HC3 in Action: SBCC in Public Health Emergencies

“Public health emergencies have no finish line. Even when the peak of a crisis has passed, the public health system must work to recover from the crisis and actively prepare for future crises.”

This brief describes key examples, challenges, and insights from projects implemented by the Health Communication Capacity Collaborative (HC3) and partners during the various phases of a health emergency response - from prevention and preparedness, through to crisis response and recovery. Using examples drawn from the Ebola and Zika outbreaks in Africa and Latin America, the brief highlights how social and behaviour change communication (SBCC) is a key mechanism for linking efforts between health systems and communities in emergencies. The examples specifically illustrate the SBCC Emergency Helix developed by HC3, which is a programmatic framework for integrating SBCC throughout a public health emergency. As explained in the brief, “The Helix highlights critical actions during an emergency in seven strategic objectives: Prepare, Inquire, Mobilize, Sustain, Adapt, Reflect and Evolve. At the core of the model, is the essential relationship between communities and health systems in building resilience. Just as our DNA adapts and evolves, the Helix is flexible and can be adapted for different types of emergencies.”  This report forms part of the "HC3 in Action" series which seeks document and synthesise the HC3 project’s experiences and lessons learned on topics that cut across the project’s diverse portfolio of activities.

Each chapter in this brief discusses the different SBCC strategic objectives outlined in the helix (prepare, inquire, mobilise, sustain, adapt, reflect and evolve) to illustrate how the Helix works.  SBCC activities are also viewed across the different stages in the crisis management process: pre-crisis, onset, response, recovery, and reconstruction.  For each phase, the chapter highlights examples of activities, the SBCC actions required, and offers HC3 resources for further reading. 

The first section describes the strategic objective of preparing for an emergency in a pre-crises stage. It describes, for example, how HC3 worked with the Center for Health Information and Communication (CICS), at the Instituto Nacional Saúde Pública (INASA), in Guinea-Bissau to strengthen the Institute’s capacity in health communication, with a special focus on emergency preparedness. This included trainings for specific groups and staff members who play a critical role during public health emergencies, including medical responders and media workers. Journalists and community radio staff learned skills for improved emergency response reporting as well as rapid community mobilisation. In order to foster public trust, INASA also established a feedback loop that engages communicators, public health workers, and community leaders.

Enquiry is considered crucial during the next onset stage of a crises, and using examples from both the Zika and Ebola emergency responses, the brief emphasises the importance of conducting a landscape mapping exercise and data collection to help develop a communication response and strategy, and ensure messages address actual key health behaviours, knowledge, beliefs, and norms impacting the crisis. In particular, information and communication technology (ICT) can be used to rapidly collect information in a crisis situation.

To describe the strategic objectives of mobilisation during the onset stage of a crises, the brief highlights how community engagement and social mobilisation became essential strategies for curbing the behaviour-driven crisis, particularly in relation to the Ebola crisis.  Activities included adapting existing tools and materials to mobilise communities by conducting rapid formative research and pre-testing with health workers, illustrators, Ebola survivors, and others to ensure relevance to the local context. To coordinate communication and community mobilisation activities being conducted by multiple national and international responders, in Latin America, HC3 conducted a Zika communication activity mapping, which was intended as a tool to support country-level coordination, and as an input to inform country-specific Zika communication plans.

In order to sustain SBCC activities (once the initial wave of response is over) during the response phase of a health emergency, it is necessary to establish mechanisms to help communities and health systems stay attentive to emergency risks and complications. Responding to fatigue is also essential for mitigating emergency flare-ups and avoiding negligence of non-emergency health issues. SBCC activities involved community-based media, such as radio, to link communities and health systems and disseminate tailored responses that respond to the changing needs of the community. The project also established a dedicated materials working group to ensure that all Ebola-related communication was correct, consistent, and harmonised. 

During the the response phase it is also necessary to adapt SBCC activities. As emergencies develop and evolve in unpredictable ways, the SBCC strategy must be highly flexible. As new information is confirmed and as the complexity of community realities become apparent, the desired behaviours and barriers to behaviour change will change. Keeping a close ear to community anxieties ensures that SBCC professionals have the information they need to adapt with the emergency. The report offers examples of how the programme responded to rumours, conducted rapid assessments to get a snapshot of community feelings towards certain issues, and held a series of district-level mapping exercises and a social mobiliser forum to gather information about challenges from social mobilisers in the field, to be used to adapt existing strategies.

The recovery phase is seen as a time to reflect on SBCC activities and to learn from what worked and what did not in order to be better prepared for the future. It is seen as an opportunity to build better health systems and communities, and to identify and share best practices and failures. For example, HC3 supported various post-emergency evaluations and research activities, and helped develop knowledge management tools and platforms to expand access to messages and lessons learned for all groups involved.

During the reconstruction phase SBCC activities should evolve to adapt to new challenges.  As explained in the brief, “[O]nce a public health emergency subsides, communities and health systems may face critical new realities as they recover and rebuild”. With regards to the Ebola crises, one new challenge was to address the strained relationships between health care providers and communities.  Activities involved rebuilding trust in the health system which included research, community dialogues between health system representatives and their community, and the revamping and rebranding of clinics.  The project also conducted post-emergency capacity building to ensure that countries are in a stronger position to respond to future emergencies with strategic SBCC.

While the SBCC response will change with the phases of a public health emergency, the brief outlines four underlying principles which remain critical throughout the cycle outlined in the SBCC Emergency Helix.  SBCC activities should be: community centred; have rapid mechanisms for research, implementation and feedback; and use a systematic approach which can harvest powerful and focused streams of information from the flood of contradicting messages. SBCC efforts should also be coordinated, establishing active and ongoing relationships between sectors, stakeholders, and the public by gathering disease control information, health system information, and audience insight, then integrating it into information that households and decision-makers really need.