Where Do We Go From Here?

As the HHS blog winds down, I will use my last entry here to lay out some ideas for what a comprehensive pandemic flu communications campaign might look like. The plan must address the various layers of interaction: HHS to individuals, HHS to intermediaries who then reach their constituents, and individuals to individuals.

The first — and most obvious — piece that needs to be put in place is a media campaign. The message should probably be an “official” announcement from the CDC or the Surgeon General that makes it clear that pandemic flu is something to worry about, with clear steps that individuals can take to be prepared. This official imprimature needs to be done using a serious tone, combining facts while tapping into the deep-seated values that will get people to take action. The campaign should be customized for various ethnic and language-based groups to ensure that the message is understood by all. In addition to television, radio and print ads, news and entertainment programs, the campaign should include social media outlets as well — creating an ongoing “soap opera” portraying what could happen when a pandemic hits with 3-minute serialized spots on YouTube; a pandemic preparedness blog that provides a more conversational and informal, yet official, source of information and news; targeted websites in addition to the pandemicflu.gov site that tie into the media campaign; and a social networking site that helps people find others in their city or county who want to collaborate on getting their community prepared. This type of campaign will cost millions of dollars, but cannot be skimped on if HHS is serious about this issue.

The second piece — reaching the intermediaries — is what HHS has been focusing on with its Leadership Forum and the toolkits designed for various industry and public sectors. As the word about preparing for pandemic flu comes down from the leaders of each field, professionals will be more likely to accept the new industry standards. Pediatricians may not be comfortable talking with their patients about pandemic flu until the American Academy of Pediatrics has recommended such a discussion. Companies may not think they need to make preparations for keeping their businesses running with a substantial percentage of their workforce absent until they see that other large, well-regarded companies are taking this possibility seriously. The easier HHS can make it for the information to be passed along and acted upon, the better.

This can also be facilitated by building partnerships with businesses like supermarket chains and home improvement stores, who can help get the word out about suggested supply lists with prepackaged kits or sales on key components of a preparedness stockpile.

The third key component of the campaign should facilitate the dissemination of information between individuals. To help empower and harness the energy of the many well-informed citizens who are already working to prepare their family, friends and communities, HHS should create something like a “Citizen Pandemic Preparedness Corps.” Centered around a website and the social network described above, the Corps would have its own online toolkit with a PowerPoint slideshow and presentation script, camera-ready handouts, a speaker’s bureau list, sample letters to the editor and other materials. The website could also provide an online location for people to meet virtually and tools to enable communities to schedule in-person “meet-ups.” Corps members could easily invite their colleagues, community members, friends and family to learn more online and have them then spread the word to their own extended social networks.

The exact content and recommendations that would be included in the messages would need to be determined by HHS, but it should be informed by considering the expertise and concerns of those who have posted many comments here on this blog. HHS, I’m sure, has its own experts on pandemic flu, but they would be well-advised to tap into the vast extended knowledge found in flublogia, whether in a formal or informal way.

I think this blog has served an important purpose as an introduction between HHS and individuals who have already been working to address pandemic flu on their own. This is the beginning of the conversation. Don’t let it be the end.

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Top Down, Bottom Up, Side to Side

Should the emphasis of a campaign to raise awareness of pandemic flu be on top-down government-led information dissemination, or should we rely on grass-roots efforts to spread the word from person to person? The answer is: absolutely!

Much of the limited awareness-building that has happened to date has come from individual concerned citizens who hear about pandemic flu, realize that this is a real threat and take it upon themselves to educate others in their community. But because of the lack of pervasive communications by the government and other high-level credible sources, their exhortations to take action may be dismissed as alarmism.

An effective initiative must use a dual-pronged approach. The institutions and people whom various audiences look up to as credible sources of information about public health issues have to speak out loudly and often about pandemic flu. Right now, the information is available, but only if people go looking for it. These credible spokespeople need to reach people where they are, whether that means having the Surgeon General mailing a postcard to every American household, HHS creating television and radio ads, working with Oprah to do a “community preparedness makeover,” featuring a pandemic flu storyline on 24, or distributing millions of grocery bags with preparedness tips through participating stores.

This blog has been a good attempt at a start to reach out online, though most of the people participating are already knowledgeable about the issue. The PandemicFlu.gov website is an excellent source of information, even if not everybody agrees with the recommendations for stockpiling. However, the site, which looks like it was created by a committee of 20, is crying out for a redesign from a user-centered design standpoint. Anyone who comes to the website without knowing exactly what they are looking for would be overwhelmed by the information overload on the home page. Different audiences need start pages customized to their specific needs, and they should be usability tested with people who are new to the issue of pandemic flu.

A centrally coordinated education campaign that reaches as many individuals and community leaders as possible will go a long way toward creating awareness. But people will be much more likely to take action when they see that other people like themselves are taking the information seriously and getting prepared for the possibility of a pandemic. And speaking with a real person who can answer questions and concerns can break down many of the barriers that keep someone from taking action.

