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Journal of Health Communication: International Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcm20

Reputation, Relationships, Risk Communication, and the Role of Trust in the Prevention and Control of Communicable Disease: A Review a

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Georgina Cairns , Marisa de Andrade & Laura MacDonald

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Institute for Social Marketing, Stirling Management School, University of Stirling , Stirling , Scotland , United Kingdom Published online: 03 Dec 2013.

To cite this article: Georgina Cairns , Marisa de Andrade & Laura MacDonald (2013) Reputation, Relationships, Risk Communication, and the Role of Trust in the Prevention and Control of Communicable Disease: A Review, Journal of Health Communication: International Perspectives, 18:12, 1550-1565, DOI: 10.1080/10810730.2013.840696 To link to this article: http://dx.doi.org/10.1080/10810730.2013.840696

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Journal of Health Communication, 18:1550–1565, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2013.840696

Reputation, Relationships, Risk Communication, and the Role of Trust in the Prevention and Control of Communicable Disease: A Review

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GEORGINA CAIRNS, MARISA DE ANDRADE, AND LAURA MACDONALD Institute for Social Marketing, Stirling Management School, University of Stirling, Stirling, Scotland, United Kingdom Population-level compliance with health protective behavioral advice to prevent and control communicable disease is essential to optimal effectiveness. Multiple factors affect perceptions of trustworthiness, and trust in advice providers is a significant predeterminant of compliance. While competency in assessment and management of communicable disease risks is critical, communications competency may be equally important. Organizational reputation, quality of stakeholder relationships and risk information provision strategies are trust moderating factors, whose impact is strongly influenced by the content, timing and coordination of communications. This article synthesizes the findings of 2 literature reviews on trust moderating communications and communicable disease prevention and control. We find a substantial evidence base on risk communication, but limited research on other trust building communications. We note that awareness of good practice historically has been limited although interest and the availability of supporting resources is growing. Good practice and policy elements are identified: recognition that crisis and risk communications require different strategies; preemptive dialogue and planning; evidence-based approaches to media relations and messaging; and building credibility for information sources. Priority areas for future research include process and cost-effectiveness evaluation and the development of frameworks that integrate communication and biomedical disease control and prevention functions, conceptually and at scale.

Declining trust in public health organizations’ undermines public perceptions regarding their legitimacy to lead public health strategy and policy. Stakeholders’ willingness to engage with institutions and health systems in recommended programs of action and general population acceptance of behavioral advice are both strongly influenced by perceptions of probity, credibility, and competency. Perceptions of trustworthiness can therefore be a critical moderator of public health systems effectiveness (Abraham, 2009, 2010; Gilson, 2003). The significance of public trust in institutions and networks tasked with the prevention and control of communicable disease is receiving We acknowledge the work of Jennifer Infanti, Jane Sixsmith, and Margaret Barry. As the authors of the literature review on risk communication for the prevention and control of communicable disease, and our research partners in the European Centre for Disease Control and Prevention Health Communications project, their scholarship and collaboration has been much appreciated. Address correspondence to Georgina Cairns, Institute for Social Marketing, Stirling Management School, University of Stirling, Stirling FK9 4LA, Scotland, United Kingdom. E-mail: [email protected]

