How well were communications handled?

Communications to the public

From everything we heard, if there is a single issue that garnered near unanimous agreement, it is that the public was confused and did not understand what they should be doing following news of the food recalls. This is not surprising, considering the complexity of the issues involved in the outbreak and the many organizations providing varying levels of information at different points in the event.

The Ontario and federal governments, other provinces, and Maple Leaf Foods were each making formal news announcements with different rates of frequency. Many others voiced their opinions about the outbreak and the way it was being handled in media reports. Over the course of several weeks, official government spokespersons, public health and food safety experts, politicians, unions, and consumer groups were interviewed frequently. The very fact that there were so many different organizations making so many statements contributed to Canadians' misunderstanding and anxiety.

Canadians generally do not understand which level of government, let alone what organization, has specific jurisdictional responsibility for public health or food safety. What they do know is that they want someone to explain to them, simply and clearly, what is happening and what they should be doing to protect themselves.

Subsequent public opinion polling, along with the personal anecdotes of family members and others who shared their views with us during this investigation, indicated that communications about the outbreak did not provide the information they needed.

Observations and Assessment

If measured by the level of activity, hours worked and sheer number of information products generated by communications staff at the Canadian Food Inspection Agency, the Public Health Agency of Canada, and Health Canada, it would seem that communications to the public were effective. However, we heard that more needs to be done to better meet Canadians' information needs during a foodborne emergency.

Initial media reports on the listeriosis outbreak focussed on the facts, closely reflecting the statements and key messages issued by the Canadian Food Inspection Agency, the Public Health Agency of Canada and provincial spokespersons. Coverage provided basic information about health risks, as well as how health authorities were managing the outbreak. As time went on, however, the federal response to the emergency and, more generally, its food safety inspection practices became the subject of critical media reporting. Indeed, the tone changed rapidly and dramatically.

After the first few days of coverage, news stories routinely reported concerns from worried consumers and criticisms from prominent health and food experts. The public discourse shifted from an emphasis on the specifics of the threat to Canadians' health to questions about the Canadian food system and whether it was an 'inhibiting' or a 'contributing' factor to the outbreak.

Other factors helped shape the nature of the coverage and influenced the debate. Ongoing discussions between the CFIA and its unions (the Public Service Alliance of Canada and the Professional Institute of the Public Service of Canada) meant that issues at the labour relations forum, especially related to staffing levels and jobs duties, became newsworthy. Media focused on these issues through the prism of the performance of food inspection before and during the outbreak.

Similarly, the fact that the outbreak occurred during the period leading up to a federal general election, and then during the campaign itself, played a role in how the outbreak was covered by the media.

While these contextual factors can have an impact on media coverage and public attitudes about an issue as serious as a listeriosis outbreak, examining the actual communications activities of the federal government during this period is important to determine if there are changes that could be made that would lead to more effective communications to the public.

We measured the effectiveness of the federal government in communicating to the public against the key objectives and the federal approach to risk communications in an emergency situation, described in the 2006 Strategic Risk Communications Framework and Handbook.

The Government of Canada's efforts were partially successful in achieving the objectives of risk communications. While communications staff demonstrated commitment, federal communications efforts during the outbreak did not consistently meet the level of performance the situation demanded. This diminished the government's ability to inform and reassure an anxious public. In fact, the performance itself became part of the story, thereby further impairing the effectiveness of the government's communication efforts.

This was due not to a major or systemic failure of the communications function, but rather to a series of substantive factors.

The overall approach to communicating the outbreak targeted primarily food safety. As such, it was not oriented enough toward informing the public of a potential hazard, but instead focused on gathering scientific evidence to confirm the foodborne illness and its source before going public about it.

Overall, the shortcomings in communicating to the public the relevant information related to the health emergency fall into three main categories:

• Timing: The federal communication efforts began at a late stage of the outbreak, after the first recall - later than the efforts of other parties involved. Against this it must be remembered that the 2008 outbreak first emerged in Ontario and was therefore under provincial leadership. The federal government was also late in using communication vehicles well-suited to reaching specific, at-risk populations. Activity dropped off dramatically after September 6th, when the election was called (not an uncommon practice during election campaigns), even though demand for information by the public was still high.
• Fragmentation: More than one source had to be accessed in order to get the complete story. In addition, greater emphasis on food safety and technical information about the outbreak, rather than on its public health dimensions, resulted in an unbalanced communications effort.
• Reactive:The federal government's communication efforts became focused on 'damage control' to answer allegations of mismanagement of the inspection services. Keeping to the usual approach for risk communication was difficult. This diminished the ability of the government to effectively address Canadians' concerns.

