|Proceedings of a Workshop—in Brief|
Building Trust in Public Health Emergency Preparedness and Response (PHEPR) Science
Proceedings of a Workshop—in Brief
On March 29–30, 2022, the National Academies of Sciences, Engineering, and Medicine hosted a workshop aimed at examining the roles of trust and trustworthiness in the public health emergency and response (PHEPR) science enterprise—the institutions, the research process, and the researchers and practitioners—across the continuum of preevent, event, response, and mitigation.1,2 The first day examined issues of trust in PHEPR science, where they originate, and what can be done to build and maintain trust in public health agencies. The second day shifted discussions to communication and strategies to address misinformation and ensure clear understanding of public health communications. The final session allowed workshop participants and public attendees—through an interactive Miro board session—to reflect on workshop discussions and share strategies to build public trust, what they can do in the next year, and what they can do in the next 5 years.3 This Proceedings of a Workshop—in Brief summarizes the presentations and discussions that occurred at the workshop. It reflects the knowledge and opinions of individual workshop participants and should not be construed as consensus among the workshop participants.
DETERMINANTS OF TRUST IN PHEPR SCIENCE
To explore the determinants of trust in PHEPR science, workshop participants discussed root causes of mistrust as well as the ability to define and measure trust and mistrust. Sandra C. Quinn, professor and chair at the University of Maryland School of Public Health, emphasized that “having trust in the science that underlies how we respond to an event is key to an effective response.” However, Brian Castrucci, president and chief executive officer of the De Beaumont Foundation, shared that the lack of public trust in PHEPR science still remains a barrier to action. Reuben Warren, professor and director of the National Center for Bioethics in Research and Health Care at Tuskegee
1 The workshop agenda and presentations are available at https://www.nationalacademies.org/event/03-29-2022/building-public-trust-in-public-health-emergency-preparedness-and-response-phepr-science-a-workshop (accessed May 25, 2022).
2 The scientific evidence base that guides and informs the actions of local, state, tribal, territorial, and federal public health agencies and how they respond effectively in the midst of a public health emergency.
3 The workshop Miro Board is available at https://www.nationalacademies.org/event/03-29-2022/building-public-trust-in-public-health-emergency-preparedness-and-response-phepr-science-a-workshop (accessed May 25, 2022).
University, framed the concept of trustworthiness around the context of ethics, specifically public health ethics, which he explained “places its emphasis on the ethical problem related to the interest and health of groups, the social justice of the distribution of social resources, and the positive or social rights of individuals.” He pointed out that an individual may be credible and trustworthy but may be operating within an institution that is not trustworthy, which compromises their position.
Exploring Historical Roots of Trust and Mistrust
Marian Moser Jones, associate professor at the College of Public Health and the History Department at The Ohio State University, discussed historical roots of trust and mistrust in science during public health emergencies, saying that the type of emergency can often influence the public’s trust towards public health efforts. For example, emergency response efforts to hurricanes or emergency sanitation are not often met with resistance, but response to a disease outbreak is, she said. This was evident in smallpox outbreaks in the late nineteenth century where vaccine campaigns had been widely adopted and accepted until the introduction of mass distribution of printing and newspapers that were responsible for spreading antivaccination propaganda, she explained. Jones also pointed out that newspapers were also responsible for the spread of misinformation surrounding cures during the influenza pandemic of 1918–1920. In addition to misinformation, timeliness also presented as a barrier to effectiveness during the 1918 pandemic. Jones said:
[During the 1918 pandemic] the local health officials had a lot of respect from politicians, from local charity leaders, and from local education leaders, and in many cities the issue was that they did not react quickly enough.
Defining and Measuring Trust
A lack of standardization for measuring trust and the public’s misunderstanding of what public health is has been a contributing factor to untrustworthy relationships between communities and public health experts and officials, said Alan Leshner, chief executive officer emeritus of the American Association for the Advancement of Science. While there have been many attempts to gauge the level of public trust, there is no uniform standardization when it comes to measuring trust, he pointed out. Leshner proposed three guiding factors in defining and measuring trust:
- Do you believe scientists are telling the truth?
- Do you like and respect scientists?
- Why is the public not following the science or implementing recommendations?
