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Conceptual framework for risk communication between emergency response

team and management team at healthcare facilities: A Malaysian perspective
Article in International Journal of Disaster Risk Reduction · August 2019

DOI: 10.1016/j.ijdrr.2019.101282
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Ab Aziz, N. F., Akashah, F. W., & Aziz, A. A. (2019). Conceptual framework for risk
communication between emergency response team and management team at healthcare
facilities: A Malaysian perspective. International Journal of Disaster Risk Reduction,
101282. doi:https://doi.org/10.1016/j.ijdrr.2019.101282
Conceptual Framework for Risk Communication between Emergency Response

Team and Management Team at Healthcare Facilities: A Malaysian Perspective
Nur Farhani Ab Aziz a, Farid Wajdi Akashah a, b, *, Aniza AbdulAziz b, c
a
Department of Building Surveying, Faculty of Built Environment, University of Malaya,
50603 Kuala Lumpur, Malaysia
b
Centre for Building, Construction & Tropical Architecture (BuCTA), Faculty of Built
Environment, University of Malaya, 50603 Kuala Lumpur, Malaysia
c
Department of Architecture, Faculty of Built Environment, University of Malaya, 50603
Kuala Lumpur, Malaysia
*Corresponding author: faridakashah@um.edu.my
The requirement to establish a Disaster Risk Management Plan (DRMP) and Emergency
Response Team (ERT) in Malaysia is stated in the Occupational Safety and Health Act
1994. DRMP provides first responder such as ERT a standard operating procedure (SOP)
when assisting evacuation and performing search and resuce. In performing such tasks,
ERT requires sufficient information outline in the DRMP and other risk communication
activities that are conducted by the management team. However, past fire incidents at
public hospitals in Malaysia shows that the current practice of risk communication at
public hospitals does not facilitate the ERT's decision-making process. This paper
intends to propose a conceptual framework of risk communication that can guide the
management team at public hospitals in delivering information regarding fire safety to
the ERT to ensure its effectiveness. Standards on disaster risk management, public
hospital's contingency plans, and past research were reviewed. This framework provides
an overall idea of how the decision-making process is made among the ERT members.
This shows the involvement of risk communication and risk perception that can affect
the ERT's judgement and actions taken during the response phase. Findings of this paper
include factors that address people’s perception towards risk and elements of risk
communication that should be considered to develop and improve risk communication
policy.
Keywords: Disaster Risk Management Plan, Emergency Response Team, risk

