CERC Transcript 06 07 2016

Zika CERC Discussion: Risk Attributes, Risk Perceptions, and Pregnancy

Presenters: Barbara Reynolds, PhD

Date/Time: June 07, 2016 1:00 pm ET

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Operator:
     
Good afternoon and thank you for standing by and welcome to the CDC’s Teleconference on Crisis and Emergency Risk Communication. All lines are in a listen-only mode until the question and answer segment. At that time you may press Star followed by the number 1. Today’s conference is being recorded if you have any objections you may disconnect at this time. I would now like to turn the call over to Dr. Barbara Reynolds, Senior Advisor on Risk Communication. Thank you. You may begin.

Dr. Barbara Reynolds:   
      
Thank you (Michelle) and welcome everyone to today’s Crisis and Emergency Risk Communication teleconference and we’re looking at a very interesting concept today and then relating it to issues around pregnancy. We’re looking at risk attributes and risk perceptions. I’m just going to give a few opening thoughts and then the idea of these phone calls is that we have a discussion. So I do hope that you’re listening to my introduction of the topic, that you’re thinking through perhaps some questions or points of view that you would like to offer. It doesn’t necessarily have to be shared with us as a question. We’re very open to hear what you’re doing and what you’re thinking around these communication topic areas as we go forward.

And I also want to suggest that we’re going to continue to have these as people continue to be interested. And it looks like we are keeping up a high volume of interest and if you have particular topic areas related to crisis and emergency risk communication that you think would be helpful for us to discuss in this forum please be sure to just let us know. I’m going to give you an email address at the end of the presentation part of the call and I hope I’ll remember to do it at the end after our discussion too. So why don’t we go ahead and get started and look at the topic.

For those of you who are following along with slides at your computer I’m going to go to the slide that I open with almost always when I’m talking about crisis and emergency risk communication. It’s a real reminder that if we get this right, if we have the right message at the right time from the right person or organization that we can save lives or reduce harm. And when we’re talking about Zika for the most part we are talking about what we can do in our communities to reduce harm from the Zika virus.

In any situation where we’re introducing new information to people who may be threatened, their health may be threatened in some way, we’re talking about different phases of communication. I’ve mentioned these in the past but I think it’s worthwhile to recognize that we’re kind of in a funny holding pattern right now especially within the continental United States. Of course our colleagues and neighbors in Puerto Rico and then internationally there may be – they’re in different phases then we are but we’re kind of at the point where we’re just beginning to help people understand here in the continental United States that there is a risk called Zika virus and helping people understand what that risk may be.

And this is a time that we need to start establishing our credibility in relationship to this topic. So the four people who are responsible for responding to this particular health threat how we communicate now even when people may not be completely attuned to it, they’re not paying attention to it perhaps as much as they will later on when it is a risk factor specifically in their community if there is possibility of local transmission or something like that then they may be more interested in and what we’re talking about, but right now we should be establishing our credibility along the way.

Once we go further into the response for Zika, into the maintenance phase I call it, is the time that we’re going to have to start to explain the risk by population groups. And as you can see I have both slides here because if I could do a matchup of these two together, it would probably be more accurate in the context of a Zika response because we’re telling people about this but we also have very specific population groups that we’re concerned about here. It doesn’t mean that only women who are pregnant can become ill from Zika but we do know that the consequences of pregnancy affected by Zika is of real concern and that’s why we’re so focused on this particular population group.

And I have to tell you next week -- and I guess I’m doing a little advertisement for next week -- next week we’re going to talk about crisis and emergency risk communication and community engagement. And I think that this is important because today as we talk about risk attributes and risk perception we have that delicate balance between having people have a realistic understanding of what the risk is, but at the same time having them understand that some population groups in their community may have a greater risk than others and how do we engage the community in a way that even though they may not have or perceive a serious threat from Zika virus for themselves that they can engage in behaviors that will help the community especially those most at risk.

We sometimes throw around the word vulnerable populations but I think that when we’re talking about Zika virus we are talking about a very important vulnerable population and that is pregnant women. And so it’s important that we engage people early on about the risk attributes and then understand their risk perceptions. As we were looking at our discussion for this week we know that subject matter experts, or the scientists, the researchers who are out there right now learning as much as they can about the Zika virus, will have a particular perspective on what the risks are.
But we also know that as people start to learn about Zika virus and risk they may have a different perception than what an expert will. And sometimes I think it’s worthwhile to understand why those two things may not match. So the attributes of risk may be one thing, but the risk perception may be something else. And let’s talk a little bit today about how we can influence those perceptions in a way that is best for our communities as we go forward.

