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OpenWHO: COVID infodemic management: risk communication and community engagement challenges

[Module 2 – Influencing Risk Perception about COVID-19 to Encourage Healthy

Behaviors]
Marsha L. Vanderford, PhD

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[Slide #1] Welcome to Module 2! In the Risk Communication and Community Engagement series. Module 2
focuses on influencing risk perception about COVID-19 to encourage healthy behaviors. My name is Marsha
Vanderford and I will be guiding you through this session. My goal today is to share research findings and
best practices about how to influence risk perception through messaging, and in turn, to encourage at-risk
groups to enact and to sustain health protection steps related to COVID-19. Although much of the work done
on risk perception has been conducted before COVID-19, a broad range of scholars and practitioners from
social and behavioral sciences has been conducting interdisciplinary reviews and analysis to see how their
fields can be applied to COVID-19. So our risk communication practice is integrating results from a broader
range of interdisciplinary work, during this outbreak than we have seen before.

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[Slide #2] Let's begin by reviewing a couple of graphs from the September 27, 2020 WHO COVID-19
dashboard. These examples show the trajectory of confirmed cases in the United States and in Spain from
last winter through September. They show substantial upticks in disease, following broad lockdowns that
flattened the disease curves last spring. As these and other countries eased stay-at-home orders, the ability
to keep transmission low relied on individuals enacting safe behaviors as they re-entered the workplace,
schools, markets and public transportation. Would people maintain physical distance and other
recommended steps to reduce transmission? The surge in cases shown in these charts and seen in many
other countries, since was caused by a number of variables, but risk perception has played a major role. We
know that people who feel at risk are more likely to take action, but influencing their risk perception is a
challenge.

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[Slide #3] According to the 2017 WHO Risk Communication Guidelines, risk perception is an individual
assessment about the likelihood that something bad will happen. Something is at risk: health, family, the
economy. This cartoon helps us to better understand risk perception by relating it to other public health
functions. So starting on the left, risk perception is when a threat is recognized. In this case we see the
recognition that some rocks might fall and hit someone causing injury. Risk assessment is when individuals
measure those risks, such as epidemiologists tracking the numbers and locations of cases of COVID. As risk
communicators, it is our job to let people know about the threat, how serious it is and what to do about it.
And if we are successful, then people will take action to avoid danger and that's risk management. So what
is the relationship of risk perception to protective action and how can we influence it with risk
communication?

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OpenWHO: COVID infodemic management: risk communication and community engagement challenges

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[Slide #4] The aim of risk communication is to help at-risk groups recognize their accurate level of risk,
prompting them to enact behaviors that prevent transmission. That's the target in the middle of the diagram,
but some groups are overestimating risk and others are under concerned. This diagram is derived from
analyses by communicators, health policy experts, health economists and social scientists and it can help us
to understand some dynamics underlying groups, who over and underestimate their risks. On the left are
people who could be characterized as overly cautious. They perceive the risk to be so great that they are not
only implementing recommendations, but are also afraid to take other actions that they need to take to stay
healthy. For example, they may avoid going to a clinic or hospital for other necessary medical reasons. In
some instances, children are not receiving immunizations for vaccine preventable diseases, in part because
some parents are afraid to take them to the clinic during the outbreak of COVID-19. WHO and UNICEF
recently warned of an alarming decline in the number of children receiving life-saving vaccines around the
world. Preliminary data for the first four months of 2020 showed a substantial drop in the number of children
completing needed doses of vaccines against diphtheria, tetanus and pertussis. In contrast, there are groups
who feel overwhelmed and fatalistic. Health economist, Nobel, calls this “learned helplessness”. These
groups perceive that their risk is so grim, they think: “nothing I do will matter anyway, so I might as well carry
on as normal”. This group has a high level of risk perception, but a low level of confidence in solutions
offered by health authorities and low confidence in their own ability to sustain physical distancing, mask
wearing, etc., for the long period of time, before vaccines may become available to them. Scholars have
found that encouraging a high level of risk perception leads people to change their behavior, but only if they
feel capable of dealing with the threat. But people often react defensively when they feel helpless to reduce
the threat. So if in our messages we create perceptions of high levels of risk, but we don't convince people
that the solutions work or that they are capable of sustaining recommended actions, then they may just give
up trying. Finally, there are the under concerned: those who perceive only a low level of risk or none at all.
These include people who experience what behavioral scientists call “optimism bias”, the belief that bad
things are less likely to befall oneself, than others. Optimism bias is attractive because it helps people to
avoid negative feelings, but it can lead them to underestimate their likelihood of harm. In the case of COVID-
19, it makes them underestimate their own risk of contracting a disease or passing it on to others. They,
therefore, ignore public health warnings and recommendations. Optimism bias is experienced by most
people some of the time, but most intensely by the young. Younger people are typically less likely to feel
vulnerable to any threats and are more likely to take risks. This bias is exacerbated in COVID-19, where the
older people are more likely to suffer severe disease and infected young people are much less likely to
become seriously ill. Finally the number of under concerned is likely to increase, due to pandemic fatigue.
We are asking people to sustain for months actions that impact our decisions many times a day. And those
actions are inconvenient, isolating and for some, costly.
As a result increasing numbers of people are finding it more and more difficult to maintain high levels of
concern that prompt safe behaviors. What is interesting as we look at these positions on the diagram is that
on a continuum of “too much” or “harmful” action to the left and “no action” on the right, groups performing
“no action” may be experiencing both very high levels of concern, that is they are overwhelmed and fatalistic
and low or no level of risk perception. They are under concerned. It is clear that we have a need to balance
both hope and worry in communication. We need to find a way for both to coexist.

