risk perception and communication

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RISK PERCEPTION AND COMMUNICATION Setting the agenda for the 5th Ministerial Conference on Environment and Health, 2009

(Final draft for limited review and comment – not for distribution)

Report of a WHO Expert Consultation Meeting Venice - Island of San Servolo Italy, 29-30 May 2006

Acknowledgements We gratefully acknowledge the financial support of the Italian Civil Protection for the Project “Risk Perception and Communication” and the organizational support provided by the Venice International University and the School for Advanced Study in Venice (SSAV).

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TABLE OF CONTENTS PREFACE Section 1 - Why should policy-makers strengthen their risk communication capacities 1.1 Ministerial mandates – the international policy context 1.2 Risk communication as a core public health competence 1.3 Poor communications and bad outcomes 1.4 Risk communication as a fundamental task of democratic governance; and 1.5 Policy-makers are calling for assistance Section 2 - How can this be done? 2.1 Building on the available evidence base 2.1.1 Developmental theories 2.1.2 Framing theses 2.1.3 Public perception research 2.2 Learning from experience 2.2.1 WHO Outbreak Communication Guidelines 2.2.2 Lessons from the BSE/CJV Saga 2.2.3 Lessons from the Food Safety Authority of Ireland 2.2.4 Lessons learned: Food safety survey – Greece, Denmark, Slovenia, United Kingdom and Germany 2.3 Assembling your toolkit 2.3.1 Approaches to public participation 2.3.2 Media monitoring 2.4 Enhancing competencies through training; and 2.5 Institutionalizing approaches 2.5.1 The Case of the Food Safety Authority of Ireland 2.5.2 The introduction of Risk Assessment Polices Section 3 - Why has it not been done more effectively to date? 3.1 3.2 3.3 3.4

The need to re-position public health communications; The counter-intuitive nature of uncertainty; Current “frames” and reframing options; and Gaps in knowledge

Section 4 - What next steps should be taken to develop WHO European Guidelines? 4.1 4.2 4.3 4.4 4.5

Recommendation Recommendation Recommendation Recommendation Recommendation

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ANNEXES Agenda Programme Technical Background Document Guidelines for the presentation of the case studies List of participants List of presentations

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PREFACE Health and environment communications, particularly as they relate to risk, are increasingly appreciated as determinants of health and healthy public policies. On the one hand, people’s perceptions, choices and behaviours are shaped by the information marketplaces within which they live, work and play. On the other hand, healthy public policies are shaped with the active input of engaged publics. While access to health and environment information varies both within and between countries in the WHO European Region, rapidly expanding national and transnational communication channels, e.g. internet, SMS and satellite television, etc, have created an unprecedented potential to inform (or misinform) and engage (or disengage) various publics more quickly and completely. Policy-makers across the WHO European Region are challenged to gain a better understanding of the multifarious factors that shape their publics’ risk perceptions and to strengthen their capacities to deliver and receive information (even in “uncertain” situations) in effective and trustworthy ways. Over the last decade, risk communication failures, due to “concealment, sedation and understatement”1 and lack of public involvement, have led to great human and economic suffering. Acknowledging this changing reality, European Ministers meeting at the Fourth Ministerial Conference on Environment and Health in Budapest in June 20042 called for “the development of risk communication guidelines as an important tool for bringing environmental health considerations to the attention of different sectors and for heightening public awareness” (Paragraph 18a of the Budapest Declaration).3 To address this challenge, WHO Regional Office for Europe/WHO European Centre for Environment and Health (ECEH), in collaboration with WHO Headquarters/Department of Protection of Human Environment Sustainable Development and Healthy Environments, convened this technical consultation meeting on Risk Perception and Communication in Venice, Island of San Servolo (Italy) on 29-30 May 2006, with the aim of identifying key issues to be addressed in the development of WHO European guidelines on public perception and risk communication. Governmental, NGO, and academic experts from across the European Region were invited to provide evidence and case study material, discuss and debate the rationale for guidance and preferred approaches at different stages of policy development and implementation. The stated aims of the Consultation Meeting were to: • •



discuss alternative approaches to risk management, perception and communication in environmental health in the light of recent public health experience; exchange information and views for the development of strategies and practical recommendations for health policy-makers and information specialists to set up institutionalized mechanisms incorporating public perceptions of environmental health hazards into policy-making for more effective risk communication; provide practical guidance to WHO Europe on ways to integrate (“mainstream”) risk perception and communication into the public health systems;

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From the presentation by Carlos Dora, WHO Headquarters, entitled “Gaps in engaging with Perceptions in Risk Communication and Policy Making - Issues raised by research on risk perceptions and communication of the BSE/CJD saga”.

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Fourth Ministerial Conference on Environment and Health” – Declaration 25 June 2004, Tools for policy-making, paragraph 18a, http://www.euro.who.int/document/e83335.pdf 3 Resolution EUR/RC54/R3, http://www.euro.who.int/Governance/resolutions/2004/20040913_7 (see point 8)

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provide guidance to WHO Europe on the development of policy guidelines on risk communication on environmental health within the framework of the Budapest mandate.

There was general agreement that the key challenge for effective risk communication was to find ways in which public concerns can provide input into health and environment policymaking, rather than remaining merely an object of policy-making. All agreed on the need for risk communication to be more than a public relations exercise. Discussions reflected a new orientation towards risk communication as a dialogue (i.e. effective two-way communication) which involves listening to the public, taking ethical considerations seriously and dealing with a range of knowledge. Most experts pointed to the need for risk communication approaches to support and enhance democratic processes and accountability. A wide variety of strategies were identified for both accessing public perception intelligence, actively engaging people at different stages of policy development, building on existing knowledge and experience and institutionalizing approaches. This report summarizes the discussions. The report is organized around four questions: 1. 2. 3. 4.

Why should policy-makers strengthen their risk communication capacities? How can this be done? Why has it not been done more effectively to date? What next steps should be taken to develop WHO European Guidelines?

Each of these questions is addressed in a section of this report. Each section incorporates relevant material from the expert presentations delivered at this Venice consultation meeting.

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Section 1 Why should policy makers strengthen their risk communication capacities? The rationale for action 1.1 Ministerial mandates4 - the international policy context This “action agenda” meeting5 on Risk Perception and Communication was organized in line with the Declaration of the Fourth Ministerial Conference on Environment and Health signed by the European Ministers (Budapest, June 2004) and the Resolution EUR/RC54/R3 approved by the Member States (Copenhagen, September 2004). Specifically, during the Ministerial Conference, Member States assigned high importance to communication on environment and health and in their declaration stated: “We affirm the importance of and need for communication with the public at large on environment and health, particularly where the interests of children and other vulnerable groups are involved. We equally emphasize the importance of the participation of children and the need for their inclusion in activities concerning the health and environment of children. We invite international organizations to help address this issue, including through support for meeting the commitments of the Århus Convention on Access to Information, Public Participation in Decision-making and Access to Justice in Environmental Matters, with the development of guidelines on risk communication as an important tool for bringing environmental health considerations to the attention of different sectors and for heightening public awareness”. ( paragraph 18a) The WHO Regional Committee for Europe, during its 54th Session held in Copenhagen on 6-9 September 2004, included in its resolution EUR/RC54/R3 a specific request to the Regional Director to continue to provide leadership to the Environment and Health process in the European Region by further promoting the Regional Office's and country offices' activities through, among other things, “identifying appropriate risk management techniques, including those addressing risk communication and perception, through the collection, analysis and interpretation of case studies as well as the identification of best practices”. Additionally, public participation is now required by international legal instruments such as the Protocol on Strategic Environmental Assessment under the Espoo EIA Convention and Articles 7 and 8 of the Århus Convention and others. 1.2. Risk communication as a core public health competence 6 Communicating about risks is an integral component of their management and is part of the daily work of any health and environment department or agency, from the local to the international level. This is a central function of the World Health Organization (WHO). Known and emerging hazards highlight the need to keep the community and the general population Remarks in this section are taken from presentation by Roberto Bertollini, Director, Special Programme on Health and Environment, WHO European Centre for Environment and Health. 5 In follow-up to the Budapest declaration and subsequent RC resolution, the WHO Rome office is coordinating a series of “action agenda” processes in the run-up to the Fifth Ministerial Conference on Environment and Health to be held in 2009, to address the specific commitments made by and needs identified by Ministers. 6 From meeting background paper. 4

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informed on the associated risks to individuals and how people should protect themselves, their families and communities. People’s risk judgments are influenced by many factors other than statistical data, such as their values, emotions, group affiliations, socio-economic status, trust in institutions, and sense of control. As part of risk management, risk communication aims to foster public resilience and inform public participation to support appropriate (often behavioural) response, thus contributing to control of the risk. However, the increasing complexity of societies, the need to cope with uncertainties and the frequent lack of information on real risks or the over-representation of them, as well as the limits of science and policy mechanisms to adequately address problems and public health issues, further complicate the picture and the decision-making process. This is particularly relevant where environment-related health risks are concerned. There is an increasing need to gain a better understanding of the interplay between public perceptions and the media, communication strategies and policy initiatives and to investigate how public authorities can both earn trust and legitimacy when communicating about uncertainty and health risks. Understanding how and why perceptions shape risk awareness is crucial for policy-making, risk assessment and communication. Guidelines are needed that will help policy-makers learn from the best experience available and customize their approaches based on an understanding of the specific attributes of their communication environments. There are a number of reasons for policy-makers at various levels to investigate public perceptions of risk. These include objectives such as: • • • • •

determining public priorities for policy action (needs assessment) assessing views about the impact of current policy (policy evaluation) assessing views about various policy options (policy formation) determining the effectiveness of information about policy (public understanding) devising successful communication strategies (policy implementation)

These elements reflect different needs for information at different stages in the policy process and among different policy actors. Clearly, the methods for producing any of this information must be appropriate to each need. 1.3 Poor communications and bad outcomes7 The bovine spongiform encephalopathy (BSE) saga has made painfully evident the limitations of risk communication as a one-way avenue, where information to the public on risks they face comes after important policy decisions have already been taken. Communication has been identified as one of the key elements of what went wrong and generated the loss of trust in government discourse in Europe. WHO and a group of European scholars8, with the support of

From presentation by Carlos Dora, WHO Headquarters, entitled: “Gaps in engaging with Perceptions in Risk Communication and Policy Making - Issues raised by research on risk perceptions and communication of the BSE/CJD saga”.

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Research was coordinated by WHO and several European research institutes participated (Finland: STAKES Research Centre, Welfare and Health, National Institute of Public Health, Helsinki; Germany: Institute for Empirical Social Studies in Munich, Institute for Agro Economy, Kiel; Italy: University of Bologna, University of Sassari; United

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the European Commission DG Research, examined the types of communication strategies adopted in four European countries at the time of the BSE crisis (Finland, Germany, Italy, United Kingdom, in the period 1986-2001), to gain a greater understanding of the interplay between public perception, the media and policy initiatives9. Findings point to the critical importance of creating mechanisms for interaction between policymakers and stakeholders early on, and at all stages of policy-making, in order for risk communication to be effective. Concealment, sedation and understatement were at the heart of the failure in communicating about risk from BSE in the UNITED KINGDOM and other countries at the time of the crisis. In an effort to reassure consumers about beef safety, uncertainty about the risk to humans deriving from BSE was too often translated as “no risk to humans”. Additionally messages were delivered from an agency, MAFF (Ministry of Agriculture, Fisheries and Food), that was perceived as having a conflict of interest related to their mandate to both promote beef and food safety. There were no health experts on BSE Advisory Committees, science was used to justify decisions and conceal tradeoffs and the public was perceived as needing reassurance. This led to an anxious public, loss of public trust, a major drop in beef consumption, and economic and political losses. Case Study 1 A Tale of Two Länder- North Rhine Westphalia and Bavaria, Germany In the late 1990s, Germany was considered free of BSE and surveillance was voluntary and undertaken individually by each Land. NR Westphalia adopted a proactive screening policy for BSE in 1999 (following a relaxation in the British export ban and the availability of a screening test). For this policy decision they were criticized by other Länder. In addition, they retained links with consumer protection. Bavaria was reluctant to screen for BSE, 80% of brains were considered unsuitable for testing, criticisms were made to NR Westphalia for wasting money in tests and there were weak links with consumer protection. In November 2000 when BSE was confirmed in Germany, the results of the different policy approaches resulted in big problems in Bavaria, with a fall in beef consumption and public trust in institutions to the point that the Minister of Health resigned; in NR Westphalia there was continued trust in institutions by the population as well as confidence in BSE policy, and beef consumption was stable. Another example10 of poor risk management and communication was the dioxin crisis in Belgium in 1999, where a small amount of animal feed became contaminated with Dioxin. An inability to identify which farms received the contaminated feed and where in the food chain the products derived from the livestock on these farms ended up resulted in a food scare involving all Belgian eggs, meat and dairy products. The Belgian Ministers of Health and Agriculture had to resign and finally the entire Government fell. The EU banned certain products from Belgium and the US banned certain food lines from the entire EU. In response to an EU alert the Irish Food Safety Authority withdrew Belgian chocolates from the market. Nobody asked the question “even if the chocolates are contaminated with a genotoxic carcinogen at the rate of parts per billion, how many chocolates would one have to eat to get an adverse effect?”. Ironically, it Kingdom: London School of Economics, London School of Hygiene and Tropical Medicine, SPRU - Sussex University Brighton). 9 The result of this work is contained in the book “Health, Hazards and Public Debate: lessons for risk communication from the BSE/CJD saga” recently published by WHO. Its contents form the background to this technical meeting. 10 From presentation “Risk Perception & Communication” by Professor Patrick G. Wall, UCD School of Public Health & Population Sciences, University College, Dublin.

