Effective Health Communication Within the Current Information Environment and the Role of the Federal Government: Proceedings of a Workshop (2023)
Chapter: 7 Capacity: Building Relationships to Enhance Effective Health Communication
7
Capacity: Building Relationships to Enhance Effective Health Communication
Building meaningful relationships and partnerships can increase the contextualization of knowledge, the understanding of and trust in evidence, and the chances that health information can be mobilized when and where it is needed, said Angela Bednarek, Director of The Evidence Project at The Pew Charitable Trusts. Panelists and participants examined challenges and opportunities to foster coordination, collaboration, and partnerships, offering concrete examples from their own work.
Many workshop speakers and participants emphasized the importance of relationship building and engagement for effective health communication, said Bednarek, but they also described the challenges of undervaluing the expertise required to do so. The skill sets, capacities, and organizational configurations necessary to build relationships are not consistently developed or resourced, and information about how to do these things effectively can be difficult to access. Fortunately, this is an area of burgeoning interest and an opportunity for health communication to draw upon insights from other sectors that face similar challenges, such as climate or education, said Bednarek. She noted that, among the funding community, there is both interest and demand for relationship building to help create infrastructure and capacity.
Several panelists offered their relationship-building experiences and research that can inform efforts to improve federal health communication.
RELATIONSHIP BUILDING DURING COVID-19 IN NYC
Janine Knudsen, Head of Clinical Innovation and Population Health at Accompany Health, shared experiences from her previous position as the Medical Director of the Commissioner’s Office Special Operations Team. In that role, she led strategic public health initiatives focused on community health equity during the COVID-19 pandemic. It was an incredibly unique time, she said, with more than half of the agency activated in the emergency response infrastructure. This structure created a melting pot of skills and expertise, gave staff greater flexibility, and allowed for the creation of interdisciplinary teams. The experience, said Knudsen, “opened my eyes to what a government entity could accomplish if it could break free from traditional structures.” In addition to these internal changes to the structure of the public health department, the department was engaging with more outside groups than ever before, including 100 community partners working in dozens of languages, advisory groups representing community leaders, and interagency collaboration across the city. These efforts required a lot of funding and coordination but were worth the investment, Knudsen said. She shared three examples of how the health department built relationships in the community and engaged in bidirectional communication during the COVID-19 pandemic.
A Community Listening Infrastructure
The first example Knudsen shared was from fall 2020, when the first waves of COVID-19 had ended, and the vaccine was on the horizon. The public health department had been disseminating public health messaging for over six months and had received feedback from community leaders expressing their feelings that their concerns were not being heard. The community engagement teams took this feedback as a “call to action,” she said. Community engagement teams partnered with the qualitative data team to establish a community listening infrastructure in the Bronx and Brooklyn, and the teams were “literally walking the streets” asking for feedback and getting a sense of what communities were talking about. Based on these data, the qualitative data team created a report that went to leadership and influenced the outgoing health messaging. Unfortunately, she said, the community infrastructure devolved as the public health department gradually went “back to business,” but the experience demonstrated what can be done when investment is made in new internal structures, qualitative data teams, and community engagement.
The Misinformation Response Unit
The second example involved the public health department’s misinformation response unit. The unit monitored misinformation trends and suggested responses based on behavioral psychology, which was a new type of undertaking for the department. Other organizations, including the Centers for Disease Control and Prevention, Project VCTR (Vaccine Communication Tracking & Response), and the Public Good Project, were instrumental in flagging community conversations related to topics like microchips, reproductive health, and ivermectin. Conversations with trusted community partners revealed that the community did not like the word “misinformation.” In their eyes, said Knudsen, the community had concerns and they were looking for answers. When the public health department did not have answers—which was often—the community looked elsewhere. A related finding was that communities were “deeply unsatisfied” with the way scientists and public health professionals were talking about uncertainty. Community members reported that their questions were often met with “I cannot answer that,” or silence; community members said they needed to hear “We do not know right now,” or “We will get the answer for you.” This kind of honesty and humility, said Knudsen, was what the community really needed at that time, and they did not get it.
Shifting the Power Dynamics with Community Partners
Knudsen said that the public health department had hundreds of community partners, but at first, the staff did not initially fully trust their partners. For example, the department gave the community partners their data, talking points, and materials, but were not necessarily listening to or responsive to the community’s needs. Over time, the department began a power shift, even though it made them “really uncomfortable.” The department began encouraging community groups to create their own materials, without the normal approval process and without the public health department’s name. Although this kind of power shift seems small, said Knudsen, it is necessary to make government more agile and effective. This experience led to a proposal for a city-wide public health corps of community-based organizations and community health workers as a strategy for emergency preparedness. However, the cost for this infrastructure was too high for city government, so short-term grant funding was pieced together to make it happen. Knudsen expressed her hope that, in the long term, sustainable funding can be secured to incentivize this type of interdisciplinary, cross-sectoral, community-based work.
