key: cord-0746285-6eg2cnxz
authors: Malecki, Kristen; Keating, Julie A; Safdar, Nasia
title: Crisis Communication and Public Perception of COVID-19 Risk in the Era of Social Media
date: 2020-06-16
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa758
sha: d7724e02604ed1d803485ad9a958e8180ac43aed
doc_id: 746285
cord_uid: 6eg2cnxz

A number of important principles in effective risk communication established in the late 20th century can provide important scientific insight into patient response to the risks posed by COVID-19 [1-3]. Early risk communication scholars studied public perceptions of risk in response to environmental disasters, or infectious disease outbreaks. They found acceptability of risk, and any limitations and acceptability of response by experts was shaped by two key components: hazard and outrage. The number of people who are exposed, infected and fall ill can be considered the hazard. How the public and patients perceive the risk and respond to messages regarding risk mitigation relates to outrage. Social and cultural factors, immediacy, uncertainty, familiarity, personal control, scientific uncertainty and trust in institutions and media all shape acceptability of response. These outrage factors influence the ever-changing public understanding of COVID-19 risk, as well as the public’s acceptance of personal and societal mitigation strategies. Risk perceptions and acceptability of mitigation strategies are also largely shaped in the context of culture and society. In concert, hazard and outrage along with cultural and economic context shape adherence to, and overall acceptance of, personal mitigation strategies including wearing facemasks, and social distancing among the general public. The spread of misinformation on social media in the context of crisis communication provides both challenges and opportunities for experts and officials to effectively communicate and influence these outrage factors. Social media offers an opportunity for experts to quickly convey true information about hazards, but offers others the opportunity to counter this with the spread of misinformation and exacerbate outrage. We propose strategies for infectious diseases clinicians to apply risk communication principles and frameworks to improve patient care and public message development in response to COVID-19.

As health care providers struggle to develop effective messaging to support patients' understanding, how the public perceives and responds to risk messages is critically important. A number of important principles in effective risk communication established in response to environmental disasters and pollution events in the late 20 th century can provide important scientific insight into patient response to the risks posed by COVID-19 [1] [2] [3] [4] . These insights have shaped risk communication and principles of risk communication for decades. Risk communication, focused on communication of hazards to potentially exposed communities, evolved in large part in the context of public health and environmental disaster response [5, 6] . In more recent years, the scope of risk communication has expanded to include communication strategies to better address ongoing public health challenges, including global pandemics and is referred to more specifically as crisis communication [6] [7] [8] [9] . Here, we discuss strategies for infectious diseases clinicians to apply these existing, early risk communication principles and frameworks to effectively support patients and the general public response to COVID-19.

Key to understanding and responding to the ongoing COVID-19 pandemic is that perceptions of risk are driven by two primary factors: hazard and outrage [2, 4] . In other words, what a particular audience perceives as acceptable or unacceptable risk includes both the nature of the hazard and degree of outrage. Among the many early leaders in risk communication, Peter Sandman, Vincent Covello, Paul Slovic were among the first to offer psychometric insights to explain the importance of risk perception as being a combination of technical perceptions of hazard and outrage [1] [2] [3] 10] . Their investigations included careful psychometric studies of risk perception and factors that shaped the interactions between scientists and the general public.

What they found was the actual threats to health were only one aspect of risk perception. Risk A c c e p t e d M a n u s c r i p t perception was also shaped by factors that altered acceptability of risk in the minds of different audiences, messages and in different context. For example, despite clear evidence that wearing masks can reduce transmission to COVID-19, the acceptability of and adherence to wearing masks varies greatly. In the United States, mask wearing has become more of a political issue than a fact-based intervention, and thus the use of masks varies widely among populations. In other communities and countries, mask wearing is seen as a reasonable strategy, and masks are commonly used by the public [11] . The variation in acceptability and willingness for individuals to respond to expert opinions creates significant challenges for health education among patients [11] . Clinicians are scientists trained to respond to facts, however, research has shown the public and patients perceptions, concerns and response do not always conform only to science and reason 4 . Subsequently, the hazard and outrage framework was established as a way to demonstrate how risks are often perceived differently among technical experts including health care providers, epidemiologists and front-line workers and the general public [3, 10] . From this the science of risk communication was established [6] .

Technical experts define risk based on quantitative hazard information regarding the burden, etiology and spread. Most often, even when factual information about a hazard is provided, the public perception of risk from an unknown and emerging hazard such as COVID-19 leads to a more emotional response, or outrage. Outrage, in turn, shapes acceptability and adherence to risk mitigation strategies such as social distancing and wearing of face masks [1, 3, 10] . Therefore, outrage factors shaping public risk perceptions are important for clinicians to understand, because they will determine how and why the general public will react and respond to messages [4] . In other words, scientists are often perplexed by public perceptions and is often more successful than if communication is led solely by individuals who are not subject matter experts [6] . As such, it is important for infectious diseases clinicians to be well prepared to lead risk communication during crises, in this case, the COVID-19 pandemic.