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subsequently turned out that the milk powder in the chocolates had been exported from Ireland to Belgium and re-imported as chocolate. 1.4 Risk communication as a fundamental task of democratic governance11 Democratization of society requires transparency of decision-making. Public participation makes the decision-making process transparent and public authorities accountable. A decision made with public involvement is more likely to receive support in its implementation. Public participation also leads to decisions that are better for the environment. The public can bring expertise and knowledge to the process. Public experts may not only criticize mistakes or see negative sides of a plan or program, but also suggest good alternative solutions. They can introduce environmental and sustainability considerations into decision-making, which will help to prevent negative impacts on the environment, including health. Public deliberation on risk issues are necessary to obtain democratic consent, to increase institutional legitimacy and to identify relevant knowledge and values. The tradition of risk communication practice12 has been one of explaining and convincing those who don’t know, don’t understand or don’t want. Based on such assumptions and goals, the strategies adopted have often been ineffective and occasionally counter-productive, even originating suspicions (not always unjustified) of manipulation and deceit. In recent years, profound and rapid changes have occurred in the interaction between science and society. In this context, ideas about inclusive risk governance have emerged, challenging the traditional view of risk assessment as the province of experts alone, prior to and rigidly separated from risk management policies and procedures. Theoretical revisions have been accompanied by field research and experimentation in the design of procedures for inclusive risk governance, mainly devoted to improving the relationship between experts, public (and occasionally private) institutions, and citizens. A number of factors have merged in promoting this new trend, including growing public concern over environmental and health risks and increasing opposition to decisions which are felt as imposed, not fully justified or justifiable. Citizens have often questioned value assumptions (for example regarding equity and distribution) and have been given technical responses instead. In order to remedy this situation, changes in risk communication practices are insufficient and radical innovations are necessary, starting with the very framing of risk issues. This is no minor task, especially for bureaucracies, which tend to be dominated by inertia and to resist change, despite discontent with present arrangements. In any event, taking stock of public perceptions can hardly be postponed, be it out of genuine recognition of legitimate public demands or the wish to manoeuvre towards discounting them. The reasons for the failures and successes of the ensuing strategies reside to a large extent in the promoters’ desired outcomes and their underlying assumptions. The framing of the former in an up-to-date, politically correct rhetoric is no guarantee of authentic involvement and commitment. Moreover, dedication on the part of just a few individuals has little chance of defeating a dominant organizational culture.

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From meeting background paper Drawn from abstract by Bruna De Marchi, Head, Mass Emergencies Programme (PEM), Institute of International Sociology of Gorizia (ISIG). 12

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1.5 Policy-makers are calling for assistance 13 “In my current capacity at this meeting, I should say that you are the experts on risk communication while I am the user. I am the decision-maker and the crisis manager that needs to be addressed by the experts for making proper decisions. The Italian Department of Civil Protection is confronted almost every day with problems of risk communication with reference to events such as landslides, floods, extreme weather events, industrial accidents, etc... But I would underline that, in addition to technical problems to be solved, we are also requested to inform the population. “Based on my experience, I should say that good risk communication requires a good spokesman with charisma and capability to speak on radio and TV. At the same time, I should also say that the population has to have trust in the institution in charge of providing risk communication messages. The Italian Civil Protection has developed the capacity to explain to the population what the institution is, what its competences are, where it is and what it does, either in the context of a crisis or on a routine basis. “We have to be able to communicate to the population what we think will happen in case of a crisis and what we expect the population should do in determined scenarios. I believe that this is not so impossible for governments to do. What we are not really able to do, and what we need from the communication experts, is advice on how to communicate with the population when policy-makers take decisions that are not easy for them to accept or are unpopular.” Case Study 2 Communicating unpopular solutions - “Waste crisis in Campania Region, Italy” “The dumping cycle in Campania is a critical problem nested in the framework of a social, environmental, and health setting. With reference to it, I would like to mention the work we are carrying out with the WHO Environment and Health Centre in Rome in collaboration with some national health and environmental institutions in the context of the “Waste crisis in Campania Region” in the southern part of Italy. The solutions identified by the Government to solve this crisis, including the installation of incinerators, have met with opposition from the local population. In particular, people consider the waste disposal plants as an unacceptable risk, which is going to impact on a territory already burdened by poor environmental and socio-economic problems. In this context a multidisciplinary group, including WHO, the Italian Institute of Health in Rome, the National Research Council in Pisa, the Health and Environment Agencies of the Campania Region, entrusted by the National Department of the Civil Protection, worked together to produce an environment and health profile of the Naples and Caserta provinces aimed at the identification of critical health and environmental issues in the area, the organization of a model of epidemiological and environmental surveillance and the assessment of health impact connected to solid urban waste management. Such information will form the basis for establishing a dialogue with the population in order to identify proper solutions to the “waste crisis”.

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From presentation “Activities of the Italian National Department for Civil Protection with reference to risk perception and communication” by Marta Di Gennaro, Director General, Major Events Office, Department of Civil Protection, Italy.

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Section 2 How can this be done? Current knowledge and experience in studying and implementing effective risk communication strategies 2.1 Building on the available evidence base 2.1.1 Developmental theories14 In 1998 Fischoff characterised the ‘Stages of development of risk communication’ as having evolved along a pathway consisting of six sequential stages approximating to: 1 2 3 4 5 6

All we have to do is get the numbers right All we have to do is tell them the numbers All we have to do is explain what we mean by the numbers All we have to do is show them that they’ve accepted similar risks in the past All we have to do is show them that it’s a good deal for them All we have to do is make them our partners

That sequence of risk communication tactics can be mapped on to the evolution of the ways in which the role of science in risk appraisal and decision-making has been understood and portrayed. The simplest model has been the technocratic model, according to which policies are based (only) on sound science. That model can be represented graphically as in Figure 1. Figure 1. The technocratic model: policy based on sound science

Science

Policy Making

In this model, scientific knowledge and understanding are portrayed as providing all the necessary and sufficient resources from which policy decisions can be derived. Technocratic approaches have long ceased to be accepted as sufficient by most scholars and policy analysts; the underlying model has been shown empirically to be inadequate. Firstly, scientific understanding on many risk issues is characterised by uncertainties, ambiguities and ignorance. That is one important reason why the scientific community rarely speaks with just one voice; disputes amongst experts are frequently encountered. Furthermore, if scientific uncertainties could be diminished or even eradicated, scientific considerations on their own could never suffice to decide policy issues concerning the acceptability of risks, typically in exchange for some anticipated benefits. Consequently, the technocratic model has been replaced with a multi-stage model that involves taking into account not just scientific considerations (typically in the context of what is usually termed ‘risk assessment’), but also non-scientific considerations (such as social, economic, cultural and political factors) in the context of a second stage that is often referred to as ‘risk 14 This section draws on the presentation “Risk communication: lessons from a study of risk assessment policy” by Erik Millstone, SPRU Science and Technology Policy Research, University of Sussex, Brighton

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management’. In that model, often called a ‘decisionist model’, which acknowledges that policies depend on decisions as much as on scientific advice, a third ‘down-stream’ stage is often introduced, termed ‘risk communication’. A decisionist model can be represented graphically as in Figure 2. Figure 2. The decisionist (Red Book) model: science first, policy-making second Scientific considerations

Risk Assessment

Non-scientific considerations

Risk Management

Risk Communication

In this model15, policy decisions are to be communicated, but uni-directionally from the policymakers to stakeholders and citizens. The decisionist model has, however, been thoroughly discredited by many policy analysts and science policy scholars. While the decisionist model can come to terms with some marginal uncertainties in the sciences that contribute to risk assessment, it does not provide the resources with which to make sense of the ways in which policy-makers and their expert advisors actually grapple (or fail to grapple) with profound uncertainties and ambiguities in assessments of risks. Moreover, the assumption that while science can influence policy, policy considerations never influence scientific assessments of risk has been shown to be unrealistic. Numerous studies have shown that scientific assessments of risk are routinely framed by a set of non-scientific assumptions concerning, for example, the scope and limits of the types of effects that are to be assessed, and the kinds of evidence that should be taken into account.16 In response, scholars have articulated what is sometimes called the ‘co-evolutionary’ or ‘transparent’ model, which represents scientific risk assessments as situated between two distinct, but inter-related, sets of risk management considerations.17 Up-stream framing assumptions configure the scope and parameters of the science-based risk assessment. For example, European assessments of the environmental risks of cultivating GM crops include, de jure, both direct and indirect effects, whereas US assessments typically confine their attention to direct effects; while Japanese assessments extend to consider effects on soil microorganisms, which are normally outside the scope of both US and European assessments.

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The model was first adopted in the USA in the 1980s, where it became known as the ‘Red Book’ model, in recognition of the influence of the 1983 report from the US National Research Council entitled Risk Assessment in the Federal Government: Managing the Process15, which was published in red covers. From the USA it spread to international bodies such as the OECD and thereby to the Codex Alimentarius Commission. In the late 1990s and early years of the 21st century, following particularly the crises created by BSE, it was adopted by the European Commission, as well as by the governments of the UNITED KINGDOM, Germany, many other EU Member States and by Japan. 16 See e.g. Science in trade disputes related to potential risks: comparative case studies, IPTS, October 2004; see http://www.jrc.es/home/publications/publication.cfm?pub=1203 17 See Zwazenberg,P., and Millstone, E. BSE: risk science and governance. Oxford University Press, 2004, Chapter 2.

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Down-stream risk management considerations are involved in taking into account scientific advice from risk assessors alongside non-scientific considerations, concerning for example estimates of costs and benefits, and judgments of feasibility and acceptability of alternative policy options. On this model, there are reciprocal bi-directional links between science and policy, and each stage involves reciprocal communication with external stakeholders. This model can be represented graphically, as in Figure 3.

Figure 3. The co-evolutionary model of science-based policy-making

Socio-economic and political considerations

Framing assumptions

Scientific considerations Technical, economic, social and political factors

Expert Assessment

Risk management decision-making

reciprocal risk communication

2.1.2 Framing theses18 Three framing theses were identified as providing insights in seeking to understand questions concerning risk perception and risk communication. These are concerned with: the informal logics shaping risk-related behaviour; the role of media accounts in understanding risk-related issues; reasoning about the trustworthiness of risk management agencies; and the underlying moral discourse of risk. Thesis 1: The informal logics of risk Reasoning about risk by lay publics typically involves a wider framing of topics, considerations and agendas than that typically used by technical experts. Such reasoning reflects personal experiences and circumstances, local contextual issues and other ‘local knowledge’. People also find a need to account for risk-related actions in ways that not only make sense to others, but also present them in morally-acceptable ways. Such motivations can generate convoluted patterns of social interactions. In this way, when actors engage with the practicalities of risk issues, in their specific contexts, a diversity of informal logics may be seen to inform their actions. Making sense of risk-related issues entails the use of whatever interpretative resources and evidence are at hand. Such sense-making is accomplished collectively by ‘talking understandings into existence’ in ways that are sometimes playfully inventive, and which have regard to ideas of social accountability and moral acceptability. This perspective has important implications for risk communication, and associated attempts by risk management agencies to shape the behaviour of lay publics. Risk communication is not just 18

This section draws from the presentation “Four theses on rationality in risk perception and communication” by Tom

Horlick-Jones, Cardiff School of Social Sciences, Cardiff (UNITED KINGDOM)

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a matter of ‘filling up the heads’ of targeted audiences with information, upon which they are expected to act ‘sensibly’. Rather, it is important for risk communicators to seek to understand the logic of the position in which target audiences find themselves. In this respect, the traditional ‘public education’ model of health promotion is flawed. Consideration needs to be given to re-casting ‘health education’ in terms of the promotion of certain behaviours in terms of their social acceptability. Thesis 2: Media accounts, everyday life and risk signature The extent to which media accounts shape people’s behaviour is clearly a key question for risk communication practice. Studies19 presented led to the hypothesis that different risk issues have different capacities to engender specific patterns of understanding and response, which was denoted its ‘signature’. This ‘signature’ of risk may be understood in terms of people’s practical reasoning, in specific circumstances, about the material nature and potential social impact of given risk issues. In this sense, it is neither a wholly objective nor wholly subjective attribute of the issue. Rather, it is about how the material characteristics are articulated in social terms. The differences in the structure of accounts reflects the degree to which understandings can be grounded in terms of everyday experience. Media accounts will have a more or less important role in shaping understandings according to the extent to which everyday experience can be called upon to provide a compelling account. Thesis 3: Trust, knowledge and reasoning Investigations of trust in regulatory agencies have found that people employ different modes of reasoning about trustworthiness according to their knowledge of the official body in question. Three overlapping domains of reasoning were identified: • • •

‘Brand’ or simple association Structural-calculative reasoning Personal experience

Those with a rudimentary knowledge of the organisation tended to reason on the basis of simple associations or ‘brand’ (a body might be trusted because its title included a word with positive connotations like ‘health’). As knowledge increased, a structural-calculative form of reasoning became important, in which typically the perceived interests, or ‘stake’, of the body with respect to the issue in question formed an important consideration. Relatively few respondents reasoned on the basis of specific personal experience of the operational effectiveness of the regulatory bodies considered. However, when this did occur, and that experience had been positive, then trust in the institution reflected this personal familiarity, sometimes despite structural features that tended to reduce trustworthiness (for instance, the regulatory body was recognised to be a part of government which, for some other reason at that time was unpopular or widely regarded as incompetent). This finding has important implications for health promotion agencies wishing to enhance their trustworthiness and credibility.

