Tag: Health

Welcome

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ADB health expert Najib Habib headed a project on Regional Solutions for COVID-19 Response and Vaccine Delivery in Selected Developing Member Countries. The research and first-person accounts are on the RKSI microsite. He introduces some public health insights in the following episodes and his discussions with ADB economist Marzia Mongiorgi-Lorenzo, who tells of her personal experiences in Beijing at the height of the pandemic.

Najib: Hello everybody, this is Najib Habib, health expert at the East Asia Department of the Asian Development Bank. Welcome to the RKSI Health podcast. We are here with Ms. Marzia Mongiorgi, a principal economist at the East Asia Department, Asian Development Bank in Manila. And we are here to talk about some experiences and lessons learned related to the COVID-19 pandemic in People’s Republic of China (the PRC), but also related to our other developing member countries. We consider that the COVID-19 pandemic was a great learning experience. Not only did COVID-19 provide very valuable experiences and lessons learned to healthcare workers, but also policy makers in all ADB developing member countries and beyond on very key issues such as managing a massive public health crisis, but also even major crises that could be related to, for example, climate change or disasters.

Now we try to highlight some lessons learned focusing on experiences of healthcare frontliners in [the PRC] and maybe how these can be applied to other countries in our region.

Ep 1. The Shock of the New: An Expat’s Life Is Upended by a Yet-Unknown Flu

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Ep 1

When the world started shutting down in early 2020, Marzia had only a vague idea what she and her family were facing. Her life in Beijing was about to change drastically.

Marzia: The hotel told us to pack up our bags and go back to Beijing. Once we arrived in Beijing, we found a very different city from what we left a few days before. We realized quickly. There was something serious happening.

Najib: We are talking to Ms. Marzia Mongiorgi, principal economist at the Asian Development Bank, who lived in Beijing during the beginning of the outbreak of COVID-19 in [the PRC].

Marzia: So in January 2020, I was living in Beijing with my family. I have two children and we were getting ready for the Chinese New Year vacation. We usually go to Chongli to ski. Chongli is where the 2022 Winter Olympics were held and we were looking forward to it, to see a lot of people. We don’t speak Chinese. So we were a bit detached from what was happening and we have heard about this strange flu. We didn’t anything too seriously.

To our surprise, the hotel was empty. The slopes were empty and we stayed there for 4 days. Totally ignoring what was happening in the rest of [the PRC]. But at one point, we were on the slopes and we were trying to go up again on the chair lift, when we realized that the mountain was closing down. And at that point we realized that there was probably something serious happening and that the flu or this strange flu, this virus was getting worse. And the cases were increasing in other parts of [the PRC] and that also there was a case in Chongli. A girl, I remember. The hotel told us to pack up our bags and go back to Beijing.

Once we arrived in Beijing, we found a very different city from what we left a few days before. People checking entry of people into the building. I remember very clearly the deliveries, which are a big, big business in [the PRC] were not reaching the lobby nor the apartment door, but they were left at the gate of buildings. And that was something that in years we have never seen. So we realized quickly that there was something serious happening. The office informed us that the virus was spreading that there was not enough knowledge of the virus to warn us on what to do. From outside [the PRC], families were calling us. What’s happening? This is serious. You might need to leave. What if it spreads into all [the PRC] and you are stuck there? So we had a lot of pressure from the families outside [the PRC] to leave [the PRC].

But I think that was fear talking. We tried to live our normal life. There was online work and online school for the kids and we had to get used to things we did not have anymore.

We did have a lot of support from the community, people in the building and I remember they were helping us carrying the drinking water, the big bottles. They were very nice to help us, because not speaking Chinese, we needed extra attention and extra help.

Najib: How did you get a sense of the scale of the outbreak then in Beijing? Did you feel that the outbreak was kind of like other seasonal flus or other diseases like dengue? Or did you get the feeling that this was something bigger?

Marzia: The feeling that it was something different and bigger came very quickly from calls from outside [the PRC]. Family friends. The fact that a lot of flights were cancelled. We were looking into ways to leave [the PRC]. There was absolutely no understanding or no knowledge of what was happening. Flights were either cancelled or full, so we finally did manage to get the flight.

We flew to Hong Kong, [China]. To go to Manila because my husband is from the Philippines. And also the headquarters of the Asian Development Bank is in the Philippines. The flight from Beijing to Hong Kong, [China] was full. Once we landed in Hong Kong, [China], the Philippines had just closed their borders to non-Filipinos. I was not allowed to fly on to the Philippines. And so we had to go back to Beijing. We got stuck two days in in Hong Kong, [China]. There was complete chaos in the airport. We couldn’t get our luggage for a day and but finally we managed to go back to Beijing.

Najib: Thanks a lot, Marzia. This shows the unprecedented nature of a global pandemic.

Ep 2. Anxiety on the Frontlines: Health Workers and Others Face Fear and Uncertainty

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Ep 2

Najib describes health workers’ psychological hardship and Marzia relates how she and her family coped during the pandemic.

Najib: Among the healthcare workers in [the PRC] what we found was one of the biggest challenges was psychological.

Healthcare workers were working almost 24 hours a day to deal with this unprecedented unknown flu, eventually called COVID-19. Healthcare workers were responsible for testing, treating, and tracking suspected cases, especially difficult when people are traveling either within the city, across the province, or even across borders. When people returned from areas that are considered higher risk, they were quarantined in a hotel for 14 days and then 7 days at home, they underwent repeated nucleic acid tests.

