Designing a health promotion campaign is never an easy task.1 This challenge becomes even more significant when the campaign takes place during a pandemic of a highly contagious disease or in the middle of a viral outbreak.2 During these critical periods, the public’s precautionary measures and their compliance with health authorities’ instructions could make all the difference in containing the virus. Otherwise, the virus may continue to propagate in the community and could eventually bring the countries health system to its knees. This is the current situation with the new coronavirus, known as COVID-19. After many months of lockdown, and before the world goes into a deep economic recession, many countries are choosing to reopen their public places and resume business as normal. However, with no verified medicine, a slow vaccination process, and the continued emergence of new COVID-19 variants, health authorities worldwide have to continue relying on lowering the numbers of infected individuals through precautionary measures. This can be achieved by increasing the public’s awareness and compliance. Hence, an effective health awareness campaign must be put in place.
Depending on the most influential mechanisms, many health campaigns choose to apply the communication processes of awareness, instruction, and persuasion to steer the audience, via messages, toward desired behavioral changes. The content of these messages would vary through different points in the campaign.3 Awareness messaging aims at “informing people what to do, specifying who should do it, and cuing them about when and where it should be done.”3 Thus it appropriate that the messages are easy to understand, and their recommended actions be simple to perform. Awareness health campaigns want to encourage the population, or segments of it, to seek more information. On the other hand, detailed instruction is only suitable if the required action is complex and where the audience needs a detailed blueprint to deal with certain health situations. This type of instruction could be seen as training in the form of a message. Meanwhile, persuasion messaging is intended more for high-involvement health practices.4
The research presented in this study focuses on the awareness process, as it is more suitable at the current level of the COVID-19 health campaign in Saudi Arabia. The targeted messages are of a simple nature and require simple, doable actions. These criteria are aligned with the previously mentioned objectives of an awareness campaign. According to Fogg Behavior Model (FBM), an individual will act and change his or her behavior if his or her motivation and ability are high, and a trigger is present at the same time.
Saudi Arabia, like other hard-hit countries, has taken stringent measures to control the rapid spread of the COVID-19 pandemic. The Saudi Arabian Ministry of Health (MOH) has conducted an intensive awareness campaign, communicated via its website, television, and various social media channels, to equip individuals with facts and precautionary measures surrounding COVID-19. Moreover, the MOH has provided a geographic information system (GIS) dashboard 5 featuring an interactive map of COVID-19–related data on a national and a municipal level (see Figure 1).
Although this map is useful, as it focuses on each region as well as each city, it does not provide details about areas within each city. The city’s overall data about COVID-19 might be sufficient for smaller towns and cities, where the population is around 100,000 or less, but may prove insufficient for larger cities such as Jeddah.
Also, the Ministry of Health has provided a number of Arabic and English mobile applications to deal with the virus outbreak. Among those are Tabaud (meaning distancing in Arabic), which can alert a person if he or she has been exposed to someone who has reported having COVID-19 and Tetamman (meaning rest-assured in Arabic), which aims to reinforce the commitment of all persons directed to self-isolation and follow-. From a technical perspective, the apps work fine; however, they are only of value if given real data. Also, since downloading and activating them is optional many individuals might choose not to do so for many reasons. These reasons include privacy concerns, as the idea of being tracked by one’s government might seem too intrusive to some.
The MOH has also launched a COVID-19 pandemic health awareness campaign through different media channels, including web platforms and social networks. The intent of this campaign is to educate the public about the highly contagious virus. These efforts include sending text messages to mobile phones, prompting the adoption of healthy habits, and encouraging the public to take appropriate virus prevention measures. A few examples are shown in Figure 2.
Designing campaigns customized to individuals or groups of individuals has been widely studied in health communication research.6 Customized text-based intervention was found to be significantly associated to greater intervention efficacy.7 For example, Pfammatter et al8 examined the impact of sending messages to patients with diabetes to increase exercise and improve fruit, fat, and vegetable intake. The participants were selected randomly and assigned to an intervention group or a control group. Participants in the intervention group who received the text messages demonstrated better improvement in health behavior compared to participants in the control group, who did not receive any text messages.8 According to Horner et al,9 using this type of intervention can assist in increasing the physical activities of patients with type 2 diabetes. Horner et al 9 designed the study as a two-parallel group randomized controlled trial, where the intervention group received text messaging twice a day. The participants satisfaction were very high with the more than 90% of them stating that they will recommend these messages program to a friend. The participants of this study described these messages as motivational, informational and educational. However, while the participants were satisfied with the text messaging, they suggested that these messages are better be personalized.9 In another study, text messaging intervention was used to increase and maintain Saudi women’s ability to educate themselves about HPV, enhancing their knowledge about HPV and cervical cancer. Around 34 Saudi women were recruited using convenience and snowball sampling techniques. The authors applied a single group, pre- and post- intervention method. The results showed a statistically significant difference in self-efficacy before and after receiving the text-messages.10
There are two methods for customized health messages: targeting and tailoring. Message targeting uses customized messages based on the characteristics of a subgroup of an overall population; for example, they would target people with similar lifestyle traits, such as fresh college graduates starting their careers or people who live in a certain geographical area. Message tailoring fits messages to individual characteristics, such as personality factors, ways of thinking, or coping styles. Each of these methods has its advantages; the ability to select which one to apply to a certain campaign depends on the campaign itself and the available data about the target audience.6
The population data available along with the resources, timing, and type of messages being propagated to the target audience make the message targeting method more suitable for this study. This health awareness campaign has been adapted to educate the public about simple safety measures to prevent them from being infected by COVID-19. The targeted audience for this customization would be those within a geographical location, namely, on a district level within the city of Jeddah. People within the targeted location would receive messages regarding how many infected cases had been reported in their particular area, the sources of infection (if available), or the recipients’ proximity to areas where many COVID-19 cases have been reported.
