Communicating a crisis

David Spiegelhalter on communicating a crisis:

There are some basic principles, which I learnt from John Krebs, former Chair of the Food Standard Agency, who had to deal with many crises. The first thing is that you should be communicating a lot, consistently and with trusted sources. You have to be open and transparent. You have to say what you do know and then you have to say what you don’t know. You have to emphasise, and keep emphasising, the uncertainty, the fact that there is much we don’t know. Then you have to say what you are planning to do and why. Finally, you have to say what people themselves can do, how they should act. The crucial thing to say is that this will change as we learn more.

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The Myth of ‘Dumbing Down’

For The Atlantic, Ian Bogost on communicating complex ideas to an audience:

One thing you learn when writing for an audience outside your expertise is that, contrary to the assumption that people might prefer the easiest answers, they are all thoughtful and curious about topics of every kind. After all, people have areas in their own lives in which they are the experts. Everyone is capable of deep understanding.

Up to a point, though: People are also busy, and they need you to help them understand why they should care. Doing that work—showing someone why a topic you know a lot about is interesting and important—is not “dumb”; it’s smart. Especially if, in the next breath, you’re also intoning about how important that knowledge is, as academics sometimes do. If information is vital to human flourishing but withheld by experts, then those experts are either overestimating its importance or hoarding it.

I struggled with this during my first year of graduate school, because it took a while to get out of my own head and imagine myself as a reader. Or, in the case of that first-year regression analysis course, I was supposed to imagine a policymaker on a tight schedule.

I would crunch numbers or whatever and write reports. My professor told me I had to do a better job explaining the meaning behind the numbers. How should a non-statistician interpret these results? It was my job as the statistician to explain.

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✚ Failure to Communicate (The Process #47)

It's about purpose. It's about who your work is for. It's about what you're trying to show. Read More

The Humility of Expertise

  Ed note: Today we welcome Junaid Nabi back to the blog. For more about Junaid, please see the bottom of this post. The following is adapted from a speech that was delivered as one of

5 Communication Lessons Learned from Hurricane Maria

Over-the-shoulder photo of two older women looking down at health communication materials in their hands.

When Category 4 Hurricane Maria made landfall in Puerto Rico, CDC assembled a team of experienced communicators who were flexible, bilingual, and culturally sensitive communicators. This group of experts prepared to deploy to Puerto Rico on short notice to support the communication needs of the Puerto Rico Health Department. I was asked to lead content development, and as a native Puerto Rican I did not hesitate to go home and help in any way I could.The 2018 hurricane season began on June 1 and will last until November 30. Learn more about hurricanes from the National Hurricane Center at the National Oceanic and Atmospheric Administration.

I was part of the first team of four health communications specialists who arrived on the island just three weeks after the hurricane. We knew our job was not going to be easy— severe electrical power outage meant that residents had no access to internet, social media, or television. Antennas had fallen during the storm, so there was very limited radio coverage and almost no cell phone connectivity. Large billboards were literally on the ground and newspapers were not circulating widely because there was no way to publish and transport them for delivery.

Hurricane Maria was an unprecedented disaster, exposing residents to an increased risk for foodborne, waterborne, infectious and non-infectious diseases, and other public health risks. We had to figure out how to communicate about multiple health risks to the public, especially to those in rural and isolated communities, when basic resources and services were not available.

We met this challenge head on, and I took away five key lessons that I hope can help other communication responders prepare for the 2018 hurricane season and any future emergency events:

1. Develop Key Messages in Advance

Every natural disaster is unique and emergency responders have to quickly adapt to the ever-changing nature of a crisis. Nonetheless, many key messages can be written before disaster strikes so they can be quickly disseminated before an event, during the response, and in the recovery stages. In disaster planning this is known as a phased approach, and it can save valuable time when in the midst of a crisis response. Before the 2017 hurricane season started, CDC developed a key message reference document for partners to have the most up-to-date science about multiple hurricane-related health threats. The key message document helped us on the ground so we could quickly create and adapt health communication products for Puerto Rican audiences.

