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Elaine Vaughan, PhD and Timothy Tinker, DrPH

Elaine Vaughan is with the Department of Psychology and Social Behavior, University of California, Irvine. Timothy Tinker is with Booz Allen Hamilton, McLean, VA.

Correspondence: Correspondence should be sent to Elaine Vaughan, Department of Psychology and Social Behavior, University of California, 3340 Social Ecology 2, Irvine, CA 92697 (e-mail: evaughan{at}uci.edu). Reprints can be ordered at http://www.ajph.org by clicking on the "Reprints/Eprints" link.

	ABSTRACT

TOP ABSTRACT INTRODUCTION PANDEMIC COMMUNICATION... INSIGHTS FROM PUBLIC HEALTH... Human Participant Protection References

 

The consequences of pandemic influenza for vulnerable populations will depend partly on the effectiveness of health risk communications. Strategic planning should fully consider how life circumstances, cultural values, and perspectives on risk influence behavior during a pandemic.

We summarize recent scientific evidence on communication challenges and examine how sociocultural, economic, psychological, and health factors can jeopardize or facilitate public health interventions that require a cooperative public. If ignored, current communication gaps for vulnerable populations could result in unequal protection across society during an influenza pandemic.

We offer insights on communication preparedness gleaned from scientific studies and the deliberations of public health experts at a meeting convened by the Centers for Disease Control and Prevention, May 1 and 2, 2008.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PANDEMIC COMMUNICATION... INSIGHTS FROM PUBLIC HEALTH... Human Participant Protection References

 
EFFECTIVE STRATEGIES FOR health risk communication are essential for protecting public health in the event of pandemic influenza.^1–3 Reducing negative consequences relies heavily on gaining cooperation from diverse countrywide entities.^1–3 Communications must successfully instruct, inform, and motivate appropriate self-protective behavior; update risk information; build trust in officials; and dispel rumors.^1–4 However, responses to influenza risk information are influenced by existing psychological, social, cultural, health, and socioeconomic factors, which greatly affect how individuals interpret health risk communications, as well as their willingness and ability to act in a timely manner.^2–4

Ideally, pandemic communications maximize the public's capacity to act as an effective partner by encouraging prevention, promoting containment, and fostering resilience and recovery.^3–6 Moreover, with an expanded role in pandemic planning and response, communication processes can prepare the public to adapt to changing circumstances or uncertainty during an emerging pandemic, educate public health planners about existing vulnerabilities and resources that affect influenza risk for specific populations, facilitate anticipation of surprising events, create dialogue between potentially affected populations and risk managers, and foster an environment of mutual trust.^3,7,8 Preparedness strategies must consider what may be asked and expected of individuals at all stages of a pandemic to guide communication planning.^2–4 A pandemic may require minimally disruptive actions (e.g., increasing hand washing), but other behaviors may be difficult, evoke strong emotions, raise concerns, and fuel controversy (e.g., quarantines and school and public facility closures).^2–6 Moreover, disturbing information may need to be conveyed without harming public cooperation.^1–3

The quality of the societal response depends partly on meeting the specific communication needs of all populations—especially those most vulnerable to the risks and most likely to experience communication gaps.^5,7,9,10 Although there is not one universally accepted definition of vulnerable populations,¹¹ from a public health perspective, vulnerability can be defined simply as an increased potential for loss in a hazardous situation, including reduced capability to respond effectively.^1,12 For an influenza pandemic, a useful framework for defining and identifying sources of vulnerability considers the likelihood of exposure, of contracting the disease if exposed, and of timely and effective response or treatment.⁷ Vulnerability can refer to individuals, groups, communities, or places and can result from many factors.^7,8,12 Health disparities, differences in treatment access, living conditions, health literacy, language, immigration status, risk perceptions, and confidence in the government's ability to respond could exacerbate risks for particular populations.^1–12 Furthermore, understanding the geographic aspects of social vulnerability in the United States can advance pandemic planning and decisions about resource allocation during an emerging event.¹²

