TB Notes Newsletter

No. 2, 2010

COMMUNICATIONS, EDUCATION, AND BEHAVIORAL STUDIES BRANCH UPDATE

The following article by CEBSB staff member Ije Agulefo first appeared in the Spring 2010 issue of the Northeastern Spotlight, the newsletter of the New Jersey Medical School Global Tuberculosis Institute. It is reprinted here in its entirety.

Crisis and Emergency Risk Communication: What TB Programs Need to Know

Crisis and emergency risk communication (also known as CERC) combines the urgency of disaster communication with the need to communicate risks, benefits, and needed action to stakeholders, healthcare providers, media, and the general public.  CERC differs from risk communication in that:

• Communication decisions on how to respond to the crisis must be made within a short time constraint;
• These decisions may be irreversible;
• Outcomes of the decision may be uncertain; and
• Decisions may need to be made based on less than perfect or incomplete information.

Overall, CERC can minimize some of the harmful human behaviors that are known to arise during a crisis.

How can TB programs use CERC?

When people are faced with a crisis or emergency situation, they take in information differently, process information differently, and act on information differently.  CERC principles can be extremely useful to TB programs during a TB outbreak or high profile event.  When an outbreak occurs, there is often a sense of panic, fear, confusion, anxiety, and helplessness.  Using CERC principles to disseminate information can help the public cope and instill a sense of empowerment within the community.  Feeling empowered to take action reduces the likelihood of feeling victimized and alleviates fear.  The use of an “action message” can provide people with the feeling that they can take steps to improve a situation.  During a TB outbreak, effective communication provides information on useful resources for those affected.  For example, during a TB outbreak, providing information on local sites to go for TB testing is a useful action message.

Five CERC principles to communicate messages successfully during a crisis or TB outbreak:

• Develop a solid communication plan. Your TB program’s outbreak communication plan should be fully integrated into the overall program’s emergency response plan.  This plan should address all of the roles, responsibilities, and resources involved in providing information to the public, media, and partners during a TB outbreak.  It should include such elements as a signed endorsement from the program’s director, regional and local media contact, and staff responsibilities.  The communication plan should be seen as a resource of information.  In general, the public tends to judge the success of a response by the success of its communication plan during a crisis.
• Be the first source of information. It is important for the TB program to be the first source of information during a TB outbreak. The public sees the speed of useful information as a marker of preparedness. In addition, when people seek information about something unknown, the first message they receive tends to carry the most credibility.  Therefore, it is important for the TB program to be the first source of information. For example, if your TB program’s first message is, “Only people who spent extended time with the student with TB are at risk of developing the disease.  We are contacting those persons to ensure they are tested,” the audience will remember this message and accept it. Later, if a subsequent message from another source says, “Everyone should be tested for TB,” the audience will compare the second message to the first message. They are more likely to accept the first one because it is from a credible source and it was the first message received.
• Express empathy early. Empathy is the ability to understand what another human being is feeling. Research has shown that it should be expressed within the first 30 seconds of message delivery. This is a very challenging but critical step in crisis communication. Empathy shows sincerity to the public, and also helps the public hear the message. For example: “We recognize that you are anxious about the recent TB outbreak and we understand your concern.  We are available to answer questions that you may have about the situation.”
• Show competence and expertise. Research shows that people believe that individuals in professional positions within respected organizations are experienced and competent. It is important to maintain the highest level of expertise as a way of fostering trust. When a TB outbreak occurs, provide necessary information to ensure the affected audience understands the situation.  For example, provide the public with information on how TB is transmitted along with the signs and symptoms of the disease.
• Remain honest and open. In many cases, when information is being disseminated following an outbreak, everyone assumes that some information is being held back. For this reason, it is best to let the public, stakeholders, and the media know that they will be updated with information as it becomes available. For example, “Currently, we do not know if there are others who may have been infected or have TB disease. We will continue to update you as we learn more.”

Message planning

Both the content as well as the method of message delivery during an outbreak are extremely important. Dissemination of appropriate messages to the community helps to reduce fear and anxiety. When developing CERC messages, it is critical that

• Affected audiences be identified;
• Key messages be developed with supporting facts included; and
• Effective dissemination channels be used.

When people are faced with a crisis, they want to receive messages that are accurate, helpful, timely, empathetic, short, and concise. Messages disseminated in response to a TB outbreak should follow the STARCC principle. 
Messages should be:

• Simple
• Timely
• Accurate
• Relevant
• Credible
• Consistent

Working with the media

When a TB outbreak or high profile event occurs, it is very likely that it will generate media interest. Use the media to your advantage!  The media can reach a large number of people quickly and can assist you with message dissemination.  The media is attracted to messages that are convenient, simple, visual, and emotional.  To assist with developing messages for the media, the key is to identify the single overriding communication objective, also known as the SOCO.  The components of the SOCO include:

• Key point or objective. What is the most significant point in the message?
• 3-4 facts or statistics (e.g., how many people may have been affected?)
• The primary and secondary audience. Who are the populations of interest?
• One key message (e.g., the patient is currently undergoing treatment.)
• Contact information. Who can be reached for more information?

