Abraham-2009-Risk and Outbreak Co

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604 Bull World Health Organ2009;87:604607 | doi:10.2471/BLT.08.058149

Policy & practice

Risk and outbreak communication: lessons rom alternative

paradigmsThomas Abraham a

Abstract Risk communication guidelines widely used in public health are based on the psychometric paradigm o risk, which ocuseson risk perception at the level o individuals. However, inectious disease outbreaks and other public health emergencies are morethan public health events and occur in a highly charged political, social and economic environment. This study examines othersociological and cultural approaches rom scholars such as Ulrich Beck and Mary Douglas or insights on how to communicate insuch environments. It recommends developing supplemental tools or outbreak communication to deal with issues such as questionso blame and airness in risk distribution and audiences who do not accept biomedical explanations o disease.

Une traduction en ranais de ce rsum fgure la fn de larticle. Al fnal del artculo se acilita una traduccin al espaol. .

a Journalism and Media Studies Centre, University o Hong Kong, Hong Kong Special Administrative Region, China.

Correspondence to Thomas Abraham (e-mail: [email protected]).

(Submitted: 26 August 2008 Revised version received: 4 February 2009 Accepted: 6 February 2009)

Introduction

WHOs guidelines on outbreak communication were devel-oped in response to the communication challenges posedby the severe acute respiratory syndrome (SARS) epidemico 2003.1 Te guidelines consist o ve principles to guidecommunication during outbreaks and other emergencies:building trust, announcing early, being transparent, respect-ing public concerns and planning in advance. On the aceo it, these guidelines are simple and straightorward. But,as the experience o SARS and the recent H1N1 outbreakhas shown, outbreak control and outbreak communicationis rarely a pure, clean process o winning public trust andtransmitting inormation objectively and openly. It is more

oten than not a messy business requiring political decisionswith winners and losers.

Communicating during an inuenza pandemic is nodierent. Decisions on distribution o scarce antivirals, quar-antines and travel and trade restrictions all have a signicantpolitical component, and so communication has to deal withopposition rom those who eel that they have been deprivedo drugs or unairly quarantined or excluded. Opposing po-litical orces oten criticize decisions made on public healthgrounds to score political points. Successul communicationin such a charged environment requires an understandingo the broader political, social and cultural environment in

which communication occurs.

Risk communication experts and practitioners are wellaware o this. Following the experience o the anthrax attacksin the United States o America, the US Centers or DiseaseControl and Prevention (CDC) developed principles andpractices to address communication in times o political andsocial stress under the title o Crisis and Emergency RiskCommunication.2 WHOs outbreak communication guide-lines also point to the political and social challenges o com-municating during times o crisis. But tools are still neededto address the challenges o communicating in these difcultcircumstances. Tese tools can be developed by looking atalternate paradigms o risk that exist within the social sciences.

Risk communication principles are based on the psycho-

metric paradigm o risk pioneered by Paul Slovic et al. in thelate 1970s.3 Tis paradigm ocuses on individual perceptions orisk, rather than the social and cultural environment in whichrisk perceptions are ormed. Other sociological and culturalapproaches to risk take a broader approach. Tis paper surveysexisting approaches and extracts useul lessons or outbreakcommunication.

The psychometric paradigm

Te psychometric paradigm is the dominant paradigm inhealth risk communication. WHOs outbreak communica-tion guidelines, as well as the national communication plans

o many countries, are based on this view o how risk isperceived and communicated.