In closing, Knudsen shared the lessons she learned from her experiences (Box 7-1).
CO-CREATION OF HEALTH COMMUNICATION AT THE LOCAL LEVEL
Hilary Karasz, Deputy Director of Communications at Public Health — Seattle & King County and Planning Committee Member, described the value of collaboration to support health communication, from the vantage point of a public health department. King County serves a population of over 2.3 million people, a third of the population of Washington State, with over 100 languages spoken and the largest media market in the region. However, prior to the COVID-19 pandemic, only four or five people were working on communication at the health department. The job of the communication team is broad, including tasks such as responding to media, helping people with health promotion projects, managing the website, and overseeing communications generated by leadership. The staff write the messages, create materials, and distribute materials to media, cities, cultural communities, and elected officials. Given these roles, the communication staff does not have the opportunity, funding, or bandwidth to systematically plan or evaluate their communications, said Karasz. The team is “experienced, capable, talented, and creative” but does not have the skillset or resources to undertake this type of endeavor. Other health departments in Washington State have even fewer staff and resources than Seattle & King County does, and often rely on nurses or other staff to perform communication work.
Federal funding during the COVID-19 pandemic enabled the health department to expand its communication team and work on building community partnerships. A major focus of this work, Karasz said, was co-creation of communications through partnering with community organizations and community members, listening to what information they wanted, and working together to create messages and materials that would resonate with the people they serve. This approach has been “fantastic,” said Karasz, but it requires time, sustainable funding, and close, ongoing partnerships. A potential role for the federal government, she suggested, would be to support these kinds of relationships and expand capacity by working with local health departments as they work with the community.
Despite the valuable partnerships, evidence of the effectiveness of these co-created messages and materials relative to health department-created messages is lacking because the health department does not have the capacity to conduct evaluation. Karasz suggested that partnering with a local academic institution, common in other areas of practice but not in communication, could effectively create capacity. Partnerships between social scientists in academia and on-the-ground communication practitioners have great potential to facilitate more systematic planning and evaluation of communication, she said.
CULTURAL HUMILITY: LESSONS FROM LEADERSHIP DURING SANDY HOOK; FLINT, MICHIGAN; AND ZIKA
Jewel Mullen, Associate Dean for Health Equity at the University of Texas at Austin Dell Medical School, said that some people may consider her a boundary spanner, but creating collaborations may require “boundary dissolvers” who work to eliminate the boundaries that keep people from working together. Drawing on her experience in federal, state, and professional organization leadership positions during multiple crises—the school shooting at Sandy Hook Elementary School, the Ebola outbreak, the Flint water crisis, and the emergence of Zika virus—Mullen shared that she saw the “best and most difficult behaviors of everyone trying to respond in crisis.”
The value of cultural humility in messaging was a particular lesson that Mullen drew from her experiences after the murders of children and teachers in the Sandy Hook shooting. She explained that when communicators and leaders focus on a particular population, they may not consider how other populations might hear the message. For example, she noted that people often said that an event like the Sandy Hook shooting was “not supposed to happen” in Newtown, Connecticut. The implication to mothers in Hartford and New Haven—who were weary of seeing their children die due to urban violence—was that it was supposed to happen in their locations.
In recalling the water crisis in Flint, Michigan, Mullen acknowledged the complexity and challenge for federal health communicators who wanted to respond but noted that sometimes the right experts are not located in health agencies. Honoring the community’s own knowledge and concerns is vitally important, said Mullen. For example, community members knew that something was wrong with their water and wanted to hear from environmental scientists who could confirm their suspicions, rather than hear messages telling them “not to worry so much.” Sometimes the best help from the government is to provide the information and leave communication to others who are closer to the community.
During the Zika epidemic, Mullen was asked to travel to Puerto Rico to speak with the governor and to bridge relationships. Governments were concerned about whether people in Puerto Rico were “taking Zika as seriously as they needed to.” This thinking was insensitive and arrogant in two ways, she said. First, it assumed that the people of Puerto Rico were incapable of understanding a threat to their health. Second, it assumed that the people place the same priority on a health issue as the government does. Mullen emphasized that people around the world care about their health holistically, and do not only consider one issue at a time. For example, there were debates about spraying for mosquitos in Puerto Rico, or about asking people to install screens or close their windows. These debates ignored the
fact that most windows had no way to attach screens, or that people did not have air conditioning and did not want their windows closed. Mullen added that the people in Puerto Rico, like those in Flint, wanted to know about the health risks but also the environmental and economic risks. The process of communication, even during a crisis, needs to start with listening to the community, understanding their concerns and priorities, and thinking before speaking. Sitting with people, being in community, and listening to one another not only makes for tremendous learning, but also takes some pressure off the government. Government leaders do not need to have all the answers because the community can help them figure out the solutions.