Okay. I have the next slide is talking about some of the psychological barriers. And I bring this up because I want to talk a little bit about people and their reactions to the Zika virus or the possible introduction of Zika virus in their community. Right now what we know is we have well over 600 people in the United States who have been diagnosed with Zika virus, but for the most part people are taking it in stride, they’re not perceiving this as a particular risk at this point. But I also know that it was just about a week or so ago there we started to talk about starting mosquito season in the continental United States. So there are factors coming to bear that may help people perceive this potential risk in a different way. And as we have other events occur in especially the continental United States risk attributes and risk perceptions will alter. So I think it’s important for us to recognize that the way people are perceiving it today may be very different from the way they’ll perceive it in a few months depending on what’s going on.

If we went back to what happened with H1N1 in 2009 we know that interest in H1N1 influenza was very high in the initial phase of our response to this pandemic. In April there was a great deal of uncertainty in 2009. We saw cases in Mexico but we didn’t know really how bad it was going to be. And that uncertainty drove some of the perceptions of risk. And for some people they may have perceived the risk to be greater than what the scientists themselves did.

And then fast forward into 2014 and look at the domestic response to Ebola. And you can see there was a long number of months where the popular perception of risk in the United States around Ebola was quite intense. And again there was this disconnect between perhaps what the experts were thinking and seeing as far as risk and what perceptions were out there. So when I talk about risk attributes that might be a finite risk from the organism that we’re talking about but it’s also what components of that risk heighten concerns by people along the way.

And there are psychological barriers that will come into play. One of the things that I think is really important is that we want people to be concerned about health threats especially if we’re offering recommendations but we don’t want them to become so concerned that they go into a state of denial where they literally believe that there’s nothing they can do about a risk and they shut down along the way. So there are number of things that we have to consider as we start our communication or continue our communication around Zika virus just as we did with H1N1 and with Ebola.

I’m going to talk a - I’m going to just float through this slide pretty quickly. It’s just a reminder that there are barriers to people being able to hear our messages depending on the context of these risk perceptions. What we know is that when people are looking at a new threat and certainly Zika virus like Ebola and like H1N1 they all represent new threats at a certain point along the way. That as they’re gaining information they may simplify that information, not only simplify it, but they may pick out the things that are most interesting or most important to them.
And if people are left to simplify the messages themselves they may get it wrong. So I think as communicators and I know that Dr. Baur last week talked a lot about the importance of plain language in relationship to public health messaging. That it’s important for us whenever possible to give people a simple – as simple of a message as we can in this context. We also need to know, and I’m going to talk a little bit about the social amplification of risk, that people tend to cling to their current beliefs when they’re looking at health threats. And that’s important in part because that means it’s on us that we have to get out there and share information as quickly as possible about a risk. And if we don’t, then we leave them vulnerable to people who may not have their best interest at heart along the way.

So the next slide is probably the most important part of this discussion it is the risk what causes risk perceptions to alter perhaps from what the risk attributes of the actual organism or risk threat may be. So why is it that sometimes people accept some risks and they don’t accept others? And there’s an interesting body of work and research that goes back decades that actually tells us that there are some attributes of a risk or a health threat that the more of those that exist in the situation the more likely people are to perceive the risk as greater perhaps then the real risk may be although it’s sometimes hard to measure what real risk actually means.

So in the business of risk analysis of risk modeling we sometimes look at the probability of a risk happening along with the magnitude of that risk. And it’s the magnitude that gets us in trouble sometimes because we tend to measure magnitude of risk by the actual ability for this thing, whatever this threat is, to cause bodily harm or economic, geographic harm, property harm. So we tend to look at the risks based on people and property. And when we do that we literally - we leave on the table another kind of measurement of risk. And if we take the time to not just look at probability but also not just look at magnitude, people and property but look at this other thing, the factors that go into the risk itself. What brings this risk about? What are the attributes of this risk? And if we look at those attributes it’s really much easier for us to then predict the degree of concern or the heightened sense of risk perception that the community may have.

