CERC Transcript 08 16 2016

Zika CERC Discussion: Summary

Presenters: Barbara Reynolds, PhD

Date/Time: August 16, 2016 1:00 pm ET

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Operator:      

Welcome and thank you for standing by. At this time all participants are in listen-only mode until the questions and answers sessions of today's conference. At that time, you may press Star 1 on your phone to ask questions. I'd like to inform all parties that today's conference is being recorded. If you have any objections, you may disconnect at this time. I'd like to now to turn the conference over to Barbara Reynolds. Thank you, you may begin.

Barbara Reynolds:   

Thanks, Dustin and welcome everyone to this week's Zika Crisis and Emergency Risk Communication Discussion. This will be our last in this series. This is our 13th of these discussions so we've done a baker's dozen I guess and with that in mind, we thought that perhaps what we should do is a survey of topics of what we have covered over the last 12 weeks and emphasize those things that seem to be most critical with where we are right now in our Zika response.

As always, I'm just going to try to throw out some ideas about crisis and emergency risk communication and then open it up for discussion and questions. So while you're listening, if you're thinking of something that you would like more clarification or if you want to add your experience or throw out an idea to the group, please do so.

Be prepared for that in just a little bit. And for those of you who are following along on the slides, you'll see that again, this week our first slide is the right message at the right time from the right person can save lives.

I think it is such an important component of communication. Why are we communicating? What are we trying to do and ultimately we're trying to save lives and reduce harm whenever we're out there talking in these kinds of emergency response situations especially as we face an emerging infectious disease which is surprising us every week as we learn more and more about it.

When we are talking about responding to people when they're under threat, their loved ones, or their economic security may be under threat, we have to recognize what are they seeking from our communication? And it goes without saying that people want the facts and I think all of us in emergency response and public health probably do a pretty good job of giving people the facts. Sometimes we're not so good at explaining that perhaps things can change as the situation evolve.

And I was just involved in an exercise here at CDC this, yesterday. And one of the things that I saw occurring that, fortunately it was an exercise so we had an opportunity to talk about it, is that we tend to want to go to certainty a little too quickly. And the underline premise of this training has been what does the public need when, what do they need when risks are uncertain? And when you're dealing with an emerging infectious disease situation, like Zika, there are going to be some uncertainties.

We're still tackling a number of questions. They may be a little more nuance than what we were looking at back in April or May of this year but there is still questions. There's questions about the disease itself and how it progresses. There are questions about the degree of risk. There's questions about how to mitigate that risk and there are questions about how to communicate about the mitigation of that risk.

So while we do want to talk about the facts, we need to realize that at times we're going to have to build into our messaging a recognition or an acknowledgment of the uncertainty that we face in the situation.

And without saying, we know that our information needs to be used in a way that people can make good decisions for themselves and the best type of risk communication is that kind of communication where people feel they've been given the information they need to make a good decision for themselves or their loved ones or their community.

So it's not just a factor of we the experts go out there and give people things to do although I always suggest that we should, we need to explain to them why the things that we're asking them to do are good things to do. So there's an element of persuasion that has to come into play and it's not heavy handed persuasion. It is the opportunity to explore the recommendations from the perspective of the people we're trying to help in the response.

We're now getting far enough along in this response and as resources are allocated to it, it's not unreasonable to expect that some people want to know how are these resources being managed? Part of our credibility as response organizations is our ability to use resources in a way that is appropriate and as the community believes is a just way. It's a fair way of using them.So I would at this point start to predict that it wouldn't be unreasonable for questions from the media or the public, could focus on how are resources being allocated? Are some communities getting more or less? If they are, why? What is the premise for that?

And if there has to be some triage of resources, some communities need it more, quicker, faster, whatever, we need to be able to explain what were the criteria for that? How did we get to that decision making process and it's much better to have that laid out ahead of time so it's not a, considered an issue of favoritism or politics unnecessarily. So think about that. And then more than anything, people want to know how long are they going to be under this threat and what are we trying to do to try to reduce the threat or to normalize, so to speak, the threat?

And any of you again who experience the work that was done by the state with the entrance of West Nile Virus in the United States will remember that we have that idea that something new and it's scary and we have to deal with it but at some point we learn how to (unintelligible) risk in a different way.
We don't yet know what that will look like for Zika but we have to expect that at some point people will be looking for our communication in that context also. So I wanted to share with you this week since it's a summary some of the basic risk communication principles for emergencies that might be useful in the context of Zika. One of the most important is to be sure that we under promise and over deliver.

