Health Communications and Community Mobilization During an Ebola Response: Partnerships with Community and Faith-Based Organizations

The 2014 Ebola outbreak is the largest Ebola outbreak in history, affecting multiple countries in West Africa.¹ Although the risk of a widespread outbreak in the United States is very low, the unfamiliar nature of the disease contributes to uncertainty and mistrust. The Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO) are working to educate and prepare communities throughout the United States for the possibility of an Ebola case in their locality. Federal, state, and local authorities; businesses; schools; charitable foundations; and community and faith-based organizations (CFBOs) all have important roles in Ebola preparedness and response. In 2008, CDC and ASTHO developed a 10-step approach for health communications with CFBOs during public health emergencies.² In this commentary, we describe how a modification of this 10-step approach can be used by state and local health departments to plan for health communications and community mobilization during an Ebola response.

APPLYING THE 10-STEP APPROACH FOR HEALTH COMMUNICATIONS WITH CFBOS TO AN EBOLA RESPONSE

Step 1: incorporate health communications and community mobilization into an overarching public health emergency response plan

During an Ebola response, communication and community outreach should be seen as vital components of an integrated public health response plan that is based on established science. When health communications initiatives are developed independently from other parts of the response plan, they may become marginalized and ineffective.³ During a response, health communications initiatives that have been developed independently and have not been formalized into preparedness plans can also easily be overlooked by others who are working in the response.

Step 2: assemble the appropriate health communications and community mobilization team and determine specific roles and responsibilities

Public health agencies should assemble an appropriate health communications and community mobilization team and outline the team's roles and responsibilities. When assembling the team to work with community organizations, agencies should consider including members who have both technical expertise and knowledge of the religions, traditions, languages, and communication channels of potentially affected communities. This cultural competency will allow communicators to better understand the narratives (religious or otherwise) that communities rely on to make sense of sickness and death during an emergency. A key point is to select staff who can respect others' beliefs, regardless of whether or not the communicators themselves share those beliefs.

Step 3: determine which factors place people in a community at risk of disease

Communication and community mobilization teams should work closely with epidemiologists to understand and communicate the factors (cultural and otherwise) that place people at risk for becoming infected with Ebola. Team members should clearly understand that Ebola is spread by direct contact with blood or body fluids of a person who is sick with Ebola. A person infected with Ebola virus is not contagious until symptoms appear.⁴ Under current CDC recommendations, people who have had a high-risk exposure (i.e., direct contact with a symptomatic Ebola patient) are actively monitored for illness for 21 days after the last potential exposure. Those who have had some risk of exposure (e.g., travelers to countries with widespread Ebola virus transmission who, while using appropriate personal protective equipment, have had direct contact with a person with symptomatic Ebola) are also placed under direct active monitoring after arriving in the United States. If a contact develops a fever or other Ebola symptoms, that person is immediately isolated, tested, and provided care. If there are no contacts with an Ebola patient, there is no risk of further spread.^5,6

The risk of a sustained outbreak in the United States is very low, and fear and stigma may have a larger impact on communities than the disease itself. Personal security may become an issue in some communities, as contacts may receive threats based on unfounded fears that they could infect others in the community. Contacts of Ebola patients may be under extreme scrutiny by the media. Contacts being monitored for fever or other symptoms may be at greater risk for negative social consequences if they are economically disadvantaged (e.g., unable to stay home from work), lack a support network (e.g., those who are socially or geographically isolated), need support with daily activities because of physical or mental disabilities or medical conditions, or are unable to speak or understand English (Figure 1).

Figure 1.

Information health communicators can use to help community and faith-based organizations understand and address stigmatization during an Ebola response

Step 4: locate communities where information about preventing Ebola and stigmatization is most needed

Staff members should identify areas where information about Ebola is most needed to prevent negative social consequences (e.g., stigma). For example, West Africans living in the United States might be at higher risk for stigmatization. Communities in which they live, work, and receive services can be provided with accurate information about Ebola transmission, including, for example, information that the virus is not spread through casual contact with a person who is not sick or showing symptoms and that people of West African descent are not at more risk for infection than others if they have not recently traveled to the region. CFBOs may be able to help health officials identify and understand communities in greatest need of accurate information about Ebola and the risk of stigmatization. Community information obtained from a single informant or annual report typically cannot address all aspects of a complex social environment. Obtaining information from multiple sources, often using different methods, is potentially more reliable than using a single source.⁷ Information for West Africans in the United States can be found at: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/communication-resources/west-africans-in-usa.html.⁸

Step 5: identify, engage, and collaborate with CFBOs that can help reach and address the needs of affected communities

Some CFBOs serve specific cultural groups, while others are characterized by functional roles. Organization size and budget do not necessarily correlate with the ability to reach communities. Large organizations may have substantial infrastructure and resources, but smaller organizations can be more important in reaching marginalized groups.⁹ Health officials may decide to engage a range of CFBOs to leverage the organizations' different strengths to reach a wider audience.

Collaboration with communities is most effective when health department staff have focused on learning about the cultural and social values and health beliefs of the communities they serve. CFBOs can be vital partners in this learning process. In the absence of a formal sociological or ethnographical community assessment, it is useful to engage community groups, attend community events, and visit neighborhoods to better appreciate specific cultures and values. It is also useful for staff to take a step back and assess how their own beliefs and experiences affect how they see and react to unfamiliar settings.¹⁰

When working with CFBOs, health department staff members should be transparent about their expectations, particularly when resources and funding are involved, because misunderstandings can easily occur. In some cases, clearly outlining expectations in an e-mail may be enough. In other cases, partners may want to use a memorandum of understanding to outline roles and responsibilities.¹¹

Resources are available to assist local and state health departments in building relationships with CFBOs (Figure 2).

