A risk communication and community engagement (RCCE) response to support maternal, infant and young child nutrition in the context of COVID-19 in Rwanda

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By Annet Birungi, Ken Limwame, Desire Rwodzi and Youssouf Koita

Annet Birungi is an experienced Communication for Development Specialist at UNICEF Rwanda where she is responsible for the design, management, execution, monitoring and evaluation of behavioural change and social mobilisation interventions for nutrition.

Ken Limwame is currently working on the COVID-19 RCCE in the Middle East and North Africa with UNICEF Regional Office. Previously he has worked in various Communications for Development (C4D) roles within UNICEF including at the Eastern and Southern Africa Region Office and in Liberia during the Ebola crisis.

Desire Rwodzi is a former Knowledge Management Officer for the Nutrition Section with the UNICEF Eastern and Southern Africa Regional Office (ESARO). Desire has over 10 years’ experience working on public health issues in Eastern and Southern Africa and Asia and the Pacific.

Youssouf Koita is the Chief of Nutrition Section at Rwanda Country Office. He has a wealth of nutrition-related knowledge and experience through his work supporting governments in several countries to fight against all forms of malnutrition in both development and humanitarian contexts.

The authors would like to thank the broader UNICEF Rwanda team as well as UNICEF’s Eastern and Southern Africa Regional Office for their support in developing this work. 

Background

At the onset of the COVID-19 outbreak in early March 2020, the Government of Rwanda, with support from UNICEF and other United Nations agencies and development partners, established the National COVID-19 Joint Task Force. The task force, led by the Ministry of Health (MoH) and the Rwanda Biomedical Centre (RBC), was vital to inform the national COVID-19 response and implemented a number of key measures to mitigate and manage the pandemic.

One such measure, following a directive from the MoH, was that nutrition interventions at community-level were instructed to continue. To inform this, clear guidelines were issued by the MoH on nutrition programme adaptations. The guidelines provided a list of nutrition activities and measures to be taken to ensure safe service provision as well as to reduce risks as far as possible to community health workers (CHWs), government and partner staff.  These measures enabled the continuity of growth monitoring services including routine screening for malnutrition, the admission and treatment of children suffering from severe acute malnutrition (SAM) and broader maternal, infant and young child nutrition (MIYCN) activities such as counselling on appropriate complementary feeding and exclusive breastfeeding. Maternal nutrition, infant and young child feeding (IYCF) and food safety and hygiene messages were also integrated into the Standard Operating Procedure (SOP) for inpatient and outpatient management of children under five years of age with SAM. The integration of MIYCN into the SOP also aimed to protect, promote and support safe and optimal feeding practices for both breastfeeding and non-breastfeeding infants and young children in light of COVID-19.

An important focus throughout the COVID-19 nutrition response has been risk communication and community engagement (RCCE) in response to numerous communication and information challenges surrounding the pandemic. The development of a clear RCCE strategy and plan of action was critical to ensure that people had, and continue to have, access to the right information, delivered in the right way and in a timely fashion. RCCE, in the context of COVID-19, aimed to empower people to adopt infection and prevention control (IPC) measures to protect themselves and to avoid the spread of myths and misconceptions about the disease and its effects. This article documents the RCCE activities undertaken by the Government of Rwanda, with support from UNICEF, to address issues related to maternal nutrition and IYCF in the context of COVID-19.

Implementation of a RCCE response to support MIYCN

Location of RCCE coordination

The planning, management and coordination of nutrition-related RCCE activities within the COVID-19 response was led by the MoH in collaboration with Nutrition Sector partners and UNICEF. Two sub-committees were set-up, one focusing on nutrition data management and the other, social behaviour change and communication (SBCC).

Development of RCCE strategy and planned activities

Rwanda already had a national RCCE strategy, initially developed as part of Ebola preparedness efforts that included nutrition-related activities and was further developed in light of COVID-19. Support was provided to the MoH by UNICEF’s Communication, Advocacy and Partnerships (CAP) section’s Communication for Development (C4D) programme to ensure that national and community-level nutrition interventions were clearly defined and in line with the East and Southern Africa Regional Office’s RCCE guidance on COVID-19.