And remember, as this moves into your community if it should at either a travel related case or if there is local transmission, recognize that it may be initially our desire to try to make things go back to normal so quickly that we start to overpromise what we can deliver.

Be careful. Help your leaders both the elected officials and your emergency response and health leaders to recognize that we have to allow for the possibility that not everything will be restored to normal immediately and that any promises implied or explicit can actually hurt our credibility in the long run and people will be paying attention to what we say early on when Zika first arrives in the community.

Instead of making bold promises about outcomes, I think the better approach in the long run is to talk about the process to fix the problem and address public safety concerns. I think people will give us a little latitude in this area if, and they recognize there's a limit to what we can do but if we're the ones that imply early on that we're going to just take care of this and there's nothing for them to worry about, we can get ourselves in trouble so remember to talk about the process and not so much on promising outcomes in those areas where you cannot.

If there is a promise to be made, it might be the commitment to the issue and helping people recognize the dedication that people have in trying to deal with this problem as we go forward.
If you have Zika in your community, you will expect that the public will ask certain questions. Be prepared now for those questions. These are basic questions that in every emergency where the public's health and well-being are at risk that you can expect these questions to occur.

They're going to ask am I safe? Is my family safe? What have you found that may affect me? And that's where the media, working with the media becomes so important because the media often takes the what does it mean to me perspective. So take advantage of that perspective that your community members will be asking that. They're going to want to know what they can do to protect themselves and their family.

In this case I think with Zika we also want to emphasize what they can do to help protect their neighbors, their community as a whole because right now some of the interventions and ways to help reduce the risk of transmission of Zika is in community involvement.

So more than anything, we have to emphasize those messages and of course, now's the time, especially if you've just experienced maybe one travel related case or you are tracking mosquitoes or looking for the type of mosquito in your community in your area that could carry Zika. Now's the time to start emphasizing to the public what they can do to protect themselves and their families in the community. They may want to know who caused this. Be careful and I'm just going to talk about stigmatization a little later.

But sometimes people are looking to cast blame. It could be blame that things haven't been, more things haven't been done to protect them. It could be blame about how the Zika virus was introduced into the community. But those questions you should expect them and be prepared to manage the answers to those. And then the public will often ask can you fix it? So they're looking for that expert support in their community for this new or emerging infectious disease public health emergency response.

What can you do? How can you help them? Be careful again, talk about process not about outcomes necessarily. And ask them to join you in trying to fix it. When you get to your messaging, especially initially in the situation, know that for your message to be heard, you need to ensure that you're offering the kinds of information that people want.

We just talked about the questions that people will ask but there's something I call the STARCC principle, S-T-A-R-C-C and this is when you're forming those first initial message, make sure it's the message itself, is simple. It doesn't necessarily have to be brief though I would vote for that whenever possible but simple in plain language using sentences that are not run on sentences.

If you're starting to use colons and semicolons in your messaging, the message is no longer simple. You're making it difficult for people who are feeling threatened in the situation to get the information they need. The messages need to be timely. When people are asking the question is when you need to be able to provide the answer. In fact, sometimes you should anticipate their questions and be prepared to answer them even before they ask them.

Now they may not pay attention to it, but the fact is the speed which you communicate in a crisis is a marker for your preparedness. We have been looking at the possibility of Zika in the continental United States since this spring.We held a summit in April with hundreds across the country and there is an expectation that we should be prepared in some way to manage Zika introduction into our communities. The messages have to be accurate and this can be tough.

Again, I have to go back to the exercise I was participating in yesterday here at CDC, there was some debate about one piece of information as a initial message that needed to get out and I said drop that out and tell people what you know.

I didn't say it quite that bluntly but that's my point in this situation. So sometimes the way to have accurate information initially is to just not have a complete message, put out the information that you know to be true in that time, and get it out there as quickly as possible.
And one of the best things you can do for your credibility is tell people what you know and tell people what you don't know, (unintelligible) should do that. And we have crisis and emergency risk communication resources and tools that provide a template, a way to help you organize your thinking early on in the crisis response.

Information has to be relevant. We just talked about the questions people have. Get to those questions before you start to tell people about long history of successes and emergency response.
We need to have credible messages and this is not easy to put your thumb on, credible is the combination of trustworthiness and expertise. So how do we, how are we trustworthy?

