Tackling Rumors and Understanding & Strengthening Trust (TRUST) in Public Health

Priority 1: Build critical communication capacities

Checklist to build trust, improve public health communication, and anticipate misinformation during public health emergencies

Summary
❏ Activity 1: Build and maintain a PHEPR communication workforce that is well-prepared and reflective of the community it serves
❏ Task 1.1: Identify and characterize existing PHEPR communication workforce assets
❏ Task 1.2: Establish and pursue avenues to remedy workforce gaps
❏ Task 1.3: Recognize and address threats to building and maintaining a PHEPR communication workforce
❏ Activity 2: Ensure that existing budgetary, operations, and financing approaches for PHEPR communication activities reflect prospective needs during an emergency
❏ Task 2.1: Understand current PHEPR communication funding
❏ Task 2.2: Curate alternative resources that may be deployed before or during a public health emergency
❏ Task 2.3: Prepare administrative strategies in anticipation of just-in-time emergency disbursements
❏ Task 2.4: Streamline bureaucratic and administrative processes that hinder responding in “feast-or-famine” financing conditions
❏ Activity 3: Know your audience and their history with public health
❏ Task 3.1: Discern audience characteristics
❏ Task 3.2: Understand intended audience’s history with public health and related institutions

Effectively communicating and maintaining trust with the public is critical, especially when implementing public health emergency preparedness and response (PHEPR) activities and addressing misinformation and disinformation that can reduce trust. Health departments’ abilities and capacities to effectively reach members of the public must be built and sustained over time. These efforts require a workforce that reflects the community being served, accompanied by strong communication skills, expertise, and experience, as well as appropriate funding and operational mechanisms to maximize resources. Furthermore, PHEPR communication efforts require a deep understanding of the community audience, including their needs and the complex factors that impact their trust in public health.¹

Activity 1: Build and maintain a PHEPR communication workforce that is well-prepared and reflective of the community it serves

Health departments must develop an appropriate PHEPR communication workforce and ensure they are prepared to establish trust, meet the community’s needs, and effectively respond during an escalating public health issue or a public health emergency (PHE).^1-4 The following tasks outline how local and state health departments can build, maintain, and protect that capacity.

Task 1.1: Identify and characterize existing PHEPR communication workforce assets

Health departments should identify their employees who would engage in PHEPR communication activities, especially those in leadership positions, and create a summary of the group’s relevant experience, expertise, and skills. Examples of such competencies include:^1,5

Lived experiences, such as growing up in communities that mirror those of intended audiences, to better spread relevant information or address misinformation.
Experience in public health-related risk communication activities, particularly past PHEPR communication activities or work with intended audiences.
Subject matter expertise in essential areas, such as formal training in social sciences and/or risk communication science, and familiarity with epidemiological principles.
Specialty skills for risk communication (eg, experience running social media for similar organizations or video production).
Foreign and accessible language skills (eg, multilingual with native speaker-level fluency or experience creating accessible content such as screen reader-compliant materials)
Community ties with relevant stakeholders (eg, trusted messengers and leaders in key audience communities, organizations, and businesses or other organizations that may be important partners).

The above list of workforce characteristics may not be fully applicable or comprehensive for every organization’s PHEPR communication needs and should be revised accordingly. Health departments also should consider that all staff members, not only the PHEPR communication team, play a part in communication activities, so leadership should assess the current and desired characteristics and competencies of the larger workforce.¹

Task 1.2: Establish and pursue avenues to remedy workforce gaps

If there are gaps in PHEPR workforce competencies and characteristics, consider the following remedies, depending on resources and context.¹

Table 1. Potential remedies to fill workforce gaps in PHEPR communication competencies

