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SARSControl deliverable D5.9 Conclusions and Recommendations for Risk Perception and Risk Communication Thomas Abraham1, Johannes Brug2, Gillian Elam3, Xinyi Jiang3, Irene Veldhuijzen4, Hélène Voeten2, Yi-Chen Wu5, Cicely Yuen4 and Onno de Zwart, 2, 4 1 Journalism and Media Studies Centre, University of Hong Kong, Hong Kong 2 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands 3 Health Protection Agency - Centre for Infections, London, United Kingdom 4 Municipal Public Health Service Rotterdam Area, Rotterdam, The Netherlands 5 Advertising of Public Relations Department, Fu-Jen Catholic University, Taiwan November 2006 SARSControl: Effective and acceptable strategies for the control of SARS and new emerging infections in China and Europe, a European Commission project funded within the Sixth Framework Programme, Thematic Priority Scientific Support to Policies, Contract number: SP22-CT-2004-003824 1 INTRODUCTION This document is based on the final reports of SARSControl Work Packages 5 and 6 listed below. The contents are grouped by topic and the conclusions are followed by the accompanying recommendations. Part 1 ‘Risk perception and efficacy’ and part 2 ‘Information sources’ are directly based upon the research conducted in both work packages. Part 3 ‘Other’ and part 4 ‘For further research’ result from group discussions among all work package participants informed by the study results and other scientific experiences. At the end of this document we have summarized all conclusions in a table. SARSControl reports that informed the conclusions : Work Package 5, Risk Perceptions − Risk Perceptions Survey; General description and international comparison and Country reports − Qualitative Stage: Impact of SARS on vulnerable communities; The United Kingdom and The Netherlands Work Package 6, Risk Communication − Risk Communication during the SARS epidemic of 2003; Case studies of China, Hong Kong, Vietnam and Singapore − Risk Communication during the SARS outbreak in Taiwan: What did we do and what have we learned? 2 RISK PERCEPTION AND EFFICACY 1. Risk perceptions for emerging infectious diseases appear to be high enough across most countries in Europe represented in SARSControl. This is especially the case if people envision an outbreak in their own country. However, efficacy beliefs, i.e. beliefs about personal control to reduce risks (‘self-efficacy’) and beliefs about efficacious measures to reduce risk (‘response efficacy’), are relatively low. Concerns arising from fear of stigma or fear of causing adverse reactions contribute to reduced self-efficacy beliefs; lack of international consistency and of locally available relevant guidance reduce response efficacy. In the Chinese communities that were assessed in the UK and the Netherlands, risk perceptions appear to be lower on average than in the general population, especially in the UK. However, even within the overall seemingly lower risk perceptions among the Chinese populations in the UK and the Netherlands, the avoidance strategies adopted as precautionary behaviour of those with higher risk perceptions had an adverse impact on the community, particularly in crowded, urban areas. Risk communication should therefore focus on: − improving specific precautionary behaviour and the efficacy beliefs necessary for this; communicating about what people can do to appropriately and effectively reduce their risks. − Risk communication messages to the public and the media should contain answers to the following questions that are uppermost in the public mind - what is happening? - what risk is it to me? - what should I do? - what is the government and the public health system doing? 2. In the affected Asian countries, efficacy beliefs are higher. Respondents from these countries have had first hand experiences of SARS, including clear instructions regarding precautionary behaviour. Most importantly, they experienced ‘surviving’ SARS. Risk communications that draw on first hand experiences and evidence-based effectiveness may therefore carry more weight with the public. Experience and feedback are important ways to (re) assesses risks and efficacy beliefs. 3. At the first stages of an outbreak, effective precautionary actions are often not clear or evidence based, since much information about the disease and its modes of transmission are not yet known. Nevertheless rising risk perceptions, particularly vulnerability, create a desire to take precautionary actions, and thus a demand for risk communications. The need for quick 3 risk communication in countries with the outbreak is clear, however, this may also be necessary in unaffected countries because of the presence of ethnic communities from affected countries. In the case of SARS, delays in risk communications from official sources in unaffected regions led vulnerable residents, like Chinese communities, to seek information from affected regions when relevant local information was absent. Sensational media coverage focusing on the seriousness of SARS and lack of scientific knowledge, together with perceived contradictions in advice from affected and unaffected regions undermined the reliability of local risk communications. Theoretically priorities for communication on precautionary actions should be: I Communicate about effective actions as soon as possible II Communicate about actions that may have detrimental effects III Communicate about non-effective non detrimental actions INFORMATION SOURCES 4. Mass media such as television and newspapers are used most often as information sources for emerging infectious diseases, and are well trusted. Use of and confidence in both television and newspapers are higher in Asia than in Europe. Governments and health agencies can use mass media to communicate risk management information to the general public; Governments and health agencies should learn how to use the media effectively. This includes that agencies are prepared to approach mass media, have a designated spokes person to address the mass media and can suggest independent experts next to government representatives. 