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Here the speaker drew upon a major multi-hazard study he had conducted with colleagues. They had recognised the methodological dangers inherent in simply taking at face value participants’ accounts of the influence of media sources on their views. So they decided to analyse the accounts provided by respondents as topics in themselves, rather than as resources that provided unproblematic information. Accounts were analysed according to the distribution of appeals to knowledge derived from everyday experiences, the experiences of families, friends and colleagues, or media sources.

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Comments: It was suggested that these factors are important considerations for the design of health promotion initiatives: • •



Consideration should be given to re-thinking health education in terms of the promotion of certain behaviours in terms of their social acceptability. Health promotion agencies need to gain a much better understanding of their target audiences, and how they reason, in practical ways, about risk and other issues. Local monitoring should include eliciting feedback from local people in informal, relatively unstructured and interactive fora. The adoption by health promotion agencies of a design-based and user-centred approach to risk communication.

2.1.3 Public perception research20 There is an extensive research base analyzing factors which influence public reactions. Policymakers and their advisers can draw on this research in anticipating/predicting level and type of public reaction (Box 6). Box 1 - Fright Factors - (Communicating about Risks to Public Health: Pointers to Good Practice, UK Department of Health pamphlet, p.5, 1999) Risks are generally more worrying (and less acceptable) if perceived: 1. to be involuntary (eg exposure to pollution) rather than voluntary (eg dangerous sports or smoking); 2. as inequitably distributed (some benefit while others suffer the consequences); 3. as inescapable by taking personal precautions; 4. to arise from an unfamiliar or novel source; 5. to result from man-made, rather than natural sources; 6. to cause hidden and irreversible damage, eg through onset of illness through many years of exposure; 7. to pose some particular danger to small children or pregnant women or more generally to future generations; 8. to threaten a form of death (or illness/injury) arousing particular dread; 9. to damage identifiable rather than anonymous victims; 10. to be poorly understood by science; 11. as subject to contradictory statements from responsible sources (or, even worse, from the same source). The most commonly accepted model – the received view/psychometric model – stresses that members of the public react negatively to technology whenever (a) it is new, (b) it gives rise to “dread”, and (c) there is low trust in experts and organizations concerned with managing the risk.

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This section draws on the presentation “Myths of the psychometric paradigm and how they can misinform risk communication” by Lennart Sjöberg, Center for Risk Research, Stockholm School of Economics

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This model suggests that there are only few and generally applicable factors. Novelty and dread with regard to a hazard are the major factors, and almost completely explain, for example, opposition to nuclear power. The model suggests that experts are objective and not influenced by the “subjective” risk factors such as novelty and dread. The model states that trust, always social trust, if it can established, will reassure the public about risk and make them believe in and accept the “objective” risk assessment. “World views” are also seen to have a large impact on risk perception. This model is broadly accepted because of its persuasive data results, closeness to commonsense, and political expediency. Recent research (presented at the meeting by L. Sjöberg), however, challenges the validity of this model. Novelty and dread have not been found to be of primary importance, especially not novelty. Other factors, such as interfering with Nature and moral values, are more important. “World views” have been found to be only weakly related to perceived risk. Epistemic trust (trust in institutions and agencies) appears to be more important than social trust. Emotions are important but need to be operationalized as personal and a broad spectrum must be covered, not only strong fear (dread). Perceived risk must be studied as both personal and general – they give partly different information. “Risk” is not the most useful concept to focus on; people are much more concerned about consequences. “The public” is not a homogenous group – there are both alarmists and risk deniers, and the latter are much more numerous. “Interfering with Nature” is a very important additional factor. Reactions to new technology are not driven by novelty per se but by other factors, such as perceived benefit or if the technology brings about unique advantages and is hard to replace. In addition, various hazards, some new (such as terrorism), require their own specific factors. Such findings have important implications for risk communicators. This current research points to the need, for example, of taking a broad range of emotions into account - not only fear. That understanding and trust in science is very important. “Risk” and probability are marginal to people who respond to notions about anticipated consequences. There are very different reactions to hazards – risk neglect is a more common and important problem than excessive alarm.

Comments: Erick Millstone – There are disagreements within science. Trying to portray science as if it was detached from all conflicts of interest does not work. Earning trust is a long process and trust has to be built up. 2.2 Learning from experience 2.2.1 WHO Outbreak Communication Guidelines21 The SARS outbreak was a wake-up call for outbreak communication activities. Experiences in dealing with that were the bases for preparation for a pandemic, whenever it does occur. WHO developed training on avian influenza, providing Ministry officials (not necessarily Ministries of Health) and WHO country staff with Guidelines. 21

This section draws on the presentation “Communications Experiences With Avian Influenza” by Gregory Hartl, Coordinator, Sustainable Development and Healthy Environments (SDE), WHO Headquarters (representing self and Dick Thompson).

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Box 2 - WHO Outbreak Communication Guidelines, 2005 Communication is a key feature and core public health function related to outbreaks. Unfortunately, examples abound of communication failures which have delayed action, undermined public trust and compliance and unnecessarily prolonged economic, social and political turmoil. Some key considerations, based on best practice examples, are listed below. Trust The overriding goal is to communicate with the public in ways that build, maintain or restore trust. This is true across cultures, political systems and levels of development. Trust in communicating with the public is critical in both directions. Evidence shows that public panic is rare, and most rare when people have been candidly informed. Announcing early The parameters of trust are established in the first official announcement. This message’s timing, candour and comprehensiveness may make it the most important of all communications. Transparency Maintaining the public’s trust throughout an event requires transparency (communication that is candid, easily understood, complete and factually accurate). Transparency characterizes the relationship between the event managers and the public. It allows the public to view the information-gathering, risk-assessing and decision-making processes associated with outbreak control. The public Understanding the public is critical to effective communication. It is usually difficult to change pre-existing beliefs unless those beliefs are explicitly addressed. And it is nearly impossible to design successful messages that bridge the gap between the expert and the public without knowing what the public thinks. •

Early risk communication was directed at informing the public about technical decisions (known as the “decide and tell” strategy). Today, risk communicators teach that crisis communication is a dialogue.



It is the job of the communicator to understand the public’s beliefs, opinions and knowledge about specific risks. This task is sometimes called “communications surveillance”.



The public’s concerns must be appreciated even if they seem unfounded.



Risk communication messages should include information about what the public can do to make themselves safer. Planning Risk communication should be incorporated into climate change/health activities, whether extreme planning for major events, advice on behavioural measures to prevent infectious diseases or all aspects of an outbreak response. The training consisted of informing on outbreak communication as a subsidiary of risk communication and on how to talk with journalists and the public. More precisely, the training provided information on what ministries/WHO should do in the pre-outbreak phase, during the outbreak and after the outbreak. In the outbreak phase it is absolutely necessary to gather information on what people think and do in order to deal with or avoid risks. This is useful to understand the level of public preparedness in facing risks and, subsequently, establish communications plans with the ministries.

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During the outbreak it is fundamental to make an early announcement, as well as to establish “internal” coordinating communication mechanisms in the next 48 hours (in SARS, there was a great reluctance among National Health Authorities to make any information public). Early risk communication should also be directed at informing the public about technical decisions. It is the job of the communicator to understand the public’s beliefs, opinions and knowledge about the risks and to establish a dialogue with the public. This task is called “communications surveillance”. After the outbreak it is important to evaluate the communication plan for lessons learnt. Main points of outbreak communications are building trust, announcing early, being transparent, respecting public concerns and planning in advance. With reference to relationships with journalists, it must be admitted that we communicate better when journalists are trained on the subject. The media may have a short memory. In the past week, a cluster of six confirmed cases of bird flu to human transmission was found in Sumatra. Over 400 journalists in the past week (90 %) assumed that this was the first time we had seen transmission. of bird flu to human In developing countries, journalists are regarded as a more trusted source than government agencies. Subsequently, we consider it to be of fundamental importance to train journalists to ask the right questions. It is also essential to monitor public concern through, for instance, Google, WHO country communications staff, occasional inputs from communicators outside WHO.

Comments: Roberto Bertollini: What about communicating vis-à-vis diseases that have long-term chronic consequences, as compared to acute? We are dealing with environmental risks. Should we use different strategies when communicating different kind of risks? There are messages that need to be communicated with well-constructed arguments (eg the message: “Poultry is safe to eat if cooked and prepared properly” needs more elaboration. Need to add, for instance, that the greatest danger is in the eviscerating). 2.2.2 Lessons from the BSE/CJV saga22 Seven keys lessons from BSE/CJV saga were identified, including: 1. Avoid perception of conflict of interest in public agencies. Separate consumer protection from economic/commercial interests. 2. Avoid restricted policy options – Once policy-makers start with reassurance, they are inhibited from learning about risk and from responding to new evidence. 3. Better risk mechanisms or efforts are needed to look into public attitudes. Avoid incorrect assumptions about the public. Many policy-makers still believe that the public

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From the presentation by Carlos Dora, WHO Headquarters, entitled “Gaps in engaging with Perceptions in Risk Communication and Policy Making - Issues raised by research on risk perceptions and communication of the BSE/CJD saga”

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wants simple answers, zero risk and complete certainty. Studies found no support for these views, as the public recognize the dimension of the uncertainty. 4. Media should be considered as both mirrors of public perceptions and at the same time contributing to public perception. Systematically analysing those two functions should help us to take stock of public perception of risks for policy-making. 5. See public opinion as a necessary input into policy-making, not something to be managed. There is a need for a framework to engage people’s perception at different stages of the policy process. The framework proposed in the “Health Hazards and Public Debate” book was: • • •

Upstream – policy objectives and options, scope of the RA (dealing with framing assumption). Midstream – managing the appraisal and uncertainty (risk assessment policy questions). Downstream – acceptability distribution of costs and benefits (trading off risks).

6. There is great potential for deliberative and participatory methods. Many useful tools and techniques are available to engage the public in decision-making – citizens’ panels, interactive web resources, open board and committee meetings. 7. Provide information before deliberation is done. Interact – not only get information from people, but dialogue about how decisions will affect people – when framing risk assessment as well as when discussing options for management 2.2.3. Lessons from the Food Safety Authority of Ireland23 “I will refer to my past experience as Chief Executive of the Food Safety Authority of Ireland between 1998 and 2003. At that time I was under the impression that risk communication consisted of announcements to reassure the public in crisis situations and public awareness campaigns and that these would lead to a desired behavioural change in the public. On the contrary these, together or individually, rarely have the desired effect. “Increasing awareness of health and environmental risks, educating people on the detail, and changing people’s attitudes and perceptions are key sequential elements on the road to behavioural change but are often not sufficient to deliver the desired outcome. A few examples include: (1) The need for doctors to wash their hands to prevent the spread of infection in hospitals - no health professional would think this a bad idea, yet the simple measure is not always practised; (2) Few people are unaware that recycling waste is a good thing to do and most are in favour of it, yet not everyone practises it; and (3) Most people consider taking daily exercise is good for their health, yet although people want to do it, often other time-consuming things take priority over their health. “The public are averse to certain perceived risks, whilst indifferent to other risks that they are exposed to which have a higher probability of occurrence. Some people are reluctant to consume genetically engineered food but have no problem clogging up their arteries with a daily dose of saturated fats. Are risks from food and the environment exaggerated or understated among the public, and do the public fear the correct types of food risks? The risk 23 Drawn from the presentation “Risk Perception and Communication” by Professor Patrick G. Wall, UCD School of Public Health & Population Sciences, University College, Dublin.

