Checklist to Build Trust, Improve Public Health

Communication, and Anticipate Misinformation

During Public Health Emergencies

July 2024
Authors
Christina M. Potter, MSPH Emily O’Donnell-Pazderka, MA, MPH
Senior Analyst, Johns Hopkins Center for Former MPH student, Johns Hopkins
Health Security Bloomberg School of Public Health
Aishwarya Nagar, MPH Tara Kirk Sell, PhD, MA
Senior Analyst, Johns Hopkins Center for Senior Scholar, Johns Hopkins Center for
Health Security Health Security
Associate Professor, Department of
Erin R. Fink, MS
Environmental Health and Engineering, Johns
Former Analyst, Johns Hopkins Center for
Hopkins Bloomberg School of Public Health
Health Security
Vanessa Grégoire, MSc
Analyst, Johns Hopkins Center for Health Contributors
Security
Alyson Browett, MPH
Jessica Malaty Rivera, MS Senior Editor, Johns Hopkins Center for
DrPH student, Johns Hopkins Bloomberg Health Security
School of Public Health, Health Security Track
Julia Cizek
Alex Zhu, MSPH Designer and Web Administrator, Johns
Analyst, Johns Hopkins Center for Health Hopkins Center for Health Security
Security

Acknowledgements
This publication was supported by the Centers for Disease Control and Prevention (CDC) of
the US Department of Health and Human Services (HHS). The contents, including references
to non-US government sites on the Internet, are those of the authors and do not necessarily
represent the official views of, nor constitute or imply endorsement by, CDC/HHS or the US
government.

Suggested citation: Potter C, Nagar A, Fink E, et al. Checklist to Build Trust, Improve Public
Health Communication, and Anticipate Misinformation During Public Health Emergencies.
Baltimore, MD: Johns Hopkins Center for Health Security; 2024.

© 2024 The Johns Hopkins University. All rights reserved.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies ii
How to Use the Checklist
This checklist is an instrument to help public health departments and communicators improve
trust and communication, especially in anticipation of serious public health issues, health
emergencies, and when misinformation is abundant. To develop the checklist, the project
team collected data on frequently observed rumors during public health emergencies (PHEs),
interventions to address misinformation and improve trust, and the experiences of 100 key
informant public health experts and practitioners working on the front lines. The checklist
reflects current communication science and the voices and lived experiences of public health
communicators who have worked in an environment of persistent rumors and misinformation
and declining trust in public health.

The checklist provides public health communicators with tools, resources, and internal
advocacy opportunities organized across 5 priority sections. These sections can broadly be
described as 1) focusing on internal operations, 2) building connections with the community, 3)
establishing opportunities with “secondary messengers,” 4) anticipating loss of trust in a PHE,
and 5) creating meaningful and accessible messages.
Priority 1 outlines how health departments or similar organizations can reflect on and
improve their in-house capacities, including budgetary, administrative, and workforce
considerations, as well as assess their current understanding of and relationships with
their communities. These capacities will help set up health departments for success
before undertaking new trust-building or public health communication initiatives.

Priority 2 describes how health departments can look outward to develop healthy,
lasting relationships with their communities in order to build trust. These connections
will help to increase the effectiveness of future public health work.

Priority 3 recommends processes for health departments to develop successful,

sustainable partnerships with and/or otherwise leverage individuals, organizations,
or other influencers in their communities—all of whom fall under the umbrella of
“secondary messengers.” By combining forces with outside help, health departments
can strengthen community ties, tap into new resources and expertise, and increase the
effectiveness of public health communication and trust-building activities.

Priority 4 suggests specific proactive initiatives that health departments may engage
in before and as PHEs or other concerning health narratives arise. These actions help to
preserve trust levels and dampen the negative effects of anticipated misinformation.

Priority 5 provides guidance on how to develop, tailor, deploy, and evaluate public
health messages during PHEs or concerning health narratives. This section builds off
strengths and capacities established in previous Priority sections. Advice from this
section is summarized in, and can be applied to, the Tailoring Tool to Increase Message
Uptake & Trust found in the Appendix.
Users are encouraged to modify and alter the checklist in ways that reflect their specific needs,
challenges, and opportunities. Users may read the checklist in its entirety or utilize a targeted
approach by checking off their existing capacities in Checklist Contents and reading select
sections associated with identified gaps or areas of interest.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies iii
Checklist Contents
How to Use the Checklist................................................................................................ iii

Glossary........................................................................................................................... vii

Priority 1: Build Critical Communication Capacities....................................................... 1

Activity 1: Build and maintain a PHEPR communication workforce that is well-prepared
and reflective of the community it serves...................................................................................1
Task 1.1: Identify and characterize existing PHEPR communication workforce
assets........................................................................................................................................ 1
Task 1.2: Establish and pursue avenues to remedy workforce gaps............................... 2
Task 1.3: Recognize and address threats to building and maintaining a PHEPR
communication workforce.................................................................................................... 3
Activity 2: Ensure that existing budgetary, operations, and financing approaches for
PHEPR communication activities reflect prospective needs during an emergency................3
Task 2.1: Understand current PHEPR communication funding....................................... 3
Task 2.2: Curate alternative resources that may be deployed before or during
a public health emergency.................................................................................................... 4
Task 2.3: Prepare administrative strategies in anticipation of just-in-time
emergency disbursements.................................................................................................... 4
Task 2.4: Streamline bureaucratic and administrative processes that hinder
responding in “feast-or-famine” financing conditions...................................................... 5
Activity 3: Know your audience and their history with public health.......................................5
Task 3.1: Discern audience characteristics.......................................................................... 5
Task 3.2: Understand intended audience’s history with public health and
related institutions.................................................................................................................. 6
Priority 1 References......................................................................................................................6

Priority 2: Develop Meaningful & Lasting Relationships with Your Community............ 9

Activity 1: Establish public health personnel as trusted members of the community............9
Task 1.1: Assess readiness for community relationships.................................................. 10
Task 1.2: Identify key principles and norms for engaging with communities................ 10
Task 1.3: Be immersed in community spaces and present at local events,
initiatives, and meetings........................................................................................................ 11
Task 1.4: Build in mechanisms for sharing decision-making processes with
communities ........................................................................................................................... 12
Activity 2: Make strategic and intentional investments in building community......................13
Task 2.1: Conduct assessments to understand community networks and needs
to inform a plan of action...................................................................................................... 13
Task 2.2: Establish a track record of supporting the community in a range of ways,
even if small............................................................................................................................. 15

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies iv
 Task 2.3: Develop avenues for community members to integrate into the local
public health community....................................................................................................... 15
Task 2.4: Prioritize sustainability when building community relationships and
evaluate progress.................................................................................................................... 16
Priority 2 References......................................................................................................................17

Priority 3: Create & Maintain Strong Partnerships with Secondary Messengers .......... 20
Activity 1: Create a strategy for maximizing the use of secondary messengers in
public health communication efforts...........................................................................................20
Task 1.1: Conduct an assessment to understand needs of key partners and likely
secondary messengers.......................................................................................................... 20
Task 1.2: Identify and engage with potential strategic partners for secondary
messaging................................................................................................................................ 21
Task 1.3: Identify public health capacities and resources that can be leveraged
as benefits to formal secondary messengers..................................................................... 23
Activity 2: Develop formal processes to engage and incorporate secondary messengers
into message development, distribution, and evaluation efforts ............................................23
Task 2.1: Develop shared expectations with potential partners ..................................... 24
Task 2.2: Collaborate with partners on message development and distribution
efforts ....................................................................................................................................... 24
Activity 3: Cultivate opportunities for informal sharing of messages.......................................25
Task 3.1: Leverage informal secondary messengers in virtual spaces............................ 25
Task 3.2: Leverage informal secondary messengers in physical spaces........................ 26
Priority 3 References......................................................................................................................26

Priority 4: Anticipate Misinformation & Potential Loss of Trust .................................... 28

Activity 1: Enable appropriate understanding of what public health is and does....................28
Task 1.1: Establish what public health is and its benefits to society.............................. 29
Task 1.2: Clarify how government services—including the public health
department—are organized.................................................................................................. 29
Task 1.3: Explain the goals and thought processes behind public health
operations................................................................................................................................ 29
Task 1.4: Plan robust public feedback mechanisms prior to an emergency................. 30
Activity 2: Set expectations for public health response and communication at the
start of a health emergency..........................................................................................................30
Task 2.1: Help members of the public understand issues of uncertainty...................... 30
Task 2.2: Establish processes and plans to communicate changes in guidance
as understanding evolves...................................................................................................... 31
Task 2.3: Set an appropriate communication cadence..................................................... 31
Activity 3: Track, analyze, understand, and plan for anticipated rumors in local
contexts...........................................................................................................................................31
Task 3.1: Establish tracking and analysis systems for social listening ............................ 31

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies v
 Task 3.2: Integrate an understanding of local audience values and needs with
expected rumors..................................................................................................................... 32
Task 3.3: Develop prebunking and inoculation messages ............................................... 32
Activity 4: Promote use of and access to trusted sources.........................................................33
Task 4.1: Facilitate access to trustworthy health information and teach critical
thinking skills to enhance information self-sufficiency..................................................... 33
Task 4.2: Enhance information accessibility and understandability............................... 33
Priority 4 References......................................................................................................................34

Priority 5: Formulate Key Message Components & Maximize Message Engagement... 36

Activity 1: Draft key messages......................................................................................................36
Task 1.1: Embrace a basic content format for communicating accurate
information in an emergency................................................................................................ 36
Task 1.2: Employ specialized approaches to confront rumors ........................................ 37
Task 1.3 Consider and apply lessons from existing messaging models.......................... 37
Activity 2: Tailor messages based on understanding of the intended audience .....................38
Task 2.1: Identify intended audiences for messaging........................................................ 38
Task 2.2 Consider specific needs of the intended audience that may influence
their perspectives on public health messages................................................................... 38
Task 2.3: Engage in dialogue to build trust, increase message effectiveness,
and combat misinformation.................................................................................................. 39
Activity 3: Ensure messages get to intended audiences via preferred channels and
trusted voices .................................................................................................................................39
Task 3.1: Tailor channel utilization to increase engagement with intended
audiences................................................................................................................................. 40
Task 3.2: Identify and integrate trusted messengers into messaging efforts
to increase uptake and effectiveness.................................................................................. 40
Activity 4: Design messages using tone and visuals that will resonate with intended
audiences ........................................................................................................................................40
Task 4.1: Increase engagement by using eye-catching visuals and other
formatting................................................................................................................................ 41
Task 4.2: Revise messaging content and tone to increase messaging reach................ 41
Task 4.3: Sync message tailoring for maximum effectiveness........................................ 41
Activity 5: Regularly evaluate the engagement and impact of PHEPR communication
efforts .............................................................................................................................................42
Task 5.1: Select and execute an evaluation process complementary to
organizational goals and capacities..................................................................................... 43
Task 5.2: Link evaluation results to message development and tailoring efforts......... 44
Priority 5 References......................................................................................................................44

Appendix: Tailoring Tool to Increase Message Uptake & Trust....................................... 47

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies vi
Glossary
● Channel: The medium through which public health messages are disseminated to the
general public (eg, social media platform, radio, in-person communication).
● Dialogue: An ongoing back-and-forth conversation, including online, between public health
communicators and the general public regarding health information or clarification (eg, Q&A
sessions).
● Disinformation: Deliberately false or misleading information usually spread via various
communication channels with the intent to manipulate, deceive, or influence beliefs,
opinions, or actions.
● Health/Science/Media Literacy: A person’s ability to effectively access, analyze, interpret,
evaluate, and use information to make informed decisions about their health, scientific facts,
and media content.
● Messenger: An individual or group who translates public health information and guidance to
the general public.
● Misinformation: False or inaccurate information.
● Prebunking: The act of addressing or refuting potential false information before an
individual is exposed. This involves educating people about common tactics of deception or
manipulation, encouraging critical thinking, and engaging target audiences.
● Public Health Communicator: An individual or group, usually in an official governmental
capacity, who translates public health information and guidance to the general public.
● Public Health Emergency Preparedness and Response (PHEPR): Engagement in public
health activities that aim to prevent, protect against, quickly respond to, and recover from
public health emergencies (PHEs).
● Rumor: A claim that is untrue, may be untrue, or is misleading.
● Secondary Messenger: People and institutions outside of public health departments and
government agencies that play important roles in PHEPR, including disseminating health
messaging, building trust in public health, and dispelling misinformation.
● Formal secondary messenger: Individuals, groups, or organizations that share health
information as part of a formal agreement with public health agencies.
● Informal secondary messenger: Individuals, groups, or organizations that share health
information without any formal agreement with public health agencies.
● Social Listening: The process of tracking information on communication platforms to
identify false information or information gaps about public health issues.
● Tailoring: The act of modifying the content, tone, visuals, channel, or other features of a
public health message to better reach and resonate with intended audiences.
● Trusted Messenger: Someone who is perceived as reliable, credible, and trustworthy to an
intended audience.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies vii
 Priority 1: Build Critical Communication Capacities
Effectively communicating and maintaining trust with the public is critical, especially when
Priority 1

implementing public health emergency preparedness and response (PHEPR) activities and
addressing misinformation and disinformation that can reduce trust. Health departments’
abilities and capacities to effectively reach members of the public must be built and
sustained over time. These efforts require a workforce that reflects the community being
served, accompanied by strong communication skills, expertise, and experience, as well as
appropriate funding and operational mechanisms to maximize resources. Furthermore, PHEPR
communication efforts require a deep understanding of the community audience, including
their needs and the complex factors that impact their trust in public health.1

Activity 1: Build and maintain a PHEPR communication workforce that is

well-prepared and reflective of the community it serves
Health departments must develop an appropriate PHEPR communication workforce and
ensure they are prepared to establish trust, meet the community’s needs, and effectively
respond during an escalating public health issue or a public health emergency (PHE).1-4 The
following tasks outline how local and state health departments can build, maintain, and protect
that capacity.

