Effective Communication in Outbreak Management: development of an evidence-based tool for Europe

Final Report Summary - E-COM@EU (Effective Communication in Outbreak Management: development of an evidence-based tool for Europe)

Executive Summary:
Although scientific knowledge to respond to outbreaks of infectious diseases has increased, deficiencies remain in the ability of health authorities to communicate the need for large-scale measures such as vaccination and antiviral therapy and increase its acceptance. For effective behavioural and communication strategies, integration is needed of social, behavioural, communication and media sciences. We brought together these disciplines to go beyond the current knowledge to develop an evidence-based behavioural and communication package for health professionals and agencies throughout Europe in case of major outbreaks.

The main findings and implications from the scientific work packages are as follows:

1. Risk perception and recognition of personal risk status can be influenced by ‘trustworthy’ sources of information; some people want official information providers to be held responsible for the information they give the public.
Implication: Develop and promote trustworthy sources of information and individual decision aids and self-risk assessment tools.

2. Mass media / digital media have a spotlight effect that increases perception of risk but moves on in advance of later advice about appropriate action.
Implication: Health officials and politicians are the most prominent sources in news about an epidemic, so they can have a big influence on the content and tone of media coverage. During the spotlight, they should ensure to inform the public where to find advice later on about appropriate action. Develop a continuous flow of trustworthy, easy to access and interpretable information through all pandemic phases.

3. There is a need to target communication and behavioural programmes for different groups based on determinants, attitudes, cultural, religious beliefs and behaviour.
Implication: Test the ‘Return On Investment’ associated with investment in targeting programmes. Develop in country and regional segmentation models and a tailored communication and behavioural programmes. Develop segmentation guidance tools.

4. A dominant current characteristic of many existing programmes is a focus on rational decision making and the transmission of accurate advice. People are however not influenced by rational decision making alone when deciding to comply with recommended actions and behaviours.
Implication: There is a need to go beyond communication dominated responses and develop interventions that focus on non-rational decision making and behavioural influence including determinants, service access, design and delivery. Develop pandemic preparation planning guidance and tools that promote ‘Comprehensive’ strategic planning driven by SMART behavioural objectives.

5. Disease characteristics, perceptions of efficacy of advice and personal risk perception have a big impact on decision making and compliance with recommended actions and behaviours.
Implication: There is a need to develop scenario planning tools that reflect different disease trajectories and responses.

6. Health Care workers are key sources of information and public opinion, but are often not used optimally in such roles due to their lack of accurate risk perception and or understanding about risks associated with pandemic events.
Implication: Investigate this lack of awareness and willingness to accept their key public health role and develop strategies and tools to better inform and engage health care workers.

7. Under-vaccinated groups (UVG) are often as diverse in their opinions and actions as the rest of the population; however they do have distinct information, access and support needs.
Implication: Test the ‘Return On Investment’ associated with investment in targeting programmes at UVG. Develop UVG intervention strategies that reflect specific needs of different communities but are based on common communication and behavioural programmes used with the whole population.

8. Testing effective behavioural intervention and communication strategies gave the following results with regard to 1) Health spokesperson language: Unambiguous language produced higher vaccination intentions compared to language emphasizing the uncertainty surrounding pandemics; 2) Symptoms descriptions: Describing the most severe case produced higher vaccination intentions and knowledge compared to describing just the average case; 3) Visualizations: The “pictograph” trend line was evaluated the most positively, while the heat map was the most preferred. The dot map was least preferred and was evaluated the most negatively; and 4) Flu labels: The H11N3 Influenza label was preferred more than the other two labels (Yarraman flu, Horse flu).
Implication: Policy makers and communicators should choose evidence-based terminology and visualizations.

Project Context and Objectives:
Although scientific knowledge to respond to outbreaks of infectious diseases has increased, deficiencies remain in the ability of health authorities to communicate the need for large-scale measures such as vaccination and antiviral therapy and increase its acceptance. For effective behavioural and communication strategies, integration is needed of social, behavioural, communication and media sciences. We brought together these disciplines to go beyond the current knowledge to develop an evidence-based behavioural and communication package for health professionals and agencies throughout Europe in case of major outbreaks. This overall aim was reached through a number of specific objectives:
1) to assess the time-dependent influences of epidemiology and risk communication including media content on human behaviour during the A/H1N1 pandemic;
2) to analyse, using Social Marketing principles, vaccination behaviour, audience segmentation, and vaccination service delivery;
3) to analyse knowledge, attitudes, risk perception, vaccination non-response and reasons for resistance during past epidemics;
4) to apply Discrete Choice Experiments to determine acceptance of preventive measures in the case of epidemic outbreaks;
5) to integrate the key findings of the studies under objectives 1-3 to determine critical factors, groups and media to be addressed in the development of effective strategies;
6) to test behavioural interventions and communication strategies tailored to different target audiences; and
7) to finalize and disseminate a package of evidence-based tools that can be tailored to individual European countries.
The first phase of the project had a research emphasis, whereas in the second phase newly developed behavioural intervention and communication strategies were tested and translated into (web application) tools. The final package was disseminated among health professionals and outbreak management agencies.

The objectives for the individual work packages were:

Objectives WP 1
1. Identify the time dependent correlations between disease severity and progress, risk communication in the media, official recommendations and public behaviour during the 2009 A/H1N1 pandemic
2. Assess the stakeholders (e.g. public health officials) perceptions on official/public action/reaction during the different phases of the A/H1N1 pandemic
3. Assess the anticipated challenges and wishes for future pandemic management from the stakeholders’ perspective

Objectives WP 2
1. To identify key drivers and critical episodes in the media that influenced the public opinion and the perceived risks associated with H1N1 and related vaccination possibilities
2. To identify key players in the media debate about H1N1 in terms of opinion leadership, trustworthiness, and social influence

Objectives WP 3
1. To analyse how behavioural influencing approaches including incentives/disincentives can be used to promote service uptake
2. To review and analyse current vaccination service delivery to the public and to health care workers, from a customer perspective, in 3-6 European countries from different key clusters
3. To develop a prototype audience segmentation model indicating subgroups of people distinguished by attitudes, beliefs and behaviours in relation to uptake - with a particular distinction between the professional (e.g. health care worker) and the public (e.g. particular risk group) audiences
4. To develop a clear set of behavioural goals that can act as service impact metrics for different phases of a pandemic, including the pre-pandemic phase

Objectives WP 4
1. To systematically review studies into risk perception during the A/H1N1 pandemic
2. To systematically review studies into vaccination and antiviral therapy acceptance during the A/H1N1 pandemic among the general population
3. To make an overview of studies on willingness to comply with preventive measures regarding AH1N1 and seasonal influenza (such as vaccination) and reasons for (non) compliance among health care workers.
4. To identify 1) knowledge, attitudes, risk perception and information needs for seasonal influenza and new emerging infectious diseases, and 2) reasons for accepting and declining vaccination and antiviral therapy in at least 4 European countries from different key clusters
5. To develop a protocol for outbreak managers to identify the urgency and level of risk communication
6. To have the protocol evaluated by the end user forum of outbreak managers of national level from different EU countries

Objectives WP5
1. To select relevant attributes for the general public’s and health care worker's choice to adhere to preventive policies or not in epidemic outbreaks
2. To design discrete choice experiments (DCEs) in which each choice set consists of two vaccination and/or anti-viral prophylaxis alternatives, containing at most six attributes, and one opt-out alternative
3. To assess which trade-offs are made by several subgroups from the general population from four European countries from different key clusters regarding vaccine and anti-viral prophylaxis acceptance in epidemic outbreaks
4. To calculate the expected uptake of several base case vaccination or anti-viral prophylaxis programmes for several subgroups from the general population from 4 European countries from different key clusters
5. To develop a tool to adapt the DCE to differences among European countries

Objectives WP6
1. To present an overview of the complete spectrum of vaccine resistant groups, in three European countries from different key clusters
2. To analyse and present the cultural beliefs of the major/ most influential vaccine resistant groups in three 3-6 European countries from different key clusters
3. To present a road map for responsible Member States’ health agencies how to communicate with vaccine resistant groups in outbreak situations

Objectives WP7
1. To integrate and analyse the key findings from all other work packages to determine critical factors, groups and media to be addressed in the development of effective behavioural and communication strategies (WP 8 and WP 9)

Objectives WP8
1. To develop logic intervention models for each form of recommendation.
2. To identify effective communication strategies to target different audience groups, and to translate this into a tool for outbreak managers.
3. To identify effective behavioural interventions to target different audience groups and to translate this into a tool for outbreak managers.

Objectives WP9
1. To develop a “Roadmap of a flu pandemic” in the form of a printed poster and interactive version
2. To develop a guidebook for the tools developed in WP8 (a text- and film based online guidebook that allows health-communication experts to quickly link a present outbreak scenario to appropriate communication strategies and effective response measures)
3. To develop a complex smartphone application, working title: “PILA – Pandemic Information and Life Assistant”

Objectives WP10
1. Fine-tuning and integration of tools developed in WP 8 and WP 9 into a package of evidence-based behavioural and communication tools (e.g. e-tools) that can be tailored to individual European countries and to specific target audiences/segments as needed.
2. Provision of training to selected end users, including the members of the end user forum, in application of the package.

Project Results:
WP1
Dealing with the 2009 A/H1N1 pandemic: Time-dependent influences of epidemiology and risk communication on human behaviour

Results – WP1 objective 1:
All five study countries (Czech Republic, Denmark, Germany, Spain and the United Kingdom) were significantly affected by two influenza A/H1N1 waves – the first in spring and the second, larger wave in autumn/winter 2009. Contrary to the recommendations of the WHO and the ECDC the five countries continued to employ a strategy of containment until July/August 2009. The five study countries also implemented a vaccination program around the time of the second wave (starting between weeks 40 to 48) and all observed relatively low vaccination coverage among risk and priority groups. Although media attention patterns differed to some extent, the media attention in all five study peaked in week 18 shortly after reports of an unusually high number of cases and deaths from influenza like illness in Mexico were released and WHO declared pandemic alert level 4 and then 5. At that time (week 18) no or only few imported cases were reported in the European study countries. Media attention then dropped to lower levels after this first peak. While rising number of A/H1N1 cases and deaths or start of vaccination in the country during the second waves of the epidemic did result in some degree of media attention, this was substantially lower than the media attention in week 18. The finding that the media curves declined long before the epidemiological curves also reflects, in the rather low risk perception of citizens with respect to influenza A/H1N1 as identified by the Flash Eurobarometer survey and also in the low vaccination uptake across the countries.

