaborate easily. The government team should also recognise that the desire of business to gain visibility and acknowledgement of their efforts is just as legitimate as that of the usual third sector players.

A good example of how business is working together with government and other players to fight coronavirus is the communication campaign developed by the National Business Compact in Kenya, led by the Marketing Society of Kenya. Multiple soap companies (Unilever, Reckitt-Benkeser, Pwani, Mengengai, Pz Cussons) are contributing by giving soap, and by funding a 3-month unbranded campaign through mass media and in digital channels. The national brief was approved by the Ministry of Information, Communication and Technology and all materials were approved by the National Emergency Task Force. The national brief was executed by BBDO who conceived the Komesha Corona (Fight Corona) campaign under the authorisation of the government. The soap companies gave media time during prime-time TV, as well as billboard space and radio placements, and agreed which of their joint influencers could be used to front the campaign. The marketing directors of the soap companies reviewed the campaign and gave feedback. Public Relations and branding of the National Business Compact is being managed on a pro bono basis by Ogilvy (https://www.covid19businessresponse.ke).

Step 3. Define which behaviours need to change and by whom

While it may initially seem obvious, the question of exactly which behaviours need to change is a difficult one. First, evidence as to what works well to prevent community transmission of COVID-19 in the community is scarce. There is controversy, for example, about the utility of wearing of masks,12 the feasibility of promoting isolation and shielding strategies and the role of contaminated surfaces and objects in viral transmission. Scientific evidence on COVID-19 transmission is being published at an unprecedented rate, but there are still many uncertainties.

Two key behaviours around which there is public health consensus are hand hygiene and physical distancing. Handwashing with soap is a particularly plausible intervention in all countries, with a moderate level of evidence that it can be effective in preventing transmission of respiratory viruses.13 14 It can also have other benefits.15 Unfortunately, we know that the practice is not common in domestic settings in normal times15 and is difficult to promote, especially when soap and facilities such as water are scarce or inconvenient to use. However, during a pandemic, motivation to practice may increase.2

Physical distancing is a novel behaviour, which contradicts normal tendencies for people to come into contact, and so interrupts normal routines and has few mental cues. Distancing may also be extraordinarily difficult in the context of the informal economies of many low-income countries, where crowded markets, workplaces, transport hubs and water points form the essential scaffold of economies and livelihoods.

Our current best guess for priority control measures against severe acute respiratory syndrome coronavirus 2 transmission are summarised in figure 1, which shows how physical distancing and regular handwashing at key moments are key to cutting the transmission routes of the virus.

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Figure 1

Breaking the chain of COVID-19 transmission in the community (distancing and hand hygiene preventive measures shown in red, not including surface hygiene and mask wearing).

Different behaviours are also expected from different subpopulations. The vulnerable, including the poorest, the elderly, the immuno-compromised and the disabled need most protection, but often they are in circumstances that make them the hardest to shield from the virus. Key workers need protection in the workplace, but the conditions for physical distancing may not be in place.

International guidelines, from WHO, for example, should form the basis of behavioural targeting, but with careful consideration of what is feasible and sustainable in local circumstances. Advice will also change as more evidence comes in. It is vital that government agree on the key behaviours they wish to promote. These should be simple, feasible and coherent. For example, in the UK clear mass messages, such as ‘stay at home’ and ‘wash your hands’ have been effective, with recent polling showing 94% of respondents saying they know what they need to do to limit their risk of contracting coronavirus and 98% of people feeling well informed about physical distancing and how it applies to them.

Step 4. Review what is already being done internationally and locally

While every country has different contexts and needs, the simple principles of blocking the transmission of the virus from one human to another remain the same everywhere (figure 1). The epidemiological consequences, however, differ from country to country depending on the demographic, social and physical circumstances and vulnerabilities of the population, as well as by the level and types of control efforts.

