Introduction
Emergency Risk Communication (ERC) or Crisis and Emergency Risk Communication (CERC) is a term introduced by the Centers for Disease Control and Prevention (CDC). The term explains the process of communicating regarding the risk with which various populations are faced during a public health emergency. Reference Parvanta, Nelson, Parvanta and Harner1 The term “emergency” encompasses crises and disasters, and also describes any event of public health or incident presenting risk to life, health, and infrastructure (e.g., natural, weather-related; and manmade destruction; infectious disease outbreaks; and exposure to harmful biological, radiological, and chemical agents). 2 According to the definition provided by World Health Organization (WHO), ERC “refers to the real-time exchange of information, advice, and opinions among experts, officials, and people who face a threat to their survival, health, or economic and social well-being. The ultimate purpose of ERC, is that everyone at risk is able to take informed decisions to mitigate the effects of the threat, such as a disease outbreak, and take protective and preventive actions.” To increase the effectiveness of the developed efforts during a crisis, ERC applies various strategies and tactics, such as media communication, social media, and community engagement. 3 ERC was also recognized as 1 of the key elements of health emergency readiness. Reference Parvanta, Nelson, Parvanta and Harner1
Although risk communication was introduced as 1 of the 8 main tasks which a WHO member emphasized to be performed as a part of international health regulations, Reference Suthar, Allen, Cifuentes, Dye and Nagata4 there are some challenges to meet the task. For example, Salvi, et al. in a review study showed that some factors such as coordination among response agencies, sustained human and financial resources, as well as a stronger engagement with communities, were the challenges for improving ERC. Reference Salvi, Frost, Couillard, Enderlein and Nitzan5 In another study, Cope, et al. demonstrated that focusing more on monitoring, and evaluating risk communication is needed. In addition, they suggested that public health agencies should make more efforts to develop a plan in terms of risk communication, and train public health practitioners, and their partners about the risk communication principles. Reference Cope, Frost, Richun and Xie6 In another study, Qiu, et al. demonstrated that during the SARS outbreak in Guangzhou, China, in 2003, the credibility of the government was affected by 2 factors which were: weak internal communications and external information blockades. Therefore, they suggested that building trust and facilitating multi-sector collaborations in dealing with a crisis, having an open and honest attitude, and actively engaging the stakeholders to meet their risk information needs are essential. Reference Qiu, Chu and Hou7 Tang, et al. reported that about 39.1% of the health emergency response employees in Chongqing, China, were not familiar with the ERC concept. Although 87.6% of them believed that ERC was extremely effective, only 24.9% of them were extremely willing to adopt it in a practical situation. Reference Tang, Zhang, Tian, Xing, Sun and Qiu8
Given the importance of strengthening capacities regarding ERC to ensure more effective responses to public health emergencies in each country, and the necessity of identifying the current situation of health care agencies about ERC and also elements requiring further development, Reference Dickmann, Biedenkopf, Keeping, Eickmann and Becker9 the present study was performed. The objective of the present study was to determine the preparedness of Primary Health Care Facilities (PHCFs) affilated to Shahrekord University of Medical Sciences, Chaharmahal and Bakhtiari Province, Iran, in terms of ERC in 2019.