Task 1.1: Identify and characterize existing PHEPR communication workforce assets
Health departments should identify their employees who would engage in PHEPR
communication activities, especially those in leadership positions, and create a summary of the
group’s relevant experience, expertise, and skills. Examples of such competencies include1,5:
• Lived experiences, such as growing up in communities that mirror those of intended
audiences, to better spread relevant information or address misinformation.
• Experience in public health-related risk communication activities, particularly past
PHEPR communication activities or work with intended audiences.
• Subject matter expertise in essential areas, such as formal training in social sciences
and/or risk communication science, and familiarity with epidemiological principles.
• Specialty skills for risk communication (eg, experience running social media for similar
organizations or video production).
• Foreign and accessible language skills (eg, multilingual with native speaker-level fluency
or experience creating accessible content such as screen reader-compliant materials).
• Community ties with relevant stakeholders (eg, trusted messengers and leaders in key
audience communities, organizations, and businesses or other organizations that may
be important partners).
The above list of workforce characteristics may not be fully applicable or comprehensive for
every organization’s PHEPR communication needs and should be revised accordingly. Health
departments also should consider that all staff members, not only the PHEPR communication
team, play a part in communication activities, so leadership should assess the current and
desired characteristics and competencies of the larger workforce.1

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 1
 Task 1.2: Establish and pursue avenues to remedy workforce gaps
If there are gaps in PHEPR workforce competencies and characteristics, consider the following
remedies, depending on resources and context.1
Priority 1

Table 1. Potential remedies to fill workforce gaps in PHEPR communication competencies

Needs Remedy Requires Timing

• Lived experience Formal partnership(s) • Completing activities and Initiate and sustain
• Language skills with secondary tasks associated with partnership prior
• Community ties messengers (eg, Priority 3 to PHE
community-based
organizations [CBOs])
to leverage community
ties, lived experience, or
relevant competencies
and skillsets
• Specialty skills Develop or use existing • Access to training materials Create access prior
• Subject matter training materials6-10 or curricula to PHE; utilize
expertise or curricula to better • Staff member bandwidth to before or during
empower existing staff complete training PHE
and new hires with
necessary skills
• Lived experience Recruit additional staff • Sufficient funding Prior to or during
• Communication from within the health • Bandwidth within existing PHE
experience department to fill PHEPR staff to train new
• Subject matter expertise, experience, or recruit(s)
expertise skill gaps on the PHEPR • Institutional and individual
• Specialty skills communication team employee bandwidth to
• Language skills allow for an increase or
• Community ties shifting of duties for internal
PHEPR team recruits
• Lived experience Hire new personnel • Sufficient funding Prior to or during
• Communication from outside the • Bandwidth within existing PHE
experience department with desired PHEPR staff to train new
• Subject matter characteristics or personnel
expertise competencies • Competitive hiring
• Specialty skills incentives in job market
• Language skills
• Community ties
• Communication Partner with • Availability and willingness Create
experience organizations (eg, of appropriate partners administrative
• Subject matter public relations firms, • Administrative capacity pathways prior
expertise academia) that can and relevant permissions to PHE; initiate
• Specialty skills provide technical to engage in contracts, partnerships
• Language skills assistance or complete memorandums of before or during
tasks that require a understanding, or similar PHE
specialized skillset, agreements necessary for
such as identifying and partnerships with third party
deploying interventions organizations
against misinformation • Sufficient funding, if needed
on social media • Bandwidth within existing
platforms PHEPR staff to liaise with
outside partners

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 2
 Task 1.3: Recognize and address threats to building and maintaining a PHEPR
communication workforce
Priority 1

Building a PHEPR communication workforce that is ready and reflective of the community is
not enough; that workforce must be maintained to preserve institutional memory and overall
capacity. Turnover is an ongoing threat to the public health workforce because of various
issues, including lack of competitive pay, stress or burnout, and harassment and violence
against public health workers.11-13 Consider ways to address potential threats and retain the
workforce,1 such as:
• Implementing a harassment mitigation system to support staff and divert harassing
messages.
• Revising compensation and benefits packages to increase job market competitiveness
and reduce attrition.
• Limiting burnout from compassion fatigue14 and exposure to harassment by moving
employees on and off PHEPR communication duties.
• Providing resources and using strategies to reduce workforce burnout, such as ensuring
employees have and use enough paid time off, quickly addressing staffing shortages,
and reducing the workload of PHEPR communication team members.
• Offering opportunities for advancement, particularly for staff members who have
unique characteristics and competencies relevant to PHEPR communication.
• Improving appreciation of and empathy for the public health workforce by
strengthening community ties and investing in community needs by implementing
activities and tasks described in Priority 2.
• Increasing public and policymaker awareness of the health department’s value to
demonstrate institutional pride in the public health workforce and their work.

Activity 2: Ensure that existing budgetary, operations, and financing

approaches for PHEPR communication activities reflect prospective needs
during an emergency
The success of PHEPR outreach activities relies heavily on available financial resources. Yet
responders often lack sustainable, sufficient funding.1-3,15-17 Prior to strengthening other public
health communication capacities, health departments must assess and address administrative
readiness to respond.

Task 2.1: Understand current PHEPR communication funding

A comprehensive understanding of fiscal support for PHEPR communication and community
engagement activities is valuable. Public health officials should first identify funding
specifically for PHEPR communications and additional funding streams that may be accessed
for communication efforts in the event of a health emergency. Second, they should identify
potential gaps between existing funding and the resources needed to engage in building trust
and countering misinformation during an emergency. These gaps may be assessed based on
how well funding has met needs in past emergencies and how operational costs might vary
based on different potential emergency situations. Funding assessments are most useful when
completed and updated regularly, with a multiyear view of future funding support and gaps.1

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 3
 Task 2.2: Curate alternative resources that may be deployed before or during a public
health emergency
Priority 1

If health departments detect a gap between existing funding and the resources needed to
conduct PHEPR communication activities, other approaches may be needed. See Table 2 for a
list of potential remedies1,18 and their associated implementation needs.

Table 2. Potential remedies to fill anticipated gaps in actual and expected PHE resources

Remedy Requires Timing

Pool resources with the • Sufficient flexibility in funding for involved Before or during
nonemergency risk communication programs PHE
budget or other programmatic • Overlap in mandates and activities between
budgets programs
• Ability to liaise and coordinate shared
activities for involved programs
Explore emergency funding • Staff time to investigate funding options Before or during
mechanisms at the local, state, and • Availability or knowledge of funding PHE
federal levels that may be leveraged mechanisms
and deployed
Build awareness of health department • Staff time to initiate and sustain relations Before or during
value among policymakers and with policymakers PHE
advocate for increased funding access • Availability and willingness of policymakers
to engage with health department liaisons

Partner with organizations (eg, PR • Availability and willingness of appropriate Create

firms, academia, temp agencies, partners administrative
Medical Reserve Corps, National • Administrative capacity and relevant pathways prior
Guard) that may be able to provide permissions to engage in contracts, to PHE; initiate
cost-effective resources, such as memorandums of understanding, or similar partnerships
technical assistance or temporary agreements necessary for partnerships with before or during
additional workforce third-party organizations PHE
• Sufficient funding, if needed
• Bandwidth within existing PHEPR staff to
liaise with outside partners
Partner with secondary messengers • Completing activities and tasks associated Initiate and
(eg, CBOs) that may be able to with Priority 3 sustain
provide cost-effective assistance partnership prior
with messaging, building trust, or to PHE
dispelling misinformation

Task 2.3: Prepare administrative strategies in anticipation of just-in-time emergency

disbursements
During high-profile PHEs, health departments may receive large disbursements of emergency
funding with short windows to process, plan for, and spend those funds.1,18 Therefore, creating
strategies in anticipation of these just-in-time disbursements will help to reduce spending
delays, maximize the cost-effectiveness of response spending, and improve the sustainability
of any capacity building or new workforce hires that occur during emergency responses. For
example, prior to an emergency, PHEPR communication teams may present health department

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 4
 leadership with a list of ranked funding priorities for emergency response communication
activities. Then, as emergency response activities wind down, PHEPR communication teams
may develop and present proposals to health department leadership on how to retain new hires
Priority 1

or sustain increased response capacity related to health department communication activities

after emergency funds expire.

Task 2.4: Streamline bureaucratic and administrative processes that hinder responding in
“feast-or-famine” financing conditions
Health departments are required to coordinate activities with numerous partners and
stakeholders during emergency response activities. This engagement brings with it
increased bureaucratic procedures, including establishing contracts and memorandums
of understanding, gaining approvals from leadership, verifying personnel credentials, and
more. Prior to an emergency, health departments should identify these potential partners
and stakeholders and manage as many administrative processes as possible. Additionally,
health department leadership should work with relevant human resource and finance staff to
streamline those processes (eg, purchasing procedures). Finally, any operational considerations
that may cause delays in accessing resources during an emergency response, such as time for
training or building partnerships, should be similarly addressed prior to the event, if possible.1,18

Activity 3: Know your audience and their history with public health
Expertise is not enough; trust in public health and the effectiveness of messaging and other
communication efforts may be greatly mediated by the characteristics of the intended
audience and their past interactions with public health and related institutions.1,19-26 Gathering
information about your community and their trust levels in public health will help lay the
groundwork for later trust-building and messaging work with intended audiences.

Task 3.1: Discern audience characteristics

The characteristics, values, and needs of audiences greatly influence how they interpret
public health messages and how communicators develop important relationships with them.27
Audience characteristics include demographic characteristics (eg, age, languages spoken and
read, education and reading levels, income level, geographical location), as well as religious
beliefs, cultural values, attitudes, and practices.28

Health departments should leverage existing official data resources—such as Mobilizing

for Action through Planning and Partnerships (MAPP) reports, other community health
needs assessments,29 and/or US Census data30—to better understand their community’s
characteristics. Additionally, health departments should consider engaging in informal or
formal qualitative or quantitative data collection to gain a clearer and more nuanced view of
their intended audiences. Public health communicators can leverage any existing relationships
the current public health workforce has with intended audiences (see Priority 2) as well as
relationships between partners and audiences (see Priority 3). Information from these sources
and any additional data collection may be utilized to inform message creation efforts, which is
discussed in Priority 5. Public health communicators should also consider if any topics require
focused messaging for new populations beyond those identified in the past.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 5
 Task 3.2: Understand intended audience’s history with public health and related
institutions
Priority 1

Historical context can significantly influence a community’s perceptions, attitudes, and

trust toward public health initiatives and government agencies. Internally and publicly
acknowledging and addressing ongoing and historical experiences25 that have reduced trust is
crucial for building trust.1,26 Public health communicators should consider how the community
may have encountered past instances of discrimination, mistreatment, or lack of access to
public health and medical services and ensure that communication efforts are sensitive to
these experiences. Leaders also should evaluate current levels of trust between public health
organizations and the community31 and conduct activities to improve trust and rebuild rapport
as needed.1

Notably, some communities may hold negative attitudes toward public health authorities
and activities. Lack of adherence to public health measures and poor effectiveness of
public health messaging within these communities may be worsened by perceived or real
disrespect, ostracization, or disregard by those promoting public health interventions. In some
cases, these populations may amplify themes of distrust, knowingly or unknowingly spread
misinformation and disinformation, or discourage other community members from engaging
in health-seeking behavior. It is important to not assume failure in communicating with these
populations, as doing so and ceasing trust building efforts may actually decrease the likelihood
of future successful communication efforts.1

Specific recommendations on trust-building and community engagement activities are

provided in Priority 2, drawing from the awareness and capacities established in this section.

Priority 1 References
1. Potter CM, Grégoire V, Nagar A, et al. A practitioner-focused checklist to build trust, address
misinformation, and improve risk communication for public health emergencies. [Manuscript
submitted for publication.]
2. National Association of County and City Health Officials (NACCHO). NACCHO’s 2019 Profile
Study: Local Health Department Capacity to Prepare for and Respond to Public Health Threats.
Published May 2020. Accessed March 4, 2024. https://www.naccho.org/uploads/downloadable-
resources/2019-Profile-Preparedness-Capacity.pdf
3. National Association of County and City Health Officials (NACCHO). NACCHO’s 2019 Profile Study:
Changes in Local Health Department Workforce and Finance Capacity Since 2008. Published May
2020. Accessed March 4, 2024. https://www.naccho.org/uploads/downloadable-resources/2019-
Profile-Workforce-and-Finance-Capacity.pdf
4. de Beaumont Foundation, Public Health National Center for Innovations. Staffing Up: Workforce
Levels Needed to Provide Basic Public Health Services for All Americans. Published October 2021.
Accessed May 22, 2023. https://debeaumont.org/wp-content/uploads/2021/10/Staffing-Up-
FINAL.pdf
5. National Commission for Health Education Credentialing. Areas of Responsibility, Competencies
and Sub-competencies for Health Education Specialist Practice Analysis II 2020 (HESPA II 2020).
Published January 2020. Accessed July 27, 2023. https://assets.speakcdn.com/assets/2251/
hespa_competencies_and_sub-competencies_052020.pdf
6. Office of the US Surgeon General. A Community Toolkit for Addressing Health Misinformation.
Published November 8, 2021. Accessed March 4, 2024. https://www.hhs.gov/sites/default/files/
health-misinformation-toolkit-english.pdf

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 6
 7. US Centers for Disease Control and Prevention. Resources for Emergency Health Professionals:
Crisis & Emergency Risk Communication Manual and Tools. Updated January 23, 2018. Accessed
June 12, 2023. https://emergency.cdc.gov/cerc/resources/index.asp
Priority 1

8. Public Health Communications Collaborative. Plain Language for Public Health. Public Health
Communications Collaborative; 2023. https://publichealthcollaborative.org/wp-content/
uploads/2023/02/PHCC_Plain-Language-for-Public-Health.pdf
9. O’Sullivan GA, Yonkler JA, Morgan W, Merritt AP. A Field Guide to Designing a Health
Communication Strategy: A Resource for Health Communication Professionals. Baltimore,
MD: Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs;
2003. Accessed July 25, 2023. http://ccp.jhu.edu/documents/A%20Field%20Guide%20to%20
Designing%20Health%20Comm%20Strategy.pdf
10. US Centers for Disease Control and Prevention. Health Communication Playbook. Centers for
Disease Control and Prevention; 2018. Accessed March 4, 2024. https://www.cdc.gov/nceh/
clearwriting/docs/health-comm-playbook-508.pdf
11. Ward JA, Stone EM, Mui P, Resnick B. Pandemic-Related Workplace Violence and Its Impact on
Public Health Officials, March 2020-January 2021. Am J Public Health. 2022;112(5):736-746.
doi:10.2105/AJPH.2021.306649
12. Leider JP, Castrucci BC, Robins M, et al. The Exodus of State And Local Public Health Employees:
Separations Started Before and Continued Throughout COVID-19. Health Affairs. 2023;42(3):338-
348. doi:10.1377/hlthaff.2022.01251
13. de Beaumont Foundation, Association of State and Territorial Health Officials. Rising Stress and
Burnout in Public Health. Published March 2022. Accessed May 22, 2023. https://debeaumont.org/
wp-content/uploads/dlm_uploads/2022/03/Stress-and-Burnout-Brief_final.pdf
14. Cocker F, Joss N. Compassion Fatigue among Healthcare, Emergency and Community Service
Workers: A Systematic Review. Int J Environ Res Public Health. 2016;13(6):618. doi:10.3390/
ijerph13060618
15. Ye J, Leep C, Newman S. Reductions of Budgets, Staffing, and Programs Among Local Health
Departments: Results From NACCHO’s Economic Surveillance Surveys, 2009-2013. J Public Health
Manag Pract. 2015;21(2):126. doi:10.1097/PHH.0000000000000074
16. Alford AA, Feeser K, Kellie H, Biesiadecki L. Prioritization of Public Health Emergency Preparedness
Funding Among Local Health Departments Preceding the COVID-19 Pandemic: Findings From
NACCHO’s 2019 National Profile of Local Health Departments. J Public Health Manag Pract.
2021;27(2):215. doi:10.1097/PHH.0000000000001338
17. Sessions, SY. Appendix D: Financing State and Local Public Health Departments: A Problem
of Chronic Illness. In: Institute of Medicine. For the Public’s Health: Investing in a Healthier
Future. Washington, DC: The National Academies Press; 2012:205-252. Accessed July 27, 2023.
doi:10.17226/13268
18. Potter C, Kaushal N, Wroblewski K, Becker S, Nuzzo JB. Identifying Operational Challenges and
Solutions During the COVID-19 Response Among US Public Health Laboratories. J Public Health
Manag Pract. 2022;28(6):607-614. doi:10.1097/PHH.0000000000001585
19. Hocevar KP, Metzger M, Flanagin AJ. Source Credibility, Expertise, and Trust in Health and Risk
Messaging. Oxford Research Encyclopedia of Communication. April 26, 2017. doi:10.1093/
acrefore/9780190228613.013.287
20. Fiske ST, Dupree C. Gaining trust as well as respect in communicating to motivated audiences
about science topics. PNAS. 2014;111(supplement_4):13593-13597. doi:10.1073/pnas.1317505111
21. Bish A, Michie S. Demographic and attitudinal determinants of protective behaviours during a
pandemic: a review. Br J Health Psychol. 2010;15(4):797-824. doi:10.1348/135910710X485826
22. Verma N, Fleischmann KR, Zhou L, et al. Trust in COVID-19 public health information. J Assoc Inf Sci
Technol. September 20, 2022. doi:10.1002/asi.24712