In addition to defining and measuring trust, the public must have a clear definition of what public health is to engender trust in public health science, Castrucci said. Alonzo Plough, vice president of research evaluation-learning and chief science officer at the Robert Wood Johnson Foundation, discussed the Los Angeles Community Disaster Resilience Project,4 which discovered the local public did not have a clear definition of public health and did not know who key players were in emergency response. The project then used local public health nurses as community allies to educate the public and build trustworthy relationships. Plough said that by creating clarity around the definition and measurement of trust, more effective solutions can be created to increase trustworthiness and action.
ASSESSING CURRENT KNOWLEDGE AND ATTITUDES TOWARDS PHEPR PRACTICE AND SCIENCE
Workshop panelists discussed current knowledge and attitudes towards PHEPR practice and science. The public’s attitude and level of trust towards PHEPR practice and science can be dependent upon the public health crisis, said Raphael Barishansky, former deputy secretary for health preparedness and community protection at the Pennsylvania Department of Health. For example, the public’s biases in the COVID-19 pandemic seemed to center around fluctuating guidance while the biases during the opioid crisis were influenced by people not understanding the crisis and the government response to the crisis, he explained. Cary Funk, director of science and society research at the Pew Research Center, shared that the importance of a trustworthy
relationship between communities in need and public health officials and experts was made abundantly clear in the COVID-19 pandemic. “COVID-19 has been an emergency on steroids, and it has brought into sharp relief the importance of trust between communities in need and the officials and experts trying to address those needs,” Funk said. She said “Trust is dynamic—it goes up and down over time, and public trust is rarely uniform. There are important distinctions among the public on their levels of trust.”
Gillian SteelFisher, senior research scientist at the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health, described a survey that revealed doctors scored high in trustworthiness.5 SteelFisher contributes this to the personal relationship doctors have with patients or “science embodied with compassion.” SteelFisher said:
So as we think about how to build trust in science and institutions of public health and public health research, it is inherently part of having an agenda that is community centered, that is trustworthy, that is compassionate.
CAUSES OF LOSS OF PUBLIC TRUST IN PHEPR SCIENCE AND PRACTICE
Panelists discussed the root causes of public loss of trust in PHEPR science and the varying factors that influence mistrust. To help provide framing to the discussion, Leshner defined lack of trust as being influenced by four factors operating simultaneously: misinformation, politicization, economic inconvenience, and inconsistent messaging from the public health science community.
Laura Bogart, senior behavioral scientist at the RAND Corporation, explained that mistrust can be a normal, adaptive coping response which, when channeled effectively, can promote resilience and empowerment by catalyzing change at the individual and community levels. It can empower a patient that may have experienced discrimination in health care to ask questions, get a second opinion, and advocate for themselves, she explained. For example, on a community level, mistrust in governments and health care systems has led to the formation of community collaborations led by Black and Latinx individuals to address health care barriers and vaccine access.
Brian Castrucci stated that the institutionalization of misinformation is a strong contributor to the growth of public mistrust in PHEPR science. Combatting misinformation starts with clearly defining what qualifies as misinformation, said Jon Roozenbeek, postdoctoral fellow at the University of Cambridge, and Tara Kirk Sell, senior scholar at the Johns Hopkins Center for Health Security, during their panel discussion. Sell described an analysis of misinformation during the Ebola crises of 2016 that resulted in the categorization of rumor types: false theories, information that mischaracterizes the disease or protective measure, scapegoating, and conspiracies. Within the analysis, about 10 percent of sources were found to be false or partially false, which is important to recognize because content can be both partially accurate and misleading thus pulling the public away from the best information (Sell et al., 2020). Similar patterns of mis- and disinformation were seen in the COVID-19 pandemic, and an analysis of the cost of mis- and disinformation related to nonvaccination in the COVID-19 pandemic revealed an estimated cost of $50 to $300 million every day (Bruns et al., 2021), stated Sell.