Crucial periods for intensive risk-communication / Spotlight effect
The combined analysis of the elements primarily shows that contrary to expectations media attention does not necessarily increase with increased numbers of infections or casualties, it rather spotlights certain key events based on their news value and novelty. Hence even if preceding events in the own country – media attention should be considered as a window of opportunity to inform the public about resources where they can seek reliable information once it becomes available and when public interest rises. One can thus establish a channel for communication when the media spotlight has moved on to other issues. Such a channel could be a downloadable ‘App’ where people could receive up to date information, a prototype ‘App’ was developed by WP9 of the project. The analysis also revealed that vaccine uptake rose steeply during the first 4 weeks after start of the A/H1N1 vaccination across the five study countries after which it levelled out. This short period too could be regarded as a crucial time where attention should be paid to clear and intensive risk-communication.

Results – WP1 objective 2 & 3:
Qualitative interviews were conducted with public health experts involved in the management of the A/H1N1 pandemic either working in public health institutes at the national or regional level or with general practitioners or nurses who had direct contact with patients. Their experiences lend support to the notion that there is an urgent need for a more systematic and well-planned implementation of risk-communication strategies within the EU countries. Key elements extracted from the stakeholder interviews are listed below:

Fostering information exchange:
• National level public health experts stated that participating in Europe wide audio-meetings organized by DG Sanco was a very good forum for information exchange. Receiving first-hand information in a short time (before it became public) and also being informed about the situation and the response activities planned in other (especially neighbouring) European countries was considered very valuable. This helped health authorities to anticipate and respond to questions the public in their country might have regarding the pandemic control measures implemented and the recommendations given. [Suggestion: Audio-meetings organized by high level health authorities for key stakeholders is perceived as a good means of receiving reliable information.]
• Some health care experts at the local level criticized that they did not have opportunities to feed-back their first-hand experiences to the regional level about problems arising or measures considered redundant. Not seeing any sense in what they were being asked to do against the background of a heavy work-load was perceived as frustrating. Public health officials mentioned being confronted with decisions during the early phases for e.g. whether to close schools where exchanging information with other municipalities on how they are handling the situation would have helped. [Suggestion: Fostering information exchange by establishing a two-way feedback-loop between the different management levels is advisable for better compliance and for avoiding potentially unnecessary activities earlier on.]
• The role of the ECDC although being technically very sound, was perceived as inconspicuous in terms of impact and visibility of their messages, especially in comparison to the CDC in the US or the WHO. The wish to be able to completely rely on the information given by the ECDC as the voice at the European level and cite it as a justification for the decisions taken, was expressed.

Dealing with information overload
• Having one trusted and reliable source that summarizes the most important aspects regularly and clearly signposts or highlights the most important announcements on the website/email/fax so that these can be picked-out immediately, was suggested as a solution for simplifying the work, avoiding confusion and information overload.
• Apart from receiving information from the regional/national level when a change of situation or mode of operation warrants this, it would have been helpful to be informed at regular intervals (for e.g. once weekly) confirming that the recommended mode of operation is still in place, was a suggestion made by a regional public health practitioner.

Transparency and trust
• The importance of being transparent about the decision making processes against the background of the then prevailing situation and the available information, in order to be prepared against later criticism, was emphasized by a national level health expert. [Suggestion: The decision steps for pandemic management at each stage should be comprehensible, clearly documented and retrievable, e.g. through a website, for justification at a later stage.]

Finding the balance when communicating risks
• A national level public health expert and epidemiologist pointed out that the question which needs to be asked is ‘when does new information merit an information update?’. Decisions should be made on threshold levels for when a new update should be sent out so as not overwhelm especially front-line health-care professionals. The expert also mentioned the exponential importance of the first statement released about a topic. This statement dominates because different media sources tend to subsequently repeat this message. [Suggestion: The threshold levels for communicating uncertainty and crucial information are narrow. Finding the right balance both timing and content wise, is pivotal in risk communication and needs to be decided in a multi-disciplinary team. A targeted approach for communicating information to specific groups e.g. GPs (GPs for e.g. do not need to get information relevant for hospitals) was also suggested].

Influences on vaccination uptake
• The interviewees mentioned issues like lack of trust in the vaccine’s safety, accelerated vaccine authorization, media messages about the dangers of the vaccine and specially the adjuvants and the relatively mild nature of the disease, as being some of reasons the for scepticism and negative public attitude. Experts from a number of European countries including Romania, Italy, Spain and Sweden stated that scepticism and negative perceptions led to a substantial drop of 15 – 25% in seasonal influenza vaccine uptake in the subsequent years and this has still not fully recovered to pre-pandemic levels in all countries.
• Countries which had well established seasonal influenza vaccination programs and good coverage rates (e.g. Sweden, Netherlands) in general also reported better pandemic influenza vaccination coverage rates. Hence well-established infrastructure and logistics are likely to enhance the success of such large scale pandemic vaccination programs and also the acceptance in the public on account of them being familiar with the system.
• Health-care support staff (e.g. midwives, GP assistants) on account of their more direct link to patients or risk groups (e.g. pregnant women) tend to have a strong influence on their health behaviour decisions as was mentioned by stakeholders from the UK. The low vaccine uptake among health professionals in many European countries highlights that the concerns these professionals have need to be identified and taken seriously. [Suggestion: Organizing meetings with key-representatives from these groups and discussing their concerns and even potential modifications of recommendations could be a way to address this issue pro-actively].
• Experts from Sweden and Spain mentioned that publically known prominent individuals especially those with outstanding communication skills and charisma can have a very decisive influence both positive and negative on the public’s decision making process and behaviour. [Suggestion: Pro-actively addressing these loud and prominent voices with the best available information and evidence is essential to counter misinformation and help reduce public confusion].

Media relationship / Using media effectively
• The benefits of establishing positive relations with the reporters of important newspapers and TV-channels in the region was pointed-out by one health care expert. Actively inviting the reporters and giving them basic information about the new pathogen and about pandemic management from the very beginning helped building a positive relationship with the journalists and becoming the relevant point of contact for questions arising during the pandemic. The WHO handbook on Effective Media Communication during Public Health Emergencies (2005) details these aspects, there is however a need to actually operationalise existing guidelines within the pandemic preparedness efforts in Europe. [Suggestion: Building mutual trust and a closer working relationship with relevant media representatives long before a threatening event occurs is a positive approach to reducing misinformation and influencing news coverage]
• Some of the interviewed public health experts pointed out that apart from paying attention to the content of the risk communication messages and the audience to be addressed it is also important to carefully select the media channels/tools through which the information is to be disseminated. One expert mentioned a certain degree of reluctance among the public when asked to read recommendations in textual form. [Suggestion: Strategically using new media like Twitter or Facebook to reach a broader spectrum of the population and using video-clips to disseminate information in user friendly format was suggested]
• Three elementary areas for effective risk communication during pandemics which emerged from the interviews were: (i) the existence of a conducive environment in which risk communication can function, (ii) fulfilment of the technical pre-requisites for functioning risk communication implying that the right person receives the right messages at the right time and (iii) the actual content of the risk messages.

WP2
Media and social media content analysis of the A/H1N1 pandemic

The ultimate goal of WP2 was to understand how pandemics are covered in the mass media, and how audiences perceive pandemic risks based on news coverage. More specifically, we focused on understanding the role of emotion in the coverage of pandemics. Results of our theoretical, qualitative and quantitative insights were reported in several manuscripts submitted to scientific journals.

The delicate role of emotion – A theoretical essay
Relations between emotion and quality journalism have been historically contentious, because emotion is often associated with sensationalism. Particularly in the context of health crisis reporting, journalists have been blamed for scare-mongering. However, our interdisciplinary review of empirical findings from three academic spheres – journalism, (health) risk communication, and media psychology – demonstrates that emotion-evoking news elements can benefit the performance of journalistic roles and may – if inscribed pointed and moderately – fulfil important functions in health crisis reporting. We conclude that any appraisal of emotion in news must particularly consider emotion’s functions and effects for the performance of different journalistic roles.

Understanding news producers - Interviews with journalists
An important step in our research was to illuminate how journalists perceive their work and their responsibilities during a pandemic. Despite journalisms’ importance in public health crises, research on this question is scarce. We conducted 22 in-depth interviews with reporters experienced in health crisis reporting in Germany and Finland for an in-depth exploration and understanding of journalist’s role perceptions. We found that in a health crisis, journalists hold multiple roles. The majority of interviewees considered mobilizing health behaviours (i.e. precautionary measures) and mobilizing social responsibility (e.g. preventing stigmatization of affected parties) as central roles during health crises. During acute crises, reporting becomes more concrete and advisory, for example, by providing clear “how-to-act” messages. Further, notwithstanding a commitment to a classic information dissemination role, the majority of reporters expressed a responsibility towards providing interpretation, contextual analysis, and commentary beyond a mere passing on of facts.

Journalists emphasized their dependence on (health) authorities, and most assumed a role as co-operatives of these. Especially during health crises journalists tended to shift from a watchdog to a more co-operative role. When coving a public health crisis, journalists may therefore experience role conflicts regarding their independence. Lastly, we find that the aforementioned dependence, as well as trust in authorities, and journalists’ own topic-related (e.g. medical) expertise are key determinants of the roles journalists adopt. Several specialist reporters described themselves as ‘sober voices’ within their news organisation that are less likely to get swayed by the panic often accompanying health crises, and more capable of fulfilling important roles such as providing contextual analysis (especially interpreting risk in context).

Identifying patterns in news content – Literature review of media analyses of A/H1N1 coverage
Another important question we considered was if media coverage was actually too emotional – or sensationalist – in past pandemics. We conducted a review on news coverage of the A/H1N1 pandemic that demonstrated that while media attention was large, it did not parallel epidemiological developments but was triggered by key real-world events like the official pandemic declaration on 11 June 2009. We found that fairly little is known on news coverage in European countries, except for the Netherlands, the UK, and the first week after the outbreak. The existing media analyses indicate that information on the severity of and vulnerability to the A/H1N1 virus was the predominant theme in news reporting followed by information of preventive measures. The pattern of coverage tonality remained nebulous due to conflicting findings and varying definitions. Also, very few of the reviewed studies examined formal features commonly linked to the tone of coverage such as imagery or language. We conclude that the perception of dramatization may have developed – inadvertently – through the sheer amount of news coverage, which as earlier research shows may amplify risk and heighten fear, as well as an overemphasis on threat over precautionary measures.

