D1.

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723

TableofContents
EXECUTIVESUMMARY.......................................................................................................................................4 1. Introduction(TitleFont:Calibri,14)...........................................................................................................7 1.1 Background..........................................................................................................................................7 1.2 ProjectAim ..........................................................................................................................................7 . 1.3 ScopeofReport....................................................................................................................................7 1.4 FormatofReport.................................................................................................................................8 2. KeyConceptsofCrisisManagement .........................................................................................................8 . 2.1CharacteristicsofCrisisorDisaster.........................................................................................................8 2.2MakingOrderOutofChaos.....................................................................................................................8 2.3GeographicNatureofDisasters...............................................................................................................9 2.4MediaHandling.......................................................................................................................................9 2.5TheTwoPhasesofCrisisManagement.................................................................................................10 3. TheImportanceofCommunicationinOutbreakControl........................................................................10 3.1RiskCommunication..............................................................................................................................10 3.2CrisisCommunication............................................................................................................................11 4. Component1Source.............................................................................................................................12 4.1OfficialChannels(GovernmentOfficials&HealthCareProviders).....................................................13 4.2UseoftheMassMedia..........................................................................................................................13 4.3UnofficialChannels(theinternet,blogs,onlinejournalistsandwebsitesetc)...................................14 4.4OtherSourcesofInformation(pressuregroups,antivaccinationmovement,charitiesand professionalbodies)....................................................................................................................................15 5. Component2TypeofCommunication.................................................................................................15 5.1Appropriate...........................................................................................................................................15 5.2Speculative............................................................................................................................................15 5.3Tone&Terminology..............................................................................................................................16 5.4PublicAwarenessCampaigns................................................................................................................16 5.5StandardizedandConsistent.................................................................................................................16 5.6Symbolism.............................................................................................................................................17 6. Component3Media..............................................................................................................................17 6.1Media(BroadcastTV,PrintandRadio).................................................................................................18 6.2SocialMedia(SocialNetworks,Blogoshpere,Wikis,VideoSharingApplications)...............................18 6.3TelephoneHotlines ...............................................................................................................................19 . 6.4Spokespeople........................................................................................................................................19 7. Component4TimingofDissemination.................................................................................................20 2

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 7.1SpeedofResponse................................................................................................................................20 7.2AnnouncingthePandemic ....................................................................................................................20 . 7.3CommunicationContinuum..................................................................................................................21 7.4InformationFatigue...............................................................................................................................21 8. Component5PublicAcceptance..........................................................................................................21 8.1TrustintheAuthorities .........................................................................................................................21 . 8.2TrustinRelationtoRiskManagement..................................................................................................22 8.3TrustintheGovernment.......................................................................................................................22 8.4PerceptionofRisk..................................................................................................................................22 8.5UnderstandingtheNeedsandInterestsofThePublic..........................................................................23 8.6CaseStudyoftheUKGovernmentsHandlingoftheBSECrisis...........................................................26 8.7AcknowledgingUncertaintyandBeingOpenandHonest....................................................................26 8.8MediaReporting....................................................................................................................................26 9. CurrentPandemicPlans...........................................................................................................................27 9.1Whyplan?.............................................................................................................................................27 9.2Risk&CrisisCommunicationPlanning..................................................................................................27 9.3SocialMedia..........................................................................................................................................28 9.4Preparedness,FlexibilityandScale.......................................................................................................28 9.5ModelsofRiskandCrisisCommunication............................................................................................29 9.6IdentifyingStakeholders........................................................................................................................30 9.7EUCoordination&Leadership..............................................................................................................30 CONCLUSIONSANDRECOMMENDATIONS.....................................................................................................31 References.......................................................................................................................................................................................32

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723

EXECUTIVESUMMARY
Context
During infection outbreaks, one of the major challenges has always been communicating with the population in order to influence behaviours, reduce the spread of disease and even avoid panic. With increasingunderstandingandrecognitionthathumanbehavioursignificantlyimpactsdiseasetransmission itisvitalthatwecontinuetoimproveandunderstandthewayinwhichwecommunicatewiththepublic. AspointedoutbyDrJongWookLee,DirectorGeneral,WHOin2004,(WHO,2005,p.viii),Wehavehad greatsuccessinthe[last]fiveyearsincontrollingoutbreaks,butwehaveonlyrecentlycometounderstand thatcommunicationsareascriticaltooutbreakcontrolaslaboratoryanalysesorepidemiology.

Aim
Thisreporthasbeenproducedinorderto; ConsiderthekeycomponentsandissuesofOutbreakCommunications IdentifytheissuesthatneedtobeconsideredbythoseshapingOutbreakCommunications Ensure that past mistakes are avoided, good practice and lessons have been learned and more successfulcommunicationsisachieved

Approach
CEDARthrees approach has been to focus on findings relating to outbreak communications issued in responsetoepidemicsandpandemicsaffectingEurope(EUMemberState)withinthelast10yearsandin particularthe2009flupandemic.Theresearch,whichisevidencebased,broadlycenteredonthefollowing keyaspectsofoutbreakcommunications;Type,Source,Media,TimingofDissemination,PublicAcceptance and Current Pandemic Plans. Although the objective has never been to produce definitive recommendationsinevitablylessonshavebeenlearnedandgoodpracticeidentifiedwhichintimewillbe clarifiedandhonedintoacomprehensivetoolsetasanoutcomefromtheoverallTELLMEprojectforuse infutureoutbreakcommunicationsituations.

SummaryofKeyFindingsandThemes
Sources
The source of information in a crisis can impact the way in which communications are interpreted, perceived and accepted. Those that provide the message and the means by which they communicate it have varying impacts. Furthermore different individuals and groups will respond differently to various media. Health care providers, particularly local and regional physicians, remain a trusted source of informationand,perhapssurprisingly,NGOsareoftenconsideredmoretrustworthythanGovernments. Messagesdeliveredbytelevisionandradioaregenerallybetter regarded by membersof the public than other sources of information. New technologies however, including social media and websites, are also beingwidelyusedbythepublictogatherhealthinformation. It is apparent that the Health Communicators strategy will benefit from using all the communication channelsandmediumavailableinordertomeetthevaryingneedsofthepublic. 4

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723

Type
The type, tone and terminology used for communications in a crisis should be appropriate to the understanding and knowledge of their intended audience. Health Authorities must communicate with empathyandunderstanding.Itisvitalthattheyareopenandaddresstheneedsandconcernsofthepublic. Speculativeandinaccuratereportingwillonlyincreasepublicfearandscepticism.Trustandcredibilityneed to be nurtured and can be eroded through inappropriate communications. In particular it is crucial that messages,preferablyfromavarietyofsources,donotconflictandareconsistent.Symbolism,asanaidto communication,canbeusedinapositivewaytoenhancemessageshowevercaremustbetakentoavoid the converse with inappropriate symbols creating a negative effect. Official announcements need to be enforcedbyongoingpublicawarenesscampaignsandcoremessagesneedtoberepeatedofteniftheyare tobewidelyaccepted.

Media
There is a wide variety of different media available for communicating with the public. The Health Authorityschosenstrategyneedstobeappropriateforandreflectiveofthediverseaudiencesforwhichit isintended.Whilstthemassmedia,includingthemodern24/7newsmedia,haveanenormousimpacton the publics understanding and perception of a crisis choosing the right blend of media to ensure that messages reach those they are intended for must also embrace modern technologies and most notably socialmedia. Socialmediaisbecomingincreasinglyprominentandisapowerfulmeansofleveraginglargesectionsofthe public.WhenusedeffectivelyitwillassistHealthAuthoritiestobemoreintunewiththeiraudiences.This togetherwithtelephonehotlines,whichhavealsoprovedaneffectivemeansofdisseminatingmessages, andappropriateandtrainedspokespeople,willallhelptotakethepressureofprimarycareservices.

Timing
Early detection and decisionmaking are crucial in managing an outbreak situation. Similarly any announcementsfromtheHealthAuthoritiesneedtobemadeasearlyaspossible.Informedandaccurate communicationshouldalsocontinuethroughoutallphasesofapandemicandonafrequentbasisinorder toavoidspeculationandfalsereporting.Authoritiesdohoweverneedtobemindfulofinformationfatigue generatedbyrepeatedandunfulfilledscares.

PublicAcceptance
Trust is one of the most significant factors related to successful crisis communications and will affect peoples judgements and subsequent acceptance of recommended measures. Trust needs to be built up over time and can be eroded by ineffective communications. In this regard it is important for Health Authoritiestobeopenandhonestandtoacknowledgeuncertainty. ItisalsovitalforHealthAuthoritiestounderstandtheneedsandinterestsofthepublic.Fearsandconcerns needtobeacknowledgedhowevermistakentheymightbe.Healthcommunicatorsmustunderstandand meet the needs and challenges of specific groups too. Messages clearly need to be personalised and relevanttotheaudience. Public adoption of protective measures is strongly affected by perception, not only by the perceived efficacyoftheproposedprotectivemeasuresbutalsobytheperceivedriskofcontractingthedisease.Itis 5

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 clearthatmediareportingcansignificantlyinfluencepublicperceptionandthereforeworkingcloselywith themediatheHealthAuthoritiescanhelptoimprovemessageaccuracyandpublicunderstanding.

CurrentPandemicPlans
Crisiscommunicationsplansshouldbepreparedasearlyaspossibleandthenstafftrainedandexercisedin theiruse.Whenthenextpandemicoccursisnotthetimetobedevelopingacrisiscommunicationplan! Despite this few organisations have detailed crisis and risk communication plans in place. The crisis communicationplanshouldbedevelopedasaseparatetask,butabsolutelysupportiveof,theactualcrisis management plan. Within the plans, Health Authorities need to embrace new technology, in particular socialmedia,andallowatwowayflowofinformationbetweenofficialsandthepublic. Understanding and addressing the needs of stakeholders is vital for effective communications. It is importanttothinkthroughhowplanningscenariosarereleasedtothepublicsoastoensureabalanced and realistic view is communicated. It is also important to have a strategic and planned approach for working with the media. Plans need to be flexible to adapt to the sometime unpredictable and changing natureofanoutbreaksituationandtheyneedtoembracethewholespectrumofcommunicationchannels andmediumavailableinordertoreachthevaryingneedsofthemulticulturalpublicaudience.Todothis effectively greater coordination is required among EU stakeholders to ensure the messages promulgated arenotonlybasedonthebestavailableadvicebutarealsoconsistent.