Country programmes need to be aware of global developments, without being overwhelmed by the plethora of information appearing on huge numbers of platforms from many different sources. Most available information is currently focused around the needs of richer countries, which have experienced the virus first, and it is hard to find reliable information relevant for low-income settings. The most authoritative sources should be sought out. These include established, reputable newspapers and news sites on digital media. The most reliable sources are generally academic in nature, but may require prior familiarity with the clinical, modelling, epidemiology and disease control sciences to interpret and it can be hard to see how research findings apply practically. Furthermore, much is being published on COVID-19 without peer review, which means that conclusions cannot always be relied on. Up-to-date research can be consulted at: https://www.ncbi.nlm.nih.gov/research/coronavirus/, https://www.thelancet.com/coronavirus, https://coronavirus.jhu.edu/map.html. Other more user-friendly sources include https://www.thecompassforsbc.org/trending-topics/covid-19-resources-social-and-behavior-change, https://community.ready-initiative.org/ and the COVID-19 Hygiene Hub https://hygienehub.info/COVID-19. These initiatives provide curated reviews and tools, up-to-date evidence summaries and resources to help translate new findings into practical implementation strategies.

A key role for one member of the national task force is to keep under review what is being produced. Good efforts should be highlighted and multiplied, while misinformation needs to be spotted and countered speedily. A press subcommittee for the task force can be formed for media advocacy, to encourage responsible journalism. If resources and time allow, a professional PR firm should ideally be brought on board to help to shape the national narrative.

Step 5. Review what is known about the drivers of risk behaviours internationally and locally, and rapidly fill in any gaps in knowledge

The country task force needs to be aware of current evidence about what drives changes in the behaviours that they wish to see. This is because behaviour is not driven by knowledge alone. An effective national communications plan will need to engage the population with information that is new and surprising so as to get and keep its attention, the communications have to be able to motivate action (revaluation), by making the behaviour something that people will find rewarding to do—for a variety of possible reasons—and above all, the advocated behaviour has to be possible, as infeasible advice is simply counterproductive.8

We already know in general what the main drivers of handwashing behaviour during non-pandemic conditions are. First of all, people wish to remove any disgusting material from their hands, whether after the toilet, after sneezing or after contacting greasy or dirty material.4 Second, people wash hands as a sign of good manners, for example, to protect others when serving food or shaking hands.16 This is, to some extent, enforced by social norms, especially when handwashing takes place in public.17 Nurture of offspring and other relatives is also a well-established motive for handwashing.18 There is also evidence that handwashing increases in the face of fear of an epidemic, although it may rapidly return to baseline level afterwards.2 These are global drivers of handwashing and do not seem to vary much between countries.19

While these motives can all be potent divers of handwashing behaviour, it still takes time and effort to wash hands, and the likelihood of compliance is dependent on the ease of performance. While only small amounts of water and soap are needed, when these are expensive, and/or hard to access, the likelihood of handwashing falls dramatically.1 National WASH efforts should be ramped up to make domestic water supply more easily available, always with the proviso that this may be hard to achieve for large populations in the short term. There may also be a case for the large-scale production, procurement, placement and management of water tanks and handwash stands, especially for work and educational places (box 2).

Much less is currently known about the drivers of distancing behaviours. Disgust of the possibility of being infected by the emanations of others is a natural response to pandemics, but this is not a recommended route to use in promotion, since any invocation of disgust could led to stigmatisation of individuals.20 Such distancing behaviours also go against a tendency to want to approach and interact with fellow humans, especially in times of distress.

Aside from motives for safer behaviour, national programmes urgently need to learn more about how to make distancing measures feasible in their own socioeconomic contexts. Here local intelligence is critical. Given time and resource, full-scale formative research into current behaviour would be desirable,8 but what can be done speedily and rigorously in a pandemic, potentially under lockdown conditions?

First of all, any valid research is better than none. Table 1 provides some suggestions for rapid canvassing of local behaviour and behavioural drivers. The emphasis should be on capturing the voices of those who are less likely to be heard, since decision-makers are generally drawn from urban elites, their anecdotal evidence may not represent what is happening in the general population. Specific research may be needed to understand the problems of particular vulnerable groups, for example, the aged and those with disabilities.