Well we can talk a little bit more about it later today but the fact is to be trustworthy means that you recognize people need information from you and try to be as honest and open and forthcoming as possible as you move through the event itself. And then your messaging needs to be consistent, consistent in terms of what you say, consistent as much as possible with what your partners say in the situation and where there is a possibility of change, we need to anticipate that possibility for the public so that they don't believe that we have been dishonest in some way with them.

Another aspect of Zika response that I think is important is the sources of social pressure. We had talked about this in the weekly discussion on community engagement. I want to come back to it because these are fundamental questions that help us understand why people may not be taking the recommendations that we're offering to help protect of their community.

If you go through this list of four questions, it may tip you off as to how you need to adjust your messaging in some way in that dynamic and I think it will be better for us to ask these questions of ourselves related to our recommendations before the recommendations start to be ignored or actually discarded in some way. The source of the social pressure are what, the questions that you would have to ask are what will I gain, so what in your messaging honestly is pointing to what will go well if we do what is recommended? Have we expressed that explicitly? If you do this, this, and this, then this is what you gain from it.

People will be asking what will it cost me when they're looking at a recommendation about a new threat or a new situation they want to know well, if I take this step, is this going to be something I haven't done perhaps in the past, what will it cost me? Is it going to be harder or more expensive or socially uncomfortable in some way?

And we know in Zika we are facing some of those very difficult questions about cost. Cost in terms of perhaps my cultural beliefs are not consistent with this. Cost in terms of my point of view around environmental issues. Cost in terms of using condoms for, to prevent sexual transmission. Cost in terms of delaying pregnancy. What will it cost me to manage this risk and to respond to the recommendations that we're making? And then a very important social pressure is people ask themselves whether they do it consciously or not they're going to be asking what do those important to me want me to do?

So if you have a population that you want to target for a particular recommendation, if you want a particular action to be taken, and you may think that for them they may feel the gain isn't high enough and the cost is too high, what do those important to me want me to do?? This is when you can apply some social pressure through engaging people around that population and allow them to encourage them to do what needs to be done and to praise people, to give them recognition for taking a step that is more altruistic in some way.

And then without question, the fourth question will be can I actually carry it out? Have to do with self-efficacy, have you offered a recommendation to me that I believe that I can do and when I say I can do it may be that we have the physical capacity but we may not have the psychological capacity, we may not have the sociological capacity in that situation. Will the society support me? Can I overcome my own psychological barriers to do what needs to be done and an example that I use that is non Zika is when I'm driving my car, people tell me if there's a tornado my way that I should jump out of the car and get in the ditch. I frankly have to ask myself, can I do that? Yes.

Will I do it? It depends. There's a part of me that doesn't want to get out what feels like a secure car and get into the ditch and I've had well-meaning people given me, give me important statistics about my chances of survival are higher if I take this action. But just know it's a pressure and it's an internal sociological pressure that might be causing me to avoid doing the thing that in a logical reasoning way seems like the right thing to do.

I mean, the statistics and the experts tell you that this is what you need to do then for goodness sake, why aren't you doing it? It's worthwhile to explore that in your community and find out why people might not be doing the very thing that you think they can carry it out. Sometimes there's some intervening issue that is invisible to us in the community and we need to find out what that is. So that's some of the work that we can be doing in terms of our public engagement and helping people do what they need to do to protect themselves.

Remember, right message right time, right person or organization could save lives or reduce harm. I said a little earlier today that I was going to talk about stigmatization and I think it's worthwhile because I do believe that as long as the risk is not being shared across all of the population the same way, there is the potential about stigmatization.

Some of our early work suggests that pregnant women don't want to be singled out as oh, we have to go through all of this. Just protect those pregnant women, starting to make them feel stigmatized in some way. Think through what are the benefits? What are the benefits of doing what we're doing?

Well, at some level, it could just be that the chance is that someone won't get Zika whether they're pregnant or not they won't get Zika so they won't have conjunctivitis, they won't have red itchy eyes. They may not have fever. They may just not be bitten by mosquitoes, and mosquito bites are not pleasant for anyone.

What do they gain? Well maybe they gain the idea that as a community they fought back something. Stigmatization is the singling out of somebody as associated with the risk whether they're causing the risk or not. So be careful about that. What are we doing that might increase stigmatization? And I think that we can do before the threat occurred during the time that you're facing the threat in community and afterward.

And communication professionals have a role in ensuring that stigmatization doesn't occur and I don't hesitate to speak directly to the media about issues with stigmatization when I can predict there is a possibility of them happening. And for those who have not experienced it in your community yet, look around and think about it and take from lessons from those areas where it may have already occurred because there are things that we can do.

