Process and components of disaster risk communication in health systems: A thematic analysis

Risk communication (RC) is one of the necessary functions in disaster management. Establishing communication processes such as planning, transparency of policies and guidelines, RC expert training, providing communication infrastructure and evaluation in the shortest period reduces confusion and management inconsistency. One of the existing challenges is not knowing the exact dimensions of risk communication and its components in disasters. The aim was to identify the components of disaster risk communication in the health system. This research was conducted by systematic review and searching of the databases of PubMed, Scopus, Web of Science, ProQuest, Google Scholar and ScienceOpen 2000–2021 to identify the components of disaster risk communication in the health system. Thematic content analysis was used for data analysis. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 chart was used for systematic search, and a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used for quality determination. Out of 12 342 articles extracted, 25 studies were included for analysis. The components of disaster risk communication were analysed in 6 categories and 19 subcategories. These categories include communication (communication processes, communication features and infrastructure), information (content production, content characteristics and publishing), risk communication management (risk perception assessment, planning, coordination and logistics), monitoring and control (monitoring and evaluation, accreditation, documentation), education and training (public and organisational) and ethics and values (culture and social beliefs, ethics and trust). According to this research, the establishment of communication infrastructure and advanced equipment such as various structured formats for communication and artificial intelligence; online and offline communication support systems; and timely and accurate notice can help achieve goals such as coordination and organisation in the health system and increase social participation. Contribution This study has clarified and explained all the main components and measures of risk communication that can be used for planning scientifically.


Introduction
organisation, management and performance of communities (Kirschenbaum 2019). Effective communication, accurate information and analysis of potential risks can play an important role in prevention, risk reduction and right decision-making (Shrestha et al. 2021). Communication processes and tools, information and communication technologies, as well as mass media, early warning systems and public education about emergencies are among the key and important measures in managing these events and reducing losses (Tinker et al. 2011) As a lesson learned from many disasters, risk communication has also been identified as a key factor in planning and responding to emergencies, and coordination and communication in the successful management of disasters has also been emphasised (Ow Yong et al. 2020).
This situation requires measures such as rescue, providing health services in prehospital and hospital, communicable and noncommunicable diseases, environmental health, family and population health, nutrition, psychosocial support, health education, laboratory services and drug supply. It is imperative for health managers, as the first decision-makers and respondents, to communicate, answer questions from senior officials, the community and journalists and interact effectively with all levels of administration and society. It should be done in the shortest time (Khangah et al. 2017). These measures are defined in the process of risk communication, which is one of the efficient components in all stages of the disaster risk management cycle from preparedness to response and rehabilitation (Khangah et al. 2017).
The process of risk communication in countries is different, and it is influenced by many factors and includes various components. In the preliminary search, systematic review studies are the subject of this research (Sato et al. 2020). One of the existing problems is the lack of transparency of risk communication components, and the clarity of risk communication components will help to plan accurately, comprehensively and adaptively. This study aims to provide a comprehensive overview to identify the components of disaster risk communication in the health system for principled and effective management of emergencies, reducing parallel work, community engagement and rumors management.

Methodology
This study was conducted by systematic review with the Prospero code CRD42021268686. Articles were included by searching in international databases such as PubMed, ProQuest, Scopus, Web of Science, Google Scholar and ScienceOpen.

Search strategy
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart 2020 (Figure 1) was used for systematic research (Page et al. 2021). According to the title and subject of research, the relevant keywords were determined and finalised by the research team based on the initial review of the texts, use of MeSH by the NCBI database, the use of keywords of related articles and the opinions of experts. This was done by using the keywords 'risk communication ', 'disaster' and 'health system'. Also, for communication synonyms, words such as 'communicative', 'communicating', 'communicator', 'communicational' and 'communicatively' were used. For the word 'disaster', synonyms such as 'emergency', 'crisis' and 'pandemic' were also used. For the term 'health systems', synonyms such as 'healthcare delivery', 'healthcare', 'healthcare system', 'health service', 'health sector', 'public health system', 'health delivery system', 'health field' and 'public health' were used.

IdenƟficaƟon
To design the search strategy, 'OR' operators and 'AND' operators were used. In the end, an exclusive research strategy was designed for each main database. Thereafter, by testing the relevance index of articles on the search page in the database (Table 1) and separate steps, the filters of title, abstract and their combination were used.

Article inclusion criteria
Studies that are relevant to disaster risk communications in the health system from 2000 to 2021, available in full text and have high quality in method and design were included in this systematic review.

