COVID-19 and the importance of effective risk communication with children.

During the current COVID-19 pandemic, effective risk communication is essential to mitigate the mental health impact on children and their families. Effective risk communication involves being honest but yet reassuring, framing issues in an actionable way, and modeling realistically reassuring communication among adults. Health care providers may discuss with families principles of modeling good media consumption habits to mitigate misinformation on social media. In addition, health numeracy and health literacy need to be integrated into proper risk communication.

Risk communication is defined as the process of how information is exchanged among experts and the public, in order to improve understanding and ensure well-informed decision-making (1). The importance of risk communication is a public health lesson which has stemmed from prior global emergencies, where it has been noted that a divide between perception of risk and actual risk worsens the mental health impact of any global disaster (2). Risk communication has, as such, been termed by the WHO as a ‘core public health intervention’ (1) in any public health emergency.

There are factors that increase subjective perception of risk—termed ‘dread’ factors (2). These include a medical situation that is uncontrollable, international in scope, potentially fatal, unequitable, and catastrophic. When dread risk factors are present, there is often a further divide between perception of risk, and actual risk. During public health emergencies where dread factors are present, such as the current coronavirus disease 2019 (COVID-19) pandemic, risk communication as a public health intervention is more important than ever.

There is increasing evidence that the COVID-19 pandemic is having a profound, and likely long-term, impact on children (3). As stated by UNICEF, “children are not the face of this pandemic but they risk being among its biggest victims.” (3) More than 1.6 billion children worldwide were affected by school closures during the pandemic, and 168 million children worldwide were out of school for almost a complete year (3). Public health measures have resulted in increasing food insecurity and reduced health care access for children, as well as worsening disparities among those families already facing adverse social determinants of health (4). The mental health impacts of social isolation and reduced access to the stabilizing forces of school and activities, among others, are just beginning to be described.

One way to help mitigate the mental health impact of the pandemic is to ensure proper risk communication with children and their families about the risks of COVID-19 disease transmission and illness. Proper risk communication ensures that the information available is communicated effectively and in an age-appropriate way. There are various frameworks for risk communication although one of the most commonly used is the Center for Disease Control and Prevention’s (CDC) Crisis and Emergency Risk Communication (CERC) framework (5). This framework focuses on six key principles—being first to provide the information, being right and credible, expressing empathy, promotion action, and showing respect (5). These key principles are incorporated into many of the current guidelines available regarding how to talk to children about the COVID-19 pandemic, including those of the Canadian Paediatric Society (CPS) and the WHO (6,7). Health care providers play an essential role in modeling effective risk communication to children and their families, and in educating families about how to speak to children about COVID-19 within their own homes.

A key focus on communicating information about the pandemic to children is to be reassuring yet honest when providing information (6). As noted by UNICEF, “Children have a right to truthful information about what’s going on in the world, but adults also have a responsibility to keep them safe from distress. Use age-appropriate language, watch their reactions, and be sensitive to their level of anxiety” (8). Information should be provided in an easily understandable way, and is best supported by starting with open-ended questions addressed to both the child and family during a clinical encounter (8). Feelings and concerns expressed by children should be acknowledged and validated (8). Discussions should be framed around actionable items to provide children with a sense of control (6). Children could be reassured, for example, that the everyday actions that they do—such as wearing a mask, washing their hands and physical distancing—are helping to reduce spread of the virus (6). Children often model their behaviour based on the actions of adults around them, and hence it is essential that health care providers and parents discuss the pandemic in a realistically reassuring way themselves (6).

Accurate communication of risk has become more difficult in the current era of social media, as children and adolescents often rely on what they see from a social media source for accurate information. Unfortunately, disinformation is rampant, and media misinformation has been magnified during the current pandemic. The director general of the WHO has stated that “we’re not just fighting an epidemic; we’re fighting an infodemic,” going on to note that misinformation ‘spreads faster and more easily than this virus’ (9). As a result, families should be reminded to be ‘mindful of media’ (6). Health care providers may discuss with families principles of modeling good media consumption habits, including reducing screen time, watching screens as a family, and focusing on media sources that can be monitored, such as podcasts (6). It is recommended to remind children that stories they read about the pandemic (including transmission and vaccination) on the internet or social media may be incorrect, and to encourage children to discuss what they read online with their families or health care providers (10). It is also essential that health care providers work with their own medical societies to use social media to reach diverse audiences, including families and children, and provide accurate information. Professional websites that are accurate, interactive and contain up to date information help to mitigate misinformation (11). Children and adolescents could be engaged about what they have read on social media during clinical encounters, and directed towards accurate resources (11).

Another important element of framing of risk is health numeracy, or the ability to understand what numbers mean (12). How numbers are framed can influence perception of risk. For example, the risk of anaphylaxis to the COVID-19 vaccine can be framed in a discussion with an adolescent in two different ways: there is approximately a 8 per million risk of a severe allergic reaction, or there is a 99.9992% chance of not having a severe allergic reaction to the COVID-19 vaccine. While these two numbers are the same, the perception of risk varies dramatically based on how it is presented. Presenting information in different ways—such as in graphs or charts—can improve understanding of risk (12). In addition, risk anchoring (comparing risks to everyday risks that are easily understandable) can also improve risk perception (12).

Medical decisions during the current pandemic should utilize a shared decision making (SDM) approach, in which clinicians and patients engage in a two-way conversation that incorporates best evidence and patient preference into decision-making (13). While there are many benefits to a SDM process in general—including improved decision quality, patient adherence, patient outcomes and health care costs—SDM has also been shown to improve risk perception through clear explanations of risk and benefits—this helps to narrow the divide between perception of, and actual, risk (13). Conversations should incorporate the family’s health literacy, or the ability to understand and process health decisions (14). Communication strategies might include speaking slowly, including pictorials, avoiding medical words, limiting key information, and repeating/confirming key points (14). All communication about COVID-19 with children should be open-ended, bi-directional, and incorporate knowledge of the family’s health literacy (8). The COVID-19 health literacy project, in partnership with Harvard Health Publishing, has age-appropriate COVID-19 fact sheets for 3 to 6-year olds, 6 to 12-year olds, and 13 to 18-year olds in 35 languages (15).

CONCLUSION

The current pandemic has created many ongoing challenges for children and their families with likely long-term if not lifelong consequences. During these difficult times, it is essential that risk is communicated effectively during clinical encounters.