ARCHIVED - Lessons Learned Review: Public Health Agency of Canada and Health Canada Response to the 2009 H1N1 Pandemic
3.5 Communicating with Canadians
The Canadian Pandemic Influenza Plan for the Health Sector stresses that public communication efforts during an influenza pandemic are required to prepare Canadians to take appropriate action and to build and maintain their confidence in the government response during a pandemic. The Communications Annex (Annex K) was developed in partnership by federal, provincial and territorial governments, providing the framework for coordinated public communications across all involved organizations during a pandemic.
Pandemic influenza communications planning for the health sector is based on a strategic risk communications approach, which aims to ensure:
- open communication about pandemic influenza risks and control options
- transparency in the decisions made during the pandemic planning process
- an understanding of the gaps and efforts made to fill them when facts are uncertain or unknown.
The Public Health Agency of Canada was responsible for H1N1 communication activities for the general population with support from Health Canada, which was itself responsible for communication activities with First Nations people living on a reserve in conjunction with First Nations leadership.
In April 2009, the Government of Canada launched a public awareness campaign, led by the Public Health Agency of Canada, to inform Canadians about the H1N1 influenza virus. A key method of communicating with Canadians was through the Public Health Agency of Canada’s multimedia, multiphased Citizen Readiness Social Marketing Campaign.
The campaign, implemented in stages over nine months, included marketing and advertising tactics focusing on infection prevention behaviours, personal preparedness and a call to action for Canadians to get vaccinated. The major focus of the campaign was television, print, radio, in-transit and online advertising that encouraged Canadians to get the information they needed to make decisions to protect themselves from the H1N1 influenza virus on the Public Health Agency of Canada’s FightFlu.ca website. A number of marketing tactics reinforced the phased messaging: distribution of a direct mail brochure to 10 million Canadian households to promote the Public Health Agency H1N1 Preparedness Guide, distribution of 1.7 million H1N1 Preparedness Guides via 1 800 O-CANADA and Canada Post outlets, and the H1N1 pages of the Public Health Agency website.
Despite these communication activities, it is important to recognize that the federal government is not the only source of information for Canadians during a public health event. More than ever before, Canadians are living in a multisource environment where information is no longer simply from local, national and international governments or academic sources transmitted through traditional media such as television and radio, but also from social media, where anyone can post information regardless of their expertise or the use of rigorous research.
Media coverage of H1N1 was extensive and, at times, overwhelming. In October 2009, a survey found over three-quarters of Canadians (78 percent) believed the media hyped and exaggerated the threat of H1N1, representing a 10-point increase from perceptions in July.Footnote 38 Correspondingly, just over half of Canadians (53 percent) surveyed in the same month (October 2009) felt the general public’s level of concern was exaggerated while close to four in ten (37 percent) felt the level of concern was consistent with the risks.Footnote 39
In public health messaging during an event, there can be a delicate balance between providing information on one hand, and raising concerns or fears unnecessarily on the other. This dynamic needs to be further balanced with the public’s growing appetite and expectation for more information.
What worked well?
Communication with the Canadian public was a key priority during the pandemic
Federal Health Portfolio communication efforts began to roll out on April 24, 2009. A news conference was held two days prior to the first confirmed case of H1N1 in Canada. This was a few days after the first samples had been received from Mexico to determine the cause of the illness that had been spreading there. These news conferences continued throughout the pandemic; almost 50 were held between April 24 and December 15, 2009.
These activities respond directly to one of the key recommendations derived from the independent review of the government’s activities during the listeriosis outbreak in the summer of 2008.Footnote 40 At that time, the government was criticized for a fragmented and untimely communications approach.Footnote 41 During the H1N1 pandemic, however, the Public Health Agency of Canada was the lead organization responsible for communicating with Canadians. Media channels, perceived as primary sources of information for Canadians, were used.Footnote 42 Having consistent news briefings also worked to establish a collaborative relationship with the media during this time, and maximized communication through traditional media.