communication, risk perception
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1 Introduction
In Section 15(2)(c) of the Occupational Safety and Health Act Malaysia, it is stated that
an employer should provide the information, instruction, training, and supervision to the
employee regarding safety and health at a workplace. The phrase ‘provide the information’
refers to the requirement to establish the DRMP and ‘training' is the activities that can be
conducted by the hospital's management to deliver the information about risk. While in Section
30(1)(a) state that it is compulsory to establish a safety committee in an organisation with more
than 40 employees. The safety committee in this section refers to the Emergency Response
Team (ERT). ERT acts as the first responder who responds to any disaster incidents including
fire incidents. ERT can effectively perform their task if they receive adequate information
about risk. This information may come from the Disaster Risk Management Plan (DRMP)
developed by the hospital’s management team and any activities conducted. The process of
information delivery is known as risk communication. Risk communication is defined as an act
of exchange of information about risk between an interested party. The goal of risk
communication is to raise awareness, encourage protective behaviour, build up knowledge on
risks, inform how to behave during a disaster, enable mutual dialogue, reassure the audience,
and improve the relationship (Gamhewage, 2014).
All public hospitals in Malaysia do develop a DRMP. The common information
provided in DRMP is the standard operating procedure (SOP) to response, evacuate, evacuate
ambulatory and non-ambulatory patient, evacuation strategy, and ERT’s responsibility.
However, the plan only majorly focuses on the external disaster plan and not much on the
internal disaster plan. Plus, the internal disaster plan is too general where no standard procedure
to response for specific types of disaster is included. Furthermore, no contingency plan for a
specific department is established. The common risk communication activities conducted by
the hospital's management team is table-top exercise and drill. The frequency of activities is at
least once a year (Hospital Kuala Lumpur, 2011; Hospital Raja Perempuan Zainab II, 2018;
Hospital Seri Manjung, 2016; Hospital Sultanah Aminah, 2011; Sibu Hospital, 2014). The
inadequacies of the hospital’s DRMP and activities conducted is also noted by Samsuddin,
Takim, Nawawi, & Syed Alwee, (2018). They rank the criticality of training (activities) and
human resource as the most critical attributes. While DRMP and emergency management SOP
as the third and fourth most critical attributes in Malaysian hospital’s disaster preparedness
respectively. Other than these two attributes, other attributes related to the functionality of
hospital’s disaster management which were noted as very critical are emergency management
guidelines, communication network and information management, alarm, safety, and security,
and emergency operation system.
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The weakness of hospital’s DRMP itself in providing the information to the ERT, and
information dissemination through risk communication activities is the root of the problem as
to why the ERT is unable to effectively respond to a disaster. This situation can be exemplified
by a previous Malaysian hospital’s fire disaster. In 2016, a fire incident occurred in an ICU
ward at a hospital in Johor Bharu resulting in six fatalities and 11 injuries. All the deceased
were patients while one of the injured was a hospital staff. It was reported that the patients were
unable to be evacuated due to rapid-fire and the patient's critical condition as they were
connected to breathing equipment (Astro Awani, 2016). With respect to this hospital’s DRMP,
the training with ERT is conducted once a year and no information on the procedure to evacuate
patients with a ventilator is included (Hospital Sultanah Aminah, 2011). This shows that the
current risk communication practice in Malaysian hospitals is unable to provide adequate
information to the ERT to facilitate their decision-making process during fire events. Hence,
this paper will propose a conceptual framework of risk communication focusing on healthcare
facilities as a first step to improve disaster risk management in Malaysian public hospitals. The
purpose of this conceptual framework is to facilitate the management team to deliver an
effective risk communication to the ERT.
2 Methodology
This paper has anchored on extensive literature review articles, chapters, books, news,
standards, and official release documents. A total of 336 articles, books, and documents were
downloaded and collated from highly-regarded databases in the built environment, social
science, and public health, such as Science Direct, Wiley Online Library, and Taylor and
Francis. After screening, 113 articles were found to meet the criteria for selection and thus were
reviewed for evidence synthesis. The articles were selected based on three criteria: 1) risk
communication, risk perception, and risk management, 2) fire safety information, and 3)
disaster management in general and in healthcare facilities.
3 Theory of risk communication

It has been established that to develop risk communication policy, first, risk perception must
be addressed. There have been suggestions that improvement in risk communication
automatically improves risk management (Bayram, 2015; Renn, 1990; Sheppard, Janoske, &
Liu, 2012; Sjoberg, 1999). Renn, (1990) further explained this theory in an organisational
context where the management team should first recognise the result from risk perception and
developed a suitable risk communication policy that meets this concern.
In ERT context, different risk perception among ERT members exists due to different
levels of knowledge about risk. Knowledge is associated with different levels of educational
background, experience with fire incidents, and years working in the particular building. From
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these factors, the ERT will interpret the risk in terms of feelings (Doyle et al., 2014). Risk
perception often relates to negative feelings such as anger, sad, scared, and anxiety (Sheppard
et al., 2012). This negative feeling may lead the ERT to make an incorrect decision and take
unnecessary or wrong action (Doyle, Mcclure, Paton, & Johnston, 2014). Then a risk
communication policy that acknowledges this issue can be developed. The risk communication
policy should provide information that can reduce the ERT's risk perception and facilitate their
decision-making process at the response phase. The effectiveness of risk communication policy
is reflected through ERT’s performance at the response phase. The ERT’s performance will
also reflect the effectiveness in the implementation of the Disaster Risk Management Plan
(DRMP) and Business Continuity Plan (BCP).
The relationship between BCP, DRMP, and ERT is further explained in BSI 2006.
When a disaster strikes, the ERT will respond to the incident. The ERT will follow all the plans,
processes, and procedures stated in the DRMP. Plans for activation, operation, coordination,
and communication should be included. As shown in the timeline in Figure 1, the BCP is
activated between the incident response phase until the recovery phase. Early activation of BCP
could reduce the direct and indirect impact of the incident to the business. BCP will ensure
business recovery in the face of business disruption. If the ERT is able to respond effectively
where there is little destruction to the building and documents, the loss will have less impact
on the business and the recovery process can be sped up. Based on the discussed theory, a
theoretical framework is developed as shown in Figure 2.
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Figure 1: Relationship between business continuity and disaster risk management against time (Source: British
Standard, 2006)
Bottom-up approach
Risk Management
Affect the effectiveness of the
implementation of DRMP
and BCP
Risk Communication
Affect ERT’s
performances
Risk Perception
Affect feelings
Figure 2: Theoretical framework

