Risky Business: Lessons about Clarity from Crisis and Emergency Risk Communication

Cynthia Baur, Ph.D.

Cynthia Baur, Ph.D.

Cynthia Baur, Ph.D., Centers for Disease Control and Prevention (CDC)

Emergency risk communication is now an everyday part of life for many public health officials. However, scientists, providers, and politicians need to recognize that people not understanding their messages is a risk factor in and of itself. We need to remind our colleagues and managers that they need to make their messaging intuitive, understandable, and relative to their target population.

Emergency events can occur at any moment. Routine issues can also cause emergency events, such as the annual flu outbreak. Other issues, like the Ebola outbreak in Guinea do not seem to pose a risk to other regions, but the health workers returning to their home countries triggered emergency events. Saying that “close contact with bodily fluids puts you at high risk” is extremely difficult to understand and is not actionable for many people. “Bodily fluids” is not an intuitive term.

Crisis and Emergency Event Communication (CERC) training at http://emergency.cdc.gov/cerc/ can help you learn how to communicate effectively during emergencies. The Clear Communication Index is another great tool to identify the most intuitive and direct way to provide a message.

Baur’s main message is that communicating about risk during a crisis or emergency event requires extra attention to clarity.  Quantifying risk is very difficult and most people to do not identify with the current low, medium or high risk assessments. Zero risk is not possible and spokespeople may not always be able to give you the exact benefits, consequences, and tradeoffs because they are dealing with gradations of risk.

Specialized communication was initially created for targeted medical professionals who would be managing the Ebola outbreak or dealing with patients. However, as time progressed and diagnoses started to occur in the U.S., the messaging needed to expand to mass communication for multiple audiences.

Types of risk statements:

  • Threats or harm to an individual or group of people
  • Outcome of a threat or harm
  • Factors that make a threat or harm more likely (risk factors)
  • Likelihood that a threat or harm will happen

Spokespeople act as if everyone shares the same understanding of risk, but to be health literate we need to understand and tailor messaging to the understanding of risk possessed by the audience. The key characteristics of Crisis and Emergency Events that affect clarity are uncertainty, nature of risk, and timing.

Best Practices from Healthy People 2020 (healthypeople.gov) on what to include in a public health message:

  • What’s known
  • What’s not known
  • How or why
  • Action steps
  • Empathy
  • Accountability
  • Commitment

A routine risk that can affect a specific area or population is a food borne outbreak. These can become so routine that people think the risk is smaller than it is. It is up to spokespeople to ensure that the public understand the urgency. The CDC’s Flu Vaccine Campaign is an example of public health messaging that forms urgency in the face of routine risk.

An example of a novel risk and the need for clarity can be found in their Ebola: Getting to Zero campaign. Other emergency events include natural disasters where general messaging on preparation is important, but once they happen there needs to be clear and targeted messages for specific populations. However the key messages of who is affected and how they are affected and what they can do can be carried across different types of messaging.

Dr. Baur’s overarching lessons about clarity in crisis and emergency events are:

  • Anticipate and practice before an emergency strikes
  • Pre-test and prepare drafts
  • Assume emotions, and allow them to guide when and how provide information and what level of detail is required
  • Recognize that understanding of risk evolves and people’s initial reaction is not where they stay
  • Include action steps


Linking Research and Practice: Strategies for a More Collaborative Health Literacy Community

Linda Neuhauser, DrPH, MPH

Linda Neuhauser, DrPH, MPH

Linda Neuhauser, DrPH, MPH, UC Berkeley School of Public Health

In this presentation, Dr. Neuhauser discussed how the gap between research and practice impacts the success of health literacy initiatives, and offered some strategies for linking the two, as well as examples of successes in this area.

Dr. Neuhauser began by sharing her early experiences trying to give advice to patients. Nobody listened to her science-based advice because they couldn’t relate to it. Her conclusion was that, while we as healthcare providers have messages to send, people have lives to live, and we have to find a way to connect our messages to their lives.

She told the story of how a vaccination program in the West African nation of Mauritania had failed for 20 years. Dr. Neuhauser was sent as part of a medical research team to figure out why. They toured the country, visited villages, talked to the people. Their process was based in design science theory, which focuses on problem solving rather than theory testing. The team was able to solve many of the problems inherent in the program by learning about how the people actually lived and what was important to them.