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 7
 23. SteelFisher GK, Findling MG, Caporello HL, et al. Trust in US Federal, State, and Local Public Health
Agencies During COVID-19: Responses And Policy Implications. Health Affairs. 2023;42(3):328-337.
doi:10.1377/hlthaff.2022.01204
Priority 1

24. Blendon RJ, Benson JM. Trust in Medicine, the Health System & Public Health. Daedalus.
2022;151(4):67-82. doi:10.1162/daed_a_01944
25. Miller F, Miller P. Transgenerational Trauma and Trust Restoration. AMA J Ethics. 2021;23(6):E480-
486. doi:10.1001/amajethics.2021.480
26. Christopher GC. Truth, Racial Healing, and Transformation: Creating Public Sentiment. Health
Equity. 2021;5(1):668-674. doi:10.1089/heq.2021.29008.ncl
27. Maibach EW, Abroms LC, Marosits M. Communication and marketing as tools to cultivate the
public’s health: a proposed “people and places” framework. BMC Public Health. May 22, 2007.
doi:10.1186/1471-2458-7-88
28. US Centers for Disease Control and Prevention. Crisis & Emergency Risk Communication (CERC):
Messages and Audiences. Updated 2018. Accessed June 8, 2023. https://emergency.cdc.gov/cerc/
ppt/CERC_Messages_and_Audiences.pdf
29. National Association of County and City Health Officials (NACCHO). Mobilizing for Action through
Planning and Partnerships (MAPP). Undated. Accessed July 27, 2023. https://www.naccho.
org/programs/public-health-infrastructure/performance-improvement/community-health-
assessment/mapp
30. US Census Bureau. Explore Census Data. Undated. Accessed July 27, 2023. https://data.census.
gov/
31. Schloemer T, Schröder-Bäck P, Cawthra J, Holland S. Measurements of public trust in the health
system: mapping the evidence. Eur J Public Health. 2021;31(Supplement_3). doi:10.1093/eurpub/
ckab165.360

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 8
 Priority 2: Develop Meaningful & Lasting Relationships with Your
Community
All actors in a community, from health departments to the people they serve, have visions
of what a healthy population looks like. These visions may or may not align. Public health
personnel can struggle to integrate their communities’ visions when planning, implementing,
and evaluating PHEPR programming, which can result in a lack of public trust or buy-in.1
Therefore, building and strengthening relationships between public health departments and
the communities they serve is a vital step in increasing trust in public health. Transparency,
accountability, and inclusive decision-making with community members is foundational to
public health.2
Priority 2

To build trust in PHEPR, public health personnel should establish themselves as trustworthy
members of their community and make strategic investments in building community.
Approaches can range from basic outreach about public health issues to more sustainable
and equitable strategies that involve a higher level of public engagement, empowerment, and
shared decision-making, as shown in Figure 1.3-5

Figure 1. This community engagement spectrum illustrates the continuum of public engagement in a participatory
process, from low to high levels of engagement (adapted from the International Association for Public Participation5 for
the Center for Wellness and Nutrition’s Community Engagement Toolkit3).

Activity 1: Establish public health personnel as trusted members of the

community
As mentioned in Priority 1, communities’ historical experiences influence their trust in public
health organizations. Because of these previous encounters, some communities are not always
quick to trust guidance from public health departments, healthcare institutions, researchers, or
government health officials.6 In order to dispel what could be harmful narratives, public health
departments must build authentic, honest, transparent, and consistent relationships with
community members to establish themselves as trustworthy. This relationship building helps
public health departments and other health officials carry out important programming in their
communities and respond to local public health issues, especially during PHEs.
Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 9
 Task 1.1: Assess readiness for community relationships
Building relationships requires time and dedicated resources, which public health departments
and other health officials may lack or prioritize elsewhere in the face of other pressing needs.
Public health agencies should conduct an internal assessment3,7 to understand whether they
have sufficient organizational buy-in, sustainable interest, and resources to build constructive
relationships and partnerships with communities. They should reflect on questions like:
• With which communities do you want to build relationships?
• Does your health department perceive community involvement as a priority in
identifying community health issues?
Priority 2

• Does your health department have a champion(s) or leader(s) who will drive efforts to
build and sustain relationships?
• What does your health department want to accomplish by developing relationships with
the community?
• How positive are existing collaborations with the community?
• How involved do you want community members to be in health department activities?
• What types of community involvement can your health department accommodate?
• How flexible can your agency be when building relationships with communities?
• What can you contribute to communities?
• Are you prepared to cede, transfer, or share decision-making processes with the
community?
• How do your answers to these questions change before, during, and after PHEs?
• Are resources, staffing, and organizational interest sustainable?
If, upon reflection, public health leaders determine they are not ready to build relationships
with communities, it would be prudent to focus on building internal readiness, using strategies
with lower levels of public involvement, or identifying which relationships might be feasible to
pursue in the future.

Task 1.2: Identify key principles and norms for engaging with communities
Public health officials can bolster their trustworthiness in communities by embodying
the values that their communities find important. When developing relationship-building
strategies, public health leaders should identify key principles that underpin their approach
to community engagement. An agreed set of internal guiding principles can standardize
approaches and ensure they are all aligned with community-centered values, such as:
• Transparency. Transparency and openness from public health officials—such as
providing timely information about risks, clarifying the science behind public health
guidance, explaining decision-making processes, and claiming accountability—are
important trust-building strategies during health emergencies, especially when
government-mandated PHEPR measures are socially disruptive and likely to provoke
strong emotional responses.8-11,20
• Flexibility. Relationships should evolve based on the real-time needs of different
communities, including their priorities and goals.6 If public health officials are willing to
change and adapt their plans to fit a community’s needs, the community will view them
as more reliable, accessible, and trustworthy.
Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 10
 • Equity. Understanding and accounting for structural inequities and social injustices
helps public health personnel build more accessible, intentional, and supportive
relationships with diverse communities, especially when there are power imbalances
between public health authorities and community members.6 Participatory
approaches like community-based participatory research, participatory budgeting,
and participatory action research are effective in building mutually beneficial
relationships.4,12,13
• Mutual respect. Showing mutual trust and respect for partners, as well as their
knowledge, expertise, and voice, is crucial for successful community-based
participatory partnerships.6,7 An absence of mutual respect and co-learning can result in
Priority 2

a loss of trust, time, and resources.4

• Honesty. When building relationships with communities, public health departments
must communicate openly and honestly or risk being perceived as opportunistic and
deceptive.7 This includes taking responsibility for mistakes and disclosing conflicts
of interest. Violating this principle may trigger misinformation rooted in distrust of
authorities and conspiracies.14
Public health personnel can use these principles, as well as any other values relevant to
their mission, to establish norms and set expectations about how they intend to work with
communities. They should be clear about the goals of their engagement efforts; make a case
for why a relationship is worthwhile for all parties involved; put in the work to learn about their
community’s culture, social networks, political and power structures, norms, and values; and
(perhaps most importantly) keep their promises after setting these expectations.7,15

Two examples that illustrate both key principles in action and how to effectively work with
communities to establish these principles include:
• The National Association of County and City Health Officials’ (NACCHO) Mobilizing
for Action through Planning and Partnerships 2.0 Handbook (MAPP 2.0), which
outlines foundational principles that were developed in collaboration with communities
and embedded into the MAPP Theory of Change to ensure engagement efforts are
community-driven.6
• The US government-funded Principles for Community Engagement, which details 9
actionable and specific key principles that guide the formation, implementation, and
sustainability of engagement efforts, developed with input from a community task
force.4

Task 1.3: Be immersed in community spaces and present at local events, initiatives, and
meetings
Public health personnel should establish both an active and passive presence in community
spaces to be more accessible for, visible to, and connected with community members.
Showing a presence can help lead to authentic development and retention of community-
based relationships. It is important to note that many traditional community participation and
engagement efforts often use a top-down approach that does not prioritize the community’s
needs and drives unequal distributions of power. This can perpetuate distrust of public health
and government officials. To build trust, public health practitioners should practice respectful
and intentional listening and engage with communities more actively.16,17 Public health leaders,
practitioners, and staff can:
Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 11
 • Network informally at in-person community events, initiatives, and meetings, and/
or attend them as a formal representative to contribute a public health perspective
or public health resources.12 For example, when YMCAs host Healthy Kids Days, local
health departments can provide public health information and materials at the event,
promote the event on social media platforms, and continue the conversation through
health education and programming.18
• Participate in virtual discussions and events and create an online presence by posting
consistently, intentionally, and meaningfully on social media platforms and websites.
Priority 5 details how public health departments can communicate more effectively
about PHEPR issues, especially online.
Priority 2

• Meet communities where they are by showing up at events that do not have an explicit
health focus.19,20 For example, academic partners who work with the Apsáalooke (Crow
Indian) Nation as part of the Messengers for Health project regularly spend time at the
reservation and attend social and cultural events.21 Public health officials should make
authentic personal connections: ask people questions, tell people about themselves,
and go where the people are.22
• Participate in community conversations and conduct outreach even when people are
initially unwelcoming or harbor deep distrust of public health.22
• Contribute logistical planning resources as a convenor and bring together diverse
community organizations, coalitions, task forces, stakeholders, and members over
shared dialogue.7
• Build relationships with community members at “third places” or neutral locations (like
salons) where people spend time, socialize, exchange ideas, and enjoy themselves
outside of their homes or workplaces.23 These locations play an important role in
cultivating a strong sense of community, and they can provide a space for public health
to engage with the community.
• Remain accessible to and build relationships with local media outlets, as community
members often rely on news to stay informed about health issues.9,24
By being present, public health personnel show they are actively part of their community,
interested in connecting, and see themselves as one with the community. While networking
with specific populations, leaders, and community members is important, public health
practitioners benefit from immersing themselves in the social fabric of their community to
avoid these interactions being viewed as a transactional process.3 Additionally, after meeting
people and making connections, public health staff should retain these relationships by making
it as easy as possible for community members to stay engaged. Examples of this might include
providing childcare at public health convenings, facilitating transportation to public health
events, meeting where communities feel comfortable, providing incentives, and more. Priority
4 explores how public health staff can pursue more formal listening and feedback gathering
mechanisms for PHEPR purposes.

Task 1.4: Build in mechanisms for sharing decision-making processes with communities
There is often an imbalance of power between public health departments and the communities
they serve, which can make communities skeptical about the intentions behind PHEPR
activities. Public health officials should empower communities, particularly those most
impacted by structural inequity, to set public health agendas, shift public health discourse, and

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 12
 make decisions about their community’s health.25 When public health fosters a “together we
can” culture, it becomes a more trustworthy collaborator.12 Public participation can enhance
the legitimacy, transparency, and justice of decision making and improve trust in public
institutions.2 However, this means that public health officials must be prepared to release
control of some actions and outcomes to the community.15 They can pursue the following
approaches for sharing decision making when developing community relationships:
• Demonstrate willingness to listen and be guided by communities’ needs, interests, and
voices.26
• Be open to unanticipated ideas and be receptive to nontraditional community
relationships.2
Priority 2

• Identify strategic opportunities for communities to share their expertise and

knowledge.26
• Practice two-way communication with the public to stay informed and engaged in
dialogue and exchange (ie, going beyond one-way mass messaging, such as public
services announcements or social media campaigns).2
• Connect with communities to help them gain more control over factors that affect their
health.26
• Use participatory approaches to collaboratively define public health problems and
solutions.2
• Actively respond to issues the community feels are important and empower community
groups to engage in open dialogue with government entities.2

Activity 2: Make strategic and intentional investments in building

community
Public health employees can convey that they are sincere, intentional, and thoughtful about
building community relationships by making proactive, strategic investments. Public health
staff and communities should work to understand how they can support each other not only
by providing information, resources, or incentives but also through collaborative ways of
interacting, acting, and recovering from public health events. By investing in communities,
public health departments show with action—not only words—that they care about the
communities they serve, which bolsters public trust in them.

Task 2.1: Conduct assessments to understand community networks and needs to inform a
plan of action
Health departments and local public health leaders need to understand the formal and informal
connections within their communities, as well as the strengths, weaknesses, gaps, and power
dynamics of these networks. Stakeholder mapping and analysis activities can help build
strategic relationships with communities and formalize partnerships with local leaders, as
explored in Priority 3. Additionally, health departments can conduct needs assessments to help
understand key health issues in the community. Engaging in these activities can help prepare
for PHEs by enhancing understanding of community needs during and after crises, effectively
leveraging relationships, and adapting communication strategies.24

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 13
 Needs assessment methods vary widely across the US, despite the presence of federal and
state standards for such assessments.27 Comprehensive community needs assessments include
CDC’s Community Needs Assessment,28 the American Hospital Association’s Community
Health Assessment Toolkit,29 NACCHO’s MAPP 2.0 Handbook,6 and the Center for Community
Health and Development at the University of Kansas’ Community Tool Box.30 During
emergencies, public health employees can use formative research methods or rapid analysis
tools like the CDC’s Community Assessment for Public Health Emergency Response Toolkit.31
These toolkits include extensive guidance on how to integrate community-based relationship-
building as both a precursor to and an outcome of needs assessments. If public health officials
are interested in pursuing a more transformative approach to assessing needs, they should:
Priority 2

• Engage, empower, and train community members to design and conduct assessments,
as well as to understand and socialize their findings.2 One way to do this is to form an
advisory committee that includes diverse stakeholders and community members to
guide the assessment process.29
• Use mixed-methods approaches and community-based participatory research
methodologies throughout the assessment process.4,7,29
• Foster diverse, multisectoral, and proactive relationships with community groups to
strengthen shared ownership and decision-making.32
Findings from needs assessments should inform an operationalized strategic action
plan. Learnings from community health assessment activities and the community health
improvement process are often used to create community health improvement plans (CHIPs).
Health departments and related government entities often use CHIPs to set public health
priorities and coordinate resources with community partners.4,32 Public health officials can also
use findings from assessments to devise an internal community engagement process, such as
the Center for Wellness and Nutrition’s process shown in Figure 2.

Figure 2. 4-step community engagement process, modified from the Center for Wellness and Nutrition.3

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 14
 Task 2.2: Establish a track record of supporting the community in a range of ways, even if
small
Public health departments are limited in the investments they can make in a community
because of funding and scope constraints. Although they may not be able to invest in ways
that meet all their community’s needs (eg, funding long-term, large-scale programs and
establishing integrated local health systems), they can show up in small ways. For example,
health departments can:
• Regularly provide community members with information about public health issues
through educational campaigns, topic-specific trainings, awareness activities, and other
efforts to improve overall health and science literacy, particularly when faced with a
Priority 2

public health issue. Because misinformation often fills gaps in knowledge, proactively
providing useful and reliable information helps public health departments establish
themselves as a visible, accessible, and trusted source of information and improve
communities’ resilience to misinformation.14,20 See Priority 4 for more on anticipating
misinformation.
• When possible, provide food, childcare, activities for children, incentives, and other
supportive services during public health programs, meetings, and convenings.3
By doing so, public health officials show they are aware of barriers to community
participation and are working to remove them. Such efforts can make community
members more receptive to relationship-building.
• Advocate for communities by pushing for policy-level solutions to community
members’ health-related concerns.33 Public health authorities often serve as mediators
among communities, the government, and healthcare systems; by escalating
community concerns into policy spaces, public health officials show they are willing
to leverage their influence in support of their community. Resources like the NACCHO
Advocacy Toolkit provide guidance on how public health officials can advocate for and
with the communities they serve.34
Being accessible, consistent, helpful, and dependable, and working in the best interests of the
community, creates a strong foundation for community-based relationships to form naturally.