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4 Standards for disaster risk management plan

Various standards have stated the requirement of activities to be conducted at different
phases as part of risk management processes. Four standards have been reviewed which are
BIP 2034:2008- Disaster and Emergency Management System, ISO 22320 - Societal security:
Emergency management: Requirements for incident response, NFPA 1600:2016 - Standard on
Disaster/Emergency Management and Business Continuity/Continuity of Operations
Programs, and MS 1722:2011 - Occupational Health and Safety Management Systems.
Interestingly, these standards have stated different activities at different phases with similar
requirements, which is to establish Disaster Risk Management Plan (DRMP) and Emergency
Response Team (ERT) as highlighted in red in Table 1. The activities at the preparedness phase
and information in DRMP also indicate a possible safety information and risk communication
activities that could be delivered by the management team. These activities are highlighted in
blue. Furthermore, these three standards also specifically accommodate the ERT with related
disaster risk knowledge.
Table 1: The safety requirement stated in various standards (Source: ISO, 2011; Malaysian Standards, 2011;
Moore, 2008; National Fire Protection Association, 2016)
BIP MS NFPA
ISO
Requirement 2034:20 1722:20 1600:20
22320
08 11 16
Hazard identification
Identify the source, condition, and
situation of hazard that may cause ✓ ✓ ✓
Mitigation/prevention
injury to people, and damage to

property
Risk assessment
Evaluate the level of risk of ✓ ✓ ✓
identified hazard.
Risk control
Control the source of risk ✓ ✓ ✓
through engineering measures
Establish Disaster Risk Management
✓ ✓ ✓ ✓
Information in
Preparedness
Plan (DRMP)
DRMP
Procedure to response ✓ ✓ ✓ ✓
Evacuation procedure ✓ ✓ ✓ ✓
Building evacuation plan ✓
Location of the assembly point ✓
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Contact number people within and

✓ ✓ ✓
outside of organisation
Rescue and medical duties ✓
Alternative communication centre ✓ ✓ ✓
Responsible person to shut down
✓ ✓
any critical plan operation
Establish Emergency Response
✓ ✓ ✓ ✓
Team
Distribute appropriate equipment to
✓ ✓ ✓
the personnel
Train workers with the evacuation
✓ ✓ ✓
process and response procedure
Provide workers with knowledge of
responsibilities, procedure, planning, ✓ ✓ ✓
and common terminology
Response and evacuate from the
✓ ✓ ✓
Implementing procedure in
building
Communication between staff ✓ ✓ ✓
Inform safety agencies such as
Response
DRMP
police, fire department and medical ✓ ✓ ✓

services
Management of resource ✓ ✓
Search and rescue, mitigate fire
✓
Investigate the cause of the disaster ✓ ✓ ✓
Assessment damage in economic
✓ ✓
and environmental impact
Assessment of personnel and
✓ ✓
Recovery
equipment required after disaster

Manage resource and financial ✓ ✓
Planning for reconstruction ✓ ✓
Reconstruction ✓ ✓
Review the post-disaster impact ✓ ✓ ✓
Review and reconstruct the ERP ✓ ✓
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5 Position of disaster risk management in Malaysian healthcare facilities
When a disaster strikes, a business will face losses, and this will affect service delivery.
The Malaysian government has acknowledged the importance of business continuity
management and disaster risk management. At the state level, the Malaysian State Disaster
Management Agency (NADMA) has established a Directive No. 20: National Security
Council: The Policy and Mechanisms on National Disaster and Relief Management in 1997
(NADMA, 2018). While at an organisation level, Director General of Malaysian Management
Modernization and Management Planning Unit (MAMPU) has issued an instruction letter to
implement business continuity management programmes. This implementation is compulsory
to all public sector and government listed companies including healthcare facilities. The
implementation of the business continuity programme at healthcare facilities in Malaysia is
still new having been introduced in 2010 (Jaafar, 2016; MAMPU, 2010). This programme
requires the organisation to establish a business continuity plan that covers the emergency plan,
incident response plan, communication plan, and disaster recovery plan. To date, the current
public hospital’s disaster risk management plan has covered all these plans except the
communication plan.
The standards listed in Table 1 provide an additional requirement for the building owner
in implementing disaster risk management in their organisations. However, the implementation
of these standards is voluntary. In Malaysia, a compulsory requirement in establishing DRMP
and ERT is stated in the Occupational Safety and Health Act 1994 (Act 514), OSHA 1994. Act
514 is required to be implemented in certain buildings namely (Law of Malaysia, 2014):
1) Manufacturing 7) Wholesale and retail trades