Tis paradigm grew out o attempts to explain the dis-parity between the way scientists and technologists measuredrisks, attributable to technological processes, and the way thelay public perceived these risks. Based on psychometric stud-ies o risk perception, Paul Slovic et al. evolved a basic modelo risk perception, listing several actors that caused peopleto perceive events as high risk, even when experts judgedthem to be low risk. Hazards that were new, uncontrollableand catastrophic in consequences were perceived as highrisk, even when experts judged a low statistical probabilityo these risks occurring. In contrast, hazards or dangers that

were amiliar and controllable were perceived as low risk,even though statistically they had a high probability. Incontrast to lay perceptions, expert perceptions o risk werebased on expected annual mortality rom a hazard or danger.4

Risk communication consultants such as Vincent Covelloet al. and Peter Sandman used the ndings o Slovic and oth-ers to develop strategies that helped experts and managers tocommunicate to the public in a way so that their perceptionso risk more closely approximated those o experts.5,6 Com-munication tool kits were devised to help communicators toeither calm public anxieties, i experts elt that these anxieties

were inappropriate, or to increase risk perceptions i experts


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Special theme Public health communication

Risk and outbreak communicationThomas Abraham

elt that the public was insufcientlyconcerned about grave risks. Tus Pe-ter Sandmans tool kits or precautionadvocacy and outrage management aredesigned to help communicators toraise or lower public risk perceptions to

match the level o the experts. Precau-tion advocacy is used to alert peoplewho are insufciently concerned byhazards that experts eel to be serious,and outrage management is used tocalm down people who are judged tobe over-concerned about minor risks.In the event o a social crisis, crisis com-munication is designed to help peopleresist their emotions and act wisely indifcult situations.7

Alternate risk paradigms

While the psychometric paradigm triesto explain the dierence between ex-pert and lay perceptions o risk inindividuals, sociological and culturalapproaches look at the impact o thesocial, cultural and political actors onthe perception o risk. In the ollowingsections, we look at insights oeredrom the sociological work o UlrichBeck, Philip Strongs model o thepsychosocial epidemics that accom-pany disease epidemics, and the work

o Mary Douglas and others on theimpact o culture on risk perception.

Distribution o risk in society

Te work o the German sociologistUlrich Beck oers insights into thesocial and political basis o the notiono risk. In his pioneering workRisk so-ciety, Beck described the distribution otechnological and other risks producedthrough the process o modernizationas a major preoccupation o modern

governments and societies.8

Tis distri-bution o risk is never equitable but ol-lows the unequal distribution o powerin national societies as well as globally.Struggles over the distribution o risksare major reasons or dierences in thescientic or expert views o risk and theviews o other sections o society.

Te main aim o health risk com-municators is to transmit health inor-mation clearly to stakeholders in waysthat encourage behavioural changesto reduce the risk. An enquiry into

the social and political oundations onwhich risk is distributed in society mayseem ar removed rom these aims butthe way audiences respond to messages

is dependent on their perceptions orisk distribution. From a public healthperspective, a armer with an outbreako avian inuenza on his arm needs totake on board a straightorward mes-sage to cull his chickens and ducks to

curtail the outbreak. From the armerspoint o view however, he is beingasked to bear the cost o destroying hislivelihood to reduce the risk to othermembers o society. He could well seehimsel as bearing a disproportionatelevel o risk and his compliance withhealth messages would depend on theextent to which these messages also ad-dress larger issues such as compensationor bearing this risk to his livelihood.

Three psychosocial

epidemicsWhile Becks work does not ocus onhealth risks or epidemics, the socialpsychologist Philip Strong has set outa compelling model o the social andpsychological upheaval created by amajor inectious disease epidemic.Strong describes the social and politicalimpact o an epidemic as a medicalversion o the Hobbesian nightmare the war o all against all. He says thatdisease epidemics are accompanied by

three kinds o psychosocial epidemics:epidemics o ear, o explanation and oaction.9 Tese three phases can occursimultaneously:

Any society gripped by a orid ormo epidemic psychology may, thereoresimultaneously experience waves o in-dividual and collective panic, outburstso interpretation as to why the diseaseoccurred, rashes o moral controversy, andplagues o competing control strategies,aimed at either containing the disease

itsel, or else at controlling the urtherepidemics o ear and social dissolution. 9

Te epidemic o ear is characterizedby widespread suspicion o riends,neighbours, ellow citizens who mightpass on the disease, suspicion o thevery environment itsel which mightbe potentially inectious. Te epidemico explanation results rom societysattempts to nd causes or the epi-demic and to understand its scope andconsequence. Tis is a period o great

intellectual conusion when a hundreddierent theories may be producedabout the origins o the disease andits potential eects.9 Many o these

questions are moral in nature: howcould God or the government haveallowed it? Who is to blame? Whatdoes the impact o the epidemic revealabout our society?