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increasing recognition (Glik, 2007; Holmes, 2008; Springston & Weaver Lariscy, 2005; Wise, 2008). The success of strategy and policy in times of low risk as well as crisis and emergency ultimately depends on a critical mass of positive stakeholder responses (i.e., the general public, at-risk groups, health care partners) to proposed voluntary actions such as immunization and handwashing (Gilson, 2003; Larson & Heymann, 2010; Pitrelli & Sturloni, 2007; Springston & Weaver Lariscy, 2005; Taylor-Goodby, 2004; Wise, 2008; Wynia, 2006). Communicable disease prevalence and transmission patterns are complex, dynamic, and uncertain phenomena. New pathogenic agents are emerging and old infectious diseases are reemerging; their prevalence and transmission is influenced by global changes in travel; diet; employment; population growth; geography; and other sociocultural behaviors, customs, and practices (Oppong, 2009). The transnational movement of goods, livestock, and people is now the norm, for example. This is contributing to a dynamic global circulation of communicable disease and limiting the potential effectiveness of traditional place-based control strategies such as exclusion zones and travel restrictions (Kittelsen, 2007). Furthermore, the rapid rise of digital information technologies has facilitated the globalization of information, discourse, and news. Stakeholders now have myriad opportunities to seek, assimilate, and act on information independently of public policy sources of information, and to challenge official opinion and advice. In contrast, technology is also creating new opportunities to gather data rapidly, to engage with priority audiences, and to support coordination at international levels. In the face of epidemiological, technological, and cultural shifts, a compelling rationale for the strategic application of communication principles and tools in the control and prevention of communicable disease is emerging: Communications can be a key moderator of stakeholder relationships, organizational reputation, risk perceptions, and stakeholder trust in the competency, credibility, and legitimacy of communicable disease public health organizations to lead strategy and policy for disease prevention and control (Glik, 2007; Longest & Rohrer, 2005; Pitrelli & Sturloni, 2007; Smith, 2006). The concepts of trust, reputation, relationships, and risk communication are intuitively understood but are challenging in terms of precisely defining them in the context of communicable disease public health. For the purpose of this review, the following definitions underpin the evidence presented: • Trust is a heuristic used by a trustee who, under conditions of uncertainty, risk, and interdependence, is willing to allow the actions of a trustor (human, institutional, or system) to act in some ways on their behalf (La Porte & Metlay, 1996; McKnight & Chervany, 1996; Rousseau, Sitkin, Burt, & Camerer, 1998). • The reputation of public institutions and systems is determined by cumulative experiences and historic accounts of trustee–trustor relationships (Rousseau et al., 1998). • Relationships and relational experiences are moderated by communication and involvement in actions and final outcomes (Gilson, 2003). • Risk perceptions and risk communication are interdependent phenomenon, underpinned by uncertainty of outcome and the possibility of loss (Lofstedt & Perri, 2008; Seeger, Sellnow, & Ulmer, 2003; Slovic, 1987). In a communicable disease risk or crisis situation, the trustee’s perceptions of the satisfactoriness of the trustor to address the risk or crisis will draw on the trustor’s

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preexisting reputation, his or her past and present relationship experiences, and the credibility of the trustee’s advice; this will, in turn, determine the willingness of the trustee to engage in preventive or emergency behaviors proposed by the trustor. An understanding of communication good practice and how to integrate with more established biomedical functions is still in its infancy but is growing; this article is a response to the emerging recognition of its critical role (Holmes, 2008; Wise, 2008). The purpose of the review was to synthesize the current evidence base with the aim of identifying good practice, underpinning theories and paradigms, and evidence gaps. The review examined the international evidence base and highlights evidence of particular relevance to European research, policy, and practice. Communication in the context of this article describes listening and the scanning of public response activities as well as the crafting and targeting of messages.