2) Mining and quarrying 8) Hotels and restaurants
3) Construction 9) Finance, insurance, real estate, and
4) Agriculture, forestry, and fishing business services
5) Utilities: electricity, gas, water, and 10) Public services and statutory
sanitary services authorities
6) Transport, storage, and
communication
The healthcare facilities fall under public services and statutory authorities. As noted
earlier, two sections that related to the requirement on the establishment of ERT and DRMP
which is Section 15(2)(c) for DRMP and Section 30(1)(a) for ERT. In Section 15(2)(c), the
requirement to conduct risk communication activities is indirectly mentioned as ‘provide
training’. Other than these two sections, Section 6(1) is another relevant section, which relates
the responsibility of building owner. It is simplified that the building owner can appoint an
individual body to advise or assist him in carrying out the requirements from this Act. This
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section directly highlights the current situation of facilities management practice at the
Malaysian public hospital, which is outsourced to the concession companies. The responsibility
of concession companies includes maintaining the building asset, maintaining medical devices,
providing cleaning and housekeeping service, providing linen cleaning service, managing both
general waste and clinical waste, and consulting building owner regarding HSS. The
consultation includes assisting building owner in developing a DRMP or Contingency Plan and
conducting training for ERT members (Bahagian Perkhidmatan Kejuruteraan, 2018). This
Contingency Plan provides the procedure to the hospital staff and HSS staff when facing
various emergencies. The situation considered as an emergency in the hospital is the disruption
of main water supply, failure of main power supply, shortage of central medical gas supply,
failure of a telecommunication system, flood, and fire.
This paper focuses on two groups namely management team and ERT. The
management team in this article is the party that delivers the information to the ERT. With
regards to DRMP in Malaysian public hospitals, the management team can be made up of the
Hospital Director, Deputy Director, Manager of concession company, and Head of Safety
Committee. As mention earlier, DRMPs in Malaysian public hospitals majorly focus on the
external disaster with little consideration of internal disaster. Thus, no ERT organisation chart
for internal disaster is published. However, a standard ERT organisation chart is shown in
Figure 3. As no ERT organisation chart for a specific department is published, the staff who
are responsible to hold the position below is unknown.
Emergency
commander
Log keeper Operation

controller
Intervention Logistic Communication

team coordinator operator
Firefighting First aid team Spillage control

team team
Figure 3: Standard ERT organisation chart (Soud, 2014)

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6 Risk communication in the context of fire safety

In disaster risk management, ERT is only involved in the preparedness phase and
response phase. At the preparedness phase, the management team is required to furnish the
ERT with knowledge on risk and any safety procedure which may be delivered through
training, workshops, and seminars. While at the response phase, the ERT will respond to the
disaster where actions such as mitigating fire, assisting evacuation, reporting the incident to
other responsible parties, and performing search and rescue processes take place. Thus, this
paper will only discuss the risk communication at the preparedness phase and response phase.
Various researchers have suggested the possible elements that should be considered to ensure
the effectiveness of risk communication. Different elements with different characteristics are
discussed for different phases. At the preparedness phase, researchers mostly discuss the
contents of information, medium of information, repetitiveness of information, and distribution
of information. While at the response phase, only the first three elements are discussed. For
contents of information, Jones et al. (2005), Li et al. (2014), and Nunavath and Prinz (2017)
have established the information needed by the ERT at three different phases. During
emergency and mitigation is included under the response phase. The summary of the findings
is tabulated in Table 2.
As for the medium of information, various preferable mediums required by the ERT at
the preparedness phase have been reported. Jones et al., (2005) and Li, Yang, Ghahramani,
Becerik-Gerber, & Soibelman, (2014) found that the ERT required more information in graphic
formats such as figures and/or drawings. Information in verbal, numerical, and/or text formats
were less preferred because they require an interpretation and sharing process. But Breakwell,
(2007) argued, the information delivered verbally (face-to-face) is more effective compared to
audio media and textual medium. While at the response phase, Jones et al., (2005) suggest that
the information should be delivered in graphic and audio. Information to be delivered in the
graphic is information that is related to building plans and information to be delivered in audio
format is the information that can be communicated through a communication device (walkie-
talkie) such as the condition of building structure, number of victims found, condition of
victims, and current status at incident point.
While for repetitiveness, Breakwell, (2007) state that information should also be
repeated over time to familiarise people with the contents. A common repetition rate practiced
at the preparedness phase is once a year. While at the response phase, no specific repetition
rate is found. However Rød, Botan, & Holen, (2012) mention that the information at response
phase must be delivered in a timely manner, up-to-date, and accurate between the active parties.
Lastly, regarding the distribution of information, Sellnow, Ulmer, Seeger, & Littlefield, (2009)
has suggested to locate the information around the buildings. They further added that the
information should be posted at locations where it is more accessible by building occupants for
both the staff and visitors.
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Table 2: Information required by ERT before the incident, during the incident, and at
the mitigation phase
Nunavath
Time to Jones et Li et al.
Information provided & Prinz
deliver al. 2005 2014
2017
Building occupancy ✓ ✓ N/A
Building layout and site plan ✓ ✓ N/A
Location of water sources ✓ N/A
Contact information of
managers, building owner, ✓ N/A
Before the and utility
emergency/ Routing information and
✓ ✓ N/A
Static map of the neighbourhood
information Location of possible hazard ✓ ✓ N/A
Location of an important
✓ N/A
document to be saved
Generators power, and
mechanical and electrical ✓ N/A
system
Location of fire, size of the
✓ ✓ ✓
fire, and duration
Presence and location of
✓ ✓
building occupants
Condition of victims ✓ ✓
Sprinkler status ✓ ✓
Status of mechanical system ✓
Location and condition of
✓ ✓ ✓
smoke
During an
Status or condition of the
emergency ✓
building structure
Building floor direction i.e:
✓
south, north, west, east.
Location of fire-fighter ✓
Resource available from
fire-fighter
Location of triage ✓
Exposure of threat to nearby
✓
buildings
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Required water flow or