NextSteps
Crisis communications plans should be developed as early as possible in preparation for a possible pandemic.Theplansshouldbebasedonthesameprinciplesofthosedevelopedforanycrisisordisaster butadditionallyincludetasksbasedonthelessonsandgoodpracticelearnedfrompreviouspandemics.An objective of the TELLME project is to produce a tool set of protocols and actions to assist in the developmentofoutbreakcommunicationsplanningandimplementation.

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723

1. Introduction
1.1 Background
InApril2009anovelstrainofaninfluenzaviruswasidentifiedinMexicoandtheUnitedStatesofAmerica whichhadthepotentialtotriggeraglobalpandemic.ThenovelstrainwasidentifiedasanH1N1sw,andthe pandemicstatuswassubsequentlyconfirmedbytheWorldHealthOrganization(WHO)inJune2009(Hine, 2009). Whilst the virus turned out to be milder than anticipated, it spread rapidly throughout various countries across the world leading to an estimated total of 201,200 respiratory deaths and an additional 83,300cardiovasculardeathsassociatedwiththe2009pandemicinfluenzaAH1N1(Dawoodetal,2012). Unfortunately,the threat ofafutureoutbreakremainsveryreal,particularly inthecontextofthehighly connectedglobalcommunityinwhichwelive.AspreviouslydemonstratedbytheSARSoutbreakinearly 2003, emerging infectious diseases can spread rapidly throughout the world and can have serious implicationsfortheglobalcommunitybothintermsofpublichealthandtheeconomy(DeZwart,2008). Having plans in place that incorporate lessons from the past to ensure a swift response to any future challengeisofcourseimportant.Whilsttherearemanyuncertaintiesastohowthenextoutbreakmight manifestitself,onecertaintyisthatnonmedicalprocedureswillbejustasimportantincontainingafuture outbreak as the production of drugs, vaccines and other medical solutions (Central Intelligence Agency (CIA),2003). The medical community remains very concerned about the threat of new and reemerging infectious disease(Setbon&Raude,2009)andthepotentialimpactitcouldhaveonhumanpopulations.Therearea range of factors that contribute to the risk of another pandemic. Many of these factors lie outside the traditional public health domain and as such require widespread collaboration in order to mitigate their impacts(DeZwart,2008). Thecontinuinggrowthofinternationaltravel,population,urbanizationandglobalcommunicationsarejust some of the factors which will have an impact in one way or another on the severity and spread of any futurepandemic. Withthecontrolofoutbreaksofinfectiousdiseaseheavilydependentuponpopulationbehaviourandan individuals willingness to conform, or not, with recommended preventative measures (Setbon & Raude, 2009),itisvitalthatweunderstandhowwecancommunicatemoreeffectivelywiththepublicduringevery phaseofapandemic.Inordertodothis,itisnecessarytounderstandthedifferentcomponentsofCrisis Communicationandhowmessagescanbecraftedaccuratelyandinsuchawaythatwillensurepeoplewill acceptandtrustwhattheyarebeingtold.

1.2 ProjectAim
The Aim of T1.2 is to identify and review the key components and issues relating to outbreak communications,summarizingthefindingsinacomprehensivereport.

1.3 ScopeofReport
Thescopeofthisreportisprimarilyfocusedon; Findings relating to outbreak communications issued in response to Epidemics / Pandemics affectingEurope(EUMemberState)withinthelast10years The2009flu(H1N1)pandemic

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 The research falls broadly under the following headings; Type, Source, Media, Timing of Dissemination, PublicAcceptanceandCurrentPandemicPlans.

1.4 FormatofReport
Thisreportonthecomponentsandissuesofoutbreakcommunicationsinacrisissituationisformattedas follows: ExecutiveSummarycontainingAim,Approach,SummaryofKeyFindingsandNextSteps IntroductioncontainingBackground,Objectives,ScopeandthisFormatofReport KeyConceptsofCrisisManagementcontainingtheCharacteristicsofCrisisorDisaster TheImportanceofCommunicationsinOutbreakControl AreviewofthekeycomponentsofCrisisCommunicationsincluding:Source,Type,Media,Timing, PublicAcceptanceandCurrentPandemicPlans ConclusionandRecommendations ReferencesoftheevidencebasedresearchedrecordedthroughouttheReport.

2. KeyConceptsofCrisisManagement
Apandemicis anepidemicoccurring worldwide or over a very wide area, crossing boundaries of several countries,andusuallyaffectingalargenumberofpeople(WHO,2007). A pandemic therefore is certainly a crisis, which itself may be defined as an inherently, unstable and complex situation that represents a threat to the strategic objectives, reputation or existence of an organization (BSi, 2011, p. 5). Crisis management is the process by which the local, national or international response manages the wider impact of a crisis such as the safety of people, business, infrastructure and media coverage. Crisis communications is at the very heart of this process and is the bedrockonwhichcrisismanagementisbuilt(BSi,2011).

2.1CharacteristicsofCrisisorDisaster
Toconsidertheissuesofcrisiscommunicationsattheoutbreakofapandemicitisusefultoconsiderthe characteristicsofacrisisordisaster. Crisescausedbynaturalormanmade eventssuch asafire,flood,earthquake,technologicalaccident or terrorist bomb are often unexpected and sudden. Some crises however develop over time such as a pandemic, which although initially not so dramatic as a sudden crisis, can develop remarkably quickly. Moderntravelpatternsmaysignificantlyreducethetimeneededforpandemicinfluenzavirusestospread globallytoafewmonthsorevenweeks(GlobalSecurity.org,2012,para.12).Thetimingandlocationofa crisismaybeunpredictableandtheimpactcannotnormallybecontainedwithinboundaries.Crisesoften causechaosorattheveryleastconfusionanduncertainty.Theyhaveaveryhumanimpact.Theremaybe casualties,peoplemaybefrightened,itmaybedifficulttounderstandwhathashappenedorevenactin response and there is a thirst for knowledge (Blakie et al, 2003). The first priority when responding to a pandemic,asintheresponsetoanycrisis,isthesafetyandwellbeingofpeople.

2.2MakingOrderOutofChaos
Crisismanagementmustthereforebeaimedatmakingorderoutofchaos,providingatimelyandeffective responsetoensurethesafetyofpeople,andreturningtheorganisationtonormalityasquicklyaspossible.

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 Organisationsmustbepreparedbeforethecrisisthatis,nowandthereforetherequirementistohave awellrehearsedplanbasedongoodcommunications. Publicscrutinyfollowingacrisiscanbeintense,andtherearemanyexamplesoforganisationsthathave sufferedacrisiswithoutanapparentcrisismanagementplanthathavesubsequentlynotsurvived(Toft& Reynolds, 2005). A good crisis management plan, properly implemented, will not only focus a practical responsebutwillalsodomuchtoprovideconfidence tothegovernments, respondingorganisationsand thepublicthattheauthoritiesareabletocope. While there is undoubtedly a risk of crises occurring, it is difficult to predict exactly what might happen, whenorwhere.Itthereforemakesgoodsensetodevelopagenericcrisismanagementplantoensurethat there can be a focused response to any type of crisis (which would include a pandemic) of whatever magnitude,wheneverandwhereveritmightoccur(UKCabinetOffice,2011).

2.3GeographicNatureofDisasters
Crisesarenormallygeographicinnature.Inotherwords,theyoftenstartinageographiclocationwhere the immediate effect is local and from where the impact might spread rapidly. The effect is similar to a pebblebeingthrownintoastillpond.Ifitisimaginedthatwherethepebbleentersthewateriswherethe crisis happens, then the ripples that spread out represent the impact. The twin towers disaster on September112001waslikeaboulderbeingthrownintothepond,withtheripplesbeingwavesofimpact thatarestillgoingroundandroundtheworldtoday.Itfollowsalsothattheresponsetoamajorcrisismust counter the impact, and that a major crisis will require a major response (US Department of Homeland Security,2006). Once the geographic nature of a crisis is understood, it is easy to see why a key principle of crisis management is that responsibility must remain at the local level, where the immediate response to an incident will start. At the same time, support for the local level must be coordinated throughout the organization. In a pandemic this would equate to coordination at every level within a country and internationally. Crisis communication remains the fundamental conduit for the gathering of information andforthedisseminationoftheplannedresponse(WHO,2005b).

2.4MediaHandling
When a major incident happens there are two stories one is how the organisation responds and the otherishowthemediareportshowtheorganisationresponds.Thepublicareinfluencedbywhattheyread and hear in the media. This leads in some cases to the medias interpretation or perception of what has happenedbecomingakindofreality As a result of the growth of 24hour news channels, it has become necessary to plan carefully how the mediawillbehandled.Themediasrequirementistoinformthepublicofthefacts.Theywillaskthesimple questionsfollowingacrisisWhathappened,howdidithappenandwhatisbeingdoneaboutit?They will soon add And who is responsible? The WHO (2005) suggested that these are all understandable questionsandshouldbeansweredwithfactsandhonesty. Themediaareuseful.Ifasked,theywillincludeontheirnewsbulletinscontactnumbersandlinkswhere authoritativeinformationmaybeobtained.Rememberthatreportersarehumantoo,theyhaveajobtodo andtheyliketohelp(WHO,2005b).

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 Allcommunicationswiththemediashouldbecoordinatedwherepossiblesothataconsistentmessageis disseminated. Responsibility for the media at the scene, however, should be delegated to the front line. Localmanagersshouldbeenlistedandtrainedasspokespeopleinanemergency.Suchastrategypositions theorganisationtoreleaseinformationrapidlyandeffectively,anywhereandatanytime,andwillsatisfy thedemandsofthemedia.Importantly,itwillalsoreflecttheorganisationsabilitytocopewiththecrisis.

2.5TheTwoPhasesofCrisisManagement
Therearetwoclearlydefinedphasesincrisismanagementtheimmediateresponseandtherecovery(BSi, 2011).Partofthefirstphase,theimmediateresponse,isidentifyingandconfirmingthatthereis,infact,a crisis.Thisisnotalwaysaseasyasitseems,assomecrisesappeartocreepupalmostunnoticedandare sometimesknownasrisingtidecrises.Tocounterthis,itisgoodpracticetouseaCrisisImpactTablethat quantifies the impact of an incident against predetermined criteria under different headings such as Operations, People, Reputation, Legal and Finance. The table acts simply as a tool to aid the decision on when to invoke the crisis management plan. A common adage is If in doubt call it out! That is, if undecided,invoketheplanandcalloutthecrisismanagementteam.Nottodosomaymeanthatitisoften necessarytotrytocatchupratherthantakingcontrolinatimelywaywithpositive,proactiveaction. The recovery, or second phase of the response, should start almost at the same time as the immediate response and run parallel with it. Recovery is a project in its own right that requires planning and coordination.Anearlystartwillspeedthereturntobusinessasusual.Astheimmediateresponsetailsoff, sotherecoverywillbecomethepriority. Thekeyconceptsofcrisismanagement,whicharebasedonthecharacteristicsofcrisesordisaster,have relevanceandaresonancetotheissuesconcernedwithoutbreakcommunicationsandthepreparationof crisiscommunicationplans.