Method Our article synthesizes two literature reviews—on trust and reputation management (Cairns, MacDonald, de Andrade, & Angus, 2011) and risk communication (Infanti, Barry, & Sixsmith, 2012). Both reviews were commissioned by the European Centre for Disease Control and Prevention. The objectives for each review were to summarize the emergent knowledge base relevant to communicable disease, and identify evidence for, and insights on, good practice, policy, and research. There was significant overlap of the evidence and good practice principles, with a much larger evidence base identified for risk communication than for trust and reputation management, reflecting the longer history of risk analysis research. Full details of the search strategies for both literature reviews are described in published reports.1 We briefly describe a combined overview of methodologies: We searched 15 databases for English-language academic references (CINAHAL, Medline, PsycINFO, Web of Science, Business Source Premier, HealthComm Key, The Johns Hopkins Institutions of health communications in noncommunication journals, Embase, EPPI-Centre, SAGE Journals Online, Scopus, Biomedical and Life Sciences Collection, Campbell Library, Cochrane Library). Health, Risk and Society was hand-searched for both literature reviews to identify additional relevant studies that were not indexed by the databases searched. The Journal of Communication in Healthcare was also hand-searched for the trust and reputation management review. Health Research Policy and Systems and the Journal of Applied Communications were hand-searched for the risk communication review. Gray literature was identified for both literature reviews by searching websites of the European Centre for Disease Control and Prevention (and the sites of the scientific and technical institutions that comprise it); the World Health Organization; the U.S. Center for Disease Prevention and Control; the U.K. Health Protection Agency; and Health Canada. In addition, the Health Protection Scotland website and Google were searched for the trust and reputation management review; and for risk communication review, the websites of the Australian Institute for Health and Welfare; Infectious Disease Research Network; King’s Fund; ProQuest Database of Dissertations and Theses; and the Networked Digital Library of Theses and Dissertations were searched. 1 Available at http://www.ecdc.europa.eu/en/publications/Publications/Forms/ECDC_ DispForm.aspx?ID=763 and http://www.ecdc.europa.eu/en/publications/technical_reports/ Pages/index.aspx

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Exploratory searching and coding found there was very little research, reporting, or commentary explicitly examining trust and reputation management for the prevention and control of communicable disease. Thus, a very broad-based search strategy, using related but indirect terms and careful reading of the literature to identify evidence on trust and reputation management included as a subtheme in reports and papers was developed and tested. In contrast, a rich and substantial body of literature on risk communication in communicable disease public health was apparent. The trust and reputation management search was restricted to English-language literature published between January 2005 and August 2010. The risk communication search strategy aimed to identify literature published during the period January 2000– 2011 in English (with additional searches for any non-English data on the websites of European Centre for Disease Control and Prevention Competent Bodies). Neither search strategy included any geographic restrictions. The trust and reputation management review identified 50 evidence sources, and the risk communication search identified 130 evidence sources. There was an overlap of eight reports/papers that were identified by both. The much larger number of references on risk communication reflects the steady growth in recognition since the 1990s of the effect of risk communication on public health outcomes, whereas as noted by Glik (2007) and confirmed by our pilot searches, trust and reputation management activity began more recently.

Results Underpinning Theories in Risk Communication Individuals’ interpretation of risk information is influenced by multiple social and cultural factors, and underpinning paradigms are inherently interdisciplinary and integrative (McComas, 2006). Industrial and ecological health risk communication research has been an important source of evidence for infectious disease risk communication (Holmes, 2008). Four risk communication models—risk perception, mental noise, negative dominance, and trust determination—were identified in the literature as useful and relevant to communicable disease (Heath, 1997). The risk communication model notes that characteristics shaping how individuals perceive risk include the voluntariness, equity, uncertainty, reversibility, and origin (human vs. natural) of the risk (National Research Council, 1989; Sandman, 1989; Slovic, 1987). Beliefs that society is exposed to severe risks and perceptions of possible threats are for many as salient as actual tangible hazards (Health Protection Network, 2008). The ability to control and manage exposure to risk also influences perceptions of risk (Eriksson, 2001; McInnes, 2005). These features moderate emotional, cognitive, and behavioral responses to the risk messages received. This, in turn, affects individual and population levels of fear, anxiety, outrage, worry, concern, anger, and hostility (Covello, 2003; Fischhoff, 1995, 2005; Fischoff, Lichentenstein, & Slovic, 1981; Sandman, 1989; Slovic, 1987). The implications are that any risk communication strategy that neglects to take into account psychosocially mediated perceptions of risk is destined to fail. In contrast, it might be successfully advanced by maintaining an interactive exchange of information with stakeholders about emergent concerns (Covello, Peters, Wojtecki, & Hyde, 2001). The mental noise model recognizes that in conditions of stress, individuals’ ability to process risk information efficiently is dramatically weakened (Baron, Hershey,

