Introduction

Since March 2020, the COVID-19 pandemic has brought about a transformative change around the world. While much of the scientific discussions, debates, and research are centered on strengthening health systems and developing therapeutics and vaccines, health authorities, scientists, and political leaders have continuously reiterated the importance of providing information on basic health and hygiene in combating the pandemic.

Stringent efforts by governments can help in the immediate adoption of personal protective measures. But these can only be sustained in the long run by bringing about lasting behavior change. There is an urgent need to undertake effective social and behavior change communication (SBCC) which is key to saving lives.

In the case of COVID-19, SBCC strategies must achieve two complementary, albeit distinct goals: (1) educate citizens on the health risks of COVID-19; and (2) promote desired behaviors to prevent infection. Effective SBCC cannot only help contain COVID-19 but can also help mitigate the adverse consequences of future pandemics.

Lessons from Past Health Interventions in Changing Behaviors

There is a broad global consensus on the behaviors required to reduce the risk of contracting or transmitting COVID-19 [1]. These include maintaining physical distance, washing hands frequently, and wearing masks that cover the nose and mouth, in public spaces.

The adoption of these measures has varied widely across nations. People in East Asian and South-East Asian countries have generally been more accepting of physical distancing and face mask mandates. In these countries, communications from public health officials and political leadership were clear and consistent, reducing confusion and bolstering trust and transparency. In fact, face masks are nearly universal in public spaces in Japan even though the country never issued a mandate to wear them.

There is evidence to suggest that although many measures were implemented for the containment and treatment of Ebola during the outbreak in West Africa in 2014, they were not well integrated within strategies for social and behavioral change during the early stages [2]. Responsive organizations tried to increase the level of threat so that people would take preventive actions by putting out messages that mostly increased fear. This resulted in people not wanting to go to Ebola treatment centers, which, in turn, increased infection transmission and subsequent deaths. During the course of the Ebola outbreak, it became clear that it is important to give people practical and doable steps that they can take to protect themselves, their families, and communities, while believing that the benefits of those actions can increase their confidence and enable them to take control of the situation.

Positive reinforcement of key messages across multiple media is particularly effective in transforming behaviors as has been witnessed from the evaluation findings of the Population Foundation of India’s SBCC initiative Main Kuch Bhi Kar Sakti Hoon (I, a woman, can achieve anything) [3]. Across three seasons, this transmedia initiative demonstrated the effectiveness of a 360-degree communication approach in changing behaviors. The amplification and reinforcement of the same key health messages were targeted through complementary channels, such as television, radio, interactive voice response system, and digital platforms, along with community mobilization and outreach. This strategy could be useful in the COVID-19 scenario given that while young people generally prefer SBCC messaging delivered through social media such as Facebook and YouTube, most adults are informed through television, newspapers, and radio.

Behavior Change Efforts in Response to COVID-19

A positive communication strategy which focuses on inspiring people to adopt healthy behaviors as well as to become agents of change has greater potential to succeed. There is enough evidence to suggest that people are more likely to adopt healthy behaviors when they observe their peers doing the same. In contrast, a communication strategy based on negative messaging and intimidation can backfire by enhancing societal fear and anxiety.

However, only providing people with accurate information does not automatically translate into the adoption of desired behaviors. There needs to be a better understanding of people’s own perception of risk in assessing how susceptible they think they are of getting the disease and the perception of their likelihood of transmitting the disease to others. Furthermore, messaging must be followed up by real interventions designed to change behaviors of the community. Some examples in the case of COVID-19 include placing alcohol-based hand sanitizers at visible locations or using chalk or paint to demarcate six feet physical distancing measures in markets, train stations, and other crowded locations. Behavior change that motivates people to transition to self-efficacy, where individuals are confident of their ability and skills to perform those behaviors habitually, represents the motivational phase of SBCC.

With the spread of the pandemic, misinformation and misconceptions surrounding COVID-19 have been increasing. Even as many turn to the internet and social media for information, there has been a veritable explosion of false and misleading posts, resulting in anxiety and frenzy surrounding the infection. Effective SBCC for COVID-19 requires an active counter-response to dispel these myths and misconceptions.

