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Risk communication and community engagement in COVID-19: Fighting infodemics among non-governmental/ community-based organizations in Africa

As the world battles the latest strain of the coronavirus known as COVID-19 characterized as a pandemic by the World Health Organization (WHO), “infodemics” – an excessive amount of (mostly untrue) information about the pandemic that makes it difficult to discern essential information – has been identified by the health body as one of the major obstacles to be tackled to win the war against the raging pandemic. In a bid to control spread of the virus, the WHO published a guideline on Risk Communication and Community Engagement (RCCE) to COVID-19, noting these responses are vital for containment. The COVID-19 pandemic is testing and stretching health systems and their ability to effectively communicate with their populations. Failure to communicate accurate public health facts could lead to losses of trust, reputation, economy, and lives. This paper turns its searchlight on nongovernmental and community-based organizations (NGOs and CBOs) in Africa, and how they handle infodemics in an information environment battling not just a health pandemic, but a hoax pandemic too. Methods: The study employed mixed method, with data drawn from Africanbased NGOs and CBOs via online questionnaire and interviews against the backdrop of the Situational Theory of Publics. Findings reveal, based on what NGO/CBO survey respondents report their local clients think, that many at the grassroots still do not believe COVID-19 is real, while others view it as government’s scheme to embezzle funds. NGO/CBOs therefore look to WHO and Health Ministries for accurate information. It concludes that RCCE with the public and atrisk populations help reduce confusion and builds trust in the public health guidance community members can take thereby restricting the disease spread as an outcome of the RCCE approach.


Introduction
As the world battles the coronavirus disease  it is clear that the World Health Organization (WHO) is not just battling to contain the spread of the virus, it is also fighting frantically to stop the spread of what the WHO Director-General, Tedros Adhanom Ghebreyesus has termed "infodemics". "We're not just fighting an epidemic; we're fighting an infodemic" the WHO Chief stated. The new term gained popularity after WHO Chief mentioned it at the Munich Security Conference which was held on 15 th February, 2020. 1 Infodemics is defined as "an overabundance of information -some accurate and some not -that makes it hard for people to find trustworthy sources and reliable guidance when they need it". 2 Referring to voluminous information regarding a subject, infodemics can multiply exponentially carrying along misinformation, rumors and information manipulation as a result of a specific incident within a short period just like it is being experienced with the current pandemic. 2 Examples of these infodemics spreading across Africa included the widespread believe in Tanzania that steam inhalation is effective in killing the virus, while in Kenya, consuming alcohol was touted as effective in killing the virus in the throat. 3 In the southern part of Africa, it was claimed that the African skin is resistant to the coronavirus. 4 Reiterating this, the WHO Chief said "We're not just battling the virus. We're also battling the trolls and conspiracy theorists that push misinformation and undermine the outbreak response". 5 Datta et al. 6 as noted while the information's quick diffusion has been instrumental in the containment of the virus in the world, it has on the other hand caused panic. Thus, unrelenting rise in access to and use of mobile phones, social media, the internet and other communication technologies is a situation which has led to an unprecedented production of information by and shared with billions of people in various parts of the world, thereby increasing the chances of people getting misinformed. 7 The danger of infodemics is its inherent ability to "cause widespread public reluc-tance to adopt well-founded infection control measures promoted by health authorities -and thus delay essential intervention", 7 hence the need for governments and leading agencies such as WHO and its partner agencies to engage in risk Journal of Public Health in Africa 2022; volume 13:1620 Availability of data and materials: All data generated or analyzed during this study are included in this published article.
Ethics approval and consent to participate: All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Research Committee and with the 1964 Helsinki declaration and its latest amendment.
Informed consent: The manuscript does not contain any individual person's data in any form.
communication and community engagement (RCCE). RCCE -a set of intricate skills which professional health workers and authorities deploy during an outbreak is vital at such a time as it helps to dispel false information by frequently spreading accurate information to regain public trust and maintain credibility. 7 While new communication challenges are encountered with every public health emergency, the COVID-19 pandemic is a challenge to "public health sectors and thus, making it hard to effectively communicate with the populations. Failure to communicate health facts lead to a loss of trust and reputation, economic impacts, and in the worst-case loss of lives". 8 In general terms, infodemics response can be quite challenging as it is deeply rooted in the society, often heard by the masses through informal means known as street talks. This spread of misinformation happens in public places such as market squares or social media in which there are no adequate means of verification.
Touted as a germane component of health emergency readiness and response activities, RCCE is believed to be "one of the most important and effective interventions in a public health response" as it aims to "proactively communicate what is known, what is unknown, and what is being done to get more information, with the objectives of saving lives and minimizing adverse consequences". 8 Melissa Fleming, Under-Secretary-General for Global Communications at the United Nations corroborates this stating that "fear, uncertainty, and the proliferation of fake news have the potential to weaken the national and global response to the virus, bolster nativist narratives and provide opportunities for those who may seek to exploit this moment to deepen social divisions". 9 WHO in its Risk Communication and Community Engagement Readiness and Response to Coronavirus Disease  interim guidance enumerates reasons why RCCE should form part of responses to a national public health emergency to include the fact that: if RCCE is effectively done, the risk of social disruption among the populace can be reduced thereby safeguarding jobs, tourism and the economy; if carried out properly, RCCE engages communities strategically as partners in response to the outbreak thereby both health experts and communities can work to develop interventions with far reaching effect; RCCE if well implemented helps in areas such as contact tracing, case reporting, surveillance among others. 8 Non-governmental organizations (NGOs) and community-based organizations (CBOs) are a perfect match in this endeavor "given their deep connection with spatial and sectorial issues" as they engage closely with communities, and know and feel the pulse at the grassroots. 10 NGOs/CBOs in Africa are a perfect match having gained the trust of many grassroots communities as a result of their efforts over time in providing much required health services and filling gaps left due to states' deficiencies in dealing with health crises such as HIV/AIDS, malaria, tuberculosis, Ebola among others. [11][12][13][14] To explore the important roles that NGOs and CBOs can play as partners in RCCE to bolster African governments efforts in the fight against COVID-19 is the reason this study was undertaken. Thus, this study intends to achieve the following 2 objectives: i) know the experiences of NGOs and CBOs in Africa with regards to infodemics at the grassroots; ii) identify how they deal with infodemics among the public and at-risk populations and its capacity to contribute to developing indigenous communication strategies capable of bringing about the needed behavior and lifestyle changes for the containment of the spread of the virus disease at the grassroots.