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& Kunreuther, 2000; Fischhoff, 1989; National Research Council, 1989). To facilitate individuals’ understanding of risk when in this state, risk communicators are advised to produce mental/conceptual models mapping out the situation with clear and logical messages using duplication and visualization to connect with target audiences (Covello et al., 2001; Fischhoff, Bostram, & Quadrel, 2002; Glik, 2007; Glik, Drury, & Cavanaugh, 2005; Morgan, Fischhoff, Bostrom, & Atman, 2001; National Research Council, 2000). The argument that negative messages should be balanced with positive and proactive messages in risk communication (Covello, 1998) is grounded in the negative dominance model, which suggests that people will focus on losses and negative effects when distressed rather than positive information and news (Covello et al., 2001; Glik, 2007; Maslow, 1970). Trust determination theory provides further explanation for the tendency of people to distrust authority when upset (Berland, Elliott, Morales, Algazy, & Kravitz, 2001; Glik, 2007; Renn & Levine, 1991). Building trust before a tangible threat arises is, thus, paramount in the construction of effective risk communication messages and strategies (Covello et al., 2010; Peters, Covello & McCallum, 1997; Slovic, 1999). More recent thinking on risk communication has been informed by social constructionist approaches. These paradigms emphasize sociocultural processes as a determinant of public acceptance of risk messages (Joffe, 2003; Lion, 2001). In these models, risk is not treated as a factor to be monitored and measured in isolation but as a modifiable social phenomenon moderated by diverse communities. Interpretation and assimilation of information is determined by audience assessment of the ability of the messenger to listen and empathsize, as well as other indicators of trustworthiness (Garvin, 2001; Lupton, 1993). These models emphasize risk communication must address the specific needs of multiple populations, including the more vulnerable (Hutchins, Truman, Merlin, & Redd, 2009). Evidence of Effectiveness Advance Planning The importance of planning communication strategies in advance and being prepared for unanticipated outbreaks/epidemics is emphasized in the literature. Preparedness will have a direct impact on the trustworthiness of an organization (Heath, 1997; Springston & Weaver Lariscy, 2005). Several guidance documents and planning materials are available (Abraham, 2011; Glik, 2007; Health Protection Network, 2008), but evidence suggests that recognition of the need for advance planning is suboptimal across all levels of the public health community (Paek, Hilyard, Freimuth, Barge, & Mindlin, 2008; Barnett et al., 2005; Fisher et al., 2011; Goddard, Delpech, Watson, Regan, & Nicoll, 2006). The Crisis Emergency and Risk Communication toolkit is an internationally recognized communication model (Hewitt, Spencer, Ramloll, & Trotta, 2008) that has been tested over the past decade, particularly during the 2009 influenza pandemic (Crouse Quinn, 2008). It includes guidance on initial precrisis phases with risk messages, warnings, and preparations (Reynolds & Seeger, 2005). Glik’s (2007) review of risk communication for public health emergencies notes the importance of pretesting risk communication messages before crises emerge, particularly with at-risk and hardto-reach communities. Planning in advance is also one of five principles set out by the World Health Organization Outbreak Communication Guidelines’ following the 2005 SARS crisis (World Health Organization, 2005).

