WHO South-East Asia Journal of Public Health

PERSPECTIVE
Year
: 2020  |  Volume : 9  |  Issue : 1  |  Page : 15--20

Strengthening risk communication systems for public health emergencies in the WHO South-East Asia Region


Roderico H Ofrin, Nilesh Buddha, Maung Maung Htike, Anil K Bhola, Supriya Bezbaruah 
 World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi, India

Correspondence Address:
Supriya Bezbaruah
World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi
India

Abstract

Risk communication and community engagement are critical aspects of public health emergency preparedness and response and therefore one of the eight original core capacities of the International Health Regulations (2005). Joint external evaluations in eight out of eleven countries of the World Health Organization South-East Asia Region reveal that there is considerable variation in risk communication capacities among countries. Of the five areas evaluated – risk communication systems, internal and partner coordination, public communication, community engagement and listening, and risky behaviour and misinformation – the strongest areas, across the region, are partner coordination and community engagement, while risk communication systems is the weakest area and needs further strengthening. For strong and sustainable risk communication for public health emergencies in the WHO South East Asia Region, institutionalized capacity-building supported by increased budgetary allocations to this area is needed. There is a strong need for advocacy to and sensitization of key policy-makers and decision-makers at country level regarding the importance and advantages of being prepared on risk communication plans and systems.



How to cite this article:
Ofrin RH, Buddha N, Htike MM, Bhola AK, Bezbaruah S. Strengthening risk communication systems for public health emergencies in the WHO South-East Asia Region.WHO South-East Asia J Public Health 2020;9:15-20


How to cite this URL:
Ofrin RH, Buddha N, Htike MM, Bhola AK, Bezbaruah S. Strengthening risk communication systems for public health emergencies in the WHO South-East Asia Region. WHO South-East Asia J Public Health [serial online] 2020 [cited 2020 Aug 6 ];9:15-20
Available from: http://www.who-seajph.org/text.asp?2020/9/1/15/282990


Full Text



 Introduction



Communities are at the forefront of any public health emergency or disaster. The affected communities bear the brunt of any disaster and at the same time are the first to respond.[1] Therefore, any communication related to minimizing health risks or mitigating the impact of a disaster or emergency needs to be grounded in the context of the affected communities. Interventions to save lives usually need the people to act – for example by washing their hands with soap and water, getting vaccinated or adhering to the doses prescribed by clinicians – and without the cooperation of and appropriate action by communities, even the best public health interventions and plans are likely to fail or remain ineffective.

The affected communities’ cooperation depends on if they are aware of what they need to do in their situation and if they are convinced of the advantages of doing so, that is, adhering to the preventive and protective behaviours. Indeed, communities often provide feasible solutions to public health emergency issues. In an increasingly interconnected world, where rumours and fake news spread faster than the truth,[2] ensuring that communities have accurate information is a growing challenge. Communicating and having continuous engagement with the public and affected communities – that is, risk communication – is therefore critical for the prevention and mitigation of public health emergencies. It is one of the eight original core capacities that States Parties are required to have in place in accordance with the revised International Health Regulations, 2005 (IHR),[3] which were adopted at the 58th World Health Assembly on 23 May 2005 and are legally binding on all Member States.

The World Health Organization (WHO) defines risk communication as “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”.[4] The WHO guideline Communicating risk in public health emergencies also explains why emergency risk communication is needed: “[It is] an intervention performed not just during but also before (as part of preparedness activities) and after (to support recovery) the emergency phase, to enable everyone at risk to take informed decisions to protect themselves, their families and communities against threats to their survival, health and well-being”.[4] Key to risk communication, therefore, is engaging those affected as equal partners and recognizing that communication is geared towards enabling them to take appropriate action to protect themselves.

The psychological condition of people during an emergency leads to unique challenges to successful risk communication. People tend to respond to perceptions rather than facts, and their perceptions and beliefs are shaped by many factors, including individual experiences, community beliefs and peer influence.[5],[6] In an emergency, however, people are in a state of great stress and anxiety, and neuroscience studies have shown that in such situations people’s ability to absorb information diminishes significantly.[7] From a more flexible type of learning during normal times, in times of stress or crisis, therefore, people shift to more rigid, habit-like behaviours.[8] To overcome this diminishing ability to absorb new information and increased tendency to fall back on previously formed habits that may not always be appropriate for an emergency situation, risk communication in emergencies requires building trust and engaging communities before an emergency, as well as intense, strategic and increasing face-to-face engagement during an emergency. Risk communication is therefore a continuous process throughout all the phases of a public health emergency.