Te measures proposed to control

an epidemic can in turn lead to urtherconicts and debates over issues likedisruption o trade and travel, inringe-ment o personal liberties and eventreatment options that might crossethical barriers in a way that would nothave been contemplated in more nor-mal times. Te consequences o theseturbulent psychosocial states are clearor risk and outbreak communicationeorts. In a climate, or example, whenthe public demand is to know thecauses o an epidemic and whether

government agencies are to blame, riskcommunicators will have difcultyavoiding these issues.

Culture and the question oblame

Te issues o blame and morality arealso central to the understanding orisk proposed by cultural anthropologistMary Douglas. She describes notionso risk in modern societies as beingpart o a politicized blaming system.

Whose ault? is the rst question.Ten, what action? which means?

what damages? what compensation?what restitution?.10 She observes thatresponses to risk are oten directed to-

wards governments and organizationsthat are responsible or either causingor ailing to prevent dangers. Risk thusbecomes a stick or beating authority.

I disease outbreaks are perceivedas part o a blaming system and thequestion uppermost in peoples minds is

on attributing blame then, once again,this has consequences or the kind orisk and outbreak communication that

will succeed in reaching and convinc-ing the public.

Understanding dierences in cul-tural practices and belies are o vitalimportance in evolving successul riskand outbreak communication practices.One o the weaknesses o the psycho-metric paradigm is that its evidencebase is largely North American. Tesubjects or the experiments on which

the paradigm was based were small,culturally specic groups o North

Amer ican s e. g. member s o theLeague o Women Voters in Oregon,


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college students or residents o townsin New Jersey.

A question oten asked, but rarelyanswered, is whether the psycho-behavioural responses o these groupscorrespond to groups in completely

dierent cultural environments. For ex-ample, would members o the Leagueo Women Voters perceive and respondsimilarly to risk as poultry armers inViet Nam? Would the same techniqueso communication be relevant orthese widely diering groups? Dier-ent cultures ascribe dierent meaningsto illness, sickness and disease andbiomedical explanations o disease arenot universally accepted.11 A study othe understandings o acute respiratoryillness among mothers and commu-

nity health volunteers in Bangladesh,or example, ound that, similar toother Asian countries, inuenza andinuenza-like illnesses were attributedto imbalances between hot and coldin the body.12 Eating oods thoughtto be cold such as rice, bananas andbeans were thought to aggravate or, insome cases, cause inuenza. Remediesconsisted o massaging the patient

with warming substances such as amixture o garlic and oil and cuminseeds. Te way people respond to health

communication messages is dependenton whether their cultural constructiono the disease is similar to that o thecommunicator. O particular interestto outbreak communication is thepossibility that, in the case o new,previously unknown illnesses, peoplemay well turn to culturally determinedexplanations o illness to help themunderstand and cope with the disease.13

Bourdieus concept o elds

Communicating during an outbreakoccurs in a complex environment in

which a variety o players compete orattention. British sociologist GrahamMurdoch et al. has used Bourdieusconcept o society as a eld to describerisk communication as occurring in anarena in which at least six sets o play-ers compete or public attention.14 Teplayers include political institutionsand policy-makers, scientic and expertcommunities, campaigning groups andsocial movements, opposition parties

and corporations, the media and thelay public.

Success in communication goes tothose players in a competitive eld who

succeed in ensuring that their interpre-tation and raming o reality dominatesthe social and political agenda. It isimportant to note that, in this model,the lay public have two characteristics.On the one hand, they are the prize

or whose attention dierent groups insociety vie. On the other hand, they areactive participants, not mere spectators,in political processes. Public perceptionsand opinion are active orces inuenc-ing the positions o other importantplayers. Outbreak communicationclearly has to take account o this com-plex environment and include strategiesto ensure that messages are not drownedout in the competition or media at-tention. In particular, communicationstrategists need to strive towards two

goals: (i) visibility the ability to get themessage across clearly and prominentlyto the public and not be drowned bycompeting voices and (ii) legitimacy ensuring that inormation is seen aslegitimate and authoritative.

