Good afternoon. I'm Kellee Waters, a health communication specialist In CDC's Center for Preparedness and Response, Division of Emergency Operations Thank you for joining us for today's webinar on overcoming message resistance. If you do not wish your participation to be recorded, please exit at this time. 

You can earn continuing education by completing this webinar. Instructions on how to earn continuing education can be found on our website: emergency. cdc. 

gov/epic. The course access code is EPIC1023, with all letters capitalized. To repeat, the course access code to receive continuing education is, in all caps, EPIC1023. 

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Today, we are going to discuss some challenges to messaging during an emergency and some strategies for overcoming message resistance. We're fortunate to have Dr. Christine Prue with us to share her perspective on this subject based on her experience working in behavioral science and on public health emergencies. 

Dr. Prue currently serves as the associate director for behavioral science at CDC's National Center for Emerging and Zoonotic Infectious Diseases. She works to apply and advance the science of health behavior and health communication to prevent and control infectious diseases that result from the interaction of people, animals, and the environment. 

Dr. Prue has a diverse portfolio of applied research projects supporting programs addressing food safety, vaccine safety, one health, Lyme disease, and viruses including rabies, Ebola, and Zika. Dr. 

Prue has expertise in program evaluation, risk communication, and scientific and health literacy. She is the coauthor of CDC's Clear Communication Index Dr. Prue uses her evaluation expertise to help NCEZID's programs build in feedback loops to ensure that interventions are working as planned. 

Dr. Prue has mentored nine evaluation fellows over the past 5 years. Thank you for joining us Dr. 

Prue Glad to be here, thank you for inviting me. To begin, I'm going to outline some of the challenges communicators face when messaging during an emergency. If it's alright Dr. 

Prue - may I call you Chris? Absolutely I'll ask for your insights throughout the presentation. Overcoming message resistance. To begin with, we're going to discuss how the challenges that communicators face in. 

public health when they're, um, overcoming messaging resistance. During public health emergencies, response organizations share advice with affected communities to help them reduce harm and even save lives. People often receive and understand these messages but still don't take the recommended actions. 

Today's webinar will draw upon communication science, behavioral science, and the experiences of emergency responders to offer some best practices for overcoming message resistance. Chris, can you give us a little bit more insight into what we're going to cover from your perspective? Yeah. Um, I love the title of this talk because it talks about, it uses the phrase "message resistance" and One of the things that I want to, sort of, challenge in using that phrasing, resistance is that, something. 

I've been working on the Ebola outbreak for the last 14 months in DRC and often times when public health folks make recommendations, when people don't immediately respond the way we want them to do, we call it resistance. And, working with colleagues on the Red Cross and WHO and Unicef we quickly realized that we can't just keep blaming the community for not doing what we want them to do. We really needed to understand what was really going on, and that's what behavioral scientists do is we want to dissect and discover what it really, what's going on in communities because communities are smart. 

They live and thrive. They know what the ins and outs of their communities. And sometimes our recommendations don't actually interesect with their culture or their context, their history or their politics, all the stuff that makes up community. 

So, in the course of this outbreak, we haven't even had time to write this up, but we developed a new framework. We call it the four Rs framework. Because soemtimes we make behavioral recommendations or actions that will support people and help protect them from threats like Ebola or Zika or anything, and they will receive that recommendation and they'll act on it. 

So, that's great. Reception is the first R. The next R is reluctance. 

And, this is a normal response when somebody's asking you to do something you may have never done before and can't figure out, well, why are they telling me to do this? And, it's a notion of, hey, you're telling me to do this thing but I don't understand why or or how, or. I have a bunch of questions and I need more answers. So, that's the second R, and that is reluctance or reticence. 

sort of this, hmmm, haven't made a decision about anything yet but I need more information before I decide what I'm going to do. The third R is refusal, and that is somebody who says, hey I heard what you told me to do, I've got all my questions answered, and, you know what, I'm choosing not to do that for whatever reason. We live in a society that allows people to choose their actions. 

So, this third R is acknowledging that some people will choose not to follow a public health recommendation. And they'll also feel the consequences of that choice. And then the fourth R gets to what you have in your title, the resistance. 