This perspective paper provides insights into increased community engagement and strategic interventions for establishing and strengthening risk communication systems in the countries of the WHO South-East Asia Region.

 Examples of good risk communication interventions



Role of religious leaders in the 2004 Indian Ocean tsunami

One of the biggest emergencies in recent times, and one that led to transformation in the field of health emergencies, was the Indian Ocean tsunami of 2004. On 26 December 2004, a massive earthquake generated a tsunami with waves over 10 m high in some places. It devastated six countries of the region – India, Indonesia, Maldives, Myanmar, Sri Lanka and Thailand – resulting in over 200 000 dead or missing and over half a million displaced. The health and nutrition of those who survived were priorities. However, in Aceh, Indonesia, and in the Maldives, the worst hit areas, people were refraining from eating fish as there were rumours that fish might have fed on bodies swept into the ocean. To fight those rumours and get people to eat fish, the Food and Agriculture Organization of the United Nations, WHO and health officials sought the assistance of religious leaders, who issued a fatwa (religious edict or advice) stating that fish should be consumed. Only then did people consume fish, averting a further health and nutrition challenge. This highlights the benefits of engaging influencers and trusted community leaders in risk communication.[9]

Importance of community trust and cultural context in the containment of the Nipah outbreak in Bangladesh in 2010

In 2010, in an outbreak in Faridpur District, Bangladesh, eight people were infected with Nipah virus, of whom seven died. The local community lost trust in the services of the local government hospitals owing to the failure of biomedical treatment to save the lives of the infected patients. Later interviews revealed that the community believed that doctors in the tertiary hospital had deliberately killed the patients because they did not want the disease to spread. They believed that supernatural forces were at work and had caused the disease. Anthropologists and risk communicators therefore set out to understand the local beliefs and cultures, with the help of local volunteers. To rebuild rapport and trust, they began by greeting villagers, striking up conversations with people they met and listening during household visits, and then they explored their beliefs and perceptions in private when the people were comfortable. Based on those insights, they used interactive communication to convey prevention messages in face-to-face community meetings at times and places selected by the community residents. The messages were explained using pictorial aids and photos and taking into account the cultural context. The most common pathway of Nipah virus transmission in Bangladesh is through drinking raw date palm sap contaminated with saliva or urine of fruit bats. Acknowledging the importance to the community’s culture of date palm sap and providing culture-centric solutions – such as not banning the drinking of the sap but emphasising the importance of boiling it before drinking – led to greater acceptance. The trust and rapport built made the community more comfortable with voicing their doubts and uncertainties to the team, and this provided openings for the risk communication team to have conversations to convince them with biomedical explanations.[10]

Middle East respiratory syndrome coronavirus in Thailand: preparedness, transparency and coordinated communication

In 2015, with a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in the Republic of Korea, all neighbouring countries were on high alert. In Thailand, the first case – an Omani national who had come to Thailand for medical treatment – was confirmed. Thailand had a dedicated risk communication unit and system in place, including a risk communication plan. It activated the plan. The Ministry of Public Health provided information on MERS and was active on social media, including fighting rumours and misinformation. It ran a cohesive information campaign, with daily media briefings and information through other channels such as posters and advertisements. Thailand has an extensive network of village health volunteers, and, to prevent panic at community level, village health volunteers were informed daily. In turn, they engaged in dialogue with their village communities. Internally, communication was coordinated: daily updates were provided to all government department heads and provincial health chiefs, as well as provincial risk communication focal points. Importantly, communication was contextual and addressed public perceptions and concerns, which were monitored and analysed using the media and social media as well as 24-hour hotlines and two perception surveys. Consequently, the case did not lead to panic.[11]

 Status of preparedness on risk communication in the region



The first pandemic of the 21st century, the 2003 global outbreak of severe acute respiratory syndrome (SARS) was a tipping point for recognizing the significance and importance of risk communication through community engagement.[12] Between 1 November 2002 and 11 July 2003, 8437 cases and 813 deaths were reported worldwide.[13] The economic impact of SARS globally was US$ 30 billion to US$ 100 billion, or around US$ 3 million to US$ 10 million per case, disproportionate to the actual impact. The fear and perception of risk among the public due to a lack of information led to dips in travel, tourism and retail and consequent economic losses.[14] This episode highlighted the critical importance of public perception and the need for effective risk communication. Risk communication was later included as a core capacity to be strengthened in the revised IHR.[3]