2. Identify New Communication Channels

When all primary communication systems and technology fail, communicators must think creatively and adapt to the crisis by identifying new communication channels. In Puerto Rico, we realized that mass producing printed materials was our best bet to get important health messages to the most vulnerable communities. As the response evolved, we identified alternate channels, such as using FEMA’s text messaging capability to disseminate health messages to their subscribers, or using outdoor speakers to run public service announcements in rural areas. We also posted targeted and relevant messages on the CDC en Español Facebook channel. We knew Puerto Ricans on the United States mainland, known as “la diáspora,” were heavily using technology to connect with family and help people on the island, so we posted targeted and relevant digital messages that could be relayed to people in Puerto Rico by word of mouth.

3. Create Culturally Appropriate Materials

Cultural norms influence how people behave, so culture has important implications for emergency communication. For the Puerto Rico response, we translated materials to Spanish and made sure to linguistically and culturally tailor our health prevention messages so they would be relevant with the Puerto Rican audience. Our team made sure to use widely understood terminology in the island to provide clear and localized language, particularly for audiences with low literacy. For example, in Puerto Rico the term “hongos” is widely understood as a translation for “mold” as opposed to “moho,” which is used in other Spanish speaking countries but has a dual-meaning in Puerto Rico. We also implemented a streamlined process for the Puerto Rico Department of Health, and CDC scientists and communication experts to vet, approve, and co-brand the communication materials.

4. Partner Up

We collaborated with the Puerto Rico Health Department to determine our number one priority, which was reaching the most vulnerable communities, including those with no access to clean water, and people who were still in isolated and rural areas. When we heard about military partners who were delivering food and water supplies to isolated communities by helicopter, we gave them boxes of our fact sheets so they could be distributed in these areas. We delivered materials to federal and local government agencies who were doing health assessments in hospitals and shelters. We also provided copies to grassroot and non-profit organizations, and religious and community leaders who went door-to-door to assist residents and organize community events. Through our commitment to partnerships, we distributed over 1.6 million copies of printed materials in a 3-month period. Topics ranged from food and water safety, to carbon monoxide, vector control, mold, leptospirosis, mental health, among others. This included fact sheets, posters, palm cards, and children’s coloring books.

5. Boots on the Ground

Once we started mass producing printed materials, we organized and attended more than 30 community events with partners to disseminate information to the public. We visited hospitals, shelters, disaster recovery centers, schools, and provided information door-to-door in rural communities. Talking with people face-to-face gave us a better understanding of the realities survivors were facing and helped identify public health information gaps in our materials so we could make adjustments.

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Evaluating Communication Campaigns

Black man holding belly of his pregnant wife making heart. Pregnant woman and loving husband hugging tummy at home. Heart of hands by multiethnic couple on pregnant belly.

Health communication and marketing campaigns that promote positive behavior change are a cornerstone of public health and behavioral science. Designing and implementing quality campaigns on a tight budget and in an urgent timeframe is a challenge that most health communication professionals share. Research and evaluation are critical for a successful campaign. CDC is using leading research and evaluation methods to develop quality campaigns, while keeping costs low and sticking to tight timelines.

A great example is CDC’s design and implementation of The Domestic Readiness Initiative on Zika Virus Disease, also Domestic Zika Campaign: By the Numbers. Since its launch in early summer 2016, the campaign has generated over 350 million impressions and nearly 555,000 clicks across search, social, and display in the United States. In Puerto Rico, the campaign got over 10 million impressions, and 26,000 clicks on a range of media buys that covered the entire island.known as the Domestic Zika Campaign. This bilingual digital campaign sought to increase Zika awareness among the general population and expectant parents in the United States and its territories. Campaign messages were also developed to change knowledge and attitudes regarding Zika transmission, beliefs about the risks of Zika, and the perceived ability (self-efficacy) to protect oneself against Zika.

CDC identified several methods to get tailored messaging to our target audiences. Based on the work for this campaign, there are 10 methods that can help you reduce costs and improve the efficacy of your communication or health marketing campaign.

