Health Communication
ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20
Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods Jeannette Sutton, Cedar League, Timothy L. Sellnow & Deanna D. Sellnow To cite this article: Jeannette Sutton, Cedar League, Timothy L. Sellnow & Deanna D. Sellnow (2015) Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods, Health Communication, 30:2, 135-143, DOI: 10.1080/10410236.2014.974124 To link to this article: http://dx.doi.org/10.1080/10410236.2014.974124
Published online: 03 Dec 2014.
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Date: 08 November 2015, At: 19:55
Health Communication, 30: 135–143, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.974124
Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods
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Jeannette Sutton Department of Communication University of Kentucky
Cedar League Trauma Health and Hazards Center University of Colorado, Colorado Springs
Timothy L. Sellnow Department of Communication University of Kentucky
Deanna D. Sellnow Division of Instructional Communication and Research University of Kentucky
Social media are quickly becoming the channel of choice for disseminating emergency warning messages. However, relatively little data-driven research exists to inform effective message design when using these media. The present study addresses that void by examining terse health-related warning messages sent by public safety agencies over Twitter during the 2013 Boulder, CO, floods. An examination of 5,100 tweets from 52 Twitter accounts over the course of the 5-day flood period yielded several key conclusions and implications. First, public health messages posted by local emergency management leaders are most frequently retweeted by organizations in our study. Second, emergency public health messages focus primarily on drinking water in this event. Third, terse messages can be designed in ways that include imperative/instructional and declarative/explanatory styles of content, both of which are essential for promoting public health during crises. These findings demonstrate that even terse messages delivered via Twitter ought to provide information about the hazard event, its impact, and actionable instructions for self-protection.
Public health impacts can be ubiquitous during both natural and human-made disasters, exhibiting a need for rapid, up-to-date information. While public health agencies are demonstrating interest in and use of social media for such communication, a lack of data-driven knowledge exists about how disaster public health messages can be effectively conveyed via social media. As public officials adopt social media to relay health information and disseminate emergency alerts, there is a need to identify effective messaging Correspondence should be addressed to Jeannette Sutton, Department of Communication, University of Kentucky, 227 Grehan Bldg, Lexington, KY 40506-0042. E-mail: [email protected]
content and style for doing so. Recently, the Centers for Disease Control and Prevention (CDC) updated its Crisis and Emergency Risk Communication (CERC) manual (CDC, 2012) to include discussions about social media and other short messaging channels. While this manual offers suggestions on how to integrate social media into crisis communication strategies, it does not provide sufficient guidance on how to communicate emergency health-related information in a disaster context over limited-content or short messaging channels. Disaster warnings are moving to short messaging channels such as Wireless Emergency Alerts (WEA), text messages, and social media messages on Twitter. These
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channels constrain the number of characters comprising a single message (e.g., 90 characters for a WEA; 160 characters for a text message; 140 characters for a tweet), resulting in extremely brief messages delivered under conditions of heightened stress during the warning period of a disaster. At present, little research has been conducted on the content and amplification of these messages during periods of imminent threat, and there is limited guidance on how to craft instructional messages for health-related threats. This article addresses this void in the literature by examining how public safety agencies communicate terse health-related warning messages to the public under a period of imminent threat. Specifically, we examine Twitter messages disseminated during the 2013 Boulder, CO, floods. Because communication about water-related emergencies was a primary issue during the flood, we focus specifically on Twitter messages involving this topic. First, we summarize the relevant literature related to emergency health messages delivered via new media. Second, we outline the Boulder case to provide context for our analysis. Third, we describe the data set and method used in our study. Finally, we move to a discussion of the results and end with a series of conclusions and recommendations.
CRISIS COMMUNICATION, NEW MEDIA, AND PUBLIC HEALTH WARNINGS Due to increasing complexity of globalization, technology, and terrorism, “the public health community has entered a new era of heightened threats with attendant new obligations for communicating warnings and mounting effective responses” (Seeger & Reynolds, 2008, p. 4). Government agencies such as the CDC have addressed this challenge with increased research and training in crisis communication. For example, the CDC promotes effective crisis communication training for public health workers worldwide through its CERC program (CDC, 2012). During the acute and recovery phases of public health crises, the CERC program emphasizes instructing those who are threatened by the crisis about how to best engage in self-protective behavior (Reynolds & Seeger, 2005). Limited attention has been paid, however, to the role of social media generally and terse messages specifically in this process. A systematic review of the literature (Moorhead et al., 2013) identified 98 original research studies on the uses, benefits, and/or limitations of social media for health communication among the general public, patients, and health professionals. The authors concluded that social media afford individuals a means to communicate about health issues, collaborate between users, and possibly improve health outcomes. The use of social media for communication about public health emergencies in a disaster also has great potential; however, these media are a relatively understudied channel for effective crisis communication.
Communicating public health information in the disaster context is key to an effective response (Glik, 2007). Crisis messages instructing those at risk about preventing exposure, evacuating, or seeking immediate treatment can be the difference between life and death (Reynolds & Seeger, 2005). Providing this essential information, however, is made difficult by the disruption created by natural disasters. For instance, following Hurricane Katrina, the CDC faced three difficult challenges for communication specialists: the rapid dissemination of health messages; the adaptation of health messages for diverse audiences, locations, and circumstances; and the delivery of key risk messages at various points in time (Vanderford, Nastoff, Telfer, & Bonzo, 2007). Moreover, very little attention has been paid to the evaluation of official messages with public-health-related content distributed over social media channels during a wide-scale disaster. More recently, attention has been given to the adoption and use of social media among public health organizations at the local and state levels (Harris, 2013; Harris, Mueller, & Snider, 2013) to disseminate information, engage followers in dialogue (Neiger, Thackeray, Burton, Thackeray, & Reese, 2013), and guide health educators (Hanson et al., 2011). Despite the surge in use of social media by public health departments and the move toward using social media for health promotions and campaigns, little attention has been devoted to the use of social media as an emergency health communication channel under conditions of imminent threat. Furthermore, there currently exists no set of commonly accepted guidelines or standards for emergency public health messaging content or style over social media channels such as Twitter, nor strategies to coordinate messaging activities among local, state, and federal agencies online. This lack of guidance suggests that public communicators must develop emergency public health messages as an event unfolds with little knowledge of strategies that may increase efficacy or compliance among those under threat. The research literature on public response to alerts and warnings for imminent threat hazards spans the last half century. A comprehensive review of warnings research (see Workshop Briefing White Paper, 2013) provides evidence that public warning messages have a higher probability of motivating appropriate and timely public protective action taking (i.e., helping people negotiate themselves out of the gap and initiate a protective action) if those messages provide information on five topics: (a) the hazard and its potential consequences (Drabek, 1999; Mayhorn & McLaughlin, 2014; Mileti & Sorensen, 1990), (b) the population and geographical area it will affect (Drabek, 1999; Mayhorn & McLaughlin, 2014; Mileti & Fitzpatrick, 1992), (c) the actions the members of the population at risk must take to protect themselves (Drabek, 1999; Frisby, Sellnow, Lane, Veil & Sellnow, 2013; Frisby, Veil, & Sellnow, 2014; Mayhorn & McLaughlin, 2014; Mileti & Sorensen, 1990), (d) the time by which this action must be taken (Sorensen,
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Shumpert, & Vogt, 2004), and (e) the source of the message sender (Lindell & Perry, 1987; Mileti & Darlington, 1995; Rogers, 1985). The research literature also provides evidence that the most effective warning messages are delivered with five style elements (Mileti & Sorensen, 1990). Stylistically, messages should (a) be clear, simply worded, and free of jargon; (b) be specific, using precise and nonambiguous words; (c) be accurate and complete; (d) be stated with certainty, authoritatively, and confidently; and (e) maintain internal and external coherence and consistency, such that there is no contradictory information contained within a single message or inconsistent information relayed over the course of the event. Recent research elaborates on Mileti and Sorensen’s claims that message style matters, differentiating between “explanatory” messages and “instructional” messages (Sellnow & Sellnow, 2010). Explanatory messages, or those that primarily provide information about the hazard context, do little to influence protective action taking. In contrast, instructional messages are shown to enhance knowledge and willingness to take protective action (Frisby et al., 2013; Sellnow, Sellnow, Lane, & Littlefield, 2012). Importantly, messages delivered over short messaging channels such as Twitter differ from those transmitted through broadcast media. In essence, these messages are described as “terse” in that they deliver limited content under conditions of imminent threat, allowing little interaction between message senders and message receivers (Sutton et al., 2014a, 2014b). By their very nature, these constrained channels restrict the level of detail that can be relayed in emergency health messages. They limit the number of characters, resulting in bite-sized, easily digestible doses (Stephens & Barrett, 2014), but in their simplified form may lack “completeness” (Pipino, Lee, & Wang, 2002). Research on terse communication over social media has begun to reveal consistent patterns for the dissemination of warning messages to the public at risk. For instance, Sutton et al. (2014a) conducted research on the dissemination of Twitter messages from public officials during the 2012 Waldo Canyon Wildfire in Colorado Springs. They identified key features of warning messages to be predictors of public message retransmission. These are hazard impact and protective action guidance content and using an imperative sentence style. Sutton et al. (2014b) conducted comparative research following the 2013 Boston Marathon bombing to identify cross-hazard similarities in message content and style during the week-long response to the terrorist event. They also examined message amplification among networked accounts representing official organizations online and detected consistent patterns related to the presentation of message content and style posted by public officials. Messages that included information about the hazard, its impact, and protective actionable directions delivered using an imperative sentence style were most frequently retransmitted (a.k.a. retweeted) among Twitter users.