I'm going to stop here for just a moment and remind everyone that the six principles of crisis and emergency risk communication are just touch points to get us into thinking about how better to communicate to people when the, there is a great deal of uncertainty or when their lives have been turned upside down in some way.

We need to be first getting information out from our organization especially if we have the authority to do so and the ability to do so. We have, if we don't, people may think we're not prepared. We have to give information accurately. We have to be right, that means sometimes giving information in increments. Be prepared to drop something out of a message if you don't think it's fully baked yet and get out there with what you know and here is one of the reasons why.

First messages carry the most weight. So we want information to be out there and we need it to be right. If information gets out there that's inaccurate, it sometimes can be very difficult to turn around and that's one of the other reasons why we have to be careful about allowing for the uncertainty of the situation and involving message.

Let people know based on what we know now, this is what we believe is the course of action. If we learn something more that changes that, we will come back and let you know and we can see from our interim guidance coming from CDC about sexual transmission of Zika that we continue to make those changes.

And information should be credible that again, is the combination of trustworthiness and expertise, all of that comes together in making sure that we don't withhold information because we think it will be troublesome for us to manage when it happens. Uncertainty is worth than not, than knowing. Uncertainty sometimes we try to undo uncertainty by being more confident of our facts and what the facts should allow us to be.

And that we also to be credible means we have to confront rumors when they happen. The last three of the six principles express empathy, putting into word what people are feeling. It helps build trust and that of course adds to our credibility. Promotes action, gives people things to do. It helps calm their anxiety and restore order. Understand we have print out actions that people actually believe that they can carry out. If we're asking to do something that goes beyond their ability, then give it to them in small steps.

You may not want to wear insect repellent for three weeks, but give it a try and see if just tomorrow can you put it on three weeks you've been traveling some place where Zika, in a Zika affected area. See if you could just put it on tomorrow. If you can to do it tomorrow, maybe you can do it the next day.

What can we do help people who've traveled to those areas to remind them that they can use insect repellent on their exposed skin for three weeks and what it means as a community and then show respect and respect is all of these things and more. It's just treating people the way you wanted to be treated and that means thinking through, what are we doing that might be disrespectful in the way we're communicating that information?

So those are just some of the things that I think we touched upon over the last 12 weeks and I'd like to finish off in our 13 week by seeing if anybody has any perspective that they'd like to add now that we've been at this Zika stuff for a while, any questions or comments. (Dustin), do you want to open it up for questions?

Operator:

Yes. Thank you. We will now begin the questions and answer session. If you would like to ask a question, please press Star 1, unmute your phone, and record your name clearly. Your name is required to introduce your question.

If you need to withdraw your question, press Star 2. Again, to ask a question, please press Star 1. It will take a few moments for your questions to come through. Please stand by.

Barbara Reynolds:   

Great. Thanks, Dustin and while we're waiting to see if anybody has any interesting comments or questions for today, I just want to emphasize that CDC held a three day global crisis and emergency risk communication training last week and we touched on a lot of the same issues.
These are universal and can be used in many settings and at the end of these three days of training, we went around and talked about what people were taking away from it.

And one of the things that struck me is somebody said for the first time that they had been introduced to a way of describing what mistrust had that have hadn't thought about before and they were going to carry that with them in the work that they do. It's a slide that I've had up here every week but I haven't emphasized that so I think I will in the moment mistrust is an outgrowth of the perception that promises were broken and values violated. I think it's important to recognize that where mistrust comes from and thinking through what are principles of CERC doing?

Are they helping us gain trust and forestall any kind of mistrust? I think so. If we apply in these ways. Dustin do we have any questions or comments?

Operator:      

Yes. We have one question from Kitty. Go ahead your line is open.

Kitty: 

Hello. I just want to thank you so much for the last 12 weeks and also for the great information. What I was wondering is there anything that you know of that will be continued? I know this is the last day but are there any other conference calls that we could join to continue to get information?

Barbara Reynolds:   

Thank you so much for that question. We have put each of these discussions online at our crisis and emergency risk communication website so that if anybody wants to go back and review them or catch up on ones they may have missed, they are there. We decided that we're not going to do them weekly at this point but that we reserve the possibility that if something critical happens that we could do that also.

And then actually it's a perfect question to remind people that there are a number of resources that we have created specific to Zika communication but also crisis and emergency risk communication generally that are out there and I would suggest that people go there to the website to see what else might be there.