Formative Research

  1. Use “mixed” methods or alternative approaches. When feasible, mixed assessment techniques can enhance and complement different types of data collection. Your budget may not allow you to conduct in-depth formative research, but you can use one primary research or evaluation method and then supplement with other methods that are less costly. For example, conducting qualitative focus groups might not account for all of your audience segments, but you could perform a literature search to complement your qualitative data. Additionally, when circumstances dictate, sometimes substituting one evaluation activity for another may be just as effective (or close to it). During the Domestic Zika Campaign we used “triad” interviews, which only involved three participants, when we did not have the time or the budget to conduct a full suite of focus groups, and this was supplemented with previous survey data on closely related topics.
  2. Invest in market data. Public, non-proprietary market data, such as data from the US Census, PEW, and Gallup, allow you to get to know your audience at no cost. Outside marketing firms may also be willing to share “older” proprietary data that may be from a year or two ago at little or no cost. During the Domestic Zika Campaign, secondary data donated from Annenberg surveys(?) were key to our analysis of each of our target demographics’ media habits and informed the mass media and digital media strategies and plans. The cost is your time in building relationships with like-minded partners and analyzing the data for a specific purpose.
  3. Identify alternative data. When traditional surveying of knowledge, attitudes, and behaviors is not feasible, sometimes you can use alternative data (usually less expensive). During the Domestic Zika Campaign, we did not have sufficient time to get approval for our survey from the Office of Management and Budget (OMB) and field a traditional campaign evaluation survey. Instead, to meet our tight timeline, we acquired data about our audiences’ insecticide purchasing behavior in the stores where our advertisements had been placed, and compared them to similar product purchasing data from stores that did not display our advertisements. Building partnerships with organizations who have data, even from related issues, that can offer insights to you is a great long-term investment in both implementing and evaluating programs—especially when we have a shared commitment to protecting people from diseases.

Monitoring & EvaluationDigital Media in an Emergency. During a public health emergency or disease outbreak, even a small number of strategically placed, paid digital media spots can deliver messages to those who need them most. This type of message can often be placed within 24 – 48 hours. During the Zika response, CDC developed and executed behavioral intent studies using data collected by Google Health and Nielsen to study the effect of media exposure on audiences’ intent to take action to protect themselves from Zika. • We monitored exposure to digital campaign banners on the Google Display Network and compared those exposures to an increase in internet search for specific Zika-related terms. • We employed channel-targeted messaging, which helped to amplify CDC’s weekly Zika theme content on Facebook to reach audiences beyond the people who were already following the CDC page. This cost-efficient strategy extended the reach of posts to tens of thousands more people within the specific geographic areas.

  1. Take advantage of social media analytics. Social media platforms like Facebook, Twitter, Instagram, and Google AdWords allow you to target specific geographic areas and have built-in analytics tools that the user has access to at no additional cost. The Domestic Zika Campaign used data analytics to look at the performance of specific advertisements and the corresponding click-through rate to Zika-related campaign websites. Using social media platforms as a primary channel for the campaign allowed for more precise audience targeting, rapid message modifications, and real-time metrics. Using the data, we developed tailored advertisements that engaged key audiences and encouraged them to take preventive actions. For example, one of our treatments, the “carousel advertisement format” on Facebook, had the highest engagement with our target audience and provided a platform to communicate in-depth information about actions people could take to prevent Zika infection. Most organizations have access to someone who specializes in web analytics who can offer their insight.
  2. Conduct A/B testing. A/B testing is a way to compare two versions of something to figure out which performs better. A/B testing is used to assess different options of campaign messages or creative concepts in real time and measures which one people actually use more among different channels, such as Facebook and Twitter. The Domestic Zika Campaign tested messages and materials on a number of social and digital platforms to determine which channels our audience preferred. For example, we conducted an A/B test of an existing “Cover Your Body and Use Repellent” advertisement against two new advertisements that presented the “Cover” and “Repellent” content as two separate messages. We conducted a qualitative analysis of user comments on the advertisements and found that users had a negative reaction to the “Cover” action step given the high temperatures in areas with risk of Zika.
  3. Refresh your materials. Build in regular measurements to track and observe public response and evaluate public complacency towards your campaign to avoid a decrease in behavioral change outcomes. This can occur for two reasons: 1. Message fatigue, when the attention of your target audience is reduced because they have had repeated exposures to the campaign messages; or 2. Risk fatigue, when your audience no longer receives or responds to messages about the health threat.  You can refresh and adjust your campaign messages without creating new messages from scratch. During the second phase of the Domestic Zika Campaign we revised materials that were targeted towards men by adding images of males with their pregnant partners because we were informed by both women and men that they had become complacent about behaviors men could perform to protect both themselves and their partners from Zika virus infection and transmission.