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A reflection on communication management during the 2009 H1N1 outbreak, however, illustrated that public health and research communities were not equipped to manage the difference between what was anticipated and what materialized. This occurred despite years of focused preparation and the issuance of guidance following previous outbreaks, because governments’ health experts had planned for a highly virulent avian influenza virus, but a less virulent influenza surfaced (Fisher et al., 2011). Planning teams were subsequently advised to experiment with communication principles under stimulated situations of time constraints and anxiety (Freimuth, Hilyard, Barge, & Sokler, 2008; Holmes, 2008; Janssen, Landry, & Warner, 2006). The literature suggests that using social marketing as a planning tool in situations may overcome some of the difficulties of managing the evolution from risk to crisis communication needs. For example, conducting formative research and pretesting and tailoring of messages to defined population segments according to psychographic characteristics such as beliefs and understanding of risk can both support the monitoring of public sentiment and enable rapid shifts in communication operations and aims (Glik, 2007; Paek et al., 2008). Designing and delivering strategic plans informed by projections of future trends is considered to be a key component of an establishment’s reputation and relationship management strategy. It can directly affect perceptions of dependability. Advance issues management planning also makes it possible for organizations to anticipate and avoid potentially hostile behaviors, while ascertaining which actions would be advantageous to key audiences (Heath, 1997; Springston & Weaver Lariscy, 2005). Anticipating the complex interaction of psychological, social and cultural influences on risk perception amongst stakeholders is also essential to pragmatic planning for risk communication (Holmes, 2008; Leiss, 1995; McComas, 2006). A message action plan that is based on knowledge of the expectations of audiences and existing relationships and lines of communication is particularly valuable for crisis communications teams (Mitchell, 1986). Such efforts may be complemented by preemptive communication strategies, such as the dissemination of updated information on educational websites and newsletters before emergency situations emerge in order to prepare key audiences for possible eventualities (Longest & Rohrer, 2005). By presenting risk communication messages long before a crisis event occurs, the probability of it occurrence might be reduced (Seeger et al., 2003; Sellnow, Ulmer, Seeger, & Littlefield, 2009). Participatory Dialogue Notwithstanding the need to plan ahead, communications teams also need to be prepared to modify messages if circumstances change (Vaughan & Tinker, 2009) and have an awareness of the active role participants play in communicative processes (Alaszewski, 2005). Participatory dialogue is especially useful when developing risk communication strategies. It may address a risk that has not progressed to crisis level or indeed may never become one (Holmes, 2008; Veil, Reynolds, Sellnow, & Seeger, 2008). A model of two-way symmetrical public relations allows for “bargaining, negotiating, and strategies of conflict resolution to bring about symbiotic changes in the ideas, attitudes, and behavior of both the organization and its publics” (Chong, 2006, p. 7). The exchange of information in this manner suggests that risk communication is intrinsically a dynamic and interactive process, supporting dialogue between several groups of significant stakeholders and audiences (Glik, 2007). Information is filtered, interpreted, and potentially distorted by receivers’ personal values and concerns. Communicators are therefore advised to overcome

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interpersonal obstacles by actively engaging with stakeholders and avoiding one-way communication from experts to the public (Abraham, 2010; Adil, 2008; Alaszewski, 2005; Holmes, 2008; Menon, 2008; World Health Organization, 2005). This serves as an act of empowerment for stakeholders: The process of receiving consequential and pertinent information raises awareness of the risks pertaining to a specific issue. This, in turn, gives stakeholders the opportunity to make informed choices and acquire a sense of control over their own well-being (Abraham, 2010; Adil, 2008; de Sa, Mounier-Jack, Coker, 2009; Health Protection Network, 2006; Menon, 2008; World Health Organization, 2005). This highlights the reality that target audiences are unlikely to simply accept advice imparted from experts through proper channels and thus make the correct decision when presented with information (Glik, 2007; Holmes, 2008; Smith, 2006). Compliance with advice might emerge only as relationships are built, nurturing trust and loyalty and a shared understanding of risk (Abraham, 2010; Adil, 2008; Alaszewski, 2005; Hastings, 2009; Holmes, 2008; Menon, 2008; World Health Organization 2005). Because different groups have diverse needs and interests, it is also necessary to remember that the public is not homogenous and that levels of engagement might change throughout the communication process (Health Protection Network, 2008; Veil et al., 2008). There have been calls for crisis, emergency, and rick communications to integrate some of the instruments of community development and participatory action research in order to draw on the abilities, aptitudes, and spirit of minority communities when responding to crisis events. It has been suggested this could help foster trust between government bodies and these minority communities in nonemergency periods (Crouse Quinn, 2008).