And then without question, my team and I have a deep interest in ensuring that we answer you your questions relating to crisis and emergency risk communication and you can reach us as a team at circrequest@cdc.gov whenever a question comes up.
So I don't know of anything formal routinely but we are certainly pop in as we think there is additional interest. I'll have to say that it's been pretty impressive over the last couple of months or so that the number of people who have participated has stayed pretty constant.

So I do believe that there is some interest but if you do have a topic area you'd like to us to discuss, we'd be very willing to put something together in the future. Thanks for that question.

Kitty: 

Thank you.

Barbara Reynolds:   

Any other questions or comments, Dustin?

Operator:      

Yes. Our next question comes from Nickelo. Go ahead, your line is open.

Nickelo:         

Hi, Barbara. Thanks as always. This has been really great, always great to get a refresher so I have a question. I didn't anticipate that our problem, we're up here in New England, would be getting people to be interested in this. You know, usually with health emergencies people are already interested and it's getting them the correct information and that's the challenge.

But you know, because we don't have the mosquitoes here, it's really just a travel situation. It's hard to get them engaged and interested so I was wondering if you had any suggestions for that.

Barbara Reynolds:   

Sure. Thanks for that question. Have you had an initial travel case yet announced in your area?

Nickelo:         

Oh yes, we've had I think eight already.

Barbara Reynolds:   

Oh, eight. Okay sorry I don't keep track.

Nickelo:         

No that's okay.

Barbara Reynolds:   

And so what do you wanting people to do perhaps that they're not doing?

Nickelo:         

I don't know if they are or not. They certainly just don't seem concerned or interested so of course we want them if they travel to take precautions you know, and obviously prevent any pregnancy related issues so it's just making sure they have that information before they go somewhere.

Barbara Reynolds:   

Right. Okay good. Good. So that gives me another perspective. So we're really trying to find those people who might be traveling into Zika affected areas. That's what you're looking for.

Nickelo:         

Right.

Barbara Reynolds:   

So without trying to put a whole health marketing campaign together in a couple of minutes, I would suggest that you would try to find those places where people go to before they traveled to get information and package it as travel tips not just Zika prevention because I can see where some of the community might not be so concerned.

I also think that it's very important even though you feel like hello, is there anybody home? Am I talking? Are you hearing me, provide the information and when the threat seems real to people and they become concerned they'll pay attention. I would also suggest that some of the conversations we've had about the Olympics and Zika concerns are probably getting through to people who might be traveling to areas where Zika, Zika affected area.

Be sure that it's easy for them to get information when they go looking for on your site or on others and just remind them every once in a while but I have to tell you in the world of risk communication, people prioritize what they want to worry about and there are a lot of things for people to worry about in the world.
Sometimes you can't get past the fact that they're just trying to balance their check book. But don't ignore it and who knows when it may become more important.

I would also suggest that story telling is an excellent way to get people to be engaged with information when they think they've already heard enough to say oh, the threat doesn't, there's no threat there for me. I'm not interested.

Even if a threat isn't personal, sometimes people will listen to it through a story so it might be that kind of thing where getting people to tell the story whether it's someone in the area or someone that has a connection back to the area in some way.

Nickelo:         

Great. Thanks.

Barbara Reynolds:   

Okay Dustin, any other comments or questions?

Operator:      

We show no other questions at this time. Again, as a reminder, please press Star 1 on your phone and record your name if you have a question. One moment please.

Barbara Reynolds:   

Okay thanks Dustin. So I talked about what causes mistrust so let me talk just a moment about what it means to act the acting trustworthy, did I say that, I'm not sure, how to act trustworthy.

Share information early, acknowledge the concerns of others, this is when I say often under promise and over deliver, make sure that whoever is speaking on your behalf is never condescending and then whenever possible, engage other people and advocates in your work along the way.

Those are just some other things we can do to act more trustingly when we're trying to reach people with our health messaging. So Dustin, do we have anyone else?

Operator:      

No we show no further questions at this time.

Barbara Reynolds:   

All right. Well everyone, I can't thank you enough for participating in our baker's dozen of crisis and emergency risk communication discussions and Zika and again, you can reach us anytime at cercrequest@cdc.gov and great deal of this information is available online and do check out those Zika communication resources that have been developed here at CDC for your use.

Thanks everyone.

Operator:      

That concludes today's conference. Thank you for participating. You may disconnect at this time.