General Rules of Thumb

  1. Do not reinvent the wheel. Know what is available in your organization.  Do you have existing contracts in place to purchase things quickly.  If you have to get permissions to do research, do you have processes in place to navigate them efficiently? As a federal agency, anytime we want to ask more than 9 people a question, we have to get approval from the Office of Management and Budget, which typically takes many months. Knowing this, CDC set up a process called the Health Message Testing System, which is generic request set up in advance with OMB that programs can use to quickly get permission to test a specific message with a specific audience. These approvals can be obtained in days instead of months.
  2. Track current events. Scan and track prominent news and social media. Be aware of current events and issues that arise over the course of your campaign. The news media will cover what is timely, and you can take advantage of this coverage to enhance your campaign efforts. During the initial phase of the Domestic Zika Campaign, the proposed use of the chemical pesticide Naled in Puerto Rico created a controversy for public health and government officials on the island. Tracking the controversy allowed us to address this issue by adding a media relations effort to the campaign and provided more opportunities to disseminate the most effective prevention messages.
  3. Partner with influential bloggers. Influential bloggers can help enhance and further disseminate your campaign messages, increasing the reach to and saturation of your target audience. One of the main goals of the Domestic Zika Campaign was to amplify CDC’s Zika prevention messages. We worked with a well-known television news celebrity who was pregnant and chose not to attend the summer Olympics in Rio de Janeiro, Brazil. We pitched the story to mom and parenting bloggers and packaged it with CDC-branded messaging and the opportunity for an interview with a CDC subject matter expert. The cost of working with a blogger can vary, and you need to vet them carefully, but there can be great benefits by partnering with someone who is a natural fit for your cause and/or message content AND who is already reaching your target audience.
  4. Welcome donated media. Opportunities may arise for you to take advantage of “value-added” or donated media, which can help extend your communication efforts and increase the number of measurement points to evaluate. If you purchase a large number of services, the outside vendor might be willing to add additional advertising or other activities so the campaign will not incur any additional costs. For instance, we acquired donated time for the public service announcements developed by the Domestic Zika Campaign to run in movie theaters in Puerto Rico.

Do you have any other suggestions to improve the quality and timeliness of health marketing and communication campaigns on a budget? Please leave a comment below.

Fred Fridinger is a Senior Health Communications Specialist in the Office of the Associate Director for Communication (OADC). During his 22- year career at CDC, he has worked on various campaigns and communication efforts, including those addressing moderate physical activity and healthy eating, genetics, chronic fatigue syndrome, and Zika prevention. In his current position, he oversees the market research function for OADC, which involves the Porter Novelli Styles and Nielsen Scarborough syndicated data bases.

The Communication Research and Evaluation blog series highlights innovative research and evaluation methods used at CDC to improve behavior change campaigns.

Shouting in the Dark: Emergency Communication in USVI After Irma and Maria

Nykole Tyson, Director of Public Relations for the US Virgin Islands Department of Health, speaking into a radio microphone.

Communication experts often say, “When you’re communicating during an emergency, always think about what you’d say to your mom. What information would she need the most? How would you explain it to her? What would you need to know for sure before you told her? And just how far would you go to reach her?”