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Retransmission is a clear sign of message saliency. These early case studies provide an in-depth look at warning messages across hazard events. However, neither of them focuses on emergency public health content or the message style. Our present research is an investigation of terse emergency health messages posted by public officials during the warning phase of a disaster. Specifically, we focus on the terse messages related to public health and water emergencies during the Boulder, CO, flood by asking the following research questions: RQ1: What official accounts disseminated emergency public health messages on Twitter? RQ2: What public health content themes were present in emergency public health messages on Twitter? RQ3: What style features were evident in emergency public health messages on Twitter? To answer these questions, we analyzed Twitter messages from agencies engaged in disaster response at the local, state, and federal level, across a variety of response sectors, during a significant disaster event with public health consequences. More specifically, we examined the content and style of messages containing emergency health-related content. We drew from prior research on effective warnings disseminated through traditional media and applied it to terse messaging on social media. The results of this study provide the basis for understanding the most prevalent types of content and style in which emergency public health messages are communicated during a disaster event.
BOULDER, COLORADO FLOOD CASE SUMMARY During September 11–15, 2013, Colorado’s Front Range experienced catastrophic flash flooding resulting in nine deaths (Denver Post, 2013a), more than a billion dollars in damages, and disaster emergencies declared in 14 counties. The city of Boulder received 17.15 inches of rainfall during September 9–16, 2013 making it a 1,000-year rain and a 100-year flood event (Daily Camera, 2013). More than 1,800 people were evacuated in Boulder County, with 345 homes destroyed and another 557 damaged (Daily Camera, 2013). Numerous public health impacts also resulted from this flash flood disaster. According to the Denver Post (2013b), “State health department engineers estimate about 20 million gallons of raw sewage poured into floodwaters untreated, as well as 150 million to 270 million gallons of partially treated sewage” (para. 10). Boil-water advisories were subsequently issued for the towns of Jamestown and Lyons, the Lefthand Canyon Water District, and Mountain Meadow Water Supply in Boulder County. Water samples collected from eight rivers in the region on September 26, 11 days following the height of flooding, showed high levels of Escherichia coli in some areas, including Boulder Creek. Furthermore, more than
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40,000 gallons of oil from oil and gas operations spilled into the South Platte Basin; however, contamination was not detected until 2 weeks after the event occurred (Denver Post, 2013b).
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METHOD We employed a case-study approach because doing so enabled us to illustrate information related to reducing health risks (Yang et al., 2010). Specifically, our case study allowed us to capture dynamics among key stakeholders over a defined period of time and to answer research questions such as how terse warning messages are written to communicate emergency public health information during a disaster, what contents are included in these terse messages, and what features of message style are identifiable. Therefore, our primary data were the publicly available messages posted to Twitter by official response agencies during the period of imminent threat of the September 2013 flood event across the state of Colorado, with a focus on the city and county of Boulder. Utilizing a case-study method, we also drew from websites and documents archived on the CDC website, such as resources and templates for public messaging during a water-related emergency. Next, we describe our online data collection method and procedures for data coding and analysis. Data Collection We initially identified the local, state, and federal Twitter accounts that were posting messages on the primary event hashtag “#boulderflood” from September 11–15, 2013, the time during which the threat was greatest. We then conducted snowball sampling to identify additional Twitter accounts that represented public safety organizations that were connected (as friends) to the initial set of accounts (regardless of their use of the #boulderflood hashtag). We also manually sifted through the websites of local government organizations to identify additional Twitter accounts that may not routinely tweet but could play a public information role. Additionally, we selected state and federal accounts that have a primary role in disaster response, such as Colorado Division of Homeland Security and Emergency Management (@COEmergency), the Federal Emergency Management Agency (@FEMARegion8), and the National Weather Service (@NOAA and @NWSBoulder). Given our interest in public health for this case study, we also made a concerted effort to identify accounts that were posting health-related information and represented local, state, and federal-level organizations such as the Colorado Department of Public Health and Environment (@CDPHE) and the Centers for Disease Control (@CDCEmergency and @CDCReady). Due to the widespread flooding across the state, dozens of official organizations participated in the
statewide flood-response efforts. To constrain our research space we chose to limit our local account selection to those serving the city or county of Boulder, a geographical area that experienced a highly significant 1,000-year rain event, as already described. For each of the targeted Twitter accounts, we retrieved their posting behavior history, including all messages posted to the public timeline for the 5-day period of interest and the timestamp for each post. We also counted the number of times each message was retweeted, the services used to post the message, and other features about the user, such as the number of followers of that account at the time of collection. We queried each of these different data points at the conclusion of the event. This data set was obtained using the Twitter Representational State Transfer Application Programming Interface, or REST API. The REST API allowed us to collect user data including tweets and their associated metadata. We used the API tools to build a continuous, long-term data collection system from a set of targeted user accounts. For the analysis, we considered content and network information from all messages posted by our set of targeted accounts, from 12:01 a.m. on September 11, 2013 (the day the flood events began) until 11:59 p.m. on September 15, 2013 (when the flood threat was concluded). Data Analysis Qualitative coding. We collected 5,100 tweets from 52 Twitter accounts over the course of the 5-day period. Two researchers, the first and second authors, coded the message content of the entire data set manually to identify a subset of messages containing emergency public health content (N = 299 from 30 accounts; 22 of the 52 Twitter accounts contained no relevant public health content). We used a closed coding approach drawing from the preidentified topics described on the CDC website as “water related emergencies and outbreaks” (CDC, 2013a). Six health communication themes were identified: (a) drinking water safety (personal water storage, wells, community water systems), (b) septic/sewage and wastewater, (c) hygiene and handwashing, (d) cleaning and sanitizing, (e) standing flood water exposure (including food safety and animals), and (f) messages referring individuals to informational resources. Messages that directed individuals to avoid active flooding areas and that provided instructions on evacuation procedures (i.e., “don’t drive through water”) were not included in the CDC water-related emergency topics and were therefore not coded as part of the emergency public health communication messages. Coders independently coded each tweet using the closed content categories and then exchanged tweets to determine intercoder agreement. Coders agreed on content theme codes in approximately 98% of cases. Disagreements were resolved by consensus, following discussion of problematic cases by the coders. We also coded for the inclusion of a weblink or URL
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(usually shortened by using bit.ly or another short URL service). To further assess the information content of each message, we followed every link within the health data set and assessed its content utilizing the CDC content codes described earlier. Emergency public health messages were also coded for aspects of message style (see Table 1). Style aspects, which emphasize how content is relayed or displayed to affect message specificity or clarity (Mileti & Sorensen, 1990), include the following: how each tweet sentence functions within the English language as declarative, imperative, interrogative, or exclamatory; and whether a tweet includes a word or phrase in ALL CAPS and, if so, whether these words function as either a category signifier or to emphasize a portion of the tweet (to increase message clarity). Each targeted account was coded according to its sphere of operations (local, state, regional, or federal/national) and its response sector (public safety, health, defense/law enforcement, environment, elected government, private industry, nonprofit). In addition, we noted the number of messages sent from each official Twitter account that contained original content or were retweets, referencing a message from another account. The focus on the “warning period” means that we did not capture all health communication messages posted during the response and recovery. Health communication extends well beyond the warning period as people reenter their homes and begin flood cleanup activities. However, key public health messages were relayed during the warning period,
TABLE 1 Message Style Features Features Sentence style: Imperative
Declarative
Exclamatory
Interrogatory
Capitalization: ALL CAPS—signifier
ALL CAPS—emphasis
Definition
A sentence that gives advice or instructions or expresses a request or command. (e.g., “Boil water first with these instructions.”) A sentence in the form of a statement. (e.g., “People are still asked to conserve water.”) A sentence that expresses strong feelings by making an exclamation. (e.g., “Be safe!”) A sentence that asks a question. (e.g., “Was your frozen food above 41◦ F 4+hours?”) Use of ALL CAPS to signify a category of information. (e.g., “UPDATE: Ralston Water Treatment Plant is back online”) Use of ALL CAPS to emphasize a word/words in the message. (e.g., “Water is SAFE to drink”)
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especially those regarding imminent threat to drinking-water systems.