To the best of our knowledge, a research exactly similar to the present study, on the assessment of the preparation of primary health care facilities of a geographical area in terms of components of ERC introduced by the CDC has not been done in other countries. In most of the research conducted, the best practices to increase the effectiveness of ERC have been reviewed. Reference Vaughan and Tinker10–Reference Jha, Lin and Short14 Some studies have determined the strengths and weaknesses of risk communication conducted in response to public health crises, while some assessed knowledge, capacity and application of ERC principles among public health workers or health emergency response staff. Reference Cope, Frost, Richun and Xie6,Reference Tang, Zhang, Tian, Xing, Sun and Qiu8,Reference Qiu, Chu and Hou15 In addition, in the few published studies, the effectiveness of developed messages during a pandemic (e.g., COVID-19) has been investigated. Reference Purohit and Mehta16,Reference Wang, Lin, Xuan, Xu, Wan and Zhou17
A brief overview of the Iranian primary health care system
The Primary Health Care (PHC) system was implemented in the Islamic Republic of Iran in the mid-1980s, to improve equal access to public health care in urban and rural areas in Iran. Correspondingly, PHC services are based on a health network, 1 per district, that stands on an extensive facility consisting of rural health centers, urban health centers, and health houses. Reference Verulava18,Reference Yazdi-Feyzabadi, Emami and Mehrolhassani19 Given that a series of health reforms for increasing access to healthcare services can reduce the catastrophic out-of-pocket payments, promotion of the equity and improvement of the quality of healthcare services were done in Iran in 2014. Reference Mosadeghrad, Esfahani and Afshari20
Method
Design and Setting
This cross-sectional study (descriptive–analytical type) was conducted in 136 PHCFs affilated to Shahrekord University of Medical Sciences, Chaharmahal and Bakhtiari Province, Iran from January to September 2019.
Procedure
At first, the validity and reliability of the ERC checklist developed by CDC, Reference Parvanta, Nelson, Parvanta and Harner1 were assessed in the Persian language. All PHCFs (n = 136) were selected using census sampling method. The participants (the employee in charge of the crisis unit in the PHCF) were informed about the study objectives and then completed a written informed consent. Afterwards, the checklist was completed by them. Notably, 4 PHCFs had no willingness to participate in the study. Finally, data of 132 PHCFs were analyzed. The ethics committee of Iran University of Medical Sciences approved the protocol of this study (code: IR.IUMS.REC.1397.890).
Data Collection
The ERC checklist was used for data collection in this study. This checklist was developed by CDC in 2011, Reference Parvanta, Nelson, Parvanta and Harner1 with 6 domains (16 items for planing, research, training, and evaluation domain; 39 items for message and audiences domain; 3 items for messanger domain; 21 items for the method of delivery and resources domain; 56 items for personnel domain; and 61 items for suggestions to be considered about resources). At first, the forward-backward procedure was used to translate the checklist. Then, the reliability and validity of the checklist were estimated. For assessing the qualitative and quantivative content validity of the checklist items, 10 experts in communication, crisis, and health education were asked to reflect their opinions on the simplicity, clarity, relevancy, and necessity of the items included. According to their comments, Content Validity Index (CVI) and Content Validity Ratio (CVR) were also assessed. Besides the items with CVR scores of 0.62 and above, Reference Lawshe21 CVI scores of 0.79 and above, Reference Polit and Beck22 were considered as satisfactory. At this stage, 8 ambiguous items were edited and the item “paper” was deleted from the suggestions for the resources domain. According to the expert panel opinion, 2 items of suggestions to be considered about resources domain as an item of “a contract with a media newswire,” and an item of “a contract with a radio newswire” were merged. Also, 4 items of suggestions to be considered about resources domain (item pens, item marketer, item highlighter, and item erasable markers) were intergrated as the stationery. Next, the reliability of the checklist was estimated using the Cohen’s kappa coefficient. In terms of the guidelines of the minimum sample size requirements for Cohen’s kappa, Reference Bujang and Baharum23 by assuming a kappa of at least 0.6 and a maximum of 0.17, alpha of 0.05, and power of 80%, 2 external trained researchers completed the checklist for 30 PHCFs. The finding showed that Cohen’s kappa of the checklist was 0.87 (P < 0.00001). According to a suggestion by Cohen, the rate of agreement between 0.81–1.00 was considered as perfect agreement. Reference McHugh24 The final checklist had 6 domains (16 items for planning, research, training, and evaluation domain; 39 items for message and audiences domain; 3 items for messanger domain; 21 items for the method of delivery and resources domain; 56 items for personnel domain; and 56 items for suggestions to be considered about resources).