That’s where the grassroots approach comes in. A vibrant and engaged community of concerned citizens has developed over time in various places online, such as the Flu Wiki and the Pandemic Flu Information Forum. On their own, they have come together to share news and preparedness tips, and many participants have tasked themselves with educating their community leaders and neighbors.

Any effective effort should see this group of self-appointed community leaders as the core of a social networking strategy to spread the word from person to person. They are passionate about the subject, and can get the ball rolling through word of mouth if they are empowered through the social marketing equivalent of a “ brand ambassador ” or “customer evangelist” program. Give them resources (e.g., an online social network site, downloadable handouts and presentations, etc.) and official support to help get the word out, and they will be key to reaching local parents, city government officials, service groups, businesses and religious institutions. As other people are convinced through their efforts, they too may become supporters and share the information with their own social networks. I hope that HHS engages rather than ignores their best natural resource.

Although not everyone is online, social media will be a key to reaching large numbers of people and having the message spread. Many people have created and posted videos about pandemic flu on YouTube, which have been viewed thousands of times. There are many pandemic and disaster planning podcasts (no link because I found them on iTunes), blogs and the wiki and forum I mentioned above. A MySpace page could be created with a badge that supporters could put on their own pages that says something like “I’m prepared, are you?” The Florida Department of Health created a humorous campaign to promote hygienic habits geared toward reducing the spread of flu, which includes TV spots uploaded on YouTube and a MySpace profile page for the main character. Outreach to bloggers who reach key constituencies like moms, people interested in health issues, or policy-minded citizens may also result in more awareness.

When credible and urgent messages about pandemic flu are coming from “on high” that have been designed based on input from they people they are intended to reach, and people are empowered to talk to their friends, family and community members about the issue, awareness and preparedness will blossom. But take the grassroots out of the equation and we may be left with lots of words and no action.

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The Road to Preparedness Starts with Awareness

We have a problem. Pandemic flu is not on the radar for most people in this country. It’s not even in the solar system.

I am embarrassed to admit this in the face of all I’ve been learning this week, but until I was invited to participate in this blog, I had never given much thought to pandemic flu. I consider myself pretty knowledgeable about health issues, I’m a member of my local Community Emergency Response Team, I have all my earthquake supplies ready to go, I get a flu shot every year. But I was almost entirely unaware of the likelihood of a flu pandemic, let alone how I should protect my family. If someone like me, with a background in public health no less, is so unaware, we have a lot of work to do.

We can’t realistically expect to jump from a state of almost total ignorance to community readiness in a short period of time. We need to be in it for the long haul. A useful way of thinking about the behavior change process is with the Stages of Change theory, or Transtheoretical Model, that we often use quite effectively in social marketing. This model says that behavior change is not a one-step process, in which first someone is not doing a behavior and then they are. Behavior change is a continuum, in which people move from stage to stage, or they may stop at any point without actually making the change. Knowing what stage they are in helps us determine the correct approaches to use to help them move to the next point.

The first stage is called precontemplation. People at this point are not aware that there is a problem or that they may be at risk, and do not intend to make any changes in their behavior. On the issue of pandemic flu, most people would fall into this group. To move them to the next stage, we need to make them aware of the issue. Greg Dworkin’s excellent post lays out the basics that people need to know before they will be willing to even consider taking action.

The next stage is contemplation, where people now know about the problem and are considering whether they want to do something about it. For this group, show the benefits they will receive from taking action, and demonstrate that people like them, as well as others they look up to, have already made this change. So, we might emphasize the benefits of protecting their family and community, staying healthy and alive, the security of feeling prepared, avoiding the inevitable rush to purchase supplies — whatever works with the different groups we need to reach. We could also share testimonials from real people who have already prepared for a flu pandemic and use spokespeople that each audience sees as credible on this issue.

Once someone decides they want to take the target action, they move into the preparation stage. They start to think about what it will take to do it, whether they are able to do it, and they start to bump up against barriers that will keep them from moving forward. At this point, people need the barriers removed — make it easy for them to do what you are asking and take away all the reasons why they will tell themselves they can’t do it. Someone in the preparation stage might acquire a list of items they need to buy, intending to get them, but run into problems like not knowing where to go to purchase face masks or not having the storage space in their home for so much food and water. We could offer things like prepackaged supply kits that obviate the need to go from store to store looking for the items on the list, tips for how to build up an emergency food supply and store it unobtrusively, fill-in-the-blank preparedness plans that businesses can customize to their own situations, and other effort-reducing approaches.

Once they are prepared and barriers are removed, then people can take action. For a one-time behavior, the action step is the end of the process. But for an action that has to be done more than once over a period of time, they will move into the maintenance stage, which may not have an end-point. Once people build up their food and medication supplies, they will eventually need to replace them with fresh items, and as they move through various life stages their needs may change as well. They will require positive feedback and ongoing motivational messaging to avoid becoming burned out on the process.