3. TheImportanceofCommunicationinOutbreakControl
As cited in The World Health Organisations (WHO), Outbreak Communication Guidance (2005, p.1) Communication, generally through the media is another feature of the outbreak environment. Unfortunately, examples abound of communication failures, some of which have hampered outbreak control, undermined public trust and compliance, and unnecessarily prolonged economic, social and political turmoil. The World Health Organization (WHO) believes it is now time to acknowledge that communication expertise has become as essential to outbreak control as epidemiological training and laboratoryanalysis.

3.1RiskCommunication
WHO (2012) state that, Risk Communication is an interactive process of exchange of information and opiniononriskamongriskassessors,riskmanagers,andotherinterestedparties(para.1).Theaimofrisk communicationistohelppeopleatalllevelsofsocietymakemoreinformeddecisionsaboutthethreatsto healthandsafety(Vaughan&Tinker,2009). Risk communication differs from Crisis Communications in that it focuses on what might happen as opposedtowhathasorishappening.RiskandCrisisCommunicationalsodifferwithregardtowhenthe communication occurs. Whilst Risk Communication is an ongoing process that takes place before an emergencyoccurs,CrisisCommunicationdescribesthemessagesthataredeliveredduringanemergency 10

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 event (Ferrante,2011).Inthecontextofanoutbreaksituationbothriskandcrisiscommunicationplay a keyrolewiththesuccessofCrisisCommunicationstosomeextentdeterminedbythesuccessofanyprior RiskCommunication. The issues facing Health Risk Communicators are complex not only incorporating medicine and epidemiology, but also ethics, politics, perception, psychology and culture, all of which influence the interpretation and impact of messages and the willingness of individuals to act as instructed (Menon, 2008). The development and implementation of effective health risk communication strategies before a crisisoccursarethereforevitalforprotectingpublichealthwhenacrisishappens.

3.2CrisisCommunication
As already stated crisis communications is the bedrock of crisis management. In the context of a flu pandemic, (crisis) communications must successfully instruct, inform and motivate the public to adopt appropriateselfprotectivebehaviourwhilstalsobuildingtrustandconfidenceinofficials,dispellingmyths and rumour and ultimately acting in partnership with the authorities overall strategy (Vaughan & Tinker, 2008). Crisiscommunicationinvolvescommunicatinginunpredictablecircumstances,thestakesareoftenhigher, thesituationmaybeunfamiliarandthetimepressuregreater.Decisionsandactionsmayalsoneedtobe takenwithoutknowledgeofthefullfactsandinintenselypressurizedcircumstances.Therearealsolikely tobemultipleorganizationsinvolvedbutlittletimetoconsultandcollaborateinordertoreachconsensus to the degree that is desired (JHSPH, 2011). The following diagram (Figure 1) shows the information mismatchexperiencedinacrisis.

TheInformationMismatch
information

Lack of information!

Crisis

time

Timelydecisionsmayneedtobemade withoutknowledgeofthefullfacts
Figure1TheInformationmismatch

hours

ThechallengefacedbyOfficialHealthCommunicators,isthatthereisaconstanttensionbetweenwanting to wait until such a time as they can give completely accurate information and the need to provide informationquickly.Thedangeristhatwhilsttheyarewaitingforafullpicturetoemerge,thegapwillbe

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 filledbyspeculation,rumourandunofficialreporting.Thiscanhoweverbeeasedbyprovidingpreliminary information,regularupdatesandaimingtosharewhatyouknowwhenyouknowit.(JHSP,2011) Instraightforwardterms,CrisisCommunicationsinvolvescarefullycommunicatingcomplexmessagesina languagethatthepublicunderstandsinordertosuccessfullyrestorepublicfaith(Menon,2008). To complicate the picture further, Crisis Communications may also be influenced by personal ambition, politicalsurvival,selfimageandindividualleadershipstyleswhichmaybeatoddswiththeoverallwelfare ofcitizensandtheneedtocommunicateaccurateandclearmessages,particularlyifthisinvolvesaccepting shortcomings or taking responsibility for failings (GesserEdelsburg & Zemach, 2010). There may also be realconcernastothepoliticalandeconomicimplicationsofannouncingacrisis,suchasputtingoffforeign investmentorlostproductivity,thatfurtherhinderthetransparentsharingofinformation(CIA,2003).In GesserEdelsburgandZemachs(2010,p.20)analysisoftheIsraeliPrimeMinistershandlingoftheIsraeli CarmelDisaster,theauthorconsiderstworiskcommunicationstrategies;strategicambiguityandcoverup risk communication. Both of these different styles and approaches to communication are used in an attempt to conceal failure and avoid personal responsibility with varying success. Such approaches undoubtedlyerodethedegreeoftrustheldbythepublicfortheauthorities,athemethatrunsthroughout thisreportandistackledinmoredetaillater.

4. Component1Source
Over the last 15 years, the internet has significantly changed the way in which patients access health information,placingvastswathesofhealthrelatedinformationatthefingertipsofconsumers(Murrayet al.,2003).Thiscombinedwithadvancesintelemedicineandothertechnologiesnowmeanshealthservices reachfarbeyondthetraditionalconfinesofaconsultingroomoroffice(Hesse,2005). Atthesametime,therangeandquantityofhealthrelatedmediacoveragehasalsointensifiedasanever increasingnumberofcommentatorsreviewtopicalhealthrelatedissues.Pharmaceuticalcompanieshave alsobeenquicktomaximizeanincreasinglyconsumerfocusedsocietybytargetingcustomersdirectlywith advertising campaigns (Ventola, 2011). All these elements are affecting the relationship between the patientandthephysician,thelatterofwhommaypreviouslyhaveactedasagatekeeperintermsofthe informationandadviceprovidedtopatients.Thishasnotonlyresultedinpatientseducatingthemselves, butalsodemandingagreatershareinthedecisionmakingprocess(Iverson,Howard&Penney,2007). Thesourcesthatpatientsdrawupontoaccesshealthrelatedinformationpaintsanincreasinglydiverseand complexpicturewhichisinturninfluencedbyanumberofdifferentelements,notleastage,sex,culture andeducation.Asmightbeexpectedyounger,bettereducatedadults,inparticularwomen,aremorelikely toaccessinformationfromtheInternetbeforeseekingadvicefromaphysician(Hesse,2005).Whilstthere issomeconcernthatonlineinformationgatheringbypatientsmaybechangingthedynamicbetweenthe patientandphysician,possiblyevenreducingthephysiciansinfluence,thereisevidencetosuggestthatit also has the potential to achieve greater patient engagement, increase knowledge and decision making, educate, reduce the potential for information overload and provide patients with the opportunity to connectonlinewithothersinsimilarpositions(Iverson,Howard,&Penney,2007).Itisalsoreportedthat consistencyofmessagesfromavarietyofsourceshelpstoreinforcethemessageandwillmeanitismore likelytobeaccepted(Powell,Chapman&Blaine,2004).

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 Studies have also highlighted that individual preference for sources of information can vary amongst differentcultures.Forexampleastudy(Wong,&Sam,2010)lookingattheissuessurroundinginfluenza informationsourcesinMalaysiashowedthatMalaysweresignificantlymorelikelytoidentifytelevisionasa main source of information whilst alternatively newspapers and family members were identified as the mainsource ofinformationbyChineseandIndians respectively. Inthissame studythe3 mostpreferred sourcesofinformationwereidentifiedastelevision,newspaperandhealthproviderswithtelevisionasthe preferredsourceofinformationamongstlowereducatedgroups.Thishighlightstheneedtoutilisemultiple communication channels and medium in order to meet the varying needs of the public. With public behaviourheavilyinfluencedbyknowledgeandperception,consideringinformationsourcesandhowthey areperceivedandtrustedbythepublicisimportantforachievingmoreeffectivecommunications(Vander Weeretal,.2011).

4.1OfficialChannels(GovernmentOfficials&HealthCareProviders)
Whilst the mass media and Internet play a significant role in disseminating information to the public, information from health care providers and other official channels remains an important source of information during an outbreak situation (McCree, Sharpe, Brandt & Robertson, 2006). According to a study conducted in the US that focused on the publics use of and trust in different sources of health information, despite an increasing number of people accessing health information on line, physicians remain the most trusted source of health information (Hesse, et al. 2005). Health care workers and municipalhealthserviceshavealsobeenfoundbyKoketaltobeconsideredthemosttrustedinformation sources during a pandemic (Kok et al., 2010) with high levels of trust in official sources in turn having a positive impact on the take up of protective behaviour and vaccination. There is however greater scepticismforGovernmentofficialsandagenciesandotherformalsourcesofinformationwiththepublic placing greater importance on advice and information provided by personal physicians, friends, relatives andcolleagues(Mechanic,2005). Not only this, Health services and providers have also been found to be the source of information that membersofthepublicmostwanttoreceiveinformationfrom(VanderWeer,etal.,2011)withadesirefor theinformationdisseminatedbythesesourcestofocusonwhattodotopreventandtreatinfection. With consistency of message vital for maintaining levels of trust, it is clear that Political Will and cooperation willthereforebeneeded fromallofficialchannels,workinghandinhandwiththemedia,in ordertoensureinfectiousdiseasepreparednessisinplaceandacoordinatedandajoinedupresponsecan beachieved(CIA,2003).