Nutrition-related RCCE needs were identified through a review of existing data from available government reports as well as mainstream media and social media reports and in consultation with Nutrition Sector partners through the sub-committees. Assessment methods included virtual meetings and/or telephone conversations with selected government representatives, representatives from other UN agencies, the United States Agency for International Development (USAID) and non-governmental organisations (NGOs) engaged in the Nutrition Sector as well as with CHWs and frontline health workers. This review helped to identify gaps in knowledge, attitudes and perceptions in relation to nutrition and COVID-19. Findings (Box 1) generated a good understanding of the populations at risk and existing communication channels and ultimately informed the objectives of the COVID-19 nutrition-related RCCE activities. As an ongoing assessment of communication needs, government supervision and CHWs’ weekly and monthly reports were adapted to include gathering information on community concerns, feedback and myths and rumours relating to nutrition and COVID-19.

Box 1: Headline findings of the nutrition RCCE review

The review identified evidence of the following concerns to be addressed through RCCE activities:

• Existence of myths and misconceptions around the prevention and spread of COVID-19 with some likening the disease to Ebola. For example, some frontline health workers were separating children from mothers suspected of having, or confirmed to have, COVID-19 which contradicted COVID-19 guidance (although recommended for Ebola).
• Rural populations suspected that COVID-19 was an urban issue and they therefore did not follow the required prevention measures for MIYCN during the pandemic.
• Caregivers/mothers were not aware of the guidance on the continuation of breastfeeding in the context of COVID-19.
• There was limited knowledge on safe feeding for pregnant and lactating mothers, safe complementary feeding of children under five years of age, household food and drinking water safety and how to help keep family members healthy during the COVID-19 pandemic.
• Caregivers were unsure as to whether to keep taking their children for routine immunisations, regular growth monitoring and promotion sessions and what to do if/when a child fell sick.
• Pregnant and lactating mothers did not know the recommended precautions to take to avoid exposure to COVID-19 for them or their babies. 

Figure 1: Target groups for RCCE activities

Capacity strengthening and training

Capacity strengthening and training were essential to ensure the rollout of RCCE activities. Facilitators from the MoH, supported by UNICEF, developed simplified MIYCN digital training materials that were distributed via WhatsApp and email to frontline health and nutrition workers. Remote training sessions, primarily via Zoom, were then held to discuss key learnings from the training material. Training sessions were attended by 47 participants initially and an additional 547 participants when lockdown was lifted in June 2020. Participants included directors of national hospitals, health centre staff, nutritionists working with CHWs, case management staff and IPC teams. These capacity strengthening activities played a critical role in ensuring a high-quality nutrition response during the pandemic, particularly in relation to RCCE activities. 

Development of key nutrition messages

MIYCN key messages and information, education and communication (IEC) materials were developed by the SBCC sub-committee in consultation with members of both sub-committees. This process was informed by the results of the needs assessment (Box 1) and feedback on community concerns, myths and rumours around child feeding practices gathered through CHW weekly and monthly reports. Regional and global guidance was also reviewed and adapted including UNICEF and World Health Organization (WHO) MIYCN counselling cards. IEC materials were developed for health workers, essential workers and CHWs as well as parents/ caregivers. Messages were adapted to guide caregivers and parents with intellectual disabilities. Tools were subsequently piloted and refined as needed. The main themes of the final IEC materials are outlined in Box 2.