This is a group of people who not only have refused it for themselves but want to actively encourage other people to refuse too. Or, even create obstacles for others from receiving information or receiving the interventions that are being offered. In the Ebola outbreak in DRC that has, resistance has happened We've had violence. 

We've had groups sort of prevent vaccine teams from getting from here to there, or other places, and that is a real definition of resistance. Not only do I not want it for myself, I want to actively prevent other people from receiving So, we have a very gradated or graded notion of different types of reactions that community members can have towards the recommendations that us public health folks make. And, I think it's, SPEAKER:  These are all legitimate and appropriate actions so having more specificity about the actual response or reaction of communities can help us address what the issues are. 

Calling everything resistance is not helpful. You've got a group of em poowho just need more information then that's really actionable on our part. If you have people who say I don't want this then respecting that or finding ways to reengage them to say help us understand your thoughts and let's reengage on a regular basis to see if we can overcome the obstacles. 

And getting to a place where we have to acknowledge where not everybody's going to do what we want them to do. SPEAKER:  Thank you. Throughout this discussion today I hope you bring in all those, not just resistance but the other Rs you talked about. 

Moving on with our discussion today we're going to talk a little bit about a subject. Some of you may have heard in other webinars that we've hosted it's a little bit of a review about how CDC communicates in a crisis so that we'll have some context for understanding Chris' recommendations for over coming communication challenges. So what is important to understand is that communicating in a crisis is different. 

We don't have the same kind of time in a crisis to develop messages and to test messages that we might outside of a crisis. People are taking in information differently. They're getting inundated from information from friends from family from news from colleagues from all different sources and it's a lot for a person to have to take in and process so they're only really able to process so much of that information that they take in. 

If they're only processing a fraction of that information what they're able to act on is a small percentage of all the information coming at them and relying on people who have been affected by an emergency to determine which pieces of information to listen to and which pieces of information not to listen to. How to interpret those pieces of information is a lot to ask of them. That I have been through something traumatic and it's up to us as communicators to consider peoples unique situations and their unique needs in persons and makure messages as simple and easy to understand and hopefully act on as possible. 

Communication sciences and years of emergency response experience tells us that the right message delivered at the right time by the right person really can save lives. So what we say and when we say it and who that message is delivered by. Whether it's someone that a community trusts to get information from is crucial in communicating during an emergency. 

We're going to discuss the six principles of crisis and emergency risk communication now and this is a whole course in and of itself but I'm going to go through a quick over view so we can get to talking to Chris about some of the challenges that come with incorporating these six principles. Outlines six specific principles to help communicators effectively message during all kinds of crisis. These principles have been demonstrated to help communicators stay organized and consider the of the audiences that they're speaking to. 

However as we're going to discuss you may find yourself with challenges. Number one is be first. Doesn't mean you have to be the very first person out there. 

They're going to be the eye reporters, they're going to be the web cams from bistanders. What it means is we need to be first in our lane. So when CDC needs to speak during an emergency we speak to public health issues. 

Going to speak to evacuation issues. We stay in our lane but we want to be prepared to spick to our expertise. We want to be ready to talk when something happens so that people will know we're reliable and we're ready to respond. 

We want to be right and that should sound intuitive but we uniquely in a crisis we don't have all the information. We don't have time to confirm everything before we say something. We need to say something whether we know it all or not. 

So be right means yes confirm the facts that we have. Share information that we know to be true but also stating what we don't know and what we're doing to get infer information. Those are three messages right there. 

What we know, what we don't know, and the process that we're taking to communicate. Be credible. Being credible means being honest being forth coming being open about what we're doing to respond to an emergency. 

We have to remember that an emergency isn't a responders Madam Foreman alone we're in a community helping them to recover from an emergency. It's their response they need to have access to what is going on and be included in that discussion. Express empathy. 

Express empathy in this case means to put into words what they're going through. Rather than saying I'm so sorry for your loss say something along the lines of we're all feeling the impact of this emergency. Rather than saying I understand you're scared say this is a scary situation. 

Expressing sympathy identifying the words scary fear anxious it shows that you're paying attention what people are going through rather than just saying it. You're observing it and you're able to give that feedback. Promote action. 

This is what crisis and emergency risk communication comes down to. This is the crucial element of communication in an emergency we want to promote positive public health behaviors we want to protect people from infectious diseases from risks. And this is where we often experience some of our challenges. 