When Hurricanes Irma and Maria hit the U.S. Virgin Islands (USVI) in September 2017, this wasn’t just advice for Nykole Tyson. Nykole is the USVI Department of Health’s (DOH’s) Director of Public Relations. She serves as the DOH spokesperson and emergency communicator. Like all of USVI’s responders and government officials, she is a survivor who was impacted by the storms. Nykole’s home had water and roof damage and she was without water or power for four months. “I caught rain water in barrels and used solar lights sent to me by friends living stateside,” Nykole said. She lived on a cot in her office in the DOH for several weeks between and after both storms. .

The storms destroyed most of the territory’s communication infrastructure, making both personal and mass communication nearly impossible. Nykole was unable to reach her own family for four days after the second hurricane. However, within hours of both storms, she was on the radio talking to her community about how to stay safe, find shelter, and stay strong. Nykole wasn’t just talking to the public, she was talking to her neighbors, her community, her family, and even her mom.

Hurricane Irma

Just hours before Hurricane Irma hit USVI, Nykole was a spokesperson on local radio stations and distributed press releases, public service announcements (PSAs), and social media messages with critical information about how to prepare for the storm. When the storm hit on September 6, electricity, cell, and Internet access was cut off across most of the territory. People sought resources, shelter, and safety, and many struggled to locate friends and loved ones. Virgin Islanders needed to know how to stay safe around downed power lines, debris, mold, and floodwaters.  There was only one working radio station after the storm and Nykole immediately went on the air to give safety tips and updates about available services. She also realized that some people were still able to access Facebook, and the social network became one of the primary means of communication throughout the response. The USVI DOH Facebook posts from September provide a glimpse into how events unfolded and demonstrate the DOH’s commitment to responding to the public’s concerns.

Hurricane Maria

Just 12 days after Irma, USVI was preparing for another major hurricane—Maria. Only this time there were limited ways to alert the public and provide health and safety information. Virgin Islanders, Nykole included, needed to find shelter or prepare their homes, many of which were already damaged, for the impact of another hurricane. Nykole did a PSA on the local radio station from her own home as she was securing her furniture and checking her emergency supplies. “We will get through this,” she repeated over the radio. Unbeknownst to the listeners, Nykole’s family had lost phone service after Irma. She had been unable to reach them so she was driving to her mom’s house to give her family the same safety information she was sharing on the air.

When the storm hit, Nykole and about one hundred other DOH staff took care of special needs patients sheltered in the DOH building. As the wind battered and shook the concrete building, they thought of their communities, homes, and families on the islands. “We were all scared,” she recalls. As soon as the clouds cleared, Nykole was back on the radio, “We survived two category fives. We lost property but we still have our lives. All is not lost. It is time for us to rebuild.”

Resourcefulness and Resilience

USVI DOH staff had to be creative and resourceful after the storms because the typical means of communication were down. The best ways to share information immediately after the storms was through paper flyers, radio, and in-person outreach. CDC and the U.S. Postal Service assisted with printing and distributing a flyer on key health tips to every mailbox on all four islands. CDC health communicators deployed to USVI to support outreach efforts started conversations the islands at churches, stores, disaster recovery centers, radio stations, and schools.

When asked about lessons learned, Nykole reflected, “Do not underestimate the power of radio.” She is still making radio appearances to engage the community, repeat the key messages, answer questions, and encourage community members. While she is running errands, people stop to thank her and comment on her energy. “There were so many times I wanted to cry when I was on the radio, but the listeners didn’t know that,” she says. People tell her how she kept them calm during the worst of the storms, and, hearing her now, still on the radio, lets them know that their government officials are still working hard for them.

Nykole’s experience shows how a talented spokesperson who is also a survivor can be the best voice to engage and reassure a community after a disaster. All responses could benefit from people who care for and communication with the public as if they are family.

Day Zero: The impact of Cape Town’s water shortage on public health

0000-0002-8715-2896 A story that’s been making the rounds recently is the impending water shortage in Cape Town. Multiple years of droughts have resulted in lower and lower water levels in the reservoirs that supply the

Did a late night TV host just change the US debate about universal health care and medical research?