So let’s look at some of the things that can contribute to the risk being perceived as more serious perhaps then what the experts might think that it is in a situation. So if a risk is involuntary meaning that people don’t have a choice whether they’re being exposed to a risk or not, it’s going to be perceived as a more dangerous risk. If it is a risk that is being controlled by others, meaning that you don’t have personal say on whether and to what degree you’re exposed to a risk, then you’re going to be more upset. So involuntary and controlled by others means you’re - you may - you as in the public, may be perceiving the risk as greater. If a risk is exotic, people haven’t been exposed to a risk before, it then therefore can be perceived as more serious perhaps than what it would otherwise be. If a risk is manmade meaning either intentionally or by accident, people bring about the problem, the risk threat, people will have a greater emotional response to that risk. If the risk results in a permanent damage and something changing that cannot be unchanged people will be more upset. If there are anecdotes meaning there are stories that the risk itself is dramatized in some way and that we’re hearing personal stories about that risk, we may then therefore perceive that risk in a different way and it might create a greater emotional strain on us especially when you’re talking about risks that involve community. If there seems to be a risk that is unfairly distributed, meaning that some members in the community are put in a position not by their own control but by others, that they are therefore a greater risk than the emotional toll for them and the perception of that risk may be higher. And then without question any risk that affects children also is perceived as a greater risk.

Now when we take this list of risk attributes and apply it to Zika not all of them will necessarily apply in the situation. But I’ll take it a step further, so these stress factors of these risk attributes if you have three or more of those that can be attributed to the risk situation the risk threat that you’re talking about, the greater the emotional toll will be on the people exposed to that risk threat. So - and that risk threat can change over time. There is the possibility that as people become more familiar with a risk when they’ve experienced it for themselves in a situation that they will not perceive it quite the same way. And I would have to say that, that familiar versus exotic is really important. Two weeks ago we talked about the planning for the first local introduction of Zika cases. So the first people who will become ill in the United States through local transmission from a mosquito not through travel and then transmission from a traveler but through a mosquito giving them the Zika virus. So whichever community is the one where this pops first it’s going to feel very, very exotic. And what we know is that over time it will be less exotic as more communities experience it, though my experience with West Nile virus tells me that as each community experiences it for the first time that they may have a strong reaction as if they have not been exposed to the idea of this threat beforehand. So anything that is unfamiliar or exotic can be very difficult.

One of the things that also adds to and heightens risk perception is the idea of dread as it’s looming out there. It’s something that they know is coming. Now we have an obligation when we are aware of risk threat to tell people that there is something that could be coming. But just understand that there is a certain amount of an emotional toll that takes place by people dreading something that is heading their way.

Another aspect of our risk attributes and how we perceive it can depend on the amount of media coverage which brings me to a discussion about the social amplification of risk. So what makes risk take a higher toll on a community? There can be factors other again then the facts of the threat itself. And social amplification of risk is a way to look at risk not just with these attributes but how the risk is being communicated within the social circle. So the attributes of information, the way that people start to get information about for example the Zika virus in the community, may contribute to their perception of how serious this is.

One of the things is volume of messaging which literally means if a lot of people are paying attention to the risk, then people will start to perceive it in a different way than they would if we all looked at it and dismissed it and nobody bothered to talk about it. Social amplification of risk can go through two means two channels in terms of the volume through the media itself what we see in social, in regular media and then of course the other way is social media or informal personal channels of communication. And so today if people are talking about Zika and concerns about Zika in social media you will see that perhaps there will be a heightened risk of concern. I would certainly think that social media that is directed toward women who are pregnant or are thinking about becoming pregnant would certainly show a heightened interest in this topic right now. I wouldn’t –I would expect that.

There’s something else there though it’s about the dramatization of the risk. And that’s kind of a big word. What does it mean? Well what I’m talking about is how do we characterize this risk? And the other is the symbolic connotations of risk. And dramatization I have to say that when we started to hear about the Zika outbreak in Brazil started to see those dark pictures of babies who were born with microcephaly that that is a dramatization that can’t be missed. It’s an image that is going to stay with people. And we have to understand that with those kinds of images and dramatization that people will have a different perception of risk because of it.

So one of the - again as I started this conversation, one of the things that we’re going to have to think about is how do we talk to people about the risk in a way that they will take the steps that they need to protect themselves but at the same time not to over create a sense of the risk that it’s so much bigger than what it is that we can’t do what needs to be done. Because if people perceive and risk as being actually too big, too much, they may shut down and not take steps that they can to protect themselves.