Article exclusion criteria
Articles dealing with various other aspects of disaster risk communication, such as communication between medical teams, communication between patients and medical staff, the challenges of risk communication and articles whose full text was not available, were excluded from the study.
Duplicate studies and then the titles and abstracts of each study were deleted in terms of relevance and unrelated studies. In the full-text selection stage, the screened studies were retrieved, and the studies whose full text was not available were deleted. Then, the process of selecting studies was done by studying the full text of the article based on the inclusion and exclusion criteria of this study. At this stage, two members of the research team, after reading the full text of each study independently, divided the studies into three categories: imported, exported and borderline. After determining the cases of agreement, the decision for disagreement was made through the decision of the third person and reaching a consensus between the research team, and finally, the selected articles included in this study.

Collecting data stages
After finalising the articles submitted to the research databases, the extracted data were entered into a Microsoft Excel file (Microsoft Corporation, Redmond, Washington, United States) which included the name of the journal, article title, year of publication, author name, country name, research method and study results for evaluation and analysis. The main features of the studies and their results are shown in Table 3.

Study risk of bias assessment
The STROBE checklist was used to evaluate the quality of articles (White et al. 2015). The Strengthening the Reporting

Data analysis
In this research, the thematic analysis method was used to analyse the data, which is one of the qualitative research methods and includes the combination and interpretation of different findings with a focus on the study subject.
Two researchers analysed all the components extracted from the articles. Duplicate components were removed. The remaining list of principal components was studied and evaluated several times. Similar components were classed into subcategories according to thematic similarity. In the next stage, during several times of study and revision, similar subcategories were classed and then the main categories were created.

Ethical considerations
Ethical approval to conduct this study was obtained from the Shahid Behehshti

Study selection
According to the PRISMA flowchart, out of 12 342 articles found using the database search strategy, 4 957 articles were deleted because of duplication, 7 238 articles were deleted on account of lack of relevance to the research topic and 41 articles were deleted because of lack of access to the full text. The full text of 112 articles was carefully reviewed and entered the critical review stage. Finally, 25 articles that had average and high quality in evaluation were included in the study using the STROBE modified tool. In this study, 48% of the articles were mixed methods, 32% were qualitative and 20% were quantitative. Articles from China, Australia, India, Britain, the United States (US) and Iran were reviewed in this article. Most of the articles are from the US, Australia and Britain. The highest number of articles was related to the years 2015-2021 (44%).

Thematic analysis
Based on the studies included in this systematic review, the elements of disaster risk communication in the health system were divided into 6 main categories and 19 subcategories, which include communications (subcategories: communication processes, communication features and communication infrastructure), information (subcategories: content production, content characteristics and content publishing), risk communication management (subcategories: risk perception assessment, planning, coordination and support), monitoring (subcategories: monitoring and evaluation, monitoring and accreditation, documentation), training and education (subcategories: public and organisational) and human ethics and values (subclasses: culture and social beliefs, justice and ethics, trust) ( Figure 2).

Communication
Based on the findings, processes and infrastructure, as well as their characteristics, are important components of risk communication.

Area Question Answer
Yes (

Communication infrastructure:
Information and communication infrastructure and the resulting opportunities lead to the establishment of extensive and highly influential  Coordination: Coordination is one of the pillars of the chain of command and is one of the basic principles of risk communication. For the establishment of a proper risk communication process, communication and coordination at the local, national and international levels must be planned and implemented before the crisis occurs (May 2005;Zhang et al. 2020). It is also necessary to provide a platform for cooperation and interaction with stakeholders, social and nonprofit organisations and researchers (Mitcham et al. 2021;. Logistics: Supporting the process of establishing risk communications includes providing the necessary resources to carry out activities, manpower, programmes and other management items in this area (Papwijitsil et al. 2021). In the current situation, there is a need to use support resources also (Covello 2003;Hobbs et al. 2004). On the other hand, in disasters, there is a possibility of damage to communication infrastructure such as electricity, telephone and the Internet, so providing a support communication system should be considered (Papwijitsil et al. 2021;Vanderford et al. 2009)

Monitoring
Monitoring is one of the components of organisational processes to improve responses and includes monitoring and evaluation, accreditation and documentation.