The national task force should commission such rapid research, but also gather reports from other partners with on-the-ground intelligence about existing behaviour and its drivers. A rapid way of extracting salient information is to hold an insight workshop. Here the data are reviewed, then all participants write down on slips of paper any facts that have struck them. These can then be grouped and arranged in order of likely importance. The point of gathering such intelligence is not academic, but to rapidly gain insight as to what is happening, and as to what could cause changes in the desired behaviours21 (https://www.lshtm.ac.uk/sites/default/files/2017-03/BCD20Guide.pdf). For example, an early online insight-generation workshop held by a design team in Tanzania zeroed in on the strong national identity and shared responsibility for each other.

Step 6. Produce a creative brief and theory of change

With the team assembled, target behaviours decided and insights about those behaviours marshalled, it is time to design the communications strategy. Table 2 gives an example of a draft creative brief produced to assist in the development of a communications strategy for COVID-19 in Tanzania. Such creative briefs are central to communications campaigns because they summarise the ‘must-have’ components for everybody involved. This example includes a problem statement, purpose, objectives, target behaviours, audience data, the persuasive argument, the tone, personality, measures of impact and materials required from the creative team.

In normal times, the creative brief would be sent out to tender for professional creative teams to bid to create a national communications campaign. The best technical and financial proposal would be selected, the company would be contracted and a design process with numerous phases of creation and reverts would be instigated. In an emergency such as this, however, the process may have to be short-circuited. The task force will need to find rapid means to source creative inputs. Help can be sought from the private sector, as set out above, from creative individuals and from international organisations with skills in communications. While all will be used to working from creative briefs, it is important to note that every client and every creative organisation employs different language about the creation of content and the task force will need to devote time to ‘getting on the same page’.

Underlying the creative brief is a theory of change. There are many ways of drawing up a theory of change. BCD employs a simple, generic version as shown in figure 2. This sets out how the communications intervention will change the social and physical environment in which people live (including the messaging they see), how this will change something in their minds persuasively (through motivation, beliefs and habits), how this will change their behaviour and how this will reduce the risk of transmission.8 The theory of change provides the links in the chain from intervention, which must be surprising, cause revaluation and be possible to perform, to impact and serves to constantly remind the team that if any of the links are broken, the communications chain will be ineffective. It also serves as a guide as to what factors need to be monitored and evaluated throughout the intervention chain and for identifying any unintended harms caused by the intervention.22

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Figure 2

Generic theory of change.

The basic principles of successful communications are shown under the diagram. Communications have to be surprising, cause revaluation of the behaviour such that individuals will be motivated to act and performance of the behaviour should be enabled (eg, by making it easier to do). We expand on these below:

Step 7. Develop a unifying national brand

With a creative team on board, the first task is to develop a unifying national brand. Communications are only effective when they are trusted.33 This is one reason why companies use brands—as a guarantee that they can be held to account for what they produce.34 The same is true for national institutions, which have vital roles to play in coordinating social responses to disasters. This trust is precious and government brands need nurturing through crises. Government has to be transparent, by admitting what they know and what they do not know (and a lot still remains unknown about this virus). They should make clear the distinction between science and politics, publish their data, explain their sources and their reasoning for adopting particular strategies.

While the bombardment of materials coming from many directions has raised awareness about the problem of the coronavirus pandemic in most countries, authoritative instructions and advice about what to do about it often remains confused. Governments need to rapidly brand their national campaigns to help to establish credibility and trust and ensure coherence.

A brand usually involves (at minimum) a tagline and a logo. The logo could be based on existing recognised government brands but needs to have new, eye-catching elements. The tagline should very briefly encapsulate the primary insight of the campaign, as set out in the brief. For example, the New Zealand government’s COVID-19 brand (https://COVID-19.govt.nz) has a tagline, ‘Unite against COVID-19’, uses consistent pictorial symbols, has a black and yellow diagonal stripe that alludes to the hazard tape used at an accident scene, employs a simple, friendly typeface and presents information that is clear, precise, pragmatic and accessible.