Task 2.3: Develop avenues for community members to integrate into the local public
health community
Just as public health employees should meet communities where they are and invest in
their goals, they can also create avenues for community members to serve as collaborators,
partners, and advocates. Public health departments can use the following approaches:
• Recruit community members into the public health workforce. Public health officials
can create pathways, opportunities, and enabling environments for community
members to serve as community health workers, public health practitioners, health
communicators, emergency response workers, and other staff roles.25 When interest
in community health increases during public health events, health department officials
should invite community members to engage as volunteers, consultants, and experts.
Even if health departments cannot provide funding or opportunities to train and hire a
community-based public health workforce, they can connect community members to
other resources, trainings, and opportunities.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 15
 • Co-create programs and strategies with multisectoral community members. Public
health departments should recruit and retain community members and CBOs as
thought partners, decision-makers, and implementers. They can convene coalitions,
task forces, advisory groups, and other mechanisms to bring diverse community
stakeholders together and co-create public health solutions, using tools like community
visioning, coalition-building, and co-creation workshops.6,35,36 Community-based
partners can leverage their deep knowledge of the community and established trust to
bring more people into contact with public health.37 Public health departments should
make sure to build bilateral and multilateral partnerships with all stakeholders—not only
health-related ones—that invest in creating a thriving future for health and wellbeing.38
Priority 2

• Implement integrated PHEPR activities with shared public health and community-
based objectives. During the COVID-19 pandemic, public health officials, primary
care providers, and CBOs mobilized quickly and effectively to implement testing,
vaccination campaigns, and other response activities for community members.37 Public
health departments and organizations with shared community health and wellbeing
objectives should intentionally connect with each other prior to emergencies to
establish mechanisms that enable integration of services. Public health officials and
their partners should build off each other’s technical capacities, and, if appropriate,
reduce operational constraints. Removing or streamlining barriers like rigid contracts
or memorandums of understanding, time-consuming reporting requirements, non-
negotiable terms, and requests for free labor will increase the likelihood of sustained
relationships.39

Task 2.4: Prioritize sustainability when building community relationships and evaluate
progress
To build sustainable, trustworthy, mutually beneficial long-term relationships with
communities, public health officials should invest in evaluating progress to understand how
partnerships, social networks, community priorities, and inter-collaborator dynamics evolve
over time. The following table includes best practices to sustain and evaluate relationships:

Table 1. Sustaining Relationships and Evaluating Progress: Do’s and Don’ts

Do Don’t
Sustaining √ Align public health priorities with × Only pursue relationships that are
Relationships community members’ priorities17 timebound and tied to specific projects1
√ Retain connections beyond the scope of × Expect communities to be ready to
a single project or funding cycle17 collaborate during a public health event
√ Build alliances well before public × Reinforce unequal and paternalistic
health events unfold and retain them power dynamics between public health
afterwards20,22 officials and communities16
√ Share decision-making, agenda- × Back out on promises or be an
setting, influence, and leadership with inconsistent, unreliable, burdensome, or
communities6 deceitful partner12
√ Make a plan for maintaining × Take communities’ time, resources, and
relationships once funding runs out20 social capital without providing benefits
√ Develop the community’s capacity to in return
engage in public health efforts over the × Give up on community relationships
long term when they get messy

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 16
 Do Don’t
√ Build positive expectations about the
trustworthiness of public health
Evaluating √ Use evidence-based frameworks and × Wait until the end of an engagement,
Progress approaches, especially participatory and program, or activity to evaluate progress
mixed-methods research3,4 × Misuse the evaluation process to focus
√ Check-in to assess progress at multiple on and further one stakeholder’s
stages of relationship-building12 interests4
√ Analyze and disseminate results in × Exclude certain community members
conjunction with communities4 because they lack technical expertise
Priority 2

√ Celebrate “wins” and milestones as

relationships grow over time3

Priority 2 References
1. de Guia S, Novais AP. Community Trust And Relationships: The Key For Strengthening Public Health
Systems. Health Affairs Forefront. Published February 28, 2023. Accessed July 25, 2023. https://
www.healthaffairs.org/content/forefront/community-trust-and-relationships-key-strengthening-
public-health-systems
2. American Public Health Association. Public Health Code of Ethics. Washington, DC: APHA; 2019.
https://www.apha.org/-/media/Files/PDF/membergroups/Ethics/Code_of_Ethics.ashx
3. Center for Wellness & Nutrition. Community Engagement Toolkit: A Participatory Action Approach
Towards Health Equity and Justice. Center for Wellness & Nutrition/Public Health Institute; 2020.
https://centerforwellnessandnutrition.org/wp-content/uploads/2020/02/FINAL-COMMUNITY-
ENGAGEMENT-TOOLKIT_-Upd2282020.pdf
4. Clinical and Translational Science Awards (CTSA) Consortium’s Community Engagement Key
Function Committee Task Force on the Principles of Community Engagement. Principles of
Community Engagement (Second Edition). National Institutes of Health, Centers for Disease
Control and Prevention; 2011. https://www.atsdr.cdc.gov/communityengagement/pdf/PCE_
Report_508_FINAL.pdf
5. International Association for Public Participation. IAP2 Spectrum of Public Participation. Published
November 2018. Accessed July 25, 2023. https://cdn.ymaws.com/www.iap2.org/resource/resmgr/
pillars/Spectrum_8.5x11_Print.pdf
6. National Association of County and City Health Officials (NACCHO). MAPP 2.0 Handbook. NACCHO;
2023. https://toolbox.naccho.org/pages/tool-view.html?id=6012
7. Giachello A. Making Community Partnerships Work: A Toolkit. White Plains, NY: March of Dimes
Foundation; 2007. https://aapcho.org/wp/wp-content/uploads/2012/02/Giachello-MakingCommu
nityPartnershipsWorkToolkit.pdf
8. Wilson AM, Withall E, Coveney J, et al. A model for (re)building consumer trust in the food system.
Health Promot Int. 2017;32(6):988-1000. doi:10.1093/heapro/daw024
9. Henderson J, Ward PR, Tonkin E, et al. Developing and Maintaining Public Trust During and Post-
COVID-19: Can We Apply a Model Developed for Responding to Food Scares? Front Public Health.
July 13, 2020. doi:10.3389/fpubh.2020.00369
10. Hall K, Wolf M. Whose crisis? Pandemic flu, “communication disasters” and the struggle for
hegemony. Health (London). November 20, 2019. doi:10.1177/1363459319886112
11. Vaughan E, Tinker T. Effective health risk communication about pandemic influenza for
vulnerable populations. Am J Public Health. 2009;99 Suppl 2(Suppl 2):S324-332. doi:10.2105/
AJPH.2009.162537

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 17
 12. Center for Public Health Practice & Research, Jiann-Ping Hsu College of Public Health at Georgia
Southern University, Cobb and Douglas Public Health. Health Departments and Authentic
Community Engagement. Center for Public Health Practice & Research; 2020. https://phaboard.
org/wp-content/uploads/4.30.20.Georgia-Southern.Health-Departments-and-Authentic-
Community-Engagement-002.pdf
13. Minkler M, Wallerstein N, eds. Community-Based Participatory Research for Health: From Process
to Outcomes. San Francisco, CA: Jossey-Bass; 2011.
14. Johns Hopkins Center for Health Security. Understanding common rumors that emerge during
public health emergencies. Tackling Rumors and Understanding & Strengthening Trust (TRUST) In
Public Health. Published July 11, 2024. https://centerforhealthsecurity.org/our-work/research-
projects/trust/tackling-rumors/trust-common-rumors-during-phes
Priority 2

15. Center for Public Health Practice. Building community relationships. Minnesota Department
of Health. Updated October 3, 2022. Accessed July 25, 2023. https://www.health.state.mn.us/
communities/practice/resources/chsadmin/community-relationships.html
16. Gautier L, Sieleunou I, Kalolo A. Deconstructing the notion of “global health research partnerships”
across Northern and African contexts. BMC Med Ethics. 2018;19(Suppl 1):49. doi:10.1186/s12910-
018-0280-7
17. Hickey G, Porter K, Tembo D, et al. What Does “Good” Community and Public Engagement Look
Like? Developing Relationships With Community Members in Global Health Research. Front Public
Health. January 27, 2022. doi:10.3389/fpubh.2021.776940
18. Bremerton Family YMCA. Bremerton Family YMCA Facebook Post. Published May 12, 2023.
Accessed July 15, 2023. https://www.facebook.com/plugins/post.php?href=https://www.
facebook.com/bremertonymca/posts/pfbid02ujwvby ACgQbftoXQXQKUEoMBJrkFK1HMux
8H1svhDCGCQeZCGrhum3QudZDi1V5gl.
19. Joszt L. Strong Community Relationships Key to Improving Health, Said Speakers at National Public
Health Week Forum. AJMC. Published April 3, 2018. Accessed July 25, 2023. https://www.ajmc.
com/view/strong-community-relationships-key-to-improving-health-said-speakers-at-national-
public-health-week-forum
20. Potter CM, Grégoire V, Nagar A, et al. A practitioner-focused checklist to build trust, address
misinformation and improve risk communication for public health emergencies. [Manuscript
submitted for publication.]
21. Christopher S, Watts V, McCormick AKHG, Young S. Building and Maintaining Trust in a
Community-Based Participatory Research Partnership. Am J Public Health. 2008;98(8):1398-1406.
doi:10.2105/AJPH.2007.125757
22. Center for Community Health, University of Kansas. Chapter 14. Core Functions in Leadership |
Section 7. Building and Sustaining Relationships. Community Tool Box. Undated. Accessed July 26,
2023. https://ctb.ku.edu/en/table-of-contents/leadership/leadership-functions/build-sustain-
relationships/main
23. Butler SM, Diaz C. “Third places” as community builders. Brookings. Published September 14, 2016.
Accessed July 26, 2023. https://www.brookings.edu/articles/third-places-as-community-builders/
24. Schoch-Spana M, Brunson E, Chandler H, et al. Recommendations on How to Manage Anticipated
Communication Dilemmas Involving Medical Countermeasures in an Emergency. Public Health Rep.
May 30, 2018. doi:10.1177/0033354918773069
25. The Commonwealth Fund Commission on a National Public Health System. Meeting America’s
Public Health Challenge: Recommendations for Building a National Public Health System That
Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust. Commonwealth
Fund; 2022. doi:10.26099/snjc-bb40
26. Human Impact Partners. Share Power with Communities. HealthEquityGuide.org. Updated
September 11, 2018. Accessed July 25, 2023. https://healthequityguide.org/strategic-practices/
share-power-with-communities/
Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 18
 27. Ravaghi H, Guisset AL, Elfeky S, et al. A scoping review of community health needs and assets
assessment: concepts, rationale, tools and uses. BMC Health Serv Res. 2023;23(1):44. doi:10.1186/
s12913-022-08983-3
28. US Centers for Disease Control and Prevention. Community Needs Assessment: Participant
Workbook. Atlanta, GA: Centers for Disease Control and Prevention; 2013. https://www.cdc.gov/
globalhealth/healthprotection/fetp/training_modules/15/community-needs_pw_final_9252013.
pdf
29. AHA Community Health Improvement. Community Health Assessment Toolkit. Published 2023.
Accessed July 26, 2023. https://www.healthycommunities.org/resources/community-health-
assessment-toolkit
30. Center for Community Health, University of Kansas. Chapter 2. Assessing Community Needs and
Priority 2

Resources Toolkit. Community Tool Box. Undated. Accessed July 26, 2023. https://ctb.ku.edu/en/
assessing-community-needs-and-resources
31. US Centers for Disease Control and Prevention. Community Assessment for Public Health
Emergency Response (CASPER) Toolkit: 3rd Edition. Atlanta, GA: Centers for Disease Control and
Prevention; 2019. https://www.cdc.gov/casper/media/pdfs/casper_toolkit.pdf
32. Rosenbaum SJ. Principles to Consider for the Implementation of a Community Health Needs
Assessment Process. Washington, DC: George Washington University; 2013. https://hsrc.
himmelfarb.gwu.edu/sphhs_policy_facpubs/863
33. Shah U. Public Health Advocacy: Informing Lawmakers about What Matters Most in Our
Communities. NACCHO Voice blog. Published February 5, 2018. Accessed July 26, 2023. https://
www.naccho.org/blog/articles/public-health-advocacy-informing-lawmakers-about-what-
matters-most-in-our-communities
34. National Association of County and City Health Officials (NACCHO). NACCHO Advocacy Toolkit.
Washington, DC: NACCHO; 2017. https://www.naccho.org/uploads/downloadable-resources/2018-
gov-advocacy-toolkit.pdf
35. United States Agency for International Development (USAID). Co-Creation: An Interactive Guide.
Washington, DC: USAID; 2022. https://www.usaid.gov/sites/default/files/2022-12/Co-Creation_
Toolkit_Interactive_Guide_-_March_2022_1.pdf
36. Center for Community Health, University of Kansas. Chapter 5. Choosing Strategies to Promote
Community Health and Development | Section 5. Coalition Building. Community Tool Box. Undated.
Accessed July 26, 2023. https://ctb.ku.edu/en/table-of-contents/assessment/promotion-
strategies/start-a-coaltion/main
37. Veenema TG, Toner E, Waldhorn R, et al. Integrating Primary Care and Public Health to Save Lives
and Improve Practice During Public Health Crises: Lessons from COVID-19. Baltimore, MD: Johns
Hopkins Center for Health Security; 2021. https://centerforhealthsecurity.org/sites/default/
files/2023-02/211214-primaryhealthcare-publichealthcovidreport.pdf
38. The Rippel Foundation. Vital Conditions for Health and Well-Being. Undated. Accessed July 26,
2023. https://rippel.org/vital-conditions-for-health-and-well-being/
39. American Public Health Association, Science and Community Action Network. Building Trust-Based
Community Partnerships for Public Health Professionals. Webinar. July 27, 2023. https://www.
pathlms.com/health/courses/55332

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 19
 Priority 3: Create & Maintain Strong Partnerships with Secondary
Messengers
Secondary messengers—people and institutions outside of public health departments and
government agencies—play important roles in PHEPR by disseminating health messaging,
building trust in public health, and dispelling misinformation.1 Health departments may create
formal partnerships with secondary messengers, such as working with CBOs that support
public health message dissemination or conduct face-to-face engagement activities. Formal
secondary messaging partners can include people and organizations that have established
trust and good rapport with community members. Alternatively, some secondary messengers
work informally or independently of health departments, such as when family members share
health information in a group chat or when medical experts share health information on social
media or other platforms.1

Creating and maintaining partnerships with secondary messengers is an effective way

for public health agencies to build social capital and gain trust with the community while
addressing gaps in health equity.2,3 Establishing partnerships, either formal or informal, with
trusted community influencers and organizations before a PHE allows health agencies to
Priority 3

allocate the time, support, and resources to be more proactive with needed health initiatives,
build stronger relationships, and establish trust.4-6 In addition to building trust and gaining new
perspectives, another benefit of these partnerships is the ability to reach more demographic
groups and potentially access hard-to-reach communities.3

Activity 1: Create a strategy for maximizing the use of secondary

messengers in public health communication efforts
While many potential partners and secondary messengers may emerge during a health
emergency, developing a pre-existing strategy that incorporates the needs of the community,
strategic partners, and processes to provide value to both public health and partners can
greatly improve engagement efforts. Furthermore, by planning for the inclusion of secondary
messengers in public health communications, health departments can improve trust
through longer term relationships and engagement with partners. Incorporating flexibility
into strategies is key, as each partnership will require discussion and compromise between
stakeholders.5,7