Tese goals do not in any waycontradict WHOs existing outbreakcommunication practices. In act, theprinciples o early announcement andtransparency and trust building helpachieve visibility and legitimacy. Tereis a need, however, to develop tools and

establish practices that explicitly ensurethat communication based on thesepractices is not drowned out by myriadother voices that seek to be heard dur-ing a social crisis o the scale causedby a pandemic or other major inec-tious disease outbreak. I messages aredrowned out, distorted or ignored bycompeting social voices, then outbreakcommunication will not achieve itspublic health goals o helping preventand control outbreaks.

Recommendations orsupplementary tools

Based on the preceding discussion, itwould be useul to develop tools andstrategies to complement WHOs out-break communication guidelines inthree areas.

First, using the work o Bourdieuas developed by Murdoch, communi-cators need to explicitly develop toolsto ensure the visibility and legitimacy

o their message in a crowded politi-cal environment.14 Te existing WHOoutbreak communication principles oearly announcement, trust and trans-

parency achieve this to a certain extent.However, additional work is requiredto develop practices and principles toensure visibility and legitimacy remaina ocus o communication so that mes-sages are not drowned out during a

crisis. Choosing the best channel ocommunication to ensure visibility,targeting the primary audiences andnding spokespeople who providelegitimacy are some o the issues thatneed to be explicitly addressed.

Second, the work o Ulrich Beckand Mary Douglas help to sensitizehealth communicators to the underly-ing political and social questions aboutblame and unair distribution o riskthat are on the public mind duringoutbreaks. Tese include questions such

as whether the government is to blameor the outbreak and, i not, who is toblame, whether drugs and vaccines havebeen airly distributed and whetherquarantine and other measures such astravel restrictions have been airly ap-plied. Health communicators need tobe able to handle these political issuesskilully and they need the training andtools to do so. Otherwise, their healthmessages run the risk o being ignoredin a storm o political outrage.

Tird, cultural and anthropologi-

cal studies, as well as the experienceo those who have worked to manageoutbreaks in dierent cultural environ-ments, show that biomedical expla-nations o disease are not universallyaccepted. However, compliance withdisease control measures is necessary toprevent outbreaks rom spreading. Tisis especially important since, in caseso unknown disease outbreaks or previ-ously unoreseen catastrophes, peoplemay turn to traditional explanations o

disease. Communicators specializingin behaviour change communicationand social mobilization have a varietyo tools to deal with these issues andso they are oten called on during out-breaks. It would be benecial i thesetools were incorporated into generaloutbreak communication principles.

Funding: Tis paper was unded byWHO. A longer version o this paperwas pre sented to a WHO workinggroup meeting on outbreak commu-

nication in Geneva, September 2007.

Competing interests: None declared.


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Reerences

1. Outbreak communication: best practices or communicating with the public

during an outbreak. Geneva: World Health Organization; 2004.

2. Reynolds B, Hunter-Galdo J, Sokler L. Crisis and emergency risk

communication. Atlanta, GA: Centres or Diseases Control and Prevention;

2002.

3. Slovic P, Fischho B, Lichtenstein S. Rating the risks. Environment1979;

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4. Slovic P. Perception o risk. Science1987;236:280-5. PMID:3563507

doi:10.1126/science.3563507

5. Covello VT, McCallum DB, Pavlova MT, Task orce on environmental cancer

and heart and lung disease. Eective risk communication: the role and

responsibility o government and nongovernment organizations. New York, NY:

Plenum; 1989.

6. Sandman P. Risk communication: acing public outrage. EPA J1987;13:21-2.

7. Sandman P. What kind o risk communication does pandemic preparedness

require?Minneapolis, MN: CIDRAP Business Source; 2007.