While news outlets have always played an important role in informing and shaping public perception of risk, social media has rapidly become a major driver of what the public understands and responds to. Experts can use social media in crisis response by rapidly spreading hazard information and helping inform the public and patients on actions they can take to mitigate risk [7] . At the very same time, social media can rapidly spread misinformation across large portions of the public. Public outrage driven by social media must be considered by experts to understand and deploy effective communication strategies aimed at mitigating and control of risks overtime [7] [8] [9] . While these larger social forces are difficult to control, the hazard plus outrage framework can help clinicians and public health experts remain trusted sources in the fight against COVID-19.

A c c e p t e d M a n u s c r i p t

The unfolding scale and intensity of the COVID-19 pandemic makes clear that engagement with and by the public is essential for effective risk reduction, mitigation and ultimate control [8, 12] . Figure 1 outlines a framework and set of guidelines that builds on past crisis and risk communication strategies that can support clinicians in their response to COVID-19 adapted from early hazard + outrage frameworks that also takes into account new understanding of the cultural and social media context shaping the pace and mode by which information is shared 2-7 . Hazard information conveyed by experts includes facts and information on the transmission, mechanisms and severity of disease. This is all set within the context of feelings and emotions that are shaping public outrage. The public perception of risk from COVID-19, as an unknown and emerging hazard, is considerably shaped by outrage. Key factors shaping outrage toward COVID-19 include catastrophic potential, familiarity, understanding, scientific uncertainty, personal control, voluntariness, trust in institutions and media attention (Table 1) . Outrage is an emotional response shaped not only by factors surrounding the nature and characteristics of hazards, but the degree to which individuals and communities deem risks as unsafe, unacceptable, or something to be fearedwhich in turn influences how individuals and communities respond to and adhere to important public health messages regarding risk mitigation [1] . It also shapes the public's acceptability of and the adherence to COVID-19 risk mitigation strategies such as social distancing and use of face masks [1, 3, 10] .

When there were only a few cases of COVID-19 scattered across the United States, public perception of COVID-19 risk was low. Despite early warnings by experts regarding the A c c e p t e d M a n u s c r i p t catastrophic potential of COVID-19, over 25% of Americans felt that they had a less than 1% chance of becoming infected [13] . This perception was reinforced by some government leaders. Consequently, early attempts by public health authorities and experts to mitigate risk by encouraging social distancing and wearing masks were seen as invasive, alarmist, too much government interference, and an unnecessary burden on economic growth. At the same time, early research from California also found that while individuals disagreed on the true nature of the hazard or risk of exposure and adverse outcomes related to COVID-19, the acceptability and adherence to social distancing increased as more information on the nature of the hazard emerged [14] .

The lack of familiarity around COVID-19 has also shaped public perception and response, with some in the public becoming extremely anxious while others downplaying risks by equating it to something more familiar such as influenza [10] . Others who are fortunate to have few personal experiences with the illness or deaths are also willing to downplay societal risks. Adding to the challenge is the difficulty in understanding the complex and constantly changing scientific uncertainty surrounding COVID-19. Early in the outbreak, the public was willing to accept uncertainty; as we move forward, the pandemic presents challenges that make specific, actionable timelines and strategies for risk mitigation difficult. This uncertainty can again increase anxiety, stress, and fear, causing the public to dismiss risk altogether, or become angry about mitigation strategies. Communicating actionable steps for the public to take can help to reduce this anxiety and fear by increasing a sense of agency and personal control [2, 3] . In the case of COVID-19 the conflicting information and changing messages from experts that alter public perceptions is especially challenging [9, 15] . For example, many state officials, clinicians, and epidemiologists are currently investigating factors that influence immunity, and recommendations for when and how to relax social distancing measures. Given significant scientific uncertainty around COVID-19 immunity and asymptomatic infection rates and transmission, experts are examining local trends and data to develop plans for the current (and potential future) waves of infections. At the same time, the public is aware on social media that some states are relaxing social distancing steps to a wide-ranging degree while others continue to maintain stringent measures. Further, a large portion of the public is now facing "quarantine fatigue" in which many have been social distancing with little to no familiarity of A c c e p t e d M a n u s c r i p t risk, while suffering real economic consequences, all of which increase outrage, or a more emotional response. At the same time, some communities and workers, such as meat packers, face insurmountable risks. A lack of understanding and voluntariness around the public's participation in social distancing measures can contribute to decreased trust in institutions, and shape the public's willingness, or lack thereof to maintain social distancing.