4.2UseoftheMassMedia
Theroleofthemassmediaduringacrisiscannotbeunderestimated(CabinetOffice,2012).Itisthrough themedia(TV,radio,newspapers)thatmostpeoplefirsthearaboutanemergencyorcrisissituationandit isalsothemediawhocontributesignificantlytoshapingpublicperceptionnotonlyofrisk,butalsoofthe officialhandlingofasituation(CabinetOffice,2012). Areviewintotheeffectivenessofpublichealthcampaigns(HealthDevelopmentAgency,2004)concludes thatthemassmediaofferthebestchanceofreachingeitheralargenumberofpeopleorspecifictarget groupswithinashortspaceoftime.Theyalsoconcludethatcommunicationswillbemosteffectivewhen themediaareonsideandwhenthebehaviouralgoalissimple,suchasimmunization. 13

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 WhilstWHOhaverecognisedtheroleofthemassmediainepidemiccontrol,recentstudiesconductedby Gholami et al. (2011) have also highlighted the importance of the media in informing physicians, further highlighting the importance of working with the media to ensure information that is disseminated is as accurateaspossible. The UK Cabinet Office (2012) suggest however, that whilst the public value the information and entertainmentprovidedbythemedia,publicattitudetothemediaisattimesambivalent.Thereisafeeling thatthemediaareresponsibleforwipinguphysteriaandsensationalisingissues,aswasseenduringthe fuel shortages in the UK during autumn 2000 where exaggerated reporting lead to panic buying in some areas. Whilst some quarters of the media may strive foraccuracy, this desire to sell stories and capture market share is seen to be at the cost of providing impartial and factual information resulting in the presentationofconflicting,scandalous,controversialandmoreexcitingperspectives.Understandably,this hasinturnleadtofeelingsofscepticismamongthepublic(Mechanic,2005),whichisthoughttobeatits highestconcerningmattersthataffectindividualspersonally,suchashealthinformation.Respectedmedia do however play an important role in making scientific information accessible to not only the public but alsotomedicalprofessionals.Onecanthenconcludethatwhatisimportantisnottoseethemediaasa single entity, but to understand and work with different mediums appropriate to the audience and situation.

4.3UnofficialChannels(theinternet,blogs,onlinejournalistsandwebsitesetc)
In a study (Hilton & Smith, 2010) examining public understanding of the 2009 swine flu pandemic, participantsidentifiedtheGovernmentandtheMediaasthetwokeyinformationsourcesthatwouldhelp themtoassesstheriskofcontractingswineflu.HoweveraHesse,etals.,(2005)reportconcludesthatan everincreasingnumberofpeopleareturningtotheWorldWideWebasasourceoffirstresort. Inrecentyears,SocialMedia,whichreferstoonlineandelectroniccommunicationtoolssuchasFacebook, Twitter, YouTube and blogs, has been set up to share and create content between multiple users (CDC, 2012). Social Media has taken on an increasingly higher profile and importance during crisis situations. WhilstmanyorganizationsarenowharnessingSocialMediatodisseminateofficialcommunicationstotheir audiences,thereisalsoaswatheofunofficialonlineactivity. It is reported (EC, 2010) that Social Media was central to influencing public opinion and decision making acrossEuropeduringtheH1N1swoutbreakin2009.WebsitessuchasLinkedIn,Facebook,Twitter,Flicker andYouTubehaveallrepeatedlyprovedanimportanthubforpubliccommunicationsduringemergencies. Certainly Facebook, Twitter and Bloggers were all highly active during the 2009 outbreak, Facebooks rankingofhottesttrendsandtopicsrevealedthatH1N1swreachedthethirdposition.Bysomeaccounts, swineflumentionstoppedoutatarateofmorethan10,000tweetsperhour.(EuropeanCommissionDG SANCO,2010,p.3). With global membership running at an estimated figure of over 1 billion users (ITU, 2012), Social Media representsapowerfulmeansofreachinglargeaudiencesatthetouchofabutton.Likeitornot,itisnowa featureofalmostanycrisisrepresentingakeyportofcallformanymembersofthepublic.TheEC(2010) also highlights the increasing importance of bloggers who in some countries have taken over the role of journalists.Itissuggestedthatitshouldbepossibletoidentifywhothesekeybloggersarewithaviewto working with them in order to get the desired message across. Social Media does therefore deserve

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 significantconsiderationifweare toembracethefullrangeof availablecommunicationstoimprovethe wayinwhichwecommunicateandreachpublicaudiencesduringafuturecrisisresponse. An analysis carried out by Collier, et al. (2011) does however caution that whilst Social Media can be a powerful tool for getting messages out to a large audience in real time, Tweets tend to be reactive to mediatrendsandcanbeambiguous.

4.4OtherSourcesofInformation(pressuregroups,antivaccinationmovement,charities andprofessionalbodies)
Studiesalsoindicatethatprofessionalbodies,pressuregroupssuchastheantivaccinationmovementand other representative groups also play an important role in risk and crisis communications. A study conductedin2001(CabinetOffice,2002)suggestthatcharities(Nongovernmentorganisations(NGOs))are thoughttobemoretrustworthythanGovernmentandassuch,thesegroupsalsoneedtobeconsideredas keystakeholderswhendevelopingCrisisCommunicationstrategies.Theymayalsohaveawiderreachand aremoreabletocommunicatewiththehardtoreach. The European Centre for Disease Control (ECDC) aims to work with NGOs to increase its reach to wider audiences,inparticularthehardtoreachpopulations(ECDC,2009). The reluctance to vaccinate during the H1N1sw pandemic was partly attributed to the increasingly vocal antivaccinationmovement(P.Shetty,2010).

5. Component2TypeofCommunication
5.1Appropriate
Itiscrucialthattheresponsetoanoutbreakofinfectiousdiseaseisasproportionateandappropriateas possible. Early reporting and transparent sharing of information is vital for a successful response so that agencies can act swiftly to put in place control measures. In the same vein it is also important not to overreact. The CIA (2003) cites a situation in India in 1994 that was reported by the Government as an outbreakoftheplague.ThiscausedworldwidealarmandmajoreconomiclosestoIndiaonlytobedeclared overbyWHOacoupleofweekslater. In order to be effective, Crisis Communication strategies need to vary for different audiences e.g. public, healthofficials,media,nationalandgeneric,localandspecific.WHO(2004),alsoremindusthatinorderto be effective communicators need direct channels to the target audience. Above all, the goal of communicationsshouldbetohelpthem(therecipients)toactintheirownbestinterests(Granger,etal. 2002).Inordertodothiscommunicationsmustbeunbiasedandresponsibleandwithoutvestedinterest. VaughanandTinker(2008)pointtoagrowingconsensusthatrecogniseshealthcommunicationsaremost effectivenotonlywhentheyareopenbutalsowhentheyaddresstheconcernsandprioritiesoftargeted populationsi.e.theyarerelevant.

5.2Speculative
Whenthemediaareinadequatelyinformed,theyaremorelikelytointerpretthesituationforthemselves. ThismayleadtoahypingupofthesituationasseenduringtheBSEcrisisintheUnitedKingdom(WHO, 15

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 2004). In their report, WHO (2004, p.24) state that Other criticism claimed that the press reported inaccuraciesandmisinterpretation,whichheightenedpublicfearandledtopublicscepticismregardingthe governmentscompetence.

5.3Tone&Terminology
Healthcommunicatorsmustcommunicateempatheticallyandwithunderstandingforthepublicinterest, somethingthatwasseenasakeyfailureduringtheBSEcrisis(WHO,2004).Notonlyisthetoneimportant when communicating, but also the choice of terminology needs to be appropriate for the audience. Effective communication systems, including the use of appropriate terminology, are key to ensuring the effectivenessoftheresponsetoanincident(BritishStandardsInstitute(BSi),2010,p.13).Communicators are however faced with the challenge of communicating with audiences who may have no shared vocabulary or conceptual background with the communicator (Granger, Fishhnoff, Bostrom, &Atman, 2002).UseofGreekandLatinterminologytodescribeBSEdisease,forinstance,mystifiedandfrightened thepublic(Harris,OShaughnessy,1997). Sager and Sharma (2009, p.1819) suggest that even the term Pandemic may have scary connotations. Theystatethat,thetermpandemictechnicallyreferstoavirusthatisspreadingrapidlybetweenhumans intwoormoreWHOregions.Itdoesnotinanywayimplythatthevirusisactuallydangerous. AreviewoftheUKsresponsetothe(Hine,2010)2009swinefluoutbreaksuggeststhatterminologyused duringtheoutbreakshouldberevisited.Inparticular,Hinesuggeststhatthewordcontainment,usedto describeastrategytoslowthespreadofthevirus,mayhavebeenmisinterpretedbysomemembersofthe public.ItispossiblethatthisleadtoaperceptionthatthemovefromContainmentPhasetoTreatment Phaseindicatedafailurebytheauthoritiestostopthevirusfromspreading. Whilst scientists are comfortable talking about statistics and odds, the public need more accurate terms. Theyalsoliketofeeltheyhavesomechoiceconcerningtheactionsthattheyshouldtake(JHSPH,2011).

5.4PublicAwarenessCampaigns
Officialannouncementsneedtobeenforcedbyongoingpublicawarenessandeducationprograms(CIA, 2003).ItissuggestedtheUKGovernmentsCatchit,Binit,Killitcampaignwasconsideredbythepublic toconfirmwhattheyalreadyknew.HiltonandSmith(2010)suggestthatitmayhavebeenmoreeffectiveif ithadencouragedpeopletochallengetheirownbehaviour.

5.5StandardizedandConsistent
Consistencyofmessageisvital.Coremessagesneedrepeatingandupdatingtoensuretheysinkin(JHSPH, 2011).Howeverwhenmultiple nations,authorities andpolicy makersareinvolvedinaresponsethereis the potential for inconsistency or disagreement. When this occurs the authorities are in danger of losing credibility,whichmaymeanpeoplestoplisteningtothemessagesthatarebeingputout(JHSPH,2011). StudieshaveshownthatifmessagesareperceivedtobeconflictingGovernmenttrustwilldecreasewhich inturnhasanimpactontheuptakeofprotectivemeasures(VandeWeerd,2011).Forinstance,duringthe H1N1swpandemicmanyGovernmentssetoutascenariomuchworsethanwhatwasactuallyexperienced whichwasperceivedtobeconflictingandcontradictoryandalsocontributedtofeelingsofcomplacency.

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 Duringthe2009flupandemic,theUKsoughttoachievecoordinationandconsistencybysettingupafour nationshealthgroupatbothministerialandofficiallevels.Itisreportedthatwhilstitwasnotperfect,the arrangementsworkedeffectivelyandhelpedachieveacommonapproach(Hine,2010).Itispossiblethis approachshouldalsobeconsideredattheEuropewidelevel.