The uncertainty around COVID-19 messaging is further complicated by the fact that the virus causing it is a new pathogen, and knowledge about the effects of the disease, its transmission, and treatment is continuously evolving. For example, confirmation that COVID-19 can be transmitted by asymptomatic carriers of the disease and that transmission is primarily air-borne required a quick pivot to the recommendation for universal masking. Again, the fact that COVID-19 is more lethal in the elderly and those with co-morbidities required clear communications of this new evidence.

SBCC messaging on COVID-19 must be empathetic and considerate. For example, how do we recommend hand-washing to those who have inadequate access to water and sanitation? How do we motivate communities who live in crowded houses in slums to physically distance? Effective SBCC should be participatory and inclusive so that it reaches out to vulnerable populations and develops a response that takes the local context into consideration.

How effectively governments communicate the messages to fight COVID-19 will determine when and how normalcy resumes. Since March 2020, the Indian government has endeavored to provide information through SBCC campaigns on COVID-19 to its citizens. Aarogya Setu, a mobile app of the Indian government, provides information on the pandemic to the public. It also provides them with advisories. The government also introduced a multilingual COVID-19-related advisory as the default telephone caller tune, demonstrating practical application of SBCC. Government of India’s citizens’ engagement platform MyGov rolled out a series of campaigns on preventive measures pertaining to COVID-19.

Civil society organizations have complemented the official SBCC campaigns. For example, the Population Foundation of India was the content partner for the MyGov’s COVID-19 campaign and supported the Ministry of Health and Family Welfare, Government of India, state governments, and civil society organizations with SBCC materials related to the COVID-19 crisis. Population Foundation of India’s messaging strategy included short films and social media creatives on crucial aspects of the disease, based on a clear understanding of the local landscape. Messages were tailored to this context, using local languages and idioms vetted by epidemiologists and public health experts. The issue of stigma was highlighted, and positive messages on kindness and gratitude to healthcare workers and non-discriminatory messages to patients were promoted. Population Foundation of India also developed the Corona Ki Adalat (The Court of Corona) animation series that used the familiar setting of a courtroom drama to disseminate key messages, tackle misinformation, and reinforce a sense of solidarity around the fight against COVID-19. The objective was to express gratitude to frontline health workers who had been facing discrimination on account of heightened fear and misinformation about the infection. Population Foundation of India developed a short film on female health workers at the forefront of COVID-19. This video was published on the Government of India’s MyGov page and has become one of their top performing posts. It received over 4.6 million hits within 24 hours.

As the country was in various stages of reopening, the Population Foundation of India has launched the Himmat Hai toh Jeet Hai (If there is courage, there is victory) campaign to reinforce a sense of unity by highlighting role models who displayed extraordinary courage in the face of challenges. The campaign aims to inspire citizens at this difficult time. The campaign anthem, which depicts the himmat (courage) shown by regular people in their everyday lives to overcome the challenges that they face, has reached of over 1.5 million on Facebook alone and has been shared by eminent influencers from the media, sports, and the political field.

Important information on COVID-19 provided by the government captured public attention and also conveyed messages that were reliable and appropriate. It also entailed disseminating messages to target audiences across languages, ages, cultural affiliations, and education levels.

Role of Media in COVID-19 Response

COVID-19 is more than just a science and health story. WHO has warned of an ‘infodemic’ or the tendency of people and organizations, particularly on social media, to have too much information flowing, often allowing misinformation a free pass. Media has a crucial role to play in empowering people with the right information. Journalists have a tough task at hand with the constant influx of new information and advisories. As research on the virus progresses, a news piece from today may become outdated tomorrow. Public health experts and researchers have been constantly revising their opinions and recommendations in accordance with the emerging information [4].

During such an unprecedented public health and humanitarian crisis, even more than in peace time, media needs to remain steadfast. It should continue to play the role of a provider of credible information, the provider of a forum where discussions are possible allowing for enriching debates, holding public authorities and the government accountable to citizens if it fails, and providing adequate attention to public health. The record of the media in all three areas has been mixed.