We want to promote actions that we know to be protective and yet they may conflict with peoples cultural they may conflict with peoples politics they may conflict with a communities val jews this is where our discussion with Chris comes in. Hopefully we'll be able to talk some about reasons why we may have a bit of push back in our efforts to do this. The sixth principle is show respect. 

We want to respect everyone we're talking to. This should be a given in any everyday conversation but in an emergency when emotions run high both responders and aforethoughted community members are tense and they are thinking about let's be honest themselves their next task their next meal their next assignment their next living situation. That's understandable. 

We just want people to remember to try to show respect for what each person is going through. Like I said these principles have been shown to help communicators to be organized in their approaches but even when you've communicated all these principles you may face some messaging resistance. Message resistance may be attributed to the unique psychology of a crisis. 

People feel an array of emotions that may negatively aforethought their behaviors. While the six principles can be helpful in addressing many of these psychological barriers to positive public health actions communicators should also appreciate the value of behavioral science in these situations. Chris how do behavioral scientists engage with communities in a crisis when faced with these barriers? SPEAKER:  In a lot of ways. 

Because of their traintheir commitment -- interacting with community both before a crisis that's actually ideally -- ideal time to figure out what people are willing to do and not willing to do and why and why not. Sometimes we wait until the middle of things that figure out how do we get people to do things or how do we protect them. But one of the biggest things they can do is help focus -- you said the behavior yourself. 

Specify what do people need to do to protect themselves and make sure that that is actually something that offers protection. A lot of times you don't have to say take charge, that's a good thing to em power people but we're going to do things that em power them from an infectious disease threat or some other threat. So that's first. 

Specifying the behaviors that offer protection. The who what when why how how often all that stuff and then understand what the drivers are for doing those behaviors. Sometimes in crisis we're asking people to do something they may have never done before. 

They don't have a lot of experience or confidence in doing it so how do you do that rapidly. Sometimes we're asking people to do things that are not in their cultural way -- the Ebola practices are different than their practices. Behavioral science can help you figure out if this is the array of drivers and drivers come in three big buckets. 

There's a model called CONM and this is the easiest way to remember what shapes drivers. C stands for capability. Do people have the physical and psychological skills to perform the behavior that we're asking because some of our behaviors are complex. 

The second bucket is called opportunity and this is the social and physical structures that actually help or hinder the behavior. If you're telling people that they need something in zika, go get repellent and spray yourself regularly the opportunity there is that you need a physical product to successfully perform and get the production. As well as the opportunity has to do with the social context. 

People influence us. For better or for worse. They just do. 

So understanding that that mix is in there. So physical and social context for performing behavior and the M is motivation. Those things that either make us do things or keep us from doing things. 

If the recommendation came out saying I had to eat fried liver and onions every week you have an emotional response to those things right. Now tell me I can have chocolate that's a whole other story. The pleasure pain the emotional dynamics and the intrinsic motivations that drive those behaviors. 

Those are three big buckets. The why the how and sort of the supporters. If you think about those buckets behavioral science can help you figure out where the livers are in looking at the consulages of things for and against performance o of that behavior and then they can help you figure out what are the right interventionprise addressing that unique consulages. 

A lot of times we like to train people and train people. Sometimes we just need to provide people the product that they need. Or we need to engineer the roads a different way. 

Public health is wonderful that we have so many different tools. We have policy we have health care services delivery. We have services and then products and all the steps social marketing gets at. 

We have lots of information for influencing peoples behavior. Sometimes we don't match them well. Our consulages of drivers don't match. 

Behavioral science can help you get that fit. Especially the fit in terms of interventions and the context and the cultural context or landscape or economic context. That's something behavioral and social science can help with. 

Certainly ideally in preparedness because we do so much preparedness helping involving social scientists to preplan solutions with communed members instead of us thinking oh we're this public health experts we've got to figure this out and then tell them what to do the best approach is to engage minutes and say okay if we had to get everybody out of this community in 24 hours or less how would we the collect of we do that and get their ideas. Because every response I have worked on where I'm engaging with communities including the one in DRC, community members have amazing insights about the solution that can help their community and protect their community and often times we don't listen to them. If we can just build in more systematic ways of listening to communities and then acting on their recommendations we'd all be winners so that's important. 