✓ N/A
foam-based
Location of the available
✓ N/A
refuge area
Mitigation Location of standing-by area ✓ N/A
Weather condition ✓ ✓ N/A
Location of the exit sign ✓ ✓ N/A
Information on emergency
✓ N/A
agencies
(Source: Jones et al. 2005; Li et al. 2014; Nunavath and Prinz 2017)
7 Factors influencing risk communication
7.1 Knowledge, familiarity, and experiences
Knowledge is found to be related to risk perception and risk communication. In risk

communication, knowledge can affect people’s decision-making process. When people are
faced with risk, they require sufficient information to take action. This information may be
received at the preparedness phase on procedures and process, and response phase on current
updates regarding the incident.
While in risk perception, knowledge can affect people’s judgement towards risk.
Research shows that people who have knowledge about risk will judge the risk as low. But this
depends on the source of knowledge. There are three sources of knowledge, which are
experiences, familiarity, and classes and training. Experiences related to experiences with
evacuation procedures and emergencies. Experience may cause people to have both either low-
risk perception or high-risk perception. Lovreglio, Ronchi, & Nilsson, 2015 found experience
can increase the level of preparedness among ERT and will influence ERT’s interpretation and
decision-making process. Kinateder, Kuligowski, Reneke, & Peacock (2015) on the other hand
found that knowledge gains from disastrous experience that lead to negative feelings may cause
people to perceive risk as high.
Familiarity denotes familiarity with the building layout. Studies have found that
occupants who are familiar with the building layout will evacuate faster because they know the
route and exits available in the building (Kobes, Helsloot, de Vries, & Post, 2010; Korhonen,
2011; Proulx, Laroche, Jaspers-Fayer, & Lavallee, 1993; Sagun, Anumba, & Bouchlaghem,
2013). In ERT context, familiarity with building layout could ease access to the location of the
incident, M&E control room, command centre, and control the occupant’s movement during
evacuation (McElvaney, 2013). The research found familiarity with the building environment
and building emergency plan make people develop positive feelings thus low-risk perception.
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But, it may change due to age, gender and level of knowledge (Alkhadim, Gidado, & Painting,
2018; Renschler et al., 2016).
Lastly, classes and training refer to risk communication activity conducted by the
management team as an effort to deliver knowledge about risk to the ERT. Kinateder et al.,
(2015) found the effect of training towards risk perception inconclusive. But, they argue that
people’s severity on perceiving risk can ensure the effectiveness of training and training is
proven to be able to directly affect people behaviour during evacuation. Training is found to
increase the level of preparedness and alertness towards fire cues. In Malaysia, classes and
training are organised by the management team of an organisation by outsourcing to the Fire
and Rescue Department of Malaysia, FRDM. These classes and training educate the staff on
the basic theory of fire safety, rules and regulations, training in handling an emergency, training
in mitigating fire, and training in handling fire equipment (Fire and Rescue Department
Malaysia, 2013). Level of knowledge is closely related to risk communication policy as it
involves information sharing process.
7.2 Trust, confidence, and credibility
Trust is cited throughout the literature as a factor that may affect risk management, risk
communication, and risk perception. In risk perception, trust towards people who deliver the
information is emphasized, while in risk communication, trust towards information delivered
is the concern because it depends on the method used. Trust in risk perception may develop
trust in risk communication which leads to trust in risk management known as cooperation
(Slovic, 1999). A similar concept of the relationship between types of risks and trust was
developed by Earle, Siegrist, & Gutscher, (2007) in their Trust, Confidence, Cooperation
(TCC) model. They relate ‘trust’ with ‘confidence’ and the relation between these two elements
then will create ‘cooperation’ in risk management. In this model, they indicate that people are
making a judgement based on the available information and decide whether to developed trust
or confidence towards the communicator and the information received. Trust value similarly,