Strategically Understanding and Managing Media Relations Information presented through the media may threaten public assurance and evoke confusion and fear, particularly in times of crisis. Evidence suggests that the public’s perceptions of risk are related to media portrayals of risk, so messages need to be carefully framed to overcome this (Glik, 2007). The measles, mumps, and rubella vaccine controversy illustrated how understanding and managing media relations on this basis are of utmost importance (Hackett, 2008). Distressing media reports about health risks might make individuals feel vulnerable as they deem themselves unable to control the situation (Holmes, 2008). Communication strategies during infectious disease outbreaks need to take into account the media’s influence on societal perceptions of well-being and poor health and the shifting suppositions about where responsibilities lie during a crisis event (Ungar, 1998). When crises or potential crises emerge, the media invariably acts as an informant with or without the assistance of authoritative agencies. Hence, organizations are advised to collaborate and meaningfully engage with the media (Health Protection Network, 2008). The literature makes reference to various countries’ and organizations’ successes and failures while working with the media during the SARS outbreak. In Taiwan, the government’s prompt establishment of horizontal and vertical communication networks to inform the media of developments had a positive influence on coverage, for example. However, it should also be noted that over-reporting of the country’s ongoing response to the epidemic in an attempt to dispel panic was found to be damaging

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(Wu, 2006). Lessons learnt from communication during the crisis included treating the media as a true partner rather than an adversary; minimizing negative statements; correcting erroneous media reports as soon as they emerge; collaborating with the foreign press and World Health Organization; and minimizing contradictory reports from local and central government bodies (Wu, 2006). The Hong Kong government was accused by the media of underpreparedness regarding its handling of the SARS outbreak. Trust and reputation was undermined further in subsequent coverage, which included accusations of impotence and unjustifiable lack of transparency. One review concluded that it might have benefited from selecting a central media spokesperson from its government communications department (Lee, 2009). In contrast, Singapore’s media management during the SARS epidemic was found to have consolidated government agencies’ credibility and transparency (Menon & Goh, 2005). Rigorous procedures were instituted, ensuring press releases were appropriate and that daily press conferences that were conducted with the Minister of Health (and at the peak of the crisis with the prime minister) answered topical queries and verified “the authority and credibility of information issued” (Menon & Goh, 2005, p. 377). Planning and disseminating press kits and articles and letters in newspapers about a public health organization’s awards and achievements during times of low risk may also serve as reputation- and trust-building exercises. These activities improve an organization’s relationship with the media and can be advantageous during times of crisis despite the terms of engagement shifting in response to changing circumstances (Longest & Rohrer, 2005). Journalists will demand access to updated information and schedules on a regular basis; seek clarification when rumors emerge; and expect to correspond with experts (Health Protection Network, 2008). Their reports will be fundamentally based on the preliminary message they receive from organizations, so the initial exchange of information needs to be comprehensive and accurate (Health Protection Network, 2008). Inaccurate health risks are likely to generate media triggers particularly if a situation is believed to be secretive and affect many people, if there is evidence of distress, or if individuals or organizations are being blamed (Health Protection Network, 2008). It has been suggested that members of health organizations should receive media training in order to develop the communication skills needed to be tolerant of media probing and to answer questions truthfully and transparently (Health Protection Network, 2008). The literature also suggests that that pre-event media monitoring and audience survey research will improve message planning and execution (Glik, 2007) and that communicators should avoid criticizing other organizations’ responses during a crisis (Health Protection Network, 2008). Credibility and Consistency of Message Source Although members of the public receive much of their information from the mass media, research suggests that they are more likely to trust messages from authoritative organizations or individuals and doctors (Hackett, 2008; Kristiansen, Halvorsen, & Gyrd-Hansen, 2007). It is imperative for these sources to have a preestablished reputation for integrity and to be consistent with one voice when trying to allay fears and avert panic (Chong, 2006). In times of crises, the public are inclined to rely on advice provided by friends, family and medical professionals who they have trusted in the past (Glik, 2007; Taylor-Goodby, 2004). They are more likely to doubt the reliability of sources