Task 1.1: Conduct an assessment to understand needs of key partners and likely
secondary messengers
Before establishing partnerships, public health communicators should learn about important
health issues in their jurisdiction, who is affected, and the major contributing factors. This
information can help in the development of region-specific plans to identify and engage with
appropriate community partners that may serve as secondary messengers. There are different
approaches to understanding community needs (see Priority 2), which vary in detail, time,
and resources required. For example, health departments may conduct their own community
health needs assessment or leverage ongoing assessments conducted by regional entities such
as local hospitals.5,7

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 20
Priority 3

Figure 1. Steps to conducting a community health needs assessment.7

Generally, community health needs assessments should be done cyclically and frequently to
identify developing health gaps and policy implications.8,9 Based on the results, public health
departments can more easily quantify what is needed from community partners, identify key
relationships, and adapt relationships as needs evolve.6,8

Task 1.2: Identify and engage with potential strategic partners for secondary messaging
After collecting information about community needs, public health departments should
identify and strengthen connections with potential partners that are well-known and trusted
in the community.6 Some potential approaches are described below. Existing free toolkits like
NACCHO’s Mobilizing for Action Through Planning & Partnerships 2.0 Handbook (MAPP 2.0)
provide in-depth guidance on best practices to identify and engage community stakeholders.6

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 21
 Table 1. Avenues to discover and connect with formal and informal secondary
messengers3,10,11

Type of partners Methods for identifying secondary messengers

Formal Messengers • Research local CBOs, including mission statements, current initiatives, and
existing community relationships, and reach out to them directly.
• Attend community events and other listening opportunities to identify local
leaders and trusted organizations.
• Host brainstorming sessions and community forums with ample opportunities
for public contribution to gather input and identify passionate interest groups.
• Create opportunities for public comment and input on public health topics of
interest to establish a list of key stakeholders.
• Release a request for proposals directed to local CBOs describing the details
and goals of the partnership.
Informal Messengers • Evaluate social media metrics to identify what posts are being shared in local
community groups and by whom.
• Host a public health booth at community events with informational handouts,
volunteer opportunities, and promotional materials about upcoming health
events. Add interested individuals to email contact lists.
• Connect with local community groups and peer networks to spread health
Priority 3

messages that can be further shared with their family and friends.
• Create an opt-in text messaging service to provide public health tips and
information to subscribed community members (eg, reminders about flu
season) that can be forwarded to family and friends.
Formal and Informal • Speak with current partners to see if they can recommend additional
Messengers stakeholders from their own networks.3
• Network at regional conferences or community events to identify individuals or
CBOs with similar goals and potential willingness to partner.
• Interact with individuals who attend public health events or reach out for
information. Health departments can ask how they heard about events and
about what or who influences their health choices and behaviors.
• Provide community members with opportunities to participate on public health
advisory boards.
• Collaborate with local healthcare organizations and networks to ensure
clinicians are confident to discuss and promote messages.
• Work with local media outlets to promote pertinent and audience-specific
health information.
• Partner with local sports teams and social groups/clubs for sponsorships,
information-sharing platforms, and partnerships.
• Host in-service trainings for community health workers and advocates about
how to promote messaging.
• Leverage advocates and secondary messengers in third places, like
barbershops or salons.
• Build coalitions of local stakeholders to advise and promote messaging
strategies.
• Mobilize young people on university and community college campuses to
promote messaging.
• Provide messaging and programmatic spaces to librarians.
• Post informational and promotional materials on notice boards throughout the
community.
• Partner with local fire and EMS departments that can provide life-saving
information to at-risk populations such as older adults and people with access
and functional needs.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 22
 Task 1.3: Identify public health capacities and resources that can be leveraged as benefits
to formal secondary messengers
Public health partnerships should be equitable and mutually beneficial to partners. To
achieve this, health departments should identify the resources and services they can offer
to formal secondary messengers, especially because limited funding may not allow for
direct compensation.3,10 Getting input from current or potential partners helps ensure that
partnerships make sense and are providing mutual benefits. Public health agencies should
regularly check-in with their secondary messaging partners before, during, and after PHEs to
verify that partners are benefiting. Some examples of benefits include assistance with non-
health emergency initiatives, financial support, health services at events, communication
resources, and workforce development assistance.10 Keeping partners informed about
guidance changes or emerging issues, as well as the science that supports any policy changes,
can also help them support the community.
Priority 3

Figure 2. Examples of public health resources that can be shared as benefits for secondary messengers.3,10,12,13

Activity 2: Develop formal processes to engage and incorporate secondary

messengers into message development, distribution, and evaluation efforts
Formal processes that incorporate selected secondary messengers into sustainable, mutually
beneficial partnerships can improve public health efforts to enhance communication and trust.
These procedures require flexibility and thorough planning and discussion, as each partnership
will be different; however, having formalized procedures provides partners with a clear
understanding of engagement, onboarding, and needs. Building these relationships before
emergencies will strengthen response capabilities and allow more time and effort to build the
partnership.5

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 23
 Task 2.1: Develop shared expectations with potential partners
Health departments should connect with prospective partners to develop mutual expectations
and delegate responsibilities. Depending on how potential partners are identified, approaches
will vary.14 For example, health departments can provide resources and information about
their initiatives to identified partners, outlining goals and reasons for the partnership.7,10 Both
public health officials and partners should discuss expectations and strategies for secondary
messaging, ensuring each stakeholder’s needs are met to achieve individual and shared goals.
Partnership terms should be developed collaboratively and regularly reevaluated to maintain
equitable alliances in evolving environments. Health departments should check in frequently
and regularly with partners to assess successes and failures, adjust strategies, provide support,
identify challenges, and evaluate the overall partnership.5,10,13 Recognizing and acknowledging
power differentials and careful planning can cultivate trust and clarify roles between
partners.5,6,10

Task 2.2: Collaborate with partners on message development and distribution efforts
Community partners can provide valuable insights, help tailor messages to specific audiences,
and reach a broader audience through existing relationships.3,6,9,12,15-17 Collaborating effectively
with already trusted community partners can help public health departments bridge gaps in
Priority 3

trust, especially with historically underserved communities.3,6,10 Depending on the partnership

and its goals, there are various ways to work with partners on message development and
dissemination. This can include identifying and crafting messages for specific audiences,
finding and filling gaps in current messaging strategies, sharing messages across partners’
social networks and other platforms, or leveraging existing community relationships to
strengthen trust in public health. It is important for health departments to share with partners
not only the messages they wish to convey but also the broader rationale behind them,
including the department’s role in decision-making. Throughout the message development and
delivery process, both partners should continuously evaluate their messaging strategies and
develop strategic plans that leverage successes and navigate barriers. See Priority 5 for further
guidance on message development, tailoring, and evaluation.

The following table shares examples of partnerships, outlining what partners shared and how
they benefited.

Table 2. Real examples of public health partnerships

Example Benefit to public health Benefit to partner

The Academic Public Health AICP revealed to APHC the need APHC held an informational
Corps (APHC) partnered with the for more culturally representative webinar for AICP audiences
Association of Islamic Charitable informational materials. AICP on COVID-19 and vaccination
Projects Massachusetts (AICP) provided guidance on how best with live Arabic translation. A
on a COVID-19 Vaccine Equity to execute the development and recording was made available to
Initiative through a competitive dissemination of the materials, those unable to attend. APHC
grant process.13 including distributing the finalized also held a Q&A session during
materials at their events.13 which community members
could discuss cultural concerns
that were not addressed in public
health messaging.13

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 24
 Example Benefit to public health Benefit to partner
The Hawai’i Public Health Institute PIDF leveraged their network HIPHI provided necessary funding
(HIPHI) ran a competitive grant of community partners to support to PIDF’s program
program to support local CBOs’ distribute more than 70,000 development and distribution
COVID-19 outreach programs. COVID test kits and personal efforts, allowing them to better
Partners in Development protective equipment to rural serve their community and meet
Foundation (PIDF), a nonprofit island communities that HIPHI their unmet public health needs.18
supporting underserved and may not have been able to
hard-to-reach communities in reach otherwise. Additionally,
Hawai’i, won one of these CBO PIDF facilitated Global Biorisk
grants to implement 2 projects.18 Advisory Council training covering
infectious disease mitigation
strategies and proper disinfection
processes for more than 400
individuals.18

Partners may also assist in increasing social media engagement, including by offering valuable
insights about community behavior and highly trafficked sites and platforms. Public health
agencies can use this information to cultivate a stronger social media presence with higher
Priority 3

potential for engaging informal secondary messengers. Additionally, promoting public health
messages and social media posts on partner platforms can increase visibility and encourage
sharing.19

Activity 3: Cultivate opportunities for informal sharing of messages

Informal secondary messengers are individuals, groups, or organizations that share health
information without any formal agreement with public health agencies. This approach is a
cost-efficient and effective way to distribute impactful information via social media platforms
or physical materials. Examples of informal secondary messaging include posting health
department memes in group chats or sharing health department posts on social media or
in-person. This approach helps public health departments or other government agencies
reach social networks and their community members who might not be reached by formal
partnerships.1

Task 3.1: Leverage informal secondary messengers in virtual spaces

Social media platforms can be a high-impact and low-effort tool for increasing public health
messaging visibility. Posting shareable infographics on public health social media pages is an
easy way to build an audience and increase message amplification. In some cases, however,
limited attention is focused on public health-sponsored pages. In these cases, identifying other
virtual spaces frequented by intended audiences is critical. Monitoring and participating in
social media trends, when appropriate, is another way public health departments can increase
engagement and gain larger audiences.19 See Priority 5 for guidance on developing impactful
social media messaging.

Health departments should keep in mind that messages may be shared in their original format
or altered. Therefore, it is important that key public health ideas are clear and prominent to
retain accuracy. Be cautious of the potential for distorted messaging or the loss of important
context during sharing.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 25
 Task 3.2: Leverage informal secondary messengers in physical spaces
Another way of leveraging informal partnerships is in physical spaces. Public health
departments can participate in community events, distribute informational materials in
community spaces, and engage in other activities that provide audiences with relevant and
up-to-date health information. Participants can take this information home or to other events
and distribute it to other audiences. For example, school-aged children who speak a different
language at home might learn about health topics at school and tell their families about the
information.1

Public health employees engaging in dialogue at events can build trust, which can help
public health messages spread through word of mouth.7 Increasing face-to-face time with
community members increases the likelihood that they will spread public health messaging
to their families, workplaces, or social circles. Public health departments should take these
opportunities to share information, answer questions, and encourage continued dialogue.

In addition to attending events, public health employees can, with permission, leave health-
related materials in community gathering spaces like the YMCA, public restrooms, local
barbershops, churches, schools, etc., for passive distribution. Customizing materials, with
Priority 3

support from formal partners, to match community demographics and cultures can help more
people see and understand such resources. See Priority 5 for more on developing materials.

Priority 3 References
1. Potter CM, Grégoire V, Nagar A, et al. A practitioner-focused checklist to build trust, address
misinformation and improve risk communication for public health emergencies. [Manuscript
submitted for publication.]
2. Schoch-Spana M, Brunson E, Chandler H, Gronvall GK, Ravi S, Sell TK, Shearer MP.
Recommendations on How to Manage Anticipated Communication Dilemmas Involving
Medical Countermeasures in an Emergency. Public Health Rep. May 30, 2018.
doi:10.1177/0033354918773069
3. Turin TC, Chowdhury N, Haque S, Rumana N, Rahman N, Lasker MAA. Meaningful and deep
community engagement efforts for pragmatic research and beyond: engaging with an immigrant/
racialised community on equitable access to care. BMJ Global Health. 2021;6(8): e006370.
4. Public Health Institute Center for Wellness and Nutrition. We’re All in This Together: Strengthening
Community Engagement Strategies Through a Collaborative Technical Assistance Model.
Sacramento, CA: Center for Wellness and Nutrition; 2022.
5. McNeish R, Rigg KK, Tran Q, Hodges S. Community-based behavioral health interventions:
Developing strong community partnerships. Eval Program Plann. December 10, 2018. doi:0.1016/j.
evalprogplan.2018.12.005
6. National Association of County and City Health Officials (NACCHO). Mobilizing for Action Through
Planning & Partnerships: MAPP 2.0 User’s Handbook. Washington, DC: NACCHO; 2023. https://
www.naccho.org/programs/public-health-infrastructure/performance-improvement/community-
health-assessment/mapp
7. Agency for Toxic Substances and Disease Registry. Public Health Assessment Guidance Manual:
Community Engagement Actions, Tools, and Activities. Reviewed April 14, 2022. Accessed March
15, 2024. https://www.atsdr.cdc.gov/pha-guidance/engaging_the_community/community_
engagement_tools_actions.html

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 26
 8. US Centers for Disease Control and Prevention (CDC). Community Needs Assessment. Atlanta,
GA: CDC; 2013. https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/15/
community-needs_pw_final_9252013.pdf
9. O’Donnell E. Seven Steps for Conducting a Successful Needs Assessment. National Institute for
Children’s Health Quality. Undated. Accessed March 15, 2024. https://nichq.org/insight/seven-
steps-conducting-successful-needs-assessment
10. National Business Coalition on Health, Community Coalitions Health Institute. Community Health
Partnerships: Tools and Information for Development and Support. March 4, 2013. https://www.
countyhealthrankings.org/sites/default/files/media/document/Community_Health_Partnerships_
tools.pdf
11. Huisman M, Biltereyst D, Joye S. Sharing is caring: the everyday informal exchange of health
information among adults aged fifty and over. Information Research. March 2020. https://
informationr.net/ir/25-1/paper848.html
12. Association of American Medical Colleges Center for Health Justice. Local Partnerships Are Key
to Building Community Trust. Published April 27, 2023. Accessed March 15, 2024. https://www.
aamchealthjustice.org/news/news/local-partnerships-key
13. Yasmin S, Haque R, Kadambaya K, Maliha M, Sheikh M. Exploring How Public Health Partnerships
with Community-Based Organizations (CBOs) can be Leveraged for Health Promotion and
Community Health. Inquiry. November 30, 2022. doi:10.1177/00469580221139372
Priority 3

14. Michener JL, Castrucci BC, Bradley DW, Hunter EL, Thomas CW, Patterson C, Corcoran E, eds. The
Practical Playbook II: Building Multisector Partnerships That Work. Oxford, UK: Oxford University
Press; 2019.
15. Vaccinate Your Family. SQuaring Up Against Disease (SQUAD) pamphlet. Undated. https://
vaccinateyourfamily.org/wp-content/uploads/2023/04/SQUAD-1-PG-2023-V2.pdf
16. Angelo, J. Vaccination and Food Resources to Nearly 200 Micronesians. Living Islands. Published
March 13, 2021. Accessed March 15, 2024. https://livingislands.org/vac313/
17. CDC Foundation, Vaccine Equity Cooperative, Health Leads. Leveraging Immunization Manager and
Community Based Organization Partnerships for COVID-19 and Beyond. CDC Foundation, Vaccine
Equity Cooperative, Health Leads webinar. February 24, 2022. Accessed March 15, 2024. https://
vaccineequitycooperative.org/resource/leveraging-immunization-manager-and-community-
based-organization-partnerships-for-covid-19-and-beyond-recording/
18. Hawai’i Public Health Institute. CBO Grant Highlight: PIDF and MCOH Complete their COVID-19
Projects. Published June 26, 2023. Accessed March 15, 2024. https://www.hiphi.org/cbo-grant-
highlight-pidf-and-mcoh-complete-their-covid-19-projects/
19. Miller MR, Snook WD, Walsh E. Social Media in Public Health: A Vital Component of Community
Engagement. de Beaumont Foundation. Published November 25, 2019. Accessed March 15,
2024. https://debeaumont.org/news/2019/social-media-in-public-health-a-vital-component-of-
community-engagement/

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 27
 Priority 4: Anticipate Misinformation & Potential Loss of Trust
Misinformation undermines trust in public health. Lack of trust in public health, due to
misinformation or other factors, reduces the effectiveness of public health communication.
While Priority 1, Priority 2, and Priority 3 recommend enabling capacities and activities that
build trust, and Priority 5 covers public health messaging and evaluation, this section describes
how public health departments can anticipate and proactively mitigate common threats that
diminish trust in public health, including misinformation. Table 1 provides a brief summary.

