8
Communications and Media

Communications and messaging efforts during the response to 2009 H1N1 focused initially on minimizing transmission of the 2009 H1N1 virus, including measures such as hand-washing technique, proper cough etiquette, and staying home when sick. Once the vaccination campaign launched, efforts shifted toward communications about the availability and prioritization of getting vaccinated. This section will focus primarily on the opportunities and challenges associated with communicating during the vaccination campaigns and not the earlier efforts focused on minimizing transmission.

Communication Challenges During the 2009 H1N1 Vaccination Campaign

Communication during the 2009 H1N1 vaccination campaign was extremely challenging. Public health authorities had to develop and convey messages about several topics, including availability, vaccine recommendations and target groups, benefits and risks, and vaccine recalls. They also had to communicate with each other and with several target groups, including healthcare providers, and separately, to members of the public. Additionally, because vaccine administration plans varied across the nation, much time was spent clarifying information to ensure local accuracy. “Accurate communication is probably one of the big struggles from last year,” noted Greg Primuth from Walgreens.

Many participants noted that federal messaging encouraging vaccination during fall 2009 increased public demand while vaccine was in short supply and was profoundly challenging for state and local health officials



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8 Communications and Media Communications and messaging efforts during the response to 2009 H1N1 focused initially on minimizing transmission of the 2009 H1N1 virus, including measures such as hand-washing technique, proper cough etiquette, and staying home when sick. Once the vaccination campaign launched, efforts shifted toward communications about the availability and prioritization of getting vaccinated. This section will focus primarily on the opportunities and challenges associated with communicating dur- ing the vaccination campaigns and not the earlier efforts focused on minimizing transmission. Communication Challenges During the 2009 H1N1 Vaccination Campaign Communication during the 2009 H1N1 vaccination campaign was extremely challenging. Public health authorities had to develop and con- vey messages about several topics, including availability, vaccine rec- ommendations and target groups, benefits and risks, and vaccine recalls. They also had to communicate with each other and with several target groups, including healthcare providers, and separately, to members of the public. Additionally, because vaccine administration plans varied across the nation, much time was spent clarifying information to ensure local accuracy. “Accurate communication is probably one of the big struggles from last year,” noted Greg Primuth from Walgreens. Many participants noted that federal messaging encouraging vaccina- tion during fall 2009 increased public demand while vaccine was in short supply and was profoundly challenging for state and local health officials 73

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74 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN and healthcare providers. As a result, private healthcare providers, healthcare systems, and public health authorities reported that they re- ceived high volumes of calls from anxious patients trying to locate vac- cine for themselves or their family members. The availability of multiple vaccine formulations with varying con- traindications interacted with the use of priority groups to create compli- cated vaccine administration plans, which in turn had to be shared with the public. For example, if only LAIV was available at a given time in a certain location, only some members of target groups could be vacci- nated there. This issue was particularly challenging for pediatricians be- cause of the variations in ages for each formulation; this is discussed in more detail below. With vaccine trickling out, there was a public perception in some ju- risdictions that vaccine was being distributed unequally, even though it was taking place on a pro rata basis. For example, LA County has a population of about 10 million, while other counties, especially in north- ern California, are much smaller and therefore received many fewer doses of vaccine. Some people in the smaller counties thought that LA County was receiving a disproportionately larger share because it re- ceived such a large quantity of vaccine, despite the pro rata distribution scheme used. A similar perception occurred in Alaska because the major- ity of the population is centered around Anchorage. To counteract the perception, public health messaging began using the words, “your fair share” to emphasize that everyone was being treated equally. Participants emphasized the need to be honest and transparent about the situation when vaccine supplies were lower than demand. Communication Among Public Health Authorities Many mechanisms were used to help maintain communications among public health authorities at federal, state, tribal, territorial, and local levels, especially during the initial months when the situation, available information, and guidance were frequently changing. These mechanisms included regular conference calls with officials from the CDC, ASTHO, NACCHO, and the National Public Health Information Coalition. These efforts were intended to disseminate information from the federal level and to share practices at each level, to gather feedback regarding what was happening in the field, and to learn about different