The state of the current information ecosystem has fueled misinformation and mistrust by creating confusion on who the public should trust, explained Briony Swire-Thompson, senior research scientist of the Network Science Institute at Northeastern University. For-profit, often predatory, journals may publish misinformation that can even appear in scientific database searches, and there are no systems in place to filter or prevent them. Retracted articles often make their way back into circulation even if they were retracted for inaccuracies or fraud, she explained. When identifying accurate and inaccurate information, time should be considered a critical element as science that
5 Dr. SteelFisher’s workshop presentation and description of the survey is available at https://www.youtube.com/watch?v=I013KNvO6W-g&list=PLGTMA6QkejfhYndW_nMnTZqse_Uy9ethe&index=3&t=2s (accessed May 20, 2022).
could have once been true may be outdated, said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Identifying information as outdated versus labeling it as misinformation is important so public health institutions do not lose credibility, he said.
Umair Shah, secretary of health of the Washington State Department of Health, pointed out that the communities that have been disproportionately affected by COVID-19 are the same communities that have also been targeted by misinformation and disinformation efforts. Trustworthiness is a main component in the correction of misinformation, said Thompson. Efforts should be made to increase public resilience so people can recognize and discern misinformation from credible information, explained Sell. Wilma Wooten, public health officer of Public Health Services at the County of San Diego, discussed an effort made by her county in which it created a website that provided guidance on how to find credible sources of information, COVID-19 claims and facts, and frequently asked questions.6
Poor Communication and Science Translation
Enola Proctor, professor at the Brown School at Washington University in St. Louis, and Michelle Andrasik, director of Social & Behavioral Sciences and Community Engagement at the COVID-19 Prevention Network, both agreed that a source of confusion and threat to trust in science in emergency situations like the COVID-19 pandemic has been changing public health messaging. However, Andrasik pointed out, this is an expected result of the scientific process yielding new understanding and science.
Divides between scientists and communicators have also contributed to poor communications and translations of sound evidence, said Mitch Stripling, director of the Pandemic Response Institute at Columbia University. The lack of a trusting relationship between scientists and communicators can result in ineffective strategies that do not lead to action, he said. Stripling said:
If we entrust those community ambassadors to go out and do the work as they know it within the community, not trying [to] put guardrails around them, that helps us to stay operationally nimble because we can also listen to what they’re saying and so that lets us kind of dial our operations up and down.
Political Narratives and Science
Castrucci discussed how the institutionalization of misinformation drives mistrust and how popularity and personal agendas in politics are prioritized over public health science. This can fuel misinformation and confusion and cause the public to lose credible perspectives on public health institutions. He shared that “the seed of mistrust…was planted long ago with the use of the term alternative facts [and] that broke science because now there cannot be truth and there cannot be facts.” Funk explained that in the beginning of the pandemic there was overall support for public health officials from Republicans and Democrats, but as of January 2022, 69 percent of Democrats said that public health officials were doing either an excellent or very good job or good job, but only 26 percent of Republicans said the same, which is down from 84 percent at the beginning of the shutdowns (Tyson and Funk, 2022). However, Funk cautioned against overgeneralizing these patterns and emphasized that there is no group that is monolithic in their views, and that views can fluctuate.
Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, also stated that public health officials are being bullied and threatened more than ever, which has led to terminations and resignations forcing them to make the decision to choose between science and maintaining relationships. He acknowledged that while many public health leaders working at the state level are science and evidence oriented, they have to balance their recommendations with the political environment in order to sustain buy-in from leadership.
Diverse Perspectives of Mistrust and Distrust
The dynamics of trust are influenced by factors such as rurality, organization, race, ethnicity, gender, religious beliefs, and education level, said Orriel Richardson, vice
president of Morgan Health. However, trust in science has eroded in minoritized communities, rooted in both egregious historical mistreatment and the continued daily discrimination faced in the health care system, said Andrasik. Hispanic communities have reported avoiding vaccination owing to fears around deportation and inquiry into immigration status even though health agencies should not be asking for that information, said Emily Brunson, associate professor at Texas State University.