Table 1. Brief summary of common threats to trust in public health and how they may be
addressed

Anticipate... Action...
People may not thoroughly understand what public Engage in pre-emergency outreach that talks about
health is or what public health departments do. the benefits and roles of public health. Provide
easy ways for the public to seek information from
public health departments before, during, and after
emergencies.
PHEs may emerge rapidly and evolve over Provide structure to and transparency of public
time, generating uncertainty. People and public health communications early and throughout
health departments may seem to be on different the emergency. Demand for information,
pages, which could generate confusion—or even interests, concerns, and emotional needs may
frustration—for everyone. fluctuate throughout the emergency, and public
health guidance likely will shift in response.1
Communicating openly and honestly at a regular
cadence will help lower the risk that the public
views potential threats as abstract or has unclear
expectations of emergency response guidance and
Priority 4

countermeasures.
Misinformation will arise that undermines trust. Establish processes to stay aware of circulating
rumors. Consider ways to make the public more
resilient to misinformation before it arises, including
promoting access to and use of trusted sources.

Activity 1: Enable appropriate understanding of what public health is and

does
Public health—as a concept, an area of work, and a government service—suffers from a lack
of shared understanding about its roles in and contributions to the community. Following the
COVID-19 pandemic, some people may think of public health only in the context of a global
health emergency or could hold negative views of public health because of certain response
efforts.2-4 These negative perceptions and misunderstandings must be addressed to prevent
the potential loss of trust during an emergency.2 This section reflects on how public health
departments can leverage existing outreach efforts to educate people about what public health
is and isn’t, how public health efforts benefit society, and how people can get in touch with
their public health department—thereby hopefully mitigating losses in trust.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 28
 Task 1.1: Establish what public health is and its benefits to society
The first time people engage with public health should not be during an emergency.2-4
Regularly exposing the community to the valuable day-to-day work of public health
departments can help build a baseline of awareness and mitigate distrust during public
health events. Communicating about the diversity of public health activities—such as keeping
people safe from drowning, making sure food is safe to eat, keeping water clean, and helping
prevent chronic diseases—helps to increase public health’s visibility and show its valuable
contributions to communities. This can be done through traditional, new, and community-
driven communication channels. For example, creating public health-related stories, posts,
and other content across health department social media platforms can build a following of
community members, raise awareness, and promote trust in the “brand” of the public health
department.2 Although these activities are often considered part of normal public health
communication activities, health departments should prioritize them as a critical part of
emergency preparedness.

Task 1.2: Clarify how government services—including the public health department—are
organized
While it is important to share what public health does well, it is equally important to inform the
community about those activities or decision-making capabilities that fall outside its scope,
as well as how activities are organized within the health department. For example, if someone
asks the HIV team about non-HIV services, public health staff should refer that person to a
point of contact responsible for those specific services and explain why they cannot help,
rather than simply declining to assist because the request falls outside their scope, as the
latter could damage trust. Having a single community engagement team that cycles through
all health department sections may aid in this effort. Investments in health and government
literacy also can help the public better identify and utilize needed public health services, as well
Priority 4

as build and maintain trust between health departments and communities.2

Task 1.3: Explain the goals and thought processes behind public health operations
Public health communicators should share their departments’ goals and processes in
transparent and accessible ways. Highlighting goals such as keeping food safe, promoting
healthy environments, and preventing disease outbreaks can help emphasize how community
values are reflected in public health activities. Similarly, explaining decision-making processes
can help to answer “how” and “why” questions related to public health actions. When the
public understands how public health departments operate and their core goals, they are more
likely to support public health activities during emergencies, even when those activities are
challenging or burdensome.2

Some specific ways that public health departments can better share public health goals and
processes include publicizing strategic planning processes and outcomes with members of the
public; providing health boards and the public with descriptions of operations around specific
health threats or topics; and ensuring that staff who regularly interact with the community,
such as health inspectors, have written materials to explain how and why they are doing their
work.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 29
 Task 1.4: Plan robust public feedback mechanisms prior to an emergency
Public health communication is not always immediately clear and comprehensive to the public.
There may be additional questions, concerns, or needs for clarification. Providing opportunities
for real-time dialogue between public health communicators and people, online or offline, as
well as other speedy feedback mechanisms, is key to avoid confusion, frustration, or potential
losses in trust. Examples include telephone hotlines staffed with public health employees who
can answer questions, address concerns, or provide information; regularly monitored email
inboxes and health department social media pages; and front desk personnel at the health
department to welcome visitors and answer phones.2

In setting up robust communication mechanisms, it is important to avoid potential

pitfalls. Failing to follow up on inquiries can lead to confusion and a reduced likelihood of
informal secondary messengers sharing health department messages effectively. Failing to
acknowledge feedback or lacking friendliness can lead to broken trust. Poorly monitored and
maintained communication methods may do more harm than good if people feel ignored and
discounted. Note that additional feedback mechanisms should be accessible to CBOs via other
means, such as designated health department staff members acting as consistent points of
contact for community partner feedback and needs.2

Furthermore, by monitoring these feedback points, health departments may be better able
to evaluate the reach and effectiveness of their communication efforts. If capacity allows,
daily monitoring of public feedback mechanisms can greatly improve the department’s
responsiveness to community needs. Formal indexing and analysis of questions, comments,
and concerns can help public health agencies better understand potential problem areas.
Advisory committees, CBO leadership forums, or focus groups can help gather community
sentiment and provide comments.2 See Priority 5 for more information on evaluating public
Priority 4

health messaging.

Activity 2: Set expectations for public health response and communication

at the start of a health emergency
Setting expectations at the start of a PHE can help ensure that the community is less surprised
by emerging issues as they evolve. Clear expectations can help keep public health agencies
accountable and, when met, preserve or increase levels of trust.

Task 2.1: Help members of the public understand issues of uncertainty

Emergencies are inherently uncertain events. As a PHE emerges, standard communication
practices are to share what is known, unknown, and what is being done to fill those gaps.3
Describing any issues of uncertainty at the start of an event, as well as the scientific
processes being undertaken that could help shed light on the situation, can help ensure public
understanding and set appropriate expectations.5

While emergency communication can be relayed through social media-focused materials and
appealing visuals, one of the most important channels to communicate uncertainty is through
in-person briefings or recorded comments by health officials. Showing humility and relatability
in stating “we don’t know” is a valuable source of empathy and connection. However, public
health departments should consider the needs of intended audiences to determine the

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 30
 best ways to share information. In some situations, audiences may perceive officials’ lack of
knowledge negatively, especially if they feel enough time has passed that answers should be
available.2

Task 2.2: Establish processes and plans to communicate changes in guidance as

understanding evolves
Along with sharing information about uncertainties, public health communicators should set
expectations that while current guidance and approaches are based on the best available
information, changes could and likely will occur as understanding about a PHE improves or the
situation evolves.6 Developing processes and plans for how to communicate these changes in
a timely and transparent way is important to maintain a rapport with the community.5 Public
health officials should emphasize that any changes will be based on continuing analyses of the
most up-to-date information.

Task 2.3: Set an appropriate communication cadence

In times of uncertainty and change, there is significant demand for new information and
situational updates. When the public does not know when to expect updates, requests for new
information can become more frequent and can leave voids that might be filled with rumors
or incorrect information. By setting a predictable, appropriate, and clear communication
cadence, public health communicators can help set expectations for when new information will
be shared and preserve trust. The appropriate frequency of updates depends on the type and
phase of emergency, health department capacities, intended audience, and communication
channels. Additional communication opportunities may be inserted into the communication
cadence if a specific need arises.2

Activity 3: Track, analyze, understand, and plan for anticipated rumors in

Priority 4

local contexts
The spread of misinformation and disinformation is now an expected part of public health
emergency events. Therefore, the public health community must anticipate misleading rumors
and design processes to deal with them ahead of time.

The project team has developed several other resources to

assist in these efforts, including a framework for anticipating
likely rumors during an emergency and the Practical playbook
for addressing health misinformation, which takes a hands-on
approach to help public health communicators recognize and
respond to health-related rumors and misinformation.7,8

Task 3.1: Establish tracking and analysis systems for social listening
Public health communicators can better understand their information environments by
tracking and analyzing online content, often referred to as “social listening.” They can use
social listening tools such as Google Alerts and Talkwalker to manage information during an
infodemic.9,10 They can also use informal methods, such as taking notes on questions asked at
in-person events. Analysis of this information can be formal, like preparing a detailed insights
report, or informal, like looking for common themes of rumors that arise.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 31
 Tracking and analyzing information at the community level can help improve understanding of
issues specific to geography or culture that could require specialized intervention. Community
health workers and public health nurses are well-positioned to help collect rumors and should
have ways to share that information with public health communication teams.2 Additionally,
public health departments should track rumors that were widespread during past health
events, as these likely will re-emerge in future emergencies.

Task 3.2: Integrate an understanding of local audience values and needs with expected
rumors
Understanding local audience needs, values, and priorities is a core component of everyday
public health operations. This knowledge is critical to ensure appropriate and trusted
communication during an emergency, which is why it is covered in-depth in Priority 1 and
Priority 2. These factors should also be considered in the context of expected rumors that
are likely to emerge during an emergency. Most rumors, misinformation, and disinformation
leverage strongly held beliefs and concerns,7 such as anxieties related to fertility, perspectives
on the role of government, and worries about profiteering.11 Undertaking efforts to broaden
understanding of local communities can help public health communicators anticipate and
prepare for these types of rumors.8

Task 3.3: Develop prebunking and inoculation messages

Prebunking is a process to “inoculate” people against misleading information, like vaccination
against a disease.12 The idea involves showing people examples of misinformation and
explaining the tactics typically used to persuade beliefs. By providing that information,
individuals are better able to understand and identify misinformation when it arises, less likely
to spread or share misinformation, and less likely to be persuaded by or believe misinformation
when exposed to it.13-17
Priority 4

The first steps to developing prebunking messages include the previous 2 tasks, understanding
possible rumors and how they resonate with local community needs and values. Existing
guidance on prebunking approaches focuses on telling the truth; exposing known tactics,
such as attributing misleading content to “experts”; and warning of expected misleading
information.18-21 The figure below, based on research from First Draft, provides more
information on developing prebunking messages.19 Public health departments can also use
gamified prebunking tools, such as Bad News and Go Viral!.22,23 For more information about
prebunking and when or how to use it, see our Practical playbook for addressing health
misinformation.8

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 32
 Figure 1. Tips for developing prebunking messages, adapted from First Draft19

Activity 4: Promote use of and access to trusted sources

People are less likely to trust or turn to misinformation if they have the skills or knowledge to
Priority 4

identify rumors as misinformation and if they have easy access to information from official
sources, like the public health department.

Task 4.1: Facilitate access to trustworthy health information and teach critical thinking
skills to enhance information self-sufficiency
Improving public resilience to misleading health information is the ultimate goal of public
health communicators. Cultivating a misinformation-resilient public involves providing
access to and tips on how to find trustworthy sources for health information and teaching
critical thinking skills to help people collect and evaluate health information.8,24,25 Working
with public health colleagues involved with other behavior change efforts, such as chronic
disease prevention or tobacco control, as well as trusted community partners, is beneficial. For
instance, including health and digital literacy training on various public health topics in school
curricula or during presentations at other community venues can be helpful.26

Task 4.2: Enhance information accessibility and understandability

Effective public health communication requires accessible and understandable content.27,28
Translators and accessibility experts are important to creating communication materials in
languages and formats that intended audiences can understand. Materials should not only
be readable but also culturally relevant. Leveraging the knowledge of community members,
including public health colleagues, or CBOs can help improve information dissemination.
Translation services should be set up before health emergencies, as contracting and funding

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 33
 mechanisms can slow timely delivery when information is changing quickly. Additionally, public
health staff can provide clear guidance on where to go for additional culturally or linguistically
appropriate health information, such as CBOs or trusted online resources.2

Priority 4 References
1. Schoch-Spana M, Gronvall G, Brunson E, Sell TK, Ravi S, Shearer MP, Collins H. How to Steward
Medical Countermeasures and Public Trust in an Emergency: A Communication Casebook for FDA
and its Public Health Partners. Baltimore, MD; UPMC Center for Health Security; 2016. https://
centerforhealthsecurity.org/sites/default/files/2022-12/fdacasebook.pdf
2. Potter CM, Grégoire V, Nagar A, et al. A practitioner-focused checklist to build trust, address
misinformation and improve risk communication for public health emergencies. [Manuscript
submitted for publication.]
3. US Centers for Disease Control and Prevention. Resources for Emergency Health Professionals:
Crisis & Emergency Risk Communication Manual and Tools. Updated January 23, 2018. Accessed
April 17, 2024. https://emergency.cdc.gov/cerc/resources/index.asp
4. Admin B. Making Public Health Visible. Big Cities Health Coalition. Published April 2, 2018. Accessed
June 7, 2024. https://www.bigcitieshealth.org/front-lines-blog-making-public-health-visible/
5. O’Malley P, Rainford J, Thompson A. Transparency during public health emergencies: from rhetoric
to reality. Bull World Health Organ. 2009;87(8):614-618. doi:10.2471/blt.08.056689
6. Hodson J, Reid D, Veletsianos G, Houlden S, Thompson C. Heuristic responses to
pandemic uncertainty: Practicable communication strategies of “reasoned transparency”
to aid public reception of changing science. Public Underst Sci. 2023;32(4):428-441.
doi:10.1177/09636625221135425
7. Johns Hopkins Center for Health Security. Understanding common rumors that emerge during
public health emergencies. Tackling Rumors and Understanding & Strengthening Trust (TRUST) In
Public Health. Published July 11, 2024. https://centerforhealthsecurity.org/our-work/research-
projects/trust/tackling-rumors/trust-common-rumors-during-phes
Priority 4

8. Nagar A, Grégoire V, Sundelson A, O’Donnell-Pazderka E, Jamison AM, Sell TK. Practical playbook
for addressing health misinformation. Baltimore, MD: Johns Hopkins Center for Health Security;
2024.
9. Google News Initiative. Google Alerts: Stay in the know. Undated. Accessed April 17, 2024. https://
newsinitiative.withgoogle.com/resources/trainings/fundamentals/google-alerts-stay-in-the-
know/
10. Talkwalker. Free Social Media Monitoring Tools. Undated. Accessed April 17, 2024. https://www.
talkwalker.com/free-social-media-monitoring-analytics-tools
11. Ecker UKH, Lewandowsky S, Cook J, et al. The psychological drivers of misinformation belief and its
resistance to correction. Nat Rev Psychol. 2022;1(1):13-29. doi:10.1038/s44159-021-00006-y
12. Harjani T, Roozenbeek J, Biddlestone M, et al. A Practical Guide to Prebunking Misinformation.
Cambridge, England: University of Cambridge, Jigsaw (Google), BBC Media Action; 2022. https://
prebunking.withgoogle.com/docs/A_Practical_Guide_to_Prebunking_Misinformation.pdf
13. McGuire WJ. Inducing resistance to persuasion. Some contemporary approaches. In: Haaland CC,
Kaelber WO, eds. Self and Society. An Anthology of Readings. (1981 ed.) Lexington, Massachusetts:
Ginn Custom Publishing; 1964:192-230.
14. Basol M, Roozenbeek J, Berriche M, Uenal F, McClanahan WP, Linden SV. Towards psychological
herd immunity: Cross-cultural evidence for two prebunking interventions against COVID-19
misinformation. Big Data Soc. May 11, 2021. doi:20539517211013868
15. Saleh NF, Roozenbeek JO, Makki FA, McClanahan WP, van Der Linden S. Active inoculation boosts
attitudinal resistance against extremist persuasion techniques: A novel approach towards the
prevention of violent extremism. Behav Public Policy. February 1, 2021. doi:10.1017/bpp.2020.60