Undoubtedly, some life circumstances predict disproportionate effects of a pandemic and present different challenges for mitigation.^10–15 Lessons learned from historical and recent public health crises suggest that inappropriate communications and insufficient planning can greatly compromise risk reduction.^15–20 A few missteps can trigger loss of trust in the government's ability to manage serious public health threats, leading to unexpected and highly undesirable outcomes for vulnerable populations.^5,18,19 Good communication practices will not substitute for bad planning, uninformed policies, or misconceptions about vulnerable populations (e.g., they are homogeneous, ignore public health messages, view pandemic flu as a remote threat, and lack the knowledge, ability, or will to change behavior). However, even the best strategies can be rendered ineffective by inadequate health risk communications or failure to integrate a communication perspective and community engagement at every stage of planning, response, and recovery.^{1–3,16–18}

Social marketing and health promotion perspectives have dominated discussions of communication preparedness for significant public health risks and provided a rationale for segmenting the population into subgroups (usually sociodemographic) for the design and delivery of risk and health protection messages.^3,9,21,22 Although useful, these paradigms do not necessarily lead to consideration of several crucial contributors to health decision-making, some barriers to effective communication (Table 1), or an analysis of pandemic influenza as an emerging risk event. Public health officials may gain additional insights about communicating with vulnerable groups from recent public health outreach efforts to at-risk and diverse populations, research on risk communication within various sociocultural contexts, and viewing pandemic communication as a dynamic process. We summarize evidence about pandemic communication challenges for vulnerable populations and offer insights on communication preparedness derived partly from the perspectives of public health experts and program managers who participated in a meeting convened by the Centers for Disease Control and Prevention (CDC) on May 1 and 2, 2008, in Atlanta, Georgia.

	PANDEMIC COMMUNICATION CHALLENGES

TOP ABSTRACT INTRODUCTION PANDEMIC COMMUNICATION... INSIGHTS FROM PUBLIC HEALTH... Human Participant Protection References

Some communication approaches assume that effective messages can be well-defined in advance and then clearly conveyed to different audiences.³ However, unplanned changes in some early messages may be required to clarify uncertainties, alter public expectations, adapt to surprising events, and convince individuals to cooperate despite some uncertainty.^2,8 Informational messages—regarding, for example, the availability, distribution, and safety of a vaccine or treatments; secondary medical complications; and recommended self-protection interventions^2,3,24,25—may need multiple corrections, repetitions, and modifications (e.g., pregnant women's concerns about side effects of medications or about keeping routine medical appointments may grow as a pandemic progresses, particularly if the media focus on cases of unanticipated complications).³

Building and Maintaining Trust
In the face of changing information, some steps to manage pandemic influenza may become controversial or difficult or may be perceived as unnecessary, increasing the challenges in engaging certain populations as partners in reducing risk.^3,25 When information is provisional or ambiguous, trust in officials is crucial, but difficult to maintain³—especially among vulnerable populations in whom skepticism about the feasibility of interventions is more pronounced.^7–10 Trust is central to how public health messages are heard, interpreted, and responded to^9,10 and can determine whether communications are successful in increasing motivation and intention to adopt or maintain recommended self-protective actions.^16,22

Trust consists of judgments about the competence, fairness, honesty, caring, accountability, and transparency of leaders or risk managers; it can be influenced by the characteristics and performance of official spokespersons and by message content during a pandemic outbreak.^2,3,8,26,27 However, because trust is also highly influenced by previous experiences, shared cultural or historical knowledge about past events, and preexisting belief and value systems,^1,10,18 efforts to build a strong foundation of trust among vulnerable populations must begin in earnest prior to the pandemic stage through engagement with targeted individuals or groups and those who serve them.^1–3,15 Public health experts suggest that such engagement helps build trust if it yields communication approaches and content that resonate with the perspectives and life circumstances of vulnerable populations. Tables 2 and 3 list specific steps to accomplish this.