EVIDENCE-BASED COLLABORATION
“Collaboration does not happen on its own, even in situations where people want it and would value it,” stated Adam Levine, Associate Professor of Health Policy and Management in the Bloomberg School of Public Health at Johns Hopkins University. Drawing on his scholarship on the science of collaboration and as the founder of the nonprofit organization research4impact, Levine shared critical principles for fostering collaboration and offered examples in which these principles are being implemented in the federal context.
The most visible type of collaboration is the formal variety, said Levine, including projects that entail shared ownership, decision-making authority, and accountability. Informal collaboration, in which collaborators exchange knowledge but do not become interdependent, is also incredibly important. Levine said that both formal and informal versions of collaboration need to be elevated and legitimized. There can be an unmet desire to collaborate, which may result from limited capacity or lack of incentives. However, sometimes collaboration is prevented because new collaborations require strangers to interact for the first time. “Strangers tend to remain strangers if left to their own devices,” he said. Levine’s research has shown that people are uncertain how to relate to one another, and building new collaborative relationships requires overcoming this uncertainty.
Surfacing the desire to collaborate with others and better understanding the uncertainty that people feel about relating to strangers can be a first step toward building productive collaborations, said Levine. To this end, he developed a tool called the unmet desire survey. Organizational leaders and others can use this tool to ask people directly about the challenges they face in their work, the information that would help them, the types of collaborations that would be valuable, and the hesitations they have about interacting with other people. The value of this survey, said Levine, is that it asks the questions people have often not been asked, and it provides actionable information needed for building collaborative relationships. There
are also evidence-based techniques for facilitating matches between collaborators, he said.
Levine shared two examples of federal agencies that are currently piloting unmet desire surveys. The Agency for Healthcare Research and Quality (AHRQ) focuses on improving primary care, which will require new collaborative relationships between practitioners, researchers, funders, and others. AHRQ and Levine are working together to field an unmet desire survey to learn more about what kinds of new collaborative relationships may be important for working toward that goal. At the U.S. Office of Management and Budget, Levine is working to use the survey to advance cross-agency collaboration related to the implementation of the Federal Evidence Act and the White House Year of Evidence.
DISCUSSION
Sustaining Relationships
Participants discussed the challenges to maintaining collaborations with community and external partners that have been supported by emergency funding related to COVID-19, which will soon run out. Karasz replied that the loss of funding will be difficult. Washington State is beginning a process to assure that foundational public health services are present in every county, along with foundational capabilities including policy, community partnerships, communication, and business practices. A “dribble of money” will support these foundational activities, and communication funding will focus on community co-creation work. However, Karasz explained that some activities will also be eliminated by choice. One area on which the health department has decided to spend less time and energy is the use of corporate media to disseminate information. Karasz noted that corporate media are not equally trusted or accessed by all members of the public, so the department is focused on building relationships with multilingual and community media.
Knudsen noted that while public health funding is vital, “it is not all about money.” Her experiences at the health department demonstrated that public health can be promoted by connecting people, dismantling systems and bureaucracy, and giving people free rein to apply their ideas in new ways. Making these changes requires courage, she said, which she has seen demonstrated in stories shared at the workshop. Mullen agreed and said that it is more about “how we do our work differently.” Researchers and public health officials need to do the day-to-day relationship building with communities, rather than “dropping in” with a specific project. Sitting with communities and listening is a “more credible starting point.” Levine said that while informal knowledge exchange collaborations are not costless,
they are a “pretty light lift.” If organizational leaders value, legitimize, and prioritize these types of collaborations, collaborations could be “really impactful.” Bednarek noted that the North Carolina Office of Strategic Partnerships offers one model for building capacity, by involving the state’s research institutions to address questions originating from state government workers.
Partnering with the Private Sector
Discussion also addressed how the federal government could engage and partner with the private sector. Mullen suggested that private-sector collaboration is important, given that the private sector is where the majority of the resources and capacity for innovation are found. However, when considering partnerships with private industry, it is also important to consider shared interests, how a partnership may influence public image and public trust, how it would benefit the public, and how it would benefit research (e.g., access to data and transparency). Levine added that any sort of new cross-sectoral collaboration will include people with diverse interests; making sure that those interests are clearly stated and commonly understood is “absolutely incredibly essential.”
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