October 1, 2008

Raising Awareness of Public Health Among Americans

By Johnson, Teddi Dineley

New campaigns address the question: What is public health? IN NEW York City, red and white stickers plastered on everything from bike racks to trash cans to hybrid buses boldly declare: "This is Public Health."

In Texas, employees of the San Patricio County Department of Public Health are sporting a logo on their shirts to tell the world they are public health workers. In Kansas City, Mo., public health officials are polishing their storytelling skills to communicate the value of public health to the public.

While separate and distinct from one another, the three initiatives share a common goal: To explain what public health is to Americans. Faced with unprecedented work force shortages and dwindling resources, public health leaders across the nation are unleashing a flurry of programs and campaigns to raise the public's awareness and understanding of public health. Their efforts come almost eight years after a coalition of public health groups convened at APHA headquarters in Washington, D.C., to craft a campaign to make public health as recognizable as any product brand name. While that effort lost momentum, the issue is still as important today as it was then.

"Americans don't quite make the link between public health and water that's safe to drink, air that's safe to breathe and food that's safe to eat," said APHA Executive Director Georges C. Benjamin, MD, FACP, FACEP (E). "We need to do a better job of letting people know when they have benefited from a public health service. When nothing happens, people benefit because of the prevention aspect of it, and we need to celebrate that more. It's about raising awareness."

Few Americans understand the full scope of public health, and many Americans continue to view public health as "health care for the poor," Benjamin said.

For public health to be supported, both financially and from a policy standpoint, the general public needs to know what it is, said Kaye Bender, PhD, RN, FAAN, dean and professor at the University of Mississippi Medical Center School of Nursing and associate vice chancellor for nursing.

"Based on my experience, most of die general public understands elements of public health when it's not there," said Bender, an APHA member.

According to public health leaders, raising the public's awareness of health agencies' responsibilities will lead to greater accountability of public health systems and improvements in quality and outcomes. Moreover, the more knowledgeable people are about public health, the more likely tiiey will be to incorporate personal public health practices into their lives, advocate for their own health and the health of their communities, or consider a career in public health.

Research conducted by the U.S. Centers for Disease Control and Prevention found that Americans do not understand the larger public health concept, but identify with public health services, said Dogan Eroglu, PhD, associate director of marketing and communication sciences at CDC's National Center for Health Marketing.

"Opportunities exist for public health professionals to connect those services with the actual public health brand by identifying visible public health services, such as restaurant inspections, vaccinations or clean water as, for example, 'provided by your public health system,'" Eroglu said.

Opportunities also exist to leverage high-profile preparedness activities by positioning diem as public health services, he said.

And while CDC researchers found that public health professionals themselves did not have a consensus on what public health means, tiiey did agree tiiat the term "public healdi" should be used "often, consistently and clearly in any communi- cation activi- ties that convey public health ser- vices, especially those associated with actions and results," Eroglu said. "This can help raise the public's awareness of both what is contained under the public health umbrella, and why it is important."

To gain a clearer under- standing of the public's understanding of public health, the Association of State and Territorial Health Officials recently conducted eight focus groups in four U.S. cities: Minneapolis, Nashville, Los Angeles and Jackson, Miss. Data gleaned from the focus groups are still being analyzed, said Michael Dickey, MPH, CHES, direc- tor of public health ser- vices for ASTHO, but some common themes have emerged. For example, participants knew very lit- tle about what public health is, and very few recalled having ever heard of the "state public health agency." Moreover, many participants were aware of public health activities occurring in their commu- nities, but did not identify the activities as being "pub- lic health" and did not know who conducted the activities. However, after receiving some information about the state public health agency's responsibil- ities, partici- pants expressed a desire to learn more and said they didn't understand why so litde effort had been made to inform them and the commu- nity about state public health agency activities.

Focus group questions were based on findings from two earlier surveys commissioned by ASTHO, conducted in 2007 by the Greenfield Online U.S. Omnibus, that polled 2,000 U.S. adults ages 18 and older on their understanding of public health. A full 31 percent of those surveyed defined public health as "the health of the general population." However, few survey participants indicated knowledge of specific public health activities. About 19 percent of those polled knew that public health controls the spread of disease, and only 9 percent were aware that public health monitors sanitation. But most respondents agreed that they could take personal action to lower their risk of disease and live healthier lives.