Needs	Remedy	Requires	Timing
Lived experience Language skills Community ties	Formal partnership(s) with secondary messengers (eg, community-based organizations [CBOs]) to leverage community ties, lived experience, or relevant competencies and skillsets	Completing activities and tasks associated with Priority 3	Initiate and sustain partnership prior to PHE
Specialty skills Subject matter expertise	Develop or use existing training materials^6-10 or curricula to better empower existing staff and new hires with necessary skills	Access to training materials or curricula Staff member bandwidth to complete training	Create access prior to PHE; utilize before or during PHE
Lived experience Communication experience Subject matter expertise Specialty skills Language skills Community ties	Recruit additional staff from within the health department to fill expertise, experience, or skill gaps on the PHEPR communication team	Sufficient funding Bandwidth within existing PHEPR staff to train new recruit(s) Institutional and individual employee bandwidth to allow for an increase or shifting of duties for internal PHEPR team recruits	Prior to or during PHE
Lived experience Communication experience Subject matter expertise Specialty skills Language skills Community ties	Hire new personnel from outside the department with desired characteristics or competencies	Sufficient funding Bandwidth within existing PHEPR staff to train new personnel Competitive hiring incentives in job market	Prior to or during PHE
Communication experience Subject matter expertise Specialty skills Language skills	Partner with organizations (eg, public relations firms, academia) that can provide technical assistance or complete tasks that require a specialized skillset, such as identifying and deploying interventions against misinformation on social media platforms	Availability and willingness of appropriate partners Administrative capacity and relevant permissions to engage in contracts, memorandums of understanding, or similar agreements necessary for partnerships with third party organizations Sufficient funding, if needed Bandwidth within existing PHEPR staff to liaise with outside partners	Create administrative pathways prior to PHE; initiate partnerships before or during PHE

Task 1.3: Recognize and address threats to building and maintaining a PHEPR communication workforce

Building a PHEPR communication workforce that is ready and reflective of the community is not enough; that workforce must be maintained to preserve institutional memory and overall capacity. Turnover is an ongoing threat to the public health workforce because of various issues, including lack of competitive pay, stress or burnout, and harassment and violence against public health workers.^11-13 Consider ways to address potential threats and retain the workforce,¹ such as:

Implementing a harassment mitigation system to support staff and divert harassing messages.
Revising compensation and benefits packages to increase job market competitiveness and reduce attrition.
Limiting burnout from compassion fatigue¹⁴ and exposure to harassment by moving employees on and off PHEPR communication duties.
Providing resources and using strategies to reduce workforce burnout, such as ensuring employees have and use enough paid time off, quickly addressing staffing shortages, and reducing the workload of PHEPR communication team members.
Offering opportunities for advancement, particularly for staff members who have unique characteristics and competencies relevant to PHEPR communication.
Improving appreciation of and empathy for the public health workforce by strengthening community ties and investing in community needs by implementing activities and tasks described in Priority 2.
Increasing public and policymaker awareness of the health department’s value to demonstrate institutional pride in the public health workforce and their work.

Activity 2: Ensure that existing budgetary, operations, and financing approaches for PHEPR communication activities reflect prospective needs during an emergency

The success of PHEPR outreach activities relies heavily on available financial resources. Yet responders often lack sustainable, sufficient funding.^1-3,15-17 Prior to strengthening other public health communication capacities, health departments must assess and address administrative readiness to respond.

Task 2.1: Understand current PHEPR communication funding

A comprehensive understanding of fiscal support for PHEPR communication and community engagement activities is valuable. Public health officials should first identify funding specifically for PHEPR communications and additional funding streams that may be accessed for communication efforts in the event of a health emergency. Second, they should identify potential gaps between existing funding and the resources needed to engage in building trust and countering misinformation during an emergency. These gaps may be assessed based on how well funding has met needs in past emergencies and how operational costs might vary based on different potential emergency situations. Funding assessments are most useful when completed and updated regularly, with a multiyear view of future funding support and gaps.¹

Task 2.2: Curate alternative resources that may be deployed before or during a public health emergency

If health departments detect a gap between existing funding and the resources needed to conduct PHEPR communication activities, other approaches may be needed. See Table 2 for a list of potential remedies^1,18 and their associated implementation needs.

Table 2. Potential remedies to fill anticipated gaps in actual and expected PHE resources

Remedy	Requires	Timing
Pool resources with the nonemergency risk communication budget or other programmatic budgets	Sufficient flexibility in funding for involved programs Overlap in mandates and activities between programs Ability to liaise and coordinate shared activities for involved programs	Before or during PHE
Explore emergency funding mechanisms at the local, state, and federal levels that may be leveraged and deployed	Staff time to investigate funding options Availability or knowledge of funding mechanisms	Before or during PHE
Build awareness of health department value among policymakers and advocate for increased funding access	Staff time to initiate and sustain relations with policymakers Availability and willingness of policymakers to engage with health department liaisons	Before or during PHE
Partner with organizations (eg, PR firms, academia, temp agencies, Medical Reserve Corps, National Guard) that may be able to provide cost-effective resources, such as technical assistance or temporary additional workforce	Availability and willingness of appropriate partners Administrative capacity and relevant permissions to engage in contracts, memorandums of understanding, or similar agreements necessary for partnerships with third-party organizations Sufficient funding, if needed Bandwidth within existing PHEPR staff to liaise with outside partners	Create administrative pathways prior to PHE; initiate partnerships before or during PHE
Partner with secondary messengers (eg, CBOs) that may be able to provide cost-effective assistance with messaging, building trust, or dispelling misinformation	Completing activities and tasks associated with Priority 3	Initiate and sustain partnership prior to PHE