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of diet-related disease is regarded differently by individuals to the risk of bacterial food poisoning, and the risk of BSE and alleged food-borne risks like Avian flu are internalized and processed differently. While many people are happy to smoke cigarettes, the same people are often worried about toxic fumes from incinerators. Despite much rhetoric about risk communication, little is known about how to engender more rational evaluation of risk by the individual. “The tendency toward panic reactions in response to catastrophic risks is something that should concern those involved in both industry and public health. The economic losses caused by overreaction, or misplaced reaction, can be huge, as can the loss of human life. Often the risk management response is in proportion to the media coverage of the issue rather than the actual risk to human health. Policy-makers and regulators are not consistent in how they address risk and Society does not treat equivalent risks with the same degree of intervention. For example, deaths from road traffic accidents are not regarded in the same way as deaths from food poisoning and do not precipitate the same degree of media coverage and reactionary risk management. “Resources are finite and to maximize health gain, interventions should be targeted to achieve the greatest yield. “In the BSE crisis in the 1990s, citizens lost confidence in their food industries’ commitment to produce safe food and the regulatory and public health agencies’ ability to police the industry and put public health interests foremost. Some national authorities had wrongly declared that there was no risk to public health from beef! The consequences of this crisis was that public health was put at risk, consumption of beef plummeted, several governments and an EU Commission were damaged and the mechanisms for how food safety was assured were reviewed and the legal framework for food safety in the EU was simplified. A range of national food safety agencies, focused on consumer protection, emerged throughout the EU and a panEU agency, the European Food Safety Agency, was created. Openness and transparency became the new buzzwords. “Generally speaking, the public do not just want to listen to risk communication messages; they really want you to tell them what you are doing to control the risk and whether you have taken the risk away completely. “Regarding the scientific views of risks, increasingly some scientists are inclined to exaggerate the risk as “if there is no risk, there is no funding for research”. Sometimes the distortion is deliberate and at other times the scientists are looking at their particular issue in isolation from all other risks society is exposed to. Risk managers and policy-makers have to prioritize the risks they address and often factors other than pure science have to be considered in determining their decisions. “The scientific risk assessment carried out on the safety of GMOs, undertaken on a case-bycase basis, in the most part concluded that there is no difference between conventional food and GMO food. But the public and professionals hold different views. The lack of any perceived benefits to the consumers has no doubt influenced the public’s conclusions. Genetic engineering as a technology is delivering benefits for mankind and genetically engineered medicines and vaccines are readily accepted by the public and health professionals. “With reference to the foot and mouth outbreak in the UNITED KINGDOM and Ireland in 2001, although this is not a human disease, the different responses in both countries contributed to a level of consumer anxiety that in no way related to the risk to human health. In Ireland, for instance, international rugby matches, horse racing and even the national St Patrick’s Day Festival were cancelled and US tourists were frightened away. It was interesting to see the

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extent of the response mounted to prevent an animal disease impacting on trade, whereas we have never seen the same mobilisation for the control of a zoonotic agent or a human disease. “We also have to realize that the culture of risk acceptance varies in different countries: for example, to consume unpasteurised cheese is considered a right in France, whereas it is considered undesirable in the UNITED KINGDOM. In the 25 EU member states citizens have different attitudes to food, food safety, to risk, to regulations, to compliance and to awareness campaigns. “Regarding risk communication in the EU, we talk a lot about science-based assessment of risk to inform our communication strategies but often risk communications consists of crisis media releases and public awareness campaigns. We do not engage enough with the social scientists and behavioural psychologists to understand what is going on in the public mind and how they are internalising and processing the different risks. “Finally, we rarely effectively evaluate our risk communication strategies. We evaluate the coverage and penetration of our campaigns but we do not know whether they influence the behaviour of citizens. The response of risk managers, in the regulatory agencies and in the food industry, is crucial to risk perception. If the risk managers react in a daft fashion, then it is no wonder we have skewed public perceptions.”

Comments: Gregory Hartl: It is true that sometimes those risks that are unknown create the biggest uproar among the public even if they are very irrelevant. Maria Neira: The risk quantification is very important as a long-term approach, not necessarily in the context of risk communication of a crisis. Lynn Frewer: I agree on the fact that is very important to frame the risk from the benefits point of view. 2.2.4. Lessons learned: Food safety survey – Greece, Denmark, Slovenia, UNITED KINGDOM and Germany24 The occurrence of recent food safety crises (e.g. BSE and consumer reactions to genetically modified foods) has reduced consumer confidence and trust in risk assessment, management and communication. To regain consumer confidence in food safety, it is important to consider an interdisciplinary approach to food risk analysis, combining insights from both the natural and social sciences, as well as the humanities. In order to optimise consumer trust in risk analysis practices, it is essential that there is a continuous multidisciplinary exchange of ideas and opinions. Priorities in risk assessment and risk management should align with consumer and stakeholder values, concerns and preferences. Activities concerning risk assessment, risk management, and risk communication and stakeholder involvement can be effectively integrated to meet the needs of all interested stakeholders. For example, many risks are also associated with benefits, which are similarly determined by societal risk perceptions. The question arises as to whether formal inclusion of benefit assessment should be incorporated into risk analysis. For example, evaluation and communication of risks and benefits could take into consideration the following aspects: 24

This section draws on the presentation “The importance of risk (benefit?) communication” by Lynn J. Frewer, Social Sciences Group Marketing and Consumer Behaviour, Wageningen University, The Netherlands.

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Health and Environment (technical assessment) • Regulatory acceptance of new methodologies? • Risk uncertainty and population level variability? (e.g. gender and reproduction, children, genetics). Economic • Impact on regional and national economies (e.g. introduction of LMOs to geographical regions – transboundary risks); • Impact on specific groups (e.g. rural farmers, artisanal producers, multinational industries); • Household and individuals (increased personal health-related costs). Social • Impact on quality of life (DALYS - disability adjusted life years or QUALYS - qualityadjusted life years), in conjunction with health assessments described above; • What is an “acceptable” quality of life? Who decides? Ethical • Trade-off between ethical cost of doing something, and cost of not doing something? We need to update risk assessment processes by improving the interplay between risk assessors and risk managers. In addition, communicators need to consider that the public may be receiving different types of recommendations from different expert communities or groups within the population, which promote a different message or messages. Specific strategies for developing consumer trust in risk management are therefore needed. Reference was made to a cross-national survey on consumers’ food risk management carried out in five countries (Greece, Denmark, Slovenia, UNITED KINGDOM and Germany). Implications of the survey’s results were as follows. In the context of communication, it is important to provide consumers who need information with the right information through a trusted and appropriate source. Public trust in risk management may increase under circumstances where there is proactive communication about various factors inherent in risk management. In terms of risk evaluation, it is important to incorporate the views and opinions of all stakeholders into the process of risk analysis. Finally, evidence to suggest that some cultures require more information about risk management practices than others was presented. While information about proactive consumer protection was common across all countries, as was the public preference for transparent risk analysis practices and the competence of experts involved in the process, some countries were more sceptical about the role of risk assessors than were others. Case Study 3 Domestic Food Handling A case study focusing on consumer domestic food handling practices was presented. The results indicated that whilst some consumers prepared food in a very safe way, others, particularly younger, single males, were more at risk from food-borne illness. Effective communication was dependent on understanding what consumers could achieve in terms of behaviour change. For example, the consumers most at risk would benefit most from information about behavioural changes which they perceived to be easily manageable. Psychological factors also represented important barriers to risk communication and behaviour change. For example, consumers with a high external locus of control, such that they perceived they could not influence their own health status personally, were not motivated to protect

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themselves. Consumers who were engaging in at least some self- protective practices could be targeted with information about behaviours which were more difficult to achieve.25 Conclusions identified the need not only to target communication to those members of the public who were most vulnerable to risk, but to also gain more knowledge about the psychological barriers to effective communication in these groups.

2.3 Assembling your toolkit 2.3.1 Approaches to public participation26 This presentation summarised lessons learnt from a study commissioned by the United Kingdom Food Standards Agency (FSA) on accessing the views of hard-to-reach consumer groups for inclusive participation in policy-making. The United Kingdom Food Standards Agency (FSA) was set up in the wake of concern about public trust governance. Following the BSE crisis, there was a broader concern with crisis of confidence in risk communication. To address this challenge, the FSA was set up with an institutionalised policy obligation to seek the views of the public. This study aimed to: • • • •

develop participatory methods for accessing and involving two selected groups of hard-to-reach people in the food policy-making process; test these methods in relation to two food policy issues; evaluate these methods in relation to their overall effectiveness and potential for use by the FSA; and develop consultation guidelines for commissioners.

The study developed and evaluated methods to involve “the hard-to-reach” in food policymaking. The “hard-to-reach” tend to be socially marginalized and so largely excluded from conventional consultation processes. The study included two groups of people – young people aged 12-16 and low-waged workers – and with two “live” policy issues – school food policies and food labels. The two issues also required consultation at different stages of the policy cycle: whole school food policies were chosen because of the concern over young people’s diets and to illustrate the whole cycle from identifying issues and agenda-setting to policy formulation and implementation; food labels were chosen as an example of consultation about the effectiveness of an existing policy instrument. The consultation process fell into two stages: Stage 1: methods of participatory appraisal to access the range of people’s views. Stage 2: deliberative methods to identify priorities and plans for action.

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Reference was made to a hierarchical cluster analysis that indicated 5 clusters of consumers based on the distribution of Rasch scores. 26 This section draws from “Lessons learnt from a study for the UNITED KINGDOM Food Standards Agency (FSA) on accessing the views of ‘hard-to-reach’ communities” by Judith Green, Senior Lecturer in Sociology, Health Services Research Unit, London School of Hygiene and Tropical Medicine and Alison Draper, Centre for Public Health Nutrition, School of Integrated Health, University of Westminster.

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The specific consultation techniques used with each group varied, but the broad process was similar in that it moved from identifying the range of people’s concerns through to focusing in on key issues and, with the young people, formulating actual policy. As the project progressed the issue and concerns raised by participants were continuously fed back to them for further discussion and confirmation. In response to the requests of the participants, a participatory dissemination process was added to provide closure of the consultation process. In this participants met with representatives from the FSA and presented their summary views not only on the two policy issues, but also on the process of consultation itself. Lesson 1: Methods for consulting people Participants valued the process but some people expressed some cynicism about whether organisations use the findings. This emphasizes the need for reporting back to people about the use of findings. The study produced useful information and ideas for risk communication, but methods have to be appropriate for topic, community and stage of policy-making cycle. Overall, the methods used in the consultations worked extremely well in accessing people’s views and their flexibility meant that they could be used in contexts, such as the workplace and classrooms, where other methods, such as questionnaires, could not have been used. Participants liked their openness, which gave them the freedom to raise any and all issues of concern to them. The relative utility of particular methods depended on the issue being considered (for instance, food labels versus school food policy), the group of people being consulted (for instance, adults versus students), and whether descriptive information was being sought (for instance, likes or dislikes about food labels) or a more considered deliberation of an issue (for instance, prioritizing issues for inclusion in a whole school food policy). Utility of different methods for consulting in relation to the policy process: Stage in Policy Process:

Agenda setting: identifying needs, identifying priorities Choosing policy options or policy implementation Policy monitoring, evaluation and review

Rationale for consulting Canvassing views

Involving users in decision making

Surveys, participatory Deliberative methods appraisal methods Participatory appraisal Deliberative methods methods Surveys, participatory Deliberative methods appraisal methods

Conclusion: Using innovative methods it is possible to involve the hard-to-reach in consultations on food policy and the overall levels of interest and participation were high in all groups of participants. Lesson 2: Institutional constraints to the communication/consultation process Drawing on critical reflections of the study, it emerged that the key barriers to effective risk communication were located in organizational structures and cultures rather than the methodological problems of accessing citizens’ views. Significant barriers in organizational capacity to utilize community views at appropriate stages of the policy-making process were identified. These barriers relate to the culture of large organizations such as the FSA, which are orientated to a ‘deficit model’ of risk understanding; to their structures, which lack the flexibility to respond appropriately to citizen concerns; and to the mismatch between organizational rhetoric about the timetables and processes of policy-making on the one hand and the realities of consultation processes on the other.