So engaging community members engaging partners in that both problem identification but solution generation are areas where behavioral scientists can be really helpful. SPEAKER:  Okay. Are there some particular methods that you use for doing these activities? SPEAKER:  Lots. 

SPEAKER:  Just a few. SPEAKER: Yeah. Obviously the interactive methods are best so you're talking about focus groups interviews observation. 

Things that get you outside of your office into the world of the people you're serving. When I worked in main which is many moons ago I didn't have a budget I didn't have a big contract I didn't have fangsy add agencies or other folks doing the work. I was going to laundry mat the. 

I was going to the places where the people who I was serving were at and talking with them about how do we -- if they face add challenge how we as a public health organization and we as a community help them discussfully protect themselves from threats. In the last year with Ebola we've partnered with red cross who has community volunteers in every community probably on this planet who is engaging people in DRCen Ebola and they're documenting peoples suggestions and questions in a way that we get boat loads of data and perspective from communities that is helping influence how we're doing. And helping us to think how do we need to do things differently to stop this outbreak. 

There's tons of different approaches between us going out and talking with people in very structured or unstructured ways. The encouraging thing is in the 30 years I've been in public health community members when they're invited to offer suggestions they are not shy. And most of the time they're really grateful that we've asked for their opinion and their assistance. 

SPEAKER:  Thank you. So we're going to talk a little about how understanding the psychology of a crisis can be incorporated into developing the messages that you are creating and tailoring them specifically to audiences with a better understanding of what those audiences actually need. In an emergency the public will judge your message. 

They're going to judge it by what it says by who says it and by how it's disseminated. Are you using the channels that the community uses to get their information. Understanding how close an audience is geographically to the emergency, how close they are emotionally to the incident and their different demographics can inform how messages are developed and shared. 

Chris, how can behavioral scientists help communicators in ascertaining this information? How can you help us understand our audience better? SPEAKER:  Well I think a lot of what I just shared are approaches certainly ways to engage audiences whether it's through research or observation or just old fashioned question asking. A lot of times we do surveys. And you can do those really quickly to find out what people know and what people don't know that's always really important because if they're not acting because they haven't heard our message because we assume people have heard our message and sometimes that doesn't happen. 

If they've heard the message and didn't quite understand it that's an important thing for us to know. Maybe we were not clear in our messaging. Or it's clear and they don't understand the relevance. 

And I think relevance is the king of kings when it comes to behavior change because if people don't see it as something relevant to their lives or relevant in addressing a threat or protecting them or fitting with their core values it's an up hill battle. So finding the openings in terms of -- especially in the realm of trust, how do we find the shared values between our commitment as public health people to protect health so that people live full and productive life's and people who don't think of health, they're just thinking I think of health when I lose it instead of it's something I actively need to take care of or how does it fit with my values. So finding the relevance piece is a big part of it. 

As well as you mentioned some of the other behavioral scientists to help you figure out who are people listening to. The social networks, the power dynamics in communities. They are there. 

As well as who are the credible messengers. Sometimes CDC is not a credible messenger there are other people who may be more credible. We need to be mindful of that and be savvy about we're not the be all and end all. 

You mentioned the channels behavior science can help you with that too. Interpersonal channels often get over looked. We're like social media and we've got those down but I think behavioral scientists can do the social networking to say these organizations are connected and they're conducted in a productive way or not productive way and gate keepers all that is part of it. 

That sounds really academic doesn't sound practical but the reality is in outbreaks this is where anthropologists, sociologies, lots of types ofologists in the science lane who can be really helpful. In this outbreak there's wonderful networks of anthropologists and sociologies who are willing to offer their insights and their understanding of the communities in DRC to shape the behaviors so we can do a better job and that's been really exciting. And don't forget community members are pretty expert about their communities. 

They all have opinions. They know the ins and outs of who's on which side and how do organizations connect so don't over look them as experts as well. And just getting a good sense of what people think and feel about a threat and again back to that relevancy and ways to address that threat. 

