Public Health Professionals

Whether operating at the local, state or federal level, public health professionals are faced with a number of constraints and challenges that can hinder communication efforts. Some of these might be obvious in an era of government budget cuts: Decreased budgets or lack of staffing resources limit the ability of many programs to employ staff whose main purpose is to oversee communication efforts. Other challenges are more subtle. One obstacle faced by disease surveillance staff involves the elusive nature of trust among populations served by public health workers. Trust and credibility are essential factors in communication about risk; without trust between audiences and officials, no amount of encouragement to heed official announcements likely will be very successful [3]. Trust, in fact, is one of five key areas for consideration that are highlighted in the WHO’s guidelines for outbreak communication (see Table 21.1). However, several trends in public perceptions currently pose major hurdles, as confidence in government, traditional social institutions, and industry has eroded in the United States and elsewhere in recent decades, because of factors like conflicting information and political infighting [4,5].

So how might trust be restored? We know that perceptions of empathy and caring, competence, commitment, and accountability on the part of message sources contribute to trust [6,7]. Note that sheer expertise is only part of this list of factors. Having access to credible information does not guarantee optimal trust among lay laypeople. Because many people have viewed public health institutions negatively at various points in recent history [8], it is especially important for such organizations to defy negative stereotypes by providing transparency and balanced information in a consistent and timely way.

Solidifying and building trust can be especially important before an outbreak unfolds, or as it is unfolding. Quinn et al. [9] have argued that pre-existing trust (or mistrust) in institutions may be especially important during unprecedented or unfamiliar events. For example, inconsistent messages from government officials and faulty information in the past contributed to widespread mistrust during the 2001 anthrax attack. As Reynolds and Seeger succinctly note, “Organizations that fail to develop credible, trusting relationships prior to a crisis will have an exceptionally difficult time doing so after a [disease outbreak] occurs” [3].

A related challenge, inherent to the field of infectious disease surveillance, is the difficulty posed by uncertainty. In any disease epidemic, there is some degree of uncertainty. At the beginning of an outbreak, we may not know exactly which populations are most at risk, the potential severity of the epidemic, or the odds of mutation to a more virulent strain, for example. It is important to be explicit about the sources and dimensions of such uncertainty rather than to hide such information. Consider the example in which a reporter poses the question of how many people are infected with an emerging illness. One might be tempted to answer, “We cannot answer that question.” But think about the implications of that response compared to this one : “We are not certain at this point because we are awaiting test results to confirm some probable cases. We expect to have better estimates of the number of people who have been infected in a few days.” When you don’t have the answer, try to describe the process (e.g., the laboratory tests take up to 2 days because …). Being explicit about the reasons for any uncertainty and when such uncertainty may be resolved can help to bolster confidence in an agency or spokesperson’s expertise and authority.

Another aspect of the life of public health workers relevant to our discussion is the dynamic (rather than static) nature of the information available during an outbreak. Recommendations have a tendency to evolve. Failure of public health professionals to prepare reporters or laypeople for such changes can result in loss of credibility as advice or estimates change midstream. In contrast, transparency about why a recommendation is changing (e.g., new information has come to light that suggests case numbers are higher than expected because some states submitted revised reports) can help prevent the perception that public health officials made a mistake or are simply indecisive.

In the last few years, the proliferation of digital and social media has made the timeliness of communication more important than ever before. Consider the case of a meningococcal outbreak in a school in the United Kingdom in 2010 [10]. On a Friday evening, two cases of the disease were identified. The following Monday, letters were issued to all students and parents. In the meantime, over the weekend, most parents had already found out about the outbreak through phone conversations, online instant messaging, or text messaging. Those who attempted to contact the school said they did not receive much information. Many students did not want to attend school on Monday for fear of catching the disease [10]. Results of qualitative research suggest that rumors circulating over the weekend caused confusion and anxiety that may have been alleviated through earlier communication by health officials or school administrators. For example, a message could have been sent to all parents via email or automated telephone message. As outlined in Box 21.1, early communication is crucial to alleviating unwarranted fears about disease outbreaks. Much as we have seen in other arenas, rumors thrive when a trickle of sensational news is followed by a vacuum of official response [11,12]. Chapter 3 provides details on surveillance systems at national, state, and local levels, and Chapter 15 describes approaches used to conduct infectious surveillance globally.

Mass Media Organizations and Professionals

Public health officials are routinely engaged with media professionals, but there has been no shortage in recent years of critique, commentary, and complaint about media coverage of health [13–15]. Media coverage of the controversy regarding the measles, mumps, rubella (MMR) vaccine, sparked by a study that has now been retracted and deemed fraudulent [13,16], discouraged parents from obtaining the vaccine for their children and contributed to a documented decline in vaccine uptake [13].

Some public health organizations nonetheless have actively embraced the opportunity to work with media outlets. The National Public Health Information Coalition, for example, serves as a support network for public information specialists in health agencies and annually recognizes excellence in interactions between public health professionals and media organizations. In 2011, the North Dakota Department of Health was awarded for its breaking news release regarding the first measles case in that state since 1987. The Virgin Islands Department of Health received recognition for its Dengue Fever outbreak campaign [17].

Defining “mass media” increasingly offers a challenge, however; we are no longer in an era when media channels are limited to television, radio, film, and printed material. The emergence of digital technology has changed that, offering an array of content platforms and devices. We now have information delivered to our mobile phones and streamed to our Internet-capable televisions. Moreover, the typical content contributor also has evolved; instead of reading well-researched investigative work by a health reporter at a large metropolitan newspaper, many people now encounter the work of freelance bloggers and other members of the public who post their thoughts. For our purposes, then, we can consider mass media to be those information technologies and forums that draw large and heterogeneous groups of people. Despite these changes, news media organizations and journalism professionals still need to be central to our discussion. Theoretically, such media outlets offer an efficient way of contacting mass audiences with crucial warnings and recommendations. People still frequently name mass media as a prevalent source of information about health and science [18,19].

However, there are challenges to accurate reporting of infectious disease information. Schwitzer [14] has assessed television news coverage of health and noted a number of tendencies that he found troubling, including a disturbing lack of data to back up sensational claims, use of hyperbole, reliance on single sources for stories, and brevity in stories that deserve a longer format. He notes a scarcity of full-time health journalists working at television news departments and points out the lack of primary investigation by local journalists (as opposed to simply repackaging information from wire services or press releases). While television news is often cited as a particularly striking example, critics have raised similar complaints about news organizations across the array of mass media. For example, data from the Pew Research Center suggests that because of a shortage of resources in the last several years, fewer newspapers are tailoring national stories to their local communities [20].

Health and science news professionals are constrained by at least four primary factors: source availability, the need to portray a story’s newsworthiness, the difficulty of communicating science to the public, and the need to demonstrate a balance in perspectives with particular incentive to present conflicting or opposing views [21]. All of these factors are useful to consider in preparing to work with journalists. Designating official media contacts in public health agencies and making them as accessible as possible, for example, can address the issue of source availability, making the lives of journalists easier and also helping to ensure reporting of key messages that are consistent with health-agency goals. Sometimes this contact will not be an infectious disease subject matter expert, but a designated public information officer. (See Box 21.2 for a summary of practical guidance for working with media professionals.)