So as communicators I think it’s worthwhile to remember an old saying that it’s much harder to un-scare people then scare them. And I don’t know where we are in each community around our conversation of Zika. I think that as response officials and public officials - public health officials, clinicians and that community, as they take this seriously that they have an obligation to talk about it and to share that information in a way that people can hear it and do what they need to do. It’s unfortunate though if people take advantage of this by dramatizing it in a way that isn’t helpful or useful to people. And of course part of that dramatization sometimes can include giving out information that is inconsistent, or incorrect or taking advantage I guess of the crisis in - or the public health emergency in a way that is inappropriate for the moment.

So on the next slide I want to talk about fear and efficacy. We talk about there’s a lot of different things that go into how people perceive a threat or a risk. There is the actual attributes of that risk and its perception based on social amplification of that risk. But when people are feeling threatened, when their loved ones are threatened, their pets yes even their pets, or their economic security are threatened and not all of these threats may apply in relationship to Zika but we do need to recognize that there may be threats beyond someone becoming ill, someone who is pregnant becoming ill and risking a birth defect, or the community itself being stigmatized or tainted in some way and there is some economic threat to the community because of Zika all of those things will come into play.

Well if we want people to take steps to help mitigate that risk to try to reduce the threat in some way it’s important that we communicate not just that this risk exists, but we have to communicate in a way that there is a sense of immediacy if there is, if the threat is there for people, and then help them move through the motivating emotion of fear. And fear really does prime us to do something. And the best outcome is that when people are frightened by a new threat or the perception of a threat that they’re being channeled or focused into doing things that they can do to protect themselves or their community in some way.

What happens is if there is an information goes out to people -- and for those of you following on the slide there is a good model here -- but if a message goes out that something has happened that there is a threat for example Zika virus in the community then people have to perceive the threat if they - if there is a threat to them I would certainly think that pregnant women would perceive the possibility of Zika virus in the community as a threat to them. And if there is no perceived threat then there will be no fear and no response. And when I say fear, fear can be in grades of fear. Not everybody feels fear exactly the same amount there’s thresholds of how people perceive fear. But to be perceiving a threat meaning it’s personal and it’s imminent to that individual, there is likely to be a fear response. And at that point what we need to do is channel that information, channel that emotion into doing something that’s protective.

If someone feels that there is nothing that they can do if they have no sense of efficacy of the ability to do what needs to be done to help protect themselves to help minimize that risk then they may go into emotional maladaptive response to that fear. And I had a slide earlier where we’re talking about denial and literally in a threat situation if people are fearful but believe that there’s nothing that they can do about it they may shut down and go into denial and say oh the fear doesn’t exist at all. So it’s critical for us to recognize that if we’re going to raise the issue of a threat, if we’re going to raise the alarm when the threat is actually there in the community, that it is in very important that we give people things to do that they believe that they can carry out.

Now we may start to prime our messaging in that way even now. I will tell you that it’s a hard thing to do to try to get people to pay attention to the threat and taking action to protect themselves minus the threat itself. So people tend to be more interested in the messaging about what to do when the threat is actually – they’re feeling imminent and personal to them. And that’s why next week we’re going to talk about community engagement because that a lot of that work has to be done before the threat itself is imminent. And it’s hard to sometimes get people to do what they need to do.

So if there is no perceived efficacy, and the threat is real, people are feeling fearful and there’s no perceived efficacy what you may get is a lot of people who are acting fearful but also acting hopeless or helpless in the situation. And I think that as we talk about threat, we talk about Zika and we talk about pregnant women, it’s very important that the pregnant woman, the loved ones around that pregnant woman, and the community around those loved ones and that pregnant woman - women all feel that they have something that they can do to mitigate that risk or to reduce that risk along the way. And we can talk about more what some of the messaging might be and we’ll talk very specifically about it next week.

I would suggest that as we are talking to people in a threat situation and they are fearful in some way that we have to be compassionate in our communication. I think it’s important that we recognize that for any woman who is visibly pregnant in a community where Zika virus may be circulating at some point that the way we respond to that person has to be in a compassionate way. And one of the things that I would like us to talk about today and to throw this out for discussion is, should we be thinking about what are the do’s and don’ts or the right way to approach people women who are pregnant in that kind of setting. Sometimes we can be intrusive when we shouldn’t be. Sometimes we could be helpful to that person if we were thoughtful in the way we approach them. So I’d like to just throw that out. How do we talk to people who are most at threat when the Zika virus is present in the community? I have ideas but I’m very open to others talking about it too.