RESULTS In this section, we report the findings of the subset of messages that focus on health-related content. First we describe features of our targeted accounts. Then we turn to a discussion about water emergency message content and style. Account Features A subset of 30 out of our 52 accounts tweeted about emergency health-related content. These 30 accounts varied by characteristics and demonstrated a variety of posting activities. We collected 17 local, two regional, eight state, and three federal-scale accounts representing the sectors of public safety, health, law enforcement, environment, government, industry, and human service organizations (see Table 2). Over the 5-day period, these 30 accounts posted an average of 10 public health-related messages each, with a maximum of 35 by @CDPHE (Colorado Department of Public Health and Environment) and a minimum of one by @MVFireRescue, BPDPoliceChief, and @boulderpolice. The most active accounts included @CDPHE (n = 35), @boulderOEM (n = 30), and @bouldercounty (n = 30), representing three sectors, health, public safety, and government. Of all the tweets containing health related content, 180 (60%) contained original content, whereas 119 (40%) were retweets (RTs) of content originated by a different account. @BoulderOEM posted 30 original tweets and no RTs of health-related content. Similarly, @BoulderCounty posted TABLE 2 Targeted Accounts by Sector and Number of Tweets Each
Sector Public safety (e.g., fire and emergency management) Health (e.g., public health and food safety) Law enforcement Environment, (e.g., wildlife, agriculture) Government (e.g., elected official) Industry (e.g., private business) Human services (including nonprofits)
Targeted Accounts per Sector (n = 30)
Health Tweets per Sector∗ (n = 299)
7 (23%)
79 (26%)
7 (23%)
82 (27%)
3 (10%) 1 (3%)
7 (2%) 3 (1%)
8 (27%)
106 (35%)
2 (7%) 5 (17%)
17 (6%) 26 (9%)
∗ Organizations may be classified in more than one sector; thus, total tweets >100%.
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primarily original content, with 28 original tweets and three RTs. The @BoulderOEM tweets were retweeted 34 times by our other official targeted accounts. @CDPHE had 26 RTs by other targeted accounts. Official state accounts (e.g., @coloradogov, @COemergency, and @FloodDSS) were primarily retweeting content as opposed to posting original content.
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Message Content We found 299 public-health-related tweets (6%) out of the 5,100 tweets in the complete data set. Of these, the primary theme was related to drinking water safety (n = 121) and included information about boil-water orders, well water, and water facility updates. This was followed by themes on floodwater exposure (n = 55), resources and information (n = 46), cleaning and sanitizing (n = 45), and sewage and wastewater (n = 27). Hygiene and handwashing was the least posted message content (n = 7; see Table 3).
TABLE 3 Message Examples by Health Content Theme
Theme Floodwater exposure
Drinking water
Number of Tweets (n = 299) 55 (18%)
122 (41%)
Resources/information
47 (16%)
Cleaning/sanitizing
43 (14%)
Handwashing/hygiene
Sewage/wastewater
7 (2%)
25 (8%)
Example Tweets Health officials say avoid flood waters, even if they look safe. Can contain sewage, debris, etc. #boulderflood http://t.co/ XNVJoqK41H (@BoulderOEM) Residents with wells should assume water is contaminated. Be Safe! Boil water first with these instrux http://t.co/ J571hpe5OB #boulderflood (@BoulderOEM) Health and Safety After a Flood. http://t.co/1GusGJNCee #boulderflood (@boulderOEM) Safe Debris Removal After a Flood #boulderflood http://t.co/ kbbN091bFP (@bouldercounty) If you’re involved in debris clean-up, wash your hands frequently with soap and clean warm water. A big thanks for helping us in #COFlood. (@CDPHE) City crews will work overnight to relieve sewer backups in #Boulder. They’ve been finding baseball-sized rocks in the pipes! #BoulderFlood (@bouldercolorado)
Of the 299 emergency health messages, 190 tweets (64%) contained 191 links to additional information from 35 different organizations. Those organizations represented 18 local (51%), two regional (6%), seven state (20%), and eight federal (23%) spheres. Boulder OEM was linked to the most (26%), followed by CDPHE (15%), Boulder County (13%), and the CDC (9%). Of the 191 links, content was removed from 64 (32%) of the links. We coded the remaining 127 active links for health content themes. Additional information on drinking water safety was the most frequent theme found in the links (28%), followed by resources and information (25%), floodwater exposure (17%), cleaning/sanitizing (16%), and sewage and wastewater (13%). No links contained information on handwashing or hygiene. Message Style Of the 299 emergency health-related tweets, 109 (36%) used the imperative sentence style, 269 used declarative sentences (90%), and 16 used a question/answer format (5%). Moreover, 87 of the 299 emergency health-related tweets included both information about the hazard impact (in declarative format) and guidance on safety precautions (in imperative format) (29%; see the example tweet for “drinking water” in Table 3). Few messages utilized capitalized letters to signify a specific category of information such as UPDATE (n = 6) or to emphasize portions of the message content (n = 19).
