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Risk communication – A moving target in the fight against infectious hazards and epidemics

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  • Risk communication – A moving target in the fight against infectious hazards and epidemics

    Weekly Epidemiological Record (WER)

    19 February 2016, vol. 91, 7 (pp. 73–88)

    73 Zika virus infection: global update on epidemiology and potentially associated clinical manifestations
    82 Risk communication – A moving target in the fight against infectious hazards and epidemics
    87 Monthly report on dracunculiasis cases, January– December 2015
    Risk communication – A moving target in the fight against infectious hazards and epidemics
    by G. Gamhewage

    Risk communication is central to epidemic and pandemic control. It has been practised widely in the past but with varying levels of success. Risk communication should have a full place at the outbreak response table, on par and in step with all other public health interventions. Lessons from recent experience provide a learning opportunity to enable this field of public health work to further evolve.

    As a specialized area of public health science, risk communication practice is used to communicate effectively in high-concern situations and is essential in building the evidence base that drives public health action during disease outbreaks and other health emergencies. Experts from many scientific disciplines frequently find themselves in the field of risk communication, some with little preparation. Many experts from biomedical and operational backgrounds lack the understanding or support needed to fully utilise the tools and strategies that have steadily evolved in this field over the past few decades.

    The principle distinction today between risk communication and other forms of communication is that risk communication facilitates an effective outbreak response by addressing challenges in the social environment of disease outbreak. It does this by replacing one-way communication with two-way dialogue among the various stakeholders - decision makers, scientists, technical experts, response teams, communities, health workers, partners, nongovernmental organizations (NGOs) and individuals; and across the many sectors that are inevitably involved in disease outbreak response. The modern risk communication principles of listening (to people’s concerns and fears), transparency and trust, together with operational strategies, such as first announcement and planning, which evolved as a result of the painful lessons learnt from the SARS1 response in 2003, should not be taken for granted.

    Risk communication has evolved considerably as a discipline, in just the last few decades. The influenza A(H1N1) 2009 pandemic, MERSCoV2 outbreaks, Ebola in West Africa of 2014 and most recently, the Zika outbreak and the outbreak of microcephaly and other neurological syndromes, have each had impact on how risk communication is viewed and used in epidemic and pandemic response.

    Evolution through research and experience In 1995 Baruch Fischhof3 analysed the lessons learnt by risk communication researchers and practitioners over the previous 20 years. He identified a series of developmental stages, each of which built upon the previous one. The lessons Fischhof drew appear to have still greater relevance more than 2 decades on.

    1. All we have to do is get the numbers right (experts assess and understand the hazard and associated risk, and it is not generally communicated with the public).

    2. All we have to do is tell them the numbers (information dissemination and “objective” communication of the risk assessment without sufficient interpretation – reflecting a desire not to simplify it too much).

    3. All we have to do is explain what we mean by the numbers (more subjective communication but generates discussion leading experts to worry about misinterpretation and the lack of ability of the audience to understand the science).

    4. All we have to do is show them that they’ve accepted similar risks (but risk comparisons are difficult to make and can appear insensitive, uncaring and condescending).

    5. All we have to do is show them that it is a good deal for them (demonstrates a benefit, but personal bias and perception determines how these are viewed).

    6. All we have to do is treat them nice (treat “audiences” or “clients” with respect, engender trust).

    7. All we have to do is make them partners (audiences become stakeholders, with acknowledgement of their views, preferences and perceptions. Risk communication becomes ever more complex, but its potential is greater than ever).

    8. All of the above. The concept of risk communication today is rooted in the increasing focus on not just the facts related to risk, but to people’s perceptions.4 Psychometric research in the second half of the 20th century identified key factors that affect risk perception: the degree to which a risk is understood; the degree to which it evokes a feeling of dread; and the number of people exposed to the risk. “A dread risk elicits visceral feelings of terror, uncontrollable, catastrophe, inequality, and uncontrolled. An unknown risk is new and unknown to science. The more a person dreads an activity, the higher its perceived risk and the more that person wants the risk reduced”.5

    The increasing focus on perception was synchronous with public demand for participation in policy making and the politics of self-determination, and the human rights agenda. This in many ways heralded in the era of two-way communication. The risks that kill people and the risks that alarm them are often completely different. Modern day risk communication gurus Vincent Covello and Peter Sandmann point out that “there is virtually no correlation between the ranking of hazards according to statistics on expected annual mortality and the ranking of the same hazards by how upsetting they are. There are many risks that make people furious even though they cause little harm – and others that kill many, but without making anybody mad (angry)”.

    The anthropology and/or sociology approach sees risk perceptions as socially constructed by institutions, cultural values, and ways of life. The Social Amplification of Risk Framework (SARF), combines research in psychology, sociology, anthropology, and communications theory. It provides an explanation of the process by which risks are amplified, receiving public attention, or attenuated, receiving less public attention. Risk events interact with individual psychological, social and other cultural factors in ways that either increase or decrease public perceptions of risk.

    Behaviours of individuals and groups then generate secondary social or economic impacts while also increasing or decreasing the physical risk itself.
    These models indicate that further evolutions are likely and can also be shaped by our practice of risk communication in epidemics and pandemics. Risk communication is different from other forms of communication Risk communication addresses the different risk perceptions that co-exist with outbreaks (from perceptions that this is terrifying, to this is a conspiracy and overstated). Perceptions are usually highly emotional and culturally impacted in disease outbreaks and influenced by traditional beliefs, religion and other socially structured views on life, health and death). Risk communication needs can change dramatically in disease outbreaks and the corresponding risk communication strategy must adapt to the evolution of the epidemic and the subsequent risk perceptions. It must tackle infodemics6 that now routinely appear – “a few facts, mixed with fear, speculation and rumour, amplified and relayed swiftly worldwide by modern information technologies, that can affect national and international economies, politics and even security in ways that are utterly disproportionate with the root realities”.