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with commercial interests in the subject (Frewer & Miles, 2003). Individuals may “make conscious decisions to avoid certain information sources” (Alaszewski, 2005, p. 101). Message sources therefore need to be selected with a view to upholding an organization’s credibility. The positive effects of selecting a demonstrably expert, trustworthy, and sincere spokesperson who is fully trained as a communicator has been emphasized in evaluations of the SARS and H1N1 outbreaks and in good practice recommendations (Abraham, 2009; Health Protection Network, 2008; Wu, 2006). If organizations fail to present credible messages in a visibly organized and responsive way, neutral or favorable precrisis reputations might become tarnished. The 2001 U.S. anthrax mail attacks provided illustrative learning and insight: Workers and government employees reported frustration with the lack of clear, consistent, and accurate information. They reported feeling that local hospitals and doctors were incapable of providing knowledgeable assistance because they had been “gagged” (Blanchard et al., 2005). The literature also highlights the need for messages to be consistent and free of jargon (Chong, 2006; Health Protection Network, 2008; Springston & Weaver Lariscy, 2005). Evaluation of the U.K. National Health Service’s consistent use of the sneezing man image and the “Catch it, bin it, kill it” slogan during the 2009 H1N1 pandemic found it to be a clear message throughout the pandemic (Hine, 2010). A useful good practice recommended for ensuring consistency and clarity of communication is to develop a “single overriding communication health objective” (Health Protection Network, 2008, p. 20). This objective should concisely and simply capture the nature of the risk and what action is required to mitigate adverse consequences and provides a quality assurance check for related messaging (Health Protection Network, 2008).

Transparency, Even of Difficult Content Communications need to convey negative developments as openly and transparently as possible. Communication management strategies need to expressly aim to refute damaging reports by the press (Menon & Goh, 2005). Message sources are strongly encouraged to avoid denying the extent of a crisis or feigning control over unknown situations. Transparency is recognized as crucial for cultivating and sustaining public trust (Health Protection Network, 2008; World Health Organization, 2005), while denial can lead to suspicion (Pitrelli & Sturloni, 2007). Furthermore, openly acknowledging “ignorance of health-critical-information” might be necessary in some circumstances (Chong, 2006, p. 10). Communicating uncertainty is at the core of risk communication because there is the possibility that risk events may not occur in the future (Abraham, 2010). The literature indicates that in risk communication it is important not to downplay ambiguities. Honestly admitting and conveying uncertainty can be key to building and maintaining public trust (Abraham, 2010; Health Protection Network, 2008; World Health Organization, 2005). Transparency is critical in risk (and also crisis) communication (University of Hong Kong Journalism and Media Studies Centre, 2006; World Health Organization, 2005). Communicating transparently is “not just a noble end in itself; it can also mitigate some of the serious reputational risks being faced” (Stronach, 2008, p. 357). The transparency and honesty of the communication messages used by the Singaporean government during the SARS epidemic have been credited as the reason for

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its success in gaining the trust and confidence of its general population (Chua, 2004; Menon, 2008).