"I think what has happened is the dots have not been connected to increase the awareness of public healdi," said John Lumpkin, MD, MPH, senior vice president and director of the Robert Wood Johnson Foundation's Health Care Group. "We have work to do. Unfortunately, both nature and man continue to present us with opportunities to deliver the message about the importance for public health."

During Lumpkin's 17 years in public heath, "not a quarter went by" without some major outbreak or event occurring somewhere in the United States, he said, including the terrorist attacks of Sept 11, 2001, the anthrax attacks and incidents of West Nile virus and monkeypox.

"Nature is letting us know that there are needs for public health services," said Lumpkin, an APHA member. "With emerging and re- emerging infections, diese are times when there is an opportunity for the public health system to clearly define what its role is, and to build support."

For its part, the Robert Wood Johnson Foundation recently joined with CDC to sponsor a new ASTHO initiative. Launched in 2007, the Public Health Marketing Initiative aims to explain the unique value and role of state-level public health in a way that will resonate with the general public, policy-makers and stakeholders, Dickey said. But describing public health in a manner that everyone understands "is not an easy task."

"Most state public health agencies don't have the resources to conduct the marketing research needed to develop proven marketing messages and strate- gies that will have the greatest impact," Dickey said. "A marketing strategy for public health will enhance the way state public health agencies communicate with the general public."

The initiative will culminate with an online marketing toolkit containing strategies to communicate with a variety of audiences through marketing messages proven to be effective in describing public health to the general public. Findings from the organization's marketing research will guide the development of the marketing messages, Dickey said.

Recognizing the need to involve nongovernmental public health organizations in awareness initiatives, ASTHO has joined with the Association of Schools of Public Healdi to share ideas, resources and lessons learned. The two organizations were planning to co-host a meeting in August to bring both public and private public health leaders to Washington, D.C, to share market research findings, discuss potential collaborations for implementing a national public health marketing strategy and examine methods to inform the public, policy-makers and stakeholders of public health's impact on daily life. The invitation list included representatives from APHA, the Association of Public Health Laboratories, CDC, the Health Resources and Services Administration, the National Association of County and City Health Officials, National Association of Local Boards of Health, the National Indian Health Board, Pfizer Public Health, the Robert Wood Johnson Foundation, the Society for Public Health Education and Trust for America's Health.

Max Michael, MD, dean of the University of Alabama at Birmingham School of Public Health and chair of ASPH's Commu- nications Commit- tee, said die deci- sion to co-host the August meeting witii ASTHO came about when each organization realized that the other was planning to bring stakeholders together in August to share ideas and best practices for educating the general public about public health.

"It's very serendipitous that we are all on the same page," said Michael, noting that the 2000 initiative lost steam, in part, because stakeholders couldn't agree on a definition of public health. Now, the group will work toward crafting a basic framework and basic tools - "materials they can adapt for their own purposes, and I think it's going to succeed this time," said Michael, an APHA member.

With ASPH's proven track record for implementing successful marketing programs, Michael might be right. The association's This is Public Health campaign took off in April when it launched during National Public Health Week. The organization has already given away about 30,000 of the campaign's This is Public Health stickers, Michael said, and requests for stickers continue to roll in almost daily from public healdi workers in a wide variety of settings, including federal agencies, health departments, nonprofits and undergraduate colleges and universities.

"Anybody who considers themselves part of the public health community can use the stickers," Michael said. "What makes this work is that we aren't trying to define it for them. We're just trying to make the process of explaining public health easier."

During the campaign's pilot run in April, groups of students from 19 schools of public health scoured their communities for examples of public health in action. The students slapped This is Public Health stickers on their finds, snapped photos of them and uploaded their pictures to the campaign's Web site at www.thisis publichealth.org.

The This is Public Healdi campaign - created by a New York marketing firm that was also instrumental in creating the Livestrong cancer campaign includes toolkits with sample presentations and interactive activities designed to help public health workers explain what public healdi is to the general public, "the idea being that if people don't understand what public health is, they can't understand what schools of public health do," Michael said.

Stories, visuals are building awareness

For years, Rex Archer, MD, MPH, director of the Kansas City Health Department in Missouri, observed that local public health lacked a brand and identity of its own. In 2006, while serving as president of NACCHO, he tasked an advisory group to develop a logo that would give local health departments a visual identity that would be universally recognized by the general public. Local governmental health departments, unlike police, fire and emergency response agencies, have historically lacked a visual identity that was universally known, he said.