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Conclusion: More work is needed on institutional mechanisms for integrating citizens’ views effectively and on how organizations use user views, rather than on how to access the views of the community. 2.3.2. Media monitoring27 In modern society mass media represents one of the most important arenas for public debate. Newspapers, radio and television are great means of communication between governments and citizens, and between producers and consumers. They do not simply constitute a bi-directional information flow within society, but as an arena they also show and display the issues and problems with which public opinion is interested and concerned. The analysis of the ways in which the media deals with issues and topics gives an idea of the symbolic environment within which people and governments perceive, think and evaluate various issues. It is likely that over time mass media and public perceptions resonate with each other, and this can be specified with a number of effect hypotheses (agenda setting, cultivation, spiral of silence, etc). Free mass media and public conversations, together with formal politics and the legal process, are the “public sphere” of a modern country. Therefore, popular public discourse on issues should and can be mapped through parameters such as issue attention (intensity of coverage), discursive content and framing, and this can be done more cost effectively than with repeated opinion polls. How the ‘mapped-out public opinion’ might be taken into account in policy-making is a different question. But for current systems of public health monitoring, the issue is, who should take responsibility for mapping public discourse? Is there a place for this in surveillance systems? Mapping of public discourse has been termed ‘parallel epidemiology’ by Bauer et al (2006). The idea is a simple one. For example, the progress of a real-world ‘plague’ has two interlocked ‘traces’ that must be traced over time as an evolving system. Firstly, tracing the plague through infection rates, monitoring, risk groups, modelling. Secondly, tracing the public discourse around this ‘plague’, including expert opinions (WHO, Research labs, universities) and public-popular discourse as measurable through media analyses. This parallel epidemiological approach is important as public and popular discourse and the ‘real plague’ enable, interfere, support and block each other. AIDS has demonstrated that the naming and the discourse of attribution of the ‘issue’ guides the disease control in the right or wrong direction and determines how the public relates to control measures. The career of a disease in public discourse is part of the problem and of the solution. Resources and methodologies are available to map popular discourses. Given the research competence and facilities, intensity figures on such issues are at hand in a matter of hours thanks to on-line newspaper archives and up-to-date internet publishing. Case Study 4 Trend analysis of genetic research The long view was demonstrated on the trend analysis of British press coverage of genetic research and biotechnology, which shows variation over two waves: from 1946 to 1972 and from 1973 into the 2000s (Bauer, in print). Each wave has a nested phase of enthusiasm and of scepticism. During the first wave, biological news has little salience and evaluation parallels the 27

This section draws on material from the presentation “Monitoring of Public Discourse: Parallel Epidemiology” by

Martin Bauer, Director of MSc in Social and Public Communication, London School of Economics, Institute of Social Psychology & Methodology Institute.

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attitudes to general science. During the second wave, genetic engineering becomes a major news item, and its phase of evaluation separates from that of general science and technology. While general science improves its public profile, biotechnology becomes publicly controversial during the 1990s. Public perceptions, as far as data is available, follows the changing trends of the press with some lag. For both waves of public sentiment the study highlighted events and topics that fuelled public imagination and that led to the present mix of controversies over genetic technology in food production, biomedicine and law enforcement.28

Comments: Erik Millstone: Policy-makers may pay disproportionate attention to what is in the media and to what average citizens think. While there is a lot to be said for monitoring of the media, it is not a substitute for engagement with citizens groups and what average citizens think. Lynn Frewer: Dedicating a lot of resources to get messages into the media is not going to be as fruitful as exploring alternative means of discourse, for example through citizens groups and networks. 2.4. Enhancing competencies through training29 Handling complex and cross-cutting risks has become a major challenge for risk management and regulation. This includes the need for adequate and effective communication between the political decision-makers, regulatory agencies, experts, representatives of civil society and the general public. What are the best means for communicating risk to different target audiences so that these audiences understand the complexity and can make their own informed judgments? Which communication instruments are effective in reaching the target audience and assist in preventing or reducing the risks to consumers and other affected groups? Answers to these and other questions were compiled in a document summarizing the results of a project for the development of a multi-stage procedure of risk communication (ERiK). The document addresses four stages of communication: • • • •

inter-agency communication; communication between agency staff and external experts; between agency staff and representatives of civil society (stakeholders); and between agency staff and the general public/media.

In order to pass on the most relevant experiences and insights from this document, DIALOGIK GmbH organised two workshops for practitioners of all federal risk assessment and management agencies interested in learning more about risk communication methods and questions. The workshops30 were held in December 2005 and April 2006 in Berlin. Together,

28 Bauer MW, S Howard, V Hagendorff, G Gasperoni and M Rusanen (2006) The BSE and CJD crisis in the press, in: C. Dora (ed) Health, Hazards and Public Debate: lesions for risk communication from the BSE/CJD saga, Copenhagen, WHO, 125-164. Bauer MW (in print for 2007) The public career of ‘genes’ – trends in public sentiment from 1946 to 2002, New Genetics and Society. 29 From the presentation “Simulating Risks: A method to improve Risk Communication?” by Ludger Benighaus (& Prof. Ortwin Renn), DIALOGIK, Non-profit Corporation for Communication and Cooperation Research, Stuttgart (D). 30 The project was conducted by the German Federal Institute of Risk Assessment (BfR) on behalf of the Federal Environmental Agency (UBA), in co-operation with the Center of Technology Assessment in Baden-Württemberg.

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more than 50 representatives from authorities, mainly specialists and executive staff, participated in these workshops (Client: Federal Institute for Risk Assessment, Berlin). The training was simulating a fictitious but realistic risk example (food sector), like a poisonous substance in bakery products. The participants simulated different situations, for example a hearing with citizens, a press conference, a stakeholder workshop and a meeting of experts. DIALOGIK worked out one individual role instruction for every participant. Everybody had the chance to role play characteristic actors within a risk process, for example “president of an authority”, “representative of a consumer organisation”, or “sceptical father”. The supervisor regularly interrupted the role play with “Freeze”, discussed specific situations, and tried to find solutions for better communication. Main results of the training: • • • •

The cooperation between different authorities intensified. The understanding of their opinion and desires increased. More empathy developed for stakeholders, media, public. The handling of risks improved.

Conclusion: The approach is a promising way of enhancing capacities to deal with crises and risk communication.

2.5 Institutionalizing approaches 2.5.1 The Case of the Irish Food Safety Authority31 The world is changing, media is changing, and that influences the way that we perceive and communicate risk. Food safety management is becoming a more complex issue due to the increasing complexity of the food manufacturing environment, diversity of food manufacturing practices, new marketing paradigms - eg functional foods, emerging food safety risks, changes to farming, changing consumer perceptions and demands, international food trade. In addition to this challenge, lifestyle is impacting eating behaviour: food service, dashboard dining and desk fast food, nibbling throughout the day. The perspectives of the different players in this scenario are those of the scientists (what are the risks at my table?), the politicians (we will eliminate all risks!), the regulator (we will oversee the elimination of risks), the public (there are no risks at my table) and the media (how many dead and injured?). Distrust of bureaucracy and of agencies varies from country to country. In Ireland, the Food Safety Authority is highly respected as compared to other agencies. Its operating principles are independence, science-based decision-making and working in partnership with main stakeholders. Risks and benefits occur concurrently. Consumers are making risk and benefit judgments all the time. We also have to move towards considering risks and benefits as a whole (risk and benefits assessment). 31 This section draws from the presentation “Risk: not at my table!” by John O’Brien, Chief Executive, Food Safety Authority of Ireland

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Food agencies are entering a new era following new legislation on health claims that may be made as a result of research into foods. Good management requires prioritization of tools such as measurement of the magnitude of risk, awareness of the uncertainty dimension, health warning on the use of models, and indirect indicators of risk and biological or mathematical thresholds. When we speak about risk perception we should take into consideration different points of view: risk perception by the assessors, by the managers, by the communicators and by the public. Risk management regulations must evolve and adapt. 2.5.2. The introduction of Risk Assessment Polices32 An important innovation occurred in 2003 when the Codex Alimentarius Commission introduced the concept of ‘risk assessment policy’ into its Procedural Manual.33 This institutional innovation represented the fullest explicit official acknowledgement yet that scientific risk assessments are routinely framed by prior up-stream non-scientific assumptions concerning, for example, the scope and limits of the types of effects that are to be assessed, and the kinds of evidence that should be taken into account. The innovative steps taken by the Codex Alimentarius Commission included invoking the concept of ‘risk assessment policy’ to refer to the up-stream framing judgments, and stipulating that: “ …risk assessment policy should be established by risk managers in advance of risk assessment, in consultation with risk assessors and all other interested parties. This procedure aims at ensuring that the risk assessment is systematic, complete, unbiased and transparent; - the mandate given by risk managers to risk assessors should be as clear as possible.”34 Risk assessment policy (or ‘RAP’) is a crucial, but insufficiently recognised and understood, part of the overall task of risk appraisal and decision-making. Risk assessments occasionally conflict because different groups of experts provide competing interpretations of a shared body of evidence: for example, guideline differences between the EU and the USA over beef hormones and GM foods. Only rarely, however, are RAP implemented as described by Codex and its WHO/FAO-based bodies or by Member States of Codex, the EU and the WTO. Findings related to RAP implementation were studied in Codex, US, EU, UK, Germany and Argentina. In none of the jurisdictions and institutional settings examined are the Codex Risk Assessment Policy guidelines being implemented – not even at Codex. Conclusion: Unless and until risk communication is enriched to include explicit and accountable deliberations on risk assessment policy issues, and until RAPs are explicitly set in democratically accountable ways by risk managers, and actually guide the practices, deliberations and 32 This section draws from the presentation “Risk communication: lessons from a study of risk assessment policy” by Erik Millstone, SPRU Science and Technology Policy Research, University of Sussex, Brighton 33 Codex Alimentarius Commission, Procedural Manual, 13th edition, Rome, 2003, pp. 43-44, para 13-16, available at http://www.fao.org/DOCREP/006/Y4971E/y4971e00.htm 34 Codex Alimentarius Commission, Procedural Manual, 13th edition, Rome, 2003, pp. 43-44, para 13-15

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conclusions of risk assessors, risk appraisal and decision-making will never achieve scientific and democratic legitimacy.

Section 3 Why has it not been done more effectively to date? Overcoming obstacles and challenges to action This section draws on issues raised in Sections 1 and 2 and identifies key challenges to strengthening policy-makers’ capacities to engage and understand their publics’ perceptions and communicate risks in more salugenic ways. 3.1 The need to re-position public health communications35 Communication, particularly related to environment and health, remains a weak area for public health advocates. Lack of skills, resources and poor channels of communication between information sources and media and private and public sectors make a bad situation worse. Government spokespeople, health professionals and NGO advocates, for example, do not generally have the marketing and advertising savvy and budgets so effectively used by the private sector. Potentially synergistic partners that could stand together at the front line of health communications are often unaware of what others are doing, mistrustful of each other’s motives and proprietary about information. Public health communicators operate, for the most part, on the margins of the settings and marketplaces where people’s behaviours, perceptions and choices are being shaped. Too often communications is seen as an add-on to “real” public health work. The urgent need to strengthen capacities in risk and crisis communication demands a fundamental change in this positioning of communications. The WHO Outbreak Communication Guidelines, discussed earlier, state that “WHO believes it is now time to acknowledge that communication expertise has become as essential to outbreak control as epidemiological training and laboratory analysis.” (WHO Outbreak Communication Guidelines, 2005, pag.1) Communications in outbreak situations, as in all risk situations, address not only immediate information needs but also provide a strategic mechanism to reshape perceptions and behaviours that may directly impact on health outcomes. Communicating about the handling of chickens, for example, to at-risk populations in eastern Turkey during the Avian Flu outbreak in January 2006 was fundamental to stemming the spread of the disease. Many discussants have identified the further need to not only strengthen communication capacities and skills but to move these inputs “upstream” in the policy process. As one communicator recently stated, “if you want us to be with you for the rocky landing, make sure we are in the cockpit when you take off.”36 In reality, all public health activities have a communications component, and the “new” demands of risk communications can help to place communications in a more centre-stage positioning. The WHO Outbreak Communication Guidelines call for a strengthening of the “trust triangle” between policy-makers, technical staff and communicators. Trust is essential between 35

This section draws on background paper “Reframing the environment and health debate: enhancing the impact of public health communications” by Franklin Apfel, Managing Director, World Health Communication Associates Ltd

36

Personal communication, Franklin Apfel.

