Response to COVID-19 through risk communication: Sri Lankan experience

First case of unknown pneumonia was reported in Wuhan City, Hubei Province of China on 31 December 2019. Since then, fast spread of rumours and myths were noted around the world and among Sri Lankans too. Health promotion Bureau (HPB) identified the need of a risk communication plan and also to activate and strengthen the prevailing rumour monitoring, reporting, verification and mitigation system. The HPB highlighted the issue of this novel virus at Influenza steering committee on 9 January 2020 organized by the Epidemiology Unit and informed that HPB has activated the rumour monitoring system.

The Health Promotion Bureau advocated the importance of a well-established risk communication system to ensure the trust of people, credibility and transparency of information and importance of naming and publishing the spokespersons for Ministry of Health, Sri Lanka, at the first meeting held at Ministry of Health chaired by the Director General Health Service (DGHS) on 27 January 2020, even before the first patient was reported in Sri Lanka. Director General of Health Services, Deputy Director General of Public Health Services (DDG PHS-I) and Chief Epidemiologist were identified as spokespersons as a positive response to advocacy done by HPB. Risk communication, spokespersons and credible information sources were included from the first national guideline on COVID-19 issued in January 2020.
Existing system was available to liaise with director general government media and all mass media networks through the Media and Publicity Unit of HPB. Further, a social media network including an official social media web page with blue tick verification and communication network with public, official trilingual website, audio visual (AV) unit with a studio geared to develop AV material, IEC development unit, Community Health Promotion Unit and Family Health Unit working with volunteer groups at grass root level for health promotion, Behaviour Surveillance Unit to conduct behaviour research and all units working with different settings at community level e.g. village, hospital, workplace, school, preschool. Furthermore, the linkage with the public health system at grass root level was utilized for communication activities and the health education officers (HEO) at district level could mediate the process. Capacity building of provincial and district health authorities and consultant community physicians on risk communication along with a risk communication drill conducted in December 2019 and regular capacity building sessions for HEO further strengthened the risk communication system. The preparedness and response activities in the risk communication system be informed and continually optimized according to community feedback through on-going behaviour surveillance and public concerns identified through 24/7 call centre, social media and mass media analysis. The HPB maintained the linkage with mass media network to strengthen the partnership with the Ministry of Health. Mass media supported the risk communication process throughout and HPB participated in the meetings of heads of media stations at regular intervals. It further prepared and disseminated the recommendations for ethical reporting on COVID-19 to the media through DGHS.
Internal communication platforms were strengthened not only within the central level but also with the health care staff at district and field levels. The social media platforms were used to communicate as well as to coordinate the risk communication activities in the community and district level.

Quick communication network was maintained with the World Health Organisation, Country Office and also with South East Region Office and Headquarters
Geneva and other development partners at regular intervals to ensure collaborative work to combat COVID-19. Further, continued collaboration was maintained with other UN agencies and nongovernmental organizations for risk communication and community engagement.
Furthermore, as the problem evolved partners and the sectors to be communicated were increased. Advocacy to political hierarchy, religious hierarchy, private sector, Ministry of Tourism, Ministry of Education, Ministry of Local Government and many other sectors was conducted by HPB.  Gradually, with the spread of the disease from zero cases to community clusters, the affected communities were identified as patients, probable patients, close contacts of patients, people in quarantine centres and people who are home quarantined. Hospital as well as field health care staff directly communicate with the affected communities through direct conversations, over the phone, home visits, public addressing system, trusted influencers and IEC materials. Both hospital and field health staff extend a committed and dedicated service including the communication engagement with affected communities throughout the day.

• Public Communication and community engagement
The importance of being empathetic to all those who are affected, regardless of their community, ethnicity, or nationality and the fact that they have not done anything wrong, and they deserve our support, compassion and kindness was conveyed to all health staff. Risk communication training was conducted to representatives from the initial 17 nominated hospitals for COVID-19 at the initial stage.
Furthermore, the guidance was provided to all provincial/district level health authorities including the fact that photos or videos of patients and their close contacts, those under quarantine and their residence should not be taken or publicized through any media by health workers creating uneasiness and stigma to the affected communities.
• Dynamic listening and rumour management "Fake news is spreading faster than the virus", thus tackling infodemic is equally important as dealing with the epidemic. Rumour monitoring, identification, verification and management system is maintained to ensure correct information to the public. Rumours are monitored through continuous analysis of social media, mass media and calls received at the 24/7 call centre of HPB. Through the established quick communication channels, the rumours/misinformation is verified and reported. Media analysis was done manually through separate teams while a software was also tested as a trial for rumour monitoring using specific key words for tracking.
Rumour management was done by triangulation of methods through social media/mass media and clarifications by call centre and other reporting mechanisms. HPB mediates to provide information promptly and accurately to the public. Dynamic listening is the key to identify public concerns mostly done through 24/7 call centre (hot line 1999). Public concerns, concerns from the health sector and rumours are compiled daily and reported to the spokespersons on a regular basis. Myth busting sessions are conducted regularly with mass media to reinforce the correct information.

Challenges
Risk communication should be based on facts and evidence. However, some officials publicize their personal opinion in mass media and contradictory information could confuse the public. Rumour management and myth busting through all available communication platforms, regular updates by spokespersons, daily technical update and description from the Epidemiology Unit through mass media was the key to overcome this challenge.
Lack of a platform for real time direct communication with the provincial and district level health care officials is noted as a gap. Establishment of webinar system facilities to be connected real time with district level officials being coordinated and proactive planning for risk communication to face the next level of disease containment strategies were identified as the steps to overcome the above challenges.

Strengths and way forward
The HPB had the existing networks and communication platforms to be effectively utilized for public communication in this pandemic. Effective long-standing partnership with mass media networks, 24/7 call centre for the public, well established social media platforms are the major strengths that will be continuously utilized for risk communication. Risk communication on COVID-19 will be continued in collaboration with the key stakeholders and with close monitoring of public concerns throughout the process. Evidence on behaviour research will be utilized while a social behaviour change approach is planned to be implemented to ensure the sustainability of preventive behaviours. Risk communication processes will be maintained and accelerated accordingly to the level of risk and public perceptions based on risk communication framework (Figure 1).