5.6Symbolism
It is suggested that symbolism, deliberate and inadvertent, played a key role in the UK Governments handlingofcommunicationsduringtheBSEcrisis(Harris&OShaughnessy,1997).Powerfulimagessuchas, DaisythecowstaggeringaboutasaresultoftheeffectsofBSE,theAgriculturalministerMrGummerwho fedabeefburgertohisfouryearolddaughterinatattempttoprovethatBritishbeefwassafeforpublic consumption, the distressing images of the victims of CreutzfeldtJakob Disease (CJD) and the burning of cattlepyresallbecamesynonymouswiththeCrisisandwereallusedbytheGovernmenttocommunicate with the public. Similarly, the wearing of a facemask became the defining symbol of the Severe Acute RespiratorySyndrome(SARS)outbreak. Thesesymbolsintensified publicconcernandaffectedpublicattitudesanditisarguedthattheabilityto usesymbolsinthemassmediaverbal,nonverbal,pictorial,musicaletcarevitalbothforpersuadingthe publicandprovidingmeaning(Larson,1995).WhilstintheBSEcrisistheUKGovernmentbecameavictim of symbolism, in that they only served to magnify the failings and poignancy of the crisis, it is argued (Harris, OShaughnessy) that effective use of symbols that capture the public imagination can enable communicatorstocompletelyredefineasituation.

6. Component3Media
Thereisawiderangeofmediaandsophisticatedtechnologyavailableforenhancingourcommunications capabilityinresponsetoapotentialpandemic.Newspapers(dailyprintandonline),radioincludingPublic Service Announcements (PSAs), Internet rapid response facts and figures through websites and social media, spokespeople conducting briefings and interviews, print material brochures, pamphlets, written andoutreachmaterialsforcommunitieswithoutInternetaccess,televisionbroadcasts,advertisements anddocumentaries,telephonehotlines,textmessagesandinformationlines,areallimportantformsof communicationinacrisis(JHSPH,2011). TheInternet,emailandteleconferencingwereallreportedtohaveassistedtheinformationdissemination process during the SARS outbreak in 2003 (CIA, 2003). In response to the pandemic flu threat, a wide varietyofmediawasalsousedinanattempttomaximizecoverageandbuildawarenessincluding;posters, pamphlets,TVcommercials,printedadvertisingcampaigns,handbooksandwebsites(Menon,2008). The Centre for Disease Control (CDC) (CDC, 2011) promote their annual national awareness campaign throughawholerangeofmediaoutletssuchas;printandinternetadds,mattearticles(consumerrelated articles), TV and radio public services announcements, personal testimony videos featuring parents who have been greatly affected by influenza, radio interviews, bites and broll packages (video highlights and interview snippets put together to produce a story), special events, websites, magazines, and collaborationwithpartners. AspointedoutbyWHO(2005b),whatisimportantisthatthecommunicationsstrategyisappropriatefor andinclusiveofthediversesocietyforwhichitisintended.Itisknownthatdifferentculturesandgroups

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 respond differently to, and are more accepting of, different forms of media (Wong & Sam, 2010). Such variationsofmedianeedtobecateredforwithinthecommunicationsstrategy. Itisunlikelythatjournalistsandthemassmediawillmeettheneedsofallthedifferingtypesofpopulations and segments of society during a healthrelated emergency (WHO, 2005b). According to WHO these include; elderly populations, disabled people, homeless people, housebound populations, racial and culturalminorities,linguisticminorities,illiteratepopulations,transientpopulations(forexample,tourists, business travellers and migrant workers) and institutionalized populations. Therefore, choosing the right blendofmediatoensurethatmessagesreachthosetheyareintendedforisanotherimportantaspectof the Crisis Communications strategy. It also strengthens the argument that health communicators should seektogetmessagesoutthroughavarietyofdifferentchannels.

6.1Media(BroadcastTV,PrintandRadio)
Newsmediahasanimportantroletoplayindisseminatingscientificinformationtothepublic,particularly inareasofriskperception.Pressreleases,pressconferencesandothertraditionalmeansofcommunicating arereportedtohavebeenthemostwidelyusedformofcommunicationsduringthe2009H1N1Pandemic (EC,2010).WhilsttheMediahasoftenbeenaccusedofoverhypinghealthrisks,areviewof2,734news articlespublishedineightUKnationalnewspapersbetween1March2009and28February2010(Hilton, Hunt, 2011) concluded that coverage was largely measured and that their role in communicating factual information should be welcomed. Hine (2010, p.16) also supports this finding in her own review of the outbreak. She credits the UK governments frequent media briefings weekly briefings, Q&A sessions, regular releases of facts and figures with successfully keeping the media informed and engaged and suggeststhatitprovidesamodelforfuturecommunicationsinalongrunningcrisis. Inadditiontelevisionhasprovedtohavebeenahighlyeffectiveformofcommunications.Notonlydoesit providearapidandimmediate transmissionofinformation,it alsoenablesspokespeopletomakeuseof visual aids and other props, all of which can help strengthen the message and understanding (WHO, 2005a). The reach and impact of radio as a means of communication should also not be forgotten. Nearly every household has a radio, allowing communicators to reach individuals and groups that might not be accessibleviaothermeans(WHO,2005b).Liketelevision,radioalsoprovidesameansofdeliveringinstant messages.Bothtelevisionandradioareseentobeatrustedandunbiasedformofcommunication(Cabinet Office,2012).

6.2SocialMedia(SocialNetworks,Blogoshpere,Wikis,VideoSharingApplications)
Social media sites are very popular. CDC (2012) quote the Pew Internet & American Life Project report (2011) Social Networking Sites and Our Lives, stating that nearly half of adults (47%) used at least one social networking site in 2010. It is thought that that number is continuing to grow rapidly. Despite the popularity of these sites, it is reported that only 5 member states used social media during the H1N1sw pandemic. Whilst CDC has been praised for its use of various social media platforms others have been criticizedforfailingtofollowthislead(EuropeanCommissionDGSANCO,2011) The European Commissions report on the Importance of Social Media during a Crisis (EC, 2011) emphatically outlines the many potential benefits of its use during a Crisis. In addition to providing the communicatorswithinformationthatwillhelpshapetheirmessaging,SocialMediaalsoenablesdecision makers and communicators to identify trends, spot earlywarnings and communicate with far reaching 18

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 audiencesinadditiontotargetgroups.Intheirreport,theECclearlysetouttheneedforMemberStatesto embrace Social Media as part of their crisis response stating that It is no longer possible to simply communicateofflineviainformationsheets,pressconferencesandpressreleases.InsteadMemberStates (andtheCommission)needtoestablishavoicenowtoensurethatifasimilarcrisisoccurstheyareready to release their information through the already established online communication channels (EC, 2011, p.9). SocialMediaalsomakesitpossibletoreviewthesuccessofcommunicationsbymonitoringthenumberof peoplewhohaveclickedonthelinksorretweetedmessagesetc.(EC,2011) Notonlythis,SocialMediapresentstheopportunitytoleveragelargenetworksanddiverseaudiencesin ordertospreadmessages(CDC,2012).ViralNetworking,oftenusingsocialmedia,whereappealingcontent is read by internet users and passed on to piers, friends, families and colleagues creating a buzz to the point where ideas or content spreads like a virus (Viral Marketing, 2012), is a powerful means of reachingalargeandcaptiveaudience(EC,2011). CDC has been praised for the extent to which they embraced Social Media during the 2009 H1N1sw pandemic.TheyestablishedTwitterandFacebookaccounts,linkstovideosonYouTube,handwashinge cardsetc.(EC,2011)anditissuggestedthattheyshouldbeheldupasanexampleforotherorganisations tofollow.Hine(2010)alsorecommendsthatthepotentialofsocialnetworkinganddigitalmediashouldbe usedtoengagewithawiderscientificcommunityandthemedia. It is reported At the height of the pandemic, May 1st 2009, @CDCemergency had more than 65,000 followers. As of May 1st 2010, they had 1,224,635 followers. People were listening to the information receivedandCDCwasseenasanexpertvoiceintheonlineworldforH1N1sw(EC,2010,p.9). TheotherbenefitofSocialMedia,unlikemanyotherformsofmasscommunication,isthatitallowsfora twowayconversationinwhichtheaudiencecanreactandaskquestions,ineffectgivingthepublicavoice. This provides communicators with greater insight and understanding of the audiences they are targeting (WHO,2005a).

6.3TelephoneHotlines
Telephone hotlines have also proved effective for the communication of authoritative messages. The provincialSARStelephonelineinTorontoregisteredabout10,000callsperdayduringthe2003outbreak (WHO, 2004). The UK Government implemented the National Pandemic Flu Service at national and regional levels during the 2009 outbreak, a telephone line which provided fast diagnosis to worried membersofthepublicandadviceonwhatfurtheractiontotakeaswellasawebsiteprovidinginformation and links to helpful resources. It is reported (Hine, 2010) that this effectively reduced the pressure on primarycareservices.Dependingonthenatureoftheemergencyitmaybeappropriatetosetupmultiple hotlinesforvariousdifferentstakeholders(e.g.Media,public,policymakers)andwherepossible,feedback fromthehotlinesshouldbepassedontothosedeliveringcommunications(WHO,2005a).

6.4Spokespeople
Howamessageiscommunicated,willnaturallyinfluenceitsimpact.Duringanemergency,spokespeople can become the public face of an organisations response. Aside from the message content, verbal and

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 nonverbalcommunicationskillsandthepersonalityofanindividual(howtrustworthyandlikeable)areall importantconsiderations(WHO,2005a). Effective spokespeople have proved to be a powerful method of communications during various crisis situations(WHO,2004).MayorRudyGiulianiintheaftermathoftheWorldTradeCentreterroristattacksin New York is an example of the enormous impact a spokesperson with the right attributes can have on people (Sirota, 2001). The performance of spokespeople can affect peoples degree of trust in the authoritiesandthesubsequentimpactofthemessage(Vaughan,Tinker,2008). Gainingaccesstospokespeopleisalsoimportant.ItwaswidelyreportedthatduringtheH1N1swcrisisin 2009journalistshadgreatdifficultyaccessingofficialsandexpertsinthevariousMemberStates(EC,2011). AsacontrastthedailymediabriefingsthatwereheldinOntarioduringtheSARScrisiswerewellreceived by journalist and other stakeholders and thought to have contributed to what is deemed a successful communicationscampaign.(WHO,2004) It is important, therefore, to appoint a lead spokesperson appropriate to the scale of the disaster. This personclearlyneedstobetrainedandexperiencedindealingwiththemediaandtoalsohaveagoodgrasp ofthekeyissues(WHO,2005a).Additionallythesettingupofapressroomsothatthemediacanreceive uptodateinformationfromofficialswillhelpavoidspeculationandpossibleconflictingreportsborneout offrustrationandalackofinformation.