Finally only one problem remained, how to keep the vaccines cold in the desert heat. It turned out that the camel drivers had the answer: There was a nationwide network of refrigerators for camel vaccines that could easily be used for storing human vaccines as well. The resulting new vaccination program ultimately reached 85% of the population. Dr. Neuhauser’s take-away: Participatory design is key to health programs, and communication is the glue that holds a program together.

She then surveyed the audience and noted that no one present felt that their organization had a high level of adoption of health literacy practices. Most felt that their organization still had a very low level of adoption. This informal survey was representative, according to Dr. Neuhauser: Only 1% of all health literacy research has been translated into action. It has taken 17 years for 14% of the relevant research to make its way into clinical practice; and it takes even longer for these practices to make an impact on the community.

Dr. Neuhauser proposed a new model that differs from the traditional NIH Model of Research Translation, which relies on research and clinical trials for gathering information. Her newer model has researchers working together with practitioners and communities to co-design and evaluate programs.

Dr. Neuhauser then laid out some strategies for putting the newer research-to-practice model in action:

  1. Set up a research-practice unit in your organization. Such a unit needs researchers that are committed to action as well as practitioners that value evidence. It also needs health literacy and communication experts–and perseverance!
  2. Use participatory design. Focus on solving problems rather than testing theories. Test the design on users. This is an iterative process, one that was used by the developers of the iPhone and tablets. (As few as six (6) members of the relevant user group can help identify major issues that need to be resolved.)
  3. Get involved with policy change in your organization, in your community, and through legislation.

She then went on to give a few examples of successful programs built using this approach, including the California First 5 Kit for New Parents and a wellness program for migrant workers in China. Dr. Neuhauser’s work on these and other programs led her to this conclusion: One of the biggest barriers to health communication is that the audience is not motivated to read the information they get. Involving them in the design process helps bring down this barrier.

In closing, Dr. Neuhauser addressed the perpetual question of how to get buy-in from one’s organization for participatory design. Her advice: Nobody likes to fail. Find a [program] failure in your organization and use it as a reason to try a new approach.
Website: HealthResearchForAction.org


Equity and Health Literacy: Examining the Link, Exploring Solutions

From left to right: Robert Logan, Ph.D, Michael Paasche-Orlow, M.D, Winston F. Wong, M.D., M.S, and Michael Villaire, MSLM (Moderator)

From left to right: Robert Logan, Ph.D, Michael Paasche-Orlow, M.D, Winston F. Wong, M.D., M.S, and Michael Villaire, MSLM (Moderator)

Michael Villaire, MSLM (Moderator), Institute for Healthcare Advancement; Michael Paasche-Orlow, M.D., Boston University; Robert Logan, Ph.D, National Library of Medicine; Winston F. Wong, M.D., M.S,, Kaiser Permanente

Each renowned in their fields, Dr. Michael Paasche-Orlow, Dr. Robert Logan and Dr. Winston F. Wong discussed their perspectives of how health disparities, social determinants of health, and social disparities influence health literacy and overall health outcomes of not only individuals, but communities as well. Health equity is a state that we all want to reach. In order to achieve this vision, health literacy, research and policy elements must be incorporated into intervention strategies.

Health literacy plays a role in the burden of disease and can be used as a tool in prevention. The more competent an organization is in health literacy best practices, the better their outcomes will be. However, health literacy strategies need to go beyond “do you understand” to “what is important to you” as an individual or community. This shift allows us to invest in the influencers that have the capacity to result in better outcomes.

Dr. Paasche-Orlow shared some of his research and provided evidence from a study that initially seemed to identify a racial health disparity in patient outcomes, but upon further investigation found the difference to be attributable to a disparity in health literacy. In this instance and in other areas of his work, a clear link between health literacy and health equity could be drawn. Not all the experts agreed on the directionality of this link, but did support the strong connection between health literacy and health equity.

Incorporating health literacy principles can help eliminate health disparities, and improve how we navigate and communicate within our complex healthcare system.  Additional tools can be used to improve access, knowledge and an understanding of health literacy and health equity interventions. The development of an electronic health literacy tool shed was suggested. More research is still needed on health literacy and health equity, but the field is on the right path and further investigation can shed light on this connection and the root causes of health disparities.