"I go back to the old school that (says) a lot of our memory is either visual memory or narrative memory, so we remember based on stories or visual images," Archer said. "If you close your eyes, you can picture a policeman, a fireman, a nurse, a doctor or a paramedic, but if you close your eyes do you have a vision of a public health worker?"

Working widi a consultant, NACCHO developed a logo in the shape of a three-pointed shield, with the words "public health" above a tag line that says "Prevent. Promote. Protect." Governmental public health agencies around the globe are encouraged to use the logo to show pride in the people and power of public health who are at work every day in every community.

According to NACCHO Program Manager Kate Grisard, the logo is being used "in a million different ways," including on stationery, business cards, posters, news releases, Web sites, buttons, pins, staff apparel, signage and on agency vehicles and mobile units. As of late 2007, the Web page on which the logo can be downloaded had been viewed more than 70,000 times, Grisard said, and the logo itself has been downloaded more than 5,100 times.

"Part of our problem has been that we've almost relished, or even celebrated, our invisibility," Archer said. "For a number of years, we have under- stood in our clinics that the job is not done until the paperwork is done, but I would argue in public health that the job isn't done until the pub- lic, the elected officials and anyone else that may be funding or supporting the activity knows diat you've done it. In a sense, it is public health malpractice to do an activity and not have die public know that you've done it."

At times, public health workers must perform their jobs "under cover," Archer said, such as during a communicable disease outbreak or to protect someone's confidentiality, "but in many cases, such as when we are out doing inspections in restaurants, the public wouldn't even know that we're there."

In addition to raising awareness through visual images, public health workers must also do a better job of telling their narrative stories, said Archer, who is an APHA member.

"We need to collect stories of who we are and what we've accomplished and tell them among ourselves and to die public," he said. "We should consider storytelling as a 'best practice.'"

Jody DeVoll, MAT, director of strategic communications for the Association of Public Health Laboratories in Silver Spring, Md., said storytelling has proved to be one of the most effective ways to explain the work of the association, which has state public health laboratories as its core membership.

"Laboratories exist as a sort of black box," DeVoIl said. "It's hard to explain what a laboratory does in general, and much harder to explain what our laboratories do. Nobody even knew about public health laboratories prior to anthrax, and then all of a sudden we were getting national publicity back in October 2001."

As a result of the 2001 anthrax attacks - which were identified by a public health lab in Florida and the renewed emphasis on preparedness, the association's member laboratories for a short time received heightened attention and increased resources, DeVoIl said, which opened the door to hiring a communications department.

"I jokingly say that I owe my job to anthrax, and there is a certain amount of truth to it," DeVoll said.

Just as the anthrax story helped raise the general public's awareness of public health laboratories, the associa- tion is using narratives to make its members' work more understand- able, she said. At least once a year, mem- bers are invited to a training ses- sion to learn how to tell the kinds of stories that will make their work understandable to people who are not technical specialists. Additionally, the association set up a recording booth at its annual meeting and invited members to tell stories, in very simple terms, about their work. The narratives will be posted to the association's Web site.

"We will be looking for ways to push this information out and use it to promote the field to those who might be interested in entering it," DeVoll said. "If we don't explain what it is that we do, and its value to the public, who would do this for us?"

For more information, visit www.apha.org, www. asph.org, wwwr.astho.org and www.naccho.org.

- Teddi Dineley Johnson

Students in Minneapolis show off their stickers from the This is Public Health campaign, which raises public health awareness.

Student Alexandra Keller of Maple River High School in Mapleton, Minn., makes the point that safety is public health.

"Most state public health agencies don't have the resources to conduct the marketing research needed to develop proven marketing messages and strategies that will have the greatest impact."

- Michael Dickey

The This is Public Health sticker is part of a campaign by the Association of Schools of Public Health.

Officials at the Clay County Public Health Center in Liberty, Mo., show off a sign that displays the NACCHO logo.

The NACCHO public health logo can be used by public health agencies nationwide.

At its annual meeting, the Association of Public Health Laboratories set up a booth to record public health stories.

Representatives from the University of Alabama School of Public Health in Birmingham demonstrate occupational safety.

Copyright American Public Health Association Sep 2008

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