Complex, confused, and challenging: Communicating risk in the modern world

I am sitting in the car with a colleague returning to Lagos from Port Harcourt to conclude my short but intense mission to support the federal and state governments for risk communications to contain the Ebola virus disease (EVD) outbreak. My colleague, a Nigerian national and environmental health professional, tells me that the outbreak of Ebola in West Africa is a defining moment in which everyone, she says, will look back and realize ‘we changed our culture, and how we live and work’. We no longer shake hands or touch each other, we are leaving behind our traditional burial practices, she continues.

Her views, albeit made during a light conversation between colleagues, are nevertheless profound. Just under their surface, we find virtually every aspect of risk communications – health threats, cultural practices, behavior change, perception, politics, security, travel, modern technology, and international concerns and support. Apart from reminding us of our complicated interdependent existence, my colleague's views place risk communications at the heart of any emergency response.

The current outbreak of EVD in West Africa – the worst the world has ever seen – has brought to the fore the complex, confusing, and critical challenges in communicating risk to the public, as well as with national and international stakeholders. It has highlighted how news and social media use increasingly influences people's perceptions and behavior. It has underscored the obvious – that public health emergencies are of intense public and political concern. Nigeria has, with its more advanced health systems, and capacity for fast response, managed to get on top of the outbreak, so far. Guinea, Liberia, and Sierra Leone still have a long way to go for an array of reasons. There are many country-specific conditions that make generalizations difficult and dangerous. But I believe that there are issues related to communicating risk that run across countries and cultures.

A new twist to an old problem

Last August, months before the unprecedented outbreak of EVD in West Africa, World Health Organization (WHO) began to rethink how the organization could better support risk communications capacity of countries. After all, WHO is the secretariat of the International Health Regulations (IHR) (2005) – the most universally ratified piece of international law pertaining to health. Their revision in 2005 resulted in the contemporary international strategy for managing threats to global health security. The IHR (2005) legally obliges all 196 states parties¹ to build, strengthen, and fulfill a set of requirements for the prevention, detection, and response to public health events, with a focus on public health events of international concern.

The IHR (2005) focuses on eight core capacities; one of them is risk communications. Risk communication is a particularly powerful determinant of how countries deal with public health emergencies. In the past, it has been one of the most overlooked.

In 2012, more than 100 countries reported² that they had none or less than 50% of the required risk communications capacities. And while the number reported by governments reduced to 25% in 2014, many countries still lack the ability to provide real-time, transparent communication and engagement of the public, in languages they understand, respecting people's beliefs and fears, and for a multitude of hazards.

In the late autumn of 2013, after reviewing the self-assessment reports of countries on risk communications capacity, as well as consulting with risk communications and national capacity building experts from around the world, WHO started mapping the diverse specialities, knowledge, expertize, and experience required to fulfill the performance indicators related to risk communications capacity under IHR (2005).

All countries agree what risk communications capacity means under the IHR (2005), but many are struggling to build and sustain this capacity. The reasons for this vary from country to country. In the aftermath of the SARS outbreak in 2003, experts realized that risk communication was a major gap and agreed on five core principles. But the lack of evidence-based, costed, practical guidance on how to operationalize these principles on a large enough scale remains a frustrating drawback.

Implementing core capacities requires political will, articulated through policy instruments and technical advice on the investments that need to be made, usually at the cost of some other public investment. For capacities such as risk communications, which require both structural change as well as soft skills – for media communication, social media, social mobilization, and behavioral change communications, as well as for mass media campaigns and social outreach – implementation can be very challenging, and monitoring of progress (and hence reporting) is subjective at best. The complexity of governance systems (for example, federal versus state and local systems), the lack of basic understanding of the principles and practice of relatively new areas like risk communications, the lack of clear monitoring measures and the skills to apply them effectively, the political nature of public announcements, etc. add to the difficulties faced by governments.

It is clear many specialities and professions that are needed to work in concert to fulfill the capacity requirements. Mapping such as this, as well as integration of the main categories of expertize, is often lacking in countries. Therefore, at the start of 2014, we settled on four components or groupings. We know that visualization – through its numerous cognitive and communicative advantages – can play an important role in assessing and conveying risks, so we applied that to our approach.

The four-legged stool

Why a stool? Because no country is too poor to have one; and because simple ideas can transcend time and place. All countries deserve at least the minimum capacity for risk communication. They have one or two or even three of the components that are needed for effective risk communication. Many have a two-legged stool or even a three-legged one albeit unbalanced. Some have a fourth leg but it is not screwed on to the stool. So, we propose four legs, evenly spaced and equally strong.