    Risk communication is not the same as but is complimentary to crisis communication. It requires risk assessment skills and the capacity to translate and transform technical scientific information into action oriented messages, products, tactics and actions. It involves the rapid interpretation of a complex sociocultural-political-economic situation to tailor the messages and the communication channels. It must have effective mechanisms for listening and must understand and manage the associated infodemic of fear, concerns, rumours and misinformation. This means effective risk communication must be embedded, from the readiness phase, in the technical public health operations with direct links to technical disease experts. Social scientists and risk communication experts must be able to provide input easily into health operations.

    Risk communication in the 21st century

    In November 2015, WHO convened a consultation workshop to provide advice and input to the development of a strategic framework to support WHO`s emergency risk communication. It brought together more than 60 experts and specialists, drawn from the UN system, partners, academia and the 3 levels of WHO to advise on principles, directions and practical actions for driving forward WHO`s future communication in outbreaks and health emergencies.

    In today’s interconnected world, the operating environment for risk communication in epidemics and pandemics is complex. The same is true for the crowded and difficult to coordinate international emergency response systems that are mobilized in epidemics and pandemics. Risk communication, while attempting to address with public health outcomes, will nevertheless impact the social, economic and political life of individuals, communities and countries. Despite increasing challenges, this area of work remains under-resourced and has a dearth of properly trained and competent personnel who can work together in an emergency. WHO’s reform of its outbreak and emergency response offers a unique opportunity to reform risk communication in disease outbreaks and health emergencies more broadly. And, WHO’s public health leadership position in disease outbreaks provides an opportunity to influence practice beyond the Organization. Some of the recurrent recommendations emerging from lessons learnt in the field of emergency risk communication include:

    1. The paradigm must shift systematically from telling people what to do (message-based communication) to systematically listening to those affected. Through risk communication, engagement and interaction can enable actions to be contextualized to achieve the health goals of outbreaks and emergencies.

    2. View risk communication, especially in outbreaks and emergencies as a broad umbrella that requires many types of communication and engagement to be used in the most suitable mix based on the context.

    3. Community engagement is one of these strategies, but one which requires its own expertise and capacity building. Communities must be at the heart of any emergency response. They should be empowered to shape strategies, not just implement them.

    4. The need to engage and coordinate with the many professional disciplines, programmes and partners in order to supply the expertise needed for effective risk communication.

    5. Risk communication must be part of health operations and preparedness. It must be part of outbreak investigation and remain central at all stages of the emergency management cycle.

    Building blocks for the next phase of the evolution

    National capacity building: Sustainable national and local capacity building should be a key driver of risk communication activities between, during and following outbreaks or health emergencies.

    Coordination: Risk communication coordination between and during outbreaks and health emergencies is essential.

    Unique roles: Governments, WHO, UN agencies, humanitarian response systems, NGOs, civil societies all have unique roles as well as overlapping ones. These need to be clarified, negotiated, communicated and acted on well before an outbreak and emergency.

    Unique considerations by hazard character: New or unfamiliar diseases, for example, generate intense fear, misinformation and rumours and response measures for disease containment creates social-economic and political consequences. The current fears about the spread of the Zika virus and its suspected complications such as microcephaly and the many unanswered questions concerning experts and the public alike requires a very different risk communication response than the outbreak of a known disease such as cholera. The same is true for some hazards such as radio nuclear or chemical events. A new respiratory disease such as a novel influenza virus with pandemic potential will be very different from Ebola. The emergency is likely to spread fast, affect multiple countries across the world and will carry special and challenging requirements for the Ebola Response Consortium (ERC) as well as the overall response. The following functions are therefore required to practice risk communication.

    Translational communication – so that science and technical knowledge can quickly be scoped, defined, translated and transformed into an understandable/contextualized format for specific stakeholders throughout the risk management cycle.

    Listening systems - that allow for dynamic listening to peoples’ concerns and fears and for rapid management of rumours and misinformation at all levels and for feeding into all types of communication and engagement using a range of methods

    Public communication – communications teams at global, regional and country levels can use a range of communications approaches to ensure that key stakeholders – those affected as well as responders and their agencies – have access to and use the products of health communications and translational communications and be apprised of risks and their management.

    Institutional communications – proactively keeping all relevant stakeholder institutions and agencies, affected and not-directly-affected countries, informed in real-time of the situation and what WHO is doing. This includes situation reports, disease outbreak news, IHR announcements and public communications from global through national levels on risks and their management using the best mix of channels.

    Community engagement – this requires support for linking up with existing community engagement networks and mechanisms to reach, mobilize, engage with and ultimately have community ownership of response action, and knowing what WHO should and should not be doing in community engagement.

    National capacity building – support to national governments and partners to build in-country capacity for ERC including in assessing existing capacity, developing national strategies, plans and associated standards operating procedures, testing the capacity through simulation exercises (SIMEXEs) or helping with after-action reviews following real events or emergencies so that strategies and plans are revised on a regular basis.

    Risk communication operations – to build up institutional capacity and manage operations including scaling up and deployments to operational locations.

    Author affiliations a Pandemic and Epidemic Diseases Department, Outbreaks and Health Emergencies Cluster, World Health Organization, Geneva, Switzerland (Corresponding author: Gaya Gamhewage, 

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