Box 2: Themes of the MIYCN IEC materials

1. The differences between COVID-19 and Ebola and the fact that mothers should continue breastfeeding even if they have suspected/confirmed COVID-19
2. Precautions for pregnant and lactating mothers to avoid being exposed to COVID-19
3. Recommended practices to feed and care for a newborn with suspected/confirmed COVID-19
4. Additional precautions needed during delivery and immediately after birth
5. Precautions to be taken during breastfeeding to keep babies safe from COVID-19
6. When and why a mother should express breastmilk
7. How to practice safe complementary feeding for children 6-24 months of age
8. Food safety, handwashing and sanitation during the COVID-19 pandemic
9. Caring and appropriate feeding for infants and young children in the context of IPC

Testimonials from mothers who had recovered from COVID-19, and who had continued breastfeeding or had given birth to healthy babies, were subsequently featured as community champions through media channels. This helped to address rumours and misinformation.¹

Channels for communication

The MoH leveraged all existing channels to disseminate key messages including print and electronic media. A total of 11,000 printed posters aimed at health workers were distributed to all 48 district hospitals and 500 health centres, including refugee camps and isolation centres, and 70,000 booklets were distributed to CHWs. Hard copies of IEC materials were distributed in conjunction with existing essential medicine and nutrition commodities. In addition, soft copies of the posters were distributed through WhatsApp and group emails. This was followed up with virtual/ telephone briefings through an MoH WhatsApp and email group for all directors of district hospitals, health centres and nutritionists within hospitals. Telephone follow ups were also made to brief staff in the use and dissemination of the materials.

To ensure information reached those with low connectivity, the MoH also made use of the Internet of Good Things (IoGT) – a UNICEF-led initiative that hosts mobile packaged, public health content information for free even on low-end mobile devices. This was initially aimed at frontline healthcare workers but, in time, content was expanded to the general public. Virtual meetings led by MoH, on platforms such as Zoom and Skype, were also used when disseminating messages to stakeholders.

Mass media communication channels were also used. Bi-weekly nutrition messages were aired on community radio stations with a population coverage of 99%. Additionally, nutrition messages during the COVID-19 pandemic were incorporated into the renowned radio drama, ‘Itetero’. Parliamentarians were used to channel information over local radio stations as is described in Box 3. Nutrition messages continue to be disseminated bi-weekly through Radio Rwanda and its five affiliated community-based radios which have a wide and broad population listenership.

Box 3: Engaging with parliamentarians to support MIYCN messaging

At the beginning of the pandemic and in parallel to RCCE activities, UNICEF began engaging with a group of dedicated members of parliament (MPs) to expand the reach of messages on MIYCN in the context of COVID-19. MPs were used to disseminate public health messages to caregivers of children under five years of age through local radio stations. Messages focused on the importance of nutrition, specifically in relation to exclusive breastfeeding and dietary diversity for children 6-59 months of age.

The group of MPs were also able to invite representatives of relevant government institutions to speak to radio listeners on what they were doing to improve MIYCN and food security in the context of COVID-19. These talk shows enabled two-way communication whereby listeners could call in, pose questions, share comments and obtain timely feedback from the panel of government representatives. Working with parliamentarians to champion advocacy and social mobilisation to improve nutrition at all levels was critical to support RCCE initiatives. A major challenge was that parliamentarians tended not to have extensive technical knowledge of nutrition. To mitigate this, UNICEF produced a set of key MIYCN messages in light of COVID-19 for MPs and also held virtual briefings to guide related discussions.

Monitoring impact of the RCCE activities

Indicators from Rwanda’s Health Information Management System (HMIS) were used as proxy measures for the effectiveness of the RCCE programme of activities including indicators around participation in growth monitoring, MNP distribution and admissions and treatment for SAM and moderate acute malnutrition (MAM). Social media dashboards were also periodically reviewed by UNICEF to monitor and track ‘mentions’, hashtags, notifications and trends to gather information and manage rumours regarding COVID-19 and nutrition. Additional monitoring was conducted through the collection of ad hoc information, for example, monitoring the separation of mothers with COVID-19 from their infants and the cessation of breastfeeding. Supervision reports for CHWs were also collated to explore the extent to which CHWs understood the adapted recommendations. It is planned that rapid qualitative and quantitative assessments will be conducted in the coming months to collect further information on the impact of RCCE activities in relation to changes to the diets of pregnant women, mothers and children during the pandemic as well as aspects such as overall breastfeeding rates and to learn more about communities’ knowledge, attitudes and perceptions regarding MIYCN in the context of COVID-19.