Furthermore, we conducted a time series analysis in five study countries (Czech Republic, Denmark, Germany, Spain and the United Kingdom) integrating epidemiological data, risk perceptions and vaccination uptake and media attention. Coherent with findings of the literature review, results of the time series analysis demonstrate that media logic does not match epidemiological developments but rather spotlights certain key events based on their news value. Consequently, media attention – even if preceding epidemiological events – should be seized as a ‘window of opportunity’ by health authorities to establish a communication channel with the public before the media spotlight (or news cycle) moves on to other issues.

Testing the effects of mass media’s coverage of a pandemic– An online experiment
A common assumption about the coverage of epidemic outbreaks is its contribution to unwarranted fears, heightened risk perception and irrational behaviours through emotion-laden reporting or news sensationalism, but the veracity of this assumption remains unclear. Although prior studies demonstrated that emotion-evoking formal news features may increase risk perceptions and negative emotions, the independent and combined effects of emotion-laden form and actual risk characteristics (vulnerability, severity) remained unexplored. Therefore, we conducted an online experiment to tackle this research gap. We also aimed to improve our understanding of the effects of perceiving coverage as “sensationalist”: Would such a perception diminish risk perceptions and risk-based behavioural intentions?

For the purpose of the experiment, eight different versions of a newspaper article on an epidemic outbreak were created that were identical except for the manipulation of the actual risk characteristics described in the article (low versus high severity, and low versus high vulnerability to risk) and the form of the article, i.e. the portrayal of the risk (factual versus emotion-laden form). As a particular strength, the experiment was conducted among a representative sample of 1324 participants in a close-to-real-life setting. News effects on the perception of risk, negative affect (e.g. fear), empathy with the victims, behavioural intentions to perform risk-reducing behaviours, and perceived sensationalism were assessed.

Results indicated that risk perceptions, negative affect, and behavioural intentions were primarily influenced by the actual risk characteristics rather than form. While respondents that read an article in an emotion-laden form reported heightened perceptions of severity and stronger empathy with the victims, they did not report stronger negative affect (e.g. fear), feel more personally vulnerable, or intend to engage in risk-reducing behaviour. However, we found that if the actual risk was high in severity but low in vulnerability (e.g. a deadly disease that spreads far away), people found the article to be more sensationalist if the risk was displayed in an emotional form. Perceived sensationalism, in turn, reduced important outcomes such as risk perception.

In summary, we find that risk perception is influenced more strongly by the actual risk characteristics than by the form or style of news portrayal. We also tentatively conclude that the public knows how to distinguish ‘fact’ from ‘fiction’ in epidemic coverage. Audiences perceive news reporting only to be sensationalist if their vulnerability is indeed low, but journalists cover the risk in a very dramatic way.

WP3
Social Marketing analysis of vaccination behaviour, audience segmentation, and service delivery.

The objectives of WP3 were to analyse how behavioural influencing approaches including incentives/disincentives can be used to promote service uptake; to review and analyse current vaccination promotion delivery to the public and to health care workers, from a customer perspective, in 3 European countries from different key clusters; to develop a prototype audience segmentation model indicating subgroups of people distinguished by attitudes, beliefs and behaviours in relation to uptake - with a particular distinction between the professional (e.g. health care worker) and the public (e.g. particular risk group) audiences; and to develop a clear set of behavioural goals that can act as service impact metrics for different phases of a pandemic, including the pre-pandemic phase. The activities conducted primarily by the partner SSM have led to a large number important findings, recommendations, and scientific and educational products.

Reviews, Tools and Guidance developed as part of WP 3
1. Review, guidance and tools have been developed focused on what is known about influencing the behaviour of professionals, and citizens during pandemic events.
2. Guidance report has been developed focused on the use of ‘Customer Journey Mapping’ as a developmental tool in relation to influencing behaviour associated with pandemic events.
3. Guidance documents on the use of segmentation in preparation and management of pandemic events has been developed together with a prototype segmentation model that could be used by European Countries’ to target their efforts.
4. Guidance and prototype model for developing SMART behavioural objectives in pandemic events has also been developed.
5. Guidance on developing and implementing behavioural change interventions using incentives and disincentives.
6. As part of WP 3, 14 tools and checklists have been developed based on the reviews and case studies undertaken. These tools have been designed to guide those responsible for developing, managing and evaluating pandemic communication and behavioural influence programmes
7. All tools developed as part of WP 3 have been collated into a single ‘compendium tool box to sit alongside the six review reports produced.
8. Work undertaken by WP 3 has also been used to inform the development of a technical guide published by the European Centre for Disease Control which captures good practice in social marketing; this tool is available from the ECDC at: http://ecdc.europa.eu/en/publications/Publications/social-marketing-guide-public-health.pdf.

Key findings from WP 3
• The complex behaviour challenges associated with pandemic events highlight the limits of conventional communication approaches.
• Multiple interventions are more successful at influencing behaviour.
• Humans are not entirely rational when making health choices and this understanding needs to be reflected in pandemic programmes.
• Behavioural models and theory can help strengthen the development delivery and evaluation of pandemic communication and behavioural programmes.
• It is not sufficient to consider an individual’s voluntary behaviour change in isolation form social and environmental factors.
• There was a lack of audience research used to inform communications strategies and tactics, the reasons for this were fairly consistent across all three countries. 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 was reasonably consistency in message content and tone of communications. The focus of messages was on the seriousness of the potential risk coupled with reassurance and suggested actions. There was little evidence that much consideration had been given to the emotional appeal in communications. Message givers varied across countries
• All three countries understood the importance of but had differing approaches to media coverage and briefing. All three countries perceived internet based communication to be problematic and not as developed as it should be as part of an overall strategy.
• Evaluation of communication interventions are seen mainly to be of relevance at the point of crisis.
• There is lack of consistency when it comes to setting out behavioural objectives in pandemic situations. Different authorities recommend different behavioural responses and this guidance is framed in differing ways by different authorities.
• There is a need for a consistent and specific setting out of specific behaviours that should be recommended and how they should be framed in different pandemic scenarios.
• Incentives and disincentives can be used to encourage the uptake of vaccination but incentives and disincentives need to be carefully researched to ensure that they are seen to be meaningful and proportionate to professionals, the public and policy makers.

Contributions to other aspects of the ECOM project
1. In addition to the key deliverables and milestones related to the four objectives set out above SSM also took the lead on delivery of a number of other aspects of the ECOM project.
2. SSM established the ECOM first edition website for the project until the second edition website was established as part of WP9. SSM staff have been maintaining this site and updating it. The website can be found at: http://www.ecomeu.info/.
3. SSM have given assistance to WP 4 re identification of data sources for analysis. SSM have actively worked with and met staff working on WP 6 on under vaccinated groups assisting in analyses model building and write up of the findings and recommendation for WP 4 repots and models. SSM have helped build the conceptual; model of a risk matrix and the key hypothesis that approaches used to engage UVG may be more effective as part of general population level strategies as well as rather than just specifically targeted programs. SSM developed and wrote the second section of the WP6 report ‘Effective communication in Outbreak management Development of an evidence-based tool for Europe’ and commented on the rest of the paper. SSM staff have assisted WP 8 with translating of materials and reviewed research instruments and general research advice.
4. SSM undertook development work with possible partners for, the final project dissemination stage of the ECOM program. Additional liaison has been undertaken with key end phase partners such as ECDC and WHO Europe, the public health departments in Italy, UK and Hungary, and Portugal to brief them about ECOM and discuss possible end stage liaison and joint work. SSM staff have attended and represented ECOM at five ‘Tell Me’ events and conferences, in Venice, Athens, Sydney and Rotterdam, Luxemburg, Stockholm, Copenhagen and London. Future dissemination events are planned for Washington and Helsinki in the coming year.
5. SSM staff have published two articles in professional journals about the ECOM project. The first was focused on findings from our three country review titled; ‘By failing to prepare you are preparing to fail’: lessons from the 2009 H1N1 ‘swine flu’ pandemic. This paper was published in the European Journal of Public Health in 2014. SSM staff have also had published in the Journal of Social Marketing quarterly in 2015 an article entitled ‘Notes from the Field: Using Social Marketing to Improve Preparedness for Pandemics: The Work of the ECOM Program. This paper summarises key findings from the ECOM project.
6. WP3 also took the lead in the collation drafting and liaison with ECOM partners the WP7 interim report.

WP4
Vaccination knowledge, attitudes, risk perception & vaccination non-response

1. Systematic review risk perception 2009 influenza A/H1N1 pandemic
A systematic review was performed to study risk perception and behavioural responses in the general population during the 2009 influenza A/H1N1 pandemic, using articles from PubMed, Embase and PsychINFO. Of the 5498 titles initially found in the three databases, 70 were included in the review. For these studies, results were summarized with regard to: knowledge, perceived severity & vulnerability, feelings of worry, perceived efficacy & self-efficacy, intention, and behaviour (including vaccination acceptance). Results were tabulated by WHO region (America’s, Europe, Asia / Australia) and by phase of the epidemic (early, pandemic peak, post-pandemic). An article was drafted describing trends over time and regional differences, as well as implications for risk communication. The article is now published (Bults et al. Perceptions and behavioral responses of the general public during the 2009 influenza A (H1N1) pandemic: a systematic review).

Main findings and recommendations
Public misconceptions were apparent regarding modes of transmission and preventive measures. Perceptions and behaviours evolved during the pandemic. In most countries, perceived vulnerability increased, but perceived severity, anxiety, self-efficacy and vaccination intention decreased. Improved hygienic practice and social distancing was practiced most commonly. However, vaccination acceptance remained low. Marked regional differences were noted. To prevent misconceptions, it is important that health authorities provide up-to-date information about the virus and possible preventive measures during future outbreaks. Therefore, they should continuously monitor public perceptions and misconceptions. Because public perceptions and behaviours varied between countries during the pandemic, risk communication should be tailored to the specific circumstances of each country. Finally, the use of health behaviour theories in studies on public perceptions and behaviours during outbreaks would greatly facilitate the development of effective public health interventions that counter the effect of an outbreak.

2. Compilation of reviews on vaccination of health care workers
We made a compilation of 8 systematic reviews which review studies that describe willingness to comply with influenza vaccination among health care workers, and reasons for (non) compliance (i.e. motivators and barriers). Because the published reviews on determinants have little overlap, and there was no single paper giving an overview of current knowledge, we wrote an article in which we made a compilation of the eight systematic reviews. The article was submitted to the journal ‘Disaster Medicine and Public Health Preparedness’, but it was turned down. We are about to submit it elsewhere.