0000-0002-8715-2896“I have a story to tell about something that happened to our family last week.” With those words, Jimmy Kimmel opened his show. Using a combination of vulnerability and humour, he told us about the

Looking Back: 5 Big Lessons from 2016

Looking through the rearview mirror while driving in the planes

Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response
Dr. Stephen Redd, Director, Office of Public Health Preparedness and Response

CDC is always there – before, during, and after emergencies – and 2016 was no exception. Through it all, we’ve brought you the best and latest science-based information on being prepared and staying safe. Here’s a look back at 5 big lessons from a very eventful year. Follow the links to discover the full stories!

1. Expect the unexpected

Emergencies can devastate a single area, as we saw with Hurricane Matthew, or span the globe, like Zika virus. This year has shown us, once again, that we can’t predict the next disaster.

Zika virus was one of the top public health stories of 2016, and will continue to make headlines in 2017. CDC has worked hard since the start of the outbreak to make sure that people know how Zika is spread and how to protect themselves and their neighbors from the virus, including how to control mosquitos inside and outside the home.

This year, our Strategic National Stockpile was called on to locate and purchase the products to assemble ~25,000 Zika Prevention Kits for pregnant women in the U.S. territories. CDC also issued 180 Zika virus import permits so scientists could conduct research to develop better diagnostic tests, vaccine, and medicines. In any developing crisis, our mission is always to “conduct critical science to inform and communicate health information that protects our nation” against public health threats.

2. A health threat anywhere is a threat everywhereAbout 2/3 of the world remains unprepared to handle a public health emergency.

Diseases like SARS and Ebola – and now Zika – compel us to focus on stopping outbreaks early and close to the source. As part of the Global Health Security Agenda, teams of international experts travel to countries, including the U.S., to report on how well their public health systems are working to prevent, detect, and respond to outbreaks. This assessment process is called the Joint External Evaluation.

In 2016, we worked at home and around the world to use the law to prepare for global health emergencies, train leaders from 25 countries in public health emergency management, and protect the health of those affected by humanitarian crises.

3. Kids and communities matter

Fred in bathtub

There’s a saying in emergency management that goes something like, “emergencies begin and end locally.” Truer words were never spoken. The minutes, hours, and days immediately following a disaster are the most critical for saving lives, and local communities are our first responders. Every community needs to be resilient and prepared to handle the unexpected.

Prepared communities look like the Georgia Department of Public Health, which conducted a statewide exercise to practice their response to a bioterrorist attack of plague, and New York City, which used lessons learned from West Nile virus to prepare for Zika.

Children are a particularly vulnerable part of our communities, and they have different needs than adults. Children need to be included and involved in planning and preparing for emergencies.

Fred the Preparedness Dog sets a great example by visiting schools across Kansas to teach kids to get a kit, make a plan, and be informed. Parents should also take steps to prepare themselves and their child in case they get separated during or after an emergency.

4. Words save lives

7 Things to Consider When Communicating About Health

In an emergency, the right message at the right time from the right person can save lives. When a crisis hits, communicators need to quickly and clearly inform people about health and safety threats. Communication is especially critical when disaster strikes suddenly and people need to take action right away, as in a flood or hurricane, or when we may not yet have all the answers, as happened with Zika virus.

To make sure people know what to do to protect their health, our trained communicators learn how to put themselves in others’ shoes: Who are the people receiving the message, what do they need to know, and how do they get information? We apply the principles of Crisis and Emergency Risk Communication in every emergency response.

5. Preparedness starts with you

brain

Get a flu shotWash your handsMake a kit. Be careful in winter weather. Prepare for your holidays. Be aware of natural disasters or circulating illnesses that may affect you or those you care about.

There are many ways to prepare, and in 2016 we provided the latest science and information to empower every one of us to take action. Whether we talked about how to clean mold from a flooded home, how to wash your hands the right way, or how to use your brain in emergencies, our timely tips and advice put the power of preparedness in your hands. What you do with it is up to you. Our hope is that you’ll resolve to be better prepared in 2017.