Factors compounding the timing, fragmentation and reactive nature of the federal government's communication efforts were:

• The lack of a single lead organization and management of the federal government's communications efforts to the public. With different parties in charge of various segments, communications activities were not always well coordinated or optimized. The Foodborne Illness Outbreak Response Protocol¹ was inadequate in this regard. From an audience point of view, having to obtain information from three different federal government sources imposed a burden on an already-confused public. The roles and responsibilities of the federal organizations involved in managing the public health emergency and in communicating to the public were not well understood by the general population. Even media representatives were not certain as to which government officials should be contacted to obtain information. The fact that provincial governments were also very active - and appropriately so - on the communications front added to the feeling of confusion. This was particularly true since, initially at least, federal information provided on the status of the outbreak was not easily reconciled with information provided by provincial authorities;
  
• While the public expects in an emergency that the lead spokesperson will be a minister, an 'elected' official, the choice of the appropriate ministerial lead was a matter of debate. The government's decision to have the Minister responsible for the CFIA act as lead, while it made sense initially given that the event was considered a food safety issue, limited the public health dimension of communications activities. We heard that consideration had been given to reassessing the choice of ministerial spokesperson, depending on changing circumstances. However, we also heard that the best practice in communications is to maintain a single spokesperson throughout an event. The Minister of Agriculture and Agri-food was prepared and available to comment on both the food safety and public health dimensions of the issue, and was assisted by senior officials in both fields. But the public view was that the government did not put enough emphasis on advising Canadians about what they needed to do to protect themselves;
• The view among some, especially in the public health community, that the Chief Public Health Officer of Canada was not visible enough during the outbreak; and,
• The lack of preparedness (e.g. unavailability of basic communications material early on for the most at-risk populations, no pre-existing arrangements with external suppliers for key communications support, insufficient simulation-type training, and inexperience with regard to applying the recently-adopted 2006 Risk Communications Framework).

Key Findings:

Our findings are based on six dimensions of the federal government's communications efforts:

• Content: We heard from consumer organizations that information about the outbreak was difficult to locate and understand. The content of messages to the public could have been improved by:
  • better integrating the food safety and public health dimensions of the outbreak;
  • getting their advice on the content as well as asking for their assistance in rapidly disseminating information to consumers;
  • Using more 'plain' language and everyday examples; and,
  • ensuring consistent and harmonized definitions and methods of calculating the number of cases among organizations and between governments.
• Timeliness: Federal communications to the public were slow off the mark, and were not sustained for a sufficient period of time
• Roles and responsibilities: The duties of federal agencies and departments involved in managing the health emergency and in communicating to the public should be well understood by both the general population and the media before an emergency occurs. This would require efforts to better position these organizations (i.e., clarifying mandate and functions; describing roles, activities and key practices before, during and after an outbreak).
• Communications strategy: An advance communications strategy and related implementation plan, including ready-made information products and the use of traditional and new media vehicles, would have improved the federal government's communications to the public during the listeriosis outbreak
• Relationship with media: Since the effectiveness of public communications is enhanced by a collaborative relationship with media that can maximize the impact of communications, a strategy to establish and maintain such relationships should be developed and implemented. During a public health emergency, the media play two roles: a) to report, in an independent manner, any related news it deems relevant, and; b) to relay important public health messages from the government regarding the emergency. The government should also make all possible efforts to ensure that its public health messages are accurately and effectively communicated.
• Spokespersons: Maple Leaf Foods took the lead in communicating to Canadians about the cause of the outbreak, assuming responsibility for it and, in the process, shaping the public perception of the event. The CFIA was aware of and supported Maple Leaf Foods' approach to communications. Meanwhile, Canadians were seeking reassurance from government that public health was being protected.
  
  Having the Minister responsible for Agriculture and Agri-food and the CFIA serve as the lead ministerial spokesperson, was considered by some to be a 'conflict of interest' even though the minister has a legitimate role in relation to the food industry. It appeared to limit government's capacity to communicate health information sought by the public. The perceived lack of federal public health leadership in the event attracted many comments.
• Leadership and coordination: Communications teams from the different federal agencies understood the importance of cooperation and they demonstrated a willingness to work together. However, the absence of a designated communications coordinator resulted in a fragmented approach and seemingly inconsistent messaging. This was compounded by the fact that the public, the media, and even provincial and territorial partners were not clear about the division of roles and responsibilities among federal organizations.
• Preparedness: Lack of appropriate advance planning resulted in sometimes onerous adjustments that delayed and impaired effective communications.

Recommendations:

7. The Public Health Agency of Canada should assume the lead role (non-ministerial) in communicating to the public for a national foodborne emergency.
8. The Canadian Food Inspection Agency and the Public Health Agency of Canada should enhance their public profile to increase awareness of their mandates.
9. The principles of risk communications should drive the federal communications strategy and activities. Therefore, the Health Canada/Public Health Agency of Canada Strategic Risk Communications Framework should be implemented and become the principal reference point and standard for federal government communication to the public on foodborne emergencies, such as listeriosis.
10. Communications staff should be aware of developing trends in communication and ensure the capability exists to use the best vehicles available to reach key audiences as quickly as possible.
    
    A "one-stop" website capability should be developed in order to provide easier public access to crucial information. Accountability for its maintenance should be clearly identified.
11. A series of communication measures that will contribute to an acceptable level of preparedness should be identified and put into place.
    