Healthcare workers monitored the returning people’s close contacts and those who have been deemed exposed to COVID-19, including possible COVID-19 contaminated food such as fruits and vegetables. The health centers in [the PRC] regularly collected samples from workers who delivered these food packages. Healthcare workers assisted the whole population in cities and provinces to deal with the mass testing. Healthcare workers worked closely with neighborhood communities, health professionals, collecting samples every day, and collected samples from those who are bedridden or sick with the disease, and also those who are quarantined. Healthcare workers were so busy they could not go for lunch, restaurants were closed and the township health centers and others had to give them instant noodles and self-heating rice just so they could take turns eating and also sleeping so the testing and vaccination of the large population shouldn’t stop.

Many of them would go home very late at night, have a few hours’ sleep and do the whole thing all over again. Sometimes it would be difficult to agree to the quarantine measures. For example, some gaps in procedures, incomplete information, or ability to correctly follow the protocols would give rise to confusion and complaints and anger in the early days of the pandemic. Sometimes coordination mechanisms and networks did not function adequately to many health workers. People who took responsibility for rolling out these essential public health measures sometimes felt wrongly blamed for a process that was unprecedented and sometimes, of course, confusing and overwhelming. How did you cope with this stress and anxiety when you were there with your family?

Marzia: We tried to have a normal routine. We had clear times for studying or working, for lunch together, for cooking. We also would set a time for some exercise together. We could still go down and go to the park. But again, the stress of not knowing how the spreading was and how you could get it. There was really complete ignorance at the time.

Najib: Transparent and consistent communication is the most important thing to do when preventing and responding to an infectious disease. Communication through trusted sources that are consistent and regular reduce anxiety and also assist the people in making correct decisions that reduce their risk.

Among the healthcare workers in [the PRC], what we found was one of the biggest challenges was psychological. Though health workers may have mastered the procedures and the skills of how to test, treat and track the disease, still, many health workers experience difficulties in communication, difficulties on how to collaborate effectively with large teams, and even psychological difficulties. Technical issues can be resolved and overcome with skills, effort, study, and practice, but anxiety is invisible. Anxiety is something that needs to be resolved and addressed almost on a personal basis, and we need to empower people to try to address this very, very important issue when dealing with large-scale pandemics such as COVID-19. Consistent and reliable communication was seen as one of the best ways to deal with this issue.

Sometimes healthcare workers felt that communities were not being helpful because they did not understand. And this method of communication, again, often with incomplete information, but to the best of expert knowledge helped a lot in trying to reduce risk of everybody.

Marzia: I completely agree that communication is critical, especially at the beginning of the pandemic, of which there is very little knowledge. And that probably was the good thing and the bad things for us. The good thing was that not understanding Chinese, I was not fully aware of what was happening. But when information came in and I understood the scale of what was happening, we didn’t really have a sense of what’s happening.

Najib: What did you do to take care of your mental health in the pandemic, and what did you do to maybe even as a mother and as a spouse?

Marzia: We were running around the apartment, we were jumping, we were using our Xbox for We Dance, being active and making it fun for the kids. There are a lot of testimonies around the world that this work from home and this living indoors and not being able to go to work and the kids to school was heavier on women, because when kids don’t feel well or they are scared or they need help with the homework, they tend to be to go to the mother.

Maybe I was in a meeting with management and I had my son asking me how to solve the problem of math and then I would have to tell him to wait. But we had clear roles for all four of us—who cooks, who does a bit of cleaning, who helps with the homework. We were working as a team.

Najib: It shows to me that in times of stress and even disaster, you really rely on your family and your community, not just for food, shelter, protection, but also for mental health resilience and just coping with the pandemic. I really admire you and what you did.

Marzia: It was not always easy. We really had to alternate being strong for our kids.

Ep 3. A Lockdown Story: A Birthday Party Has an Unexpected Sequel

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Ep 3

Marzia: Suddenly I hear crying and shouting in the living room. It was my daughter. She was having a hysterical breakdown because they went down to meet the mother of her friend. They realized we were in a full lockdown. So the building was sealed off and nobody could get out of the building.

Najib: I heard you hosted a birthday party and something unexpected happened.

Marzia: In June, it was my daughter’s 11th birthday, we decided to have a small dinner party with her good friends. At the time, some cases were popping up in Beijing but life was almost normal. The kids were having fun and it was time for the first friend to go home. So my daughter brought her down to the lobby to meet her mother and suddenly I hear crying and shouting in the living room. It was my daughter. She was having a hysterical breakdown because they went down to meet the mother of her friend, they realized we were in a full lockdown. So the building was sealed off and nobody could get out of the building because there was a potential close contact in our building.

So we realized quickly that we had 10 11-year-old kids in our apartment. And thank goodness it was a potential close contact, so it was only 5 days of lockdown. If it was a positive case, we would have been locked for 10 days with the kids. Now I can smile about it and even laugh about it. But at the time it was a big shock. Imagine the other parents, they couldn’t get their kids. The other parents were more anxious than us. We had to handle the situation. We had a camp in our in our living room. We arranged all the beds. Kids at that age, some are more independent than others. Some kids were not used to sleepovers. Some kids had the best time of their life. We had to arrange for food, have games because we didn’t want them to spend the whole day on the TV or phones. Monday came the school organized online classes and online games. They even arranged psychologists to talk to the kids individually. For us it was a bit of a shock in terms of logistics and spending so many days with kids. But for such young kids, we don’t know what’s the implication on mental health.

Then they became famous in school. They were called the Famous 10. It was not always easy. But we had support from everybody. The parents got organized very quickly. Each parent got a lunch or a dinner to support us. And they were sending comfort food for their own kids.