5. In the minority communities in unaffected regions with strong familial and business links with affected regions, the social network appears to be an additional important and trustworthy source and medium for risk and risk management information. This includes networks both in the country of residence and from affected regions. A community-based communication approach can therefore be helpful to reach such communities in an effective way. This means that a community-communication strategy including contact with community organizations, key figures and media from communities, needs to be in place. Existing networks need to be identified that can be used for communitybased risk communication. 4 6. Chinese communities in the UK and the Netherlands used Chinese-based mass media intensively alongside European media. The Chinese mass media included media originating from affected regions, from unaffected countries of residence in Europe and other regions. Vulnerable and minority communities will use a variety of information sources due to language barriers and a desire for ‘first hand’ information from affected regions. Governments and health agencies should take the communications in the Chinese media into account when addressing the Chinese communities. In general it is important to take into account media from countries of origin of ethnic communities. 7. In the absence of prompt and rapid information from the authorities, rumours spread during infectious disease epidemics. This is clear from the SARS experience in both Hong Kong and Singapore. Public health authorities need to be geared for the rapidly correct rumours. OTHER 8. Health communicators should make sure that relevant risk communications from respected sources coincide with reports of serious and threatening emerging infections. This means that communication channels and sources should be in place, including international networks to facilitate consistency and appropriateness of risk communications in both affected and unaffected regions. 9. Risk communication should be dialogue. Feedback from the public and from health workers is necessary in order to learn how the public respond to such communications and what additional information is required to effect appropriate precautionary actions. Vulnerable communities need to be identified and relevant communications developed for them. 10. Governmental and/or health agency’s risk communication strategies and infrastructure should be in place before a new infectious disease emerges. Risk communication for emerging infectious diseases is often ‘crisis communication’. A risk communication infrastructure and culture that are effective globally and locally cannot be created in a short time span. 11. A risk communication strategy and infrastructure of governments and health agencies should include a strategy and infrastructure for communication with different target groups, like different ethnic communities / immigrants. Especially in light of their links with countries where an actual outbreak may take place. In developing such a strategy and infrastructure for communication it is important to also include strategies to reach groups like newly arrived immigrants, students and seasonal workers and those with ‘irregular’ status. 5 FOR FURTHER RESEARCH 12. More research is needed to look at cultural differences in general perceptions of risk and efficacy beliefs and how these differences may influence precautionary actions. 13. The European Union, maybe through the ECDC, and member states should have a survey system in place to monitor risk perceptions, efficacy beliefs and precautionary actions, to be able to react timely and tailored to risk perceptions in the general population and special interest groups. The experience gained through the SARSControl project working with both a survey and focus groups are a good starting points for such a survey system. 14. Further research on new media such as text messaging, www, e-mail, blogs, for risk communication is needed. SUMMARY a. BE PREPARED, ALSO FOR RISK COMMUNICATION b. TAKE DIFFERENT SUBGROUPS INTO ACCOUNT c. USE DIFFERENT CHANNELS AND SOURCES OF INFORMATION d. IMPACT OF OUTBREAKS ON COMMUNITIES WITH LINKS WITH AFFECTED REGIONS Conclusions Recommendations Risk perception and efficacy In Europe: risk perceptions are high; but efficacy beliefs are relatively low In Asia efficacy beliefs are higher, likely because of first hand experience with SARS Among communities originating from affected regions, lower RP at population level still led to take up of PB with adverse impact; RC from affected regions used in unaffected regions Risk communication delivery Impact of delays in RC on info seeking and PB Impact of global media and international-social Implications for risk communication content Specific precautionary behaviour and the efficacy beliefs necessary for this Implications for effective content Specific needs of such communities and subgroups; timely communication about effective, detrimental, non-effective actions Implications for risk communication delivery Timing of risk communication Need for global media strategy and 6 networks on RP & PB in vulnerable group; Multiple sources of media used from different origins; needs relate to: language; cultural communication; relationship to affected region Sources of info (influential and trusted) Evolution of RP and PB Crisis communication; time needed to communicate effectively to different subgroups infrastructure; relevance; use of social networks; consistency; heterogeneity; use of community channels; language; don’t rely on one source Communication channels Need for dialogue Risk communication strategies and infrastructure should be in place before a new infectious disease emerges Implications for further research More research is needed to look at cultural differences in general perceptions of risk and efficacy beliefs and how these differences may influence precautionary actions Have survey system to monitor risk perceptions, efficacy beliefs and precautionary actions in place; SARS control survey and focus group outline are good starting points for that. Further research on the use of new media such as text messaging, blogs, etc. is needed. RC – risk communication RP – risk perception PB – precautionary behaviour 7