depends on shared values between inter-organisational members. While confidence value
experience in the long-term depends on the institution past performances and/or expectations
for future performances. They stated that long-term trust may lead to confidence that will
develop cooperation within the organisation to manage the risk within their facilities and
business.
Trust and confidence in risk communication are influenced by the credibility of the
source and reliability of the information. The credibility of the source is related to the credibility
of information delivered to the audience. Kinateder et al., (2015) and Renn & Levine, (1991)
defined the credibility of a source in terms of information processing which rely on the source
of information and performances of informants. For the source of information, Renn and
Levine (1991) understand that people will judge the information based on i) objectivity—
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perceived lack of bias in information, and ii) faith—perceived good intention. Kinateder, et al.
(2015) only consider one factor in judging the information which is through the origin of the
source. They believed that if people received the information from a trustworthy source and
informant, they will have low-risk perception. As for performances of informants, Renn and
Levine (1991) hypothesised that people will judge the source as credible if they developed their
trust towards the informants. Trust depends on the informants' i) competency—the level of
technical expertise, ii) fairness—acknowledge others relevant point of view, and iii)
consistency—experience with past communication effort. Kinateder, et al. (2015) have a
similar opinion. They indicate that trust towards the informants is influenced by their
competency, and experience and past performances.
In ERT context, the information delivery ensues at the preparedness phase and response
phase. For the former, the information is delivered by the management team and for the latter,
the communication only between the ERT members at the command post and incident point.
Trust towards information and informants at the preparedness phase is always lacking as the
information comes from various sources and informants. The ERT require time to evaluate the
information before trusting the information. Management team’s constant performance in
sustaining the safety culture within the organisation plays important roles in gaining trust
among ERT (Santos-reyes & Beard, 2001). Compared with risk communication at response
phase, trust is easier to be gained as the information only come from the instruction by Incident
Commander at the command post and the real-time information from ERT members at incident
point (Rake, 2018).
7.3 Voluntary and willingness
Researchers in risk communication and risk perception state that voluntary and willingness
can affect people’s perception towards risk (Alhakami & Slovic, 1994; Arru et al., 2016;
Barnett & Breakwell, 2001; O’Neill, 2004; Renn, 2004). Their perception reflects their reaction
towards particular hazards and their ability to deal with those risk (O’Neill, 2004). Alhakami
& Slovic (1994) defines voluntariness as a willingness to take the risk while considering the
level of benefit they will acquire. Chauncey, (1969) defined voluntary as a decision made by
an individual which based on his evaluation of experiences, while involuntary activity is where
individual options are determined by an organisation or body. The definitions put forth by
Chauncey (1969) are significant with the situation faced by ERT. ERT's are faced with high
risk and gain the least benefits when performing tasks during fire situations. This may lead to
an unwillingness to perform their task. Unwillingness is also caused by involuntariness to join
the ERT. In some organisation, members of ERT are chosen by the management team itself
instead of the staff voluntarily electing to join the team. Voluntariness to work among ERT is
important as people who voluntarily take the risk will have the low-risk perception (Barnett &
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Breakwell, 2001). This leads to a low level of anxiety because these people describe the risk
as not threatening. When people are consumed with anxiety during an emergency, it could
impair their ability to make judgement thus affecting the decision-making process during fire
emergency (Lu et al., 2016).
8 Discussion
The effectiveness in delivering the information about risk to an individual is affected by