Figure 2.

Resources for health communicators on how to work with community and faith-based organizations to prepare for an Ebola response and other public health emergencies

HHS = Department of Health and Human Services

CDC = Centers for Disease Control and Prevention

ASTHO = Association of State and Territorial Health Officials

Step 6: anticipate and identify specific information needs

Communication teams should identify information needs of the community. At the national level, CDC held two calls for CFBOs about Ebola in October 2014 with more than 2,000 individuals representing several hundred organizations across the United States. Communication needs identified during the calls included basic information about Ebola symptoms and transmission, public health policies on travel and contact tracing, strategies for reducing stigma and anxiety, and communication products in plain language. Anticipating communication and language needs can allow community mobilization teams to engage CFBOs from the start of an Ebola response and optimally collaborate with CFBOs as trusted sources of information to deliver messages within their communities. The most current Ebola information and communication resources are available at http://www.cdc.gov/vhf/ebola/index.html.¹

Step 7: work together to develop messages as part of a community mobilization strategy for Ebola response

Effective engagement requires two-way learning. Communication teams should understand both Ebola and their audiences. When developing health messages, they may need to learn more about perceptions of preparedness, disease, and disaster, and the language needs of specific communities.² Understanding health beliefs and language needs can help the team develop messages that are consistent with the community's experiences and expectations. For staff members unfamiliar with a particular culture or faith, it is better to be honest about unfamiliarity, express interest in learning, and ask respectful questions rather than make generalizations and risk creating ineffective messages.

Health departments may choose to take the lead in developing drafts of messages and then share them with community partners for feedback, or they may develop communication materials initially based on needs identified by CFBOs. In other instances, CFBOs may develop their own messages and share them with public health staff members to review for scientific accuracy. It is best to use plain language for these messages so that community members can easily understand them. Messages should:

• Be simple, clear, and direct;

• Use the fewest words needed to convey key information;

• Communicate one to three key points at most;

• Be free of jargon and aimed at approximately a sixth-grade reading level (guidelines on simplifying messages can be found in the U.S. government's Plain Language Action and Information Network Quick Reference Guide¹² and the Clear Communication Index);¹³

• Be translated in appropriate languages for communities; and

• Be framed in positive terms (i.e., focused on what to do as opposed to what not to do).

Step 8: use a variety of methods to convey and amplify messages

Health department communications and community mobilization teams may find it useful to disseminate health messages through existing, established networks (e.g., ethnic media outlets) rather than trying to create new channels. Working through existing networks may better meet partners' needs and help to ensure overall message sustainability. CFBOs can provide important insight into these established networks. For effective communications, health officials should consider engaging at multiple levels. Low-level engagement uses channels such as traditional advertisements, websites, flyers, and press releases. Medium-level engagement uses a mix of indirect and semidirect communication pathways (e.g., prerecorded, widely distributed phone messages). High-level engagement relies on face-to-face, direct communication.¹⁴

Trusted messengers are vital in conveying -information because a message's acceptability is often highly dependent on who delivers it. Trusted messengers can be found among a variety of community groups, including advocacy groups, neighborhood associations, schools, workplaces, assisted-living facilities, caregivers, senior centers, and literacy groups.¹⁵ Useful ways to communicate include mailed newsletters, prerecorded messages from trusted community and religious leaders on a designated call-in phone number, and printed copies of daily teaching guides from trusted leaders. Many CFBOs also use newer communication channels such as text messages, Twitter, and Facebook.

Step 9: monitor and evaluate the impact of health communications and community mobilization to make improvements

Evaluation of communication and community mobilization activities can help identify barriers, demonstrate the need for additional resources, provide evidence of success, help communication teams improve their programs, and encourage ongoing collaborations with CFBOs and other organizations.¹⁶ Many CFBOs lack the staff and financial resources to commit to long-term evaluation. Nevertheless, it is important to include them in evaluations to improve project implementation, ensure buy-in for project activities, and lay the groundwork for future collaborations. Some evaluation metrics can be obtained on Web traffic (i.e., the number of visitors to a particular website), tweets and retweets, Facebook comments, and other social media.¹⁷

Step 10: recognize, publicly affirm, and maintain relationships with CFBOs

Health departments should maintain mutually respectful relationships with CFBOs once the Ebola response has ended. Mutually beneficial relationships may be maintained by acknowledging the contributions of CFBOs and other community members through press releases and organized events, as well as continued engagement and consultation after the response has ended. Maintaining relationships can be difficult amid shifting health department priorities, funding, and staffing. It is helpful for health agencies to designate a staff member to build and maintain partnerships as a formal part of their duty. Long-term commitment by the department's leadership to maintaining community relationships can help sustain these partnerships through times of organizational change.

PUBLIC HEALTH IMPLICATIONS

CFBOs play a key role in reaching communities during an Ebola response. Many of the principles outlined here for Ebola-related communications are already being used in other public health efforts. For example, in efforts to increase seasonal influenza vaccinations, New Jersey health officials helped congregations with translations and information sharing to communicate with segments of a population that have been difficult to reach using traditional means. In another example, the Arkansas state health department worked with CFBOs to refute myths that were hampering communications. They can now work with these CFBOs more readily during public health emergencies (Unpublished data. ASTHO. Public health and faith community partnerships, 2014).

Partnerships with CFBOs remain an underdeveloped resource in health communications. If collaborative efforts are effectively initiated before a case of Ebola is detected, health departments can activate networks and convey timely health information to communities during an Ebola response.