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75 COMMUNICATIONS AND MEDIA stakeholders’ needs. More details about CDC efforts to ensure effective communication among public health entities are available on the CDC website (CDC, 2010c). ASTHO and NACCHO developed resources and tools to help state and local health departments and partner organizations address issues related to pandemic flu response. Listservs were also used to provide an ongoing dialogue in which members could ask questions and discuss suggestions. “It was phenomenal to be able to go to [NACCHO’s] web- site and see best practices and to see what other people are doing and to not reinvent the wheel,” said Georgia’s Blackwell. Communication and coordination among health authorities at the federal, state, and local levels regarding the timing and content of com- munications campaigns for the public was sometimes challenging, noted some workshop participants. Some state and local public health officials expected a national 2009 H1N1 communications campaign from the be- ginning of the response and planned to provide only information particu- lar to their community. “We really thought that we were going to see all of the prevention materials come out of CDC or HHS,” said Greg Wilkinson of Alaska Health and Social Services. “It meant for a lot of shifting of gears real quick at the very beginning, and we kind of missed out on a chance to nationalize a message and really drive it home.” However, as dis- cussed below, developing tailored messages to fit community needs was very important. In addition, there were also concerns that a national communications campaign would only exacerbate difficulties related to low vaccine supply. As a result, although the CDC encouraged vaccina- tion among the priority groups as soon as vaccine became available, it delayed promoting vaccination more aggressively through traditional media campaign strategies until December, when supply was more plen- tiful. However, some workshop participants said that advanced information about the design and contents of the federal vaccination communications campaign would have allowed states to align their own campaigns and improve message consistency. Communicating with Healthcare Providers Many healthcare providers feel overwhelmed by information on a regular basis. This was particularly true during the 2009 H1N1 vaccina- tion campaign with its multiple formulations, priority groups, and often-

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76 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN changing information about upcoming vaccine supply. Local public health authorities appreciated the CDC’s efforts to help them understand what was happening on a national level so that they could, in turn, ex- plain what was going on to their local physicians and other healthcare providers. “Without that informed decision making, it would have made it a lot more difficult for us, and I think that helps in providing that trans- parency,” said Diane Yu, public health officer for Washington’s Thurston and Mason counties. But ensuring healthcare providers got the information they needed was difficult. Delaware reported that most Health Alert Notices did not reach most physicians and that blast faxes were sometimes thrown away by staff before they reached physicians. Zach Moore from the North Carolina Division of Public Health noted, “We never got out of the sin- gle digits with the percentage of providers reached with any given mes- sage.” North Carolina did not have the capability to directly e-mail healthcare providers in the state. Instead, many physicians received in- formation the same way the public did—through the evening news. Box 8-1 shows examples of mechanisms used by public health authorities to communicate with healthcare providers. Many jurisdictions partnered with medical societies and associations to get the messages out to physicians and other healthcare providers— with mixed results. NACCHO’s Herrmann said, “What we learned from our membership was that those who had preexisting relationships with those associations probably did better—at least anecdotally—than those who did not.” Those who did report success credited the societies and associations as being vital in reaching certain populations and their healthcare providers, such as OB/GYNs and pediatricians. BOX 8-1 Examples of Tools Used to Communicate with Healthcare Providers • • Medical and professional societies Faxes • • Conference calls/video conferences E-mails • • Hotlines/call centers Websites • • Hospital seminars Health Alert Notices