DISCUSSION Thirty of the 52 Twitter official accounts collected and examined in this study included at least one message with content about emergency public health information. Some accounts have a primary role in communicating about the disaster in general (e.g., by sphere [local] and sector [government]). Some have a primary role in communicating public health information over time (e.g., by sector [public health]). We discovered that local emergency management (@BoulderOEM) took the lead in communicating emergency public health information and was the most frequently retweeted account and that state and federal agencies mainly functioned to promote or amplify local messages. This finding matches well with previous research indicating that local organizations take the lead in communicating during an event, reinforce each other, and are often amplified by organizations at the state and federal level (Sutton et al., 2014b). That said, however, the analysis of content themes revealed that only 6% (n = 299) of the 5,100 tweets in the complete data set focused on public health. Moreover, about 40% (n = 121) of those 299 tweets were devoted to
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drinking-water safety. Similarly, the primary content theme of the links attached to tweets addressed drinking-water safety. Although attention to drinking-water safety is important, the tweets in this study appeared to privilege attention to it above other issues of safety and self-protection (e.g., floodwater exposure, cleaning and sanitizing, sewage and wastewater, hygiene and handwashing). On the basis of these results, official response agencies could be more mindful about providing balanced coverage regarding self-protective instructions for public health safety. Regarding style, nearly 90% of the tweets examined in this study were declarative, 36% were imperative, and 29% contained a combination of both. We suggest that there is a direct link between sentence style and sentence function; where declarative sentences explain the hazard and its impact, imperative sentences are more instructional. Although previous research suggests warning messages be composed of a mix of declarative and imperative sentences (Frisby et al., 2013), the heavy reliance on declarative/explanatory style over imperative/instructional style could hinder desired behavioral actions from receivers. Instead, research on instructional messaging has emphasized that instructive guidance provided in an imperative style must be presented along with information about the hazard for receivers to take appropriate protective action (Sellnow & Sellnow, 2010). The tweets examined in this analysis suggest that the mix is highly unbalanced and agencies ought to be mindful to offer more tweets framed using an imperative/instructional message style to increase the likely of achieving their behavioral outcome goals. In 2013, the CDC (2013b) created the “Drinking Water Advisory Communication Toolbox” as a practical guide for stakeholder communication in water emergencies. The toolbox proposes this single template for designing announcements to be sent over short messaging services: “The [name of water system] is asking customers to boil tap water or use bottled water. For more information, go to [www. watersystemwebsite.org] or call [###-###-####].” Although this template provides a starting point for message design, it fails to include demonstrated components of effective messages for an imminent threat hazard event. Importantly, these messages provide no information about the hazard event, its impact, or instructions for safety and self-protection. Terse messages could do so, however, by offering explanations about the hazard impact and actionable instructions using a combination of declarative and imperative sentences in a single message (e.g., the message about drinking water in Table 3). Limitations Several limitations are noted about this case study. First, this analysis focused on the warning period of a natural disaster. Therefore, we did not examine messages disseminated after the height of imminent threat. An examination of
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long-term crisis communication activities would allow us to identify shifts in message content over time and any changes in message delivery and amplification among organizations. Second, our research is limited to an examination of message content and style by senders. Therefore, we did not examine human behavioral responses to them (e.g., information seeking, information sharing, protective action behaviors). Future Research As more health departments adopt social media to communicate during crisis events, they will need to consider how to do so most effectively. This case study verifies the relevance of terse messaging channels for emergency health communication during crisis events. Moreover, this study reveals that despite the brevity of terse messages, they can include “bite-sized” pieces of explanatory information while delivering guidance-focused content in an instructional manner. Future research should explore the balance between imperative/instructive messages and declarative/explanatory messages. This exploration is important for two reasons. First, limited information is available on the appropriate balance of these two essential stylistic variables. Second, much more information is needed about the impact terse message frameworks may have on public response behavior. This analysis concentrated on a set of terse messages collected over a critical period of time. Thus, we observed the cumulative content of a series of tweets, across multiple accounts. Further research should address this cumulative impact. We know that key information can be provided in a single terse message. The extent to which additional information delivered through a series of terse messages creates the desired public health response warrants further analysis. A third compelling area for future study involves the timing of terse messages. Recent research indicates that the volume of Twitter messages and related retweeting is most prevalent leading up to a predictable disaster such as a hurricane (Spence, Lachlan, Lin, & Del Greco, in press). For crises that occur with little forewarning, such as a flash flood event, time for information searching and sharing is cut short. Future research should emphasize the role of terse messages across all phases of disaster including preevent, imminent threat warnings, and crisis communication throughout the recovery period.
CONCLUSION The shifting landscape of communication with the advent of new media has made terse messaging one of the preferred formats in many communication contexts—including public health emergencies. Thus, government agencies such as the CDC now include social media and terse messaging in their training materials. Other agencies such as the Food and
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Drug Administration and many state agencies have joined CDC in sending terse messages routinely, as well as during crises. The Boulder flood provides a vivid case study of how informational needs arise and how terse messages can efficiently fulfill those needs. Much more needs to be known about how terse messages can contribute to public health during disasters. This study, however, reveals the tremendous potential for terse messages delivered over social media to play a prominent role in protecting the public’s health during crises.
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FUNDING This research was supported by the National Science Foundation, awards CMMI-1031853 and CMMI-1031779. Any opinions, findings and conclusions, or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation. Part of the research conducted by Sutton was performed while she was a senior research scientist at the University of Colorado, Colorado Springs. Sutton is now at the University of Kentucky. REFERENCES Centers for Disease Control and Prevention. (2012). Crisis and emergency risk communication, 2012 edition. Retrieved from http://emergency.cdc. gov/cerc/pdf/CERC_2012edition.pdf Centers for Disease Control and Prevention. (2013a). Water-related emergencies and outbreaks. Retrieved from www.cdc.gov/healthywater/ emergency Centers for Disease Control and Prevention. (2013b). Drinking water advisory communication toolbox. Retrieved from www.cdc.gov/healthywater/ emergency/dwa-comm-toolbox/index.html Daily Camera. (2013, September 21). Eight days, 1,000-year rain, 100year flood. Retrieved from www.dailycamera.com/news/boulder-flood/ ci_24148258/boulder-county-colorado-flood-2013-survival-100-rain100-year-flood Denver Post. (2013a, October 8). Body of 9th Colorado flooding victim identified. Retrieved from www.denverpost.com/news/ci_24266050/ body-9th-colorado-flooding-victim-identified Denver Post. (2013b, October 8). E. coli found in Colorado flood zones, but no oil, gas contamination. Retrieved from www.denverpost.com/ breakingnews/ci_24264793/e-coli-found-colorado-flood-zones-butno#ixzz2r0u3XXYc Drabek, T. E. (1999). Understanding disaster warning responses. Social Science Journal, 36, 515–523. Frisby, B. N., Sellnow, D. D., Lane, D. R., Veil, S. R., & Sellnow, T. L. (2013). Instruction in crisis: Targeting learning preferences and efficacy. Risk Management, 15, 250–271. Frisby, B. N., Veil, S. R., & Sellnow, T. L. (2014). Instructional messages during health-related crises: Essential content for self-protection. Health Communication, 29, 347–354. Glik, D. C. (2007). Risk communication for public health emergencies. Annual Review of Public Health, 28, 33–54. Hanson, C., West, J., Neiger, B., Thackeray, R., Barnes, M., & McIntyre, E. (2011). Use and acceptance of social media among health educators. American Journal of Health Education, 42, 197–204.
Harris, J. K. (2013). The network of Web 2.0 connections among state health departments: New pathways for dissemination. Journal of Public Health Management and Practice, 19(3), E20–24. Harris, J. K., Mueller, N. L., & Snider, D. (2013). Social media adoption in local health departments nationwide. American Journal of Public Health, 103, 1700–1707. Lindell, M. K., & Perry, R. W. (1987). Warning mechanisms in emergency response. International Journal of Mass Emergencies and Disasters, 5(2), 127–153. Mayhorn, C. B., & McLaughlin, A. C. (2014). Warning the world of extreme events: A global perspective on risk communication for natural and technological disaster. Safety Science, 61, 43–50. Mileti, D. S., & Sorensen, J. H. (1990). Communication of emergency public warnings. Landslides, 1, 6. Mileti, D.S. & Fitzpatrick, C. (1992). The causal sequence of risk communication in the Parkfield Earthquake Prediction Experiment. Risk Analysis, 12, 393–400. Mileti, D. S., & Darlington, J. D. (1995). Societal response to revised earthquake probabilities in the San Francisco Bay Area. International Journal of Mass Emergencies & Disasters, 13, 119–145. Moorhead, S. A., Hazlett, D. E., Harrison, L., Carroll, J. K., Irwin, A., & Hoving, C. (2013). A new dimension of health care: Systematic review of the uses, benefits, and limitations of social media for health communication. Journal of Medical Internet Research, 15(4), e85. Neiger, B. L., Thackeray, R., Burton, S. H., Thackeray, C. R., & Reese, J. H. (2013). Use of Twitter among local health departments: An analysis of information sharing, engagement, and action. Journal of Medical Internet Research, 15(8), e177. Pipino, L., Lee, Y. W., & Wang, R. Y. (2002). Data quality assessment. Communications of the ACM 45(4), 211–218. Reynolds, B., & Seeger, M. W. (2005). Crisis and emergency risk communication as an integrative model. Journal of Health Communication, 10, 43–55. Rogers, G. O. (1985). Human components of emergency warning: Implications for planning and management. Pittsburgh, PA: University Center for Social and Urban Research, University of Pittsburgh. Seeger, M. W., & Reynolds, B. (2008). Integrating approaches and new imperatives. In M. W. Seeger, T. L. Sellnow, & R. R. Ulmer (Eds.), Crisis communication and the public health (pp. 3–20). Creskill, NJ: Hampton Press. Sellnow, T., & Sellnow, D. (2010). The instructional dynamic of risk and crisis communication: Distinguishing instructional messages from dialogue. Review of Communication, 10, 112–126. Sellnow, T. L., Sellnow, D. D., Lane, D. R., & Littlefield, R. S. (2012). The value of instructional communication in crisis situations: Restoring order to chaos. Risk Analysis, 32, 633–643. Sorensen, J. H., Shumpert, B. L., & Vogt, B. M. (2004). Planning for protective action decision making: Evacuate or shelter-in-place. Journal of Hazardous Materials, 109(1), 1–11. Spence, P. R., Lachlan, K. A., Lin, X, & Del Greco, M. (in press). Variability in Twitter content across the stages of a natural disaster: Implications for crisis communication. Communication Quarterly. Stephens, K. K., & Barrett, A. K. (2014). Communicating briefly: Technically. International Journal of Business Communication. Advance online publication. doi:10.1177/2329488414525463 Sutton, J., Spiro, E. S., Johnson, B., Fitzhugh, S., Gibson, B., & Butts, C. T. (2014a). Warning tweets: Serial transmission of messages during the warning phase of a disaster event. Information, Communication & Society, 17, 765–787. Sutton, J., Spiro, E., Johnson, B., Fitzhugh, S., Gibson, B., & Butts, C. T. (2014b). Terse message amplification in the Boston bombing response. In S. R. Hiltz, M. S. Pfaff, L. Plotnick, & A. C. Robinson (Eds.), Proceedings of the 11th International ISCRAM Conference (pp. 612–621). University Park, PA: Pennsylvania State University.