the risk communication elements such as the source and contents of the information and the
characteristics of the audience (Bockting, 1995; Breakwell, 2007; Breakwell, 2000; McCallum
& Heming, 2006). The framework in Figure 4 has listed the possible risk communication
elements to be considered at both the preparedness phase and response phase. Both phases
should consider the contents of the information and repetition in delivering the information.
The contents at both phases vary. Roughly, the contents are as illustrated in Table 1 and Table
2. Additional information such as evacuation strategy, different types of patient evacuation
procedures, response procedure, secure patient’s information data, and location of refuge area
can be delivered at preparedness phase in a situation at healthcare facilities (Landesman, 2005).
Repetition rate in delivering the information is considered as it can facilitate people’s memory
to familiarise themselves with the contents of information (Breakwell, 2007).
Other than these two elements, the format of information and location are chosen to
distribute the information is important as well. The literature findings in Section 6 has
extensively discussed the effective and preferred format chosen by the ERT. Findings in
Section 4 also show the possible activities to be conducted by the management team in
improve/increase/ensure the effectiveness of risk communication. Based on these findings, it
is possible to suggest that information delivery in training that involve both verbal explanations
and physical activity is able to increase the effectiveness of risk communication. Other than
training, certain contents of information are suggested to be delivered diagrammatically (i.e.
emergency building layout), in writing (i.e. response procedure, evacuation procedures,
emergency contact information), or verbally (i.e. information delivery in class, or talk). The
contents of the information in these three formats can be distributed to the ERT members and
building occupants by placing the information around the building. Sellnow, Ulmer, Seeger, &
Littlefield (2009) advice that the information should be posted at the location where it is more
accessible by building occupants, staff and visitors.
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Figure 4: Proposed conceptual framework
These four elements in delivering information may be able to give effectiveness in risk
communication. However, persuasion and motivation from the management team to instil
safety culture among the ERT are vital as well. The motivation and persuasion comes from the
effort made by the management team in delivering safety information by understanding
people's view towards risk, people’s needs from the information, active participation in
monitoring the safety performance, clear demonstration on managing the risk, and active
involvement from both parties (Abunyewah, Gajendran, & Maund, 2018; Furness & Martin,
2007). This is the reason why possible mediating factors and risk perception are included in
this framework. The mediating factors and risk perception could alter an individual’s
judgement as people’s judgement requires an interpretation process from what they see and
what they feel (Chionis, 2018; De Weerdt, 2005; Tancogne-Dejean & Laclémence, 2016).
Three possible mediating factors were found in the literature. The effect of these factors
towards risk perception are discussed below.
Knowledge: Knowledge may come from available information, experiences, and

familiarity. Available information at the preparedness phase is the information received
by the management team and at response phase information is collected through
information exchange between ERT members. Familiarity refers to familiarity with
building layout especially evacuation routes. While experiences refer to experience in
any fire incident and the evacuation process at the current building or any other
building. According to Siegrist & Cvetkovich, (2000) and Sjoberg, (1999), an
individual with an adequate level of knowledge could judge the risk as smaller. Thus,
generating positive feelings.
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Trust: Trust with sub-categories of credible source and reliability of information

depends on the source of information, the performance of informants, and level of
knowledge. An individual who has a low level of knowledge will have high-risk
perception and will depend on their trust towards informants and information received
to take action (Earle, 2010; Katsuya, 2002; Siegrist, 1999). An individual who trusts
the information and informants will generate positive feelings (Slovic, Flynn, &
Layman, 1991). Trust towards management team (informants) and information itself
can be gained through transparency in information sharing, informant's consistent
performance in delivering credible information, management team's long-term
performance in managing risk, and practicing two-way communication by allowing all
audience to participate in policymaking (Engdahl & Lidskog, 2014; Palenchar & Heath,
2007).
Voluntary: Voluntarily electing to be part of the ERT team can be considered as part of
voluntary acceptance of the risk. Tasks conducted by ERT members are risky as any
disaster is full of risks. People who are willing to accept the risk will have low-risk
perception and are thus able to perform their task effectively (Barnett & Breakwell,
2001). Voluntarily taking depends on the level of knowledge, risk perception, and
indirectly associated with the level of trust. Sharing reliable information and providing
more training could change people's perception towards risk and foster trust among the
participating parties. Thus, will increase people’s voluntariness to be part of ERT
(Earle, 2010; Gamhewage, 2014).
The final aspect of the decision-making process is taking action. As mentioned earlier,
risk perception could affect people's judgement thus, influencing their behaviour in responding
to an event. According to Savoia, Lin, & Gamhewage, (2017), an individual who is able to
understand the information will take action towards self-protection and survival. Therefore,
there are two possible outcomes for testing the effectiveness of risk communication strategy
delivered to ERT, which are responsive behaviour that follows the standard of procedures
stated in DRMP as positive outcome or behaviour that cause failure in response and evacuation
process as a negative outcome. Alexander, (2015) has suggested exercises, drills, and field-
based simulation as some of the ways for testing the effectiveness of DRMP as well as risk
communication strategy.
Five Malaysian hospital’s DRMP which available online was reviewed. All the
information listed in Table 1 (information in DRMP) are included in these five DRMPs except
alternative communication centre, and responsible person to shut down any critical plan
operation. Additional information such as SOP to evacuate patients, ERT’s organisation chart
and responsibilities is included as well. But the ability of these DRMPs in providing the
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information to ERT is weak, also the information dissemination at preparedness phase.