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OpenWHO: COVID infodemic management: risk communication and community engagement challenges

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[Slide #5] So of these reactions, what are you seeing where you work? Please take a look at these choices
and consider what best represents the members or of the public or stakeholders you interact with on COVID-
19.

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[Slide #6] How have you developed your understanding about their level of risk perception for most of your
stakeholders? Which of the activities on this slide have you conducted to determine risk perception? One of
the challenges that risk communication staff have had in the past has been getting data from monitoring
these channels, but then not being able to process it in real time and that includes information gained from
monitoring stakeholders concerned. These, when they were gathered, weren't consistently incorporated into
the evolving risk communication strategies, activities and messaging

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[Slide #7] So having access to both the resources to gather data about risk perception and the ability to
integrate it into messaging and other communication activities is essential for risk communication staff to
conduct our primary roles. And those include influencing how at-risk groups perceive their level of risk,
diminishing overreaction and increasing under reaction, in order to motivate risk to take precautions.

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[Slide #8] A meta-analysis of risk perception related to COVID-19 was conducted this spring by the National
Academies of Science in the United States. The review concluded that people who feel at risk for COVID-19
are more likely to take protective actions, but that it can be difficult to persuade people that they are at risk.
Importantly that they found that merely explaining the science behind the need to take protective steps does
not translate to actual change in behaviors. And while scientists are persuaded by data about disease
prevalence and severity, research indicates that many lay people are not. Instead, public understanding of
risk is influenced by emotions and other considerations, such as the threat's familiarity, uncertainty, dread
catastrophic potential, controllability, equity, risk to future generations and perception of one's peers.

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[Slide #9] This chart shows us, on the right, the characteristics of threats that generally increase public
concern and worry. That is high risk perception. On the left are those characteristics that cause less worry.
People are more concerned and worry about risks that they have not accepted willingly, as opposed to risk
that they might accept willingly if they voluntarily were participating in, for example, a high-risk sport. People
are more concerned about risk that they have no control over than those they know how to prevent
personally. They are more worried over unfamiliar threats than those that are familiar. Man-made threats
cause more concern than those that are seen as emerging from natural causes. Risks that cause permanent
harm or are catastrophic are more fear than those that are reversible. Threats to children cause more fear
and worry than those that primarily target adults. Lack of fairness also tends to cause more concern when a
disease threat impacts some groups more than others through no fault of their own. Acute severe disease

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OpenWHO: COVID infodemic management: risk communication and community engagement challenges

causes more concern than something that is gradual or chronic. The strip in green on this graph reflects the
work of Health Policy Experts who conclude that humans respond more aggressively to threats to identifiable
people than to those where an individual can easily imagine being or caring about. So threats to identifiable
humans cause more reaction than threats to statistical cases reported in population level accounts.

