TABLE 1.

Factors Affecting the Acceptance of Public Health Messages

Environmental factors	Vulnerable populations are at increased risk from pandemic influenza because of a host of life conditions and environmental factors, including biology, age, gender, immune status, sociocultural behaviors, underlying chronic diseases, and disabilities. In addition, preexisting inequities in resources, significantly higher rates of poverty and near poverty, language barriers (e.g., limited English proficiency), and low rates of literacy influence communication needs. Access to health care, whether it is measured as having a usual source of care, a lack of health insurance, or other indicators, can also be worse for subgroups in these populations.
Social and cultural characteristics	Myriad individual, group, and subgroup differences affect response to infectious disease outbreaks (e.g., perceived gender roles, generational differences, language preferences, religious beliefs, and varying health literacy and education levels). The public health officials at the CDC meeting strongly agreed that there is a need to understand these factors and to develop and aggregate communication strategies that strengthen rather than diminish the value of community beliefs and traditions. For example, in some immigrant and refugee communities, how should our communications accommodate or alter traditional practices such as maintaining private bird flocks, cock fighting, the use of a communal pot for meals, or the 3-day-long funerals that are common in many cultures? Is there an incentive for leveraging these traditional practices as an opportunity to introduce the public health intervention in a culturally palatable way?
Language preferences	Both the appropriateness of the language and the translation of language are important. Ideally, all messages, materials, and documents should be culturally sensitive, match the language proficiency of targeted individuals, and be responsive to the changing conditions and needs of the audience as the crisis unfolds.
Difficulty of and attitudes toward public health interventions	Communication is critical in increasing the understanding, and ultimately the acceptability or unacceptability, of core pharmaceutical and nonpharmaceutical interventions.
	Vaccines: Supplies, access, and perceived effectiveness of vaccines have enormous implications for vulnerable populations because individuals and groups will be required to make decisions and take actions that may be incongruent with their health beliefs and values. Communications that address concerns arising from values, beliefs, and cultural traditions, and that feature spokespersons who are credible from the perspectives of targeted populations, will be more persuasive.
	Social distancing: Individuals who have limited financial means, rely on schools as a food source for their children, or have to work to feed their families may have difficulty following guidance to stay at home. Prepandemic planning and communications need to identify ways to make actions feasible and communications credible.
	PPE: Affordability, accessibility, availability, and appropriateness are real considerations for vulnerable populations in regard to PPE. Equally important are language considerations and ensuring that instructions on how and when to use PPE (e.g., masks, gloves) are clear and workable. Also, messages should inform about resources to obtain PPE if limited income is a factor.
	Hygiene: The concept of hygiene is defined differently across racial and ethnic populations. Moreover, for subgroups with limited economic resources there are real concerns about the cost of good hygiene practices and the amount of money that is required to achieve the standard of hygiene presented by government officials, the media, and others. Another concern is the stigmatizing stereotype that these subgroups may lack basic hygiene because they are poor.

Note. PPE=personal protective equipment.