Results

Influence on nutrition indicators

Service uptake was monitored to indicate the influence of RCCE interventions. HMIS routine data on nutrition indicators noted that total SAM admissions increased from 9,200 admissions in April 2020 to 10,022 in February 2021. In the same timeframe, the coverage of growth monitoring services grew from 82% to 87% and the coverage of distribution of MNP to children aged 6-23 months increased from 42% to 44%. While there are many other factors at play and these figures should be read with caution given the challenges of data collection during this time, these findings point to some degree to the success of the RCCE efforts as community members clearly continued to utilise nutrition services during the pandemic. 

Changes in practices

Social media and community-level monitoring revealed that mothers reported washing their hands with soap and running water more frequently than prior to the COVID-19 pandemic. A GeoPoll survey for April 2020 indicated that 98% of respondents took measures to protect themselves from exposure to COVID-19 and 37% of respondents prioritised increasing hygiene practices².

Reach of communications targeted to and via health workers

The December 2020 report from the RBC indicated that all frontline staff, including nutritionists, received the posters with nutrition messages that were disseminated. A total of 60,000 CHWs received the booklets and qualitative feedback within the RBC report demonstrated that CHWs were using the booklets within growth monitoring sessions and during household visits. The RBC also reported that, across all 30 districts, 67% of CHWs were confident in conducting MIYCN counselling, growth monitoring sessions and home visits during the COVID-19 pandemic as a result of following social distancing protocols. It was reported that 85% of caregivers of children under five years of age were reached with MIYCN messages through non-digital methods. The reports also showed that the use of mobile platforms allowed CHWs, social workers and nutritionists to continue to provide dietary diversity messages and nutrition education to caregivers/parents.  

In refugee camps, RCCE activities were monitored on a weekly and monthly basis through reports and participation lists provided by CHWs and partner NGOs. Those lists provided the number of refugees who had attended the RCCE sessions, participated in growth monitoring services and received MNP and children who received treatment for wasting. Reports showed that, by the end of 2020, approximately 8,300 caregivers had received nutrition services including messages on MIYCN best practices in the context of COVID-19. Feedback collection, rumour tracking and complaints were compiled through weekly and monthly reports which would also feed into the abovementioned processes.

Reach of mass media communication

By the end of May 2020, the COVID-19 MIYCN and IPC messages were estimated to have reached over three million people through the medium of radio. Community feedback suggested that most caregivers appreciated the radio talk shows and counselling by CHWs regarding how best to feed infants and young children in the context of COVID-19. It was noted that they understood that poor diets have the potential to exacerbate pre-existing conditions, putting mothers and children at elevated risk of contracting COVID-19. One community member shared,   

"You know before, we feared that Corona [virus] was like Ebola, but I learnt [through the radio show] that it’s different, we now know how to protect ourselves and the children. The radio programmes are helping us to protect our families, and that makes me feel safe. I learnt that my family, especially young children, need to eat nutritious food every day to provide energy and nutrition to keep them strong".

Use of Twitter, Facebook and other social media platforms offered numerous opportunities to deliver MIYCN messages to reach target audiences with key information and elicit engagement that related to changes in behaviour. In addition, UNICEF developed a video called ‘You can trust these tips from a UNICEF Nutrition Expert’ which aimed to raise awareness of the importance and benefits of breastfeeding and optimal complementary feeding. The video generated 69.7k views, 70 shares and 2.2k likes on Facebook. Social media, however, also enabled the continued circulation of myths and misconceptions (as discussed below).

Challenges

In spite of strong MIYCN messaging to the contrary, myths and misconceptions around the breastfeeding of infants when a mother was a suspected or confirmed COVID-19 patient resulted in some mothers being separated from their infants for the two-week isolation period. Although no quantitative data was available to understand the degree to which this was happening and the subsequent impact on breastfeeding rates, supervision reports indicated that this was a significant issue which resulted in some mothers being unable to relactate when united with their infants. To mitigate these challenges, sensitisation of frontline health workers was conducted through face-to-face and virtual meetings and printed materials with clear messages were disseminated.