To maintain trust, public health officials will need to justify the timing of action or inaction through appropriate communications and to explain any errors in previous or early communications. For some vulnerable populations, uncertainties at early stages may discourage or delay compliance, particularly if self-protective actions extract a cost and are associated with life disruptions, economic hardships, or social risks.^28–30 Iterative communication processes and outreach strategies at the prepandemic and early pandemic stages (Tables 2 and 3) can provide critical insights for risk managers about how to ease the burden of carrying out protection recommendations among vulnerable populations and to increase self-efficacy about proposed actions, especially when risk information is perceived as tentative.⁷

Other issues could threaten implementation of local, state, or national plans to mitigate the effects of pandemic influenza. Authorities and service providers need considerable flexibility in the emphasis, content, and goals of communications and in the delivery of services to vulnerable populations.^1–3,10 Developing events can trigger distrust of traditional provider-based services if unexpected difficulties arise in implementing a preexisting plan, as witnessed during Hurricane Katrina.^18–20 Therefore, containment and treatment strategies must extend beyond the usual intervention settings, media, and personnel, and messages should reflect these changes.¹⁰ Good preparedness plans anticipate a possible need to regain public trust and sustain or renew interactions with vulnerable populations. This need could arise from uncertainty about health risks, new information (or rumors) about vaccine safety, perceived unfairness of interventions, subsequent and unanticipated waves of influenza, or less-than-predicted effectiveness of some treatment and prevention actions.^{2,10,26,30–33}

During a changing risk event, different skills are required of risk communicators and service providers, and plans may be inadequate if the dynamic aspects of an influenza pandemic wave are underemphasized in preparedness exercises or drills.^22–25 A communication process that has built sociodemographic, geographic, risk, and resilience profiles of vulnerable groups during the prepandemic period (e.g., locations, life circumstances, languages, and community resources to support public health efforts) will ensure that appropriate skills are emphasized in planning and training prior to an emerging pandemic.^8,10–12

Psychology of Communication Responses
Many factors that increase physical vulnerability to the spread and health consequences of pandemic influenza also influence how individuals respond psychologically.³⁴ Overcrowding, poverty, inadequate housing, malnutrition, immune suppression, and poor health status can affect a person's receptiveness to information and recommendations.^35–38 During a pandemic, the way new information is filtered, processed, and evaluated will be influenced by individuals' daily life circumstances, cultural and psychological risk orientations, traditions regarding health practices, reasoning strategies, past experiences, and trust in government and public health systems.^26,33 These factors provide the lens through which a pandemic and communications regarding it are viewed; they also suggest ways to enhance communication strategies.

Some orientations facilitate action; others act as barriers to action and greatly intensify negative emotions or fear, risk perceptions, and skepticism about official recommendations, particularly among those who believe their livelihood is threatened or who feel little control over the situation.^3,9,32–35 When distress is high, individuals are less likely to accept the validity of communications.³⁴ Other psychological processes can promote apathy, denial, and reluctance to actively participate in risk reduction efforts.^31,32,35,36

Preparedness for pandemic influenza must anticipate which health risk communication approaches successfully reinforce desirable health attitudes and behaviors. For example, communication processes that personalize influenza risk for vulnerable and other populations (while increasing self-efficacy) and provide clear instructions about specific actions increase the chances of successful adoption of recommended self-protective actions.^10,15,34 A growing consensus in the relevant literature and among experienced practitioners is that communications are most useful when they are open and transparent in addressing the concerns and priorities of targeted populations, culturally grounded, personally relevant, and strong in promoting self-efficacy about protective behaviors.^{14,26,33,34,39} Risk managers and public health planners can take several tangible steps (detailed in Tables 2 and 3) to ensure that early health risk communications build community capacity to respond effectively.

Individuals can also be vulnerable to pandemic influenza risks because of life circumstances that affect the beliefs and motivations associated with health appraisals and self-protective behavior.^29–38 For example, chronic economic deprivation can create negative attitudes, such as lowered self-efficacy and decreased sense of control over life events,^34,35,40 that are important barriers to the initiation or continued performance of precautionary practices.⁴¹ Health campaigns among vulnerable populations are most successful when communications address motivations, emotions, and ideas that might impede desirable behavioral change but also are compatible with individuals' reasoning strategies.^{2,33,34,38,42,43}

Some current communication preparedness plans incorrectly assume that the public's reasoning about prevention, containment, and treatment will be guided by an almost exclusive focus on risk beliefs about influenza instead of the more likely risk–benefit framing of the problem.^3,10 The latter is a common decision-making strategy whereby risks are weighed against the costs of protective actions. Costs include the effort or expense associated with treatment or prevention, interference with economic livelihood, social consequences, and risk perceptions about recommended actions.^7,27,28 Risks are evaluated within the context of people's lives and priorities,³ and because of this, some risks may be judged as acceptable: people may be willing to take a chance by not adopting certain precautions. If individuals are overwhelmed by the difficulty of engaging in protective actions, any perceived uncertainty in risk information can provide a reason to avoid information, to hesitate to change behavior, or to selectively process messages, all of which can reduce the chances of timely action.³² When daily life circumstances present pragmatic challenges for both pharmaceutical and nonpharmaceutical interventions,¹⁰ then one function of health risk communication as a component of prepandemic planning is to generate information that results in feasible implementation plans for influenza interventions among vulnerable populations.

