Our findings are summarized in seven key messages. More information on our findings is given under each of the key messages below.
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1. Trustworthy information source
Which information sources are reliable and who carries the responsibility for decisions made and actions recommended and implemented? These are essential questions for public health professionals both at institutional level as well as for professionals in direct contact with the public and patients.
Public health officials want to base their decisions on sound information and make clear the reasons for their recommendations and actions. Public transparency in the decision making process is important in order to be prepared for later criticism. Healthcare professionals with direct public contact want to be informed in a timely manner by a responsible authority whom they can rely on and hold accountable for the consequences of any recommended action, such as, for example, antiviral use or vaccination during the A/H1N1 pandemic.
Establish a trustworthy information source long before any pandemic is in sight, so that the public, the professionals involved, and the media can familiarize themselves with it. Make sure the rationale behind the decisions for pandemic control recommendations and official measures taken, is comprehensible and well-documented and retrievable for later justification, e.g. through a website.
2. Media spotlight and communication channel
Media logic does not equate epidemiological logic, that is media attention does not increase with increased numbers of infections or casualties but spotlights certain key events based on their news value. How can media attention be used to propagate reliable information to the public long before it is available?
Both our literature review and our country-comparative analysis of media coverage found that the 2009 A/H1N1 pandemic received great media attention. Media attention peaked very early in the outbreak; long before in-country transmission started and first deaths were reported, and also long before reliable information on the disease dynamics became available. The highest peak in media attention was observed soon after the A/H1N1 outbreak in Veracruz, Mexico, when first imported cases were identified in other countries and WHO declared pandemic phases 4 and 5. Overall, findings show that media logic does not equate epidemiological logic: news attention does not increase with increased casualties or people affected by an epidemic, but rather follows the laws of news values. Media attention is typically highest at the onset of a pandemic; other typical key events spotlighted are the first national case and first death.
Media spotlights (even when preceding events in the own country) provide windows of opportunity to inform the public about resources where they can seek reliable information when it becomes available. Therefore, establish a channel for communication independent of traditional news media, before the media spotlight has moved on to other issues. Use this opportunity also for establishing good relations between public health and media experts. Build up mutual trust between information givers and seekers by a regular exchange of information (i.e. also during non-pandemic phases) to make sure this process works in times of crisis.
3. Audience research and tailoring of information
Research of public health communication during the A/H1N1 pandemic in three European countries showed that there was a lack of audience research to inform communication strategies, despite an understanding amongst practitioners and policy makers of the benefits of doing so. Generally there was little evidence of the use of segmentation to plan interventions, or customer journey mapping to assess public interaction with interventions and service delivery.
There is a need to tailor communication and behavioural programmes to different groups based on determinants as attitudes, cultural or religious beliefs and behaviour. Audience research should be performed about these determinants to enable audience segmentation. Also, interventions should be developed from a citizen perspective and use customer journey mapping as a method for doing so.
Test the Return On Investment associated with investment in tailoring programmes; i.e. test whether investing in tailored information leads to more positive outcomes than having a ‘one size fits all’ approach. Develop in-country and regional segmentation models and tailor communication and behavioural programmes. Develop segmentation guidance tools.
4. Behavioural influence beyond rational decision making
A dominant current characteristic of many existing programmes is a focus on rational decision making and the transmission of accurate advice. The assumption is that when you give accurate advice, people will automatically adhere to it. People are however not influenced by rational decision making alone when deciding to comply with recommended actions and behaviours.
Humans are not just rational when making health choices; this understanding needs to be reflected in pandemic programmes. Behavioural models and behaviour change theory can help development, delivery and evaluation of campaigns. There is a need to consider an individual’s behaviour change as it relates to and is influenced by social, economic and environmental factors and not just his/her understanding and knowledge levels.
Behavioural influence and communication often exists as a bolted-on adjunct to the influence of medical and epidemiological understanding in the policy/strategy development process. A significant cultural and technical shift is required within governments/agencies to a more customer-led marketing approach, and a fully integrated partnership between marketing/communication professionals and policy/delivery professionals.
Go beyond communication dominated responses and develop interventions that focus on non-rational decision making and behavioural influence, including determinants and service access, design and delivery. Move away from a top down one-way communication dominated model. Better integrate the advances in the field of behaviour change theory into pandemic communication/preparedness programmes. Develop pandemic preparation guidance and tools that promote Comprehensive strategic planning driven by SMART behavioural objectives.
5. Vaccination preferences predicting vaccination uptake
Insights in the preferences of European citizens for vaccination programmes for future pandemic outbreaks, can facilitate health policy makers to improve pandemic preparedness plans and communication strategies, in order to make future vaccination programmes more successful.
In case of a severe outbreak, vaccine effectiveness is the most important characteristic determining vaccination preference. The body that advises a vaccination is found to also strongly affect preferences in all countries, with respondents being more sensitive to advice against compared to advice in favour of vaccination. In Sweden, the advice of family and/or friends and the advice of physicians strongly affect vaccination preferences, in contrast to Poland and Spain, where the advice of (international) health authorities is more important. Besides the vaccination advice, out-of-pocket costs are important for Dutch and Swedish respondents in the case of a mild outbreak, while for respondents from Poland and Spain effectiveness of the vaccine is important. A tool has been developed through which different vaccination uptake scenarios can be simulated to support the planning of a vaccination strategy.
Differences between countries with regard to preferences for pandemic vaccination are substantial. Increase vaccination uptake by letting different representatives, such as physicians or international health officials, step forward within each European country, to advise the general public on vaccinations during future pandemic outbreaks.
6. Healthcare workers and vaccination uptake
Healthcare professionals are the primary contact for the public in health matters. They therefore have an important role in informing the public and promoting the adoption of preventive measures. Europe-wide surveys showed that 80% – 90% of people trust health professionals most to inform them about the pandemic flu.
General practitioners (GPs), but also healthcare support staff like midwives and GP-assistants, have a strong influence on vaccination decisions that people make. However, healthcare workers themselves are often not vaccinated for seasonal flu, nor were they for A/H1N1. They sometimes feel that they do not belong to a risk group (on account of their age for example), ignoring that they belong to a priority group for vaccination on account of their profession. Non-vaccinated healthcare workers are shown to have less knowledge about influenza/vaccination and feel less comfortable to promote vaccination to patients.
Develop special risk communication strategies for healthcare workers and educate them on their role and responsibility in influenza transmission and prevention. Rather than generic information, provide information tailored to the need of different professional groups to get them on board. Combine educational campaigns with vaccination promotion strategies for healthcare workers, like improved access to vaccination, the use of incentives/disincentives, or the use of role models. Mandatory vaccination programs for healthcare workers have reached maximum uptake levels, but remain controversial.
7. Communication strategies for under-vaccinated groups
Under-vaccinated groups (UVGs) can be identified by means of outbreaks within their community, by vaccination coverage studies, and by (grey) literature. It is necessary to develop outbreak communication plans for these groups in case of major epidemic outbreaks of a vaccine preventable disease.
UVGs are often as diverse in their opinions and actions regarding vaccination as the rest of the population; however they do have distinct information, access and support needs. There is overlap with the needs of the general population.
To be effective, do not wait for the next outbreak to initiate communication with UVGs. Undertake regular and proactive communication and dialogue with these groups to build relationships and trust. Develop intervention strategies for UVGs that are directed at important determinants, which can similarly be used for the general public, and that are based on common communication and behavioural tactics used with the whole population. Nevertheless, adapt the tactics to reflect specific needs of different communities in order to be effective.