Member States of the WHO South-East Asia Region have since reported on their risk communication capacity every year. The State Party annual reporting tool has one indicator for risk communication. In 2018, one country – Thailand – reported achieving 100% in risk communication. Maldives and Nepal gave themselves a score of 20%. The Democratic People’s Republic of Korea and India gave a score of 80%. All other countries rated themselves at 60%, indicating that they had some capacity but that there was scope for further strengthening.[15]

Eight of the eleven Member States of the region have also undergone a voluntary joint external evaluation (JEE), a more extensive evaluation of capacities undertaken by external and internal experts together in a country.[16] The JEEs evaluated the countries on the following five indicators that represent critical areas of risk communication work (see [Figure 1]).{Figure 1}

Risk communication systems: this includes a dedicated national risk communication unit; a risk communication plan, complete with chain of command to local level; staff with defined responsibilities; and a dedicated budget for risk communication.Partner and internal coordination: this involves coordination for communication and information sharing among partners, and internal government departments, and all those involved in the emergency, so that all speak with one voice to increase the effectiveness of response and public trust.Public communication: this refers to all forms of communication to the public, including the media.Community engagement: this covers dialogue with vulnerable or affected communities.Addressing perceptions, risky behaviour and misinformation: since perceptions drive people’s actions, and wrong or false information can lead to false perceptions, it is essential to tackle this area.

[Figure 1] highlights that, among the five areas, the weakest is risk communication systems, followed by rumour management and public communication. Both internal and partner coordination and community engagement are equally strong, based on the JEE scores. Capacities in these five areas varied widely among countries. The scores by country (see [Table 1]) highlight the variation in capacities among countries and among indicators.{Table 1}

Risk communication systems

Most countries have risk communication plans for specific diseases, and some have an all-hazards risk communication plan. However, Thailand is the only country of the region to have all of the following: a dedicated risk communication unit for public health emergencies; an all-hazards risk communication plan, complete with chain of command to local level; staff with defined responsibilities; and a dedicated budget. Most countries do not have a dedicated risk communication unit or even dedicated risk communication staff for public health emergencies.

Risk communication is considered a part of disaster preparedness and response planning. Five countries reported during their JEEs that integrated risk communication was mentioned in disaster-related plans. Five countries reported having designated spokespersons to address the media during emergencies. Indonesia has regulations in place with risk communication provisions in emergencies, according to its JEE report.[17]

Gaps and challenges

Most Member States need to develop an integrated all-hazards risk communication plan, test it and regularly update it. A risk communication function and focal point, with specific terms of reference, is also lacking in most countries. Capacity needs to be enhanced through more training on risk communication for health personnel and by increasing the numbers of emergency communication specialists at all levels. Finally, and crucially, financial resources in this area need to be shored up. Only one country of the region allocates resources specifically to emergency risk communication as a whole, although some specific areas such as information education communication materials do have budget.

Internal and partner coordination

Internal and partner coordination is rated the strongest of the risk communication areas in the region. Four countries – Indonesia, Maldives, Myanmar and Thailand – mentioned cross-agency communication coordination as a strength, with formal and informal mechanisms in place for multisectoral and partner coordination, in line with emergency response plans. Indonesia and Maldives have even tested communication coordination in simulation exercises. Most have communication coordination in place through mechanisms such as websites, text messaging, or social media platforms such as WhatsApp.[17]

Gaps and challenges

To strengthen communication coordination and collaboration across all sectors, there is a need for standard operating procedures that define the roles and responsibilities of communication partners. Engagement and coordination beyond government sectors, with civil society organizations and other important non-state actors, is also needed. In countries with decentralized health systems, greater coordination with local government is necessary.

Public communication

Risk communication is widely perceived as public communication, including media communication, and this area has received considerable attention. Consequently, almost all countries of the region have trained media spokespersons, and many have dedicated external communication units in their ministries of health. Multiple modes of communication are used, including mainstream media and social media. Most countries mention regular media briefings and sensitization of media reporters.[17]

Gaps and challenges

Evaluation of public communication for its impact and greater evidence-based communication for behaviour change are needed. One area of public communication that is evolving and changing rapidly is social media, and countries need to strengthen their use of social media and adapt to using different modes of communication for different audiences. More sustained, systematic training on public communication is also needed. Sensitization of journalists needs to be frequent, as there is a high turnover of health journalists, who tend to move on to other fields of reporting.