I go back to ways to address a threat because the reality is sometimes the interventions we offer may not fit the situation and I think a lot of times we over look asking communities is there another way to get to this outcome. Protection or whatever the shared value is, how can we get there and going through a process and a lot of people think that has to take years and years and years of academic work. A lot of times it's very intensive conversations and meetings over a couple weeks to get to outcomes. 

Depending on the threat, the nature of the threat, the complexity of the behavior. Depending on who needs to do it. Sometimes not everybody in a community needs to do it. 

There may be some people who are especialliyy vulnerable so having a consulages of different approaches and allowing people choice and allowing a lot of creative problems is a big part of it. We like to feel like we're in control. The power dynamics the control issues. 

A lot of times we just need to say and build relationships with community members that says we are in this together we have made recommendations because of course CDC we do everything evidence based. Sometimes the evidence is pretty weak so we're growing the evidence as we go and that's part of CERC is we're all learning but having a more iterative process throughout course of emergency response and it goes back to what I said earlier we have to do a lot more in the preparedness phase. A lot of this is perfect. 

Prime the pump. Build the relationships. Meeting people for the first time in the midst of a crisis is not the best time to build trust. 

As public health professionals do we have a spot on our monthy calendar or our monthly to do list that gets us out of our office engaging with different constituencies in our area. In my community it was the city of Portland. I had meetings with the refugee settlement program. 

Face time. A lot of times we don't build that into our cal enders so when something does happen we are sort of primed at the pump. The relationship is there and we can problem solve together. 

SPEAKER:  Thank you. So as we've touched on community engagement is critical. It's critical communication and behavioral science activity during any crisis. 

There will never be enough emergency responders to individually assist all of the people aforethoughted by a large scale crisis. Good messages can guide people towards positive public health behaviors. But we need their feedback. 

Helpful feedback from communities can inform the development of messages that are more understandable, more accessible and more actionable. Ultimately the outcome of any emergency response depends on how well responders work with affected communities. I'd like to ask a few more questions Chris I actually want to ask a lot more questions but I'm going to start with these and we'll just keep talking. 

What are some challenges to engage in communities. If you have some examples that had be great and what are some best practices for over coming those common engagement issues? SPEAKER:  Okay great question. We could go on for years. 

Some of the biggest challenges I've seen in many of the outbreak responses I have been involved with over the years had to do with power dynamics and control dynamics. Either both between responding agencies and themselves, responding agencies and the communities, because every community has an infrastructure. Social, some of it's clear some of it's not. 

And just navigating those systems and services is really tricky. So at a minimum a best practices is understanding that there are power dynamics at play and making a commitment to being a trusting worthy organization within that construct or within that sort of infrastructure. Building trust really takes intentionalalty. 

How good is your organization. How good you personally are at making promises and fulfilling those promises. Do we over promise and under deliver or under promise and over deliver. 

That in and of itself establishes sort of a reputation of either being trust worthy or not trust worthy and I'll tell you organization that are not trusted have a hard time engaging communities. It's not saying that I can't build trust because you build trust everyday. You can lose trust by your behaviors everyday. 

So one of the challenges in the DRC context it's a war zone. Who do you trust, how do you trust. Will trusting this group will cost me my life or not. 

So the dynamics of power and control are a big deal. And I would say that's true in most communities in the United States as well. So just being honest and open about that and trying to build strong relationships with people so that's important as a challenge that you need to be mindful of. 

Do everyday go into work to say what am I doing that's building trust or what am I doing that's breaking trust and there are concrete behavior that build and break trust. Promising something and not doing brakes trust. That's a basic but there's other things too. 

Building trust is being open sharing influence receiving ideas delegating not doing it all ourself. A lot of times we think we have to do it all. The reality is in a time of crisis I have found everybody wants to contribute. 

Everybody want to be part of the solution. So what a golden opportunity to tell people how they can contribute. So nacrite that participation and then actually allow people to participate is a big one. 

I think the other challenge in response is speed. A lot of times everything has to be fixed right away or we don't have all the information we need. There's a balance between having enough information to make informed decisions, it not being important, getting enough information to make helpful decisions. 