Not only are we talking about compassion in our communication to women who are visibly pregnant, but we need to think about how do we talk to women who or couples who are looking at pregnancy planning. We know we’re telling our health providers that it’s a deeply personal and complex subject that needs to be approached carefully. But we will be at some point expected to enter into some conversation with these particular population groups. And the more we understand how threats are perceived, the risks are perceived, and the idea that giving people things to do helps to reduce fear and we hope move people into a more pro-social approach, I think it’s worthwhile.

There are delicate subjects that are going to come out as we look at Zika. It is important I think that we get comfortable with conversations about things that we may not on a routine basis talk about and one of them is discussion and education on condom use, and to the idea that to be effective, condoms must be used correctly each time. And I underline that word in my head because I see CDC saying that over and over and over again. And for anyone who is putting out that message I think we have to ask ourselves what is the level of education or understanding of condom use correct condom use and the idea of protection against a virus in our population? How well do they know? I mean how much do they know?

The CDC Web site offers some very specific information on helping people understand this risk. I can remember 25 years ago being in school in a Masters of Public Health program. And at the time HIV/AIDS was a devastating illness that killed people. It was before we have the drugs now that are helping us think of HIV as a chronic disease but the time it was killing people. It was really important that people understood how to have safe sex.

And there was a lot of education 25 years ago about the proper use of condoms but I don’t know if that education has continued. And I do want to encourage people that if we’re talking about risk attributes and we’re talking about the things that people can do, we have to make them believe that they can do this, and if we need them to effectively use a condom correctly each time that they have a sexual relationship then we need to teach them how to do that. We need to make them feel that they have the efficacy, the ability to do that. And that’s just one example of where it becomes really important. We can manage the risk attributes and the risk perception. We can manage the emotional toll that this can take only if we do our best job of communicating to people what they need to know in the moment to protect themselves and have them believe that they can do it. And we need to show them the way and this is just one example where we could do that.

So those following along on those slides I always have with my six principles of crisis and emergency risk communication, be first, be right, meaning give information in increments whenever we can. Tell the truth that adds to our credibility. And tell the truth in a way with simple information in ways that people can actually take it in because sometimes I think we fall back on some of our scientific jargon and don’t do as well as we should. So take advantage of what Dr. Baur taught us last week and not only tell the truth but tell it in a way that’s simple enough that we all can understand it. And express empathy. Without question when we’re talking about threats to a pregnancy we are talking about people who need to hear that others understand what they’re going through. And we should put that into words that people are concerned, that they’re worried, that they feel perhaps that they’ve lost some control in the situation. Promote action. We talked about why that’s so important to help manage the fear the people will feel in the situation. And then without question, show respect and showing respect means that we have to have confidence that people as individuals and people within the community can do what needs to be done to protect themselves in the situation.

And the final slide is always a slide on some of the risk communication resources that we have here at CDC. And I want you to know if you have any questions that go beyond our discussion this afternoon that you can reach us at cercrequest@cdc.gov that email is CERC -- C-E-R-C -- request@cdc.gov. (Michelle) if you can I’d like to open it up for discussion see if we have someone who has a point of view or wants to address some of the questions I’ve brought up or ask a question on their own?

Operator:

Thank you. At this time if you’d like to ask a question or if you have any comments you may press Star 1. Again that is Star 1 if you’d like to ask a question and please unmute your phones and state your first and last name when prompted.

Dr. Barbara Reynolds:

Okay (Michelle) while we’re waiting for someone to take on this conversation with me to have a little discussion I’d like to talk about some of the risk communication resources that we have here. If you go to the CDC Zika web site it’s as simple as www.cdc.gov/zika there’s a lot of information there, and specific information for some of the populations that are going to be most at risk as Zika is or enters into our community. Then we also have at our emergency.cdc.gov web site some CERC crisis and emergency risk communication resources there too. So (Michelle) do we have any comments or questions?

Operator:

Once again if you do have any questions or comments please press Star 1, again that is Star 1. At this time I am showing no questions.

Dr. Barbara Reynolds:

Okay. I won’t beat people into answering or entering into the discussion but you’re again always welcome to reach us through cercrequest@cdc.gov and have additional information on the web site. And again next week we’re going to be talking about community engagement Zika and crisis and emergency risk communication. We look forward to talking to you all then. Thank you.

Operator:

And thank you. You may go ahead and disconnect at this time. This concludes today’s conference call.