Monitoring and evaluation:
The process of risk communication needs to be established in all stages of the disaster management cycle; therefore, it is necessary to continue its evaluation during this cycle (Vanderford et al. 2007;Zhang et al. 2020). Moreover, the activity of communication networks in terms of software and hardware should also be evaluated periodically (Gallardo-Paúls 2021). The information process, as the most important components of risk communication, must also be monitored to ensure access to accurate information, at the right time and in the right way (Dickmann et al. 2015). Finally, incorrect information and rumours must be managed and even removed by identifying them (Gallardo-Paúls 2021; Vanderford et al. 2007).
Accreditation: It is necessary to monitor the establishment of risk communication, which always has many challenges (Golding & Rubin 2011). In addition, monitoring the implementation of protocols and providing feedback should be considered by managers and experts from the beginning of the risk communication process to improve decisionmaking and response (Dickmann et al. 2016). Accreditation of risk communication processes in responsible organisations should be done periodically or annually (Granatt 2004).
Documentation: Documenting individual and organisational experiences and lessons learned in risk communication, exchanging lessons learned at national and international levels and using lessons learned in future programmes will enhance the risk communication process (Granatt 2004;Spialek & Houston 2018;White et al. 2015). In some studies, it has been suggested that a monitoring team should be present along with the assessment team from the beginning of the risk communication process (Covello 2003;Johnson 2006).

Education
For the establishment and effectiveness of the risk communication process, training at the public and organisational levels should be included in the pre-, mid-and even post-disaster stage of programmes. Public education will help by producing and distributing educational content and media at the community level to bring in positive behaviour, improve risk reduction indicators and increase disaster preparedness among families and the general public (Bagheriet al. 2021;Spialek & Houston 2018). In addition to improving the knowledge of managers and experts in the field of risk communication and their components, concepts, strategies and plans and responsibilities (May 2005), other key people in the organisation should also be made familiar with risk communication processes (Ow Yong et al. 2020;Vanderford et al. 2007). In this regard, risk communication manoeuvres can be planned (Gallardo-Paúls 2021; Golding & Rubin 2011).

Ethics and values
Risk communication as a community-oriented process must always include human ethics and values such as culture and social beliefs, trust, justice and ethics.
Social culture and beliefs: Economic and social conditions must be considered to plan and formulate risk communication protocols to determine the main sources of public information (Covello 2003;Maxwell 2003). Also, the risk communication plan and content production should be adapted to the culture (Holmes et al. 2009;Vanderford et al. 2007). On the other hand, due to the importance of public opinion management, it should be done while giving hope in the society through effective risk communication and rebuilding the thoughts and feelings of the society (Ow Yong et al. 2020;Spialek & Houston 2018;.