In the present study, the scores between 1 and 61 were considered as poor preparedness regarding the ERC, those between 62 and 122 as moderate preparedness, and the scores between 123 and 184 as good prepardeness. In addition, demographic characteristics including the number of population covered by PHCFs and their ethnicity, existence of independent crisis-related unit in the PHCFs, level of education of employees in charge of the unit of crisis-related communications in the PHCFs, and history of crisis in the last year were gathered using a researcher-made instrument.
Data analysis
Finally, the obtained data were analyzed. The Chi square and Fisher’s exact tests were also used to examine the relationship between qualitative demographic variables and the level of preparedness of the PHCFs. The obtained data were reported as frequency, mean, and standard deviation. In this study, P < 0.05 was considered as statistically significant.
Results
10 centers including district 1 health network, and district 9 health centers had independent units for crisis-related responsibilities. Demographic features of the PHCFs and their relationships with the level of ERC are shown in Table 1. In most of the PHCFs, the staff in charge of the crisis unit were experts in environmental health. In these PHCFs, the crisis team included a physician, an environmental health expert, and an expert in disease control. The findings showed that there was a statistically significant difference between the level of ERC and type of the PHCF (district health network, district health center, urban health center, rural health center, and urban-rural health center) (P < 0.0001), the level of education of the employees in charge of the unit of crisis-related communication in the PHCF (P < 0.0001), and the history of crisis in the past year in the covered region (P = 0.005).
Table 1. Demographic characteristics of the primary health care facilities (n = 132)
The relationship between the demographic variables of the primary health care facility and the level of ERC (Chi Square):* P < 0.05.
The results showed that 65.9% of the PHCFs had low preparedness in terms of the ERC, 33.3% had moderate, and 0.8% had good preparedness. In Farsan town, 8.3% of the PHCFs had good preparedness regarding the ERC. The lowest preparedness was seen in the PHCFs of Lordegan town. In Table 3, the preparedness of the PHCFs of each town regarding the ERC is shown. In addition, the results showed that 73.5% of the PHCFs had crisis communication operational plan to inform the public, media, partners, and stakeholders. Notably, there was no structure called Joint Information Center (JIC) in the PHCFs. The Emergency Operation Center (EOC) had direct comunication only with the district health network and district health centers. Town hall meeting was the most important channel used by PHCFs for communcating with various populations during a crisis. There were inadequate expert employees in the crisis team or available in an emergency with skills in various areas including public affairs, health communication, communication officer, health education, training, writer/editor, technical writer/editor, audio/visual, and internet/web designs in the PHCFs. For example, there were public affair and health education specialists in the crisis team of 50.8% and 7.6% of the PHCFs, respectively (see Table 2). In the command and control sub-domain, 56.8% of the PHCFs activated a plan based on the careful assessment of the situation as well as the expected demands for information media, partners, and the public. Findings showed that 78.8% of the PHCFs identified specific populations and sub-populations of their region. To ensure that the messages were consistent and within the scope of the organization’s responsibility, only 39.4% of the PHCFs were coordinated with horizontal communication partners. About 18.2% of the PHCFs reviewed and approved materials for regular release to the media, public, and partners, and 25% regularly cleared the materials released to media on policy or sensitive topic-related information which were not previously cleared. The results showed that 96.2% of the PHCFs had a plan for communication with the public, media, and partner organizations, regarding the prevalent waterborne and foodborne diseases, respectively. In Table 2, the frequency of responses regarding ERC items is shown.
Table 2. The frequency of responses regarding emergency risk communication checklist items
Discussion
The findings of the study showed that 65.9% of the PHCFs had low preparedness in terms of the ERC, 33.3% had moderate preparedness, and 0.8% had high preparedness. The PHCFs of Farsan and Lordegan towns had the highest and lowest prepareness levels regarding the ERC, respectively. Rural health centers had low preparedness compared with other health care facilities. To the best of our knowledge, the preparedness of PHCFs in terms of the ERC has not been widely studied yet. However, our findings are consistent with those of Malik, et al., indicating that the score of risk communication, as 1 part of the pandemic preparedness plan, was 46% in the countries in the Eastern Mediterranean region. Reference Malik, Haq, Saeed, Riley and Khan25 In another study, Sambala, et al. evaluated pandemic influenza preparedness plans in 47 countries of the WHO African region. Accordingly, they reported that 22 studied plans had a communication strategy. The score of preparation and risk communication of the countries was 48%. Reference Sambala, Kanyenda, Iwu, Iwu, Jaca and Wiysonge26 Given that the majority of the studied PHCFs were in a low preparedness level regarding the ERC, it is suggested that the health system in Iran should be further considered with respect to this field, and the gaps identified in this study should be addressed.