She then discussed the efforts of CommuniVax teams in Prince George’s County, Maryland, that revealed many black residents reported their local and state public health departments had been “missing in action” for years. While this perspective is likely attributed to the lack of funding for public health agencies, residents saw this as a reason for mistrust because other public health issues such as type 2 diabetes, heart disease, and access to care had been ignored. Likewise in Alabama, many black communities referenced the Tuskegee syphilis study when discussing COVID-19 vaccinations, said Brunson. “Nobody wants to go back to normal because back to normal means far too many Black and Brown people live sicker and die younger,” said Stephen Thomas, director of the Center for Health Equity at the University of Maryland. Similarly, Raymond Foxworth, vice president of the First National Development Institute, cited a survey from indigenous participants in which a quarter of respondents believed they have not been referred to a specialist when needed and 28 percent of respondents cited they had been denied or delayed access to necessary care (African American Research Collaborative and The Commonwealth Fund, 2021).
Because of these perspectives within tribal communities, establishing continual engagement with local communities should be a priority as health information from trusted members within the community is often received better, Brunson explained. According to Amber Anderson, research epidemiologist at the University of Oklahoma Health Sciences Center, the Association of American Indian Physicians has a COVID-19 response campaign that includes videos from indigenous providers nationwide encouraging indigenous peoples to get vaccinated, as well as providing a culturally branded website to educate and provide resources to community members and tribal leaders.7
POTENTIAL STRATEGIES FOR (RE)BUILDING AND MAINTAINING PUBLIC TRUST IN PHEPR SCIENCE
To combat the loss of trust and misinformation related to public health, panelists discussed strategies to rebuild and maintain public trust in PHEPR science. Trust should be a deliberate and intentional component of any public health policy initiative, said Francisco García, deputy county administrator for community and health services and chief medical officer of Pima County. “If we don’t start with trust as a foundational principle or as a foundational element you will have lost the battle even before you start,” García emphasized. Andrasik pointed out that because trust is dynamic and can fluctuate amid a crisis or emergency, timely responses that identify gaps in response efforts and formulate plans that tap into community strengths are crucial. For example, Andrasik’s organization, the Fred Hutchinson Cancer Center, has been working with communities around the country on HIV vaccine research since 1999, so when it was asked to pivot to COVID-19 vaccine research the process was relatively seamless. Since the center had been working with those communities for decades, it already had an established network of trust. It achieved this trust by involving community members as part of the research protocol teams, incorporating the use of community-based practice research, and having community members review materials before they are disseminated. When initiating COVID-19 vaccine research, the center reached out to community partners to ensure that clinical trials, expert panels, and community advisory boards were inclusive and diverse. This resulted in a large number of Black, Brown, and indigenous people enrolling in the center’s trials.
It is also important for public health leaders to “show up” and take responsibility for their institution’s histories, even if the present team was not responsible for past failures, said Valenzuela. Admit past mistakes and failings of public health entities, whether it is federal, state, or local, and show evidence of change
in future efforts, said Jennifer Kiger, director of the COVID-19 Division at Harris County Public Health. Shah said:
Building confidence and trust we know is hard work. It’s longitudinal work. It doesn’t happen overnight, but losing this confidence and trust can happen quickly, and that’s one of the challenges that we’ve seen in our country.
The Washington State Department of Health implemented several initiatives to help build trust among the public to increase COVID-19 vaccination uptake, including the Power of Providers Initiative and the Care-a-Van effort.8,9
Sustainable Community Engagement and Decision Making
Cultivating relationships as an investment in relational infrastructure with community stakeholders must be an ongoing, intentional process and not something initiated at the time of an emergency declaration, explained García and Matias Valenzuela, director of the Office of Equity and Community Partnership of Seattle and King County Public Health. During a panel discussion, Cathy Slemp, former commissioner and state health officer of the West Virginia Bureau for Public Health, and SteelFisher emphasized the importance of dissolving the idea of us and them between governments and people in communities and reframing the dynamic as a collaboration to cosolve issues and having initiatives that are community led. Ysabel Duron, president and executive director of the Latino Cancer Institute, said:
Community-based organizations, particularly those run by communities of color, are a reflection of the loss of belief in the system because they had to continually build out their own assets to respond to their own identified needs because systems were not listening or they failed them. But now that these organizations are built, it would be beneficial for public health, academic, other social and civic organizations to engage and partner with these community groups.