Literature review
COVID-19 is surging in most African countries which were late to record cases while other countries have reached the peak and the numbers are now dropping steadily. Apart from being the least equipped continent in addressing health catastrophes and bearing a double weight of the COVID-19 pandemic, Africa has become a worldwide aggravation as the virus spread throughout the continent. 15 Globally, over 22 million people have been infected and Africa is approaching one million confirmed cases as of 21st August, 2020. However, the death rate in Africa is still low with a steadily increasing recovery rate ( Figure 1). Figure 1 shows the cumulative number of confirmed cases by regions as of the 21 st of August, 2020. The report indicates that the Americas recorded the highest while Africa is second to the last with over 900 thousand confirmed cases.

NGOs/CBOs responses to pandemics in Africa
After COVID-19 pandemic broke out in China and started spreading in other parts of the world, African countries had no recorded cases until March 2020. Since then, African governments have formulated different policy measures to help contain the infection rate like other countries. NGOs/CBOs are engaged in community sensitization and awareness creation as well as supply the needy with basic necessities such as food, hygiene kits (nose masks, hand sanitizer), medicines, and supporting maintenance of critical health services as full and partial lockdowns were ordered. 16 The NGOs/CBOs are engaged in massive community engagement through awareness creation. One such NGO like World Vision organization is present in almost every part of Africa. They collaborate with governments for awareness creation, dissemination of WHO/Ministry of Health approved information. As part of its intervention, the World Vision "conducted community awareness creation prevention measures, through the spread of brochures and flyers. Endorsement of 5% Zone Programs' budget to go towards COVID-19 response". 17 Furthermore, West African Health Organization (WAHO) under ECOWAS, as part of its mandate for diseases control and prevention, among others, conducted several activities to contain the virus in West Africa. One such activities was offering of free training on risk communication and community engagement to NGOs, CBOs, government officials, and youths. WAHO describe risk communication as it refers to the real-time exchange of information, advice and opinions between experts and those exposed to threats related to their health and economic and social wellbeing. 18 Its objective is to give out correct and timely information to the people so they can take precautionary measures and make informed decisions to protect themselves.
It is evident that WAHO and its partners are working hard to contain COVID-19 in West Africa in which case fatality rate is at 1.50%, total confirmed cases 158,110, recovery 130,081, death 2368 and active COVID-19 cases 25,660. 19 This is just to exemplify the works of NGOs/CBOs in response to COVID-19 in Africa. In addition, the Office of Youth Envoy at the African Union conducted a youth consultation series in which several experts were invited to speak to the youths on various topics on a weekly basis ranging from economics, to business, health, entrepreneurship, among others. 20 Both NGO's and CBO's have consistently put some efforts on responding to COVID-19 pandemic and infodemics in Africa. However, they are still confronted with hurdles like political involvement in infodemic response. For instance, the late Tanzanian President John Magufuli, a wellknown coronavirus skeptic, had a long-lasting impact on vaccine recipients. Tanzania has witnessed a low response to vaccine since the previous president did not believe in the benefits of vaccines and Tanzania refused to engage in vaccination efforts because they believed there was no coronavirus. 21 The fact that no vaccines were necessary was a part of his argument, making it difficult to persuade people otherwise.
On the other hand, in most of rural Africa the ability to obtain accurate information has been hindered. The bulk of COVID-19 awareness information and materials presented are ambiguous, fostering doubt and hostility among the public, as well as distrust among health professionals. Individuals are frequently deceived and disregard other vital information when signals are confusing. 22 According to the study, the majority of the awareness messages opposed interaction with animals. However, evidence did not support this, and it is possible that this impacted how rural inhabitants, particularly livestock farmers, understood the facts.
However, the African Centers for Disease Control and Prevention (Africa CDC) and the International Federation of Red Cross and Red Crescent Societies (IFRC) have established a new cooperation to increase community resilience and public health emergency response. A Memorandum of Understanding was formed between the two groups to assist countries with pandemic devastating COVID-19 infections, including testing, community mobilization, advocacy, and contact tracing. 23

