Leaving No One Behind: Pakistan's Risk Communication and Community Engagement during COVID-19

"In a country that did not have a formal risk communication mechanism, a vibrant RCCE platform is now available..."

Pakistan, a low- to middle-income country (LMIC) with a fragmented health system, was challenged to promote behaviours like physical distancing and wearing of face masks as the COVID-19 pandemic arrived in its midst. Against this backdrop, Pakistan set up risk communication and community engagement (RCCE) and implemented multi-pronged strategic interventions. This short report provides a summary of RCCE-related lessons learned in Pakistan to date.

In the early phase of the response, the Ministry of National Health Services, Regulations & Coordination (NHSR&C) constituted an RCCE Taskforce, supported by the Inter-Services Public Relations (ISPR), the media wing of the Pakistan Armed Forces. In late March 2020, the National Command and Operations Centre (NCOC) was formed to facilitate a data-driven, coherent, and targeted response. The collective effort led to a dynamic RCCE approach characterised by regular examination of the COVID-19 data and behavioural insights for strategic response adjustment. The evolving epidemiological and psycho-behavioural picture informed the communication decisions guided by the social constructionist approach, whereby risk is seen to be interrelated with sociocultural context and not just a scientific measure. Global guidance adapted to the local context was implemented, while maximising the opportunities offered by different communication platforms.

This strategy guided the following six interconnected streams:

1. Policy statements via pressers were broadcast on national networks every day or on alternate days to inform the public in real time.
2. Public service messages using creative concepts to promote priority health behaviours presented through animations and live-action videos were broadcast on electronic and social media. Some featured testimonials of health workers, religious scholars, athletes, and celebrities. Theoretical guidance from behaviour change models like Social Norms Theory and the Health Belief Model was used to develop these persuasive messages.
3. To ensure trust in government communication through two-way dialogue, Pakistan started a toll-free, call-in helpline during the first month of the pandemic, which went on to receive over 25,000 calls per day during the next year.
4. Since relatively few Pakistanis have access to TV and social media, the focus was on the country's 183 million mobile phone users in an effort to reach as many people as possible. This goal was achieved through recorded voice messages, used as call-waiting ringtones. Rural communities that may not have even mobile phone penetration were reached through vaccinators via mobile miking from their motorbikes, or through announcements at mosques before the call for prayer (adhan), five times a day.
5. Out of concern for frontline health workers (FLHWs), the We Care campaign was launched, comprised of skill-based training of all cadres of FLHWs on the use of personal protective equipment (PPE) in their setting, efforts to respond to their need for psychological support, and the building of a positive social environment of mutual care between medics and community.
6. Monitoring all forms of media enabled authorities to spot misinformation and fake news and to respond accordingly - not just by countering rumours but by addressing the underlying issue(s), where possible. An institutional mechanism was also established along with the Ministry of Interior to deal with the accounts that consistently generated fake information.

As reported here, this RCCE approach built and maintained a high level of trust in the government's response decisions. Outcomes-wise, several waves of independent surveys from institutions like Johns Hopkins University documented that about 95% of respondents remembered at least one specific symptom, about 50% of Pakistanis consistently showed trust in government actions, and between 60% and 80% practiced social distancing, face mask use, and regular handwashing. The 1166 helpline - originally for the polio programme but adapted for COVID-19 - has become a permanent interface between the people and the public healthcare system.

Among the lessons learned:

• Locally, consistent policy messages coupled with creative messaging helped remind the population of desired actions.
• A two-way dialogue is a necessity for people to seek advice and also report their complaints.
• Information needs of groups having special context must be considered separately. For low-literate or those with poor access to conventional media, mobile phone-based audio messaging is effective.
• Rumour management is crucial although not easy. In some situations - e.g., spontaneous questions in a provincial or district-level presser, where the capacity of an individual (health worker to a health expert to minister) may not be such that they can readily apply the principles of crisis communication - the inability to debunk a rumour was observed, underscoring the need for capacity building at all levels during the preparedness phase (not just in rumour management, but in broader RCCE capacities).
• Principles from global guidance like coordinated communication, message redundancy, continuous flow of information, tailored messaging, and efforts to reaching everyone were implemented, and they worked. However, experience sharing and knowledge management are required to refine the global guidance to make it more nuanced and helpful for countries and programmes in addressing strategic, tactical, and content development aspects, along with their monitoring and evaluation.