We ended up having boxes of deliveries that we had to return once the 5 days were over. My daughter was having a blast. But at one point I also asked her to put some rules, say, cleaning their beds, cleaning the garbage. She put down a list of tasks for everyone, we really had at the end a good time.

The kids made us a drawing to thank us at the end. I have to admit I was glad when it was over. Now this is an incredible, memorable experience that will stay with us forever. The most difficult thing, though, is my son was locked out with somebody else. My son was having himself a birthday party with his friends when we got locked down. Things could come in, but nothing could get out. So we told him that you can stay with your friends. Thanks to the mom of his friends. So he also had a fantastic 5-day party with his own friends.

Najib: Thank you very much, Marzia. What an incredible story.

Ep 4. Heroes: Health Workers Battle Stress and Exhaustion

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Ep 4

Many frontline workers were traumatized by the physical toll their work took on their well-being. Najib quotes some of them.

Najib: Some healthcare workers were saying “I had to wear diapers, and so I don’t need to go to the toilet. And even to go to the toilet or take a shower, we had to stand in line because there were just so many people in different shifts.”

Healthcare workers had to go through incredible amounts of stress in dealing with the pandemic, not just in [the PRC], but in all of our developing member countries. Healthcare workers said, “I didn’t drink anything at the hospital. We couldn’t eat anything because there was a lack of food for the workers because they were so busy and there were so many cases. The hospital provided lunchboxes as much as they could.”

However, because of the surge of cases, many healthcare workers themselves got ill and had to be treated in hospital, either because they got COVID or they had other issues related to stress. One healthcare worker was mentioning “Even after work, when I should have been resting, I had to communicate with patient’s families from the hospital or other people in my community to address their concerns and try to address their issues related to COVID-19.” They had to use their own phones, their own homes, their own methods of communication, because people knew they were healthcare workers, not just doctors and nurses, but healthcare workers. Many people did not have COVID but had diabetes, had heart disease or were suffering from strokes were not able to access healthcare services. These are the kind of issues that many people in our developing member countries faced.

Some healthcare workers were saying “I had to wear diapers, and so I don’t need to go to the toilet. And even to go to the toilet or take a shower, we had to stand in line because there were just so many people in different shifts.”

We’d like to express our appreciation and our recognition that healthcare workers in [the PRC] and in all developing member countries and certainly across the world really had a difficult time. We really appreciate their hard work during this time of COVID-19.

Ep 5. COVID-19 Prevention: Communication Is Key

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Ep 5

Najib explains the urban grid system and Marzia shows how it worked in her community.

Marzia, we have heard that in [the PRC] one element that was very effective was community engagement, especially at all levels, not just in townships and cities, but even province wide.

What was your experience of the community helping you as a resident, as an expat living in Beijing in these early days of the COVID-19 spread? And how do you think that was effective or useful?

Marzia: As soon as the emergency was declared, the community got immediately organized for two purposes. One is to support the people in the neighborhood, and two is to try to contain the spread or to understand the movements of the people in the neighborhood. There were people from the community committee that were helping with the basic supplies like water or telling us where to buy food. Then there were people that were supposed to help with the communication and information on the virus. We could indeed get a lot of support, especially on practical issues. It was very well organized from the start.

Najib: Communities are critical battlegrounds for preventing and controlling COVID-19 early detection, reporting, and reducing transmission risk are the preventive tools that can be employed at the community level are most effective. An example of community-level approaches is the community grid. The local government made use of the urban grid system extensively, in terms of testing, treating, and tracking COVID-19. The system organizes neighborhoods into several grids, each managed by a grid team. These team members collect information on the needs of residents. They conduct health education on how to prevent COVID-19. They monitor residents’ body temperature daily, which many of our developing member countries did to test for fever for a risk of COVID-19, so you can eventually do testing. Grid teams disinfected the surroundings. They helped conduct surveys which are really, really important in terms of tracking people who are deemed at high risk and who have been ill, and also mass testing whenever someone may have tested positive for COVID-19. Grid teams are also responsible for buying and delivering supplies and necessities in communities, including medicines, especially for quarantined households. Grid teams in [the PRC] use electronic information to accurately and quickly locate areas of high risk and enable orderly distribution of prevention and control materials in order to reduce the impact or spread of a crisis.

Misinformation about infectious diseases is probably one of the most dangerous aspects of disease prevention and control in a pandemic. That’s why public health education is so important.

Public health education and health promotion in communities are usually done through information and education drives. Many of these can include something as simple as mobile loudspeakers making the rounds to just remind people to wear face masks, wash their hands, practice social distancing, ensure ventilation, make sure that you don’t cough in public and observe etiquette. And also, just the simple things as providing posters in neighborhoods, especially those at high risk. Representatives in communities are also very important because they compile the concerns of the community and provide a feedback mechanism for public opinion. Public opinion messages help shape key messaging in pandemics. One way to quickly and easily gather opinions and key messages and areas of concern are social media and different types of mobile apps. 

We must show that when everybody follows the rules, the whole community can better protect themselves and their loved ones. We are only as strong as our weakest link.

Marzia, you were living in the midst of the COVID-19 pandemic in Beijing. What was your experience of the communication and education on COVID-19 happening through social media and mobile applications in [the PRC]?

Marzia: We all know for this type of pandemic, tracing is one of the critical aspects for public health and we used the WeChat application. We had to have a QR code that was either green, amber, or red and that would determine where you could go. Now this QR code was based on your personal data and on the results of the PCR tests. The number of PCR tests needed depended on the level of risk where you lived. So when my neighbor became medium risk, we were asked to take a PCR every day. It was extremely well organized. On every corner there was a white tent for people to go and take the test. It was very convenient. Mostly everybody had a tent under their building, so it became part of the normal life. The testing facilities were open from early morning to late evenings.