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ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20
Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods Jeannette Sutton, Cedar League, Timothy L. Sellnow & Deanna D. Sellnow To cite this article: Jeannette Sutton, Cedar League, Timothy L. Sellnow & Deanna D. Sellnow (2015) Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods, Health Communication, 30:2, 135-143, DOI: 10.1080/10410236.2014.974124 To link to this article: http://dx.doi.org/10.1080/10410236.2014.974124
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Date: 08 November 2015, At: 19:55
Health Communication, 30: 135–143, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.974124
Terse Messaging and Public Health in the Midst of Natural Disasters: The Case of the Boulder Floods
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Jeannette Sutton Department of Communication University of Kentucky
Cedar League Trauma Health and Hazards Center University of Colorado, Colorado Springs
Timothy L. Sellnow Department of Communication University of Kentucky
Deanna D. Sellnow Division of Instructional Communication and Research University of Kentucky
Social media are quickly becoming the channel of choice for disseminating emergency warning messages. However, relatively little data-driven research exists to inform effective message design when using these media. The present study addresses that void by examining terse health-related warning messages sent by public safety agencies over Twitter during the 2013 Boulder, CO, floods. An examination of 5,100 tweets from 52 Twitter accounts over the course of the 5-day flood period yielded several key conclusions and implications. First, public health messages posted by local emergency management leaders are most frequently retweeted by organizations in our study. Second, emergency public health messages focus primarily on drinking water in this event. Third, terse messages can be designed in ways that include imperative/instructional and declarative/explanatory styles of content, both of which are essential for promoting public health during crises. These findings demonstrate that even terse messages delivered via Twitter ought to provide information about the hazard event, its impact, and actionable instructions for self-protection.
Public health impacts can be ubiquitous during both natural and human-made disasters, exhibiting a need for rapid, up-to-date information. While public health agencies are demonstrating interest in and use of social media for such communication, a lack of data-driven knowledge exists about how disaster public health messages can be effectively conveyed via social media. As public officials adopt social media to relay health information and disseminate emergency alerts, there is a need to identify effective messaging Correspondence should be addressed to Jeannette Sutton, Department of Communication, University of Kentucky, 227 Grehan Bldg, Lexington, KY 40506-0042. E-mail: [email protected]
content and style for doing so. Recently, the Centers for Disease Control and Prevention (CDC) updated its Crisis and Emergency Risk Communication (CERC) manual (CDC, 2012) to include discussions about social media and other short messaging channels. While this manual offers suggestions on how to integrate social media into crisis communication strategies, it does not provide sufficient guidance on how to communicate emergency health-related information in a disaster context over limited-content or short messaging channels. Disaster warnings are moving to short messaging channels such as Wireless Emergency Alerts (WEA), text messages, and social media messages on Twitter. These
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channels constrain the number of characters comprising a single message (e.g., 90 characters for a WEA; 160 characters for a text message; 140 characters for a tweet), resulting in extremely brief messages delivered under conditions of heightened stress during the warning period of a disaster. At present, little research has been conducted on the content and amplification of these messages during periods of imminent threat, and there is limited guidance on how to craft instructional messages for health-related threats. This article addresses this void in the literature by examining how public safety agencies communicate terse health-related warning messages to the public under a period of imminent threat. Specifically, we examine Twitter messages disseminated during the 2013 Boulder, CO, floods. Because communication about water-related emergencies was a primary issue during the flood, we focus specifically on Twitter messages involving this topic. First, we summarize the relevant literature related to emergency health messages delivered via new media. Second, we outline the Boulder case to provide context for our analysis. Third, we describe the data set and method used in our study. Finally, we move to a discussion of the results and end with a series of conclusions and recommendations.
CRISIS COMMUNICATION, NEW MEDIA, AND PUBLIC HEALTH WARNINGS Due to increasing complexity of globalization, technology, and terrorism, “the public health community has entered a new era of heightened threats with attendant new obligations for communicating warnings and mounting effective responses” (Seeger & Reynolds, 2008, p. 4). Government agencies such as the CDC have addressed this challenge with increased research and training in crisis communication. For example, the CDC promotes effective crisis communication training for public health workers worldwide through its CERC program (CDC, 2012). During the acute and recovery phases of public health crises, the CERC program emphasizes instructing those who are threatened by the crisis about how to best engage in self-protective behavior (Reynolds & Seeger, 2005). Limited attention has been paid, however, to the role of social media generally and terse messages specifically in this process. A systematic review of the literature (Moorhead et al., 2013) identified 98 original research studies on the uses, benefits, and/or limitations of social media for health communication among the general public, patients, and health professionals. The authors concluded that social media afford individuals a means to communicate about health issues, collaborate between users, and possibly improve health outcomes. The use of social media for communication about public health emergencies in a disaster also has great potential; however, these media are a relatively understudied channel for effective crisis communication.