Several journalists and representatives from the media have risen to the occasion and made efforts to ensure that the public discourse around COVID-19 remains a priority. Probably for the first time, India (and the world) have witnessed an amalgamation of science and mainstream news reporting. Journalists have been educating themselves constantly to ensure that the science behind COVID-19 does not remain restricted to a select few who have the knowledge and understanding of scientific concepts. Practices such as mask-wearing, hand-washing, and physical distancing, that must be cultivated by the population at large to fight the pandemic, have been greatly promoted by the media. The media has also raised issues around the challenges that people faced at the ground level during the lockdown.

The media promoted an active and continuous discourse on the subject by constantly bringing to the forefront the latest research and developments pertaining to the disease. Scientists and public health researchers, on the other hand, also realized the need for continuous conversations between mainstream media and science. The collaboration of the media and public health workers and doctors has been commendable. Online portals like The Wire, Scroll, and The Print among others and news anchors like Karan Thapar and Barkha Dutt took time out to doggedly capture the changing picture, day in and day out and week after week, through detailed interviews and stories on the science and health dimensions of the crisis, its impact on the economy, and destruction of lives of thousands of urban migrants because of the lockdown.

We witnessed the Chairman of the Public Health Foundation of India, Dr. Srinath Reddy’s deployment of cricket metaphors on COVID-19 on a popular television channel. A noted mental health expert Dr. Vikram Patel was able to help cut the noise levels on television and get his points across about the need to recognize and battle mental health problems. The media has been consistently seeking the views of noted and trusted experts like Dr. Randeep Guleria, Director of the All India Institute of Medical Sciences, among others to keep the public informed about the causes of the pandemic and the preventative measures for avoiding contagion. The good work to disseminate information that public health professionals have done is hard to measure. Professionals in the private sector have also been forthcoming, in giving time to the media to help educate people and to dispel the myths around COVID-19. Professionals like Dr. Naresh Trehan, Ms. Kiran Mazumdar-Shaw, and Dr. Sangeeta Pratap, to name a few, stepped up and enriched the discourse.

There have been disappointments too, and these should serve as learnings for the future. There were times when the media allowed what should have been a laser-like focus on COVID-19, to slip and be hijacked by divisive and disproportionate coverage of the gathering at the Tablighi Jamaat headquarters in New Delhi, or the matter of the unfortunate death of a young actor in Mumbai. The authorities, by initially singling out the Tablighi Jamaat congregation as the main source of the spread of the virus erred, in our opinion as that could have stigmatized certain communities and groups. But we must recognize that they were quick to recant and drop the classification when it became clear that it was a red herring. There has been a view that media did not question public authorities enough for their inability to provide for citizens or for not thinking through the consequences before announcing lockdowns. But by and large, media personnel, despite the fear of the disease, job losses that haunted the sector, and the stringent lockdown conditions they encountered, did manage to get the news out and prioritized public health during this unprecedented crisis.

Concluding Comments

COVID-19 is the most significant public health challenge the world has faced in our lifetimes. With every passing day, we are coming to terms with the extent of its impact, the nature of infection transmission, preventive measures, and treatment that could be most effective. The longer-term impact of COVID-19 is still not fully comprehended, but from what we know so far, the disease is going to be a part of our lives in the near-term. Much of what we do and say today will influence and shape how the pandemic will impact us in the long run.

In the past few months, we have truly witnessed the power of the media and SBCC. Even if the media did not always keep up with the challenge, it has created a crucial opportunity to think about promoting health literacy beyond COVID-19. As all public health officials tell us, it is important to prepare for future crises and build the resilience and stamina of the people.

Never before has SBCC been accelerated to the extent that it has been in the wake of the pandemic. It has been a mammoth task to get a country with a population of 1.3 billion to adopt novel practices such as mask-wearing, physical distancing, and maintaining personal hygiene in such a short duration. In the past, large-scale campaigns have failed to inculcate new habits. We have a unique opportunity to align insights from the social and behavioral sciences, epidemiology, and public health to create powerful, meaningful, and sustainable SBCC campaigns. Communication efforts in response to COVID-19 must not be viewed as one issue. They should be seen as a step toward meaningful social change. This will enable people to meet the challenges of future public health crises by respecting scientific solutions with a sense of solidarity among citizens.

Until there is universal availability of the COVID-19 vaccine, the only way to protect people and to minimize the burden it places on public health systems is to promote widespread behavior change. And this will only be possible through a collaborative effort of the government, media, civil society organizations, and public health experts.