And then once you took the test, that result within few hours would go into the WeChat app and that would either confirm your green status or raise an issue or, say, that if you are positive then you become red code and then you go into the into quarantine.

But one small issue was the WeChat app was in Chinese and the health workers have difficulty sometimes in spelling foreign names. And imagine my name is not easy for Italians to pronounce. So “Mongiorgi” was kind of complicated for them. So sometimes they would give us their device and we would type in our own name and this was done for many of the foreigners. But the tracing app was good, was very well organized. Sometimes there were some glitches. So you become amber without reason, but then it would be sorted out quickly within a few hours. My experience in terms of the app was very good and made me feel safe because I knew that they knew where the cases were.

Najib: Were the testing and treatment free? Was it easy to access? Were the apps easy to use? And in your experience, is that a very important issue when dealing with pandemic on a day-to-day basis?

Marzia: The testing facilities were everywhere. They made it easy because we had to do it every day in some periods. But there were enough places in the city where you could go. We had one near our apartment and then one near the office. And then sometimes I missed the working hours of the one near my place. And so we went to the one near the park. We didn’t have to pay. We just walked in. And if you choose the timing well, you didn’t even have to queue. There were also some testing facilities where you had to pay very little. The QR code app for tracing of COVID-19 was really easy to use. It was demanding in the sense that everywhere you went you had to scan. And then you have to show the person at the entrance of the building or a shop that you were green and that had two purposes. One is to know where you were going and then two is to show the person of the building that you were allowed to go in. I didn’t find any difficulty in using it. And was very simple, very effective. And it became part of my daily routine.

Ep 6. Pandemic Preparedness: Standardizing Training for Future Crises

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Ep 6

Najib underlines how important it is for countries to have surge capacity and for health workers to hone their skills, since this pandemic won’t be the last one.

Distribution and use of standardized applications, information, diagnosis, treatment are really, really important to try to deal with future pandemics and also other kinds of issues.

Najib: Overall, when dealing with pandemics and trying to gather as much standardized and accurate information as possible, it’s really important to follow standardized and centralized procedures. In this way, information can be quickly analyzed and quickly reported, and it’s also important to have standardized methods of diagnosis and treatment, because you know what you’re dealing with. So, this distribution and use of standardized applications, information, diagnosis, treatment are really, really important to try to deal with future pandemics and also other kinds of issues.

But that said, it’s also important to break it down into small pieces and ensure that the communities and those in the frontline can use them properly. Information can be centralized, but then that information needs to be brought down to a community level to make sure the supplies and resources that are limited anyway because of a pandemic can be put to good use.

Training of healthcare workers has been mentioned as one of the key ways to make sure high-quality services are delivered.  Many doctors and nurses who just finished medical school or nursing school or were still studying, were asked to participate in COVID-19 response. A lot of the basic skills such as sample collection of PCRs, taking temperatures and different kinds of procedures, including surveys, can be done quite easily with very basic public health training. Though what’s important and has been mentioned several times in [the PRC] and in many other developing countries, in these kind of extraordinary circumstances, it’s very important to have surge capacity, meaning the buffer of resources you have and also to make sure that some healthcare workers are ready to learn while doing or getting their training while doing, which is one of the best ways to get your training. This was seen as a good opportunity for many healthcare workers to learn and provide their skills when they’re needed most.

Engaging the Community to Defeat COVID-19 in the PRC

A volunteer registers information for a resident at a COVID-19 testing site in Jilin city, Northeast PRC's Jilin province, 18 March 2022. [Photo/Xinhua]

Rainbow community, Huiji district, Zhengzhou city, Henan province

In the People’s Republic of China (PRC), the community is the critical battlefield for preventing and controlling the coronavirus disease (COVID-19). Early detection, early reporting, and reduction of transmission risk are the community’s weapons. Community engagement is key to “turning off the tap” of COVID-19. Rainbow, a community of 5,655 households, embodied these good practices.

On 24 January 2020, the eve of Chinese New Year, millions were on the road rushing to family reunions. That was when the news broke: a lot of COVID-19 cases had been found in Wuhan and the city was locked down from the evening of 23 January 2020. Rainbow’s New Year preparations came to a halt, and the fight against the pandemic started and has continued since then.

Community mobilization

“Protect neighborhoods for our communities, protect communities for our city.” ~ Community branch secretary

Rainbow’s leadership immediately mobilized residents into joint working groups and set up a data platform and a health communication network. “We declared war on COVID-19,” said the community branch secretary. “Our duty is to control it.”

Strengthening community leadership and organization

Community leaders called emergency meetings. They formed a joint prevention and control leadership working group, with representatives from the community committee, health sector, grid team, and residents. They set up a communication and information exchange mechanism among local organizations and formed working groups for the neighborhood committee, health care, volunteers, and residents (Figure 1).

Figure 1. Rainbow Community Response and Working Groups for Community Engagement

Building community information database

The joint team built an information database to understand residents’ baseline conditions. Committee members conducted a diagnosis and needs assessment in the first 2 weeks. Community workers went door to door to survey households. They screened those who had returned from Wuhan and other high-risk areas. They collected households’ health management information, including personal information, work settings, travel history, and so on, and stored it in the database to guide the groups’ work.

Public health education and health promotion

Committee members launched health information and education drives. Mobile loudspeakers made the rounds to remind people to wear face masks, wash their hands, practice social distancing, ensure their rooms’ natural ventilation, observe cough etiquette, among others. Health workers put up more than 3,000 posters containing key health messages in neighborhoods and handed out brochures about how residents could protect themselves.