8. Beck U. Risk society: towards a new modernity [translation by Mark Ritter].

London: Sage Publications; 1992.

9. Strong P. Epidemic psychology: a model. Sociol Health Illn1990;12:249-59.

doi:10.1111/1467-9566.ep11347150

10. Douglas M. Risk and blame: essays in cultural theory. London & New York, NY:

Routledge;1992.

11. Lupton D. Medicine as culture: illness, disease and the body in western

societies. London: Sage Publications;2003.

12. Rashid SF, Hadi A, Asana K, Begum SA. Acute respiratory inections in rural

Bangladesh: cultural understandings, practices and the role o mothers

and community health volunteers. Trop Med Int Health2001;6:249-55.

PMID:11348514doi:10.1046/j.1365-3156.2001.00702.x

13. Henderson JN, Henderson LC. Cultural construction o disease:

a supernormal construct o dementia in an American Indian

tribe. J Cross Cult Gerontol2002;17:197-212. PMID:14617965

doi:10.1023/A:1021268922685

14. Murdock G, Petts J, Horlick-Jones T. Ater amplication: rethinking the role o

media in risk communication. In: Pidgeon N, Kasperson R, Slovic P, eds. The

social amplifcation o risk. Cambridge: Cambridge University Press; 2003.

Rsum

Communication au sujet des risques et des fambes pidmiques : enseignements ournis par des modlesnon traditionnels

Dans le domaine de la sant publique, la communication proposdes risques sappuie sur des recommandations largement utilises

qui sinspirent dun modle psychomtrique des risques ax surla perception de ces risques au niveau des individus. Cependant,les fambes de maladies inectieuses et autres urgences desant publique sont plus que des vnements de sant publiqueet interviennent dans des environnements trs lourds sur lesplans politique, social et conomique. La prsente tude examine

dautres approches sociologiques et culturelles, ormules par desexperts comme Ulrich Beck et Mary Douglas, la recherche dides

sur la manire de communiquer dans de tels environnements.Elle recommande de dvelopper des outils complmentaires pourcommuniquer en cas de fambe pidmique, qui aideraient rpondre des questions telles que la culpabilit et lquit dansla rpartition des risques et sadresser des publics nacceptantpas les explications biomdicales de la maladie.

Resumen

Comunicacin sobre riesgos y brotes: enseanzas extradas de paradigmas alternativos

Las directrices sobre comunicacin de riesgos ms ampliamenteutilizadas en el campo de la salud pblica se basan en el

paradigma psicomtrico del riesgo, centrado en la percepcin delriesgo a nivel individual. Sin embargo, los brotes de enermedadesinecciosas y otras emergencias de salud pblica son algo msque eventos de salud pblica y surgen en un entorno poltico,social y econmico muy cargado. En este estudio se analizanotros enoques sociolgicos y culturales de expertos como Ulrich

Beck y Mary Douglas para identicar algunas claves respectoa la manera de comunicar la inormacin en esos entornos. Se

recomienda crear nuevos instrumentos para la comunicacinsobre los brotes a n de abordar cuestiones como la culpaciny la justicia en lo que atae a la distribucin de los riesgos o laresistencia de parte de la poblacin a aceptar las explicacionesbiomdicas de la enermedad.

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http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=3563507&dopt=Abstracthttp://dx.doi.org/10.1126/science.3563507http://dx.doi.org/10.1111/1467-9566.ep11347150http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=11348514&dopt=Abstracthttp://dx.doi.org/10.1046/j.1365-3156.2001.00702.xhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=14617965&dopt=Abstracthttp://dx.doi.org/10.1023/A%3A1021268922685http://dx.doi.org/10.1023/A%3A1021268922685http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=14617965&dopt=Abstracthttp://dx.doi.org/10.1046/j.1365-3156.2001.00702.xhttp://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=11348514&dopt=Abstracthttp://dx.doi.org/10.1111/1467-9566.ep11347150http://dx.doi.org/10.1126/science.3563507http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=3563507&dopt=Abstract

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Abraham-2009-Risk and Outbreak Co