Our challenge, then, is to help people move through all of these stages. The first priority, based on where the majority of the population lies, is in raising awareness of the issue — not in getting individuals to take action (yet). We need to use all methods available to shout the message from the mountaintops so that people are as knowledgeable about pandemic flu as they are about the lives of Paris Hilton and Britney Spears. We can work with the news media, professional organizations, schools, entertainment TV (like E.R. or 24), TV and radio talk shows, local emergency response organizations, physicians, boy scout troops, online social networks, blogs, and other means of disseminating information. HHS should consider using the Surgeon General as a prominent spokesperson to underscore the seriousness of this public health issue, as C. Everett Koop did with his brochure on AIDS that was sent to every American household in 1988.

The awareness communications should include a website or phone number, which will then offer the types of messaging and social reinforcement that will bring people to the next step. Different types of approaches can be devised for people in each behavior change stage, as well as for different audiences. Leaders in each sector will need to play an important role in getting the word about about the existence of the threat of pandemic flu to their constituents, and HHS can help to facilitate that. The volume of communications to create the necessary level of awareness will not be cheap.

So far, there have been many great ideas coming out of this blog as to how to get people to take action. But let’s not get ahead of ourselves. The focus right now needs to be on getting the words “pandemic flu” onto the tips of hundreds of millions of tongues.

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Preparing for Persuasion

We don’t know exactly what a flu pandemic will look like or when it will come, but we do know enough to be able to put systems in place so that we’re ready. Because we will not be able to rely on the government to take care of everyone when the pandemic comes, we need to make sure that citizens, schools, businesses and other organizations are prepared beforehand and take appropriate actions to mitigate its effects throughout its duration. How do we persuade people to do the right thing?

Generally, governments and organizations have used three ways to bring about social change or action on a broad scale. First, through education — telling people the facts and hoping they will do the rational thing to protect their families and others. Providing lists of supplies, statistics about likely morbidity and mortality, and medical symptoms are all part of the educational approach. Unfortunately, as we know from issues like smoking and exercise, knowledge is often not sufficient to bring about behavior change. Second, coercion by passing laws or enacting policies at the governmental or organizational levels can be very effective. This method might be necessary to enforce quarantines, but we can’t very well legislate the purchase of an adequate supply of emergency food by each household. The third approach is social marketing, persuading people to take action by appealing to their values and emotions by “selling” the desired behaviors using the same effective techniques as companies like Apple or Nike.

Social marketing brings about change by promoting the benefits that are most appealing to members of the target audience, whether it’s that pandemic preparedness is just another way to be a good parent or that other people like themselves have already bought their supplies and think they should too. It also focuses on identifying the reasons why people are not taking action and figuring out ways to remove those barriers — packaging supplies in an easy-to-buy kit, relating pandemic preparedness to planning for more familiar natural disasters (e.g., earthquakes, hurricanes, etc.), or using the flu epidemic of 1918 as a way of making the potential devastation less abstract.

When most people hear the word “marketing,” they think of things like commercials and billboards. Yes, communication is usually a big part of marketing, but it is just a piece of the puzzle. The marketing approach also offers us a strategic way to think through all the aspects of convincing someone to take action. Some of the questions we would need to answer include:

• Who are each of the key groups who need to take action? (e.g., parents, seniors, school administrators, local government officials, business managers, etc.)
• What exactly do you want each of those groups to do? (e.g., purchase a 2-week supply of food and water for each member of their families, practice good hygieine habits, have a formal school closure plan that will be triggered by a particular threshold, etc.)
• What are the key practical or emotional benefits that would motivate each of these groups? (e.g., feelings of responsibility, desire for social acceptability)
• What are the barriers to taking action, and how can we remove those barriers? (e.g., not seeing flu pandemic as real threat, hassle of buying all the supplies)
• What are the times and places we can best reach each audience, particularly when they may be thinking about flu, family health, or disaster preparedness issues? Are there places they may be in a position to take action? (e.g., at a home supply store, at a pharmacy)
• What are some of the methods we can use to reach each of the audiences with our messages? (e.g., online social networks, blogs, Oprah, school district newsletters)
• Who are the spokespeople that are seen as most credible by each audience? (e.g., local officials, doctors, peers)
• Who are the partners that we need to hook up with in order to best reach each audience? (e.g., doctors, “mommy bloggers,” media organizations)

Now is the time, before the pandemic comes, to set good habits, get supplies in place, and establish social norms around the actions that will help people survive. We may not want to even necessarily talk about these things in the context of a flu pandemic, if we find that this concept is too foreign for people to connect with, but relate it to general emergency preparedness or good health habits. I see a parallel with the hype and hysteria around global warming, which makes many people tune out when its proponents could more effectively convince people to take energy saving measures for more concrete reasons like reducing our dependence on foreign oil or preventing environmental damage.

I will admit that I am not an expert on pandemic flu, so I will now turn it over to the rest of you for your comments. How do you think we can apply the strategic issues I’ve posed here to marketing pandemic flu preparedness?

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