The residents’ representatives were key. They compiled residents’ concerns and inquiries for public opinion monitoring, which shaped key messages and information. They documented rumors and misinformation so that community health workers could counter them with the help of health education professionals. The residents’ representatives closely followed official social media accounts and forwarded the latest information, announcements, and knowledge to everyone in their social media networks.

Community participation and involvement

The residents were the backbone of COVID-19 prevention and control (Figure 2).

Management workers of residential buildings (i) sent out epidemic notifications, government policies, and updates via residents’ networks and WeChat groups; (ii) called on everyone to take action and do their share by not traveling, for example, or gathering or going out; and (iii) quickly notified the health-care working group of high-risk people arriving from abroad or high-risk areas.

Community singing and dance groups shared health education information with their members every day. “Everyone’s more aware of how to prevent and control COVID-19,” Yi Wang, the community dance team leader, said proudly. “They stay home, easing the checkpoint personnel’s work.”

Figure 2. Community volunteers guarding the entrance of a residential complex, where they asked visitors and residents about their travel history, took their body temperature, and provided them with face masks, health education leaflets, disinfection services, among others. Source: Meipan.cn

The 1-2-3-4 model for managing home quarantine

Rainbow strictly implemented the 1-2-3-4 model to manage home quarantine. With the virus spreading and more people returning from Wuhan and other high-risk areas, home quarantine was an important deterrent against COVID-19. Rainbow recruited volunteers for the Little Red Elephant team to bring support services to quarantined people 24/7.

The 1-2-3-4 model was carried out as follows:

  1. Community grid team members inspected quarantined households every day to ensure people did not go out. Team members asked questions such as, “Did anyone of you travel for the Spring Festival or other reason? Does anyone here have flu symptoms?” They also instructed household members to monitor their body temperature.
  2. Community health workers were responsible for two things: (i) visiting people’s homes to monitor the body temperature and symptoms of those in quarantine and (ii) providing them with psychological counseling and teaching them to protect themselves and disinfect their homes.
  3. Community volunteers collected household garbage every day for centralized disinfection.
  4. Community volunteers delivered vegetables and other necessities to those in quarantine, shopped for them, and gave them packs containing a thermometer, a face mask, a registration form, disinfectant, and health education materials. All goods ordered by those in isolation were delivered to the entrance of the neighborhood. Then community workers and volunteers instructed residents to get them in batches according to a schedule, avoiding direct contact with anyone and maintaining social distance. Community workers and volunteers also helped patients with chronic diseases buy medicine or visit hospitals for check-ups.

Menglan Zhang, a resident, was grateful to the community workers and volunteers. “When I ran out of food, they brought me food. When I needed something, I called them and they shopped for me. They even sent us yuanxiao (glutinous-rice balls) for the Lantern Festival even though we didn’t ask for them.”

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

Good Practice: Health Education to Promote COVID-19 Vaccination in the PRC

A woman receives a booster dose in Chaoyang district of Beijing on 13 July 2022. [Photo/Xinhua]

The PRC has fully vaccinated 90% of its 1.413 billion people. Health education and promotion have been crucial to achieving such a high rate of protection.

Background

The success of coronavirus disease (COVID-19) vaccine development has been key to ending the pandemic. The vaccines have not only prevented transmission but also reduced the rates of severe COVID-19 and mortality. To build herd immunity, the PRC has vaccinated almost everyone since four vaccines were conditionally approved on 31 December 2020.1 Although the vaccines have controlled the pandemic and their benefits have been clearly demonstrated, a significant proportion of people still refuse to be vaccinated. A well-designed health education approach to overcome vaccine hesitancy is important to improve vaccination rates.

The PRC’s vaccination strategy

The national vaccination strategy has three steps:

  • Vaccinate populations at higher risk of infection, such as health-care professionals, customs staff, airport employees, teachers, community health workers, and others whose work puts them at risk.
  • Vaccinate the elderly (60 years or older), adults with medical conditions, and those over 18.
  • Vaccinate the whole population, including children and adolescents, as vaccine supply is guaranteed.

Source: Z. An, F. Wang, A. Pan, Z. Yin, L. Rodewald, and Z. Feng. 2021. Vaccination Strategy and Challenges for Consolidating Successful Containment of COVID-19 with Population Immunity in China. BMJ. 1 (375): e066125.

Health education strategy

Because the COVID-19 vaccine was an innovation, many people took a wait-and-see attitude toward vaccination.

A Beijing Municipality survey in May 2020 found that about 70% of the respondents were willing to be vaccinated.2 The most cited reasons for refusing the vaccine were that (i) production was rushed and thus the vaccine was dangerous, (ii) the vaccine was useless because COVID-19 was “harmless,” (iii) the vaccine’s efficacy was doubtful, (iv) respondents believed they were already immune, and (v) the vaccine’s provenience was uncertain.3

To increase vaccine coverage, health workers and other responsibility bearers should improve people’s vaccine knowledge and attitudes. Health education and health promotion include policy advocacy, social mobilization, community engagement, communication and dissemination of health information, and effective evaluation.

Policy advocacy and social mobilization. The government released policies and regulations early on to make vaccination accessible and safe. The measures covered equitable access, vaccination location and scheduling, vaccine supply with cold chain infrastructure, health-care service staff training in vaccination, and vaccination management.4 The government formed joint working teams from multiple sectors to expedite vaccination.