A SOCO worksheet is available in the publication: “Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit” on the CDC website. View a sample single overriding communications objective (SOCO) worksheet  (MS Word - 36kb)¹

A spokesperson to represent your TB program should be identified to interact with the media during an outbreak. Having a spokesperson gives an identity to your program, and shows competence and expertise. Your spokesperson should be well trained, have the ability to effectively connect with the audience, and communicate accurate and useful information about an outbreak. It is important to include your spokesperson in message development. This helps to ensure that he or she “owns” the statements and will help convey confidence, believability, and trust. Your spokesperson should not only know the needs of the TB program, but should also show empathy to the affected audience. Your spokesperson should not: be defensive, express personal opinions, over-reassure nor use humor, jargon, one-liners, or clichés.

Partnerships and communication

Joining forces with your partners creates an opportunity to foster respect, trust, and commitment with your target audiences. In crisis communication planning, it is important to identify and involve your partners and stakeholders to gain access to their skills and resources. Partners can assist with developing messages that are appropriate, sustainable, and effective for the audience. When a TB outbreak occurs, providing timely and accurate information to key internal and external partners and stakeholders helps to strengthen existing relationships. To learn more about partnership planning, access the publication: “Forging Partnerships to Eliminate Tuberculosis: A Guide and Toolkit” on the CDC website and view Planning with Partners: Moving from Goals to Effective Action Checklist   (MS Word - 34kb)²

Evaluation of messages

The key to communicating effectively during an outbreak is to evaluate messages at various stages of dissemination. Seeking audience feedback is useful to refine the communication strategy, and to improve the effectiveness of the messages.

The evaluation methods that should be used to evaluate risk communication messages are as follows:

• Formative evaluation is used to “pilot-test” messages prior to dissemination to the target audience. After messages are developed, share them with your internal and external partners to determine if the messages are clear and comprehensive. Feedback obtained can then be used to revise and improve the messages before they are disseminated widely.
• Process evaluation examines the procedures and tasks involved in implementing an activity, such as the channels of delivery and the number of messages disseminated. After the messages are disseminated, it is important to monitor the methods of message delivery (e.g., on-line, print distribution). In addition, also determine the number of materials distributed (e.g., number of factsheets disseminated to the public, number of public inquiries received as a result of the message).
• Outcome evaluation assesses the effectiveness of the messages being disseminated. The effectiveness can be determined by changes in the behavior of the target audience as a result of the messages received. Outcome evaluation can obtain descriptive data and show the immediate effects of the messages disseminated. For example, after disseminating messages following an outbreak, obtain data on the affected audience coming in for testing.
• Impact evaluation focuses on the long term effects of the messages being disseminated during an outbreak, such as number of persons with TB infection or TB disease identified. Impact evaluation is harder to accomplish because it is difficult to separate the impact of disseminated messages on the audience from the effects of other activities.

To learn more about evaluation of risk communication programs, view evaluation primer on health risk communication programs on the CDC website.³

—Submitted by Ijeoma Agulefo, MPH
Div of TB Elimination

References

1. CDC. website, 2007. Forging partnerships to eliminate tuberculosis: a guide and toolkit. [online] (page last updated 1 June 2009). [accessed on February 5, 2010].
2. CDC website, 2007. Forging partnerships to eliminate tuberculosis: a guide and toolkit. [online] (page last updated 1 June 2009). [accessed on February 5, 2010].
3. Agency for Toxic Substances and Disease Registry website, 1997. Evaluation primer on risk communication programs: types of evaluation. [online] (page revised May 1997). [accessed on February 8th, 2010].
   
   From: CDC. Crisis and Emergency Risk Communication. October 2002.

Invitation to Participate in Website Usability Studies

The Communications, Education, and Behavioral Studies Branch of DTBE would like to invite you to participate in a usability study of a CDC website. The studies will be conducted at two conferences in 2010:

The National TB Conference, June 21-24, and The 10th annual TB Education and Training Network (TB ETN) Conference, August 10-12, 2010.

Your feedback will be used to improve the usability of the website.

If you would like to participate in either of these studies while attending the conferences, please e-mail Sharon McAleer at zoo0@cdc.gov to schedule a time to participate.

We greatly appreciate your time and assistance.

—Submitted by Sharon Mc Aleer, MISM, CUA
Div of TB Elimination