The findings of the present study showed that there was a significant difference between the level of ERC and history of crisis in the past year, PHCF type, and the education level of the employees in charge of the crisis unit in the PHCF. The facilities with crisis - unit employees, who had masters and PhD degrees were more prepared for ERC compared to other facilities. In the same line, Al-Hunaishi, et al. reported that the desire to participate in natural disasters management was higher among health care workers with bachelor and postgraduate degrees compared to those holding a diploma degree. Reference Al-Hunaishi, Hoe and Chinna27 In recent years, some efforts were made in Iran to prepare the health professionals of PHCFs for disasters. However, more efforts are needed for employing employees who are experts in crisis, in all PHCFs, and preparing them in terms of communication in disasters while emphasizing the preparation of the local PHCFs workers such as health houses, and rural health centers about ERC.
The results showed that 78.8% of the PHCFs had identified specific populations and sub-populations of their region that need to be targeted with specific messages during a public health emergency (Table 3). Likewise, Sambala, et al. surveyed pandemic influenza preparedness plans in 47 countries of the WHO African region plan. They reported that in 23 plans, key target groups have been defined for developing specific preventative messages about influenza. Reference Sambala, Kanyenda, Iwu, Iwu, Jaca and Wiysonge26 Andrulis, et al. showed that integrating the factors related to race, culture, and language diverse communities into risk communication efforts of would be needed in the future. Reference Andrulis, Siddiqui and Gantner28 Cole, et al. also demonstrated that for increasing the effectiveness of risk communication messages, several factors such as ethnicity, class, gender, and similar demographic characteristics of audiences should be adapted. Reference Cole and Fellows29 Since having a picture from vulnerable populations of a community may help to provide effective communication messages and interactions, Reference Hutchins, Truman, Merlin and Redd30 planning to identify the populations is essential in each region. In addition, the results of the present study showed that 52.3% of the PHCFs had suggested that stakeholder organizations or populations should have an active interest in monitoring those activities that should receive direct communication during a public health emergency. Also, 22% of the PHCFs have established their communication protocols based on the pre-arranged agreements with the identified partners and stakeholders (see Table 3). Toppenberg-Pejcic, et al. reported that improving the effectiveness of responses to a crisis, requires local communities to be involved with ERC processes before the occurrence of an emergency. Reference Toppenberg-Pejcic, Noyes, Allen, Alexander, Vanderford and Gamhewage31 It is suggested that policy makers of Iran’s health system should consider establishing the protocols to identify and involve the key stakeholders and groups in decision-making in terms of the ERC. In another study, Novak, et al. noted that developing strategies and tactics to foster participation among all stakeholders is important in ERC. Reference Novak, Day and Sopory11
Table 3. The level of prepareness of the primary health care facilities of each town regarding ERC
The findings showed that town hall meetings were used more frequently than other communication channels such as websites during the emergencies by the PHCFs (Table 3). These findings are inconsistent with the results of Tam, et al.’s study. They showed that television (56%) and the Internet (16%) were more preferred than other communication channels across all age groups in public health emergencies in Hong Kong. Reference Tam, Huang and Chan32 Also, the results of another study showed that most of the people in the United States received Zika-related information through television and radio (85%). 33 In this regard, Edworthy, et al. showed that during the emergencies, when participants were not allowed to use the telephone, they primarily chose email communication followed by face-to-face communication. They also demonstrated that written communication generally facilitated more accurate transmission of information when compared to spoken communication. Reference Edworthy, Hellier, Newbold and Titchener34 Sambala, et al. revealed that among 47 WHO African region plans about pandemic influenza preparedness, 31 plans had materials published in multi-media such as newspapers, radio, television, and social networking sites on the Internet. Reference Sambala, Kanyenda, Iwu, Iwu, Jaca and Wiysonge26 More efforts to train employees engaged in the public health emergencies in using various media and communication channels, instead of communication restricted to a method or channel, may help better transmit information and warning messages during an emergency.