We like everything but happened up nice and tidy before we communicate to the world or do something and outbreak response and emergency responses are never tidy they're messy and we have to realize they're messy on a public health side, on a data side, in how they play out in the community. Not that you get comfortable working in messiness but you acknowledge that mess is part of working in that context and you do what you can to create order out of the chaos by building strong relationships. By over communicating and trying to focus on clear communication as well as inviting people to participate in the discovery process in the understanding the problem process and then the coming up with solutions process. 

So that's really important. Transparency. Which is a big principle in CERC is a big way to build engagement. 

Honest brokering communication and transparent communication about decisions and actions. I think another challenge in a community engagement often is this notion that maybe we haven't established all the relationships we have on an on going basis so that we're connecting with people for the first time in the middle of a crisis. And we may not know them well enough or know their organization well enough to know that they're thriv on what they promise. 

So it can be really risky if me as a public health person said I found this greatthey're going to do this and we're doing this and then maybe they drop the ball. And you know how do we build in redemptive processes when people may all be on a steep learning curve together. So I think that's a really important thing. 

To build in cushions for dropped balls and build in a certain amount of mercy that we're all on a learning curve together and that we stick to it. There's a commitment to say we're going to get from here to there together no matter what. And that we're building relationships that are enduring not just in that response but beyond. 

Especially if we're building a new relationship in the middle of a response. You have to build in some sort of mercy redemption learning curve forgiveness. But also accountability. 

The reality is lives are on the line and if we're making commitments that we want to be part of solution we need to deliver on those commitments. So I think those are the big buckets in my perspective. SPEAKER:  And your position, even this concept of behavioral science influencing communication is kind of unique. 

It's sort of new to probably some of our people who called in but definitely taking a forefront in the last several emergency responses. For organizations that don't you mentioned that have smaller budgets for organizations that maybe don't have a dedicated behavioral scientist or access to those what are your recommendations to connecting with organizations like you mentioned the red cross cross. With connecting with already established organizations and communities that can help with these results. 

SPEAKER:  I would say most community organizations almost every UNICEF funded organization or writed way has some evaluation component. They have people who think through what's my program what's it doing what's it's affects and how do we know we're getting there. I guarantee you there are people with social science skills in your communities already. 

Tap into them already. Also I would say most health educators. Most public health degree programs have some evaluation, some social or at least one behavioral social science class, have some methods classes. 

So use those skills. Even at CDC. Find ways to apply those skills on a regular basis in how you approach that. 

There's also if your community has a university there are academic folks who do this all the time. I'm a big fan of students because I think in public health you learn by doing. This isn't stuff you can read a book about and do this is stuff you have to learn by doing. 

If you don't have partnerships with trainers at universities and aren't using students you are missing out on A offering pima mazing opportunity taz learn the trade but also get really good in tell on your community. So I would challenge. I mean I have students coming and interning with me here at CDC all the time because I've got plenty of work to keep people busy and they're always very rich experiences because again this is only stuff you learn by doing. 

I would say academics, there's a lot of talented people. One of the things I've found with academics is you have to make sure that the goal is helping you inform your response and help you inform what you're doing in communities instead of just writing a paper for peer review yearnles. I'm not against peer review journals. 

But the goal of this kind of work is not research or generalizable knowledge. It's not that it's not all that. But here this is really applied stuff. 

Help people using research methodologies and community engagement methodologies to help you figure out how best to serve your community in a crisis or during a crisis or on the other side of a crisis. So it's very very applied in nature. SPEAKER:  Thank you. 

I know a lot of the partner organizations that participate in our calls don't have the resources or the time. So the staffing or time and resources and it's helpful to know they can reach out to other people in their communities. Just something to keep in mind when you are working with behavioral scientists communicators can keep in the back of their minds. 

If you are able to do this yourself if you're thinning about these questions what is most important in a community when faced with a problem and specifically in your community and like Chris was saying I really need to do a little bit of leg work, a little bit of preparation to know that or work with established organizations who have done that work. What are specific risks and benefits associated with the different solutions as Chris already said giving public health recommendations that we know to be scientifically effective is not helpful if it can't be used in the context of that communities capabilities, their opportunities, their access. So we really need to ask ourselves these questions in the preparation phase but when an emergency happens and consider what our resources are for developing better messages that are most important to the communities affected and be able to craft public health recommendations within a relevant context. 