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Evidence Gaps The review identified various guidelines and essential elements of effective risk communication in the context of communicable disease public health. Evaluations of communications during the global outbreak of SARS in 2003, in particular, have been used as a source of learning for good practice in communicable diseases communication (Menon, 2008). There is, however, a lack of appraisal of how risk and in the event of a crisis emerging, communication processes unfold during real-life events (Glik, 2007). Evaluations of the cost-effectiveness of investments in routine monitoring and other long-term strategic predictions in building trust, are also absent from the current literature. Several studies have shown that risk communication for communicable diseases has failed to reach intended communities particularly those most at risk (Blumenshine et al., 2008; Braverman, Egerter, Cubbin, & Marchi, 2004; Crouse Quinn, 2008; Reynolds, 2007). To understand why, there is a need for research that captures the breadth, depth, and variability of public comprehensions and perceptions of risk; optimal sources of risk information; and common health beliefs, especially among minority and hardto-reach communities (Blanchard et al., 2005; Elledge, Brand, Regens, & Boatright, 2008; Morrison & Yardley, 2009; Voeten et al., 2009). Although research highlights the value of a participatory approach to communication (Holmes, 2008; Veil et al., 2008), there is a paucity of work addressing how conflicts between stakeholders can be managed, particularly when crises emerge. Stakeholder management in this context is hardly discussed. Research on communication during non-outbreak/crises phases is also needed to understand more about optimal approaches (Schuchat, Bell, & Redd, 2011). Immediately initiating research at the start of an outbreak can be useful, revealing knowledge gaps and capacity limitations of health systems at local, national, and international levels (Fisher et al., 2011). Adopting an integrated global and local approach is now increasingly recognized as fundamental to effective risk communication because of the global transmission of communicable disease and information. However, there is little empirical evidence on how systems of surveillance and communication can be harmonized and how economic, political, and structural determinants may encourage the diffusion of information (Elbe, 2005). Evidence-based strategies for contingency planning, needs assessments, and other advance-planning activities such as public education, awareness, and engagement schemes, are distinctly deficient in the literature (Barnett et al., 2005; Fisher et al., 2011; Goddard et al., 2006; Paek et al., 2008). Incorporating models of long-term behavior change into these communication tools may also contribute insight on good practice (Abraham, 2011; Kamate et al., 2007). Research on how the presentation of public health data and advice, moderates audiences’ assimilation and appraisal, and subsequent risk perceptions and risk reduction choices is also needed (Menon, 2008). Although there is clear evidence that an organization’s reputation will be damaged and its legitimacy undermined when it fails to communicate with the public effectively during times of crisis, there is still scant evidence on cure strategies when an organization has suffered trust and reputational damage (Chong, 2006; Longest & Rohrer, 2005; Menon, 2006; Paek et al., 2008; Springston & Weaver Lariscy, 2005; Stronach, 2008).

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Discussion Literature and practice is complicated by indistinct definitions and overlaps between risk communication and crisis communication. There is a critical difference between the two constructs. While the latter is directive and precise and deals with visible hazards, risk communication is innately indeterminate because it is the communication of uncertainty. Risk communication is not an instructive instrument, it is probably better understood as a discourse—the exchange of ideas between various stakeholders about something that might or might not become a threat in the future. Crisis management, including communications is fundamentally more reactive and reliant on short-term strategies prompted by emergency situations. It too can, however, be improved by advanced planning. The implementation of preemptive and strategic plans in non-outbreak periods, if successfully executed, can build reputation and prime stakeholders to engage and work together when outbreaks occur. Consistency in messaging locally, regionally, nationally, and internationally requires health agencies and systems to coordinate intelligence gathering and analysis as well as their external communications across and between national borders. Relationship and reputation management as well as risk communication are organizational functions critical to building trust, which is an organizational outcome. These three functions and the overall trustworthiness capital of the organization are, in turn, critical influencers on the effectiveness of the leadership required in communicable disease for prevention and control. At the policy level, investment in strategic planning is of the essence. Encouraging risk communications teams to develop plans with a broad base of stakeholders, but especially community-level health providers, opinion leaders, and the media is highly recommended. For researchers, building a more rigorous and comprehensive evidence base will be challenging and requires a cross-disciplinary approach. Theories and models of risk communication provide a valuable foundation from which to build more integrative models in the future. Research directly relevant to policy needs and drawing on the experience of practitioners and policymakers can provide strategic direction for the design of practice-based, academic research. The literature indicates that conducting process evaluations should also be a future priority. As communicable disease communications are multistep processes with sequencing and timing being important but difficult to plan and manage, better understanding of operational monitoring and management may also contribute to success in many rapidly evolving risk or crisis scenarios. Evidence on cost-efficiency is clearly also important for practitioners and policymakers, as communications must justify budgets otherwise available for traditional biomedical functions such as surveillance.

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