Communicating public health information in the disaster context is key to an effective response (Glik, 2007). Crisis messages instructing those at risk about preventing exposure, evacuating, or seeking immediate treatment can be the difference between life and death (Reynolds & Seeger, 2005). Providing this essential information, however, is made difficult by the disruption created by natural disasters. For instance, following Hurricane Katrina, the CDC faced three difficult challenges for communication specialists: the rapid dissemination of health messages; the adaptation of health messages for diverse audiences, locations, and circumstances; and the delivery of key risk messages at various points in time (Vanderford, Nastoff, Telfer, & Bonzo, 2007). Moreover, very little attention has been paid to the evaluation of official messages with public-health-related content distributed over social media channels during a wide-scale disaster. More recently, attention has been given to the adoption and use of social media among public health organizations at the local and state levels (Harris, 2013; Harris, Mueller, & Snider, 2013) to disseminate information, engage followers in dialogue (Neiger, Thackeray, Burton, Thackeray, & Reese, 2013), and guide health educators (Hanson et al., 2011). Despite the surge in use of social media by public health departments and the move toward using social media for health promotions and campaigns, little attention has been devoted to the use of social media as an emergency health communication channel under conditions of imminent threat. Furthermore, there currently exists no set of commonly accepted guidelines or standards for emergency public health messaging content or style over social media channels such as Twitter, nor strategies to coordinate messaging activities among local, state, and federal agencies online. This lack of guidance suggests that public communicators must develop emergency public health messages as an event unfolds with little knowledge of strategies that may increase efficacy or compliance among those under threat. The research literature on public response to alerts and warnings for imminent threat hazards spans the last half century. A comprehensive review of warnings research (see Workshop Briefing White Paper, 2013) provides evidence that public warning messages have a higher probability of motivating appropriate and timely public protective action taking (i.e., helping people negotiate themselves out of the gap and initiate a protective action) if those messages provide information on five topics: (a) the hazard and its potential consequences (Drabek, 1999; Mayhorn & McLaughlin, 2014; Mileti & Sorensen, 1990), (b) the population and geographical area it will affect (Drabek, 1999; Mayhorn & McLaughlin, 2014; Mileti & Fitzpatrick, 1992), (c) the actions the members of the population at risk must take to protect themselves (Drabek, 1999; Frisby, Sellnow, Lane, Veil & Sellnow, 2013; Frisby, Veil, & Sellnow, 2014; Mayhorn & McLaughlin, 2014; Mileti & Sorensen, 1990), (d) the time by which this action must be taken (Sorensen,
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Shumpert, & Vogt, 2004), and (e) the source of the message sender (Lindell & Perry, 1987; Mileti & Darlington, 1995; Rogers, 1985). The research literature also provides evidence that the most effective warning messages are delivered with five style elements (Mileti & Sorensen, 1990). Stylistically, messages should (a) be clear, simply worded, and free of jargon; (b) be specific, using precise and nonambiguous words; (c) be accurate and complete; (d) be stated with certainty, authoritatively, and confidently; and (e) maintain internal and external coherence and consistency, such that there is no contradictory information contained within a single message or inconsistent information relayed over the course of the event. Recent research elaborates on Mileti and Sorensen’s claims that message style matters, differentiating between “explanatory” messages and “instructional” messages (Sellnow & Sellnow, 2010). Explanatory messages, or those that primarily provide information about the hazard context, do little to influence protective action taking. In contrast, instructional messages are shown to enhance knowledge and willingness to take protective action (Frisby et al., 2013; Sellnow, Sellnow, Lane, & Littlefield, 2012). Importantly, messages delivered over short messaging channels such as Twitter differ from those transmitted through broadcast media. In essence, these messages are described as “terse” in that they deliver limited content under conditions of imminent threat, allowing little interaction between message senders and message receivers (Sutton et al., 2014a, 2014b). By their very nature, these constrained channels restrict the level of detail that can be relayed in emergency health messages. They limit the number of characters, resulting in bite-sized, easily digestible doses (Stephens & Barrett, 2014), but in their simplified form may lack “completeness” (Pipino, Lee, & Wang, 2002). Research on terse communication over social media has begun to reveal consistent patterns for the dissemination of warning messages to the public at risk. For instance, Sutton et al. (2014a) conducted research on the dissemination of Twitter messages from public officials during the 2012 Waldo Canyon Wildfire in Colorado Springs. They identified key features of warning messages to be predictors of public message retransmission. These are hazard impact and protective action guidance content and using an imperative sentence style. Sutton et al. (2014b) conducted comparative research following the 2013 Boston Marathon bombing to identify cross-hazard similarities in message content and style during the week-long response to the terrorist event. They also examined message amplification among networked accounts representing official organizations online and detected consistent patterns related to the presentation of message content and style posted by public officials. Messages that included information about the hazard, its impact, and protective actionable directions delivered using an imperative sentence style were most frequently retransmitted (a.k.a. retweeted) among Twitter users.
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Retransmission is a clear sign of message saliency. These early case studies provide an in-depth look at warning messages across hazard events. However, neither of them focuses on emergency public health content or the message style. Our present research is an investigation of terse emergency health messages posted by public officials during the warning phase of a disaster. Specifically, we focus on the terse messages related to public health and water emergencies during the Boulder, CO, flood by asking the following research questions: RQ1: What official accounts disseminated emergency public health messages on Twitter? RQ2: What public health content themes were present in emergency public health messages on Twitter? RQ3: What style features were evident in emergency public health messages on Twitter? To answer these questions, we analyzed Twitter messages from agencies engaged in disaster response at the local, state, and federal level, across a variety of response sectors, during a significant disaster event with public health consequences. More specifically, we examined the content and style of messages containing emergency health-related content. We drew from prior research on effective warnings disseminated through traditional media and applied it to terse messaging on social media. The results of this study provide the basis for understanding the most prevalent types of content and style in which emergency public health messages are communicated during a disaster event.
BOULDER, COLORADO FLOOD CASE SUMMARY During September 11–15, 2013, Colorado’s Front Range experienced catastrophic flash flooding resulting in nine deaths (Denver Post, 2013a), more than a billion dollars in damages, and disaster emergencies declared in 14 counties. The city of Boulder received 17.15 inches of rainfall during September 9–16, 2013 making it a 1,000-year rain and a 100-year flood event (Daily Camera, 2013). More than 1,800 people were evacuated in Boulder County, with 345 homes destroyed and another 557 damaged (Daily Camera, 2013). Numerous public health impacts also resulted from this flash flood disaster. According to the Denver Post (2013b), “State health department engineers estimate about 20 million gallons of raw sewage poured into floodwaters untreated, as well as 150 million to 270 million gallons of partially treated sewage” (para. 10). Boil-water advisories were subsequently issued for the towns of Jamestown and Lyons, the Lefthand Canyon Water District, and Mountain Meadow Water Supply in Boulder County. Water samples collected from eight rivers in the region on September 26, 11 days following the height of flooding, showed high levels of Escherichia coli in some areas, including Boulder Creek. Furthermore, more than
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40,000 gallons of oil from oil and gas operations spilled into the South Platte Basin; however, contamination was not detected until 2 weeks after the event occurred (Denver Post, 2013b).