Chris do you have any additional suggestions for communicators faced with messaging resistance? SPEAKER:  Yeah I would say when you're looking at particular audiences and you just mentioned this in terms of looking at local resources. I think back to the zika outbreak a few years ago in puerto rico where pregnant women were facing an amazing threat. Talk about emotional time. 

You're pregnant and you're faced with the threat of zika virus in your community and the long list of behavioral recommendations we gave pregnant women to do. Some of them completely within their control. Some of them way outside of their control. 

SPEAKER:  We had 36 pages of messages. SPEAKER:  Exactly. So the notion that we partner with communities who are already expert. 

The best thing about the puerto rico experience was working with the program, they are experts with pregnant women. So if you want to adapt messages to an audience I don't know why you would go anywhere else because they serve these women day in and day out. And they were just an amazing partner. 

We would go into their waiting rooms and we would interview women and ask what's possible what's not possible. We mocked up the zika prevention kit and got feedback. Would this be helpful. 

Very very practical. So don't think that you have to figure it all out. You have resources in your community that you just need to ask for help from and that starts with just humility. 

And being committed to saying how do I really reach the people in my community and help them successfully perform the behaviors that we know will protect them. And we can say we think the behaviors should be this but having the courage to ask them this is what the recommendation is from a science perspective. How does this intersect with your life's reality and how do we adapt this recommendation so we get the outcome, protection that we want but so it is done successfully. 

We want people to succeed. So the notion of just being committed and creative and humble enough to engage people to say how can we help people successfullyper form the behaviors that will protect them from the threats that they're facing and as much as possible do that before a crisis comes so that we've learned the in tell and early in the crisis we check it and make sure it's still true and then go into implementation mode. Part of it may be communication, service delivery. 

We understood to get water from here to there. Or repellent from here to there or burry people in a different way. Whatever the intervention is that it has, it's gone through some vetting with real life community members before we're implementing it. 

And also building in feedback loops in responses. We haven't talk burden this but communicators usually have wonderful feedback loops. Social media monitoring, hot lines where they get questions from people. 

All those are incredibly rich state data sets that give you feedback on what people know, what people don't know, what people need, what people need help with. So don't over look the resources that you already have that give you a sense of okay there's a problem here let's engage the community in figuring out what the solution is and let's do it together. SPEAKER:  Okay. 

I know we could talk about this for days but we are going to answer some questions because I know we've gotten a few that have come through our chat box. If you do have a question make sure that you've put it in the Q and A box. That's what Jonathan is going to be monitoring and we're going to transition to him now Jonathan can you read the first question. 

SPEAKER:  Our first question is coming from Danielle who asks how does one engage religious and community leaders from different cultures to engage with scientifically proofen approaches such as vaccines or improved hygiene. SPEAKER:  You have conversations. There's no shortcut to this. 

Obviously if you're dealing with vaccine issues in your community and you have a variety of religious groups who have a stance on this or you don't even know what their stance is. Having the conversations and saying hey here's the public health perspective on this. We care about all members of our community. 

We don't want outbreaks. We're really committed to everybody thriving. Here's the recommendation as we know it. 

How does this intersect with the values of your organization and of your belief system. This is where public health folks need to be learners and not experts. A lot of times we want to be the talkers and the experts in the room. 

Well we've got lots of experts in the community who are religious leaders, different sector leaders who we just need to say we need to learn from them and find out what the intersection is. Find out what the shared values are between public health and the different organizations to say okay we do have common ground how can we work together. How can we work together with our shared values to get to some agreement on either methods or approaches because there's not just one way to get things done. 

SPEAKER:  Okay our next question is from C fields who asks what is the best approach to mending a community relationship and correcting trust when a formal employee did not have good follow through. SPEAKER:  Apologizing. Start with anna apology and ask for forgiveness. 

Make a commitment that things will change and deliver on that commitment. Your behaviors, your behaviors today and tomorrow and the next day will build that trust. SPEAKER:  Okay thank you. 

Next question is from SJ Robinson who asks, who says so Chris is talking about the COM model. What happened to the health belief model? Is that also a good model for behavioral research? SPEAKER:  All are lots of great models. Health belief modself one that we use a lot, infectious disease model. 

There's hundreds of models actually. I like the COMB model because for a lay person it's an easy way to remember the buckets. There's things that are either psych logically keep you from doing things. 