Trust in public health officials is likely to be diminished if self-protective guidance in communications does not seem credible. Iterative communication processes can help identify existing capabilities, resources (e.g., schools, faith- and community-based organizations, and alternative media outlets), and message dissemination strategies that can be used to strengthen response capacity and resilience during a pandemic.^12,15,20,43 Highly relevant information to many of the more difficult pandemic interventions includes the locations and daily life challenges of subgroups within vulnerable populations that affect exposure and resistance to an infectious disease agent.^7,9,10 Because of existing communication gaps, groups that may especially benefit from these types of early communication, mapping, and outreach activities include difficult-to-access urban populations, undocumented immigrants, non-English speakers, and the homeless.^7–10,43

Even if communication processes successfully identify where and how to reach vulnerable populations, the messages themselves must be compatible with the cultural orientations, information priorities, and reasoning strategies of affected populations. A recent publication from the US Department of Health and Human Services provided detailed recommendations to health officials: "Emphasize the rationale and importance of adherence to public health measures that some people may consider intrusive (e.g., quarantine)."^2(S10-I) However, this advice often translates into messages that assume analytical or deliberative reasoning styles for information processing, even though individuals may not evaluate health or safety information in this way.^41,43,44 Instead, they frequently employ legitimate alternative ways of reasoning about and framing the risks of an influenza pandemic.³⁴ Unless a communication plan is compatible with the affected populations' reasoning strategies, often characterized by different decision rules or simpler heuristics to assess the validity of risk information,⁴⁴ then even the most valid and reliable scientific information may be ignored, minimized, or processed in a way that results in unanticipated public responses.⁴⁵

The reasoning process and interpretation of health risk communications during a pandemic can be greatly influenced by preexisting beliefs. The most extensive national survey to date of beliefs about possible public health interventions for pandemic influenza suggests considerable variability within the American population.⁴ This survey, conducted by Blendon et al. from the Harvard School of Public Health and the CDC, revealed that beliefs about pandemics varied by socioeconomic circumstances, cultural background, and health status. For example, a large percentage of African Americans and low-income, disabled, or chronically ill adults reported that they would have difficulty in finding someone to help should distancing interventions require them to remain and be cared for at home for an extended time.⁴

Employment security concerns also were more prevalent in certain social groups. Overall, only a minority of employed adults (29%) believed that they would be able to work from home for a month because of pandemic influenza; 44% of high-income workers and only 13% of low-income workers believed this was a possibility. Low-income, African American, and Hispanic individuals also were more likely to believe that salary or job loss would result if they or a family member adhered to public health recommendations to stay at home for more than a few days.⁴ In general, a greater percentage of certain social groups and chronically ill individuals believed that they would experience problems in complying with several public health recommendations, a significant issue for subgroups within these populations who are more vulnerable to risk.

These results highlight the need for informed risk reduction strategies that are realistic and for communications that promote a sense of self-efficacy. Repeated and considerable efforts by experts will be required because coverage of a serious and emerging influenza pandemic in mass media outlets may not emphasize information that promotes self-efficacy and confidence in government officials.⁴⁶ Even among populations that are not typically defined as vulnerable (e.g., college-educated persons or high-income households), significant doubts may exist about the government's ability to stop the spread of a serious influenza outbreak.⁴⁷ Because national studies on risk perceptions and knowledge regarding pandemic influenza are few, evidence from investigations of public responses to other public health emergencies, such as the recent outbreaks of severe acute respiratory syndrome in several countries^48,49 and Hurricane Katrina,^19,20 can supplement knowledge gained from prepandemic preparedness activities in vulnerable populations (Tables 1 and 2).