The Public Health Agency of Canada’s communications and marketing activities all contained a primary call to action to drive Canadians to its FightFlu.ca website, where they could find the information needed to protect themselves from the H1N1 influenza virus. Research on these marketing activities indicates that Canadians took steps to prevent the spread of influenza, including handwashing or coughing into one’s arm instead of one’s hand. The Public Health Agency of Canada’s H1N1 web content received 6.4 million visits, had over 20 million pages of content viewed, and had more than 200,000 H1N1 information products downloaded.
Health alert notices also played an important role in the early stages of the Public Health Agency of Canada’s response. Four million health alert notices were distributed to travellers at 24 Canadian airports between April 27 and May 18, 2009. Infection prevention behaviour information was displayed on screens in Canada’s international airports during the first wave of H1N1. Posters outlining quarantine measures and infection prevention practices were also distributed in these locations.
Key spokespeople, like the Minister of Health and the Chief Public Health Officer, were visible throughout the pandemic
An additional key recommendation of the independent listeriosis review was the identification of a primary spokesperson during public health emergencies to demonstrate consistent federal public health leadership. Media analysis indicates that the Chief Public Health Officer and the Minister of Health received a very high number of media mentions on a wide range of issues concerning H1N1. They were positioned as credible, authoritative and effective communicators throughout the pandemic period.
Advance planning ensured key communication products and activities were quickly implemented
The Public Health Agency of Canada’s Risk Communications Strategy for Pandemic Influenza, developed in 2006, guided the overall planning for the communications and social marketing response during the H1N1 pandemic. Without key activities, such as media training and creative development for the advertising campaign, it would have been very difficult to launch a multiphase, multifaceted campaign. During the H1N1 pandemic, the campaign contributed to informing Canadians and encouraging them to adopt appropriate infection prevention behaviours. As part of this strategy, advance work with national and international partners formed important links that were useful during the H1N1 response.
Social marketing efforts helped to change infection prevention behaviours
As mentioned, the Public Health Agency of Canada implemented a number of social marketing/advertising tactics during the pandemic aimed at encouraging behaviour change among Canadians. The Citizen Readiness Social Marketing Campaign’s first phase promoted infection prevention behaviours including: frequent handwashing, coughing into one’s arm not hand, staying home if sick. These messages were later complemented with personal preparedness and immunization information. Research conducted shows that Public Health Agency marketing and advertising efforts helped to increase infection prevention behaviours by Canadians. For example, of those members of the public asked if they had seen the Public Health Agency of Canada’s infection prevention ads that ran in the fall of 2009, almost half (46 percent) reported taking action as a result, of which roughly six in 10 (59 percent) stated (without prompting) that they started to wash their hands more often.Footnote 43
Basic infection prevention information (handwashing, coughing into one’s arm not hand, staying home when sick) are appropriate for overall infection prevention in both pandemic and non-pandemic situations to reduce the risk of common infectious diseases such as the seasonal influenza. Infection prevention messages should be continued on an annual basis, aligning with annual influenza season.
There was strong and effective coordination of communication activities between federal and provincial/territorial governments
Consistent messaging to Canadians across federal and provincial/territorial jurisdictions was needed to maintain public confidence in the response to the H1N1 influenza virus. While there were instances where this consistency was not always achieved (as will be described below), the federal, provincial and territorial governments coordinated their approaches, communications and marketing tools, tactics and messaging.
Federal, provincial and territorial heads of communications met daily to share information and intelligence on emerging issues, concerns and announcements, and to coordinate outreach and public education efforts. Collaboration was facilitated through two subgroups: the Communications subgroup and the Social Marketing subgroup, with representatives from the provinces and territories and the Government of Canada. The Communications subgroup focused its efforts on issues management and media relations, including the creation of common speaking points and media lines on various issues for use by all jurisdictions. The Social Marketing subgroup focused on ensuring Canadians received consistent public awareness and marketing information (including television, print, radio, in-transit and online advertising) across jurisdictions.