Theoretical framework
The Situational Theory of Publics (STP) guided the study. This theory explains how organizations and institutions identify the people plus the best and most effective way to communicate with them, as well as to observe their communication behavior with regards to information seeking and processing. 24,25 The theory "states that communication behaviors of the people can be best understood by measuring how members of publics perceive situations in which they are affected by such organizational consequence". 24 STP consists of three independent variables to measure its outcome namely: problem recognition (this helps to detect a problem howbeit, with no immediate solution), constraint recognition (this helps to point out hindrances to finding a solution to the detected problem), and level of involvement (refers to the level of perceived connection to the problem). 24,25 The dependent variables in STP are low awareness, low involvement, and ignorance among the public. STP group people into four main types such as non-publics (these are those people who do not recognize the problem or the existence of the problem or the consequences of the problem), latent public (these are people who recognize that there is a problem, but the public is not aware of the problem), aware public (group recognizes the problem), and active public (group organizes to respond to the problem). Therefore, infodemics emerge from the first three group of people because they are either unaware or do not recognize the problem. The finding of this study revealed that spread of infodemics during COVID-19 pandemic is a result of unawareness, misinformation, and unwillingness to recognize the problem.

Research method
This research adopted mixed methods, a combination of both qualitative and quantitative methods. Thus, structured questionnaire (Google form) was used to gather first-hand information on how NGOs/CBOs are handling infodemics during the COVID-19 pandemic. Employing the opportunistic sampling method, the questionnaire was sent to a total of 30 participants, all of whom are staff of NGOs/CBOs across Africa. 24 responses in total were received and analyzed.

Analysis and discussion
The research adopted mixed methods of research to collate, study and analyze the data. The data was drawn from a total of 24 respondents affiliated with NGOs/CBOs across Africa. Respondents from NGOs/CBOs based in West Africa 17 (70.8%) were the highest, followed by 6 (25%) in East Africa and 1 (4.2%) based in North Africa.
The analysis commenced with the demographic information of the respondents, analysis of infodemics which respondents reported in the communities they serve, and the measures taken to handle the misinformation circulating in the communities. Figure 2 represents gender of the respondents. Out of 24 respondents 18 (75%) were males while 6 (25%) females. This means that more males participated in comparison to females. Figure 3 indicates the age of the respondents in which the majority are 15 (62.5%) fall within the age bracket of 28-37, 4 (16.7%), 18-27 years, 3 (12.5%), 38-47 years and only 2 (8.3%) are within the age bracket 48-57. This means that majority are youth and demonstrating the youthful population of Africa. Therefore, the youth are both advocates against infodemics and carriers of infodemics. These youth are chosen from CBOs/NGOs who are in a decision making position to ensure the reliability and trustworthiness of their information supplied in this study. They are either program managers or project managers or communication officers of their organizations.