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[Slide #10] So what can we do with these principles to help us with COVID-19? Although there are other
implications, I want to suggest how these can be used in messaging. We can use the principles to frame
information and use language in ways that generate more or less concern in order to bring stakeholders a
risk perception in alignment with their actual risk levels and encourage appropriate recommended actions.
How can we message so people do this? Although we have at our disposal only what is known about the
virus at the moment, we can choose the content language and emphasis for our messaging that best aligns
COVID-19 information and guidance with characteristics on the left side of the slide for those who are under
concerned to raise their level of risk perception. Or to align with the characteristics on the right side to lower
the level of concern among those who are overly cautious. To increase risk perception, we need to
emphasize the threat's novelty, acute impact, severity, impacts on children, lack of individual concern, or lack
of individual control, concerned of our peers, human-caused harm and identifiable persons who are harmed.
To lower risk perception we can emphasize in our messaging things about the threat that are familiar, that
cause mild cases, that have smaller impacts on children, where we have self-control, or we have control over
the disease, where peers are confident of their ability to perform recommendations relative to the threat,
where there are natural causes of harm and we can emphasize statistical impacts.

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[Slide #11] Here are some examples of how that can be done. These are statements from messages from
country-level ministries of health and from WHO. They show how four risk perception principles can increase
or decrease public concern. On the left side are messages that highlight the acute nature of the disease.
Message one. COVID-19 can cause serious illness: about one in every five people who catch it need
hospital care. This message emphasizes acute onset and severity of the disease. Message 2. COVID-19
has pushed this country over the edge with many health workers on the front line frustrated and bereft. One
physician recently said he is exhausted by politics, exhausted by rumor and ignorance and exhausted by
greed and poverty. This message focuses on man-made activities, which worsen the threat and cause
higher levels of risk perception. Those are amongst the principles that increase public outrage, fear and
concern. Now, on the right side, we see principles applied that should lower public concern. Number 3.
Illness due to COVID-19 infection is generally mild, especially for children and young adults. So the message
focuses on low impact on children. Message number 4. We can channel our concerns into actions to protect
ourselves, our loved ones and our communities. First and foremost among these actions is regular and
thorough hand washing and good respiratory hygiene, so the risk perception principle focused on, in number
four, is: you have control over protective actions.

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[Slide #12] Now let's do an example. I'm going to ask you to identify the risk perception principles on the
right, with examples of those principles as they exist in examples on the left. Let's read through them.
Number one: “We are no better off today than eight months ago, we still do not have a vaccine or treatment
for COVID-19”. Message two: People with underlying health conditions “are particularly susceptible to
hospitalizations, severe disease and death. Message three: COVID-19 is disrupting life-saving immunization
services around the world, putting millions of children at risk for diseases like diphtheria, measles and polio.
Message four: wash fruits and vegetables the same as you do under any circumstances. Before handling
them wash your hands with soap and water, then wash fruits and vegetables. Okay. Let's take these one at
a time.

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[Slide #12a] The message is “we are no better off today than eight months ago, we still do not have vaccine
or treatment for COVID-19”. The risk perception principle illustrated in this message is principle A: raise
concern by referencing lack of control over the threat or the intervention.

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[Slide #12b] The message is “people with underlying health conditions are particularly susceptible to
hospitalization, severe illness and death”. The risk perception principle illustrated in this message is C: raise
concern based on sudden onset and the severe nature of disease.

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[Slide #12c]
This message is: “COVID-19 is disrupting life-saving immunization services around the world putting millions
of children at risk of diseases like diphtheria, measles and polio”. The risk perception principle illustrated in
this message is D: raising concern based on the impact of the threat on children or the intervention required.

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[Slide #12d] The message is “wash fruits and vegetables the same way you should do under any
circumstances.Before handling them, wash your hands with soap and water then wash fruits and vegetables
thoroughly with clean water”. The risk perception principle illustrated in this message is B: lower concern
based on familiarity of the disease or recommended behaviors.

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[Slide #13] These are just a few examples of how the principles can be used in messages targeted to at-risk
groups experiencing different levels of concern. For those who are under concerned, we can use the
principles to advocate for more caution. For the overly concerned, we can use them to bring concern and
fear to a lower level, so they can safely access available services while staying healthy. For the
overwhelmed and those feeling helpless, the principles can be used to create messages that emphasize
effective solutions and peer confidence. We will not be able to influence everyone's risk perception. Political
affiliations and impacts of rumors and conspiracy theories create other barriers, but if health authorities are

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OpenWHO: COVID infodemic management: risk communication and community engagement challenges

aware of stakeholders position on the risk continuum and consistently tailor messages to address those
perceptions, we can impact how people respond to the disease.

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[Slide #14] As communicators, we can use the principles of public concern to influence a risk perception of
stakeholders. We cannot alter the facts about COVID-19, but we can frame them in ways that help
communities perceive their accurate levels of risk and act accordingly. Thank you.