RCCE Strategies to Overcome COVID-19 Fatigue in the Eastern Mediterranean, Middle East and North Africa

"'Pandemic fatigue' (demotivation to follow recommended protective behaviours...) and complacency are affected by a range of factors and community concerns that cannot be anticipated nor well understood without engaging with communities."

In response to the COVID-19 pandemic, all countries in the Eastern Mediterranean/Middle East and North Africa (MENA) region have introduced some form of public health measures to reduce transmission of the virus. These measures can lead to substantial negative socio-economic impacts, which challenge people's ability to sustain motivation and adhere to key preventive behaviours. This brief from the Social Science in Humanitarian Action Platform (SSHAP) focuses on social and cultural influences for sustained COVID-19 prevention and risk reduction in the Eastern Mediterranean/MENA region. It is intended to inform the development of risk communication and community engagement (RCCE) strategies and regional guidance and tools as the COVID-19 crisis evolves.

The first section synthesises findings from qualitative and quantitative studies on knowledge of, attitudes about, social drivers of, and behaviour and structural barriers related to various infection prevention measures identified as relevant to pandemic fatigue in the region. In brief:

• Mask-wearing: High awareness of the importance of mask-wearing to prevent infection has been found in the region, but the data indicate that more than knowledge is needed for behaviour change. Evidence suggesting gendered differences in mask-wearing has been seen, for example, among Hajj pilgrims. Media reports have reported low mask use and defiance of requirements to wear a mask in several countries.
• Hand hygiene: Studies found high levels of awareness of the importance of handwashing, and hand hygiene was documented as substantially improved across multiple countries as a result of COVID-19 campaigns. Social norms and pressures, role models, faith, and religious practices were found to influence handwashing behaviours. For example, obligatory ritual handwashing is part of daily life for Muslims, and many religious scholars have asserted that the use of hand sanitiser does not conflict with Islam's prohibition of alcohol. However, lack of supplies and infrastructure have been reported to be major barriers, especially in places such as camp settings.
• Physical distancing: Across the region, many countries report high awareness of the need to maintain physical distance, as well as willingness to comply with recommendations; however, social norms and attitudes, faith and religious practices, influencers and role models, gender norms, the threat of stigma, and trust and politics affect whether or not people actually comply. For example, religious leaders have used their authority to reassure disappointed pilgrims that Muslims are rewarded even for the religious intention of performing Hajj and that everything is determined by the will of Allah. Underlying structural issues also influence compliance for many vulnerable groups: Low-income groups, migrant workers, refugees, and internally displaced persons (IDPs) tend to live, work, commute, and dine in crowded conditions.

The brief offers the following considerations with a view to normalising and sustaining key prevention behaviours in the region in the context of response fatigue and successive waves of COVID-19. Strategies will need to be adjusted according to the evolution of the epidemic in each country (including availability of vaccines), the real and perceived health and economic risks, and local public reaction to measures taken thus far:

• Localise and co-design communications to prevent fatigue and build trust - RCCE strategies are more likely to be successful if they are co-designed throughcommunity-centred approaches, capitalising on existing local knowledge, capacities and networks.
• Encourage community agency to develop "COVID-19-safe" opportunities - For example, religious leaders could be engaged to advocate for greater personal responsibility and community agency to manage protective behaviours and local risks safely and aligned with their teachings.
• Address structural barriers and shift away from approaches that are not practicable - Working with communities to understand the local situation is essential for crafting strategies that are feasible, sustainable, and effective.
• Harness religious leaders and teachings as enablers - This requires understanding the values and norms associated with the various faiths in the region, as well as within different subgroups, being aware that, in some contexts, religious leaders may not be effective influencers, particularly where there are underlying sensitivities and conflicts that have undermined trust in them.
• Check representativeness and behavioural compliance of influencers - It is important to match the diversity of subgroups who are to be reached with the right influencer/s, and via the most effective channels for each subgroup.
• Address gender-related risks - For example, men tend to have more freedom of movement and general autonomy, and an interplay of factors mean they are more prone to taking risks.
• Harness media, especially social media - Local assessments are needed to fully differentiate: preferred channels; trusted sources of information; levels of literacy, health literacy, and media literacy; and preferred languages and formats for receiving and sharing messages.
• Focus on empathy and communications based on values - Overuse of fear can result in inaction or poor compliance; instead, with strong religious and cultural values evident across the region, it is advisable to reflect empathy for the hardships endured, and emphasise collectivism and responsibility for protecting the family and building the resilience of the community.
• Be aware of the influence of politics on trust - The political context must be taken into account when developing strategies for RCCE.

The brief concludes with a series of recommendations for future research to address gaps in the evidence around social and cultural drivers for compliance with specific prevention behaviours in the region. Contextual research can also help illuminate the secondary effects of prevention measures and how these influence the ability or motivation to adopt preventive behaviours.