    These would include simulation training, contingency planning to ensure availability of key resources and ready access to outside suppliers. The measures should also include the preparation of certain communications material in advance, such as basic information on listeriosis and other foodborne illnesses for at-risk populations and health providers.
    
    It would also include the development of a communications strategy, based on solid marketing research and analysis, and a related implementation plan. The strategy should identify the target audiences, their information requirements, and how and by whom they are best reached.

Communications to physicians

The Canadian Medical Association (CMA) maintains an e-panel made up of 950 physician members of CMA who have agreed to respond to regular brief electronic questionnaires about a variety of topical issues.

In April 2009, following discussions between the CMA and our team, an e-panel survey² on listeriosis asked about the use of health alert advisories, information needed to diagnose and treat listeriosis cases, and preferred sources of information and methods of communication during a national disease outbreak. The survey was a combination of open- and closed-ended questions.

Key survey results:

• 60% of the physicians surveyed remembered receiving a health alert on listeriosis (from some source), and of those, almost everyone (94%) judged it useful.
• Responses to the open-ended questions highlighted the need for alerts to be concise and from one source, a centralized web site for physician information such as guidelines and screening tools, and notification of physicians before the media.
• Physicians' greatest challenges in educating patients about minimizing risks of foodborne illness are lack of patient friendly materials (77%), lack of knowledge on the outbreak (69%), and lack of time (69%).
• Their preferred sources of information during a foodborne outbreak are the local public health unit (79%) and the provincial or territorial department of health (78%) or the provincial or territorial Chief Medical Officer of Health (75%). The next most frequent sources would be Google (70%), the Centers for Disease Control and Prevention in Atlanta, USA (62%) and the Public Health Agency of Canada (57%).
• Their preferred methods for receiving information during a national disease outbreak are email alert (100%), web site (92%), fax alert (69%) and mail (57%).
• To more effectively diagnose and treat suspected listeriosis cases, physicians report they need situation-specific clinical practice guidelines (96%), information on lab testing (90%), clinical case definitions (89%), screening questionnaires (86%) and websites tailored to physicians (86%).

Key Findings:

• Physicians value 'just in time' information from credible source - outbreak (and local situation) update, guidelines, patient materials, etc.
• They look first to local/provincial public health for information about an outbreak

Public Education

Before the 2008 outbreak and the widespread media coverage of the foodborne disease outbreak, even well informed Canadians were likely unaware of listeriosis. Given that older Canadians - one of the fastest growing segments of the population - are the most susceptible to the disease and that there are things individuals can do to protect themselves, there is a strong argument for public education programs to raise awareness about the disease and its transmission. Information geared to members of high-risk groups or those who care for them is especially important.

One of the primary functions of public health is to prevent and reduce disease and premature death. They do so by identifying and reducing health threats. Directly related to this role, another key activity of public health officials is educating people about how to protect themselves from illness and injury, and prevent the spread of diseases.

With some exceptions, public education efforts to raise awareness about listeriosis were minimal when the crisis struck. The majority of Canadians were unaware of those at greatest risk of becoming ill if exposed to Listeria monocytogenes, what foods these individuals should avoid, or proper food preparation and handling measures or the unique characteristics of Listeria.

Overall, the scarcity of educational materials, coupled with the lack of awareness of listeriosis, contributed to public confusion about what individuals could and should do to protect themselves during the 2008 outbreak.

The fact that there were nearly two and a half million visits to the CFIA's website between August 17 and September 14, and, that telephone calls from consumers to the CFIA climbed from an average of 75 calls per day to more than 1,400 daily following the food recalls is a clear indication of the public's urgent need for information about the outbreak and how to avoid eating contaminated foods.

Health Canada and the Public Health Agency of Canada provided general information about listeriosis on their web sites. However, a telephone hotline and other interactive communications vehicles were not available, so it is not possible to compare the level of public interest in receiving information about the disease.

Another example of targeted public education is labelling. We have heard support for warning labels, which could be targeted to vulnerable populations to help educate and prevent the use of food products that could pose a risk to their health. We also heard other views from industry and institutional associations of the risk of over utilization of such labelling causing the public to become indifferent to their intent.

Recommendation:

42. To protect vulnerable populations, including the immuno-compromised, older people and pregnant women, Health Canada should promote consumer education into the risks associated with Listeria. This could include targeted measures, such as precautionary labelling. This should be accomplished in collaboration with the Public Health Agency of Canada and in conjunction with provincial and territorial health partners.

Next chapter

"Following the 2008 outbreak, each of the key federal organizations (Health Canada, the Public Health Agency of Canada and the Canadian Food Inspection Agency) involved in the event prepared 'lessons learned' reports."

¹ FIORP is a joint federal, provincial and territorial protocol to guide multi-jurisdictional responses when a foodborne emergency arises. The roles and responsibilities of all governments charged with investigating and managing such an outbreak are outlined in the protocol.

² The survey was conducted in April 2009, seven to eight months after the outbreak occurred. According to the CMA, a 23% response rate is acceptable for e-panel surveys. The e-panel includes physicians who use electronic communication methods, thus their preferences are representative of this cohort.