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77 COMMUNICATIONS AND MEDIA One successful model for communicating to healthcare providers was suggested by Karen Remley, Virginia’s state health commissioner. The state can communicate with anyone licensed through the Department of Health Professions during a public health emergency, she said. The contact list includes not only physicians and nurses, but also funeral di- rectors and pharmacists and other healthcare providers. The state de- clared a public health emergency in part to activate this capability. Every Friday, a summary of one to two pages went out to about 250,000 practi- tioners, providing an update on the pandemic and vaccinations. Practitio- ners, in turn, often shared this information with their patients, helping to ensure that everyone had the most updated information. Other states, such as Indiana, also have the capability to directly e-mail all physicians in the state. Some other states, including Texas, that did not have the ca- pability at the beginning of the pandemic are updating legislation and regulations to provide the capability. Communicating with the Public Public health authorities developed multifaceted strategies to convey messages to the public. Healthcare providers also developed means to communicate relevant information to their patients. Workshop partici- pants discussed the importance of tailoring messages to intended audi- ences. These topics are all discussed below. Although many communications challenges arose during the 2009 H1N1 response, particularly relating to the vaccination campaign, many participants said the CDC’s 2009 H1N1 communications campaign used good practices that should be continued for future emergency responses. The CDC focused its messages on articulating the CDC’s goals and ac- tions, acknowledging what was known and what was not, and setting the expectation that the information and advice would change as the situation evolved. The CDC campaign also focused on providing frequent updates, using a consistent set of spokespeople, and conducting ongoing research on public understanding and attitudes about 2009 H1N1–related topics so that messages could be revised for greatest effectiveness. Additional de- tails about the CDC’s communications approach are available on the website (CDC, 2010e).

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78 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN Tools and Mechanisms Public health authorities reached out to their communities using nu- merous tools (Box 8-2). Although not a comprehensive review of state and local public health communications campaigns, this section dis- cusses some of the mechanisms used by public health authorities to com- municate with the public, particularly those mechanisms deemed by participants to have been successful. In some public health jurisdictions, live call-in radio and television shows featuring physicians and health educators were an effective vehi- cle for connecting with the public. Besides allaying some fears, it was a good way to educate the public about the risks they could be facing and highlight prevention and vaccination campaigns. In Arkansas, a live call- in television show with medical experts was credited as a turning point for vaccinations of pregnant women because the OB/GYN on the show revealed that six pregnant women were on ventilators due to 2009 H1N1. After the program, increased demand for vaccine was seen among preg- nant women. Many public health authorities, healthcare providers, and other enti- ties used websites to communicate with the public during the vaccination campaign. Katterman’s Pharmacy in Seattle used a Twitter feed on its website to update the public on when vaccine was expected and when it was available. Other healthcare providers posted availability on their website BOX 8-2 Examples of Tools Used to Communicate with the Public • • Cable television stations Movie theater advertisements • • Radio Internet advertisements • • Websites Hotlines and call centers • • Public service announcements Social media: Facebook, in multiple languages MySpace, Twitter • • Media stories and press releases Reverse 9-1-1 calls • • Newspaper inserts Automated school call systems • • Posters Text messaging • • Billboards and bus ads Signs in physicians’ offices

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79 COMMUNICATIONS AND MEDIA to alleviate the workload of their front-desk staff. For example, Kane- shiro’s pediatric office created a traffic-light system on its website that allowed parents to see when vaccine was available based on a child’s age and health status. Call centers, such as the Colorado Health Emergency Line (CoHELP), were used to provide and collect information during the 2009 H1N1 event. CoHELP provided information from state health to the public and assisted the public and healthcare providers who called in to make in- formed decisions about treatment options and self-care. Additionally, the call center spent much time clarifying, refining, and correcting messages received through the media. Greg Bogdan, research director and medical toxicology coordinator with the Rocky Mountain Poison & Drug Center at Denver Health, which runs CoHELP, reported that CoHELP’s biggest chal- lenge was helping residents understand the situation and how it differed from national messages. Others reported that their biggest challenge in running hotlines was keeping everyone on the hotline updated with the most current, accurate information because it frequently changed. “It is really important to have a system and have it established before an event because it does take a lot of time to put it together,” Bogdan noted. Targeting Messages to Audiences Participants pointed out that messages and delivery methods should be targeted for their intended audiences to be effective. For example, Selena Manychildren, public information officer for the Navajo Division of Health, noted the first step of the division’s communications campaign was gathering health representatives together to choose a name for 2009 H1N1 in Navajo. They relied heavily on radio in both Navajo and Eng- lish to reach their community, she said. The African American community was underrepresented in mass vaccination clinics, and the lack of appropriately targeted messaging was noted as one potential contributing factor. Benjamin Rackley, executive director of the Tuskegee Area Health Education Center, Inc., said that faith-based organizations, usually a good partner in spreading messages in the community, were not generally effective this time. “They didn’t believe in this vaccine,” Rackley said. “This is why they didn’t promote it. They weren’t sure it was safe.” This was a clear breakdown in com- munications—the vaccine safety message was not reaching the target