7. Component4TimingofDissemination
7.1SpeedofResponse
EarlyDetection,surveillanceanddecisionmakingareallcrucialinmanaginganoutbreaksituation.Many factorsincludinginternationaltravelandvaryingimmunityhaveallhadamajorimpactonthespeedand reach of infectious disease. As a consequence there is an everincreasing need for evidence based surveillanceandearlydetectionanddecisionmakingmethods(Scarpino,Dimitrov&Meyers,2012). Similarly,theonlineworldhasacceleratedthespeedatwhichnewscantravelwhichalsohasimplications forcommunicators.Whilstsocialnetworksmaybereportinganinfectiousoutbreakinrealtime,anofficial announcementmightcomesometimelater.Itisreportedthat(Collier,Bguyen&Nguyen,2011,p.1),the averagedelayinreceivinganddisseminatingdatafromtraditionalsentinelphysiciannetworksisabouttwo weeks.However,itisalsosuggestedthatitmaybepossibleforsocialnetworks,ormicroblogs,tobe usedtohelpwithearlyidentificationandonwardtrackingandmonitoringofanoutbreakandinsodoing gosomewaytosolvingtheproblemthattheycreate. SocialMediaalsoprovideshealthcommunicatorswiththeopportunitytocommunicateinstantlywithkey stakeholdersratherthanhavingtowaitforjournaliststoreport(EC,2010).

7.2AnnouncingthePandemic
Many previous high profile crises, including The Dioxins Crisis in Belgium (WHO, 2004) where the Government failed to communicate adequately leaving the mass media to speculate and uncover problems,servetohighlighttheimportanceofnotifyingstakeholdersasearlyaspossible.Theimmediate reactionofmostgovernmentshoweveristohideinformationaboutanoutbreakfromthepublicforfearof triggering panic and an overreaction (Menon, 2008). An issue here though is that if news breaks and it 20

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 emergesthattheauthoritieshavebeenpurposefullywithholdinginformationthentrustisdestroyedand theresponseisundermined. AscitedbyWHO,intheirOutbreakCommunicationGuidance,itislikelythatanoutbreaksituationmaybe reportedonthewebbeforeofficialsmakeaformalannouncement.Keepinganoutbreakhiddenfromthe publicisalmostimpossible.Itisthereforerecommendedthatearlyreportingwillhelptopreventrumour andmisinformation(WHO,2005a).WHOgoontoadvisethatondecidingwhentoinformthepublicofa pandemic situation, An announcement must be made when public behaviour might reduce risk or contributetothecontainmentoftheoutbreakandthatthebenefitsofearlywarningoutweightherisks.

7.3CommunicationContinuum
It is important that there is communication throughout all phases of the emergency (JHSPH, 2011). However,itistypicalforwhatGesserEdelsburgandZemach(2012)refertoasacommunicationsvacuum toappearfollowingacrisisascommentatorsreturntobusinessasusualandmediaattentionturnstofresh stories.Itisalsosuggestedthatthisneedstobeavoidedandreplacedwithacommunicationscontinuum in order to ensure the publics fears are addressed, questions answered and ultimately steps taken to prepare for the next disaster. In the same vein it is important to consider the level and content of communicationsbetweenpandemicsaswellasthelevelandcontentduringthepandemicstages(WHO, 2004). AsingoodcrisismanagementpracticeCommunicatingkeydecisionsinatimelyfashionisasimportantas making the decisions in the first place. (BSi, 2010). This sentiment is particularly pertinent due to the increasingly rapid transmission of infectious disease. Communications at all levels of the response to a pandemic is important as unless the public know what is happening, what they should do and why it is likelythattherewillbeconfusionandabreakdownoftrust(WHO,2004).

7.4InformationFatigue
Publiccomplacencyandfatiguegeneratedbyrepeatedandunfulfilledscaresandscientificuncertaintyalso create problems for health communicators (Menon, 2008). This is particularly true in countries such as SouthEastAsiathathavebeenhighonthefluradarforsomeyearsandwhichhaveotherrealcrisesto dealwith,suchasfinancialcrises,floods,earthquakesorothernaturaldisasters.Howtoretaininterestin theissueandmaintainreadinessishoweveranissueforallparticularlysincethe2009pandemicfellshort ofthescenariosthathadbeenpredicted(Hine,2010).

8. Component5PublicAcceptance
8.1TrustintheAuthorities
It is widely and overwhelmingly acknowledged that trust is one of the most significant factors related to successful Crisis Communications (De Zwart, 2008). In relation to outbreak situations there needs to be trust,notjustbetweenofficialsandthepublicbutalsobetweencommunicatorsandtechnicalteams(EC, 2010).WHO(2005a,p.2)statethatAbundantresearchandprominentpublichealthexamplessupportthe hypothesisthatthelesspeopletrustthosewhoaresupposedtoprotectthem,themoreafraidthepublic will be and less likely they will be to conform their choices and behaviour with outbreak management instructions.So,PublicacceptanceofrecommendedmeasuresisheavilyinfluencedbyTrust,whichinturn affectsthepublicsjudgmentofrisksandbenefits.ThisconceptissupportedbyWeerdetal.(2011)who 21

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 state,Ahighlevelofpublicperceptionandtrustisrelatedtocompliancewithrecommendedmeasures. Figure2outlinesfactorsthatincreasepublictrustincrisiscommunicationsandFigure3outlinesthefactors thatdecreasepublictrust.

8.2TrustinRelationtoRiskManagement
VanderWeerdetal(2011),whoexaminedtrust,riskperceptionandtheintentionofthegeneralpublicto adopt protective measures during the H1N1sw Pandemic in the Netherlands identified trust as an important factor in risk management. This is because trust can affect the public's judgments of risks and benefits,andcanthereforeinfluencetheacceptanceofrecommendedmeasuresandsuccessorfailureof communicationcampaigns.(Vaughan&Tinker,2008).

Studies examining peoples willingness to comply with public health recommendations have also been carriedoutincountrieswithexperienceofdealingwithSARSandAvianFluoutbreaks.Findingsherewould alsosuggest the mostpertinentfactoraffectingcomplianceispeoplesunderstandingandassessmentof theperceivedriskofcontractingtheinfectionanditsseverity(Hilton&Smith,2010). According to the results of 16 cross section telephone surveys undertaken in the Netherlands between AugustandNovember2009,Riskandcrisiscommunicationbythegovernmentshouldfocusonbuilding and maintaining trust by providing information about preventing infection in close collaboration with municipalhealthservices,healthcareproviders,andthemedia.(VanDerWeerdetal.,2011).

8.3TrustintheGovernment
HarrisandOShaughnessy(p.36)(citingAndrews,1996)suggestthattheBSEcrisisepitomizedamalaisein British(orEnglish)societyanditspoliticalOrganisation.Theypointoutthattheexistingpublicmoodand general view of politicians in areas unrelated to a crisis will impact public opinion during a crisis in turn impacting feelings of trust in the government, political figures and the socalled authorities. For example theMPexpensesscandalintheUK,followedbytheLevesonenquiryintomediastandardshavebothledto increasing mistrust of political figures. Existing perceptions of sleaze and incompetence connected to previouseventscanthereforeundermineauthority.Itisinmanycasesalsothemassmediawhoinfluence publicperceptionoftheperformanceofofficialspickinguponinconsistenciesorcontradictions(Vaughan& Tinker,2008). InGesserEdelsburgandZemachs(2012,p.1)analysisoftheIsraeliCarmelDisaster,theimportanceofthe mediainhelpingNetanyahustrengthenhispublicimageandthewayinwhichthepublicperceivedhehad handledthecrisisisnoted;ThemediaalsohelpedbuildNetanyahuscredibilityandcooperatedwithhim byprovidinghimwiththetelevisedstage.Itissuggestedthatthiscombinedwithanabsenceofanyreal pressure on behalf of the press to conduct an inquiry, all helped Netanyahu to build a positive and favourablepublicimagedespite many shortcomingsintheresponse.Itisalsosuggestedthatthislack of pressure from the Media and success in securing a positive public image resulted in inaction and complacencyfollowingthedisasterwithregardtoreducingfuturerisk.

8.4PerceptionofRisk
PerceptioncanbepowerfulinaCrisisandhavedirectimpactsonpeoplesbehaviour(VanderWeerdetal., 2011). Findings from a national telephone survey conducted in the UK following the H1N1sw outbreak concludethattheperceivedriskofoneselfbeingaffectedandlevelsofworryisakeyfactorintheextentto which members of the public adopt recommended behaviours (Rubin, Potts & Michie, 2010). These 22

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 findings are supported by The Health Belief Model, and The Protection Motivation Theory (PMT) (De Zwart,2009).Centraltobothofthesetheoriesistheconceptthatpublicadoptionofprotectivemeasuresis stronglyinfluencedbyahighlevelofriskperceptioni.e.perceivedsusceptibilitythatheorshewillcontract thediseaseandhowseveretheimpactofcontractingthediseasewouldbeonhisorherself.Inadditionto vulnerabilityandsusceptibility,beliefintheefficacyofavailableprotectiveactions,andtheperceptionan individualhasintheirabilitytocarryouttheproposedprotectiveactionsarealsoidentifiedasimportant factorsaffectingbehaviourchange(DeZwart,2008). Whilststudiessuggestthatduringthe2009H1N1swoutbreakmembersofthepublicthoughtcontracting swinefluwasinevitable,thereislittleevidencetosuggestthatindividualsperceivedcontractingthevirus tobelifethreateningforhealthypeople(Hilton&Smith,2010).Thismayexplainwhyuptakeofprotective behavioursandlevelsofworrywerelow,evenwhenthenumberofcaseswasrising. Anotherreasonforlowacceptanceofprotectivebehavioursisthatwhilsttheaccelerateddevelopmentofa vaccine during the H1N1sw outbreak may have met medical standards, the public perception was that it had not undergone the rigorous testing other vaccines go through and may therefore have posed a potential risk. This may have affected uptake of the vaccine and even created distrust amongst the populationsuspiciousofthemotivesofprofiteeringPharmaceuticalcompaniesandtheGovernment,and possiblyevencontributedtothefeelingthatthesituationwasbeingoverhypedforcommercialreasons (Henrich&Homes,2009). AnotherelementthatalsoaffectspeoplesdecisionmakingiswhatVaughanandTinker(2008)describeas the riskbenefit framing of the problem whereby risks are weighed up against the costs of taking protective actions. These costs might include disruption to personal circumstances and in particular economic livelihood, expenses associated with treatment as well as social consequences. Risks are considered within the context of peoples lives, which is why in some circumstances they may be consideredacceptable.