Anne Zink, chief medical officer of the State of Alaska; Lindsey Leininger, clinical professor at Tuck School of Business Dartmouth University; Supriya Bezbaruah, team lead of science and knowledge translation at the World Health Organization; Marian Moser Jones, associate professor at The Ohio State University, and Foxworth agreed that building and sustaining long-term relationships with community groups and small businesses that exist outside the boundaries of public health work are key factors in responses and communications during emergencies. This was successful during efforts by the National Health Service in the UK and in San Diego where local institutions such as faith-based organizations were involved in the vaccine rollout, said Roozenbeek.
Engaging Community Health Workers
Emphasizing the concept of community engagement, panelists discussed the importance of collaborating with trusted community leaders and community health workers (CHWs) as messengers of PHEPR science and efforts. Because CHWs are trusted members of the community and many have been trained on how to deal with behavioral health issues, as well as disaster preparedness and recovery, they can serve as an intersection between doctors, patients, and researchers, explained Venus Ginés, president and founder of Día de la Mujer Latina. Tribes have successfully disseminated public health information through Native American health workers and tribal leaders, who are ranked high in trustworthiness, said Foxworth. In engaging with CHWs, it is essential they remain active members of the community and do not become embedded into existing systems because their active community roles are what make them valuable and insightful partners, said Duron.
Trusted Community Leaders as Key Messengers
Andrasik stated that any community advisory board must have representatives from grassroots and faith-based initiatives to serve as key messengers. Trusted leaders will look different for every community. Thomas described a University of Maryland Center for Health Equity initiative, which aimed to build relationships
between black communities and local medical systems and public health departments. Black barbershops and beauty salons, which are pillars of trust in Black communities, became settings for clinical services and clinical trials. They pivoted this relationship from health disparities to a COVID-19 vaccination campaign and recruited more than 1,000 barbershops and beauty salons across the nation into the network. Zink also shared a collaboration between an Alaskan state health representative and a local whaling captain in which the captains acted as collaborators and messengers for public health initiatives because of their high levels of trust in the community.
Panelists also discussed strategies for regaining trust lost amongst communities in the United States. Amber Anderson said:
Given the historical context of these relationships, trust is often easily earned, but also very easily broken. And so these concepts of reciprocity and equitable contribution are critical to sustaining relationships with tribal nations.
Because of this, ongoing authentic community engagement and empowerment is key to rebuilding trust, agreed Anderson and Bogart. Engagement should include needs assessments, understanding the sources of mistrust, resources, capacity building, and transparent data and information, as well as allowing the community to lead the way, Anderson said.
I think one of the things that we hear commonly from the community is that accountability is extremely important…We’ve created a new accountability tool. In our pandemic and racism advisory group, we take the lead from community leaders. They represent the steering committee—a super majority—and we’ve worked with them on multiple policies from early on in the [COVID-19] mask directive.
Lisa Letourneau, senior advisor at the Maine Department of Health and Human Services, discussed focus groups and listening sessions that were held with racially and ethnically diverse populations in urban areas as well as with rural, mostly White populations to discuss the COVID-19 pandemic. Letourneau and her colleagues learned early on that their constituents needed more ownership of issues. This understanding allowed Letourneau and her colleagues to direct resources more appropriately and to establish contracting structures with ethnically and community-based organizations, ultimately resulting in contracts with 35 community-based organizations to create social service support that largely used CHWs in COVID-19 prevention and response efforts.
Improving Translation and Communication of PHEPR Science Information
PHEPR science messaging should be culturally appropriate, accurately translated, and delivered by a workforce that reflects the languages of the receiving communities, said Ginés and Christian Capo, health equity manager of East Harris County Empowerment Council. Public health programs and communications should consider the diversity of audiences, including factors such as age, income level, ethnicity, immigration status, and rural versus urban versus suburban, Capo further explained. To be successful, Bogart recommended using positive framing that presents transparent messages, channels community strengths, promotes holistic health, acknowledges sources of mistrust, and is nonjudgmental and nonconfrontational.
Amy Acton, former director of the Ohio Department of Health, and Wooten emphasized transparency, vulnerability, and empowerment as core principals in public health communications and the ability for experts to admit to not knowing the answers when the data is not clear. Communication strategies for leaders should shift the focus from the disaster to the individual, which contributes to building relationships, said Warren. Anderson described a concept developed by an indigenous elder, Alberta Marshall, called “two eye seeing,” which combines the acknowledgement of strengths in both
Western and indigenous perspectives as an approach to serving communities and public health.