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80 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN audience appropriately. Rackley said his group had success with peer-to- peer educators for high school students and sororities and fraternities for college students, as well as social networks such as Twitter. To reach sen- ior citizens, face-to-face conversations were used to convey the message. Immigrants and refugees were also challenging to reach. Not only are the messages hard to spread—the population may not read or speak English—but the population is continually growing and shifting. Mohamed Sheikh Hassan, executive director for the Afrique Service Center, which serves primarily East African community members in the Seattle area, noted that the refugee population is growing. “In the future,” he stated, “if we don’t change the way we are doing messaging, we may not be [as] lucky as we’ve been.” He also noted a real need for a holistic approach because many in this population have complicating factors such as diabetes, hypertension, HIV, and post-traumatic stress syndrome. Showing up once a year for flu vaccinations, or during an emergency that may or may not affect them, is not the way to reach them. “I think it doesn’t resonate with them,” Hassan said, adding that a year-round ap- proach is needed. In Chicago an ethnic media roundtable was held that included state and local public health officials, clinicians, CDC representatives, and a number of different ethnic-media reporters. Discussions were held about disease, the impact on minorities, immunization coverage, the benefits of vaccine, safety issues, and disparity issues. Chicago Department of Pub- lic Health’s Morita told workshop participants to engage the ethnic me- dia now—make them well informed and better prepared so they can communicate those messages to their communities. Media Relations Participants noted that navigating their relationships with the media was challenging at times and time-consuming. They noted that when done effectively, it involved public health officials being available and responsive to media members, helping reporters understand the science and the details of the vaccination campaign, and building relationships between public health and the media. Maggie Fox, health and science editor at Reuters, noted that one of the primary challenges for news organizations covering 2009 H1N1 was that it was not the flu they had prepared to cover. Like public health offi-

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81 COMMUNICATIONS AND MEDIA cials, she had prepared for H5N1 influenza, including developing a system of reporters, located primarily in Indonesia, who were knowledgeable about H5N1. She had not been working with the reporters based in Mexico, where many of the early cases of H1N1 were found, to educate them on influenza issues and science, so the initial learning curve was steep. Several participants noted that broad news coverage can sometimes be used to convey important information to the public. Alaska’s Wilkinson noted, “The agencies that were able to use that media interest to get their message out were able to communicate to the public, I think, in as effec- tive a way as they could just by buying media or ad time.” But media capabilities varied from region to region. In areas such as Atlanta, with four large media outlets, partnerships created and maintained over the past decade paid off tremendously in spreading the news. Despite helpfulness in some circumstances, the media are not a venue to accomplish all the goals of a public health communications campaign. First, many areas of the country do not have ready access to large media outlets. Some jurisdictions, such as Delaware, have no tele- vision stations of their own and few or no local newspapers. Others have imbalances between urban and rural areas. In Utah, the single communi- cation outlet is located in Salt Lake City, where the population is the most dense, which means that it became a challenge to share information relevant to remote parts of the state. Second, reporters and other mem- bers of the media have their own goals and agendas that do not always align with those of public health authorities, who often had to rely on paid advertising and other communications to ensure that they reached the right audiences and conveyed the information they believed was most important. Over the course of the workshops, several participants expressed concern that the press tends to focus on deficiencies, inadequacies, and problems, rather than what is being done right. David Brown of The Washington Post explained that that is where the stories are. He added, though, that proactively engaging reporters and explaining the situation, the difficult decisions, and the factors that impacted the decisions may help. Delaware and Boston invited a few reporters to come behind the scenes and see how vaccine allocation was handled. The resulting stories were informative and highlighted the complex nature of distributing vac- cine, including the complicating factor of different formulations and their indications (e.g., Smith, 2009). Karyl Rattay from the Delaware Depart- ment of Health and Social Services noted that too many reporters from