Considerable delays (up to a month) were experienced in approving messages and communication materials for dissemination in both print and digital form. Consistent engagement with stakeholders enabled their eventual approval and dissemination. Additional human resource capacities were posted to MoH, with UNICEF support, and contributed to addressing some of the challenges. Two staff members from UNICEF’s CAP section and one staff member from the Nutrition Section were recruited to support additional needs and challenges.

Despite correct messages having been disseminated widely, limited access to resources, such as face masks, other personal protective equipment (PPE), clean running water, soap and alcohol rub, hindered CHWs from providing timely nutrition counselling services which threatened the adoption of the recommended MIYCN practices.

Some radio talk show discussions and social media communications demonstrated that myths and misconceptions around IYCF and COVID-19 continued and spread throughout the pandemic. To address this issue, UNICEF has started supporting the Government to partner with agencies such as the Rwanda Red Cross to analyse feedback through existing complaints mechanisms, track rumours and misconceptions and monitor the reach of RCCE activities. Within the partnership with Rwanda Red Cross, for example, data in relation to handwashing practices, the use of masks and broader social distancing and prevailing rumours and myths is collected. This data is used to inform the government response.  

Lessons learned

Establishing a coordination structure through the development of sub-committees, where roles and responsibilities were clearly defined, was an effective way to harmonise nutrition RCCE and ensure the efficient use of resources in the context of COVID-19. The creation of the sub-committees was noted to be effective in bringing together and coordinating a wide range of stakeholders in relation to nutrition RCCE messaging. It further helped to identify potential gaps in the RCCE response, facilitated the sharing of information to enable the development of key messages and appropriate IEC materials and helped to avoid duplication.

Identifying supporters/collaborators for RCCE activities on nutrition early on in the response, including other ministries, public institutions and civil society organisations (CSOs), was noted to be a critical element for developing and disseminating harmonised nutrition messages.

Wide dissemination of appropriate evidence-based RCCE nutrition messaging through multiple channels helped to build the capacity of caregivers/parents to protect themselves and their children in light of COVID-19. Adaptation of available regional and global guidance to support message development on nutrition in the context of COVID-19 was seen to be an effective starting point for developing contextualised key nutrition-related RCCE activities.

Due to the country’s total lockdown, strengthening the capacity of frontline health workers to improve child nutrition in the country’s hardest-to-reach areas and to promote and support appropriate MIYCN in the context of the pandemic was a challenge. This was overcome during the facilitation of remote online training and follow-up.

Given movement restrictions and social distancing requirements, conducting rapid assessments to understand communities’ knowledge, attitudes and perceptions in relation to MIYCN in the context of COVID-19 was not possible. As a result, developing appropriate RCCE content was challenging. The RCCE nutrition needs assessment exercise helped to overcome this gap and enabled the rapid identification of gaps in knowledge, attitudes and perceptions around nutrition. Similar exercises focusing on key areas such as breastfeeding practices could be used to further guide messaging. 

Conclusion

As COVID-19 continues to impact the lives of many, adapting appropriate RCCE messages and exploring alternative communication channels is vital to ensure it has an impact on targeted behaviours. More research is needed to explore the critical context-specific factors responsible for improving the diets of women and children and those that may act as barriers for the uptake of nutrition services. As a next step, the Government of Rwanda intends to conduct a rapid qualitative and quantitative assessment to learn more about the communities’ knowledge, attitudes and perceptions regarding MIYCN for children under five years of age in light of COVID-19, how COVID-19 has affected children’s nutrition, communication patterns and channels as well as the impact of the pandemic on nutrition services. Such assessments will help the government to understand the extent to which RCCE messages have impacted on behaviour and to further develop optimal RCCE interventions for nutrition, forming part of the country’s comprehensive COVID-19 response strategy.

For more information, please contact Annet Birungi at abirungi@unicef.org