Anita Chandra, vice president and director of social and economic well-being at the RAND Corporation, highlighted how public health data sharing could improve translation and communication of scientific findings, and while there has been some progress with data transparency and data sharing, there has been less consideration of how civil society organizations can help contextualize the findings within the history and culture of communities and take an active role in translating data to action.
Addressing the Information Environment
The current environment for communication of PHEPR science information has been heavily affected by politics, pandemic fatigue, messaging fatigue, and misinformation, said Bezbaruah. Efforts should be made to get ahead of misinformation by prebunking common conspiracies and myths, said Roozenbeek. However, efforts to combat misinformation should also go beyond addressing falsehoods and address real concerns and hesitancies the public has around recommendations, said David Broniatowski, associate professor at the School of Engineering & Applied Science at The George Washington University.
Combatting Inconsistent Messaging
Communication strategies should integrate principles such as empathy, according to Li-Vollmer and Kimberly Henderson, director of communications and community relations at the District of Columbia Department of Health, and consistency, according to Raphael Barishansky, former deputy secretary for health preparedness and community protection at Pennsylvania Department of Health, and Ulie Seal, fire chief and emergency manager of the Bloomington Fire Department. Inconsistency in recommendations and messages to the public can cause loss of credibility, especially when policies do not follow the science, said Meredith Li-Vollmer, risk communication manager of Seattle and King County Public Health, and Barishansky. Messaging should be direct, simple, and relevant to people’s situations.
These guiding principles can be followed by informing messaging strategies with data from frequently repeated surveys or by directly answering people’s questions on social media and communication networks, agreed Wooten and Henderson. Efforts should be made to normalize constantly evolving knowledge with an emphasis that new evidence is a good thing that does not undermine the trustworthiness of science, said Proctor. Maintaining transparency and acknowledging that current guidance is based on the best information currently available is the best method to maintain trust throughout a science environment that is constantly changing, stated Andrasik.
Crisis and Emergency Risk Communication
Crisis communication plans should clarify roles and responsibilities when disaster occurs and include guidance on how to communicate messages, what information is needed, how information will be gathered quickly, what the communication pathways are to other agencies, and how public information materials will be released, stated Henderson. Jeanette Sutton, associate professor at University of Albany SUNY, and Henderson suggested frameworks that include the crisis and emergency risk communication model from the Centers for Disease Control and Prevention (CDC), which is based on the following six principles: be first, be right, be credible, express empathy, promote action, show respect,10 said Henderson. Sutton suggested a social psychology approach to communication strategies for emergency warnings. Research on psychological reactions and behavior of individuals and local populations in disaster have served to develop communication strategies to prevent panic and minimize emotional and psychological failures.
Seal, Sutton, and David Olson, reporter at Newsday, pointed out that it is difficult to convince people of a risk and to take action in a timely manner because people seek confirmation and evidence of risk through multiple channels before they can be persuaded to act. People have to believe they are at risk and that the message is truthful and then personalize the information so they are willing and decide to take action, said Olson. To reduce
the time it takes people to take action, the message style should include the following elements: be from a credible and known source, contain a threat and consequences, define locations and populations, include protective actions, and list the action time and expiration.
Effective methods of relaying communication are just as important as the messaging itself. Stripling pointed out the divide that exists between scientists and communicators can result in public health guidance that is too complex for public consumption. Storytelling should be prioritized in the guidance of PHEPR message creation so it is as valued as public health expertise. A variety of dissemination channels such as social media, peer-to-peer advocacy, social influencers, Black community newspapers, and radio stations should be used and identified in crisis communication plans, agreed Proctor and Bogart. Efforts should be made to create collaborative tools for civil society organizations and community leaders to communicate public health information using local dialects, which is not always as comfortable with governmental public health, said Chandra, Bezbaruah, and Henderson. Leininger also suggested integrating science translation platforms into the public health communications infrastructure so they are backed by public health experts and serve as a medium to relay and translate public health science in times of crises.
