Learning From the Past: The Role of Social and Behavior Change Programming in Public Health Emergencies

"[I]t is the continuous and flexible deployment of SBC [social and behaviour change] strategies in an evidence-based and holistic manner in conjunction with epidemiological and clinical interventions that can yield the greatest benefits for public health when all integrated within an EID [emerging infectious disease] response."

Influencing human behaviour is often the first line of defense to slow transmission of emerging infectious diseases (EIDs). However, social and behaviour change (SBC) experts are still not consistently included in outbreak response teams. To explain the importance of their voices, this article offers 5 lessons learned that emerge from examples of SBC research and programming during emergency responses to 6 recent EIDs that reached epidemic proportions: HIV, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Zika virus (ZIKV), Ebola virus disease, and COVID-19.

Lessons learned include:

1. Engage communities as a key pillar of emergency response: In the context of EIDs, this approach involves working collaboratively through community groups and using dialogue to establish trust with a community - e.g., by hosting local community meetings, recruiting community members for social mobilisation activities, collaborating with religious leaders, or engaging with local journalists and radio for risk communication that considers the unique traits of the community. Examples include:
   • Ebola: In Guinea, Liberia, and Sierra Leone, past wars, ethnic tensions, and the legacy of colonialism produced high levels of fear and hostility to national and international outbreak response teams during the summer of 2014. In Guinea, 8 outbreak responders were murdered; a local police officer said the villagers believed that Ebola "is nothing more than an invention of white people to kill black people." Within this environment of distrust, top-down externally driven responses were inappropriate for local needs. Public health responders saw that collective problem analysis, cocreation of solutions, tailored interventions, and local ownership of response were needed. In a post-Ebola qualitative study in Liberia, participants mentioned the importance of "strengthening existing community institutions and relationships in calm, non-emergency settings", with leadership from district health officers to formalise communication strategies by the health systems before health crises occur.
   • COVID-19: In populations such as Singapore's migrant communities, a series of missteps in community engagement led to high infection rates and deep mistrust of leadership. Subsequent broad, 2-way engagement with a focus on agency, autonomy, and empowerment of communities resulted in 90% of migrant workers in Singapore being vaccinated. Calls to action for a community-engaged response have included establishing local community COVID-19 vaccine task forces to ensure bidirectional communication and deep understanding of factors likely to drive vaccine uptake.
2. Build trust through transparent risk communication: Open sharing of information as it is gathered can help build and maintain public trust in health institutions, public health authorities, and community leaders. Examples include:
   • SARS: At the outset of the epidemic in 2002, local officials in China failed to communicate the gravity of the situation, and SARS spread around the globe, ultimately reaching 29 countries and causing 774 deaths. In contrast, Singapore was internationally praised for building and maintaining trust with the public, sharing information openly, and encouraging public participation in public health action. For example, the Ministry of Health and officials from the Singaporean government held joint press briefings via traditional media where they committed to sharing information in a timely yet informed manner. Their transparency and willingness to publicly showcase the behaviours they were promoting, such as mask wearing, reportedly made the Singaporean government effective in communicating risks and supporting behaviour change.
   • MERS: The early response to MERS by the South Korean government was heavily criticised for its opacity, so many South Koreans turned away from traditional media and toward social media to gain information about this disease. The interpersonal nature of social media increased the likelihood that users believed their trusted online contacts' information or opinions on MERS. One study found that social media stimulated the adoption of preventative behaviours such as mask wearing, handwashing, and contact avoidance.
   • COVID-19: As seen in this EID, social media can also contribute to an "infodemic" - an overabundance of information that can be hijacked by misinformation. More broadly, although all countries were challenged in reconciling risk communication with a lack of evidence at the beginning of the COVID-19 pandemic, some countries, such as Greece, committed themselves to transparent risk communication; others, such as the United States (US), emerged as super-spreaders of misinformation, as early mismanagement of risk communication eroded public trust.