8.5UnderstandingtheNeedsandInterestsofThePublic
Itisvitalforhealthcommunicatorstounderstandtheneedsandinterestsofthepublic(WHO,2005a).This was something that the UK Government failed to achieve during the BSE crisis (WHO, 2004) resulting in increasingmistrustandsuspicion. It is important for communicators to listen to their audience with respect whilst also understanding the needsofthemedia(JHSPH,2011).Thisincludesbeingrespectfulofpeoplesfearsandconcerns.Itisvital toacknowledgethepublicviewandanywidelyheldbeliefsorconcerns,howevermistakenorunfounded they might seem , (WHO, 2005a, p.6). When a publicly held view is mistaken, it should still be acknowledged publicly and corrected, not ignored, patronized or ridiculed. Where misinformation isnt addressed, it can lead to public confusion, chaos, loss of government credibility and have serious consequences. In this way, the needs and concerns of the public should shape the content and focus of communications. For instance the audience may desire simple instructions or they may be looking for a rangeofinformationonwhichtomakeindependentdecisions(Grangeretal,2002). Managingandunderstandingthepsychologicalandbehaviouralreactionsofthepubliciskeytomanaging the response. As cited by WHO (2005a, p.6), It is usually difficult to change preexisting beliefs unless thosebeliefsareexplicitlyaddressed.Anditisnearlyimpossibletodesignsuccessfulmessagesthatbridge 23

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 the gap between the expert and the public without knowing what the public thinks. History has proved thatfailingtodothiscanprovecostly.BymonitoringandengaginginwhatsbeingdiscussedonlineSocial Mediacanhelporganizationstogetabetterfeelforthepublicinterestandwhatthecurrenthottopicsare, whichinturnshouldinformtheoverallcommunicationsstrategy(EC,2010). ItisalsoimportantthatCommunicatorsunderstandtheneedsandchallengesofspecific groupssuch as; those with limited access to technology, nonEnglish speakers, difficult to access urban populations, the illiterate,thehomelessandundocumentedimmigrants(Vaughan&Tinker,2008).Notonlyisitimportant thatcommunicationsreachvulnerablepopulations(includingthosewhomightnottypicallybedescribedas vulnerable),theyalsoneedtoberelevanttotheculturalneedsandprioritiesofthosepopulations,which canhaveasignificantimpactonindividualresponsestoanoutbreaksituation. Risk reduction strategies and advice also need to be realistic and appropriate if they are going to be acceptedandadopted.Forexamplerecommendationstoworkathomeforaprolongedperiodofamonth haveonlybeenfoundviableforaminorityofemployedpeople(Vaughan&Tinker,2008).

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D1.2 2ReviewofCrisisComm munications s MEprojectGA:278723 3 TELLM

FactorsT ThatIncrea asePublic cTrustinCrisisCom mmunications

Figu ure2Facto orsthatincre easepublictrust

FactorsT ThatDecre easePubli icTrustin nCrisisCommunicat tions

Figu ure3Facto orsthatdecre easepublict trust

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723

8.6CaseStudyoftheUKGovernmentsHandlingoftheBSECrisis
In Harris and OShaughnessy (1997) analysis of the UK Governments much criticized handling of communications during the BSE Crisis, it is suggested that a key element of the failure was that the Government believed and tried to sell the crisis to the public as a technical problem with a technical solution.Indoingthis,theymisjudgedpublicfeelingandinterpretationofthesituation,whichonlyserved tointensifyfeelingsofmistrustandsuspicion. Duringthiscrisis,theoverridingconcernamongstthepublicwasthatthediseasecouldpassfromcattleto humans unless successfully proved otherwise. This widely held theory was repeatedly denied by various government officials, an approach that failed to win over public opinion and only resulted in casting the authoritiesinanincreasinglysuspiciouslightanderodingthepublicstrust. It is also suggested that the UK Governments approach to communications during the BSE Crisis was further undermined by scientific tentativeness and an inability to communicate in a language that the publicunderstood(Harris&OShaughnessy,1997).Itisarguedthatduringacrisisthepublicdesireclarity andbrevityandthattheirunderstandingofproofmaybetotallyatoddswiththescientificinterpretation ofasituation. Public behaviour and cooperation are key to controlling an outbreak of infectious disease. However, as surprisingasitmightseem,merelytellingpeoplethattheirbehaviourisputtingthematriskisnotenough tomakethemchangetheirhabits(DeZwart,2008).

8.7AcknowledgingUncertaintyandBeingOpenandHonest
As with the characteristic of many crises and despite huge medical and scientific developments, it is acknowledgedthatinthecontextofapandemicoroutbreaksituation,itisimpossibletopredictwhatwill happen(Sager&Sharma,2009)andwhen.Whilsthealthcommunicatorsmayfeelthatacknowledgingthis uncertaintywouldincreasepublicinsecurity,thereisinfactevidencetosuggestitisbettertobeopenand honest about any limitations (WHO, 2005a). Covering up risks or a lack of information can reduce public confidenceindecisionmakersandincreaseanxiety(WHO,2004). TheimportanceofopennessandhonestyisfurtherunderlinedbySagerandSharma(2009)whoarguethat anobsessionwithpaniccanoftencauseofficialsandmanagerstowithholdvitalinformationinthebelief thatitwilljustscarepeople.Thisisexactlytheoppositeofwhatshouldbedone.(Sager&Sharma,2009). Itiswidelyreportedthatpanicisinfactrareandthatmostpeoplerespondcooperativelyandrationallyto natural and manmade disasters. So panic should never be used as a reason to withhold information or provide false reassurances (WHO, 2005b). It follows therefore that it is important not to understate the risksordismisspeoplesfearsandforofficialstoprovideclearinstructionsastothemeasuresthatshould befollowed.Politicalandeconomicconcernsmighthoweverbeatoddswithtransparency.Thishappened inChinafollowingtheSARSoutbreakwhenthesituationwasreportedlycoveredupduringtheinitialstages directlyhinderingtheresponseandhavinghugeimplicationsfortherestoftheglobe(CIA,2003).

8.8MediaReporting
The media can have a significant impact on public perception. Not only do they reflect public views on certainissues,buttheyalsotellsocietywhattothinkaboutit.Inthisway,themediacanimpactbothhow thepublicperceiveasituationaswellastheirperceivedviewofhowwelltheauthoritiesarerespondingto asituation,regardlessofwhatthefactsmaybe 26

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 ClaimsbyGermanyin2011,thattoxicSpanishcucumberswereresponsibleforadeadlyoutbreakofE.coli. resultingin14deathshadadramaticeffectonSpainsexportofthesetwoproductsandbadlydamaged thereputationofSpanishagriculture.Thisisdespitetheclaimsneverbeingsubstantiated(Rainsford,2011). It is difficult to quantify to what extent the media influence attitudes and behaviour, but it is generally acceptedthatitwilldependonthesocialcontextinwhichmessagesarereceived(Powell,Chapmanand Blaine, 2004) the extent to which the issue resonates with the public, as well as the availability of alternative sources of information. It is also argued that the public form beliefs rapidly, and that once formedtheyrationaliseawayinformationthatconflictswiththatbelief.Therateatwhichthesebeliefsare thoughttobeformedwouldsuggestthatthespeedofresponsebyofficialinformationsourcesisinturn vitalforensuringthatthedesiredmessageisbeingwidelydisseminatedquickly,soastocontendwithany inaccurateorunhelpfulmediareporting. Despite public scepticism, in a crisis the media do however act as an important source of public health information,anditisreportedthatthevolumeandfocusofmediareportingcanmorespecificallyinfluence theperceivedefficacyandsubsequentuptakeofrecommendedbehaviours(Rbin,Potts &Michie,2010). Thisclearlyhassignificantimplicationsforthemanagementandcontainmentofoutbreaksituations. Some reports (Powell, Chapman and Blaine, 2004) do however suggest that in a crisis situation there is greatercooperationbetweenindustry,governmentagencies,themediaandthepublicandthataccessto trainedspokespeoplecanimprovetheaccuracyofmediamessages.

9. CurrentPandemicPlans
9.1Whyplan?
TherearemanyreasonswhyGovernmentsandorganisationsputinplaceplansforapotentialpandemic. Effectiveplanningmayhelptoreducetheimpactofapandemicandsubsequentlydecreasehospitalisation and deaths. Preplanning that considers how resources are going to be deployed with reduced staffing levels should also enable organisations to maintain critical services. This in turn may help to reduce the massiveeconomicandsocialimpactthatapandemicmighthaveacrosstheglobe(WHO,2005b).Lackof preparation and planning is likely to result in a poorly coordinated and ineffective response that fails to meet the challenges posed by an outbreak situation. It is generally accepted that the benefits of preparationfaroutweighsthecost(Hine,2010). So, aside from the obvious social and moral responsibility to plan, putting in place arrangements to deal withsuchapotentiallydisruptiveeventisbasiccommonsense.Goodpreparednessdictateshoweverthat we should be continually striving to improve the arrangements that we have in place and identify opportunities for development (Hine, 2010). Lessons must be learned from previous events to improve crisisplanningforthefuture?

9.2Risk&CrisisCommunicationPlanning
Somewhatsurprisinglyveryfeworganisationshaveprepareddetailedcrisisandriskcommunicationplans in the same way that they have prepared other contingency plans. Given the importance of communications in an outbreak situation, crisis communications plans should be thought through and developed in relation to all elements of outbreak response, rather than as an add on or after thought 27

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 (WHO,2005a).Itshouldalsobeseenasaseparatetasktotheactualmanagementanddecisionmakingof thecrisis(WHO,2004). In addition to developing plans for communication among agencies, health communicators also need to developaplanforcommunicatingwiththepublicduringahealthemergency(JHSP,2011). In their review of the BSE crisis it is also concluded (Harris & OShaughnessy, 1997, p.37), that the UK Governmentdidnothaveastrategicplannedapproachtopublicrelationsmanagementineitherthefood industryorelsewhere.ThismeantthattherewasnoplanforcommunicationofthefactsonBSEandlittle evidence of sustained media management, instead there was a reactive response by government which wasoftencontradictory. Appropriate spokespeople need to be identified and trained prior to a crisis with consideration given to positions and personalities who will be most acceptable and effective at getting messages across to the public(WHO,2010).Withhealthprofessionalsatlocalandregionallevelsremainingwellregardedsources ofinformation,plansshouldalsostrivetoensurethatkeepingprofessionalsatthislevelinformedisakey priority. Arrangements also need to ensure a fast flow of information between different levels of the response alongside a sufficiently rapid public response as soon as a situation develops (WHO, 2010). This is particularly important given the speed ofother reporting networks, such as the media and Social Media, whichwillbequicktopickuponanylocalisedoutbreaks. ItissuggestedthatSurveillanceNetworkscouldimprovethespeedandqualityofdatathattheygenerate by incorporating newer approaches such as immunological assays and school/work place absenteeism rapid molecular diagnostic assays, ad hoc syndromic surveillance systems , school and work place absenteeism registers, hospital admission data, sentinel surveillances, which may then enable an increasinglyrapidresponse.Itisalsosuggestedthatsurveillancenetworkscouldalsobeusedasvehicles forprovidingpublichealthmessagesandadvicetopractitioners,Organisations(schools)andthegeneral public(Chengetal.,2009).