Main findings and recommendations
Main reasons for influenza vaccination compliance among health care workers (HCW) are: belief of personally being at risk, belief that influenza is severe, and belief in the vaccine’s efficacy. Main reasons for influenza non-compliance are: concerns about vaccine safety/side effects, doubts about vaccine efficacy, not feeling at risk, and the perception that influenza is not serious/fatal. Non-vaccinated HCW have less knowledge about influenza/vaccination, and feel less comfortable to promote vaccination to patients. It is important to education HCW in campaigns about: the true risk of vaccine-related side-effects; the effectiveness of the vaccine; the severity of influenza and the risk of complications or death for patients; HCW’s role in influenza transmission and prevention; and vaccination recommendations. This should be combined with strategies like improved access to vaccination, the use of incentives/disincentives, or the use of role-models. Mandatory vaccination programs for HCW have reached maximum uptake levels, but remain controversial.

3. International survey on risk perception during pandemic influenza scenarios
We performed an online survey research among 500 respondents in the UK, Sweden, Poland, and Spain, through an ISO certified research company. Questions were asked about seasonal influenza, as well as on 1 of 3 pandemic influenza scenarios (mild versus moderate versus severe scenario; respondents randomly received 1 of 3 scenarios). An article was written about the results, which is about to be submitted for publication.

Main findings
• Good hygiene and avoiding people who are coughing and sneezing was considered to be more effective in preventing seasonal and pandemic influenza than vaccination.
• 40% of all respondents were willing to be vaccinated against seasonal influenza. This percentage was highest in the UK (57%).
• Of the 4 countries, respondents from Sweden had the lowest risk perception towards both seasonal and pandemic influenza, the lowest belief in the effectiveness of preventive measures (response efficacy), and the lowest intention to perform these measures.
• Respondents from Poland scored highest on risk perception, response efficacy and intention to perform preventive measures regarding seasonal influenza. Respondents from the UK scored highest on these issues regarding pandemic influenza.
• Sketching a mild versus an intermediate versus a severe pandemic influenza scenario (in terms of number of deaths and percentage infected) only had a small influence on perceived severity, vulnerability, and intention to perform preventive measures. It had no influence on response efficacy and self-efficacy.
• Swedish respondents reported more often than others that they were unwilling to get vaccinated because of fear of serious side effects; Polish respondents more often reported doubt about the effectiveness of vaccine as main barrier to getting vaccinated.

Main recommendations
• Public health authorities can promote the influenza vaccination by stressing that it is far more effective than performing good hygiene and avoiding people who are coughing and sneezing.
• In case of pandemic influenza, European health authorities should be aware that there can be large differences between countries in risk perception of the public and in willingness to perform preventive measures. It may be necessary to increase public awareness and risk perception in some countries, but to decrease it in others. Therefore it is important to perform risk perception studies, to be informed about national/regional/local differences.
• In a pandemic situation, the general public may not be able to discriminate between a mild versus a severe situation only based on epidemiological data such as (large) numbers of deaths and percentage infected. Health authorities should describe scenarios in a more personal way (e.g. the chance is large that you will know somebody who has died of influenza), in order to increase or decrease their risk perception and willingness to perform preventive measures.

4. Tools: ‘Checklist Risk Communication’ and ‘Standard Risk Perception Survey’
Two checklists for outbreak managers to identify the urgency and level of risk communication in case of an outbreak were developed, based on previous studies performed in the field of risk perception of (emerging) infectious diseases such as pandemic influenza, Q fever and Lyme disease (see four papers of Bults M. et al.):

• A checklist to describe the characteristics of the disease (e.g. transmission route, incubation time, fatality, contagiousness, outbreak setting, treatment options, preventive measures).
• A checklist to estimate the risk perception and experience of the public (e.g. knowledge, perceived severity, distrust, risk for children/pregnant women, media/political interest)

Based on these data, a broad assessment can be made of the urgency of risk communication, the target group(s), and the means and materials to be used.

The two checklists are made available as one ‘tool’ on the ECOM website, called ‘Checklist Risk Communication in case of an Infectious Disease Outbreak’.

Also, a standard risk perception questionnaire was developed as ‘tool’, giving example questions for public surveys on risk perception of (an outbreak of) infectious diseases. An appendix to the questionnaire gives insight into the organisation of public surveys, analysis of the results, and translation into communication messages.

The 2 tools were evaluated by 11 end-users in an online survey. Results show that most of them found the tools understandable, found their purpose clear, and found them quite useful, especially for other (less developed) countries.

WP5
Acceptance of preventive measures: Discrete Choice Experiments (DCE)

We selected the most relevant attributes and attribute levels based on: 1) a systematic literature search in several online databases as well as using the results of the review study by WP4, 2) a focus group study based on theoretic behaviour models (Health Belief Model and the Protection Motivation Theory) in four countries (in total 15 group discussions were conducted), and 3) nine international expert interviews. As a result, we selected two relevant disease specific scenario variables: severity of the disease and susceptibility to the disease, and five relevant vaccination programme attributes: effectiveness of the vaccination, out-of-pocket costs of the vaccination, safety of the vaccination, by which body the vaccine was advised and how the vaccine was discussed in the media.

In total, 2,068 internet panel members (samples representative per country based on age, gender, region and educational level) of four different countries completed the questionnaire during the summer of 2013. The results of the direct ranking question, in which respondents were asked to rank factors that influence their decision to get vaccinated from most to least important, are comparable with the results of the focus group discussions and the DCE results and therefore support the convergent validity. In all included countries except Sweden, effectiveness of the vaccination was ranked by the majority of the respondents as most important when deciding to get vaccinated or not, while in Sweden, the majority considered safety of the vaccine as most important. Swedish focus group participants mentioned frequently that their negative experiences with the Influenza A/H1N1 pandemic vaccine would influence their vaccine uptake behaviour during future pandemics.

Based on the choice data, three latent classes were identified. The average class probability was 0.44 0.35 and 0.21 for class 1, 2, and 3 respectively. The country of residence partly explains class membership, which is an indication for preference heterogeneity between countries. Respondents from Poland and Spain had a significantly higher chance to belong to class 1 (0.55 and 0.53 respectively, p<0.01) than respondents from other countries, those from the Netherlands more often belonged to class 2 (0.42 p<0.01) and those from Sweden to class 3 (0.36 p<0.01).

Preferences of all included countries were in the same direction, which indicates that across countries similar considerations about having vaccinations were put forward. Vaccinations with higher out-of-pocket costs and less certainty about future side effects, as well as the negative advice by friends/family or physician and negative media coverage influenced respondents’ preferences for pandemic vaccination negatively. A higher vaccination effectiveness and positive advice of friends/family, physician, government and public health institute and international organizations influenced preferences for pandemic vaccination positively. In all included countries, the effectiveness of the vaccine interacted with the seriousness of the disease. This indicates that the influence of effectiveness of a vaccination on the preference for pandemic vaccination is dependent upon the levels of severity and susceptibility of a disease. If the susceptibility to or severity of a disease are considered to be higher, while the effectiveness of a vaccination is the same, preference for vaccination increases relative to no vaccination.

The relative importance of attributes varied with the seriousness of the disease. In the case of a severe outbreak, vaccine effectiveness was the most important characteristic determining vaccination preference in all countries. This was followed by the body that advises the vaccine, 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 vaccine preferences, in contrast to Poland and Spain, where the advice of (international) health authorities was more decisive. In the case of a mild outbreak, the vaccination advice and out-of-pocket costs were most important in the Netherlands and Sweden, while vaccine effectiveness and vaccination advice were most important in Poland and Spain.

Additionally, our results showed that subgroups within the included countries can be distinguished. For example, Dutch data showed that in general (i) female respondents made different trade-offs than males, and (ii) respondents who stated that they were never in favour of vaccination made different trade-offs than respondents who stated that they were (possibly) willing to get vaccinated.
Irrespective of disease scenario or programme characteristics, the predicted vaccination uptakes were lowest in Sweden, and highest in Poland. The mean predicted uptake of a base-case vaccination programme (i.e. a vaccine with an effectiveness of 70%, that was supposed to be safe, was advised by friends, received positive traditional media attention and had no out-of-pocket costs) for a mild pandemic ranged from 36% in Sweden up to 50%, 74%, and 62% for the Netherlands, Poland and Spain respectively. When an outbreak is more serious, the vaccine uptake increased in all countries (up to 88%, 90%, 89%, and 76% for the Netherlands, Poland, Spain and Sweden respectively).

We have summarized all clearly significant results in three papers (see publication list).

WP6
Under-vaccinated group analysis

“The rose in the vineyard”

Firstly, WP6 defined an under-vaccinated group (UVG) as a group of persons who share the same beliefs and/or live in socially close-knit communities in Europe and who have/had historically low vaccination coverage and/or experienced outbreaks of vaccine preventable diseases since 1950.

For national public health institutes the self-evident and obvious way to identify the under-vaccinated groups in their country is to monitor outbreaks of vaccine preventable diseases. If such an outbreak occurs in a group of persons with the same belief, the UVG is identified. These outbreaks in under-vaccinated groups can cause “spill over” disease in the general population. For example, in the 2008 outbreak in Germany, spill over occurred from the anthroposophic community to the general population. In the Netherlands in 1999-2000, measles transmission started among unvaccinated members of Orthodox Protestant Reformed churches and spread to children of vaccinating parents, whose children were susceptible as they were still too young to be vaccinated. Monitoring vaccine preventable disease in under-vaccinated groups can act as an early warning for transmission in the general population. Under-vaccinated groups thus can act as “a rose in the vineyard” (roses are planted on the borders of vineyards, to act as sentinels that give early warning signs for action in case of disease).

Secondly, to map the European situation, WP6 performed a literature search with a search term combination based on the list of vaccine preventable diseases and any of the terms outbreak, epidemic or low vaccination coverage and any of the terms community, minority, ethnic, group or subgroup. 48 Articles were selected in which we identified five UVGs: Orthodox Protestants (11 articles), Anthroposophists (9 articles), Roma (19 articles), Irish Travellers (6 articles) and Orthodox Jewish (8 articles) communities.

Thirdly, pen portraits were made of six under-vaccinated groups (UVG) identified in the Netherlands, Portugal and Romania, i.e. Anthroposophists, Orthodox Protestants, NVKP (Dutch Association for Conscientious Vaccination), Roma community, the ‘macrobiotics’, and the ‘conscientious citizens’. These groups are present in several other EU countries.

