What role does risk communication and community engagement play in managing the infodemic during a health emergency?

This is one of eleven primers that the organizing team of the WHO infodemiology conference (June/July 2020) prepared to feed into multidisciplinary discussions in working groups that were discussing a public health research agenda. The primer is not intended to be exhaustive review of literature, but more a rapid review and a starting point for discussion. I will be publishing the primers over the course of next weeks. Hope you find them useful as well. Thank you to colleagues from Demand for Immunization Team at US CDC for participation in primer preparation.

Definitions and key concepts

• RCCE: Abbreviation for risk communication and community engagement.
• Risk communication: The dissemination of information to the public about health risks and events, such as outbreaks of disease and instructions on how to change behavior to mitigate those risks.
• Community engagement: The process by which community benefit organizations and individuals build a long-term relationship with a collective vision for the benefit of the community.
• Demand generation: An activity to build individual and community health-seeking uptake of health services.

How risk communication and community engagement intertwine

Risk communication and community engagement (RCCE) are important strategies for developing and disseminating accurate information, and have been associated with more successful communication strategies in outbreaks[1]. When they are framed within the cultural, social, political and historical context, and “owned” by communities, they help develop credibility and trust in health service delivery.

Risk communication is used to inform the public about health risks associated with an emergency, providing guidance on what people can do to protect themselves and their families. Messages are often used to increase awareness of risks and encourage a specific protective behavior, such as getting immunized after a yellow fever outbreak or avoiding unboiled tap water during a cholera epidemic.

When the pathogen is not well known or understood, and if the effects are dramatic or disproportionally affect children or other vulnerable groups, risk communications address immediate concerns and evolve with the outbreak response as new information emerges[2]. Populations’ information needs and desired behaviors may also change over time.

Community engagement is a set of activities that involves stakeholders in creating context-specific messaging and dialogue in order to seek buy-in or collaboration for achieving a specific common goal. It can encompass many modalities of engagement, from community meetings with religious leaders to street theater to livestreaming a town hall or hosting radio call-in shows. It can be used in regular public health programming to keep communities informed of available health services and encourage community demand.

In the midst of a health crisis, community engagement can quickly reach community influencers and members to facilitate a dialogue[3]. Two-way communication mechanisms are better suited for listening to and addressing concerns, especially if they emerge from misinformation.

Both risk communications and community engagement fit within broader domains of health communication and demand generation for health services at the national, sub-national, district, and health-facility level. The activities are generally conducted by health system staff and stakeholders, and directed toward the target population to support uptake of health services or encourage positive health behaviors. 

In a public health emergency or outbreak, typical service delivery may be disrupted and health authorities may not yet know all the facts[4], leading to confusion and anxiety. Rapid assessments of knowledge, attitudes, practices and behaviors can inform RCCE strategies and data should be collected in an ongoing manner to update messages and more effectively address concerns that may stem from rumors or misinformation. Essential components to mitigating the spread of misinformation at the community level are to maintain trust in health authorities or other health influencers, and increase the quality and quantity of actionable health information to the public, both of which can be partially addressed through risk communication and community engagement.

Even when information is available for health authorities to communicate, it is not always communicated through the right messenger, at the right time, through the right medium or in the right language. Additionally, as the science evolves, the messages need to change too, which can spur further confusion, with people trying to separate accurate information from misinformation[5]. Different communities have different information needs, and framing information within an epidemiological lens is not always sufficient for clearing up misperceptions or supplanting misinformation[6]. There are often deeper, historical issues that can affect trust in health authorities and make communities less inclined to listen, especially if they aren’t asked to take an active role in their own community’s response[7].

Early missteps in the public communications response during the West African Ebola outbreak in 2014 included developing messages and engagement strategies without a full understanding of cultural, social, and historical context[8]. With low trust, messages and attempts at engagement from health authorities are not effective in influencing behavior[9]. This can lead to low uptake of health services or weak adherence to public health guidance, especially if there is a perception that promises have been broken and values violated, such as insufficient supply to meet demand or perceived differing levels of service provision for different groups.

Recent examples from HIV to Ebola to Zika to polio have demonstrated the tremendous cost to public health and health systems when misinformation breeds in an environment steeped in distrust, aggravated by a poor public health communications response[10]. It was further exacerbated by the lack of active community collaboration in the health response early on, especially as these complex epidemics unfolded. Today, most emergency and outbreak guidance emphasize the value of listening to communities, involving them early in the response and communicating clearly with them in a timely manner.

Robust evaluations of RCCE responses are important to identify best practices and develop improved models and activities for future outbreaks and emergencies.

[1] Walker, B. F., & Adukwu, E. C. (2020). The 2013–2016 Ebola epidemic: evaluating communication strategies between two affected countries in West Africa. European Journal of Public Health, 30(1), 118-124.

[2] World Health Organization (WHO). (2020). Risk Communication and Community Engagement (RCCE) Action Plan Guidance: COVID-19 Preparedness & Response. World Health Organisation.

[3] Marston, C., Renedo, A., & Miles, S. (2020). Community participation is crucial in a pandemic. The Lancet, 395(10238), 1676-1678.

[4] Reynolds, B., & Seeger, M. W. (2012). Crisis+ emergency risk communication.

[5] Balog-Way, D. H., & McComas, K. A. (2020). COVID-19: Reflections on trust, tradeoffs, and preparedness. Journal of Risk Research, 1-11.

[6] Chandler, C., Fairhead, J., Kelly, A., Leach, M., Martineau, F., Mokuwa, E., ... & Wilkinson, A. (2015). Ebola: limitations of correcting misinformation. The Lancet, 385(9975), 1275-1277.

[7] Ramsbottom, A., O’Brien, E., Ciotti, L., & Takacs, J. (2018). Enablers and barriers to community engagement in public health emergency preparedness: A literature review. Journal of community health, 43(2), 412-420.

[8] Richardson, E. T., McGinnis, T., & Frankfurter, R. (2019). Ebola and the narrative of mistrust. BMJ Global Health, 4(6).

[9] Gillespie, A. M., Obregon, R., El Asawi, R., Richey, C., Manoncourt, E., Joshi, K., ... & Quereshi, S. (2016). Social mobilization and community engagement central to the Ebola response in West Africa: lessons for future public health emergencies. Global Health: Science and Practice, 4(4), 626-646.

[10] Vicol, D., Tannous, N., Belesiotis, P., & Tchakerian, N. (2020). Health misinformation in Africa, Latin America and the UK: Impacts and possible solutions (pp. 4-32, Rep.). London: Full Fact.