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communicators and technical outbreak staff who may not see the need to communicate with the public, especially if it means diverting them from other tasks. The relationships between these three key public health actors are best developed before crises occur. The guidelines point to the fact that “this can be complicated because different stakeholders, perhaps representing different ministries, may have conflicts of interest which will require consensus building among partners.” 3.2 The “counter-intuitive” nature of uncertainty37 Faced with risk “uncertainty”, policy-makers tend to look for ways to demonstrate that they are in control and on top of the risk situation. Most frequently they demand that their agency “speak with one voice” and that that voice provide trustworthy reassurance. Fears abound of “public panic” if agencies admit uncertainty. Evidence, in fact, points to the fact that public panic is rare and most rare when people have been candidly informed. The extent to which outbreak managers trust the public’s ability to tolerate incomplete and sometimes alarming information influences communication decision-making and effectiveness. P. Sandman provides this scenario: “A company or government agency explains a situation to the public in a way that makes it seem less complicated, less uncertain, less debatable, and therefore less upsetting than it really is. The public swallows its doubts and accepts this interpretation. Then the complexities, uncertainties and debates start to emerge. In large part because it feels blindsided and misled, the public now gets more upset than the situation justifies. And the company or agency fails to notice that its own earlier decision not to brief the public properly is what precipitated the overreaction. It concludes instead that people obviously cannot take the unvarnished truth, so the wisest course of action is to keep pretending that things are less complicated, less uncertain, less debatable, and therefore less upsetting than they really are. ‘Speak with one voice’ is a key component of this endlessly repeated mistake. By contrast, letting opinion diversity show is how you teach the public that there are no easy answers - so the difficult, uncertain, debatable, imperfect answers we’re all stuck with feel less like betrayal and more like problem solving.” The BSE saga, discussed earlier, pointed to problems related to reassurance – that when the UK agency MAFF took this approach, it closed off other options and began the cycle of miscommunication that led to the loss of public confidence in beef and consequent economic and political disaster. The ability of policy-makers to deal with uncertainties and share these with the public within a context of actively looking for solutions has been associated with “successful” risk communication experiences. Issues related to transparency were discussed38. Increased transparency means that both uncertainties and population level variability in risk also become open to public scrutiny. Decreased transparency may reduce confidence, as the question that the public will ask is “what is being hidden?” In terms of promoting public trust in risk analysis activities, it is also important to proactively communicate to the public about what is being done 37 This section draws upon evidence presented in WHO Outbreak Communication Guidelines and the article “Speak with One Voice - Why I disagree” by Peter Sandman, 27/7/06 on http://www.psandman.com/onevoice.htm accessed 7/11/06. 38 This section draws on the presentation “The importance of risk (benefit?) communication” by Lynn J. Frewer, Social Sciences Group Marketing and Consumer Behaviour, Wageningen University, The Netherlands.

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to optimize public protection. Transparency allows the public to “view” the informationgathering, risk-assessing and decision-making processes associated with risk control. Maintaining the public’s trust throughout a risk response requires communication that is candid, easily understood, complete and factually accurate. It should address: • • • •

Uncertainties (of different types, e.g. measurement versus who is affected). Methodological issues (e.g. probabilistic versus deterministic risk assessment). Variability in risk across populations. Values used in the decision-making process (management and assessment).

Additionally, it was emphasized that communication about personal preventive measures is particularly useful as it empowers the public to take some responsibility for their own health. Providing effective ways to help policy-makers to gain a better understanding of the counterintuitive nature of communicating uncertainty and learn how to communicate transparently with “trustworthy candour” is a key challenge for the proposed Guidelines process. 3.3 Current framing and re-framing options39 Understanding how you and your publics frame issues related to risks is a key to taking action. ‘Framing’ provides the context which shapes how perceptions related to an issue are managed/manipulated. Frames create the context within which policy debate takes place. Simply put, if you get people asking the wrong questions the answers do not matter. For example, marketing people hired by the tobacco industry have been very successful in framing tobacco issues around freedom, autonomy and choice as opposed to public health. Key to the success of the Framework Convention on Tobacco Control was the ability of public health advocates to reframe the issue around public health concerns, e.g. “Tobacco Kills Don’t be Duped”. Framing plays a central role in the process of public health policy formation because of the solutions that it implies. Debates over public health policy issues represent a battle for framing the issue in the eyes of the public and policy-makers. When environment and health debates are framed around freedom, independence, etc, health and social protection concerns fall off the policy agenda. When public health advocates speak up, they are painted as “zealots, health fascists, paternalists and government interventionists.”i A number of framing “syndromes” were identified as potential obstacles to public health action40. The control syndrome The first syndrome is what can be called the “control syndrome”. Example: I was a young doctor working with “Médécins sans Frontières” in Central America. We were supposed to build refugee camps in Honduras close to the border with Nicaragua and we were convinced of being right in having selected a specific area for the settlement, but the resident people living there didn’t have the same opinion. When the architect came in, the local people were looking at us and shaking their heads. We were irritated and we just wanted them This section draws on background paper “Reframing the environment and health debate: enhancing the impact of public health communications” by Franklin Apfel, Managing Director, World Health Communication Associates Ltd 40 This section draws on the presentation “Risk communication and its syndromes” by Maria Neira, Director, Department of Protection of the Human Environment, WHO Headquarters. 39

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to go away. After 5 weeks the camp was finished but it was completely flooded. The local people were saying to us: “See, we were expecting this, we knew that it was going to happen”. I asked them: “Why didn’t you tell us about this danger?” They answered by saying: “Because you didn’t ask us.” As noted in the WHO Outbreak Communication Guidelines, “It is nearly impossible to design successful messages that bridge the gap between the expert and the public without knowing what the public thinks.” (p.6) We should learn that we can never “control” a situation, although we have the final responsibility of taking policy decisions. There are many actors around us who may well know more and have key information. It is necessary to consult in a humble way and have 100 percent sense of responsibility and not 100 percent sense of control. The logic syndrome The second syndrome is the “logic syndrome”. We believe that since the science and logic is with us, people will be with us and we would expect people and the media to react in a certain way but, unfortunately, this is not necessarily what happens! Example: WHO was involved in a campaign to raise awareness on anti-microbial resistance; we prepared very sensationalist messages explaining how this could affect the public. This campaign didn’t produce any effect. We were afraid to generate panic but nothing happened. On the contrary, when I was at the Food Safety Agency in Spain, a respected person published an article in the magazine “Nature” on salmon contamination. This article created an incredible crisis in Spain because our salmon was recommended by the Spanish authorities as a healthy food. We learnt that fear is free, fear is something that you cannot control. In writing about Media Sensationalism and Risk, Peter Sandman offers some additional explanation for this syndrome: “How upset people are about a risk (“outrage”), is intrinsically more interesting than how dangerous that risk is to health or safety (“hazard”). Industrial hygienists do not think so – but they are industrial hygienists. The rest of us pay more attention to trust, responsiveness, control, dread, and the like than we do to mortality and morbidity statistics. Since we do, so do reporters. The media do not manufacture outrage, but like vultures they do prey on it – and in the process they certainly amplify it… The quantity of media coverage is proportional to the size of the outrage, not the size of the hazard. Upsetting risks are newsworthy whether they are serious or not. Boring risks are not newsworthy, again whether they are serious or not.”41 “Christiane Amanpour syndrome” Another syndrome is what I call the “Christiane Amanpour syndrome”. She is a famous CNN journalist. I met her in Zaire close to the border with Rwanda at the time when thousands of refugees were crossing the border and going to Goma. Some NGOs were foreseeing a massive cholera outbreak with thousands of deaths but fortunately it didn’t happen. As a reaction, Christiane Amanpour told me: “Why were you lying to me? Next time you will need more deaths to get me moving!”

41

http://www.psandman.com/col/media.htm

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Here clearly the CNN definition of crisis and what would interest their viewers wasn’t a story of crisis averted. They expected and wanted to deliver images of massive deaths. Working with the media means knowing how they operate and what stories will interest them . The “we-they” separation syndrome Too often “we” the scientist/policy-makers separate ourselves from “you”, the citizens. This is completely wrong. We should not play a paternalistic role (“don’t worry”, “we are taking care of you”, or “all you have to do is listen to me”). This links with the “Syndrome of total protection” (simplification of the crisis). For instance, we have seen this kind of syndrome in connection with the Avian flu crisis. One country in Europe reassured the citizens by saying: “It is true that chickens are dangerous but our national chickens are all good”. But once the balloon of total protection was punctured (just one chicken found with illness), the reassurance strategy collapsed. Communication as PR exercise Too often people think that risk communication corresponds to a public relations activity. We concentrate too much on communicating, and think that once we have communicated, it looks like we have already done the risk management part. This is completely wrong. We have people who prepare the messages and get them into the press. Because they are so good at communicating and accepted by the public, then it is perceived that the crisis is over and there is nothing more to do in terms of risk management. On the contrary, we should tell the policy-makers that the final goal is not good communication but properly addressing the risk. Our final goal is not just to communicate but to decrease the risk or make sure that it will not create impact. Emphasize the positive If we really want to change people’s behaviour, we should show the positive aspects. For instance, if we are talking about obesity we cannot set up a communication strategy by saying that people with such health problems are going to die from hypertension or high cholesterol. This does not work. We should tell them why their quality of life would improve if they accept a behavioural change in life style and what would be the benefits. We should simply use common sense. If we want to get in touch with public perceptions, we should be sure that we are in touch with normal people. In addition, if we communicate a risk we should learn how to frame it by attributing to it a quantification meaning. 3.4 Gaps in knowledge - A research agenda42 A research agenda on how to incorporate perceptions of risk into everyday policy-making should give special attention to the testing of innovative arrangements for institutionalization of risk perception and communication, and to evaluating their cost and effectiveness. This could include studies evaluating how public perceptions are taken up in policy-making and comparing different methods for achieving this. Factors to be explored as part of the research might include: • • • 42

at which stage public perception of risks should be considered in policy-making; which methods and tools should be considered as more appropriate to take into consideration for policy-making; which are the reliable indicators and which factors may affect, promote or strengthen public trust in institutions;

From meeting background paper.

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• •

what the assumptions should be of those commissioning and implementing policies and related communication strategies for effectively taking into account public risk perception; new arrangements/experiences already in place and showing modifications of the existing health and environmental information systems aimed at gathering intelligence on public perception of risk and engaging public opinions into policy-making such as: o the introduction of awareness/training sessions for staff about the public’s and stakeholders’ views (and how to access them); o the recruitment into the above systems of specialist social science resources; o the creation of a new type of risk communicator skilled in gathering intelligence on people’s perceptions and engaging them in communication and policy processes; o the integration of social mobilization experts capable of shaping messages for behavioural change through understanding of risk perception in close collaboration with the risk communicators; o experience gained with efforts to institutionalize public participation in decisionmaking on environmental and health matters: advantages and disadvantages; o experience dealing with adverse public risk perception and in general with populations exposed to dangerous or unhealthy environmental or unstable living conditions; o experience showing that for effective risk communication it is necessary to find ways in which public concerns can provide input to policy-making, rather than remaining merely an object of policy-making; o experience oriented towards dialogue (i.e. effective two-way communication) visà-vis the traditional one-way communication from experts to the public.

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Section 4 What next steps should be taken to develop WHO European Guidelines? This section draws on practical lessons in the first three sections and makes recommendations regarding next steps for WHO Europe and partners in developing practical risk communication guidelines that will usefully support actions of all Member States.

4.1 Recommendation 1: The process is as important as the product The proposed WHO Guidelines development process can itself help raise awareness about the need to strengthen public health communication capacities, especially as they relate to risk communication. Currently, there are great differences in approaches to risk communication both within and between WHO European Member States. The guideline development process offers a unique opportunity to engage relevant policy-makers, scientists, communicators and NGOs across the Region and catalyse a Region-wide dialogue regarding proposed guidance. Furthermore, the process of guideline development relative to public participation and risk communication should itself “walk the talk” and demonstrate the proposed techniques and approaches in “real time.” A communication plan needs developing which will outline steps in this process to 2009.