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METHOD We employed a case-study approach because doing so enabled us to illustrate information related to reducing health risks (Yang et al., 2010). Specifically, our case study allowed us to capture dynamics among key stakeholders over a defined period of time and to answer research questions such as how terse warning messages are written to communicate emergency public health information during a disaster, what contents are included in these terse messages, and what features of message style are identifiable. Therefore, our primary data were the publicly available messages posted to Twitter by official response agencies during the period of imminent threat of the September 2013 flood event across the state of Colorado, with a focus on the city and county of Boulder. Utilizing a case-study method, we also drew from websites and documents archived on the CDC website, such as resources and templates for public messaging during a water-related emergency. Next, we describe our online data collection method and procedures for data coding and analysis. Data Collection We initially identified the local, state, and federal Twitter accounts that were posting messages on the primary event hashtag “#boulderflood” from September 11–15, 2013, the time during which the threat was greatest. We then conducted snowball sampling to identify additional Twitter accounts that represented public safety organizations that were connected (as friends) to the initial set of accounts (regardless of their use of the #boulderflood hashtag). We also manually sifted through the websites of local government organizations to identify additional Twitter accounts that may not routinely tweet but could play a public information role. Additionally, we selected state and federal accounts that have a primary role in disaster response, such as Colorado Division of Homeland Security and Emergency Management (@COEmergency), the Federal Emergency Management Agency (@FEMARegion8), and the National Weather Service (@NOAA and @NWSBoulder). Given our interest in public health for this case study, we also made a concerted effort to identify accounts that were posting health-related information and represented local, state, and federal-level organizations such as the Colorado Department of Public Health and Environment (@CDPHE) and the Centers for Disease Control (@CDCEmergency and @CDCReady). Due to the widespread flooding across the state, dozens of official organizations participated in the
statewide flood-response efforts. To constrain our research space we chose to limit our local account selection to those serving the city or county of Boulder, a geographical area that experienced a highly significant 1,000-year rain event, as already described. For each of the targeted Twitter accounts, we retrieved their posting behavior history, including all messages posted to the public timeline for the 5-day period of interest and the timestamp for each post. We also counted the number of times each message was retweeted, the services used to post the message, and other features about the user, such as the number of followers of that account at the time of collection. We queried each of these different data points at the conclusion of the event. This data set was obtained using the Twitter Representational State Transfer Application Programming Interface, or REST API. The REST API allowed us to collect user data including tweets and their associated metadata. We used the API tools to build a continuous, long-term data collection system from a set of targeted user accounts. For the analysis, we considered content and network information from all messages posted by our set of targeted accounts, from 12:01 a.m. on September 11, 2013 (the day the flood events began) until 11:59 p.m. on September 15, 2013 (when the flood threat was concluded). Data Analysis Qualitative coding. We collected 5,100 tweets from 52 Twitter accounts over the course of the 5-day period. Two researchers, the first and second authors, coded the message content of the entire data set manually to identify a subset of messages containing emergency public health content (N = 299 from 30 accounts; 22 of the 52 Twitter accounts contained no relevant public health content). We used a closed coding approach drawing from the preidentified topics described on the CDC website as “water related emergencies and outbreaks” (CDC, 2013a). Six health communication themes were identified: (a) drinking water safety (personal water storage, wells, community water systems), (b) septic/sewage and wastewater, (c) hygiene and handwashing, (d) cleaning and sanitizing, (e) standing flood water exposure (including food safety and animals), and (f) messages referring individuals to informational resources. Messages that directed individuals to avoid active flooding areas and that provided instructions on evacuation procedures (i.e., “don’t drive through water”) were not included in the CDC water-related emergency topics and were therefore not coded as part of the emergency public health communication messages. Coders independently coded each tweet using the closed content categories and then exchanged tweets to determine intercoder agreement. Coders agreed on content theme codes in approximately 98% of cases. Disagreements were resolved by consensus, following discussion of problematic cases by the coders. We also coded for the inclusion of a weblink or URL
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(usually shortened by using bit.ly or another short URL service). To further assess the information content of each message, we followed every link within the health data set and assessed its content utilizing the CDC content codes described earlier. Emergency public health messages were also coded for aspects of message style (see Table 1). Style aspects, which emphasize how content is relayed or displayed to affect message specificity or clarity (Mileti & Sorensen, 1990), include the following: how each tweet sentence functions within the English language as declarative, imperative, interrogative, or exclamatory; and whether a tweet includes a word or phrase in ALL CAPS and, if so, whether these words function as either a category signifier or to emphasize a portion of the tweet (to increase message clarity). Each targeted account was coded according to its sphere of operations (local, state, regional, or federal/national) and its response sector (public safety, health, defense/law enforcement, environment, elected government, private industry, nonprofit). In addition, we noted the number of messages sent from each official Twitter account that contained original content or were retweets, referencing a message from another account. The focus on the “warning period” means that we did not capture all health communication messages posted during the response and recovery. Health communication extends well beyond the warning period as people reenter their homes and begin flood cleanup activities. However, key public health messages were relayed during the warning period,
TABLE 1 Message Style Features Features Sentence style: Imperative
Declarative
Exclamatory
Interrogatory
Capitalization: ALL CAPS—signifier
ALL CAPS—emphasis
Definition
A sentence that gives advice or instructions or expresses a request or command. (e.g., “Boil water first with these instructions.”) A sentence in the form of a statement. (e.g., “People are still asked to conserve water.”) A sentence that expresses strong feelings by making an exclamation. (e.g., “Be safe!”) A sentence that asks a question. (e.g., “Was your frozen food above 41◦ F 4+hours?”) Use of ALL CAPS to signify a category of information. (e.g., “UPDATE: Ralston Water Treatment Plant is back online”) Use of ALL CAPS to emphasize a word/words in the message. (e.g., “Water is SAFE to drink”)
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especially those regarding imminent threat to drinking-water systems.
RESULTS In this section, we report the findings of the subset of messages that focus on health-related content. First we describe features of our targeted accounts. Then we turn to a discussion about water emergency message content and style. Account Features A subset of 30 out of our 52 accounts tweeted about emergency health-related content. These 30 accounts varied by characteristics and demonstrated a variety of posting activities. We collected 17 local, two regional, eight state, and three federal-scale accounts representing the sectors of public safety, health, law enforcement, environment, government, industry, and human service organizations (see Table 2). Over the 5-day period, these 30 accounts posted an average of 10 public health-related messages each, with a maximum of 35 by @CDPHE (Colorado Department of Public Health and Environment) and a minimum of one by @MVFireRescue, BPDPoliceChief, and @boulderpolice. The most active accounts included @CDPHE (n = 35), @boulderOEM (n = 30), and @bouldercounty (n = 30), representing three sectors, health, public safety, and government. Of all the tweets containing health related content, 180 (60%) contained original content, whereas 119 (40%) were retweets (RTs) of content originated by a different account. @BoulderOEM posted 30 original tweets and no RTs of health-related content. Similarly, @BoulderCounty posted TABLE 2 Targeted Accounts by Sector and Number of Tweets Each
Sector Public safety (e.g., fire and emergency management) Health (e.g., public health and food safety) Law enforcement Environment, (e.g., wildlife, agriculture) Government (e.g., elected official) Industry (e.g., private business) Human services (including nonprofits)
Targeted Accounts per Sector (n = 30)
Health Tweets per Sector∗ (n = 299)
7 (23%)
79 (26%)
7 (23%)
82 (27%)
3 (10%) 1 (3%)
7 (2%) 3 (1%)
8 (27%)
106 (35%)
2 (7%) 5 (17%)
17 (6%) 26 (9%)
∗ Organizations may be classified in more than one sector; thus, total tweets >100%.
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primarily original content, with 28 original tweets and three RTs. The @BoulderOEM tweets were retweeted 34 times by our other official targeted accounts. @CDPHE had 26 RTs by other targeted accounts. Official state accounts (e.g., @coloradogov, @COemergency, and @FloodDSS) were primarily retweeting content as opposed to posting original content.
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Message Content We found 299 public-health-related tweets (6%) out of the 5,100 tweets in the complete data set. Of these, the primary theme was related to drinking water safety (n = 121) and included information about boil-water orders, well water, and water facility updates. This was followed by themes on floodwater exposure (n = 55), resources and information (n = 46), cleaning and sanitizing (n = 45), and sewage and wastewater (n = 27). Hygiene and handwashing was the least posted message content (n = 7; see Table 3).
TABLE 3 Message Examples by Health Content Theme
Theme Floodwater exposure
Drinking water
Number of Tweets (n = 299) 55 (18%)
122 (41%)
Resources/information
47 (16%)
Cleaning/sanitizing
43 (14%)
Handwashing/hygiene
Sewage/wastewater
7 (2%)
25 (8%)
Example Tweets Health officials say avoid flood waters, even if they look safe. Can contain sewage, debris, etc. #boulderflood http://t.co/ XNVJoqK41H (@BoulderOEM) Residents with wells should assume water is contaminated. Be Safe! Boil water first with these instrux http://t.co/ J571hpe5OB #boulderflood (@BoulderOEM) Health and Safety After a Flood. http://t.co/1GusGJNCee #boulderflood (@boulderOEM) Safe Debris Removal After a Flood #boulderflood http://t.co/ kbbN091bFP (@bouldercounty) If you’re involved in debris clean-up, wash your hands frequently with soap and clean warm water. A big thanks for helping us in #COFlood. (@CDPHE) City crews will work overnight to relieve sewer backups in #Boulder. They’ve been finding baseball-sized rocks in the pipes! #BoulderFlood (@bouldercolorado)
Of the 299 emergency health messages, 190 tweets (64%) contained 191 links to additional information from 35 different organizations. Those organizations represented 18 local (51%), two regional (6%), seven state (20%), and eight federal (23%) spheres. Boulder OEM was linked to the most (26%), followed by CDPHE (15%), Boulder County (13%), and the CDC (9%). Of the 191 links, content was removed from 64 (32%) of the links. We coded the remaining 127 active links for health content themes. Additional information on drinking water safety was the most frequent theme found in the links (28%), followed by resources and information (25%), floodwater exposure (17%), cleaning/sanitizing (16%), and sewage and wastewater (13%). No links contained information on handwashing or hygiene. Message Style Of the 299 emergency health-related tweets, 109 (36%) used the imperative sentence style, 269 used declarative sentences (90%), and 16 used a question/answer format (5%). Moreover, 87 of the 299 emergency health-related tweets included both information about the hazard impact (in declarative format) and guidance on safety precautions (in imperative format) (29%; see the example tweet for “drinking water” in Table 3). Few messages utilized capitalized letters to signify a specific category of information such as UPDATE (n = 6) or to emphasize portions of the message content (n = 19).