Fourthly, to identify the determinants of (non) vaccination in these UVG WP6 performed a second literature search. The search term combination included again the list of vaccine preventable diseases and any of the search terms ethnic groups, minority groups, religion, anthroposophic or complementary therapies and any of the search terms attitude, belief, argument, treatment refusal, patient acceptance of health care, “health knowledge, attitude, practice”, decision making, patient compliance, ideology or objection. 11 Articles were selected in which we identified seven most important determinants regarding (non)vaccination: the perceived non-severity of traditional “childhood” diseases, fear of vaccine side effects, doubts about the effectiveness of the vaccine, religious objections, protective effect of natural lifestyle, low access to health care centres, and low trust in the public health authorities.

WP6 identified and contacted scientists and community health workers that are involved with research and development among the six UVG’s in the selected countries. The results of the literature search were presented and discussed in this multidisciplinary expert group.

The group concluded that, among each UVG identified, there is a variety of beliefs and objections to vaccination and not all members have the same beliefs (within-group heterogeneity). Importantly, some of the UVGs shared similar beliefs (between-group homogeneity) and, even more important, similar beliefs are present in the general population. Therefore, the group concluded that monitoring the beliefs and objections in under-vaccinated groups can be used as an early warning sentinel for beliefs and objections in the general public. Also for this, under-vaccinated groups can act as “a rose in the vineyard”.

As a fifth step, WP6 produced a Determinants and Performance Objectives Matrix Tool (DPOMT). This matrix with measurable program objectives to achieve (SMART matrix) was used as a framework for presenting communication tactics recommendations.

The sixth step was to map evidence based communication tactics on the determinants most easily influenced or amenable to change and shared by most UVGs and the general public. Based on the SMART matrix this resulted in a list of suggested tactics for UVGs, that can be used by health professionals and agencies throughout Europe, in the framework of their own NIP and their own UVGs and during and in between outbreaks. The communication approaches are not presented as a total and complete set of interventions; rather they are illustrative of several communications components of a fuller programme.

In addition, health care workers (HCWs) are the first interlocutor for health concerns for members of these groups thus it is very important to include them in the communication process. It seems impossible to motivate UVGs without the support and the motivation of HCWs. Therefore, we also need to consider how to convince HCWs of the benefits of vaccination. Different tools, guide and documents are available on ECDC and WHO-Europe websites to assist health professionals in their day-to-day work as it relates to immunization. In WP4, attention to HCW’s has been discussed.

Communication strategies directed at the common factors shared by different groups, frequently also present among the general population, will establish a trusty and reliable relationship with these groups and might increase their vaccine uptake, as well as the uptake of the vaccine by the public. Furthermore, improving access to health care could certainly increase vaccine uptake in Roma and Irish travellers.

To be better prepared for the next outbreak it is wise for public health institutes in inter-pandemic periods to get in contact with their under-vaccinated groups, liaise with (key persons from) these groups, and set up communication channels.

Implications:
“be happy with the rose provided”:
- UVG‘s can act as sentinel for early warning of circulation of vaccine preventable disease
- UVG‘s can act as sentinel for early warning of determinants for non-vaccination
THUS... in inter-pandemic periods... set up communication with UVG’s!

WP7
Integration of key findings from WP 1-6

A meeting was held with the whole consortium in Rotterdam on in February 2014, to decide amongst ourselves the main findings per WP, and the 7 overall main findings for WP1 to WP6. Subsequently, a document was prepared including the key findings and results of WP 1-6, and the 7 main overall main findings and suggested solutions. The results were presented at a consortium meeting, where 11 end-users were present. Also, critical factors, groups and media to be addressed in the development of effective behavioural and communication strategies in WP8 and 9 were discussed.

The main 7 findings and implications from WP1-WP6 were formulated as follows:
1. Risk perception and recognition of personal risk status can be influenced by ‘trustworthy’ sources of information; some people want official information providers to be held responsible for the information they give the public.
Implication: Develop and promote trustworthy sources of information and individual decision aids and self-risk assessment tools.
2. Mass media / digital media have a spotlight effect that increases perception of risk but moves on in advance of later advice about appropriate action.
Implication: Health officials and politicians are the most prominent sources in news about an epidemic, so they can have a big influence on the content and tone of media coverage. During the spotlight, they should ensure to inform the public where to find advice later on about appropriate action. Develop a continuous flow of trustworthy, easy to access and interpretable information through all pandemic phases.
3. There is a need to target communication and behavioural programmes for different groups based on determinants, attitudes, cultural, religious beliefs and behaviour.
Implication: Test the ‘Return On Investment’ associated with investment in targeting programmes. Develop in country and regional segmentation models and a tailored communication and behavioural programmes. Develop segmentation guidance tools.
4. A dominant current characteristic of many existing programmes is a focus on rational decision making and the transmission of accurate advice. People are however not influenced by rational decision making alone when deciding to comply with recommended actions and behaviours.
Implication: There is a need to go beyond communication dominated responses and develop interventions that focus on non-rational decision making and behavioural influence including determinants, service access, design and delivery. Develop pandemic preparation planning guidance and tools that promote ‘Comprehensive’ strategic planning driven by SMART behavioural objectives.
5. Disease characteristics, perceptions of efficacy of advice and personal risk perception have a big impact on decision making and compliance with recommended actions and behaviours.
Implication: There is a need to develop scenario planning tools that reflect different disease trajectories and responses.
6. Health Care workers are key sources of information and public opinion, but are often not optimally used in such roles due to their lack of accurate risk perception and or understanding about risks associated with pandemic events.
Implication: Investigate this lack of awareness and willingness to accept their key public health role and develop strategies and tools to better inform and engage health care workers.
7. Under-vaccinated groups (UVG) are often as diverse in their opinions and actions as the rest of the population; however they do have distinct information, access and support needs.
Implication: Test the ‘Return On Investment’ associated with investment in targeting programmes at UVG. Develop UVG intervention strategies that reflect specific needs of different communities but are based on common communication and behavioural programmes used with the whole population.

WP8
Testing effective behavioural intervention and communication strategies

The primary goals of work package 8 was to identify the most effective communication strategies and interventions for different audience groups. To accomplish these goals we conducted 8 studies in 6 countries (described below). After reviewing the results of these 8 studies, we chose the top 5 communication strategies to test in one large study that was conducted in 10 countries (United Kingdom, Norway, Sweden, Finland, Poland, Hungary, Italy, Spain, Netherlands, and Germany). This allowed us to determine if communication strategies and interventions differed by country. Additionally, for all studies we had participants complete numerous individual difference measures to determine if different strategies worked for different types of people. We will first briefly summarize the results of the 8 studies. We will then focus on the results of the 10 country study and provide recommendations for the best methods for communicating information for each country.

Study 1 (Netherlands with 2762 participants) tested the impact of the rapidity of spread, the description of symptoms (mild vs. moderate vs. severe and whether symptoms were described as the worst case or the typical case), and the precision of description of cases and deaths (using gist or verbatim language) of a hypothetical flu outbreak. Results showed that to encourage vaccinations, the most important piece of information to emphasize (of those we tested) is the severity of the average case (not the worst case) of influenza. Neither quickness of spread nor severity of the most severe case influenced vaccinations. This pattern of results were similar for other health behaviour intentions we tested. Risk perceptions were most influenced by spread of disease, followed by severity of the average case of influenza.

Study 2 (United Kingdom with 3610 participants) assessed the impact of the visualization of risk of the spread of flu. Participants who received a heat map had the best knowledge compared to other graphics (e.g. dot maps).

Study 3 (Germany with 2472 participants) tested the use of narrative language to target segments of the population, as well as convey emotionality in an outbreak situation. In particular, we were interested in manipulating the main character’s immigrant status (German vs. Turkish), role within a hospital setting (visitor vs. health care worker), exemplar behaviour (vaccinated vs. not vaccinated), and motivations for behaviour (self-interested vs. driven by others). Results suggested that people were less worried about getting influenza if they had read a story about other people who were vaccinated.

Study 4a (United Kingdom with 959 participants) assessed the use of metaphors (none vs. weeds vs. army) as a communication strategy to target different audience groups. There was no main effect of metaphor use on risk perceptions or behavioral intentions. However, we did find that metaphors were helpful for certain types of people. For example, vaccinations intentions increased for people who scored high in naturalist orientation and received the weed metaphor as well as for people who scored high in aversion to war and in naturalist orientation and received the army metaphor.

Study 4b (United Kingdom with 3700 participants) tested the influence of flu labels (horse flu vs. H11N3 vs. Yarraman flu) and vaccine descriptions and the method of administration of a flu vaccine (i.e. nasal spray vs. shot). Participants who read about “horse flu” perceived the flu as less of a threat, less likely to spread, and less severe than participants in the H11N3 and/or Yarraman flu conditions. H11N3 had the least impact on people’s likelihood to read about the pandemic, think about it or talk to others about the pandemic in order to protect one self. However, the flu labels did not have an effect on preference for receiving a vaccination. There were also no effects on risk perceptions or willingness to vaccinate by how the vaccine was administered.

Study 5a (Denmark with 1819 participants) explored whether highlighting the impact of illness would influence vaccination uptake. Specifically, we provided participants with stories of people who became ill from influenza and who had one of the following consequences from their illness: 1) missing work and unable to care for children, 2) missing a vacation, 3) getting someone at home sick, 4) getting someone at work sick, and 5) getting someone who can’t be vaccinated sick. Analysis found that vaccination intentions increased for participants who received the condition in which the character in the story infected her nephew (p < .001), with the exception of the missing vacation condition.

Study 5b (Poland with 1229 participants) again tested the impact of metaphors and the impact of influenza on different types of immune systems (all, weak, strong). We did not find any main effects on vaccine intentions in this study. One interesting finding is that there was a significant main effect (p=.049) of metaphor, in that people who scored higher on our technology subscale have a greater willingness to get vaccinated compared to people who scored lower.

Study 6 (Spain with 2705 participants) tested the impact of ambiguity vs. confidence and the acknowledgment of uncertainty of vaccines in a spokesperson’s statements. Participants were randomized to read a news article in which a health official expressed overconfident language, ambiguous language, or ambiguous language with normalising statements regarding the flu severity and susceptibility, and vaccine effectiveness. Vaccine intentions were highest in the overconfident language condition.

Study 7 tested the top five risk communication strategies that emerged from the 8 studies described above (countries and sample sizes listed in Table at right). These strategies were: 1) description of symptoms (Study 1), 2) visualization of incidence and death (Study 2), 3) metaphors (Study 4a), 4) flu labels (Study 4b), and 5) ambiguity/certainty of spokesperson’s language (from Study 6). While we are still conducting data analysis on these data, we do have some recommendations of the best way to discuss influenza and vaccinations that could be useful to health communicators including public spokespeople, health care providers, and journalists. Below describes the results across all countries, followed by a table of caveats by country.