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82 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN other outlets also wanted the same kind of access as the few reporters invited behind the scenes, which was just not possible. Opportunities for Improving Communications During Future Emergency Vaccination Programs Numerous individual suggestions were made about opportunities to improve communications during future emergency vaccination pro- grams. These suggestions are compiled here as part of the factual sum- mary of the workshops and should not be construed as reflecting consensus or endorsement by the workshops, the Preparedness Forum, or The National Academies. Communication and Coordination Within Public Health There were many individual suggestions for enhancing communica- tion and coordination within public health for consideration by public health authorities. These included • Coordinate among stakeholders to ensure better alignment of messaging, particularly among federal, state, and local public health agencies. • The National Public Health Information Coalition should develop a mechanism to enable rapid sharing of focus group results and other communication materials so that public health departments can benefit from the information and avoid unnecessarily duplicating efforts. • Ensure messaging at the national level is consistent with the level of vaccine supply. This will ease the volume of calls to healthcare providers’ offices and better manage expectations. Participants noted that message timing and content would be im- proved by using more situational awareness and real-time data gained from a stronger relationship between federal authorities and vaccine producers and the development of better systems for tracking distribution and allocation, as discussed in the relevant sections above.

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83 COMMUNICATIONS AND MEDIA Communicating with Healthcare Providers There were many individual suggestions for enhancing communica- tion with healthcare providers for consideration by public health authori- ties. These included • For physicians who do not receive vaccine, provide their of- fice managers with information about where people can get vaccinated so they can give that information to patients who call the office. • Leverage existing call systems (e.g., VFC and West Nile Vi- rus and health plan hotlines) to provide hotlines for the pub- lic and healthcare providers. • Work with medical societies and associations to educate healthcare providers and communicate with them about logistics. Communicating with the Public There were many individual suggestions for enhancing communica- tion with the public for consideration by public health authorities, health systems, and healthcare providers, among others. These included • Use electronic medical records to identify priority group pa- tients and provide targeted communications to them. • Use school systems’ automated phone networks to reach parents. • Capitalize on parents’ influence over college students by reaching out to them to encourage their children to be vaccinated. • Use text messages: People text in their zip code and get back clinic locations and a text message 1 week later reminding them to be vaccinated. • Investigate partnering with health plans’ existing call cen- ters, integrating that capacity into the public health response. The extra capacity will help keep public health from becoming

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84 THE 2009 H1N1 INFLUENZA VACCINATION CAMPAIGN overwhelmed, and callers can be given information and instruc- tions specific to their individual insurance carrier. • Think outside the box for opportunities to create new partner- ships. For example, public health departments in Oregon worked with the Portland Trailblazers to create a public service announce- ment. “It allowed us to reach different segments of the population that may not necessarily hear us, and hear us in a different way,” said Bill Beamer of Portland’s Multnomah County Health Department. • Educate faith leaders and other trusted community leaders regarding the importance of vaccination and safety. • Communicate with vulnerable populations, refugees, and mi- nority communities before events and in partnership with the community. The messenger and message need to be culturally appropriate to the community. That message should be targeted to specific populations in understandable language, words, and pictures. • Research effective methodologies for reaching different popu- lations with risk communications and vaccine messaging. This would include both a retrospective evaluation of the effectiveness of communications efforts during the 2009 H1N1 response and re- search to develop and test new messaging strategies. Media Relations There were several individual suggestions for enhancing communica- tion with the media for consideration by public health authorities. These included • Proactively engage media (e.g., by inviting them to observe decision-making meetings or vaccine clinics) to provide journal- ists with accurate information and an understanding of the situa- tion, be ready for any developing stories, and build trust. This strategy can be risky, but it can also help journalists be prepared for story. Brown of The Washington Post noted that difficult decisions, contradictions, and differences of opinion and approach cannot be avoided, but those difficulties should not be finessed or explained af- ter the fact.