The first leg brings together anthropologists, social scientists, behavior change experts, health educators, health promotion officers, and more recently “communication for development” professionals. They have a pre-existing relationship with and outreach tools for communities, are trusted, and tackle a variety of different risks from vaccination, to maternal child health to outbreaks deal in social mobilization, health communication, behavior change, and health education and promotion. These frontline soldiers in the fight to protect health engage directly in one-on-one and house-to-house interaction, listening and understanding the needs and concerns of communities.

The second leg includes communications professionals, experts in media and social media communications, crisis and emergency communications, spokespersons, and their associates. This is the mass media communications, trying to reach large audiences. This group includes health campaign experts and large-scale public outreach and marketing professionals. We also include social media – the bane of many governments – in this group. Here, we are in the shifting sands of “audience generated content” and the exchange of views rather than the dissemination of facts. This group intensifies its engagement when an emergency occurs, and its work is often carried out at a central governmental level.

The third leg includes experts in health systems strengthening, who look at the policy, plans, standard operating procedures, coordination, resource mobilization and management, and partner communications. This group will create a solid foundation for risk communication capacity building and will enable country-ownership and sustainability.

The fourth leg brings together operational research experts, evidence and technical guidance. These are all the things needed to have evidence-based and evidence-informed risk communications. This group will also look at evaluating the outcomes and impact of risk communications capacity building, not just measure outputs. By developing this area, the science that governs risk communications is supported by ongoing research that can contribute to the body of scholarship and translational knowledge around this model.

Genuine partnership is the obvious and practical seat on which the four legs stand, but this base needs to be strong for the structure to be reliable. Despite the current global trend characterized by diminishing resources and increased competition, partner organizations have committed themselves to working in partnership for risk communication. These include the US Centers for Disease Control and Prevention, The International Federation of the Red Cross and Red Crescent Societies, and UNICEF. But unsurprisingly, the biggest champions are the countries who now see the model as both a conceptual and a management tool to operationalize and sustain their risk communications capacities.

There is an additional, critically important component – the cross bars that keep the legs stable and equidistant. In our model, this is the surge risk communications capacity that governments can rely on during health emergencies. To contribute to this, WHO has created a rapid response pool of 50 specially pre-selected and trained professionals who form the WHO Emergency Communications Network. They have been deployed to West African countries battling EVD, are kept operationally ready to respond to any humanitarian or public health emergency, and are prepared to work in an influenza pandemic, should it arise. Deploying the network also allows on-the-spot capacity building during an unfolding emergency response.

There were two big questions that arose a year ago: (1) can current models of risk communications be applied across different cultures and socio-economic and political contexts, especially non-“western” countries; and (2) how do we know what types of risk communications interventions actually work? The four-leg model allows for both of these questions to be addressed.

Were any of the elements of the model new? No. But it was the first time WHO brought together four distinct risk communications components and areas of expertize, to be coordinated by a central single team, which had at its disposal the ability to call on resources across WHO.

From theory into practice

WHO regularly receives requests for risk communication capacity building and training. One of the most common issues ‘member states’ grapple with is that while everyone agrees with the principles of risk communications, it is very difficult to apply them into building sustained capacity within countries.

This model, just as any other, is useless if it does not work in practice.

In the EVD outbreak response by the government of Nigeria, I saw exactly these four areas operationalized. What did we learn there? We learnt that the model captures all the main elements needed for risk communications capacity. We learnt that building bridges between the legs and partners is hard work but pays rich dividends. We learnt that it is possible to carry out operational research even in the middle of an emergency if the technical knowledge, political will, and resources are available. The model will be used to support 30 countries around the world in the next 2 years. There will undoubtedly be a great deal more to learn, especially about sustaining any risk communications capacities that are strengthened.

The sound of the rain on the roof of the departure terminal of Part Harcourt airport is deafening. It brings a very welcome sense of coolness into the packed waiting area. My colleague and I now having completed the Ebola screening at the airport, checked-in, and beyond the security check, wait for our delayed flight to be ready to take us back to Lagos where we will continue working with the Ebola Emergency Operations Center of the Nigerian government. This is where we have to put theory into practice. In addition, learn lessons from the practice to improve our theory. This is the real lesson of capacity building.

Disclosure of conflicts

None