There are things that structurally and socially keep you from doing things and then there's just the skills involved so it's just a very simple model. You can use whatever model you want and there are in academic literature some models work better for some types. There's models that work together for karannic disease and nutrition and more preventive behaviors and there's ones that work better for infectious disease, acute health model works better for infectious disease where there's a short time lag. 

So lots of choice. I'm a big fan of the COMB model because not only is it simple to learn it's also has a book if you want to read it that helps you once you learn what drivers of behavior it can help you pick the right interventions for that behavior. It's called the behavior change wheel. 

You can Google it. Actually I can they have an app now and all sorts of other things that can help you make strategic decisions about what your portfolio of drivers are for a specific behave jury and then what the right approaches are because that will help you overcome the mismatch between what are the drivers and accidently picking the wrong intervention strategy. We don't want to do that. 

SPEAKER:  Okay thank you. The next question comes from abigail who asks isn't it problematic to use behavioral scientific approaches as an in to a community. Special especially when these approaches are built on western concepts and philosophy that are not necessarily compatible with all communities. 

SPEAKER:  That's interesting. Behavioral science approaches I think are not just a western thing. I think listening to community and engaging communities is something that most communities want to be heard want to be engaged. 

I think if you're thinking about going in to research a community that's what not what I'm talking about. I'm talking about engaging communities and cocreating solutions that will help the community deal with a threat or protect members in their community. Maybe we have different understandings of how behavioral science can be employed in an emergency response. 

SPEAKER:  Thank you. The next question comes from it's a comment from rosemary who says as someone who has some background in anthropology and behavioral science how could one best market those skills. I'm only asking this question because you've mentioned your mentoring. 

And is there a place in general for anthropologists and behavioral scientists in public health? SPEAKER:  There's absolutely a place but I'm going to be really honest. It's taken a long time for us to get to the table. Even at CDC where we understand the importance of social and behavioral sciences there's a patch work in different parts of CDCs scientific portfolio. 

The area I work in infectious diseases is pretty lean on behavioral and social scientists where the crayonic disease center and HIV and injury, where behavior is so integral to everything they do it's baked in. A lot of times in the infectious disease world we do a lot of outbreak response through just sheer wonderful epidemiology which bite way is a social science. And shoe leather detective work and lab work. 

Fortunately over the last decade there has been a real support for building this capacity and the infectious disease side of the house -- even in the zika virus we've seen a great emphasis on bringing this to the table. I don't know and I doubt that most state and local departments have an abundance but my dream over the next 20 years is to see that breathing. The reality is I don't think with the complex world we live in that public health will succeed if we don't have more anthropologists and sociologies built into the public health work force and infrastructure. 

Definitely knock on doors. -- public health departments aren't the only placess to do public health. A lot of NGOs theres a lot of public health functions that are performed outside of a health didn't so don't forget that you can have a huge impact on public health in local NGOs, international NGOs and all that stuff but definitely keep knocking on doors and tell people how you can help them. 

Be successful in protecting communities from threats and show them how you can be helpful. One of the challenges though for some social scientists and behavioral scientists is the academic training for most of the disciplines is very academic and very theoretical. There are more and more programs that are becoming more applied in nature but there are fewer traditional very theory based. 

As well as in public health we have to do very robust very fast and most of our training programs don't do the speed part. So we're having to even at CDC find ways to balance the rigor speed in terms of being able to add value to responses and still stay true to ourment to rigor and representing community and engaging community. SPEAKER:  Okay guys we have more questions and they're great questions but it's two oh clock. 

So for follow-up questions we will do our best to follow-up questions that are sent to epic at CDC dot gov'. I'll go back to Kelly now. SPEAKER:  Thank you and Chris thank you so much for participating with us today. 

I know we have a lot of questions that didn't get answered but like Jonathan said please do send them to epic at CDC dot GOV. If you send your comments or your questions to that e-mail address we will do our best to get them answered. If you as a reminder that todays presentation has been recorded you can earn continuing education for our participates. 

Please follow the instructions found on the emergency dot CDC dot GOV back slash epic website. The course access code one more time is EP I C one zero two three with all letters capitalized. Thank you again everyone. 

Goodbye.