Task 2.3: Prepare administrative strategies in anticipation of just-in-time emergency disbursements

During high-profile PHEs, health departments may receive large disbursements of emergency funding with short windows to process, plan for, and spend those funds.^1,18 Therefore, creating strategies in anticipation of these just-in-time disbursements will help to reduce spending delays, maximize the cost-effectiveness of response spending, and improve the sustainability of any capacity building or new workforce hires that occur during emergency responses. For example, prior to an emergency, PHEPR communication teams may present health department leadership with a list of ranked funding priorities for emergency response communication activities. Then, as emergency response activities wind down, PHEPR communication teams may develop and present proposals to health department leadership on how to retain new hires or sustain increased response capacity related to health department communication activities after emergency funds expire.

Task 2.4: Streamline bureaucratic and administrative processes that hinder responding in “feast-or-famine” financing conditions

Health departments are required to coordinate activities with numerous partners and stakeholders during emergency response activities. This engagement brings with it increased bureaucratic procedures, including establishing contracts and memorandums of understanding, gaining approvals from leadership, verifying personnel credentials, and more. Prior to an emergency, health departments should identify these potential partners and stakeholders and manage as many administrative processes as possible. Additionally, health department leadership should work with relevant human resource and finance staff to streamline those processes (eg, purchasing procedures). Finally, any operational considerations that may cause delays in accessing resources during an emergency response, such as time for training or building partnerships, should be similarly addressed prior to the event, if possible.^1,18

Activity 3: Know your audience and their history with public health

Expertise is not enough; trust in public health and the effectiveness of messaging and other communication efforts may be greatly mediated by the characteristics of the intended audience and their past interactions with public health and related institutions.^1,19-26Gathering information about your community and their trust levels in public health will help lay the groundwork for later trust-building and messaging work with intended audiences.

Task 3.1: Discern audience characteristics

The characteristics, values, and needs of audiences greatly influence how they interpret public health messages and how communicators develop important relationships with them.²⁷ Audience characteristics include demographic characteristics (eg, age, languages spoken and read, education and reading levels, income level, geographical location), as well as religious beliefs, cultural values, attitudes, and practices.²⁸

Health departments should leverage existing official data resources—such as Mobilizing for Action through Planning and Partnerships (MAPP) reports, other community health needs assessments,²⁹ and/or US Census data³⁰—to better understand their community’s characteristics. Additionally, health departments should consider engaging in informal or formal qualitative or quantitative data collection to gain a clearer and more nuanced view of their intended audiences. Public health communicators can leverage any existing relationships the current public health workforce has with intended audiences (see Priority 2 )as well as relationships between partners and audiences (see Priority 3). Information from these sources and any additional data collection may be utilized to inform message creation efforts, which is discussed in Priority 5. Public health communicators should also consider if any topics require focused messaging for new populations beyond those identified in the past.

Task 3.2: Understand intended audience’s history with public health and related institutions

Historical context can significantly influence a community’s perceptions, attitudes, and trust toward public health initiatives and government agencies. Internally and publicly acknowledging and addressing ongoing and historical experiences²⁵ that have reduced trust is crucial for building trust.^1,26 Public health communicators should consider how the community may have encountered past instances of discrimination, mistreatment, or lack of access to public health and medical services and ensure that communication efforts are sensitive to these experiences. Leaders also should evaluate current levels of trust between public health organizations and the community³¹ and conduct activities to improve trust and rebuild rapport as needed.¹

Notably, some communities may hold negative attitudes toward public health authorities and activities. Lack of adherence to public health measures and poor effectiveness of public health messaging within these communities may be worsened by perceived or real disrespect, ostracization, or disregard by those promoting public health interventions. In some cases, these populations may amplify themes of distrust, knowingly or unknowingly spread misinformation and disinformation, or discourage other community members from engaging in health-seeking behavior. It is important to not assume failure in communicating with these populations, as doing so and ceasing trust building efforts may actually decrease the likelihood of future successful communication efforts.¹

Specific recommendations on trust-building and community engagement activities are provided in Priority 2, drawing from the awareness and capacities established in this section.