This research aims to design, develop, and evaluate the content of a customized awareness campaign to reinforce precautionary health behaviors of individuals during the COVID-19 pandemic. This message-based campaign will be developed in two sequential phases. The first phase aims to design and evaluate messages by employing the Fogg behavior model (FBM).11 The FBM is a holistic model describing behavior change as the convergence of three components: motivation, ability, and trigger. These three elements are the building blocks of our campaign content. FBM was initially developed to guide the design of persuasive technology, which is technology that aims to promote a certain behavior. In this study, the model is followed to develop an awareness campaign aiming to promote precautionary health behavior using messaging intervention. The awareness campaign content is then evaluated by domain experts for its relevance to the three conceptual components of FBM.12,13
The second phase of this research applies a geospatial intelligence platform to profile the city of Jeddah. These location-aware profiles, combined with behavior-change messages built in the first phase, will be used to target the locals of each district differently. The content of this phase will be driven by statistics of confirmed COVID-19 cases and the source of the infection on a district level, both analyzed using ArcMap. 14
1.3. Theoretical Framework
To change or promote a certain human behavior, theories of behavior change are needed. The present study is guided by FBM to build the content of the messages. The Fogg model highlights three main factors: motivation, ability, and trigger. To embrace a new behavior, a person must be motivated, have the ability to perform the behavior, and be prompted to do so with an effective trigger.
For example, if the target behavior is to wear a face mask while a person is outside, a person must have sufficient (high) motivation, ability, and an effective trigger. These factors must be present at the same instant for the behavior to occur, which is to wear a face mask every time this individual goes outside.
As reported by Fogg, while designing the motivation, the goal must be to move the user to a higher position in the FBM landscape, which means to increase the user’s motivation. There are three core motivators: pleasure/pain, hope/fear, and social acceptance/social rejection. In this study, we will use the hope/fear motivator to build the content of the messages. The hope/fear motivation is sourced from the anticipation of something good (hope) or bad (fear) happening. For example, the hope of not being infected by COVID-19 will motivate a person to follow government safety roles and stay at home, while a person will wear a face mask to overcome the fear of getting infected by COVID-19. Another example is that a person will keep a social distance to overcome the fear built from the anticipation of getting COVID-19.
The second factor in FBM is ability. The most important condition in this factor is simplicity, since, as stated by Fogg, “Simplicity changes behaviors.”11 To increase a person’s ability, the persuasive technology design must make the behavior easy to do. For example, one-click shopping on Amazon or short and easy-to-understand messages on a phone or social media account. The author defined six elements that detract from simplicity: time, money, physical effort, brain cycles, social deviance, and non-routine. If the new or target behavior requires time to perform, it is not simple. The money element of simplicity refers to the financial requirements of the behavior; if the target behavior is costly or requires money, it is not simple, especially for users with limited monetary resources. The third element is physical effort: the new behavior must not require physical effort; otherwise, it will not be simple to do. The fourth element is brain cycles, meaning that hard thinking is required. If the target behavior requires the user to think a lot, the task is not simple. Another element is social deviance; this element describes going against the norm or breaking society’s rules. If performing a new behavior will break certain rules, it is not simple. Finally, the last element is non-routine, indicating that the new behavior is not from a user’s routine. If a person is seeking a behavior that is not from his or her routine, he or she may think it is not simple.11 An example of a new behavior required during the COVID-19 health crisis is wearing a face mask. Performing this behavior will not take time, especially if a person follows some tips, such as putting the mask near the entrance. A face mask is not expensive. Also, there is no effort required to wear the mask. The user will not need efforted thinking to wear the mask. Furthermore, this behavior is not currently against society’s rules, as it is one of the safety rules. Finally, non-routine: yes, wearing a face mask is not a routine, but it will be. Therefore, in most societies, people must consider this behavior as part of their routine while going outside their home.
The third factor is trigger. Fogg defines trigger as “something that tells people to perform a behavior now.”11 There are three types of triggers: facilitators, signals, and sparks. Facilitator triggers are used if the users have high motivation but lack ability. This type of trigger can be expressed in text, video, graphics, and by other means. They are effective if they focus on simplifying the target behavior, for example, by telling users that performing a certain behavior is easy, does not take time, and is not costly. The second trigger type is signals. These triggers are a good fit if the users are high in motivation and ability, but just need a reminder. For example, a morning message to remind people to wear their face mask if they are going outside is a signal trigger. Finally, sparks triggers are used if the person lacks the motivation to perform the target behavior. The technology that will be used here must focus on the motivational element, for instance, texts to highlight the fear of catching COVID-19, or videos that highlight hope of not getting COVID-19. The most important element of these triggers is that they are “presented to the user at a moment when they can take action.”11