Some infodemics identified by the NGOs/CBOs during Covid-19 in Africa
Evidently, most of the respondents agreed that there are infodemics or misinformation circulating in Africa like wildfire. All the 24 respondents stated that infodemics like "Coronavirus does not exist or not real among them". They claimed that "African governments are using COVID-19 to get funds from the Western World" or "an opportunity to embezzle public funds". Also, the existing infodemics such as "Coronavirus is a rich man's sickness", "blacks are immune to Coronavirus", "COVID-19 is as a result of 5G network, bioweapon leakage", and "the virus cannot survive in hot temperature". Therefore, "hot tea or chili pepper can serve as a cure to the virus". These are all considered conspiracy theories in which the propagators take advantage of the situation with an ulterior motive to mislead the people. This aligns with one of the principles of Situational Theory of Publics which is the recognition of the situation as a problem, 25 and so those who heed the misinformation are subject to take action that are of no effect on disease transmission such as drinking hot tea or eating chili.

How is your organization handling such misinformation or Infodemics during COVID-19?
Out of 24 (100%) respondents, 6 (25%) respondents said their NGO/CBO train, enlighten and educate members of the public on how to fact check or verify information they receive about COVID-19, while 9 (37.5%) of respondents' NGO/CBO raise awareness about COVID-19 sticking only to relevant information provided by certified government agencies, Health Ministry and the WHO such as encouraging personal hygiene like hand washing, social distancing and use of hand sanitizer and face masks. Another 4 (16.7%) of respondents revealed that their NGO/CBO sensitize using the radio to engage in community dialogue backed up with one-on-one sensitization of members of the public with a special focus on religious leaders who have a following and can influence them. The last 5 (20.8%) respondents revealed that their organizations via their Rumor Tracking Committee capture misinformation and work with the Message and Material Development Committee to develop messages and materials to dispel false information/myths about COVID-19.
Aligning with a variable of STP, 25 the method of handling the misinformation and infodemics noted above employs a level of involvement of the audience so they are connected to the problem and by so doing can process information actively to bring about behavioral change needed to contain the spread of the virus.

What impact do you think that "infodemics" or misinformation could have on the lives of the people?
Moreover, 7(29.2%) of respondents believe infodemics can lead to increased spread of the virus. 5 (20.8%) respondents say it brings about loss of lives to the virus. 6 (25%) respondents opine that people can make poor health choices such as refusing testing or refusal to practice COVID-19 protocols such as social distancing.
The last 6 (25%) state that infodemics can have negative psychological effects such as panic, fear and lack of trust in health authorities and experts.
This highlights the constraint recognition of STP as this point out infodemics as a hindrance to finding a solution to the COVID-19 pandemic.

Does your organization benefit from any risk communication and community engagement training of WHO and its partners?
17 (70.8%) respondents said their organizations did not receive any RCCE training from the WHO or its partners, thus leaving them to find information and train themselves. Only 7 (29.2%) respondents reported they were trained by WHO and/or its partners.
This reveals the communication behavior of the African based NGOs/CBOs surveyed according to Grunig, 24 is active as they take the pains to seek out and digest needed information about the ongoing COVID-19 pandemic.

Conclusions
From the foregoing, it is clear that surveyed NGOs/CBOs in Africa are dealing with infodemics at the grassroots, but with an active communication behavior, they intend to pass on same to the public hence they look to the WHO and Health Ministries for accurate information to counter infodemics. The WHO and its partners, especially governments at the local level, through the Health Ministries, should as a matter of urgency reach out to these NGOs/CBOs with required training so they can stay up to date with relevant RCCE skills. Armed with updated RCCE skills and knowledge coupled with the NGOs/CBOs mechanisms such as the Rumor Tracking and Message and Material Development, African based NGOs and CBOs can contribute in developing ingenious communication strategies capable of bringing about the needed behavior and lifestyle changes for the containment of the spread of the virus disease at the grassroots.
Within the larger context of infodemic response by the whole of society in Africa. NGOs/CBOs from the onset of the pandemic expected to support in other critical areas such as patient care, community sensitization, and promotion of hygiene, government support, and contact tracing. This comes on the heels of a costly lesson learned during their response to the Ebola outbreak -early community engagement pays best as it checks misinformation, resistance to treatment and violence against health workers by members of the community. 26 Evidently, RCCE with the public and atrisk populations help reduce confusion, avoid misunderstandings, builds trust in the response, with higher chances of health advice being followed, thereby restricting the disease spread. These are the outcomes of risk communication and community engagement.