DISCUSSION Thirty of the 52 Twitter official accounts collected and examined in this study included at least one message with content about emergency public health information. Some accounts have a primary role in communicating about the disaster in general (e.g., by sphere [local] and sector [government]). Some have a primary role in communicating public health information over time (e.g., by sector [public health]). We discovered that local emergency management (@BoulderOEM) took the lead in communicating emergency public health information and was the most frequently retweeted account and that state and federal agencies mainly functioned to promote or amplify local messages. This finding matches well with previous research indicating that local organizations take the lead in communicating during an event, reinforce each other, and are often amplified by organizations at the state and federal level (Sutton et al., 2014b). That said, however, the analysis of content themes revealed that only 6% (n = 299) of the 5,100 tweets in the complete data set focused on public health. Moreover, about 40% (n = 121) of those 299 tweets were devoted to
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drinking-water safety. Similarly, the primary content theme of the links attached to tweets addressed drinking-water safety. Although attention to drinking-water safety is important, the tweets in this study appeared to privilege attention to it above other issues of safety and self-protection (e.g., floodwater exposure, cleaning and sanitizing, sewage and wastewater, hygiene and handwashing). On the basis of these results, official response agencies could be more mindful about providing balanced coverage regarding self-protective instructions for public health safety. Regarding style, nearly 90% of the tweets examined in this study were declarative, 36% were imperative, and 29% contained a combination of both. We suggest that there is a direct link between sentence style and sentence function; where declarative sentences explain the hazard and its impact, imperative sentences are more instructional. Although previous research suggests warning messages be composed of a mix of declarative and imperative sentences (Frisby et al., 2013), the heavy reliance on declarative/explanatory style over imperative/instructional style could hinder desired behavioral actions from receivers. Instead, research on instructional messaging has emphasized that instructive guidance provided in an imperative style must be presented along with information about the hazard for receivers to take appropriate protective action (Sellnow & Sellnow, 2010). The tweets examined in this analysis suggest that the mix is highly unbalanced and agencies ought to be mindful to offer more tweets framed using an imperative/instructional message style to increase the likely of achieving their behavioral outcome goals. In 2013, the CDC (2013b) created the “Drinking Water Advisory Communication Toolbox” as a practical guide for stakeholder communication in water emergencies. The toolbox proposes this single template for designing announcements to be sent over short messaging services: “The [name of water system] is asking customers to boil tap water or use bottled water. For more information, go to [www. watersystemwebsite.org] or call [###-###-####].” Although this template provides a starting point for message design, it fails to include demonstrated components of effective messages for an imminent threat hazard event. Importantly, these messages provide no information about the hazard event, its impact, or instructions for safety and self-protection. Terse messages could do so, however, by offering explanations about the hazard impact and actionable instructions using a combination of declarative and imperative sentences in a single message (e.g., the message about drinking water in Table 3). Limitations Several limitations are noted about this case study. First, this analysis focused on the warning period of a natural disaster. Therefore, we did not examine messages disseminated after the height of imminent threat. An examination of
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long-term crisis communication activities would allow us to identify shifts in message content over time and any changes in message delivery and amplification among organizations. Second, our research is limited to an examination of message content and style by senders. Therefore, we did not examine human behavioral responses to them (e.g., information seeking, information sharing, protective action behaviors). Future Research As more health departments adopt social media to communicate during crisis events, they will need to consider how to do so most effectively. This case study verifies the relevance of terse messaging channels for emergency health communication during crisis events. Moreover, this study reveals that despite the brevity of terse messages, they can include “bite-sized” pieces of explanatory information while delivering guidance-focused content in an instructional manner. Future research should explore the balance between imperative/instructive messages and declarative/explanatory messages. This exploration is important for two reasons. First, limited information is available on the appropriate balance of these two essential stylistic variables. Second, much more information is needed about the impact terse message frameworks may have on public response behavior. This analysis concentrated on a set of terse messages collected over a critical period of time. Thus, we observed the cumulative content of a series of tweets, across multiple accounts. Further research should address this cumulative impact. We know that key information can be provided in a single terse message. The extent to which additional information delivered through a series of terse messages creates the desired public health response warrants further analysis. A third compelling area for future study involves the timing of terse messages. Recent research indicates that the volume of Twitter messages and related retweeting is most prevalent leading up to a predictable disaster such as a hurricane (Spence, Lachlan, Lin, & Del Greco, in press). For crises that occur with little forewarning, such as a flash flood event, time for information searching and sharing is cut short. Future research should emphasize the role of terse messages across all phases of disaster including preevent, imminent threat warnings, and crisis communication throughout the recovery period.
CONCLUSION The shifting landscape of communication with the advent of new media has made terse messaging one of the preferred formats in many communication contexts—including public health emergencies. Thus, government agencies such as the CDC now include social media and terse messaging in their training materials. Other agencies such as the Food and
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Drug Administration and many state agencies have joined CDC in sending terse messages routinely, as well as during crises. The Boulder flood provides a vivid case study of how informational needs arise and how terse messages can efficiently fulfill those needs. Much more needs to be known about how terse messages can contribute to public health during disasters. This study, however, reveals the tremendous potential for terse messages delivered over social media to play a prominent role in protecting the public’s health during crises.
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FUNDING This research was supported by the National Science Foundation, awards CMMI-1031853 and CMMI-1031779. Any opinions, findings and conclusions, or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation. Part of the research conducted by Sutton was performed while she was a senior research scientist at the University of Colorado, Colorado Springs. Sutton is now at the University of Kentucky. REFERENCES Centers for Disease Control and Prevention. (2012). Crisis and emergency risk communication, 2012 edition. Retrieved from http://emergency.cdc. gov/cerc/pdf/CERC_2012edition.pdf Centers for Disease Control and Prevention. (2013a). Water-related emergencies and outbreaks. Retrieved from www.cdc.gov/healthywater/ emergency Centers for Disease Control and Prevention. (2013b). Drinking water advisory communication toolbox. Retrieved from www.cdc.gov/healthywater/ emergency/dwa-comm-toolbox/index.html Daily Camera. (2013, September 21). Eight days, 1,000-year rain, 100year flood. Retrieved from www.dailycamera.com/news/boulder-flood/ ci_24148258/boulder-county-colorado-flood-2013-survival-100-rain100-year-flood Denver Post. (2013a, October 8). Body of 9th Colorado flooding victim identified. Retrieved from www.denverpost.com/news/ci_24266050/ body-9th-colorado-flooding-victim-identified Denver Post. (2013b, October 8). E. coli found in Colorado flood zones, but no oil, gas contamination. Retrieved from www.denverpost.com/ breakingnews/ci_24264793/e-coli-found-colorado-flood-zones-butno#ixzz2r0u3XXYc Drabek, T. E. (1999). Understanding disaster warning responses. Social Science Journal, 36, 515–523. Frisby, B. N., Sellnow, D. D., Lane, D. R., Veil, S. R., & Sellnow, T. L. (2013). Instruction in crisis: Targeting learning preferences and efficacy. Risk Management, 15, 250–271. Frisby, B. N., Veil, S. R., & Sellnow, T. L. (2014). Instructional messages during health-related crises: Essential content for self-protection. Health Communication, 29, 347–354. Glik, D. C. (2007). Risk communication for public health emergencies. Annual Review of Public Health, 28, 33–54. Hanson, C., West, J., Neiger, B., Thackeray, R., Barnes, M., & McIntyre, E. (2011). Use and acceptance of social media among health educators. American Journal of Health Education, 42, 197–204.
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