CHANGING PUBLIC HEALTH INFRASTRUCTURE, WORKFORCE, AND PRACTICE TO IMPROVE TRUST
Panelists discussed ideas to improve the current public health infrastructure and build a skilled workforce to support practices to improve trust. Chandra said:
We’ve not spent a lot of time in public health schools talking about systems analysis in deep ways, talking about politics and history. That needs to be embedded more going forward in terms of our workforce readiness.
Plough emphasized the need for public health departments to prioritize capacity building efforts so the workforce is trained and has the resources necessary to do predisaster work. “Functional infrastructure and a trained, reliable workforce are of value, and those things require resources,” said Jefferson Ketchell, executive director of the Washington State Public Health Association. To build sustained efforts, Ketchell and SteelFisher agreed long-term funding schemas are needed so response efforts and community partnerships are not dependent on short-term grants. Plescia said:
There is a consistent understanding since the beginning of the pandemic that the shortcoming of public health in dealing with this pandemic is the result of decades of neglect. We have data that show that over the last 10 years there was a 10 percent decrease in funding going into public health.
Thomas emphasized that public health efforts have to be sustainable and holistic to earn and keep the trust of communities or one-off efforts will do more harm than good.
Anderson and Chandra emphasized that continual engagement with community-based organizations (CBOs), CHWs, and community members should be integrated as a core principle in public health efforts and decision making. Warren suggested having “an interface with individuals so that when disaster comes, the focus is not on the disaster but on the individual…the whole notion of parachuting in has tremendous impact, particularly in communities of color.” To support continual engagement as a core principle of public health efforts, engagement should be a priority in workforce trainings of physicians, scientists, and public health practitioners to build trustworthiness and personalization, argued Shah and Leshner.
Andrasik and Shah both agreed CBOs should be a focus of engagement for state-level health institutions and community advisory boards; CBOs should serve as key messengers to the public. CBOs and CHWs that partnered with local health departments proved to be effective in identifying cases during the COVID-19 pandemic, stated Duron. To support the engagement of CHWs, Richardson suggested introducing standardization to the CHW profession in terms of education and developing a national corps of CHWs for emergency preparedness. Community members should also be a part of local public health departments in communities, suggested
SteelFisher. Community-led research initiatives can create culturally relevant public health information that is produced in native languages and disseminated through media and draws on cultural values, worldviews, and belief systems, said Foxworth. CHWs and community ambassadors should be allowed the autonomy to stray from formal communication mechanisms and instead use strategies they know will work in their communities, agreed Stripling and Li-Vollmer during their panel discussion. Duron said:
The challenge here is to make sure that they [communities] are not unappreciated…but in fact, they’re woven into the system not to become, not to be swallowed up by it, but to stand side by side equally and independently.
ENVISIONING THE FUTURE
Abbigail Tumpey, associate director for Communication Science at the CDC’s Center for Surveillance, Epidemiology, and Laboratory Services, highlighted CDC efforts in building and restoring trust in public health, while Quinn summarized several key themes that surfaced throughout the workshop panels and discussions. Tumpey noted that when the Delta variant developed, urgent efforts were taken to conduct focus groups with scientists and communication experts to develop timely, effective communications to urge mask wearing following the “be first, be right, be credible” approach. Efforts to monitor and correct misinformation have also led CDC to undertake a 4-year digital modernization initiative to strengthen digital health communication for both emergencies and nonemergencies. Health equity has also been made a priority, and in addition to the creation of a multidisciplinary team to address health equity efforts across CDC programming, CDC has partnered with AmeriCorps to launch Public Health AmeriCorps, a new pathway program to recruit, train, and develop the next generation of public health leaders, representing the communities they serve. “Health equity must be at the core of everything we do. It’s in our actions and our leadership together that will make a difference,” said Tumpey.
Quinn highlighted the challenge of public information overload, which is further complicated by having multiple public health officials and other leaders communicating simultaneously. She explained that this often stems from the tension between the scientific process, which tends to move slowly, and the need to communicate quickly in an emergency. She shared that official guidance should help communities understand that uncertainty is normal, science will evolve, and change in messaging can be expected. Quinn further stated that efforts are needed to help researchers become more comfortable with speaking to the evolution of science and being able to provide guidance to public health agencies in a timely manner during emergencies. She pointed out that communication is not messaging, but rather “a two-way process of listening, engaging, developing communication tools, having our community partners look at the tools, providing feedback, and tailoring them in ways that makes sense for our diverse communities.”