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 34
 16. Iles IA, Gillman AS, Platter HN, Ferrer RA, Klein WM. Investigating the potential of inoculation
messages and self-affirmation in reducing the effects of health misinformation. Sci Commun.
October 5, 2021. doi:10.1177/10755470211048480
17. van der Linden S, Leiserowitz A, Rosenthal S, Maibach E. Inoculating the public against
misinformation about climate change. Glob Chall. January 23, 2017. doi:10.1002/gch2.201600008
18. Roozenbeek J, van der Linden S, Nygren T. Prebunking interventions based on ‘‘inoculation’’ theory
can reduce susceptibility to misinformation across cultures. Harv Kennedy Sch Misinformation Rev.
February 3, 2020. https://misinforeview.hks.harvard.edu/article/global-vaccination-badnews
19. Garcia L, Shane T. A guide to prebunking: a promising way to inoculate against misinformation.
First Draft. Published June 29, 2021. Accessed April 17, 2024. https://firstdraftnews.org/articles/a-
guide-to-prebunking-a-promising-way-to-inoculate-against-misinformation
20. Cook J, Lewandowsky S, Ecker UK. Neutralizing misinformation through inoculation: Exposing
misleading argumentation techniques reduces their influence. PLoS One. 2017;12(5):e0175799.
21. UNICEF Middle East and North Africa, Public Goods Project, First Draft, Yale Institute for Global
Health. Vaccine Misinformation Management Field Guide. UNICEF; 2020. https://www.unicef.org/
mena/reports/vaccine-misinformation-management-field-guide
22. Social Decision-Making Lab at the University of Cambridge, Tilt, Gusmanson. Bad News. Undated.
Accessed April 17, 2024. https://www.getbadnews.com/books/english
23. Social Decision-Making Lab at the University of Cambridge, Drog, Tilt, Gusmanson, UK Cabinet
Office. Go Viral!. Undated. Accessed April 17, 2024. https://www.goviralgame.com/books/go-viral
24. Howell EL, Brossard D. (Mis)informed about what? What it means to be a science-literate citizen in
a digital world. Proc Natl Acad Sci USA. 2021;118(15):e1912436117. doi:10.1073/pnas.1912436117
25. Wang S. Back to the Basics: Education as the Solution to Health Misinformation. Harvard Political
Review. Published February 6, 2023. Accessed June 7, 2024. https://harvardpolitics.com/basics-
health-misinformation/
26. Sundelson AE, Jamison AM, Huhn N, Pasquino SL, Sell TK. Fighting the infodemic: the 4 i
Framework for Advancing Communication and Trust. BMC Public Health. 2023;23(1):1662
Priority 4

doi:10.1186/s12889-023-16612-9
27. Flores AL, Meunier J, Peacock G. “Include Me”: Implementing Inclusive and Accessible
Communication in Public Health. Assist Technol Outcomes Benefits. 2022;16(2):104-110.
28. Public Health Communications Collaborative. Plain Language for Public Health. Public Health
Communications Collaborative; 2023. https://publichealthcollaborative.org/wp-content/
uploads/2023/02/PHCC_Plain-Language-for-Public-Health.pdf

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 35
 Priority 5: Formulate Key Message Components & Maximize
Message Engagement
Developing, tailoring, and evaluating key messages is essential to increase messaging
effectiveness and the likelihood of positive health behavior change.1-3 Key messages are the
primary pieces of information that messengers want their audiences to receive, comprehend,
remember, and use.4 Tailoring these messages, which involves adapting major message
features like the messenger, channel, use of dialogue, content, tone, and visuals, can help
strengthen message effectiveness and reach. Formatting these messages requires careful
attention to details like history, culture, shared values, empathy, available technology, and the
trustworthiness of the cited source. Messaging efforts should also be continually evaluated
to assess their reach and impact to inform further tailoring or new message development.
Neglecting these actions can result in low engagement and low uptake of messaging or a
failure to reach intended audiences. The Tailoring Tool to Increase Message Uptake & Trust in
the Appendix can be used to summarize and apply advice from this section.

Activity 1: Draft key messages

The first step of message development is to formulate key messages based on the information
needs of the community. See Priority 2 and Priority 3 for more on how to understand the
information needs of communities.

Task 1.1: Embrace a basic content format for communicating accurate information in an
emergency
During a PHE, health departments need to quickly disseminate accurate information and
recommendations to the public. Effective messages often use the following format and
approach:

Introductory statement: This can be a statement of shared concern or a

statement of intent or purpose for the message. Generally, cultural competence
and empathy should be emphasized.5
Key Messages: These include 3–5 of the most important takeaway statements.
Public health communicators should consider these 5 elements to motivate
public action and compliance.6
● What is the action?
Priority 5

● When should the action take place?

● Where and who should act?
● Why should they act?
● Whose advice is being shared?
Justification: Messages may benefit from including a justification, such as
data from reliable sources trusted by the audience, to support the takeaway
statements.
Conclusion: End with a limited number of summarizing statements and include
simplified repetition of key messages. Communicators should work to leave
time or create other opportunities for questions and discussion if possible.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 36
 Task 1.2: Employ specialized approaches to confront rumors
When public health practitioners are responding to existing or anticipated misinformation, they
need to consider the risks posed by the spread of that specific rumor and the capacity of the
health department to respond. For example, an approach called the “truth sandwich” can be
an effective way to prevent the unintentional spread of false or misleading claims.7-9 Messages
should:
• Start with the truth
• Indicate the lie and avoid amplifying specific language, if possible
• Return to the truth
See the “Truth Sandwich” Sample Script callout box for more details. For more specific
guidance on how to craft content to address misinformation, see our Practical playbook for
addressing health misinformation.11

“Truth Sandwich” Sample Script

“Disease X,” a term coined by the World Health Organization (WHO), represents a future
unknown disease with uncertain characteristics.10 Uncertainty in the early stages of an
emerging PHE is common, and rumors can circulate widely in these situations. Here is an
example of how the truth sandwich would be used in this situation:
We understand there is a lot of public concern related to the emergence of Disease X.
Truth
What we know right now is that Disease X causes [insert true symptoms].
There is no evidence that Disease X has caused [insert false claim: eg, infertility] in
Lie
children or adults.
Disease X causes [insert true symptoms], and we will continue to share information
Truth
as it becomes available.

Task 1.3: Consider and apply lessons from existing messaging models
There is a growing body of work related to key message development. Resources like toolkits,
vetted talking points, and infographics created by the Public Health Communications
Collaborative (PHCC) have served as a framework for many individual and community
Priority 5

leaders to draft their messages. Additionally, the Crisis and Emergency Risk Communication
(CERC) program, created by the Centers for Disease Control and Prevention (CDC), provides
trainings, tools, and resources to help communicators, emergency responders, and leaders of
organizations communicate effectively during emergencies.12 Public health messaging should
be simple, concise, empathetic, memorable, tailored, and impactful.

Table 1. Message components based on the CERC framework13

CERC considerations Application

Present a concise message Avoid jargon, keep it simple, only include relevant information
Repeat the main message Frequently heard messages can help with retention when
uncertainty is high

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 37
 CERC considerations Application
Give action steps in positives (when Tell people what to do, more than what not to do
feasible)
Create action steps in threes and fours Short lists are easier to remember
Use personal pronouns Humanize the message with I/we statements
Respect people’s fears and Recognize emotions, avoid judgement and condescension
perceptions
Give people options Avoid patronizing or domineering ways to inform decision making

Health departments may also draw from their own experiences, considering prior successful
messages for similar events or pre-scripting messages for later updating and tailoring.

Activity 2: Tailor messages based on understanding of the intended

audience
Message development should center around understanding messaging needs from audiences
and their preferences for how to receive and meaningfully engage with information. Providing
information is not enough, especially in populations distrustful or suspicious of public
health officials. Messages should be framed appropriately according to intended audience
characteristics and values.14 Furthermore, public health communicators should consider the
value of incorporating two-way dialogue, rather than one-way messages with no feedback
mechanism, to increase receptiveness, promote trust, facilitate evaluation efforts, and improve
effectiveness.1

Task 2.1: Identify intended audiences for messaging

Often, a public health message is directed at the general public, but sometimes health
departments want to prioritize messaging toward a specific intended audience. These
audiences may be identified based on demand for accurate information, poor reach of existing
accurate messaging, dynamics of circulating rumors, unique information delivery needs, or
increased risk or vulnerability to the public health emergency at the time. Some audiences may
be large and broad (eg, a demographic category at greater risk of severe disease outcomes),
small (eg, a specific affected neighborhood), or even a specific individual (eg, a community
member with questions). Prior to an emergency, communicators can use past experience,
Priority 5

community data, real-time situational awareness (cultivated in Priority 1 and Priority 2),
partner expertise (drawn from Priority 3), and community feedback (established in Priority 4)
to identify potential intended audiences for key messages.1,11

Task 2.2: Consider specific needs of the intended audience that may influence their
perspectives on public health messages
Different intended audiences have varying needs in how best to frame and present messages
to ensure the information fits within their values and belief systems. Message developers
should review their knowledge of their intended audience as laid out in Priority 1 and reflect
on the demographic characteristics, values, and needs of the audience. Then, public health
communicators should reframe message content based on that information as well as input
from partners.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 38
 Here are a few examples1 of how messages may be reframed according to intended audience
characteristics:
• Audiences that distrust public health authorities may be more receptive to messages
that do not reference public health authorities.
• Resource-strained communities may prefer messages to be accompanied by support to
carry out recommended actions, such as providing masks when recommending mask
wearing.
• Broad messaging to diverse audiences with variable needs and willingness to adhere to
public health measures may benefit from a harm-reduction approach so that individuals
can tailor their actions to address their own risk profiles.
• Populations with strong values regarding personal choice and freedoms may respond
better to messages that share information to help with health decision making or
personal stories about difficult decision making from members of their own community.
• Populations with limited awareness of public health may benefit from regularly
engaging with a specific spokesperson or outreach team.

Task 2.3: Engage in dialogue to build trust, increase message effectiveness, and combat
misinformation
Two-way dialogue between messengers and community members can build trust and increase
messaging effectiveness. This may involve engaging with the intended audience over the long-
term, taking part in feedback sessions, providing dedicated space for responding to specific
questions or concerns, or receiving feedback regarding communication activities. Two-way
communication is important to improve awareness of public health, facilitate identification
of and response to the community’s information needs, conduct social listening to monitor
circulating rumors, actively combat misinformation and disinformation, evaluate receptiveness
to messaging, and, overall, increase trust with communities.1

Two-way communication between public health messengers and intended audiences can be
conducted in various ways depending on the needs and preferences of community members
and health department abilities.15 Examples include allowing for Q&A after a town hall, turning
on and answering comments on social media posts, or conducting in-person community
engagement at events or in third places.1,15,16 When considering engagement in debunking
Priority 5

disinformation on social media, critically evaluate the time it takes and the possible impact,
including the potential to elevate disinformation. Public health communication teams should
always engage with community members with a polite, calm, respectful, compassionate, and
nonjudgmental demeanor, even if that same attitude is not returned, as bystanders can be
sensitive to perceived disrespect toward community members.1

Activity 3: Ensure messages get to intended audiences via preferred

channels and trusted voices
Understanding which communication channels and voices will reach and be trusted by your
intended audience is essential for a message to be heard and internalized. Options for message
channels and engagement of trusted voices may be dependent on the available resources,
skills, or leadership support.1

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 39
 Task 3.1: Tailor channel utilization to increase engagement with intended audiences
Often, intended audiences are more receptive to receiving information from certain
communication channels more than others. Some important communication channels include
social media platforms, messaging apps like WhatsApp, radio stations, television broadcasts,
print media, press releases, email newsletters, flyers, and in-person engagements such as
neighborhood events, religious gatherings, and town halls.17 Some audience members may
have differing levels of accessibility to receive and understand communications or differing
levels of trust for information received through certain channels compared with others. For
example, younger generations may be more likely to engage with messaging delivered through
social media or memes,1,6 while rural populations may find messaging through the radio or in-
person engagements more accessible due to lack of broadband coverage.1,18

These different channels require different messaging approaches, and some channels are
more appropriate for certain message content and complexity. For example, to create effective
messaging for social media, engaging content often consists of bright colors, adapting content
based off existing trends on platforms, use of emotionally engaging content, and other similar
“viral” tactics.19,20 The most effective communication channels will not simply expose intended
audiences to information but also enhance opportunities to build trust in public health
messaging. Public health communicators should consider infrastructure, personal choice,
social norms, and economic levels, among other features, as potential factors that influence
intended audiences’ choice of communication channels.2 In many cases, communicators will
need to use more than one channel to ensure broad visibility.1

Task 3.2: Identify and integrate trusted messengers into messaging efforts to increase
uptake and effectiveness
Message developers should review their knowledge of the intended audience, as discussed
in Priority 1, reflect on who the trusted messengers are for that audience, and consider what
individuals or organizations could deter message uptake. Intended audiences are less likely
to be receptive of messengers they view as untrustworthy or inaccurate while they may be
more receptive of messengers they perceive as trustworthy according to shared values, history
of interaction, reputation, and affiliation.2 For example, intended audiences with low trust in
public health may be more receptive to messaging coming from a local non-health-related
community leader rather than an official health department spokesperson.1 These secondary
messengers should also have a voice in message development and tailoring as circumstances
Priority 5

allow to increase message effectiveness. Otherwise, messages may come off as inauthentic.
For more information on fostering successful partnerships with secondary messengers (ie,
non-health department messengers), see Priority 2.

Activity 4: Design messages using tone and visuals that will resonate with
intended audiences
Incorporating the correct tone and visual components of the message is important to increase
reach and opportunities for additional spread through secondary messengers. In some cases,
this may mean detouring from standard public health language toward approaches with
more humor or lighthearted features.21 Innovation, creativity, and risk-taking beyond existing
PHEPR communication practices are needed to keep up with a rapidly evolving communication
and media landscape and maximize engagement. However, as always, public health

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 40
 communicators should take an issue-specific approach to incorporation of these features to
find an appropriate balance for the topic at hand.1

Task 4.1: Increase engagement by using eye-catching visuals and other formatting
Incorporating visuals, particularly for social media or online content, is key to maximizing
engagement, including “likes,” comments, and sharing/reposting.19 In general, good practices
include the use of bright colors, simplistic graphics, positive imagery, easy-to-read text, visuals
of people and locations representative of the intended audience, accessible visuals and audio,
and native speaker translation of language, if applicable. On social media, using hashtags in
descriptions, presenting interactive content, embracing visuals or audio from social media
trends, creating or enhancing a character persona for the speaker, and including movement/
video instead of static imagery can all increase intended audience engagement.20,22 When
making decisions on how best to incorporate and utilize visuals, consider the nature of the
emergency, the identity of the messenger, the channel used to deliver the message, the
intended tone of the message, and the greater cultural, situational, and historical contexts.1,23

Task 4.2: Revise messaging content and tone to increase messaging reach
Intended audiences may engage more with alternative, more creative, or “outside-of-the-
box” message content and tone. Examples include messages that use humor or references
to current cultural trends (eg, social media platform trends, memes), reference common
experiences of the intended audience (eg, use of cultural touchstones or hyperlocal geographic
icons), or reframe recommendations based on moral values for issues that have become
politicized.1,20,22-24 These types of content changes and tone shifts are best implemented when
those with lived experience similar to the intended audience (eg, outside partners who are a
part of and serve that intended audience) are leading message tailoring or able to provide input
and feedback. Otherwise, this kind of tailoring could backfire23 and risks being perceived as
insensitive, inappropriate, or even offensive. See Priority 1 and Priority 2 for more information
on recruiting individuals to help with this type of tailoring.