Dissemination of vaccination knowledge and information. The government developed and distributed health education and information material targeting different groups. Agencies used various channels or media, such as government press conferences, government websites, TV, radio, posters, leaflets, question-and-answer kits, and social media platforms such as WeChat official accounts and WeChat videos. The aim was to spread knowledge on the COVID-19 vaccine: why it was important to get vaccinated, the benefits of vaccination, how to make a vaccination appointment, and who were eligible for a vaccination, among others.

Community engagement. Community organizers aimed to encourage residents, especially older adults, to get vaccinated. Community engagement not only provided health education for target groups but also organized residents to make appointments and provided transport to vaccination sites, including community health service centers, centers for disease control (CDCs), hospitals, and clinics.

Community health education included (i) delivery of key health messages through banners, announcements (vaccination rates and numbers on neighborhood boards), and community WeChat groups; (ii) community lectures by professional and technical personnel, followed by questions and answers and discussions; (iii) counseling on vaccination through a hotline; and (iv) health education and counseling during home visits by community health workers and volunteers.

Organization involvement. Organizations, including institutes, enterprises, schools, and companies, were among the best promoters of health education. Their activities included mobilization meetings, posting information on websites, and announcements on public boards. To expedite vaccination, for example, organizations scheduled their workers’ shots in the workplace.

Vaccinating older adults

Vaccinations are one of the most widely accepted preventive services in the PRC. Vulnerable populations such as elderly adults and people with underlying chronic diseases need them most. In March 2021, Beijing became the first city to vaccinate those 60 years and older. However, the elderly vaccination rate is lower than in Europe, the United States, and other Asian countries because elderly Chinese know less about vaccination and are more hesitant to get vaccinated. Awareness of COVID-19 vaccines must be raised and public confidence in vaccines heightened. Take what Beijing authorities did as an example:

What did the elderly need? Health workers assessed the needs of the elderly through home visits and community meetings. The Beijing CDC used the results to develop a health education plan:

Key point for health education 1

Assess needs to understand the target group, what factors influence its members’ decision on vaccination, including barriers and facilitating factors (who, what, why).

Who was the target group? Those aged 60 years and older.

Why didn’t people want to be vaccinated? They (i) believed that vaccines were not safe, (ii) were uncertain of the vaccine’s effectiveness, and (iii) thought staying home meant no risk of infection.5

What content should be delivered? Based on the needs assessment, health education professionals summarized the concerns that must be tackled when disseminating information about vaccination:

Six key questions that need to be answered about the COVID-19 vaccine

  1. Why do the elderly need to be vaccinated?
  2. What if the elderly have side effects?
  3. Why do the elderly need three doses of the vaccine?
  4. If the unvaccinated elderly stay home, are they safe?
  5. Is the vaccine safe for the elderly suffering from hypertension, diabetes, and coronary heart disease?
  6. Why should the elderly be observed for half an hour after vaccination?

Key point for health education 2

Design dissemination methods based on the best way to reach target groups (when, where, how).

Designing dissemination methods

Those reaching out to target groups must understand when, where, and how to deliver health messages.

When. Health educators must know when to release scientific data. Evidence from Hong Kong, China demonstrated that of those who died at a median age of 86 years, 92% had had a long history of illness and 72% had not been vaccinated.6 The Beijing Health Commission used published and reported data on Hong Kong, China to promote vaccination among the elderly. Health educators used scientific data when publishing in official webchat accounts and websites. Counseling of the elderly on vaccination increased.

Where. WeChat became the most popular channel for getting information, messages, and knowledge to people. Health education materials were published by the Beijing CDC WeChat account and posted by district CDCs and others on their websites.

How. The needs assessment showed that the elderly got health information mainly from family members, TV, posters, and WeChat videos and that they trusted health experts and key opinion leaders.

Posters showing the elderly being vaccinated. Health educators designed posters using images of elderly advocates or endorsers getting vaccinated.7

Posters promoting vaccination of older adults

Posters showing key opinion leaders’ answers to questions. The top national experts are the most respected and trusted by the elderly. Posters used such an expert for posters showing Six Questions and Answers on vaccination.8 Dr. Guiqiang Wang is a famous chief physician of infectious disease, a member of the National Expertise Team on COVID-19 Prevention and Control, and director of the Infection Department of the First Affiliated Hospital, Peking University. The posters were published in People’s Daily WeChat, the most respected and trusted official account.

Six Key Questions and Answers by Dr. Guiqiang Wang

BTV WeChat video. Yang-Sheng-Tang [养生堂, How to Stay Healthy and Live Long] is a highly popular TV show among the elderly. A mini video was shown on the Beijing Satellite TV official WeChat.

Mini video: Vaccination, to protect yourself and the people you love most 

Effectiveness

By April 2022, the elderly vaccination rate had reached 80% in Beijing.9 By August, a total of 3.43 billion doses of the vaccine had been administered in the PRC, and 1.27 billion or 89.9% of the total population had been fully vaccinated. A total of 239 million people over the age of 60 (90.24% of all elderly) had been vaccinated and 226 million (85.33%) had completed the full course. A total of 176 million elderly had received booster shots.10

1 Press conference by the Joint Prevention and Control Mechanism of the State Council, 31 December 2020.
2 R. Ma, L. Suo, L. Lu, et al. 2021. Willingness of the General Public to Receive the COVID-19 Vaccine During a Second-Level Alert—Beijing Municipality, China. CCDC Weekly. 3 (25):7. 
3 G. Troiano and A. Nardi. 2021. Vaccine Hesitancy in the Era of COVID-19. Public Health. 194 (2).
4 COVID-19 Vaccine Technical Working Group. 2021. Technical Vaccination Recommendations for COVID-19 Vaccines in China. CCDC Weekly. 3 (21).
5 R. Ma, L. Suo, L. Lu, et al. 2021. Willingness of the General Public to Receive the COVID-19 Vaccine During a Second-Level Alert—Beijing Municipality, China. CCDC Weekly. 3 (25): 7.
6 Government of the Hong Kong Special Administrative Region of the People’s Republic of China. Together, We Fight the Virus!
7 Beijing CDC WeChat official account.
8 People’s Daily WeChat official account.
9 Baidu. 2022. 北京60岁及以上人群新冠病毒疫苗接种率超80% [Over 80% of people aged 60 and over in Beijing have been vaccinated against COVID-19]. 13 April.
10 Press conference of the Joint Prevention and Control Mechanism of the State Council, 8 July 2022.