Quinn noted that better understanding is needed on how to use research to inform science, frameworks, the models that can help and form communications, and our ability to build trust and become more trustworthy. She asked what research can be drawn upon to understand characteristics of trustworthiness in public health agencies and noted that longitudinal research is rare in the context of a crisis yet critical to helping us understand public reactions and how things change over time within communities.
She emphasized that sustained funding underlies all efforts to improve emergency preparedness planning and build community engagement science and relationships. Many local agencies rely on funding sources that are episodic. To build trustworthy community relationships, agencies need sustainable, long-term funding to invest in the building of networks that include ambassadors, promotors, and CHWs. The workforce infrastructures need to reflect the diversity of communities and staff training, which includes crisis and emergency risk communication, new methods of data surveillance, and how to engage with communities. All of these themes serve to improve public trust in PHEPR science, but “to build trust and to be trustworthy means that we need to also be human. We need to have empathy. We need to be able to be honest with what we know and what we don’t know.” Other key suggestions from panelists on strategies to improve public trust in PHEPR science are described in Box 1 below.
African American Research Collaborative and The Commonwealth Fund. 2021. American COVID-19 vaccine poll. https://covidvaccinepoll.com/app/aarc/covid-19-vaccine-messaging/#/ (accessed July 10, 2022).
Bruns, R., D. Hosangadi, M. Trotochaud, and T. K. Sell. 2021. COVID-19 vaccine misinformation and disinformation costs an estimated $50 to $300 million each day. Baltimore, MD: The Johns Hopkins Center for Health Security. https://www.centerforhealthsecurity.org/our-work/publications/covid-19-vaccine-misinformation-and-disinformation-costs-an-estimated-50-to-300-million-each-da (accessed July 10, 2022).
Sell, T. K., D. Hosangadi, and M. Trotochaud. 2020. Misinformation and the US Ebola communication crisis: Analyzing the veracity and content of social media messages related to a fear-inducing infectious disease outbreak. BMC Public Health 20:550. https://doi.org/10.1186/s12889-020-08697-3 (accessed July 10, 2022).
Tyson, A., and C. Funk. 2022. Increasing public criticism, confusion over COVID-19 response in U.S. Washington, DC: Pew Research Center. https://www.pewresearch.org/science/2022/02/09/increasing-public-criticism-confusion-over-covid-19-response-in-u-s/ (accessed July 10, 2022).
DISCLAIMER: This Proceedings of a Workshop—in Brief has been prepared by JUSTIN SNAIR, MATTHEW MASIELLO, MARGARET MCCARTHY, and LISA BROWN as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. The planning committee comprises SANDRA C. QUINN, University of Maryland School of Public Health; DOMINIQUE BROSSARD, University of Madison–Wisconsin; ESTHER D. CHERNAK, Drexel University Dornsife School of Public Health and Drexel College of Medicine; KENNY HENDRICKSON, University of the Virgin Islands; HILARY N. KARASZ, Public Health—Seattle and King County; JENNIFER N. KIGER, Harris County Public Health; RACHAEL PILTCH-LOEB, Harvard T.H. Chan School of Public Health; KAI RUGGERI, Columbia University Mailman School of Public Health; MONICA L. SCHOCH-SPANA, Johns Hopkins Bloomberg School of Public Health; and CATHY SLEMP, Deepa Consulting, LLC.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by RAPHAEL M. BARISHANSKY, Pennsylvania State University, and ANITA CHANDRA, RAND Corporation. LESLIE SIMS, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was supported by the Centers for Disease Control and Prevention.
STAFF: Lisa Brown, Matthew Masiello, Margaret McCarthy, Board on Health Sciences Policy, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine
For additional information regarding the workshop, visit https://www.nationalacademies.org/our-work/building-public-trust-in-public-health-emergency-preparedness-and-response-phepr-science-a-workshop.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Building trust in Public Health Emergency Preparedness and Response (PHEPR) science: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26658.
For additional information on this workshop series, visit https://www.nationalacademies.org/.
Health and Medicine Division
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