4.2 Recommendation 2: Don’t reinvent the wheel – Modify existing guidance This expert consultation demonstrated that there is a lot of existing guidance43 and research available here. The challenge is to package/re-package existing guidance in a way that is relevant, accessible, and useful to European policy-makers and other stakeholders across the whole Region. A wide variety of key (mostly “how to”) themes and issues were highlighted for inclusion in guidance. These included: • • • • • • • • •

Rationalising investment in risk communication How to shift from one-way to two-way risk communication How to address the dimension and degrees of uncertainty How to use knowledge on risk communication for the development of more effective messages/ communication strategies How to accurately measure risk perceptions/public opinion/views. Use of techniques/tools: public opinion surveys, monitoring media trends, citizens’ panels/deliberative processes, community interventions How to train in risk communication How to institutionalize risk communication in bureaucracies How to deal with both crises/emergencies but also social/personal behaviours (e.g. smoking, obesity, exercise) How to make the case for allocating resources to risk communication capacity development

4.3 Recommendation 3: Keep it simple, practical and targeted The principle guidance, as mandated in Budapest, calls for a document to be targeted to policymakers. Experts felt that this should be a relatively short document written in clear, simple and non-academic language. Language and tone need to move away from the ‘propagandist’ 43 For example, the 276-page Crisis and Emergency Risk Communication handbook produced by the US Centers for Disease Control and Prevention (CDC)

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tradition. Key points should be supported graphically. The 2005 WHO Outbreak Communication Guidelines were felt to be a good model of presentation. It was thought that this core guidance should be accompanied by a more comprehensive and “interactive” handbook for a broader audience of scientists, communicators and other relevant stakeholders. This handbook should provide far greater detail and evidence. The emphasis should still be practical, however, with the inclusion of simulation exercises, case studies and communication challenges. In particular the handbook should capture what we have learned from old crises, e.g. BSE, Dioxin, etc. It should make use of new technologies effectively – websites, CD- ROMs etc.

4.4 Recommendation 4: Mainstream the Guidance Development process Build guidance development activities into all events and meetings in the run-up to the 2009 Ministerial Conference. Consider linking the process with the European Environment and Health Committee (EEHC). Look at the risk communication and public consultation aspects of each Budapest follow-up issue: chemicals and children, etc. Develop a Health and Environment Risk Communicators Network, both virtual and real, for the on-going sharing of ideas and experience. Utilise this network as a training ground for risk communicators, policy-makers and others. Use the development process to broaden consultative capacities on relevant environment and health issues. Regional and national consultative/training workshops, for example, could combine data-gathering from selected target groups as well as provide training in consultative techniques. Build communication activities into any planned Regional disaster simulation exercises. Link with other relevant agencies that might be involved. Develop a cadre of trained risk communicators that could support crises in the Region and/or provide training and consultation.

4.5 Recommendation 5: Convene a steering group to oversee the process WHO should establish an on-going steering group to agree a development plan and oversee the process.

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ANNEXES AGENDA

1.

Opening of the meeting

2.

Welcoming addresses

3.

Presentation of the objectives and expected outcomes of the meeting

4.

Nomination of the Chairperson and Rapporteur

5.

Adoption of the provisional agenda and programme

6.

Background to the meeting

7.

Session 1 – Assessing public risk-perception for a successful risk-communication. Lessons learnt and gaps

8.

Session 2 – The epidemiology of public perceptions

9.

Session 3 (Part 1) – From citizens to institutions: tools to take stock of public risk perception into health and environmental policy making

10.

Session 3 (Part 2) - From citizens to institutions: governance and institutional mechanisms to take stock of public risk perception into health and environmental policy making

11.

Session 4 – Improving communication strategies as part of good policy making and engaging with public concern. Working groups for developing the WHO Guidelines on "Taking Stock from Public Perceptions of Risk for Risk Management and Communication"

12.

Closure of the meeting

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PROGRAMME

Monday, 29 May 2006 10:00 – 10:30

Registration of participants and welcome coffee

10:30 – 10:40

Opening of the meeting Welcome address by Stefano Micelli, Dean of Venice International University

10:40 – 10:50

Welcome address by Ignazio Musu, School for Advanced Study in Venice (SSAV)

10:50 – 11:00

Welcome address and presentation of the objectives and expected outcomes of the meeting by Roberto Bertollini, Director Special Programme on Health and Environment, WHO European Centre for Environment and Health

11:00 - 11:10

Nomination of the Chairperson and Rapporteur Adoption of the provisional agenda and programme

11:10 – 11:30

Background to the meeting: gaps in engaging with people’s risk perceptions as part of risk communication and of policy making. Issues raised by the research in the BSE/CJD saga and challenges facing health/food/environment information systems today, by Carlos Dora, WHO Headquarters

11:30 – 13:10

Session 1 – Assessing public risk perception for a successful risk communication. Lessons learnt and gaps

11:30 – 11:40

Introduction by the Chairperson – Issues and questions

Panel discussion with the participation of: 11:40 – 11:55

Patrick G. Wall, Professor of Public Health School of Public Health and Population Sciences University College Dublin and Former Chief Executive Food Safety Authority of Ireland

11:55 – 12:10

Maria Neira, Director, Department of Protection of the Human Environment, WHO Headquarters

12:10 – 12:25

Marta Di Gennaro, Director General, Major Events Office, Department of Civil Defence, Italy

12:25 – 12:40

Bruna De Marchi, Head, Mass Emergencies Programme ISIG - Institute of International Sociology of Gorizia

12:40 – 13:10

Discussion (Facilitator: Franklin Apfel, Managing Director, World Health Communication Associates)

13:10 – 14:00

Lunch

14:00 – 16:00

Session 2 - The epidemiology of public perceptions

14:00 – 14:10

Introduction by the Chairperson – Issues and questions

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Speakers: 14:10 – 14:25

Lennart Sjöberg, Director, Centre for Risk Research Stockholm School of Economics

14:25 – 14:40

Martin Bauer, Director of MSc in Social and Public Communication, London School of Economics, Institute of Social Psychology & Methodology Institute

14:40 – 14:55

Tom Horlick-Jones, Cardiff School of Social Sciences, Cardiff

14:55 – 15:10

Ludger Benighaus, DIALOGIK, Non-profit corporation for communication and cooperation research, Stuttgart

15:10 – 15:25

Gregory

15:25 – 16:00

Discussion (Facilitator: Franklin Apfel)

16:00 – 16:30

Coffee break

16:30 – 18:00

Session 3 (Part I) - From citizens to institutions: tools to take stock of public risk perception into health and environmental policy making

16:30 – 16:40

Introduction to case study presentations and reflections for the discussion by the Chairperson

Hartl, Coordinator, Sustainable Environments (SDE), WHO Headquarters

Development

and

Healthy

Speakers: 16:40 – 16:55

John O’Brien, Chief Executive Food Safety Authority of Ireland

16:55 – 17:10

Judith Green, Senior Lecturer in Sociology, Health Services Research Unit, London School of Hygiene and Tropical Medicine and Alizon Draper, Centre for Public Health Nutrition, School of Integrated Health, University of Westminster

17:10 – 17:25

Lynn J. Frewer, Social Sciences Group Marketing and Consumer Behaviour Wageningen University, The Netherlands

17:25 – 18:00

Discussion (Facilitator: Franklin Apfel)

21:00

Social dinner

Tuesday, 30 May 2006 09:00 – 10:30

Session 3 (part II) - From citizens to institutions: governance and institutional mechanisms to take stock of public risk perception into health and environmental policy making

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09:00 – 09:15

Introduction by the Chairperson, main points brought up during the previous day's discussion and issues to be completed on the second day of the meeting

09:15 – 09:30

Erik Millstone, SPRU Science and Technology Policy Research, University of Sussex, Brighton

09:30 – 09:45

Maria Grazia Giannichedda, Department of Economy of Institutions, University of Sassari

09:45 – 10:30

Discussion (Facilitator: Franklin Apfel)

10:30 – 11:00

Coffee break

11:00 – 15:00

Session 4 – Improving communication strategies as part of good policy making and engaging with public concern. Working groups for developing the WHO Guidelines on "Taking Stock from Public Perceptions of Risk for Risk Management and Communication"

11:00 – 11:30

Introduction by the Chairperson, summaries of the outcomes of the discussions in Session 1, 2 and 3

11:30 – 12:30

Decisions on proposed contents and strategy for the development of a WHO guideline on "taking stock from people's perceptions of risk for risk management and communication" and setting up of the working groups to refine and develop further the proposed contents for the Guidelines by the

Chairperson 12:30 – 14:00 14:00 – 14:45

Working groups (Coffee and sandwiches will be available during working

groups’ work)

Presentation of the results of the working groups by the moderators and discussion on the process developing the WHO Guidelines "Taking Stock

from Public Perceptions of Risk for Risk Management and Communication"

Identifying potential contributions towards the Guidelines from the participants and agreeing in principle how this would be done by the

Chairperson

14:45 – 15:00

Conclusions and recap of the coming working process by the Chairperson

15.00

Closure of the Meeting

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TECHNICAL BACKGROUND DOCUMENT

1. Institutional background With reference to the importance of the communication on environment and health, the Declaration of the Fourth Ministerial Conference on Environment and Health signed by the European Ministers (Budapest, June 2004), states44: “We affirm the importance of and need for communication with the public at large on environment and health, particularly where the interests of children and other vulnerable groups are involved. We equally emphasize the importance of the participation of children and the need for their inclusion in activities concerning the health and environment of children. We invite international organizations to help address this issue, including through support for meeting the commitments of the Århus Convention on Access to Information, Public Participation in Decision- making and Access to Justice in Environmental Matters45, with the development of guidelines on risk communication as an important tool for bringing environmental health considerations to the attention of different sectors and for heightening public awareness” (Paragraph 18a of the Declaration). The Regional Committee, during its 54th Session requested the “Regional Director to continue to provide leadership to the Environment and Health process in the European Region by further promoting the Regional Office's and country offices' activities” in some areas as such as in “risk management techniques, including those addressing risk communication and perception, through the collection, analysis and interpretation of case studies as well as the identification of best practices” 46. To address this challenge, in line with the Declaration of the Fourth Ministerial Conference on Environment and Health and the Resolution EUR/RC54/R3 approved by the Member States, the WHO Regional Office for Europe, through the European Centre on Environment and Health, in collaboration with WHO Headquarters, is calling for a Consultation Technical Meeting on Risk Perception and Communication with the aim at contributing to the development of risk

communication guidelines.

2. Why to investigate public perceptions of risks? Communicating about hazards is an integral part of the daily work of any health department or agency, from the local to the international level and is a central function of the World Health Organization (WHO). Risk communication is thus a key public health tool. The understanding of communication processes to this regard is therefore essential to any effective public health policy. Moreover, as part of risk management, risk communication aims to foster public resilience and inform public participation to support appropriate response, thus contributing to the risks’ control. However, the increasing complexity of societies, the need to cope with uncertainties and the frequent lack of information on real risks or the over representation of them, as well as the 44

Fourth Ministerial Conference on Environment and Health” – Declaration 25 June 2004, Tools for policy making, paragraph 18a. 45 http://www.unece.org/env/pp/documents/cep43e.pdf Turkey has reservations on this paragraph, since it is not signatory to the Århus Convention. 46 Resolution EUR/RC54/R3 (Copenhagen, September 2004), http://www.euro.who.int/eprise/main/who/aboutwho/Governance/resolutions/2004/20040913_7(see point 8).

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limits of science and policy mechanisms to adequately address problems and public health issues, further complicates the picture and the decision-making process. This is particularly relevant when environment related health risks are concerned. So far, the majority of analysis has addressed two aspects of communication: what influences people's perceptions of risk and how to convey a message adequately for the potential users. There is an increasing need to gain a better understanding of the interplay between public perceptions and the media, communication strategies and policy initiatives and to investigate how public authorities can both earn trust and legitimacy when communicating about uncertainty and health risks. Understanding how and why perceptions moulds risk awareness is crucial for policy-making, risk assessment and communication. There are a number of reasons for policy-makers at various levels to investigate public perceptions of risk. These include objectives such as: • • • • •

determining public priorities for policy action (needs assessment). assessing views of the impact of current policy (policy evaluation) assessing views of various policy options (policy formation). determining the effectiveness of information about policy (public understanding); devising successful communication strategies (policy implementation).

These elements reflect different needs for information at different stages in the policy process and among different policy actors. Clearly, the methods for producing any of this information must be appropriate to each need.

3. Promoting and understanding public participation foresees a correct evaluation of public risk perception of environmental and health risks Public participation is a key step to improving our environment. But often it comes too late – or not at all. New international tools are now bringing this improvement to earlier and higher-level decision making. They can make a real difference – for democracy and for the environment. Why do we need public participation in environmental decision making? Why not just leave it to the experts? Some governmental officials believe that public participation takes a lot of time and creates additional burdens. But democratization of society requires transparency of decision making. Its participation makes the decision making process transparent and public authorities accountable. A decision made with public involvement is more likely to receive support in its implementation. Public participation also leads to decisions that are better for the environment. The public can bring expertise and knowledge to the process. Public experts may not only criticize mistakes or see negative sides of a plan or program, but also suggest good alternative solutions. They can introduce environmental and sustainability considerations into decision making, which will help to prevent negative impacts on the environment, including health.

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Public participation is now required by international legal instruments such as the Protocol on Strategic Environmental Assessment under the Espoo EIA Convention and Articles 7 and 8 of the Aarhus Convention and others. Therefore, promoting and understanding public participation foresees a correct evaluation of public perceptions and this is therefore crucial for policy-makers, risk assessors and communicators in order to determining public priorities for policy action, assessing views of the impact of current policy, assessing views of various policy options (policy formation), determining the effectiveness of information about policy and devising successful communication strategies (policy implementation).