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

Risk Communication in the PRC:
Good Practices in Zhejiang Province

Doctors offer services to residents at a community in Nanhu district of Jiaxing, East PRC's Zhejiang province, 11 January 2023. [Photo/Xinhua]

Risk communication is “the real-time exchange of information, advice and opinions between experts, community leaders or officials and the people who are at risk, which is an integral part of any emergency response.” 1

Risk communication aims to provide scientifically accurate, adaptable messages to help people be prepared and stay informed. It involves risk assessment, risk awareness, knowledge dissemination, and community intervention.2During the coronavirus disease (COVID-19) pandemic, people relied on accurate, timely communication to prevent misinformation and to guide them to respond appropriately. Effective practices of various aspects of COVID-19 risk communication in Zhejiang are summarized below.

1. Risk assessment

Risk assessment is the first step in understanding the scope of risk and the influencing factors, thus enabling decision making on adequate prevention and control measures. Key to developing an effective risk communication plan and implementation strategy are what (key messages), whom (target groups), who (organizations or professionals to deliver key messages to target groups), when (time of delivery), and how (methods and channels to communicate with target groups).

On 26–28 January 2022, a total of 44 confirmed cases of COVID-19 were reported in Hangzhou City, with 12 in Xiaoshan District, 21 in Binjiang, 1 in Xihu, 2 in Shangcheng, 6 in Fuyang, and 2 in Gongshu. They included the latest 18 confirmed cases detected among close contacts at centralized isolation sites.

The provincial government strengthened risk communication mechanisms to respond to the COVID-19 outbreak. The Zhejiang Provincial Center for Disease Control and Prevention (CDC) immediately assessed the public health risk.

1.1. Assessment of risk scope and influencing factors

Outbreak period. The first confirmed COVID-19 case was reported on 26 January 2022, after which new cases were identified and reported daily. The outbreak happened 1 week before Chinese New Year (1 February 2022). Prevention and control of the pandemic urgently needed risk management, including risk communication.

Social-psychological factors. Zhejiang is one of the most developed provinces in the PRC. Many people from all over the country migrate to Zhejiang to work. Hangzhou, the capital of Zhejiang, is a popular tourist spot. The city faced two challenges, both risk factors for the spread of the virus: (i) some migrant workers would go back to their hometown for Chinese New Year family reunions, and (ii) many tourists would visit Hangzhou for Chinese New Year

Rumors and misinformation. People living in high-risk communities, where new cases and close contacts had been identified, were scared and worried. Rumors and misinformation were spreading.

2. Risk awareness

The best way to prevent and slow the transmission of the COVID-19 pandemic is through risk awareness, which is achieved by communicating risk assessment and is an important measure to control the infodemic.3

Risk awareness relies on trust, timely release of information, transparency, and advance planning.

Government and health institutes are trusted sources of data and information. The government must announce COVID-19 information and prevention measures daily through mass media such as TV, radio, newspapers, and government social media accounts.

2.1. Daily news release mechanism established to publish vital information

The Information Office of the Zhejiang provincial government held a press conference every day to announce the latest number of confirmed cases, the general situation of the COVID-19 pandemic, and prevention and control measures, among other matters (Figure 1). The governor and health experts answered reporter’s questions, which were of great public concern. Live broadcasts provided updates on the latest developments and tackled public concerns at home and abroad.

Figure 1. Zhejiang Provincial Government Information Office Press Conference, 29 January 2022

Source: Zhejiang Center for Disease Control and Prevention.

2.2. Daily reporting system launched to provide accurate and comprehensive data

The Provincial Health Commission announced on its website and other platforms daily updates on the latest numbers of newly confirmed cases, suspected cases, those on quarantine, close contacts under medical observation, and asymptomatic cases.

The epidemic map was updated in real time to display infection figures. All regions could refer to it, which was supported by big data technology, for the precise location and number of cases in a specific community to allow health authorities to quickly respond and promptly formulate prevention measures.

2.3. Health education plan developed

The Zhejiang CDC developed a work plan for health education to guide and expedite risk communication with target groups. The plan included key messages, health education methods, and media platforms:

  • Key messages for different target groups were developed.
  • Key target groups were identified as migrant workers, students, and residents in high-risk communities.
  • Key settings were workplaces with a significant number of migrant workers, schools, transport stations, communities with confirmed new cases and close contacts, and public places such as shopping centers and restaurants.

For migrant workers. Key messages on prevention and control for migrants returning to their hometowns for Chinese New Year were developed through sample questions and answers (Figure 2). The messages were delivered through posters, flyers, the provincial CDC WeChat account, workplaces, and enterprises.

Figure 2. Q&A on Preventive Measures for Migrant Workers Traveling during Chinese New Year

Source: Zhejiang Center for Disease Control and Prevention.

For students. Health education professionals developed “The First Class” for the new semester. It was taught by CDC staff in one school and broadcast live online to all other schools. It imparted knowledge, attitudes, and skills to prevent COVID-19 (Figure 3).

