In the first part, A/H1N1 epidemic curves were plotted for five EU countries (CZ, DE, DK, ES, and UK). In a time-series analysis, the following topics were explored for each country: 1) key events and major pandemic control measures implemented; 2) number of media messages released per week; and 3) public perception and public behaviour (vaccination uptake). In the second part, expert stakeholders from eight European countries, involved in the management of the pandemic, were interviewed with the aim of gathering qualitative information on the risk communication difficulties and their wishes for what could be improved.

Graphs illustrating the epidemiology, key events, media attention, and vaccination uptake during the A/H1N1 pandemic in the study countries, are available as country profiles and as a detailed report on this website. The stakeholder analysis report gives a detailed account of the information gathered from the interviews. Its key findings are summarized in a scientific article and in a report on this website.

Detailed content analysis of TV and newspaper messages published during the course of the pandemic A/H1N1 was conducted for three EU countries (CZ, DE, and ES). For each country the following topics were hand coded: 1) number of media messages; 2) content of media messages in terms of e.g. risk and safety measure reporting; 3) tone of coverage; and 4) stakeholders. A comparison of messages across different media, countries, and across time yielded how the media reported on A/H1N1.

Graphs illustrating the media attention during the A/H1N1 pandemic in the study countries, are available as country profiles and as a detailed report on this website. A media influence report describes critical episodes in the European media and a stakeholder analysis report identifies key players in the media debate. A journal article describes the relationship between media reporting and public risk perceptions and health behaviours.

Key findings from the behavioural review were: 1) conventional communication approaches have limits; 2) multiple interventions are more successful at influencing behaviour; 3) humans are not entirely rational when making health choices; 4) behavioural models and theory can help strengthen pandemic communication and behavioural programmes; and 5) it is not sufficient to consider an individual’s voluntary behaviour change in isolation from social and environmental factors. The segmentation and customer journey mapping of three countries showed that there was a lack of audience research used to inform communication strategies and tactics. Little consideration had been given to the emotional appeal in communication. The review of behavioural objective setting discovered that there is not a consistent set of SMART behavioural objectives for pandemic management.

Practitioners need to move towards a model that is based on citizen’s needs, dialogue and feedback and an approach that is responsive to demands and changing circumstances. The advances in the field of systematic health programmes and behaviour change planning need to be better integrated into pandemic communication and behavioural influence programme management. Behavioural influence and communications often exists as a bolted on adjunct to the influence of medical and epidemiological understanding in the policy development and strategy development process. Marketing and communication must be more strategically engaged in pandemic preparedness policy formulation.

A systematic review was performed on studies into risk perception and vaccination acceptance among the general population during the A/H1N1 pandemic. Also reviewed was vaccination willingness among healthcare workers, during both seasonal influenza and the A/H1N1 pandemic. Furthermore, an online survey was held in the UK, Poland, Spain and Sweden to study knowledge, attitudes, risk perception and information needs for seasonal influenza and a hypothetical pandemic influenza scenario. Reasons for accepting and declining vaccination were addressed in the survey as well. Lastly, the research team has developed a protocol for outbreak managers to identify the urgency and level of risk communication. The protocol was evaluated by the end user forum of outbreak managers from different EU countries.

Main reasons for vaccination refusal among healthcare workers are: 1) concerns about vaccine safety/side effects; 2) doubts about vaccine efficacy; 3) not feeling at risk; and 4) the perception that influenza is not serious/fatal. Non-vaccinated healthcare workers have less knowledge about influenza/vaccination and feel less comfortable to promote vaccination to patients. The public considers good hygiene and avoiding coughing/sneezing people to be more effective in preventing seasonal influenza than vaccination. Sketching a mild versus a severe pandemic influenza scenario (in terms of number of deaths and percentage infected) only has a minor influence on perceived severity, vulnerability, and intention to perform preventive measures.

Sixteen focus groups and a Discrete Choice Experiment (questionnaire) study among 2,000 adults were conducted in the Netherlands, Poland, Spain, and Sweden. Our research showed inter-country differences in vaccination preferences, especially regarding effectiveness, costs and pandemic vaccination advice. To increase vaccination uptake, the most important representative for a certain country, such as physicians or international health officials, will need to step forward to advise the general public on vaccination during future pandemic outbreaks.

For many people, to get vaccinated or not depends on disease characteristics (i.e. severity and susceptibility) and vaccination programme characteristics (i.e. effectiveness, safety, price, advice, and media attention). With the results of WP5, vaccination uptake can be simulated under different epidemic infectious scenarios with the developed scenario planning tool.

Six UVGs were identified in three countries (the Netherlands, Portugal and Romania) by means of outbreaks within their community, by vaccination coverage studies and by detailed review of (grey) literature: Anthroposophists, Orthodox Protestants, The Association for Conscientious Vaccination, Roma community, the ‘macrobiotics’, and the ‘critical citizens’. Their main determinants regarding vaccination were: 1) the perceived non-severity of traditional “childhood” diseases; 2) fear of vaccine side effects; 3) doubts about the effectiveness of the vaccine; 4) religious objections; 5) natural lifestyle; 6) low access to healthcare centres; and 7) little trust in public health authorities.

Among each identified UVG, there is a variety of beliefs and objections to vaccination and not all members have the same beliefs (within-group heterogeneity). However, various UVGs share similar beliefs (between-group homogeneity). For setting-up interventions, it is important to know which determinants are influencing intention and vaccination behaviour, so that interventions can be directed to the most important determinants. A matrix was developed with suggested communication and behavioural influence tactics for the determinants most easily influenced or amenable to change and most common among the different UVGs.

In this integration WP, a report was written including the key findings and results of WP 1-6, to be discussed at a joint meeting of all work package leaders. At this meeting, the main 7 key messages of the ECOM project were determined and elaborated on. These messages are presented elsewhere at this website.

An integration report was written, summarizing the findings of the first 24 months of the ECOM project. The report can be found under “Downloads”.

The CBSSM research group will test communication strategies in experimental designs using an Internet sample. One study aims to test uncertainty during the beginning stages of a pandemic. A second study will test the use of visualizations as tools to communicate information about incidence, mortality, and spread of the flu. It is the intention to incorporate effective visualizations into a final tool for outbreak managers which will be created by Elastique.. Two other studies will test the effectiveness of metaphors and testimonials as communication strategies to target segments of the population, convey emotionality in an outbreak situation, as well as test communication strategies for healthcare workers in the event of a pandemic.

Several reports detailing effective crisis communication, messaging, and online communication strategies to embed in outbreak responses, will be developed. Additionally, a report on potential behavioural intervention options using incentives and disincentives will be provided. The CBSSM research group is working closely with Elastique. to provide content for a communication tool for public health professionals and the public, to be utilized in the event of an outbreak.

In the Ecom project, Elastique. works in a consulting and practical way. A part of the work is to prove and improve the communication quality of scientific information graphics for a better risk perception. Through a close collaboration between scientific research, economy, and design, it is possible to develop and produce applications that are tailored to the particular needs of the different target audiences. Therefore, the printed and digital tools provide a better understanding and an applied support in a scenario of a pandemic outbreak.

Elastique. developed the poster Roadmap of a flu pandemic and its interactive version, which clarify the complex process of the course of a pandemic and give basic action directives. Secondly, they developed a prototype of the smartphone app PILA – Pandemic Information & Life Assistant, that can help health officials to communicate to their audience in times of an outbreak. The deliverables are completed by a collection of various guidance tools extended by two films. The first film gives a quick overview about the main findings of the whole Ecom project and the main tools contained in the final toolbox. The second film works as an index and shows quickly the use and benefit of each tool.