In contracts and memoranda of sub-domain agreement, only 0.8% of the PHCFs had a contract with a (media, radio) newswire. None of them had any contract with writers, public relations personnel who can augment the staff or a contract, administrative support, and a phone system contractor to supply a phone menu that directs the type of caller and level of desired information. Sambala, et al. reported that in 13 pandemic influenza preparedness plans in 47 countries of the WHO African region, local distribution channels and telephone lines were used for dissemination of information. Reference Sambala, Kanyenda, Iwu, Iwu, Jaca and Wiysonge26 Given the necessity of access to multiple resources during a public health emergency such as local distribution channels, contracting and memoranda of agreement with these resources before an emergency may increase the preparedness of the PHCFs regarding the ERC.
A major item of ERC checklist was selecting and training the spokespersons to ensure the rapid dissemination of consistent and core messages. Spokespersons present some information such as current activities and some special events. Reference Radović and Curčić35 They should be well aware of the ERC principles and be trained prior to the occurrence of an event. 2 In the present study, 57.6% of the PHCFs had selected public health spokespersons for media and public appearances during an emergency. Only 40.2% and 34.1% of the PHCFs had trained spokespersons about the media or risk communication and crisis/risk communication principles, respectively. Cope, et al. reported that 16 (out of 20) officials who were interviewed reported that their agency had a designated spokesperson. Reference Cope, Frost, Richun and Xie6 Selecting credible spokespersons and training them prior to the occurrence of an event in the public health system in Iran are suggested.
The results of this study also showed that 96.2% of the PHCFs had a plan for communication with the public, media, and partner organizations regarding the prevalent waterborne, and foodborne diseases respectively. Notably, there were no specific plans to communicate with the public, media, and partner organizations regarding some other disasters. Cole, et al. demonstrated that preparing messages and assessing its credibility to their recipient audiences are essential responsibilities before the crisis. Reference Cole and Fellows29 Preparedness for the types of disasters with which health care agencies are likely to face is essential. 2
Limitations
This study had 2 limitations. First, the checklist was completed by the employees in charge of the crisis unit in the PHCF. Therefore, the responses in the checklist may be affected by the perceptions and interpretation of the respondent. However, for decreasing this bias, 1 of the researchers answered the respondents’ questions about the checklist items. Second, another limitation of the present study was that the data collected from the PHCFs were related to Shahrekord University of Medical Sciences, Chaharmahal, and Bakhtiari Province, Iran; therefore, the findings could not be generalized to the other geographical regions in Iran. It is recommended that preparedness of PHCFs regarding the ERC should be assessed in the other geographic regions of Iran.
Conclusion
The findings of this study showed that only 0.8% of the PHCFs had a good preparedness in terms of the ERC. Thus, the PHCFs need to increase their capacity and capability in the field of emergency preparedness. Moreover, the public health system in Iran should incorporate ERC in crisis management. Providing basic foundations of ERC and increasing the knowledge of the public health workforce regarding the ERC principles may also help the public response to crises, reduce the likelihood of rumors and misinformation, and present a good crisis leadership.
Data availability statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Acknowledgments
We appreciate the responsible employees of the crisis units in the primary health care facilities affilated to Shahrekord University of Medical Sciences, Chaharmahal and Bakhtiari Province, Iran involved in the study for their cooperation.
Conflict of interest
The authors declare that they have no competing interests.
Funding statement
This study was funded by Iran University of Medical Sciences. The funder had no involvement in the design, analysis, interpretation or writing up of the results of study.