Figure 3. The First Class in the New Semester

Source: Zhejiang Center for Disease Control and Prevention.

At 3 PM, on 24 February 2020, health education expert Qi Zhang, associate physician of Zhejiang CDC, held “The First Class” at Yucai-Jinhang Elementary School in Hangzhou. The topic was COVID-19 protection guidelines for students. “The First Class” was streamed, allowing more than 7,000 students in other schools to attend.

To further strengthen health education in schools, the Health Education Institute of Zhejiang CDC will continue to use media platforms to create more online, live, high-quality courses.

For residents in communities. Since the COVID-19 outbreak was reported in Hangzhou on 26 January 2020, communities and workplaces have been divided into zones for containment, control, and prevention, following national and provincial policies:

  • Containment zones. People stayed home and community workers provided door-to-door service.
  • Control zones. No one could go out or gather.
  • Prevention zones. People were advised to stay in the area and not gather.

Zhejiang CDC developed key messages for residents in the zones and produced and handed out posters and flyers carrying the key messages (Figure 4).

The coverage of the three zones was adjusted quickly depending on the risk after cases at isolation sites reached zero. On 10 February 2020, the containment, control, and prevention zones were opened.

Figure 4. Key Messages for the Community

Source: Zhejiang Center for Disease Control and Prevention.

For all residents. On Chinese New Year’s Eve in 2022, Zhejiang CDC published an open letter on the Spring Festival Initiative on Epidemic Prevention. It admonished people to (i) be aware of the risks; (ii) monitor their temperature, cough, and other symptoms; (iii) stay home; (iv) cooperate with health workers in investigation, nucleic acid testing, and disinfection; (v) not believe or spread rumors; and (vi) immediately report epidemic risks (Figure 5).

Figure 5. Open Letter on the Spring Festival Initiative on Epidemic Prevention

Source: Zhejiang Center for Disease Control and Prevention.

3. Knowledge dissemination

Zhejiang CDC’s practical prevention and control tips, key messages, and guidelines were delivered through posters, flyers, and professional social media accounts. The measures covered self-protection, disease prevention under specific conditions, travel, family, public places, public transport, and medical observation at home. Zhejiang CDC developed a question-and-answer manual for rural residents.

Key opinion leaders played a major role in raising public awareness of scientific disease prevention and control. Famous doctors and public experts from provincial health organizations and research institutions regularly expressed their professional opinions and suggestions via press conferences, interviews, and the internet, and widely promoted simple but effective self-protection measures such as wearing face masks, washing hands regularly, and ventilating rooms.

News and mainstream media were the vehicles for mass dissemination of knowledge, policies, updates, and inspiring stories about the fight against the pandemic.

  • Knowledge, key messages, and guidelines were developed and disseminated through different channels by Zhejiang CDC. Daily news and updates were released via the popular Zhejiang Health Education WeChat account.
  • Key opinion leaders were interviewed in the health section of a weekly local TV program that discussed issues concerning the public.
  • A health hotline provided the public with health advice and guidance on where to access nucleic acid testing and COVID-19 vaccines, and answered questions about individual and family preventive measures, medical observation at home, and medical treatment. The hotline also provided psychological counseling 24 hours a day. All CDCs (provincial, city, county, and district) in Zhejiang disseminated the health hotline number (Figures 6 and 7).
  • News and mainstream media, including digital media, widely disseminated knowledge, policies, updates, and inspiring stories about the fight against the pandemic. They helped allay people’s anxiety and fears, identified problems, and helped solve them. A good number of media outlets dedicated space for epidemiological updates and analytics on the COVID-19 situation and for countering of rumors and dis- and misinformation.

4. Community-based intervention

The community is crucial in risk communication. Community-based management has been key in curbing the spread of the virus. A report on the PRC’s fight against COVID-19 puts it clearly: “As an extension of governance for social management, 4 million community workers, together with volunteers, visited 650,000 urban and rural communities across the country to communicate epidemic prevention knowledge, offered psychological counseling and helped households receive daily necessities. They helped provide dragnet screening of potential virus carriers, made sure every corner was disinfected, and helped millions of households with difficulties in making a living.”4

Zhejiang CDC worked with community committees and other partners to mobilize community resources (health workers, neighborhoods, volunteers, grid workers, and residents’ representatives) for risk communication. They developed key messages that targeted gaps in information, awareness, and understanding about how to protect individuals and the community, especially the most vulnerable. Community involvement helped stop stigma, rumors, and misinformation. It was particularly useful in rapid information sharing; mobilization of community resources for prevention, care, and support; and regular collection of feedback from the entire community.

1 World Health Organization (WHO). 2017. Communicating Risk in Public Health Emergencies: A WHO Guideline for Emergency Risk Communication (ERC) Policy and Practice. Geneva. 
2 S. Du, A. Mao, K. Wang, Y. Meng, Y. Yang, M. Zhao, W. Qiu [都率, 毛阿燕, 王坤, 孟月莉, 杨玉洁, 赵敏捷, 邱五七]. 2021. 风险沟通原则在我国新型冠状病毒肺炎（COVID-19）疫情防控中的实践 [Practice of Risk Communication Principles in the Prevention and Control of the COVID-19 in China]. Soft Science of Health. 7 (35). pp. 90–92.
3 R. Chaterjee et al. 2020. COVID-19 Risk Assessment Tool: Dual Application of Risk Communication and Risk Governance. Progress in Disaster Science. 7. 
4China Daily. 2021. China’s Fight against COVID-19. 

Author
Xuefeng Zhong

Xuefeng Zhong

Public Health Specialist (Consultant)

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