Country # of subjects % of total sample
Finland 1,554 0.9
Germany 1,546 10.9
Hungary 765 5.4
Italy 1,509 10.6
Netherlands 1,938 13.6
Norway 764 5.4
Poland 1,509 10.6
Spain 1,604 11.3
Sweden 1,539 10.8
UK 1,519 10.7
Total 14,247

To Increase Vaccination Intentions
• Use a heat map to communicate the number of influenza cases and deaths in each country. Participants also preferred heat maps.
• Describe the symptoms associated with the most severe cases.
• When possible, communicate the information about the influenza pandemic as being certain and express confidence in the vaccine recommendations.

To Increase Attention to Information Being Communicated About the Pandemic
• Describe the symptoms associated with the most severe cases or describe both the symptoms associated with the average case and the most severe cases.
• Acknowledge when uncertainty about the influenza pandemic information exists and highlight that this uncertainty is common during almost all pandemics.

To Increase Interest in More Information about the Epidemic
• Use a heat or dot map to communicate the number of influenza cases and deaths in each country.
• When possible, communicate the information about the influenza pandemic as being certain and be confident in the recommendations.
• Use a flu label that is connected to the animal vector (e.g. Swine flu) or that sounds unusual (e.g. Porcine flu).

Individual differences
• Overall, increased numeracy was associated with increased concern about the dangerousness of the disease (vs. the safety of the vaccine), increased interest in seeking information about the severity of the flu, and more positive evaluations of the data visualization.
• Overall, feeling like you might be the person who would experience a rare event was associated with a perceived likelihood of contracting the flu. This relationship was reduced when the symptoms of the most severe case was presented and increased when both sets of symptoms were presented.
• Overall, increased uncertainty aversion was associated with 1) reduced vaccination intentions, but this relationship was eliminated when the symptoms of the most severe case were presented,
2) increased perceived risk of contracting the flu, but this relationship increased when the flu was referred to as “H11N3 influenza” and reversed when the flu was referred to as the “Horse flu”.
• Overall, an increased naturalist orientation was associated with 1) decreased vaccination intentions, but this relationship was eliminated when risk information was presented using the dot maps and became more negative for picto-trendlines, 2) increased perceived risk of contracting the flu, but this relationship increased when the symptoms of the average case were presented and decreased when the symptoms of the most severe case were presented and when the director of the health organization indicated certainty about the flu pandemic information, 3) greater concern about vaccine safety (than the flu), but this relationship is eliminated when the director of the health organization used uncertain language, 4) increased confidence and trust in the director of the health organization, but this relationship was eliminated when the director indicated certainty about the flu pandemic information, and 5) greater concern about vaccine safety (than the flu), but this relationship is eliminated when the war metaphor was used.

Caveats for Specific Countries
To increase vaccination intentions, there are caveats for some individual countries:
Poland: Present the symptoms of the average case
Sweden: Present both sets of symptoms

To increase attention to information, there are caveats for many individual countries:
Finland: Present symptoms of most severe case; Avoid referring to flu using a scientific sounding name (H11N3)
Germany: Present symptoms of most severe case; Refer to flu using a scientific sounding name (H11N3); Use war and gardening metaphors
Hungary: Present symptoms of average and most severe symptoms; Refer to flu using a scientific name and avoid labels connected to the animal vector; Use war and gardening metaphors
Italy: Refer to flu using a scientific name and avoid labels connected to the animal vector; Use war metaphors
Norway: Present symptoms of most severe case; Avoid referring to the flu using a label connected to the animal vector (e.g. swine flu) and using war metaphors
Spain: Present the symptoms of the most severe cases and use metaphorical (e.g. war, gardening) language, particularly war metaphors; Avoid referring to the flu using a scientific sounding name.
Sweden: Avoid referring to the flu using a scientific sounding name; Use literal (re: non-metaphorical) language

WP9
Building of web application tools

Insights:
Elastique became partner in the ECOM@EU project to produce several on- and offline communication tools based on the scientific research. As a commercial agency for communication, especially in the field of digital brand communication and the communication of „hard to explain“-content it has been a great opportunity to work closely together with the scientific consortium.
In the beginning we were told that in projects like this agencies like us are very often commissioned as subcontractors – simply to put scientific output into a nice design.

In this project Elastique had been commissioned as real and equal partner & consultants from the beginning. Looking back this has been a very good decision by the project leaders and the European commission. This is why we would like to report some important learnings, besides of reporting about the final products and applications.

Entering a project like this coming from fields far outside the professional scientific background of outbreak communication gave us the opportunity to see and specify some structural problems that may have led to an insufficient communication during former outbreaks.

Inside view vs. public view
We could see that of course many of the end users from professional health care institutions are dealing with very abstract and complex problems on a daily basis. They are very often collaborating with scientists to obtain the best possible evaluation of the actual situation – the normal situation over the year or the one during outbreaks. Working together with the scientists and end users over the four years of the project, we found that in the beginning many of our partners were heaving problems breaking down studies, findings, results and proposed actions to an easy to digest level. They have a very “inside view” on their topics which is absolutely natural. We can see the same happening with our clients from the commercial sector. But the goal was that the outbreak communication should be improved and not only reach the public, but can be really understood by it.
So communication and information must be as simple as possible without being meaningless.

The collaboration with the scientists and end users on one side and us on the other side became very fruitful: Starting being seen as designers, who only “wrap” information into a nice design, over time we became creative consultants with an outside view on topics and messages. This led for example to the focus on the six main findings resulting from the research and scientific analysis. It helped to become really clear about what to communicate to end users and the public. Based on these main findings we developed communicative tools that can solve some of the communicative problems articulated by the findings.

Our recommendation
In our opinion it is crucial for future projects on outbreak communication as well as for communicative tasks in the field of health communication to involve professional agencies that are not necessarily specialized in health communication as early as possible as equal consulting partners in the process. This ensures a vivid “outside view” on the communicative problems and a counterpart to the professional scientific way to communicate things. Because in the end the only thing that counts it that the message is being understood by the public.

Visual and communicative approach
Based on the fact, that nowadays it is much easier to dive into a complex topic by viewing a film, we developed two animated movies. The first one gives an overview about the project, the problems in former outbreak communication and explains the findings and results of the scientific research during the ECOM project. The second movie is a quick overview about the final tools and their usage.

During the project we developed an illustrational style that may seem unusual for a serious topic like outbreak communication. Not only that the visuals look somehow friendly, even funny: we even used illustrative metaphors (e.g. for infection) that make you smile.

Why do we do that?
We believe in the fact that people like to deal with complex and even serious topics much more, if the messages come to you in an emotional not too rational way. In our various commercial projects over the years we found that even super-technical and “dry” topics can enthuse people if the storytelling somehow touches them.

After presenting the first version of the ECOM movie to scientists and end users at the London meeting 2014, we were happy to see that this strategy worked its way into the minds and hearts of the participants. We got a lot of very positive feedback of the end users that this style and kind of communication really came through. These people have to deal with tons and tons of paperwork every day. Most of their actions are tied to mostly abstract and highly formulated orders. The direct feedback was that it was relieving for them to get presented important findings and information in a very lively, smart, precise and emotional way. They told us that this function that we had in that project – namely being “translators” of complex information into smart, simple and emotional communication measures – is very often missing. Based on these findings and feedback we pushed that kind of communication even further to develop the demonstrator of the smartphone app.

The most important task was to structure the app in a way that the complex process of a pandemic outbreak, the problems people have to deal with and the directives that they are given to protect themselves, must be understood as easy as possible. Even for persons who do not like or cannot read too much. The final result is an app, that looks super-simple, is easy to use and guides you emotionally positive and precisely through the different modules. Compared to many internet informational platforms about actual outbreaks, the app tries to transport every aspect with as less as possible texts. Users do not have to search their way through too much information – it is more that the app is structured in a way that is oriented to the crucial needs and questions of “normal”, non-professional people in times of an outbreak.

We would be very happy if the EU would provide a way to fund a follow-up project that takes this demonstrator of the app to a fully functional app with real content and a complex content management system as well as with an editorial team to be rolled out and tested as a pilot project in one European country.

Key findings
The key findings of our part in the project are – despite of the practical output (films, apps, website, poster):
1. To improve outbreak communication, integrate a professional creative communication agency as a “translator” of the professional content to be perfectly understood by the public. Do that from the beginning of the process as an integral partner.
2. Communicate as clearly and precisely as possible. Focus on just the most important communicative information in the first level.
3. Communicate in an emotional and touching way, that people are willing to adopt.
4. Be careful not just to communicate from a standpoint of an internal “professional” view to a broader audience. Let someone with an “outside view” translate your findings into easy to digest messages.

WP 10
Tool finalisation

WP 10 had two key objectives
1. Fine-tuning and integration of tools developed in WP 8 and WP 9 into a package of evidence-based behavioural and communication tools (e.g. e-tools) that can be tailored to individual European countries and to specific target audiences/segments as needed
2. Provision of training to selected end users, including the members of the end user forum, in application of the package

Tools development
Tools developed by all the ECOM partners have been placed on the ECOM website, http://www.ecomeu.info/. The project website functions as an easily to navigate tool in itself and as a portal to all reports and tools developed by the project. In addition to the website the ECOM project has developed two explanatory and summary videos that explain the purpose and findings of the project, both of which are posted on YouTube and on the project website.

ECOM tools consist of reports focused on all agreed ECOM project outputs together with a summary compendium of tools developed as part of WP 3 and other work packages. Specifically these tools consist of review reports, reports of research carried out by ECOM partners and evidence-based behavioural and communication tools. These tools are generic in nature and can be tailored to individual European countries and to specific target audiences/segments as needed. Work undertaken by WP 3 has also been used to inform the development of a technical guide published by the European Centre for Disease Control which captures good practice in social marketing; this tool is available from the ECDC at: http://ecdc.europa.eu/en/publications/Publications/social-marketing-guide-public-health.pdf

In addition to the ECOM website which will be maintained for three years after the end of the project period all ECOM partner organisations have undertaken and will continue to undertake disseminating and training activity based on the tools and reviews delivered as part of the ECOM project. Details of the dissemination activity and planned activity are set out in full in the ECOM dissemination table.

End user engagement and training
An extensive end user forum has been maintained during the life of the ECOM project. Meeting with the formal end user forum have taken place in Rotterdam Hamburg and London. A wider mail list of interested organisations and individuals have also been developed and used to promote the work of the ECOM project.