9.3SocialMedia
Traditionalcommunicationshavebeenfairlyhierarchicalinnature.Socialmediachangesthis,openingupa two way conversation between officials and the public ,It is no longer possible to simply communicate offline via information sheets, press conferences and press releases (EC, 2010, p9). In this report, the EuropeanCommission,makeclearrecommendationsthatmoreorganisationsneedtofollowtheleadof CDC during the 2009 pandemic by firmly embracing Social Media as part of their crisis communications strategy. As part of this process, and in order for organisations to establish themselves as a credible and trusted sourcewithanengagedandcaptiveaudience,theyneedtodeveloptheirprofilesandsocialmediastatuses beforeapandemicoroutbreaksituationoccurs(EC,2010).

9.4Preparedness,FlexibilityandScale
Basedonthelessonsofthe2009outbreakwhentherewasconsiderableuncertaintyovertheimpactofthe diseaseandnatureoftheoutbreak,Hine(2010)emphasisestheimportanceofbuildinggreaterflexibility 28

D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 into planning arrangements. Hine acknowledges that even with improvements in evidence gathering and scientificadvice,andaswithmanycrisissituations,decisionswillstillhavetobemadewithoutknowingthe fullfactsofthesituation,akeyfeatureofcrisismanagement.Notonlythis,certainlyintheUK,the2009 pandemicresponsewasfoundtohavebeeninsufficientlyflexiblewitharrangementsverymuchfocusedon aworstcasescenariothatweredifficulttoscalebacktofitthelessseveresituationthatwasunfolding. Hine (2010) suggests that there are two options available when responding to future pandemics: 1) respondingbasedonthehighendoftheplanningassumptionssetoutintheNationalFrameworkandthen scaling back as more information is established or 2) making calculated judgements based on the information and evidence available and resource the response accordingly. Whilst this would help to ensureamoreproportionateresponse,underestimatingtheseverityofthesituationcouldleavetheHealth Serviceunabletocope. TheWHO(2010)alsorecommendthatagenericplanframework,containingchecklistsappropriatenotonly foraworstcasescenario,isdevelopedthatcanbeappliedflexiblytothesituationasrequired,ratherthan developingextensivelydetaileddocumentation.Itissuggestedthatthiswillhelpresponderstoadapttoa changingsituationasrequired.Theprincipleofdevelopingagenericplanthatcanbeappliedflexiblyhas longbeenrecognisedasakeytenantofgoodcrisismanagement. Exercisesimulationstoachievefamiliarityandfacilitateplandevelopmentalsoneedtobeincorporatewith planningactivities(WHO,2010). Thereareawiderangeoffactorsthatcouldleadtodecreasinglevelsofpublictrustinofficialsduringan outbreaksituation.Notleasttheuncertainandchangingnatureofthesituationthatmayportraythosein chargeasincompetent.Preparednessplansshould thereforealsoanticipateandprepareforthe need to rebuildpublictrust,particularlywithvulnerablepopulations(Vaughan,Tinker,2008). AnotheraspecttoconsiderishighlightedinDameDiedreHines(Hine,2010)reviewoftheUKsresponseto the 2009 Influenza pandemic, where it is reported that planning assumptions and worstcase scenario figures,whichwerepubliclyreleasedtofacilitateemergencyplanningactivities,werewronglytakentobe predictionsratherthanplanningfigures.Shegoesontorecommendthereforethatworkshouldbecarried outtoreviewhowplanningscenariosarereleasedandusedinpublicinthefuturetohelpensurethata balanced and realistic reasonable worstcase scenarios can be developed. This may help to avoid any futureperceptionsofoverreactionorhypingup. Pandemicpreparednessneedsofcoursetobesupportedbyappropriatefundingtoensureactivitiescanbe sustained(WHO,2010).

9.5ModelsofRiskandCrisisCommunication
As described in this report, crisis and risk communication needs to consider many different technical, psychological,sociologicalandculturalperspectivesinordertounderstand,anticipateandrespondtothe needsofthepublicinrelationtovariousrisks.Therearemanycomplexinterrelated,aswellasunrelated, and sometimes conflicting issues that need to be considered by those responsible for health communications. As to be expected, the development of conceptual frameworks and tools to assist with thisprocesscontinuestobeconsideredimportant.

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D1.2ReviewofCrisisCommunications TELLMEprojectGA:278723 The Centers for Disease Control and Prevention (CDC) have developed an integrated model, or tool, to providehealthprofessionalswithaframeworkforemergencycommunications.Thetoolisreferredtoas Crisis and Emergency Risk Communication [CERC] and was developed in response to the everincreasing expectations and challenges that fall upon public health professionals for communications in a crisis situation (Veil, Reynolds, Sellnow, & Seeger, 2008). Whilst it is recognized by CDC that more work is needed to develop CERC, the model provides a systematic and structured approach to crisis and risk communication reflecting the closely interrelated nature of these two disciplines, and thousands of individuals have already been trained in CERC via a variety of methods. Not only does the model bring togetherawiderangeofmethodologiesandapproaches,italsorecognizestheparticipatorynatureofcrisis andimportanceofgivingpeoplesomethingtodoinordertoencourageselfefficacyandreducefeelingsof anxietyandpowerlessness.Importantly,italsosetsoutcommunicationactivities,strategiesandoutcomes that can be applied at a practical level by the health professional dealing with crisis communications. Anotherexampleofamodelormodelsthatstrivetolinkboththetechnicalassessmentofriskwithwider psychological, sociological and cultural perspectives of risk and risk perception in order to gain a better understanding of public response to risk is presented by Kasperson, et al (1988) who aims to provide a structuraldescriptionofthethesocialamplificationofrisk. Howeverhelpfultheseorothersimilarmodels,itisnonethelessargued(Backer,Rogers&Dopory,1992) thatnoonemodelwilltotallyfulfiltheneedsofallpubliccommunicationcampaignsandcanonlybeused asaguidingtoolcombinedwith,andvalidatedby,practicalexperience.

9.6IdentifyingStakeholders
Plansneedtobemadefromtheperspectiveofthosetheytargetandsensitivetotheneedsandchallenges oftheaudience.Misconceptionsandunrealisticassumptionsarebarrierstosuccessfulimplementationof strategies, which no matter how good they are need also to consider the life circumstances and communicationneedsthatinfluencedecisionmakingandbehaviour(Vaughan&Tinker,2008).Inorderto achievethis,stakeholdersneedalsotoberepresentedduringtheplanningprocess(WHO,2010). ItisarguedthatduringtheBSEcrisis,thegovernmentdidnotunderstandthedifferentstakeholdersthat needed to be communicated with. To address this Harris and OShaughnessy (1997, p.37) emphasise the needtobuildontheprinciplesofGrunigandRepper(1992): Identifying,analyzingandmappingstrategicallyimportantstakeholderrelationships. Identifying those stakeholder groups who are affected by, or whose actions may affect, the organization,andwhoareaffectedbytheissue. Anticipating the likely emergence of issues that may arise out of the organizations relationship withitsvariousstakeholders.

9.7EUCoordination&Leadership
A major outbreak situation, such as an influenza pandemic, requires significant and prolonged central governmentcoordination.Beyondthis,italsorequiresmultisectoralandinternationalcoordination(Hine, 2010). Strong leadership is required not only during a pandemic response but also during the pandemic planning stage. Multisectoral engagement and coordination is also required (WHO, 2010) with international planning and interoperability between countries and regions to achieve consistency and coordination. It has also been identified by EMA that communication activities need to be better coordinated among the main EU stakeholders (EMA, 2011). This coordination should include the developmentofkeymessagestohelpachieveconsistencyofmessages(WHO,2010). 30

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CONCLUSIONSANDRECOMMENDATIONS
The World Health Organization (WHO) believes it is now time to acknowledge that communication expertisehasbecomeasessentialtooutbreakcontrolasepidemiologicaltrainingandlaboratoryanalysis. Theaimofgoodoutbreakorcrisiscommunicationsmustbetosuccessfullyinstruct,informandmotivate the public to adopt appropriate selfprotective behaviour whilst also building trust and confidence in officials, dispelling myths and rumour and ultimately acting in partnership with the authorities overall strategy. Pandemic outbreak communications involves three distinct areas; the source i.e. those who compose messages,themediaandthemeansbywhichthemessagesarecommunicatedandtheaudiencesorpublic who receive them. Many issues or factors impact all three areas including some which may appear intangibleatfirstbutwhichareneverthelessofcrucialimportancesuchastrustwhichisbuiltonhonesty, clarity,consistencyandtransparencyandwhichmeetstheneedsofthepublic.Type,toneandterminology usedforthemessagesandthetimingandmeansbywhichtheyarecommunicatedalsoplaytheirpartas donewtechnologiessuchasSocialMedia. Publicacceptanceandbehaviouralresponsewilldifferdependingontheaudience,theirculture,faith,their trustintheauthorsofadvice,theirknowledgeandunderstandingofapandemicanditsrealorperceived risks. The influencing factors are many and at times counter balancing (Figure 4). It is apparent that the Health Communicators strategy will benefit from not only taking into account these many and varied influencingfactorsbutalsouseallthecommunicationchannelsandmediumavailableinordertomeetthe varyingneedsofthepublic.

Public Acceptance?

Knowledge Timing Trust

Perception Media Source

Internet Blog Twitter Facebook

Risk Myths Culture Audience

Figure4Someofthemanyfactorsthatwillinfluencepublicacceptance

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