Cultural Values and Risk Communication
Public health officials and scholars agree that cultural values and traditions significantly influence responses to pandemic influenza,^9,22,34 but certain groups' problem-solving perspectives, expectations, and values have not been routinely incorporated into plans.^42,43 African Americans and many low-income community residents are more likely to evaluate risk problems and decision options in terms of fairness, equity, and justice.⁵⁰ This can lead to more intense and durable emotional responses to health risks, greater risk perceptions, increased negative emotions such as anger or fear,⁵¹ and different challenges for risk reduction during a pandemic.^15,16 For certain individuals, a shortage of vaccine or a decision to triage patient needs could lead to perceptions of unfair or discriminatory health services distribution,^7,10 especially where large numbers of uninsured or urban minority populations are more likely to seek treatment in crowded emergency rooms during an influenza pandemic.⁷ Such circumstances not only test the surge capacity of care facilities and providers during an influenza pandemic,²³ but also require public health officials to communicate clearly about distributive justice issues and justify actions taken²³ or else risk social disruption that could threaten public health interventions.¹⁶

Other cultural values (e.g., social norms importance, strong family ties, and social networks) can either impede or facilitate risk reduction efforts.^43,52,53 Self-protective actions may be a family-level decision process,^5,10 and messages about protecting loved ones may be more effective than those about just the individual.^33,54 Effective communication strategies must fit the cultural values, life circumstances, and risk perceptions of targeted audiences.^42,43,53,54

Pandemic influenza plans may acknowledge the importance of cultural relevance in theory,^1,2,7,52,54 but it is not always reflected in practice.⁵⁵ For example, a recent content analysis of a state's emergency preparedness communication materials targeting low-income African American and Hispanic populations found them inadequate.⁴² Other recent analyses of public health emergency messages concluded that many materials were inappropriate for certain vulnerable populations (e.g., recent immigrants) because of readability issues, cultural references, language, or required health literacy level.^{9,21,43,50–55}

	INSIGHTS FROM PUBLIC HEALTH EXPERTS AND RESEARCH

TOP ABSTRACT INTRODUCTION PANDEMIC COMMUNICATION... INSIGHTS FROM PUBLIC HEALTH... Human Participant Protection References

 
Experts' conclusions at the CDC-convened meeting were similar to themes in the scientific literature (Table 4 provides more detail):

• Communication strategies are most effective when not based on misconceptions.
  
• Plans should be made from the perspective of the targeted population.
  
• Messages must be sensitive to and relevant for the audience.
  
• Communications must be integrated.
  

Current communication plans for pandemic influenza reflect thoughtful, evidence-based strategies but could be strengthened by more emphasis on managing a dynamic risk event and improving the fit between communication processes and life circumstances that influence behavior during a pandemic. Current evidence about factors that contribute to vulnerability and resiliency during public health emergencies^12,57 can help officials anticipate where adjustments in effort and planning are likely to be required for optimal risk reduction and communication during an evolving influenza pandemic. Although the underlying communication goals are similar across populations, strategies to achieve these objectives require a range of approaches that address the specific communication needs of vulnerable populations during the prepandemic period through the recovery stage.^{18,21,42,54,57,58}

Because of the dynamic nature of a pandemic, delineating it into prepandemic, pandemic, and postpandemic stages may present too simplistic a model for designing the most effective exercises and preparedness drills. An identified pandemic episode is unlikely to progress in a strictly linear fashion and may unfold over a prolonged period or in multiple waves. The communication demands of the pandemic stage are best described in more dynamic terms, emphasizing how developing and emerging events could modify communication needs and demand flexibility in the content and delivery of crucial messages, especially for vulnerable populations.^8,10,12 Several strategies to enhance health risk communication preparedness are offered in Table 3. These insights from our review of the literature and from experts at the CDC meeting underscore how participatory and phased communication approaches can support efforts to produce a good fit between the vulnerable populations targeted for influenza risk reduction and adopted strategies. Several pandemic preparedness Web sites now emphasize these approaches.^1,2,56,59

	Human Participant Protection

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No protocol approval was required because no research involving human participants was conducted.

	Footnotes

 
Peer Reviewed

Contributors

E. Vaughan took the lead role in conceptualizing and writing the article and contributed to the revision of each draft. T. Tinker participated in the conceptualization and revision of the article and wrote some sections.

Accepted for publication July 4, 2009.

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