Principles of ethics:
One of the measures that should be taken up in the precrisis phase is the development of ethical principles of risk communication (Granatt 2004;Johnson & Chess 2006). Stakeholders and the media must also adhere to moral obligations (Covello 2003;Holmes et al. 2009). It is necessary to learn ethical criteria to avoid embarrassing the people and not blaming or holding other organisations accountable, which affects communication processes.
Trust: Risk communication activities, information paths and content produced should all lead to mutual trust between the government and the people to pave the way for the flow of risk communication (Dickmann et al. 2015;Hobbs et al. 2004). Efforts should be made to improve public confidence in official sources of information (Venkatraman & Manoharan 2021;Wray et al. 2008), which will facilitate the management of public opinion, social networks and rumours (Mohd Hanafiah et al. 2021).
Disaster risk communication is a multidimensional and long-term process that plays a principal role in reducing risk and organisational and extra-organisational preparedness. Effective disaster risk communication lead to right decision-making, increase risk understanding, improve community engagement and preparedness. Explaining the factors and elements of disaster risk communication in the health system leads to an appropriate response based on need, without wasting resources and parallel work, and improving rehabilitation processes and, most importantly, health system resilience in all stages of health management in disasters.
In this research, planning and information are the most important things related to disaster risk. These components require an assessment of the existing situation and planning based on the culture, social and economic issues and health literacy community to create a consistent programme. The process of risk communication provides a more appropriate response to disasters, public behaviour change and evidencebased decisions.
A study by Mebane et al. (2003) showed that if an organisation has even the most sophisticated forecasting models and advanced early warning systems, but the information is not transmitted promptly, it will not allow the end user to understand and act correctly, and finally, it will be useless (Mebane et al. 2003).
These findings concur with the current research. On the other hand, to communicate at different levels and with a wide range of audiences, a differently structured format, specialised and comprehensive communication platforms must be used to ensure the availability of the information (Dickmann et al. 2016;Papwijitsil et al. 2021).
Paying attention to the values as well as the ecology of risk communication with an emphasis on cultural, social, economic and educational issues of the community for audience evaluation, contingency and audience-oriented planning, determining communication channels and information needed to promote risk communication processes and building public trust is very effective, which is explained in this study as one of the main components. On the other hand, studies have shown that in most countries, maintaining and promoting public trust is very important and necessary, and in this direction, in addition to clear and timely information, there should be a two-way interaction and attention should be paid to understanding the risk and people's needs (Boholm 2019).
Active information production as well as completing the information gap from before the disaster to the rehabilitation phase, in addition to increasing public trust, will lead to the management of social networks and rumours, which will help manage the stress and turmoil caused by crises (Sezgin, Karaaslan & Ersoy 2020). Content producing, there must be an intelligent data collection system to fill the information gap at the intra-organisational and community levels (Bernard et al. 2021;Johnson & Chess 2006) in many communities educating people to correct rumours, manage public opinion and reduce the burden. Emotional and psychological events and disasters are part of precrisis risk communication programmes (Granatt 2004;).
Finally, from the perspective of the researchers in this study, assessing the relationship between disaster risk understanding, the components of the communication process and describing the relationship between these elements, including how the process evolves and how structures relate to each other and outcomes, should be clear.
In this study, monitoring focuses on evaluation, accreditation and documentation. Monitoring and evaluation are one of the main elements of management and are of great importance in risk communication also. However, Dickmann et al. (2016), points out that communication interventions in public health emergencies (such as infectious disease outbreaks) are increasingly recognised as a critical determinant of success in preparedness, response, and recovery. It is possible that its impact can be measured through the evaluation of related performance parameters (Hooker & Leask 2020). In this framework and similar studies, only information listening, the communication framework including actions, key messages and strategies, and finally coordination at different levels are evaluated (Dickmann et al. 2016).
According to this research, the establishment of communication processes, preparation and provision of communication infrastructure from simple to advanced equipment, such as the use of various structured formats for communication, artificial intelligence for communication and determining online and offline communication support systems, can achieve goals. Internal and interdepartmental coordination and organisation and increasing community engagement increases the organisational preparedness to deal with disasters.
Another dimension of the risk communication process is to establish an effective, appropriate and continuous relationship with the community, which requires the establishment of communication between them, the formation of community networks and the use of key persons at the community level (Hobbs et al. 2004;Savoia et al. 2017;Venkatraman & Manoharan 2021). Tambo et al. (2021) showed in their study that social and global solidarity requires strong governance, broad community participation and sufficient trust to enhance preparedness and early response to epidemics , which emphasises the findings of the current study. Gathering information and providing infrastructure based on artificial intelligence and machine learning algorithms will be useful and effective in promoting risk communication interventions and building public trust (Ghomian et al. 2018;Seeger et al. 2018;. The recording, storage and dissemination of information through the appropriate platform will help to promote adaptive prevention and control programmes for emerging epidemics, evidence-based decision-making, integration of data and models for information and the provision of effective and sustainable risk communication strategies (Johnson & Chess 2006).

Conclusion
In general, disaster risk communication has many and varied components because of its vital and effective functions, which are fully enumerated in this study. One of the reasons for the failure of communication programmes is the risk of interdisciplinary approaches in this field, which has caused some important elements to be ignored. The development of programmes, protocols, guidelines and instructions can use all the elements extracted in this study, in addition to strengthening risk communication, preventing the entry of managerial and policy tastes as much as possible and leading to internal and external coordination. Increasing coordination in all steps of risk communication will increase social participation and public trust as the first step in changing the positive behaviour of society in the field of health. This study has extracted the risk communication components with an all-hazard approach, but it is suggested to conduct a specific investigation regarding the major disaster.
Implementation of interactive risk communication and information on the disaster risk reduction phase based on the community needs can develop knowledge and lead to behaviour changes. The ecology of risk communication should be given the attention of policymakers in this field. Mass information production will not have much effect regardless of the knowledge, experience, values, economic, social and religious status of the society. Laws and ethical principles related to disaster risk communication should be formulated, keeping in mind the spread of social networks and the increase of infodemics.

Strengths and limitations
One of the strengths of this research was the study of risk communication elements in the time of coronavirus disease 2019 (COVID-19), which itself is a result of the existing conditions and the use of different policies, leading to the explanation of all the components without any shortcomings. Mind map software was also used to provide a big picture to familiarise the audience with all aspects of disaster risk communication. One of the limitations of this research was the lack of access to the full text of some articles and books, the breadth of the content and the number of articles included in the study.