Referring to the framework, the information delivery at the preparedness phase is the first step
to ensure the effectiveness of risk communication. Considering the staff turnover rate, a
standardised DRMP in terms of i) contents of information i.e. DRMP for specific department,
evacuation strategy, location of assembly point, ERT’s responsibilities, ERT’s organisation
chart, contact number related authorities, SOP to response, evacuate, and evacuate patients,
etc., and ii) format of information i.e. procedures in flowchart, procedures to evacuate patients
in graphic, ERT’s responsibilities in table, emergency contact in writings, etc. for all public
hospitals should be established. This is to familiarise the hospital’s staff with the information
delivery method and flow of emergency procedures. Certain information such as the location
of assembly point, building layout, types of risk may differ, but it will give similar contents of
the information in DRMP. Furthermore, the frequency of delivering the information should be
more than once a year and more types of risk communication activities should be conducted to
enhance ERT's ability in making a decision during emergency. Possible risk communication
activities are drill, talk with visual aids, learning techniques of role-plays, demonstration, and
scenario-based learning (Renschler et al., 2016).
9 Conclusion
The use of risk communication in disaster risk management has been shown to have a
lot of contribution to reducing disaster risk impact. Thus, a conceptual framework for risk
communication was established in this paper. Four elements were included which are contents
of information, the format of information, information distribution, and repetition rate in
delivering the information. These four elements are suggested to assist the management team
in delivering the information to the ERT. In ERT context, the concept of giving more
information to ERT at the preparedness phase will improve their performance during the
response phase in facilitating their decision-making process. This hypothesis implies certain
factors and with consideration of their risk perception. Three factors were discussed in this
paper, which are the level of knowledge, level of trust, and voluntary. The implementation of
this risk communication framework in Malaysian healthcare facilities along with the suggestion
made in the previous section could help the management team to plan an effective information
delivery plan to the ERT. The implementation of a risk communication plan can be considered
effective if the ERT is able to perform their task according to the information received during
fire emergency response. However, this suggestion is implying with other factors such as
education background, working experience in public hospitals, and working experience at a
certain department. These factors will help the ERT to be familiar and able to understand the
information delivered in DRMP.
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Conceptual framework for risk communication between emergency response

Article in International Journal of Disaster Risk Reduction · August 2019

Nur Farhani Ab Aziz Farid Wajdi Akashah

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Classification of purpose built offices in Malaysia 2010 View project

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Conceptual Framework for Risk Communication between Emergency Response

Keywords: Disaster Risk Management Plan, Emergency Response Team, risk

3 Theory of risk communication

Figure 2: Theoretical framework

4 Standards for disaster risk management plan

injury to people, and damage to

Contact number people within and

police, fire department and medical ✓ ✓ ✓

equipment required after disaster

5 Position of disaster risk management in Malaysian healthcare facilities

1) Manufacturing 7) Wholesale and retail trades

Log keeper Operation

Intervention Logistic Communication

Firefighting First aid team Spillage control

Figure 3: Standard ERT organisation chart (Soud, 2014)

6 Risk communication in the context of fire safety

Required water flow or

7 Factors influencing risk communication

7.1 Knowledge, familiarity, and experiences

Knowledge is found to be related to risk perception and risk communication. In risk

7.2 Trust, confidence, and credibility

7.3 Voluntary and willingness

The effectiveness in delivering the information about risk to an individual is affected by

Figure 4: Proposed conceptual framework

Knowledge: Knowledge may come from available information, experiences, and

Trust: Trust with sub-categories of credible source and reliability of information

information to ERT is weak, also the information dissemination at preparedness phase.

Discussion Paper World Bank, (0533), 1–34.

Technology1. Applied Social Psychology, 29(10), 2093–2106.

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