A final dissemination symposium for the project was held in Stockholm in November 2015. During this symposium, a hands-on training session was given to the audience consisting of 40 end users and other interested individuals. Each participant could attend 3 short workshops, in which they were explained how a certain tool works and how to use this tool. All tools can be downloaded from our project website.

As part of WP10, SSM and other ECOM partners carried out meetings with key stakeholder groups and individuals up to month 48 of the project. These stakeholders will continue to help with the ongoing dissemination of ECOM findings, recommendations and tools. In addition to this engagement activity SSM staff have liaised actively with the EU funded ‘Tell Me’ project which was also focused on communication aspects of pandemic preparedness. SSM staff attended meetings with the ‘Tell Me’ and took part in seminars and board meetings with Tell Me staff. SSM also provided technical advice into the development of the ‘Tell Me’ scenario planning model. Staff from ECOM project partners have met with staff from the EU Threats Unit and discussed with them how best to disseminate final ECOM outputs. Meetings have also been held with staff from WHO Europe and the European Centre for Disease Control to ensure that they were aware of the ECOM project and would assist with the dissemination of its final reports. SSM as part of ECOM has also been active in the steering group of the EU funded ‘ASSET’ project which is working to capture and spread good practice in relation to pandemic communication and behavioural influence. This project will assist with the dissemination of all ECOM outputs and findings. SSM staff will continue this work beyond month 48 of the ECOM project and have joined the steering group pf the ‘ASSET’ project and will continue to provide input into this project for the next two years.

Scientific (peer-reviewed) publications (up to March 2016)

WP 1

1. Cloes R, Ahmad A, Reintjes R. Risk communication during the 2009 influenza A (H1N1) pandemic: stakeholder experiences from eight European countries. Disaster Med Public Health Prep. 2015 Apr;9(2):127-33. doi: 10.1017/dmp.2014.124.

2. Reintjes R, Das E, Klemm C, Richardus JH, Kessler V, Ahmad A. “Pandemic Public Health Paradox”: Time series analysis of the 2009/10 influenza A / H1N1 epidemiology, media attention, risk perception and public reactions in 5 European countries. Plos One (accepted)

WP 2

3. Klemm C, Das E, Hartmann T. (2016). Swine flu and hype: a systematic review of media dramatization of the H1N1 influenza pandemic, Journal of Risk Research, 19:1, 1-20, DOI: 10.1080/13669877.2014.923029

4. Klemm C, Hartmann T, Das E. (under review). Cold facts in hot crisis? An essay on the role of emotion in health crisis reporting. Paper submitted to Journalism.

5. Klemm C, Das E, Hartmann T. (under review). Changed priorities ahead: Journalists’ shifting role perceptions when covering public health crises. Paper submitted to Journalism.

6. Klemm C, Hartmann T, Das E. (in preparation). Fear-mongering or fact-driven? Illuminating the interplay of actual risk characteristics and emotion-evoking news portrayal on audience response to epidemic news. Paper prepared for submission to Communication Research.

WP 3

7. Crosier A, McVey D, French J. (2014) ‘By failing to prepare you are preparing to fail’: lessons from the 2009 H1N1 ‘swine flu’ pandemic. European Journal of Public Health 2014: 1311-131. Doi: 10.1093/eurpub/cku13

8. French J. (2015) Notes from the Field: Using Social Marketing to Improve Preparedness for Pandemics: The Work of the Ecom Program. Social Marketing Quarterly 1-5. 2015. Sage

WP 4

9. Bults M, Beaujean DJ, Richardus JH, Voeten HACM. Perceptions and behavioral responses of the general public during the 2009 influenza A (H1N1) pandemic: a systematic review. Disaster Med Public Health Prep. 2015 Apr;9(2):207-19. doi: 10.1017/dmp.2014.160. Review.

10. Voeten HACM, Bults M, Richardus JH. Determinants of healthcare workers’ compliance with influenza vaccination: a compilation of published reviews. (full draft, to be submitted)

11. Voeten HACM, Bults M, Meima A, Determann D, Korfage IJ, Fagerlin A, Ahmad A, Richardus JH. Risk perception and intention to perform preventive measures in response to a future influenza pandemic; a European 4-country study. (full draft, to be submitted)

WP 5

12. Determann D, Korfage IJ, Lambooij MS, Bliemer MCJ, Richardus JH, Steyerberg EW, de Bekker-Grob EW. Acceptance of vaccinations in pandemic outbreaks: A discrete choice experiment in the Netherlands. Plos One. 2014 Jul;9(7):e102505. doi: 10.1371/journal.pone.0102505

13. Determann D, Korfage IJ, Fagerlin A, Steyerberg EW, Bliemer MCJ, Voeten HACM, Richardus JH, Lambooij MS, de Bekker-Grob EW. Public preferences for vaccination programmes during pandemics - a discrete choice experiment in four European countries. Eurosurveillance. 2016 (in press)

14. Determann D, de Bekker-Grob EW, French J, Voeten HACM, Richardus JH, Das E, Korfage IJ. Future pandemics and vaccination: Public opinion and attitudes across three European countries. Vaccine. 2016 Feb 3;34(6):803-8. doi: 10.1016/j.vaccine.2015.12.035.

WP 6

15. Fournet N, Mollema L, Ruijs W, Harmsen I, Keck F, Durand J, Cunha M, Wamsiedel M, Reis R, French J, Smit E, Kitching A, Steenbergen J. Under-vaccinated groups in Europe and their beliefs, attitudes and reasons for non-vaccination; two literature reviews. BMC Public Health. 2016 (in press)

WP 7

16. Richardus JH, Korfage IJ, French J, van Steenbergen J, Das E, Hartmann T, Voeten HACM, Ahmad A, Reintjes R, on behalf of the E-com@eu consortium. Communicating in Outbreaks: Towards a New Reality. (full draft, submitted)

Potential Impact:
Expected impacts listed in the EU work programme
There are four overarching impacts that the research activities in this project aimed to achieve: 1) better communication preparedness for the next major epidemic outbreak; 2) minimize deviations between perceived and intended messages during the full course of the pandemic; 3) establish a means for dialogue between citizens and policy makers at the national and supranational level during future pandemics; and 4) provide tools to gain and strengthen trust of citizens in national and EU institutions concerned with risk communication.

Wider project impact
According to the EU Assessment report of 2010, all EU member states have well-developed pandemic preparedness plans and vaccination strategies in place, yet most EU countries (except four) report that their vaccination goals were not met, especially among high risk groups. The public plays a key role in containing or spreading an illness, depending on the protective behaviour they are ready to adopt. The real challenge is to impact on what people actually do. Surveys found that people in general felt adequately informed to take decisions for or against getting vaccinated. While increasing knowledge and raising awareness certainly is necessary, the perceived threat of contracting a severe disease, the perceived net benefits, the real and perceived barriers in adopting a certain behaviour and the believed self-efficacy are all factors that influence whether people actually take up a certain behaviour (e.g. getting vaccinated) or not. It is precisely these key-influencing factors that have been analysed in this project from different perspectives.

The project’s main impact will be a contribution to the development of coherent, co-ordinated and effective national and regional risk communication strategies and tools. It is essential for effective outbreak management and coordination across Europe, to integrate a much stronger behavioural focus into member states intervention and communication responses. An in-depth understanding of the dynamics of what influenced people in different EU countries to adopt or reject certain protective behaviours and also how they differed from each other will help taking these factors into account when developing risk communication strategies and protective recommendations during future pandemics.

Conspiracy theories and accusations like those of the involvement of international health organisations with the vaccine producing pharmaceutical industry damaged the trust and credibility these institutions enjoy among the public. It is of utmost importance to protect and strengthen the public’s trust in the independence and credibility of these institutions under all circumstances. Understanding what creates trust when uncertain and difficult messages have to be communicated is what this project intended to accomplish through a combination of different analytical methods from social marketing, behavioural science and media analysis.

Our ECOM project fostered an innovative and integrated research approach to support the development of effective risk communication strategies. We aimed both at building upon countries key experience in communicable diseases control during the A/H1N1 pandemic as well as strengthening their capacity and achieving better regional sustainability. The US participation widened the horizon of our project to incorporate non-European experiences. Building on the capacity and lessons learned in the USA during the A/H1N1 pandemic also fostered a better co-operation between EU and US academic institutions and strengthened capacity building. The impact of the project will thus be considerable at national and European level and also promote a more effective and harmonised risk communication at the European level with repercussions internationally.

Specific project impact
The first phase of the ECOM project included a number of studies dealing with different aspects of human behaviour and communication in the context of a major epidemic outbreak. These studies lead to a better understanding of how to deal with uncertainties regarding and resistance to vaccination. Through the integration work package the key findings were brought together to provide a solid basis for developing and testing effective behavioural intervention and communication strategies. These strategies are meant for the health professionals and agencies who are responsible for pandemic preparedness and outbreak management, and who need to engage with vaccine resistant groups. In the final phase of the project we developed tools. Besides web-based tools, we provide instruments to assist in the framing of difficult messages and the choice of communication strategies. In addition, there are guidelines on how to involve the media in the different stages of an epidemic. The tools also contain training and development materials for key health service staff. The tools are constructed in such a way that these can be tailored to individual countries and different population groups. The whole approach of our project is intended to achieve the expected impact, both in terms of communication preparedness and effectiveness.

The “Roadmap of a flu pandemic” (printed and interactive poster) is a visual tool that shows the course of a pandemic and enables journalists and the public to understand the surrounding dynamics in terms of media attention and WHO/national pandemic control measures, using the real example of the A/H1N1 pandemic. The text and film-based online guidebook will allow health-communication experts to quickly link a present outbreak scenario to appropriate communication strategies and effective response measures. The PILA smartphone app will help people to assess their personal risk during a pandemic and will provide advice and information to both the public and health care professionals. The tools are on the projects’ website (www.ecomeu.info).

The consortium through interdisciplinary collaboration has a broad appreciation of how to influence human behaviour and to sustain this over time. Traditional work in public health protection areas has tended to rely on an underlying assumption about rationality (‘rational economic man’ ideas) as the primary way to influence behaviour – relying on a limited ‘knowledge → attitudes → behaviour’ approach (with ‘skills / self-efficacy’ sometimes added in). However there is now a growing recognition that much of human behaviour is not a result of conscious rational reflection and consideration, and instead is much more about routine, habit, context, emotion, mood, and the physical and social environment. Borrowing from the concepts of social marketing, we have developed an audience segmentation model that clusters together population groups not just by epidemiology and demography but also by values, beliefs, knowledge and behaviours. This enables us to identify distinct groups which have different reasons for their specific behaviour and therefore also require different communication strategies to effect behaviour change. By clustering different audiences we are also able to indicate how different levels of incentives and disincentives work differently for different audiences and in different EU countries. These results will have a substantial impact in that they will help to develop highly personalised and targeted instruments and key messages for risk communication and behaviour change.