Public trust in institutions that are perceived to be providing reliable information is important in crisis and risk communication [6, 10] . Early messaging by public officials that the COVID-19 pandemic was "under control" reduced the authority and messaging being delivered by technical experts regarding the true nature of risk. Similarly, the changing messaging from public officials around social distancing and use of face masks is likely to reduce trust in governmental institutions. Relative differences in media attention around the risk posed by COVID-19 differentially influenced the public's perception of the risk and mitigation strategies necessary to appropriately contain COVID-19 [7] .

The media has always played a critically important role in informing the public during crises and emergencies disasters; social media now also plays a large and growing role in shaping outrage and thus the public's perceptions of risks and mitigation [5] [6] [7] [8] [9] . Social media offers opportunities for both experts and the general public to quickly spread information to a large number of individuals [7, 12, 16] . Social media is therefore both an asset and barrier to developing effective risk communication strategies and response.

Clinicians can play a critically important role as trusted sources on social media to support the spread of new information as it becomes available, and address individuals patient concerns as they evolve, knowing that public perceptions of risk will vary greatly across A c c e p t e d M a n u s c r i p t individuals. The general public tends to choose select media channels for news, often in the context of political preference based on sources of news they trust [ 12, 15 ] . Social media can create an "echo chamber" of media attention, with individuals sharing messages and news with likeminded followers. Some consumers of social media will work to sort through the different information, however, this process increases the chances of encountering conflicting news and messages, and additional potential of finding material aiming to discredit reliable experts and news sources. Contradicting information can again increase a lack of understanding and reduce individuals' perceptions of their agency and control regarding risk and mitigation.

While our current social media era poses challenges in supporting the public's perceptions of risk, it can also offer experts many advantages [16] . If clinicians and public health experts can get ahead of the public in shaping messages, social media offers an almost immediate opportunity to spread information, become a trusted source, and to build relationships with the public. Experts can also use social media to quickly to contradict misinformation with accurate information, for example, by offering links to trusted health care providers and/or public health sources providing the same or similar messaging.

The dynamic nature of pandemics means that experts and public officials need to address different aspects of both hazard and outrage as information evolves [11, 16] . The actions required by the public to respond to pandemics also vary over time. The World Health Organization and Centers for Disease Control and Prevention have developed guidance to address the hazards and outrage shaping public perceptions of risk as crises unfold from pre-crisis to mid-crisis to postcrisis [8, 16] . In the case of COVID-19, there will likely be multiple phases of outbreaks and messaging that will need to be continually modified to meet these ongoing-communication Table 2 outlines key principles which may be useful in planning such communication at the individual, health system or population level including knowing your audience, engaging audience as partners, developing a plan, speaking with compassion, being transparent and honest, and evaluating frequently.

Months into the COVID-19 pandemic in the US, public outrage remains high with significant uncertainty around public perception of risk, the need for mitigation strategies, and the individual actions to take for appropriate mitigation. There are no right or wrongs, but we do have much that can be learned from the past. Understanding the fundamentals of risk perception is critical for clinicians and public health experts to be a collective and effective voice to mitigate risk and save lives. M a n u s c r i p t stay informed about how messages are being perceived and refine them to reach the right audience and consider cadence to avoid information overload while providing substantive updates.

Know your audience and develop new messages that address their changing concerns in a language that is relatable.

M a n u s c r i p t 

Perception of Risk

Risk Communication: Facing Public Outrage

Risk Communication, Risk Statistics, and Risk Comparison: A Manual for Plant Managers

Hazard versus Outrage in the Public Perception of Risk

Disaster planning and risk communication with vulnerable communities: lessons from Hurricane Katrina

Risk communication for public health emergencies

Coverage of Epidemics in American Newspapers Through the Lens of the Crisis and Emergency Risk Communication Framework

Crisis Communication in Public Health Emergencies: The Limits of 'Legal Control' and the Risks for Harmful Outcomes in a Digital Age

The Mediated Amplification of a Crisis: Communicating the A/H1N1 Pandemic in Press Releases and Press Coverage in Europe

The realities of risk-cost-benefit analysis

Rational use of face masks in the COVID-19 pandemic

Crisis Communication Best Practices: Some Quibbles and Aditions

Slightly More Than 1 Out of 4 Americans Believe They Have Almost No Chance of Being Infected With Coronavirus in Next 3 Months

USC Study Finds Increasing Actions and Risk Perceptions for Coronavirus

The Dark Side of Information Proliferation

Strategic Uses of Facebook in Zika Outbreak Communication: Implications for the Crisis and Emergency Risk Communication Model

M a n u s c r i p t NOTES:

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health."

Nasia Safdar is supported by the National Institute Of Allergy And Infectious Diseases of the National Institutes of Health under Award Number DP2AI144244.

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