Community engagement

All countries of the region that have been externally evaluated reported strong community engagement systems. All countries have networks of community health workers and community health volunteers, which are trusted and play a crucial role in communicating during emergencies. There are innovative mechanisms for community engagement: in Indonesia, for example, the government has memoranda of understanding with community-based organization people–public–private partnerships on disseminating information material to communities. The government also supports communities through awards incentives. Thailand regularly monitors public perceptions through opinion polls.[17]

Gaps and challenges

While there are strong networks of community health workers and community health volunteers to engage with and persuade communities to make them part of the public health emergency response process and solution, more training is needed for health professionals. Community engagement is essential but resource intensive, and most countries do not have the necessary resources. There is also a need for more evaluation tools for communication and engagement with affected communities during disasters or health emergencies.

Addressing perceptions, risky behaviour and misinformation

Fake news and misinformation are a major source of concern during emergencies as mobile internet penetration extends to previously inaccessible areas. Addressing people’s fears and perceptions is key to stopping rumours.

Bangladesh, Bhutan, Indonesia, Maldives, Sri Lanka and Thailand have hotlines and other mechanisms through which the public can access government authorities to discuss their concerns. This also allows governments to understand people’s perceptions and concerns and address rumours. Thailand has an extensive and systematic public perception and rumour detection system, which includes information from media and social media and health volunteers, as well as regular perception surveys. The information is analysed and used to design public campaigns, including through the media and social media. Indonesia also has standard operating procedures in place for managing rumours. Bangladesh, Bhutan, Maldives, Myanmar and Sri Lanka have systems for addressing rumours through the media.

Gaps and challenges

None of the countries evaluated, except for Thailand, has a systematic process for rumour detection and management in place. Apart from Thailand, no country has a system in place for mitigating rumours early, except by issuing media statements, which are not always effective and can sometimes be counterproductive. Although media and social media monitoring is conducted, there are no systematic and regular analyses to identify rumours early and proactively plan appropriate communication for rumour mitigation. Training for health professionals in communication skills also needs to be strengthened; patients are most likely to turn to them for information or clarification during an emergency. More risk communication experts are also needed at subnational/provincial level.

 Conclusion and the way forward



The areas covered by the five risk communication indicators of the JEE are closely interrelated and interdependent. Improvements in these areas therefore require an integrated and holistic approach, and the cornerstone is a risk communication system. Fundamental to building such a system are financial resources and technical expertise, and a national risk communication plan.

In particular, preparedness and capacity-building on developing risk communication systems is poorly funded in the region. Technical experts in this area are also limited. There are media and public relations experts. There are community-level health promotion experts, who often work in areas such as HIV or tuberculosis, or other communicable or noncommunicable diseases. However, emergency risk communication requires the expertise of both, to be applied in the time-limited and high-stress conditions that occur in an emergency. All countries of the region except the Democratic People’s Republic of Korea have had capacity-building workshops on risk communication, but these have largely been ad hoc, of short duration (less than a week) and of variable quality. Those trained have often been public health professionals who then move on to other areas of public health. To have an adequate pool of trained experts for emergencies, a planned and institutionalized approach to capacity-building is needed.

Financial resources and building risk communication expertise are therefore critical priorities for the region. Obtaining both those resources will require the endorsement of senior policy-makers. Advocacy to policy-makers and key decision-makers on the role and impact of risk communication is therefore very important.

A third priority is strengthening systematic listening to public concerns. First, in an increasingly connected world, this is important because misinformation or wrong information can reach millions in minutes and – depending on the message – has the potential for great harm. Understanding this and responding rapidly can mitigate dangers. Second, only if public concerns are understood can they be properly addressed, and information about risk communicated effectively in this context. Systematic listening means receiving information from and about the public through multiple channels, including the media, social media and key community figures, and then analysing this information and responding appropriately to public needs.

How the community perceives various emergencies, what they perceive to be their role, how they are influenced and how their views tally with the biomedical approach are not widely recorded in the WHO South-East Asia Region. This is a region of rich social and geographical diversity, and therefore risk communication response to emergencies will also need to take diverse approaches. Ethnographic and anthropological/social research on emergencies in the region will help to improve understanding of the acceptability of response to emergencies.

All of these priorities are delineated in the Risk communication strategy for public health emergencies in the WHO South-East Asia Region: 2019–2023.[17] The strategy was endorsed in the 72nd session of the WHO Regional Committee for South-East Asia and all the Member States committed to it.