The discrete choice experiment approach has modelled the decision making process of individuals by quantitatively analysing the trade-offs people make between vaccination risk and disease risk, by asking value questions. It also provides valuable insight into the differences in preferences among different population groups and explores factors, which would encourage people to take up a desired behaviour. These results too will help to inform a target group oriented formulation of key risk communication messages thereby directly aiming to impact behaviour change. The project has made a tool available to assist individual country-level health authorities to estimate potential vaccination uptake and the weight of factors involved in decision making by the public.

Vaccine resistant groups are increasingly influencing public perception. By studying the ideologies, beliefs and communication pathways of vaccine resistant groups the project aimed to understand the influence these groups exert on the general population. We do not intend to persuade staunch anti-vaccination advocates through counter arguments, yet it is important to understand their arguments, to minimise their influence on those parts of the population that are unsure, undecided or fearful. Biomedical and scientific facts generally do not suffice as counter measures and hence this analysis impacts the way in which recommendations to adopt protective measures, like vaccination, are formulated.

We have gained access to a large group of relevant end users in Europe through the Health Security Committee Communicators’ Network of the DG SANCO - Health Threats Unit in Luxembourg. Also, we have organised a final dissemination symposium as a preconference meeting of the European Scientific Conference on Applied Infectious Disease Epidemiology (ESCAIDE) in Stockholm on the 10th November, 2015, which was attended by health care professionals and policy makers throughout Europe, representing a very important target population (end users) of our project. After completion of the project, we will continue to liaise with the above mentioned organisations to further disseminate the findings of ECOM.

Country impact and beyond
The consortium has experience in working across Europe, and fully appreciates the diversity among the different member states and that what may work in one country, often does not in another. It would be inappropriate to just focus on countries with highly developed systems and infrastructures and assume that the outputs from this would be relevant to countries with less developed or different systems. While resources did not allow us to examine in detail every country and produce individually tailored recommendations and outputs, it was nevertheless possible to address this challenge of diversity in two key ways. Firstly the criteria for selecting EU countries to analyse the risk communication practices, public perceptions and human behaviour during the A/H1N1 pandemic was based on differences in their health care systems and infrastructures and political systems. We chose countries from each of the following four clusters, thus ensuring that the resources and tools developed will find application across a wide range of countries.

1. Western European countries with more highly developed health care infrastructures (i.e. UK, Germany and the Netherlands)
2. Northern European Scandinavian countries with stronger social health cultures (i.e. Sweden, Denmark and Finland)
3. Southern European Mediterranean countries with established health care infrastructure (i.e. Spain, Italy and Portugal)
4. Eastern European countries (i.e. Hungary, Poland, Czech Republic and Romania)

Secondly, our consortium is also fundamentally concerned with building on countries existing capacity and skills. There are many experts within individual countries and their existing knowledge and skills need to be recognised and valued if a more coordinated response across Europe is to be achieved. Hence key stakeholders and risk communication experts from many EU countries have been identified and informed about the nature of the work, and have had opportunities to give their comments through the end-user forum.

European Added value
The European added value of this project is threefold. Firstly, it supports and strengthens the development of a comprehensive European network of research institutions that are involved in pandemic preparedness and response activities and expand this to include research institutions from the United States, thereby looking beyond the boundaries of Europe. Secondly, the knowledge gained and resources and tools developed in this project, will be better coordinated and integrated at EU level, and benefit from the supra-national input of experts and be made available to a much wider network of institutions and member states within the EU. Thirdly, the involvement of EU institutions will be critical for an effective risk communication and a desired response since neither risk communication nor behaviour change during pandemics are restricted to national borders.

Assessing the interactions between disease severity and risk communication in the mainstream media and how it was understood, perceived and discussed by the public across different EU member states enabled the development of tools which are specifically adapted to the European situation and not a mere copy of overarching international guidelines and recommendations. This enables EU institutions and member states to react independently and strengthen pandemic preparedness and response within Europe

The web application tools will enable both EU institutions and member states to intervene rapidly and adapt communication strategies and response measures according to the prevailing opinions and apprehensions thereby allowing a flexibility of response tailored to the needs of individual member states and also providing an overall picture to EU institutions. These monitoring tools would not only improve the effectiveness of and compliance with recommended response measures, but also help to judge where to intensify efforts and set priorities. Many decisions taken to respond to the A/H1N1 pandemic were based on pre-developed preparedness plans which lacked flexibility and hence the tools developed in this project would also harness the enormous costs and achieve better value for money.

It is essential for EU member states and European health institutions to strengthen their expertise and independently base responses on their own evaluations in consultation with international organisations, which is ensured through the mix of countries in this project.

A vision for a new reality in communicating during (pandemic) outbreaks
Our vision for the impact of the ECOM project is that of a new reality in communicating during outbreaks. Knowledge, evidence and guidelines regarding communication during (pandemic) outbreaks have accumulated exponentially over recent years. Effective implementation however, has lagged behind. There is a need for a change of mind-set among health authorities, in which action is taken ahead of time through the development and maintenance of productive communication channels and partnerships with citizens, communities, representatives of media, and relevant health care professionals. In this way optimal use can be made of the spotlight moment when media attention for threatening outbreaks is at its peak. There will be ongoing and evolving knowledge on sentiments regarding vaccination in the population and divergent opinions would not be seen as threats but as opportunities for timely strengthening of public health responses during pandemics. Communication of interventions requiring behavioural changes will be handled at the highest policy level with sufficient means to convey coordinated, trustworthy and consistent messages and plans of action. Full use will be made of modern systems of online and interactive communication channels to support professionals at all levels to do their job effectively and help them through the forest of information overload. This new reality in communication during outbreaks of infectious diseases is within reach if we apply what we know.

Main dissemination activities and exploitation of results

Dissemination strategy
The ECOM consortium has been strongly focused on sustainability, and on achieving a real legacy from the investment provided. There are many European programmes that have produced wonderful resources and tools, many of which within a short space of time get put on the shelf and rarely used or applied. The consortium’s aim however was to not just provide sound practical guidance and advice for member countries, but to leave a real legacy of expertise and skills as part of the process. One that enhances and builds countries capacity and does not lock this up in paper or electronic resources.

For dissemination of the project results, we have not waited until the end of the project, but begun from day one, by engaging key country leaders in the field of infectious disease control in the development process and ensuring they are kept informed and are able to input to the work as it developed. The consortium has experience in working across the huge diversity of Europe, and fully appreciated that what may work in one country, often does not in another. We were therefore committed to ensuring the outputs from the work are tailored to countries with quite different contexts and infrastructures. We fully appreciate that ‘one-size-does-not-fit-all’ however well written or designed the material may be.

Targets and means of dissemination
The dissemination of the project results has been on multiple levels: local country level, European, and international level. The project coordinator had a major role in the international dissemination and exploitation of the results of the consortium. The strategy was to maximize the benefit arising from the collaboration to develop an evidence-based behavioural and communication package that can be applied effectively by health professionals and agencies throughout Europe in case of major epidemic outbreaks.

Other important end users include key policy makers and technical experts at the national level who advise national Ministries of Health on infectious disease control policy. Many of the participants in this project were members of, or regularly present their findings to their national policy-making forums. Thus they were excellently placed to influence policy decisions directly. In addition, since the proposed project has led to a wide range of relevant evidence, there was the possibility to inform decision-making on a wide range of issues from large-scale health policies to tailored health education and risk communication of specific groups.

The establishment of links with countries and institutions other than those involved in the partnership helped ensuring the wider acceptability and sustainability of the project. International organizations, such as WHO and ECDC also formed an important body of end users and a channel for exploitation. Active links to scientific and professional societies such as European Public Health Association and its infectious disease section, as well as e.g. International Society of Behavioural Medicine, provided further forums for dissemination.

An important aspect of exploitation is the in-built knowledge transfer and training of people functioning on different levels in the infectious disease control in the source countries. Training happens through information exchange, material development, on-site training, work and study visits, good practice development, guideline development, which all have been targeted in the project to enhance sustainability.

Dissemination included participation in international conferences, publication in high quality scientific journals (addressing the wider scientific community), and external reports to disseminate project progress. In addition, a website has been created from which reports resulting from this project are available to project participants and any other interested parties. We also used advanced Internet technology, e-learning applications, to have interactive project meetings, and to e.g. fine-tune common measurement instruments.

Dissemination of scientific results
Participants in the project have excellent scientific publication track records and we have produced and still are producing scientific articles in international peer-reviewed journals. Furthermore, we make research findings accessible to a large audience through our project website, and through conferences aimed at scientific and a public policy audiences, civil society and media. Details of the data content, access arrangements, validation results, quality checks, and codebooks are also available at our website. Similarly, all articles, books and papers based on the collected data, whether substantive or methodological, is documented and catalogued. Finally, since most project partners are affiliated with universities, results of the projected have been incorporated in seminars and workshops, so students will learn about the various findings of the ECOM project and its relevance to pandemic control measures in Europe and beyond.

In total 69 dissemination activities have taken place during the project period by members of the ECOM consortium; 14 activities targeted policy makers; 43 the scientific community; 8 civil society; and 4 the media.

The final symposium of ECOM was held in Stockholm on 10th November 2015, as an official pre-conference meeting prior to the ESCAIDE congress (European Scientific Conference on Applied Infectious Disease Epidemiology). The ESCAIDE conference is organised by ECDC and attended by health care professionals and policy makers throughout Europe, representing a very important target population of our project. There were 40 participants in our symposium. In an online evaluation a few days after the conference (response rate 34%), the mean score given for the full symposium was 7.7 (on a scale from 1 to 10). Individual parts were scored from 7.4 till 8.9. All but 1 respondent found the symposium quite/very relevant for their work.

Beside the ECOM website, which will be maintained for three years after the end of the project period, all ECOM partner organisations have undertaken and will continue to undertake disseminating and training activities based on the tools and reviews delivered as part of the ECOM project. Details of the dissemination activities and planned activities are set out in full in the ECOM dissemination table.

List of Websites:
www.ecomeu.info

Final Report Summary - E-COM@EU (Effective Communication in Outbreak Management: development of an evidence-based tool for Europe)

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