This collaboration was highlighted when a television ad on infection prevention behaviours (creative produced by the Ontario government) was broadcast nationally (media paid for by the federal government) on behalf of the federal, provincial and territorial governments. This effort allowed smaller jurisdictions that did not have budgets for television advertising to benefit from the ad.
Areas for action
Conflusion (the aggregation of streaming together of multiple confusing items, as in a confluence of confusion) is what the public is feeling in response to the seemingly endless stream of contradictory news about H1N1 influenza.Footnote 44
―André Picard, The Globe and Mail, October 9, 2009
Improve consistency of information communicated to Canadians across different jurisdictions
As previously mentioned, there was a strong effort to coordinate information to Canadians across different jurisdictions. However, there were cases where contradictory or slightly different messages were communicated based on federal, provincial or territorial policy decisions. This caused some confusion among citizens. One example of confusion was the varying approach across jurisdictions to the seasonal influenza vaccination during the second wave of H1N1, where some provinces and territories chose not to move ahead with the seasonal vaccine.
The media reported on the discrepancies between messages during H1N1. Australia faced a similar challenge and reported that “the complexity of Australia’s federation, requiring coordination of one national and eight state and territory governments” may have been a contributing factor for inconsistent messaging across the country.
Differences in the timing, scope and severity of the H1N1 pandemic across jurisdictions – as well as varying response measures, public health capacity and governance structures – limit the extent to which best practices in risk communications can be consistently applied. It is expected that messaging based on individual or jurisdictional policies, communication channels and responsibilities may result in variation. However, this does create confusion among the general public and should be minimized wherever possible.
Review strategies to communicate uncertainty, risks and shifts in scientific knowledge in order to build public trust
While prevention campaigns appeared to have an impact on the general population, the Health Portfolio needs to reconsider how to communicate uncertainty, risk or shifts in scientific knowledge to the Canadian public. Some of these issues are not unique to Canada’response to H1N1. One of the recommendations coming out of the experience with H1N1 in the United Kingdom was to portray pandemics as accurately as possible, including the levels of risk, as well as to ensure greater transparency of scientific findings when communicating to stakeholders and the general public.Footnote 45
Examples of lessons from other jurisdictions:
- United Kingdom
The communication of only the ‘reasonable worst–case’ planning assumptions meant that there was an obvious gap between what the government was saying and what was observable on the ground, namely that the disease was mild in most cases and that mortality levels were low. This gap could have risked damaging the government’s credibility and undermining public trust in the response.Footnote 46
In order to raise public awareness, it was decided to adopt a communication strategy based on a worst case scenario. In line with the World Health Organization’s reports on the escalation of the pandemic (phase 2/3/4/5/6), this strategy was justifiably the right choice. But due to the lack of coordination between the various stakeholders, within a relatively short time the messages became confused. The delay in the delivery of the vaccine and the extensive academic discussions which took place about “which vaccine for whom?” were at the heart of this confusion. To complicate matters even further, the escalation phase then turned into a de-escalation phase; clear, credible communication became close to impossible.Footnote 47
Communication has been inconsistent partly because different parts of Australia have gone through the pandemic at different times and officials have been faced with the challenge of adjusting the response to cope with an infection that has not been as dangerous as the worst case scenario expectations that underpinned planning.Footnote 48
As with these jurisdictions, communicating risk, uncertainty and the scientific process affected the Public Health Agency’s and Health Canada’s overall response to H1N1. A recommendation on the development of strategies for communicating these issues to a diverse audience (including the general population, stakeholders and internal groups such as decision makers and decision influencers, with specific reference to central agencies) is discussed in more detail in section 4, Summary and recommendations.
Issues relating to the appropriateness of language and formatting for guidance documents are discussed in section 3.3, Guidance. In addition, specific communication activities are presented in section 3.2, Collaboration with provinces and territories. For particular communication activities with on-reserve First Nation communities, see section 3.6, Federal response in on-reserve First Nation communities.
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