4. Problems to be solved One of the serious challenges facing governments, agencies and other policy actors is that they do not have the luxury of engaging in lengthy research to reach/understand public perception. They need reasonably reliable indicators of public perception and factors that affect public trust, along with methods for capturing and interpreting such indicators. In the light of the above, in order for risk communication to be effective, it might be of critical importance the creation of institutionalized mechanisms to let policy-makers and stakeholders interact early-on and at all stages of policy making process through effective evidence and well structured mechanisms.

5. The needs It is thus critical to provide practical advice to policy-makers on how incorporate public perceptions of health and environmental risk into their communication. In particular: reviewing and commenting on methods currently available and used to understand risk perception, and discussing their potential value for policy-makers; drawing lessons by examining the types of communication strategies adopted in different countries, to gain a greater understanding of the interplay between public perceptions, communication, the media, and policy initiatives; investigating how public authorities can earn trust and legitimacy when communicating about uncertainty and risks to health; developing a better communication of scientific uncertainty.

6. A research agenda A research agenda on how to incorporate perceptions of risk into everyday policy making should give special attention to the testing of innovative arrangements for institutionalization of risk perception and communication, and to evaluating their cost and effectiveness. This could include studies evaluating how public perceptions are taken up in policy-making and comparing different methods for achieving this. Factors to be explored as part of the research might include: • at which stage public perception of risks should be considered in policy-making;

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• which methods and tools should be considered as more appropriate to take them in consideration for policy-making; • which are the reliable indicators and which factors may affect, promote or strengthen the public trust in institutions; • which should be the assumptions of those commissioning and implementing policies and related communication strategies for taking effectively into account public risk perception? • new arrangements/experiences already in place and showing modifications of the existing health and environmental information systems aimed at gathering intelligence on public perception of risk and engaging public opinions into policy-making such as: - the introduction of awareness/ training sessions for staff about the public's and stakeholders' views (and how to access them); - the recruitment into the above systems of resources specialized in social science; - the creation of a new type of risk communicator with skills gathering intelligence on people's perceptions and engaging them in communication and policy processes - the integration of social mobilization experts capable of shaping messages for a behavioural change through understanding of risk perception in close collaboration with the risk communicators; - experience gained with efforts to institutionalize public participation in decision-making on environmental and health matters: advantages and disadvantages; - experience dealing with adverse public risk perception and in general with populations exposed to dangerous or unhealthy environmental or unstable living conditions; - experience showing that for effective risk communication it is necessary to find ways in which public concerns can provide input to policy-making, rather than remaining merely an object of policy-making; - experience oriented towards dialogue (i.e. effective two-way communication) vis-à-vis the traditional one way communication from experts to the public.

7. What challenge for risk communication guidelines? Effective risk communication is not about just providing reassurance. Effective risk communication is not about just reciting regulatory measures either: It is unlikely that it would be achieved solely by better surveillance of public opinions whether through media analyses, surveys or questionnaires, or any other research methodologies. Whilst those tactics would constitute a significant improvement on historical practice, on their own they will not solve the underlying problems of science and governance. The challenge for effective risk communication is to find other ways in which public concerns can provide input into policy-making, rather than remaining merely an object of policy-making. Public engagement needs to be focused on policy objectives arising from specific issues such as health and environmental risks, on what the strategy to meet those objectives should be, and on how well the ostensible objectives are being met. The new orientation towards dialogue (i.e. effective two-way communication) involves listening to the public, taking ethics seriously, dealing with a range of knowledge, and engaging with democratic citizenship. Based on the above considerations, how public health systems could should evolve or take much more in consideration such prospective?

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GUIDELINES FOR THE PRESENTATION OF THE CASE STUDIES

Key issues Understanding the public is part of an effective communication. Messages bridging the gap between the expert and the public can be successful only if they take into consideration what the public thinks. It is thus critical to provide practical advice to policy-makers on how incorporate public perceptions of health and environmental risk into their communication. In particular: • reviewing and commenting on methods currently available and used to understand risk perception, and discussing their potential value for policy-makers; • drawing lessons by examining the types of communication strategies adopted in different countries, to gain a greater understanding of the interplay between public perceptions, communication, the media, and policy initiatives; • investigating how public authorities can earn trust and legitimacy when communicating about uncertainty and risks to health; • developing a better communication of scientific uncertainty. In the light of the above and in order for risk communication to be effective, it might be of critical importance the creation of institutionalized mechanisms incorporating public perceptions of environmental health hazards into risk communication, to let policy-makers and stakeholders interact early-on and at all stages of policy making process through effective or uncertain evidence and well structured mechanisms. Presentation of case studies The key speakers will be asked to share their knowledge and experience and to prepare short presentations and short summary background documents specifically referring to case studies on the linkages between risk assessment, risk management, risk perception and risk communication. The discussion which will follow the presentation of case studies should particularly focus on the following aspects: Methodological • at which stage public risk perceptions should be considered in policy-making; • which methods and tools should be considered as more appropriate to incorporate public perception of risks; • which are the reliable indicators of public risk perception and which factors may affect, promote or strengthen the public trust in institutions? • which should be the assumptions of those commissioning and implementing policies and related communication strategies for taking effectively into account public risk perception. Institutional Revision of existing health and environmental information systems, particularly in view of gathering intelligence on perceptions of risk and engaging public opinions into policy-making such as: • the introduction of awareness/training sessions for staff about the public's and stakeholders' views (and how to access them);

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• the recruitment into those systems of resources specialized in social science; • the creation of a new type of risk communicator with skills in gathering intelligence on people's perceptions and engaging them into communication and policy processes; • the integration of social mobilization experts capable of shaping messages for a behavioural change through understanding of risk perception in close collaboration with the risk communicators; Governance • experience gained with efforts to institutionalize public participation in decision-making on environmental and health matters: advantages and disadvantages; • experience dealing with adverse public risk perception and in general with populations exposed to dangerous or unhealthy environmental or unstable living conditions; • experience showing that for effective risk communication it is necessary to find ways in which public concerns can provide input to policy-making, rather than remaining merely an object of policy-making; • experience oriented towards dialogue (i.e. effective two-way communication) vis-à-vis the traditional one way communication from experts to the public.

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List of participants

Mr Franklin Apfel Managing Director World Health Communication Associates Little Harborne Churche Lane Compton Bishop BS26 2HD Axbridge Somerset United Kingdom Mr Martin W. Bauer Director of MSc in Social and Public Communication London School of Economics Institute of Social Psychology & Methodology Institute Houghton Street WC2A 2AE London United Kingdom Mr Ludger Benighaus DIALOGIK gGmbH Non-profit corporation for communication and cooperation research Karl Philipp Fohr Strasse 10 69121 Heidelberg Germany Dr Marta Di Gennaro Director, Major Events Office Italian Civil Protection Via Ulpiano, 11 00193 Rome Italy Dr Alizon Draper Centre for Public Health Nutrition School of Integrated Health Westminster University 115 New Cavendish Street London W1W 6UW United Kingdom Professor Lynn Frewer Food Safety and Consumer Behaviour Marketing and Consumer Behaviour Group Wageningen University Hollandseweg 1 6706 KN Wageningen The Netherlands

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Ms Judith Green Senior Lecturer in Sociology Health Services Research Unit London School of Hygiene and Tropical Medicine Keppel Street WC1E 7HT London United Kingdom Dr Tom Horlick-Jones Cardiff School of Social Sciences Cardiff University Glamorgan Building King Edward VII Avenue Cardiff CF10 3WT, Wales United Kingdom Mr Erik Millstone SPRU Science and Technology Policy Research University of Sussex Mantell Building BN1 9RF Brighton United Kingdom Dr John O'Brien Chief Executive Food Safety Authority of Ireland Lwr Abbey St Dublin 1 Ireland Dr Lennart Sjöberg Director, Centre for Risk Research Stockholm School of Economics P.O. Box 6501 113 83 Stockholm Sweden Ms Diana Smith Communications consultant EPHA Environment Network (EEN) 23 rue Saint Blaise F-75020 Paris France Mr Roger Steen Deputy Director - Head of Analysis and Research Directorate for Civil Protection and Emergency Planning P.O. Box 2014 3103 Tonsberg Norway

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Dr Stefania Tonin Faculty of Urban and Regional Planning University of Venice 1957 Santa Croce I-30125 Venice Italy Prof. Margherita Turvani Faculty of Urban and Regional Planning University of Venice 1957 Santa Croce I-30125 Venice Italy Professor Patrick G. Wall Associate Professor of Public Health School of Public Health and Population Science University College Dublin Woodview House Belfield Dublin 4 Ireland

Observers Marco Leonardi Health and Environment Service Italian Civil Protection Via Ulpiano, 11 00193 Rome Italy

World Health Organization Regional Office for Europe Dr Roberto Bertollini Director, Special Programme on Health and Environment European Centre for Environment and Health Via Francesco Crispi, 10 00187 Rome Italy Ms Cristiana Chiapparelli Secretary, Communication and Advocacy Special Programme on Health and Environment European Centre for Environment and Health Via Francesco Crispi, 10 00187 Rome Italy

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Mr Michele Faberi Regional Adviser, Sustainable Development Special Programme on Health and Environment European Centre for Environment and Health Via Francesco Crispi, 10 00187 Rome Italy Ms Maria Chiara Venier Technical Officer, Risk Perception Special Programme on Health and Environment European Centre for Environment and Health Via Francesco Crispi, 10 00187 Rome Italy

Headquarters Dr Carlos Dora Scientist, Occupational and Environmental Health Protection of Human Environment Sustainable Development and Healthy Environments 20, Avenue Appia CH-1211 Geneva 27 Switzerland Ms Elaine Fletcher Technical Officer, Department of Protection of Human Environment Sustainable Development and Healthy Environments 20 Avenue Appia CH-1211 Geneva 27 Switzerland Mr Gregory Hartl Coordinator, Sustainable Development and Healthy Environments (SDE) 20, Avenue Appia CH-1211 Geneva 27 Switzerland Dr Maria Neira Director, Protection of Human Environment Sustainable Development and Healthy Environments 20, Avenue Appia CH-1211 Geneva 27 Switzerland

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List of presentations

1. “Gaps in engaging with Perceptions in Risk Communication and Policy Making Issues raised by research on risk perceptions and communication of the BSE/CJD saga”, by Carlos Dora, WHO Headquarters, Switzerland 2. “Risk Perception & Communication”, by Patrick G. Wall, UCD School of Public Health & Population Sciences, University College Dublin, Ireland 3. “Risk communication and its syndromes” by Maria Neira, Director, Department of Protection of the Human Environment, WHO Headquarters. 4. “Activities of the Italian National Department for civil protection with reference to risk perception and communication” by Marta Di Gennaro, Department of Civil Protection, Italy. 5. “Change language to re-address though”, by Bruna De Marchi, Head, Mass Emergencies Programme (PEM), Institute of International Sociology of Gorizia (ISIG). 6. “Myths of the psychometric paradigm and how they can misinform risk communication” by Lennart Sjöberg, Center for Risk Research, Stockholm School of Economics, Sweden. 7.“Monitoring of Public Discourse: Parallel Epidemiology” by Martin Bauer, MSc in Social and Public Communication, London School of Economics, Institute of Social Psychology & Methodology Institute, United Kingdom. 8. “ Four theses on rationality in risk perception and communication” by Tom HorlickJones, Cardiff School of Social Sciences, Cardiff, United Kingdom. 9. “Simulating Risks: A method to improve Risk Communication?“ by Ludger Benighaus (& Prof. Ortwin Renn) DIALOGIK, Non-profit Corporation for Communication and Cooperation Research, Stuttgart, Germany. 10. “Communications Experiences with Avian Influenza” by Gregory Hartl, Sustainable Development and Healthy Environments (SDE), WHO Headquarters. 11. “Risk: not at my table!” by John O’Brien, Executive Food Safety Authority of Ireland, Ireland. 12. “Lessons learnt from a study for the FSA on accessing the views of ‘hard-toreach’ communities” by Judith Green, Health Services Research Unit, London School of Hygiene and Tropical Medicine and Alizon Draper, Centre for Public Health Nutrition, School of Integrated Health, University of Westminster, United Kingdom. 13. “The importance of risk (benefit?) communication” by Lynn J. Frewer, Social Sciences Group Marketing and Consumer Behaviour Wageningen University, The Netherlands. 14. “Risk communication: lessons from a study of risk assessment policy” by Erik Millstone, SPRU Science and Technology Policy Research, University of Sussex, Brighton, United Kingdom.

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