3. Segment audiences for tailored interventions: Audience segmentation and tailored interventions help meet the needs of specific types of audiences based on characteristics such as attitudes, perceptions, beliefs, concerns, and information needs. Examples include:
   • HIV: Segmentation has helped understand at-risk and impacted populations and ensured that public health messaging and interventions reflect their unique circumstances. One such intervention involves the recruiting and training of trusted and revered individuals in the community, known as popular opinion leaders (POLs), to have conversations with friends about reducing the risk of contracting HIV. To connect with specific communities, such as young, Black, gay, and bisexual men, POL training is tailored to reflect the unique hurdles each group faces - leading to more specific and appropriate solutions.
   • ZIKV: However, imbalanced audience segmentation and tailoring can lead to stigmatised, biased, and gendered health responses. For instance, the government of Jamaica was one of several countries recommending that women avoid pregnancy for at least 18 months until the ZIKV epidemic subsided. These early communications assumed female reproductive autonomy and ignored structural barriers that still exist within the region, largely leaving men out of prevention messaging.
   • COVID-19: Behavioural typologies, or the types of behaviours that characterise particular subgroups, have been used to distinguish people and populations for COVID-19 vaccine uptake. For example, "easy sells" are those who place a high amount of trust in healthcare providers but lack awareness of vaccine availability, and "active resistors" are those with personal, cultural, or religious antivaccine beliefs. This knowledge is being used in health campaigns to address key perceptual and behavioural structures that influence intent to get vaccinated.
4. Prioritise behaviours: Information overload at the beginning of EIDs can result in conflicting and confusing messages. Behavioural prioritisation is the process through which consensus is reached among key stakeholders to prioritise the behaviours with the most potential to prevent EID transmission. Examples include:
   • ZIKV: The early response to the outbreak was challenged by a dearth of scientific knowledge about the disease's evolved transmission routes and health consequences. In the first year of the response, more than 30 variations of preventive behaviours were promoted. By 2018, behaviour prioritisation conducted at the regional level helped reduce the recommendations to 7 behaviours, which were prioritised through a participatory process.
   • COVID-19: The communication of priority behaviours for COVID-19 was not always coherent or evidence-based. For example, early in the pandemic, many health agencies around the world recommended that people clean and disinfect surfaces. However, it emerged that COVID-19 is not transmitted in this way, so health agencies pivoted in their behavioural recommendations accordingly. This example highlights the importance of communicating new evidence as it becomes available while acknowledging the impact it may have on reprioritising behaviours.
5. Cultivate political will and commitment: Across all recent EIDs, behaviour change has been key to protecting health. However, the example of the SBC response "failure" around COVID-19 in the US highlights what can happen when there is a lack of political will and support. Early in the pandemic, US leadership consistently downplayed the threat posed by COVID-19 and contradicted and undercut messages being relayed by public health experts. A slow US federal response led to the highest number of COVID-19-related deaths in the world. On the other hand, as reported here, Greece successfully managed the first wave of COVID-19 because of evidence-based decision making by strong and decisive leadership, effective intragovernmental coordination, and transparent communication that supported high citizen compliance. To communicate these risks, the government of Greece featured 2 leaders during COVID-19 press briefings who "spoke with one voice" and contributed to public satisfaction with governmental leadership.

As noted here, these lessons learned must not be seen as siloed approaches or sequential in nature. Instead, they represent interconnected, continuous efforts that must be iteratively deployed through the ebbs and flows of a public health emergency. The article illustrates this point by looking at more depth at the problem of COVID-19 vaccine hesitancy in the US.

The article suggests that these lessons learned can be operationalised for future responses to ensure the inclusion of SBC experts and other stakeholders who are prepared to navigate the complexities of behavioural change. See Table 2 in the document.

The article concludes that, if further integrated into EID preparedness and responses, SBC experts can implement a proactive, multidimensional approach based on the lessons learned presented. "Now is the time to emphasize the value of SBC and advocate for its inclusion as central to the global health emergency response ecosystem going forward."