Step 8. Develop executions employing the most relevant channels for the target audiences

With a brand established, the next task is to develop creative materials such as ads, posters and other media that embody the brand message and insight. These have to be designed to fit the dominant channels of communication in society, (set out in the brief). Content may take the form of standard TV and radio commercials, or of ‘memes’ for social media, or of content for existing TV and radio shows to generate discussion and social media sharing.

Communications should employ trusted sources: marketers have long found it profitable to use members of trusted groups, such as doctors or celebrities, as vehicles for their messaging. The trusted spokespeople should be recognised by their communities and be relevant to the content of the message. Public health authorities, have a key role here, though they need to be able to speak with confidence and experience. Trying to cover up for failings, rather than acknowledging them tends to be counterproductive of trust since it is hard to disguise from the public.35 Religious leaders can be trusted figures, but may also spread misinformation and bad advice (as in the case of those who advocate coming together for religious services in the face of government recommendations).

In lockdown conditions, live shooting or recording may create difficulties. However, these can be overcome through CGI, animation and remote conferencing. For messaging to go viral it must be worth sharing, that is, one person who sees the ‘meme’ must believe it will entertain or enlighten the next person to see it. It must serve as a desirable gift, not just noise. This makes it all the more important that content is surprising, engaging, enlightening and useful to people. For executions to be effective, they should show the target behaviours in their actual settings, and acknowledge the limitations of how far it will be possible to actually carry them out. Table 3 sets out some examples of good communications materials along with some explanation of why they are likely to be effective.

Step 9. Rapidly pretest and continually revise materials

In an ideal world, new communications content is pretested with samples of target audiences to establish comprehensibility, believability, engagement, likeability and the likelihood that it will be acted on. In emergency conditions, some pretesting, for example, through phone calls with small samples of target audiences, who are asked to view candidate materials online, and respond to them, will still be valuable, allowing course corrections before poorly performing materials are released.

Content will also need to be revised and refreshed often, as the impact of communications diminishes as surprise fades and circumstances evolve (including government policies about what is required at a given stage to control the disease). It may be possible, however, to develop an evolving story line, with engaging characters whose behaviour gradually evolves as the situation develops. An example is the Soul City TV and radio series broadcast from South Africa, anchored in the reality of life in a poor community, which has covered a large range of evolving health and social issues including mother and child health, HIV, cancer and alcohol abuse.

Step 10. Monitor, evaluate and share lessons

Continual monitoring of the effect of communications on behaviour and behavioural indicators is essential to allow course corrections. For example, in the UK, when it became obvious that public transport use had fallen to some 10% of prepandemic levels, it was realised that it would not be necessary to focus on reducing the use of public transport in communications. Usage will be continue to be closely monitored as and when lockdown measures are relaxed.

Monitoring of the effect of communications offers particular challenges in pandemic circumstances. Industry, however, is well used to using professional telephone panel survey companies to remotely monitor the effects of their brand-related communications. Such companies are now offering their services in the current pandemic. For example, Geopoll has conducted a remote SMS study of the effects that coronavirus is having in 12 African countries. Ninety-six per cent of participants reported that they had taken measures to protect themselves by increasing handwashing and avoiding public places. Ninety per cent of Rwandans (who are under lockdown) reported staying home while only 57% of Beninois said that they were. In the sample, trust that government was doing the right thing was highest in Rwanda and lowest in Kenya.36

Because these surveys will be repeated at regular intervals they can provide indicators of the success, or otherwise, of government-led communication programmes. It is, of course, recognised that such surveys inevitably oversample the literate and the phone user. To counter this, special surveys could be commissioned targeting the old and the vulnerable, by reaching members of their families. They can also be used to detect the unintended consequences of an intervention, as for example, when, in the above survey, 80% of respondents said that they were worried that they would not have enough food to eat, mainly due to local market closures.

There are multiple existing and new international fora exchanging information and learning about COVID-19. While joining such fora may not seem a priority at the start of an emergency, COVID-19 is a global problem which will not disappear any time soon and reciprocal efforts to share lessons will pay off eventually for the whole planet.