Finally, monitoring and evaluation of risk communication actions – both for process and impact – which is a part of the regional strategy, will provide insights into what works in this region and what does not, and thus make it possible to adapt to achieve the most effective mechanisms for risk communication.

Source of support: None.

Source of support: None declared.

Authorship: RHO provided suggestions about the risk communication analysis and reviewed the article and suggested ways to improve it. NB, MMH and AKB reviewed the risk communication analysis and provided suggestions. SB did the research on the content and analysis of risk communication in the region, developed the structure and wrote the article.

References

1A strategic framework for emergency preparedness. Geneva: World Health Organization; 2016 (https://extranet.who.int/sph/sites/default/files/document-library/document/Preparedness-9789241511827-eng.pdf, accessed 3 February 2020).
2Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science. 2018 Mar;359(6380):1146–51. https://doi.org/10.1126/science.aap9559 PMID:29590045
3International Health Regulations (2005), 2nd edition. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/bitstream/handle/ 10665/43883/9789241580410_eng.pdf;jsessionid=2235E048F3EA0 FDC617685709535EEB0?sequence=1, accessed 3 February 2020).
4Communicating risk in public health emergencies: a WHO guideline for emergency risk communication (ERC) policy and practice. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/handle/10665/259807/9789241550208-eng.pdf; jsessionid=378F4B716BCF7DF949752B278187E098?sequence=2, accessed 3 February 2020).
5Ropeik D. Understanding factors of risk perception. Nieman Reports. 2002;56(4):52 (https://niemanreports.org/articles/understanding-factors-of-risk-perception/, accessed 3 February 2020).
6Barnett DJ, Balicer RD, Blodgett DW, Everly GS Jr, Omer SB, Parker CL, et al. Applying risk perception theory to public health workforce preparedness training. J Public Health Manag Pract. 2005 Nov;11(6 Suppl):S33–7. https://doi.org/10.1097/00124784-200511001-00006 PMID:16205540
7Vogel S, Kluen LM, Fernández G, Schwabe L. Stress affects the neural ensemble for integrating new information and prior knowledge. Neuroimage. 2018 Jun;173:176–87. https://doi.org/10.1016/j.neuroimage.2018.02.038 PMID:29476913
8Schwabe L, Wolf OT. Stress prompts habit behavior in humans. J Neurosci. 2009 Jun;29(22):7191–8. https://doi.org/10.1523/JNEUROSCI.0979-09.2009 PMID:19494141
9Moving beyond the tsunami: the WHO story. New Delhi: World Health Organization Regional Office for South-East Asia; 2005 (http://apps.searo.who.int/PDS_DOCS/B0026.pdf?ua=1, accessed 3 February2020).
10Parveen S, Islam MS, Begum M, Alam MU, Sazzad HM, Sultana R, et al. It’s not only what you say, it’s also how you say it: communicating Nipah virus prevention messages during an outbreak in Bangladesh. BMC Public Health. 2016 Aug;16(1):726–37. https://doi.org/10.1186/s12889-016-3416-z PMID:27495927
11Risk communications for public health emergencies: bridging the national mechanism with healthcare workers. Singapore: Asia-Europe Foundation; 2015 (https://www.asef.org/images/docs/Langkawi%20 report.pdf, accessed 3 February 2020).
12LeDuc JW, Barry MA. SARS, the first pandemic of the 21st century. Emerg Infect Dis. 2004 Nov;10(11):e-26. https://doi.org/10.3201/eid1011.040797_02
13World Health Organization. Emergencies preparedness, response. Cumulative number of reported probable cases of SARS (https://www.who.int/csr/sars/country/2003_07_11/en/, accessed 3 February 2020).
14Smith RD. Responding to global infectious disease outbreaks: lessons from SARS on the role of risk perception, communication and management. Soc Sci Med. 2006 Dec;63(12):3113–23. https://doi.org/10.1016/j.socscimed.2006.08.004 PMID:16978751
15State Party self-assessment annual reporting tool. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/272432/WHO-WHE-CPI-2018.16-eng.pdf?sequence=1, accessed 3 January 2020).
16Joint external evaluation tool: International Health Regulations (2005). Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/204368/9789241510172_eng.pdf?sequence=1, accessed 5 December 2019).
17Risk communication strategy for public health emergencies in the WHO South-East Asia Region: 2019–2023. New Delhi: World Health Organization Regional Office for South-East Asia; 2019 (https://apps.who.int/iris/bitstream/handle/10665/326853/9789290227229-eng.pdf?sequence=1&isAllowed=y, accessed 3 February 2020).