When done correctly, tailoring can make it more likely that intended audiences will engage with
the message and even share the message within their own peer or family groups, expanding
message reach. Furthermore, social media content of a humorous or emotional nature is more
likely to be promoted and viewed on feeds,25 and social media algorithms are more likely to
promote demographically tailored and/or trendy content to intended audience viewers.1,20,22
Priority 5

Task 4.3: Sync message tailoring for maximum effectiveness

After determining the most appropriate and effective tailoring for the messenger, channel, use
of dialogue, visuals and other formatting, and message content and tone, it is important that
communication teams ensure that each piece complements others appropriately. Message
tailoring efforts should be synced while keeping in mind the nature of the emergency, intended
audience values, the information being conveyed, and cultural, situational, and historical
contexts. It is recommended that syncing efforts be done in conjunction with input from or
evaluation by individuals with lived experience similar to the intended audience (eg, staff
members local to the area, CBOs that serve the intended audience).1 Further guidance on
messaging evaluation is described in Activity 5 below.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 41
 For example, by following the V.I.R.A.L. mnemonic depicted below, social media videos
communicating preventative health behaviors may be best tailored with humorous tones, use
of positive imagery, and incorporation of social media trends.1,20

Figure 1. V.I.R.A.L. mnemonic for social media engagement strategies in infectious diseases, adapted from Langford BJ
et al.20

However, other messages or other channels may be best paired with different types of
tailoring. For example, in-person engagement with populations distrustful of public health may
be better accepted if they address concerns via dialogue with a calm, neutral, empathetic tone
rather than using humor, which would be inappropriate in this setting.

Activity 5: Regularly evaluate the engagement and impact of PHEPR

communication efforts
Determining whether messaging influences successful behavior change is difficult to
evaluate, but various methods can help health departments assess and adjust their PHEPR
Priority 5

communication activities.26-28 These methods should be built into the cycle of developing and
disseminating PHEPR content to help tailor messages, reach intended audiences, and increase
messaging effectiveness.11 Ideally, messages should be evaluated before and after being
shared, as shown in the figure below.1

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 42
 Figure 2. Message evaluation cycle

Task 5.1: Select and execute an evaluation process complementary to organizational

goals and capacities
It can be difficult to determine the direct or indirect impacts that risk communication activities
have on health-related behavior change.29-32 Health departments can use a variety of evaluation
Priority 5

processes, summarized in the table below, to estimate public health messaging impacts.
Evaluation methods can focus on engagement with or awareness of information, attitudes
related to health threats, or health-related behaviors or actions.1-3,26,33 They can use qualitative
analysis (eg, focus groups, community advisory board feedback), quantitative analysis (eg,
factor analysis, meta-regression), or mixed-methods approaches.34 Notably, evaluation efforts
should always be informed, and may be limited, by organizational capacities and resources as
well as response needs.

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 43
 Table 2. Examples of PHEPR messaging evaluation methods and metrics

Communication area being Examples of evaluation methods or metrics

evaluated
Awareness of/engagement with Social media engagement statistics (eg, views, likes, shares, comments);
public health messaging webpage views; pre/post calls to information lines; pre/post attendance
of health department events; content analysis of feedback submitted via
health department social media messaging, email, or phone
Awareness of/engagement with Social media content analysis, including engagement statistics (eg,
misinformation views, likes, shares, comments); topic and volume of questions related to
misinformation
Accurate health knowledge Pre/post messaging campaign survey, focus group, social media content
and/or belief in misinformation analysis
Risk perception of health threat Survey, focus group, social media content analysis
Self-efficacy regarding health Survey, focus group, social media content analysis
behaviors
Behavior changes in response Comparison of self-reported behavior change of those exposed to
to health messaging messaging and those not exposed to messaging via survey or social
media content analysis, pre/post campaign rate of health services use
statistics

Task 5.2: Link evaluation results to message development and tailoring efforts
By using one or more of the evaluation methods above, health departments will better
understand the factors that make their messages more effective or increase message uptake.
These may include: messenger; channel(s) used; inclusion of dialogue; message components,
including tone, visuals, or other formatting; delivery timing and frequency, especially
compared to the greater context of the emergency and public concerns; and usage of
concurrent messages with different tailoring.1-3,33,35 PHEPR communication teams can use their
findings to adjust the next round of message development or tailoring to maximize its future
effectiveness.

Priority 5 References
Priority 5

1. Potter CM, Grégoire V, Nagar A, et al. A practitioner-focused checklist to build trust, address
misinformation and improve risk communication for public health emergencies. [Manuscript
submitted for publication.]
2. Seeger MW, Pechta LE, Price SM, et al. A Conceptual Model for Evaluating Emergency Risk
Communication in Public Health. Health Security. 2018;16(3):193-203. doi:10.1089/hs.2018.0020
3. Kreps GL. Epilogue: lessons learned about evaluating health communication programs. J Health
Commun. 2014;19(12):1510-1514. doi:10.1080/10810730.2014.954085
4. US Centers for Disease Control and Prevention. Health Communication Playbook. Centers for
Disease Control and Prevention; 2018. Accessed June 7, 2024. https://www.cdc.gov/nceh/
clearwriting/docs/health-comm-playbook-508.pdf
5. Substance Abuse and Mental Health Services Administration (SAMHSA). Communicating in a
Crisis: Risk Communication Guidelines for Public Officials Communicating in a Crisis. Rockville, MD:
SAMHSA; 2019. https://store.samhsa.gov/sites/default/files/d7/priv/pep19-01-01-005.pdf

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 6. Schoch-Spana M, Brunson E, Chandler H, et al. Recommendations on How to Manage Anticipated
Communication Dilemmas Involving Medical Countermeasures in an Emergency. Public Health Rep.
May 30, 2018. doi:10.1177/0033354918773069
7. Tulin M, Hameleers M, de Vreese C, Opgenhaffen M, Wouters F. Beyond Belief Correction: Effects
of the Truth Sandwich on Perceptions of Fact-Checkers and Verification Intentions. Journal Pract.
February 2, 2024. doi:10.1080/17512786.2024.2311311
8. George Lakoff. “Truth Sandwich: 1. Start with the truth. The first frame gets the advantage. 2.
Indicate the lie. Avoid amplifying the specific language if possible. 3. Return to the truth. Always
repeat truths more than lies. Hear more in Ep 14 of FrameLab w/@gilduran76” December 1, 2018.
https://twitter.com/georgelakoff/status/1068891959882846208?lang=en
9. Apperson, M. What is a “truth sandwich”? PBS Standards. Updated June 17, 2022. Accessed June
4, 2024. https://www.pbs.org/standards/blogs/standards-articles/what-is-a-truth-sandwich/
10. Tam TWS. Preparing for uncertainty during public health emergencies: What Canadian health
leaders can do now to optimize future emergency response. Healthc Manage Forum. March 31,
2020. doi:10.1177/0840470420917172
11. Nagar A, Grégoire V, Sundelson A, O’Donnell-Pazderka E, Jamison AM, Sell TK. Practical playbook
for addressing health misinformation. Baltimore, MD: Johns Hopkins Center for Health Security;
2024.
12. US Centers for Disease Control and Prevention. CDC Emergency Preparedness and Response:
Manual and Tools. Updated January 23, 2018. Accessed June 12, 2023. https://emergency.cdc.gov/
cerc/resources/index.asp
13. US Centers for Disease Control and Prevention. CDC Crisis & Emergency Risk Communication
(CERC): Home. Updated January 23, 2018. Accessed June 12, 2023. https://emergency.cdc.gov/
cerc/index.asp
14. Public Health Communications Collaborative. Plain Language for Public Health. Public Health
Communications Collaborative; 2023. Accessed June 7, 2024. https://publichealthcollaborative.
org/wp-content/uploads/2023/02/PHCC_Plain-Language-for-Public-Health.pdf
15. US Centers for Disease Control and Prevention. Crisis and Emergency Risk Communication Manual:
Community Engagement. Updated 2018. Accessed June 7, 2024. https://emergency.cdc.gov/cerc/
ppt/CERC_CommunityEngagement.pdf
16. Diaz SMB and C. “Third places” as community builders. Brookings. Published September 14, 2016.
Accessed June 4, 2024. https://www.brookings.edu/blog/up-front/2016/09/14/third-places-as-
community-builders/
17. US Centers for Disease Control and Prevention. Crisis and Emergency Risk Communication Manual:
Priority 5

Messages and Audiences. Updated 2018. Accessed June 7, 2024. https://emergency.cdc.gov/cerc/

ppt/CERC_Messages_and_Audiences.pdf
18. Early J, Hernandez A. Digital Disenfranchisement and COVID-19: Broadband Internet Access as a
Social Determinant of Health. Health Promot Pract. May 6, 2021. doi:10.1177/15248399211014490
19. Ibrahim AM, Lillemoe KD, Klingensmith ME, Dimick JB. Visual Abstracts to Disseminate Research
on Social Media: A Prospective, Case-control Crossover Study. Ann Surg. 2017;266(6):e46-e48.
doi:10.1097/SLA.0000000000002277
20. Langford BJ, Laguio-Vila M, Gauthier TP, Shah A. Go V.I.R.A.L.: Social Media Engagement Strategies
in Infectious Diseases. Clin Infect Dis. May 15, 2022. doi:10.1093/cid/ciac051
21. Boston University School of Public Health. Phrasing and Word Choice. Undated. Accessed June 7,
2024. https://www.bu.edu/sph/students/student-services/student-resources/academic-support/
communication-resources/phrasing-and-word-choice/

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 22. Kim HS. Attracting Views and Going Viral: How Message Features and News-Sharing Channels Affect
Health News Diffusion. J Commun. May 14, 2015. doi:10.1111/jcom.12160
23. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial.
Pediatrics. March 3, 2014. doi:10.1542/peds.2013-2365
24. Basch CH, Fera J, Pierce I, Basch CE. Promoting Mask Use on TikTok: Descriptive, Cross-sectional
Study. JMIR Public Health Surveill. 2021;7(2):e26392. doi:10.2196/26392
25. Kaplan JT, Vaccaro A, Henning M, Christov-Moore L. Moral reframing of messages about mask-
wearing during the COVID-19 pandemic. Sci Rep. 2023;13(1):10140. doi:10.1038/s41598-023-
37075-3
26. Ghahramani A, de Courten M, Prokofieva M. The potential of social media in health promotion
beyond creating awareness: an integrative review. BMC Public Health. 2022;22(1):2402. doi:10.1186/
s12889-022-14885-0
27. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex
interventions to improve health. BMJ. 2000;321(7262):694-696. doi:10.1136/bmj.321.7262.694
28. Reynolds B, Seeger MW. Crisis and Emergency Risk Communication as an Integrative Model. J
Health Commun. 2005;10(1):43-55. doi:10.1080/10810730590904571
29. Blanchard-Coehm RD. Understanding Public Response to Increased Risk from Natural Hazards:
Application of the Hazards Risk Communication Framework. Int J Mass Emerg Disasters.
1998;16(3):247-278. doi:10.1177/028072709801600302
30. Heydari ST, Zarei L, Sadati AK, et al. The effect of risk communication on preventive and protective
behaviours during the COVID-19 outbreak: mediating role of risk perception. BMC Public Health.
2021;21(1):54. doi:10.1186/s12889-020-10125-5
31. Bish A, Michie S. Demographic and attitudinal determinants of protective behaviours during a
pandemic: A review. Br J Health Psychol. January 28, 2010. doi:10.1348/135910710X485826
32. Moore G, Audrey S, Barker M, et al. Process evaluation in complex public health intervention studies:
the need for guidance. J Epidemiol Community Health. 2014;68(2):101-102. doi:10.1136/jech-2013-
202869
33. Dickmann P, McClelland A, Gamhewage GM, de Souza PP, Apfel F. Making sense of communication
interventions in public health emergencies – an evaluation framework for risk communication. J
Commun Healthc. December 11, 2015. doi:10.1080/17538068.2015.1101962
34. US Centers for Disease Control and Prevention. Evaluating Communication Campaigns. Public
Health Matters Blog. Published April 2, 2018. Accessed June 7, 2024. https://blogs.cdc.gov/
publichealthmatters/2018/04/evaluating-campaigns/
35. Michie S, West R, Sheals K, Godinho CA. Evaluating the effectiveness of behavior change techniques
in health-related behavior: a scoping review of methods used. Transl Behav Med. 2018;8(2):212-224.
Priority 5

doi:10.1093/tbm/ibx019

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 46
 Appendix: Tailoring Tool to Increase Message Uptake & Trust
This tool summarizes how health departments can apply recommendations from Priority 5 to
their own message development and tailoring efforts. You can download and edit the tool at
this link.

Table 1. Tailoring Tool to Increase Message Uptake & Trust

Action Your Response

Message goal(s) Describe the reason for or desired effect of
messaging
Initial message Note the desired takeaway messages for
audiences developed in Priority 5 Activity
1, including how messages may need to
be formatted according to government
rules or best practices for addressing
misinformation, if applicable
Intended audience Briefly define the intended audience
identified in Priority 5 Activity 2 and any
additional reasoning why this requires
a tailored approach, if applicable (eg,
circulating misinformation is affecting this
community)
Sources of Consider what sources of information
information for gathered in Priority 5 Activity 2 may be
intended audience consulted to aid tailoring:
• What is the history of the health
department with this community? What
past lessons learned, including evaluation
of past messaging campaigns conducted
in Priority 5 Activity 5, are known?
• How can health department staff
contribute?
• Do partners who actively work with this
audience have bandwidth to consult on
message development?
• Are community members who are part of
this audience willing to provide feedback
on messages?
• Are there health department reports,
peer-reviewed literature, or other data
sources that can be referenced to better
understand this audience?
Context for trust/ Answer these questions to help shape
distrust with public context:
Appendix

health & institutions • How do you characterize the trust levels of

this community?
• How have they engaged with the health
department and greater public health
efforts in the past?
• Are there barriers to building trust and
context for lack of trust?

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 47
 Action Your Response
Additional traits, Describe the audience’s values, attitudes,
beliefs & motivations and goals that may facilitate or challenge
messaging
Preferred audience Based on the information above and advice
themes from Priority 5 Activity 2, what themes can
messaging emphasize to increase trust in
and effectiveness of messaging?
Preferred audience Based on information above and advice from
channels Priority 5 Activity 3, what are the channels
that may increase engagement with and
uptake of messaging?
Preferred Based on information above and advice from
justification & Priority 5 Activity 3, what trusted voices
citation and/or sources would help promote trust
and increase messaging effectiveness?
Other preferred Based on information above and advice
formatting from Priority 5 Activity 4 and Activity 5,
are there other considerations (eg, visuals,
tone, evaluation mechanisms) to improve
messaging reach and uptake?
Tailored message Based on the above information, describe
the plan for the tailored message, including
content, channel(s), messenger(s), and other
formatting.
Appendix

Checklist to Build Trust, Improve Public Health Communication, and Anticipate Misinformation During Public Health Emergencies 48