CONTEXT AND RATIONALE

During health emergencies local public health departments are often responsible for communicating about rapidly evolving scientific guidance with diverse audiences. Yet they face siloed systems that limit the flow of critical resources and expertise, outdated infrastructure, and a complex information environment (NASEM, 2023b). Additionally, state and local leaders consistently cite fragmentation, mistrust, and a lack of coordination as significant barriers to communicating effectively with the public during emergencies (NASEM, 2023a). In the context of scarce resources, other mandated public health preparedness responsibilities and requirements have often overshadowed communication, although this situation has been changing (Schoch-Spana et al., 2013).

The “public” in “public health communication” is quite varied, and any communication needs to reach people from very diverse sectors and communities. One of the core challenges of any communication effort is gaining the attention of the people that you aim to reach. People are more likely to pay attention to speakers when they perceive that they are knowledgeable and trustworthy about the topic at hand (Lupia, 2013). The challenge for public health communication is that, because the public is so diverse, different segments are going to consider different speakers to be credible on health-related topics. For instance, research has identified differences across racial groups in terms of degree of trust in their physicians and also degree of trust in less formal sources of health information (Nana-Sinkam et al., 2021). Given this diversity in audiences, the processes of deciding the optimal messages and speakers, implementing communication and ensuring its effectiveness depend on collaborative relationships with trusted community members from across society.

When collaboration is lacking, public health responses often suffer. For example, duplicated outreach and inconsistent messaging can weaken community trust. Analyses of the early COVID-19 vaccine rollout found that fragmented federal–state coordination led to inconsistent eligibility rules, uneven distribution, and missed opportunities to reach priority populations (Clouston et al., 2023; Tewarson et al., 2021). Scholars have also noted that limited cross-sector engagement undermined the equity of pandemic response. Communities of color experienced greater barriers to accessing testing for COVID-19, timely vaccinations, paid sick leave, sufficient personal protective equipment on the job, and telehealth opportunities; additionally, they were also disproportionately less likely to enroll in clinical trials (Nana-Sinkam et al., 2021).

While the root cause of many of these disparities stems from factors that go well beyond communication, a lack of collaboratively engaged communication may have been a contributing factor. For instance, because of racial disparities in clinical trial enrollment, one proposal called for a “collaboratively designed Operation Build Trustworthiness” that would complement Operation Warp Speed and be “firmly grounded in grassroots involvement of individuals with well-earned reputations for trustworthiness” in diverse communities, including “elected representatives, trusted local and national faith leaders, community advocates, and others (Warren et al. 2020).”

Effective and strategic collaboration for public health communication is vital for meeting both ongoing public health goals and responding to crises. Such collaboration can enhance health outcomes, engage diverse populations, tackle complex health challenges, and ensure successful prevention and response efforts during emergencies (Mabery et al., 2013; Tsai et al., 2022). The COVID-19 pandemic highlighted the importance of public health communication partnerships in reaching at-risk populations and informing the public. These collaborations improved health communication outcomes, helped prevent COVID-19 transmission, and reduced health disparities (Chung et al., 2021; Quinn et al., 2023; Wieland et al., 2021; Yasmin et al., 2021).

Public health communication collaborations take many forms, involving diverse partners and approaches. They can include institutional partnerships among public health agencies, other government entities, community organizations, universities, health care systems, and emergency response agencies. They may also extend to individual stakeholders such as frontline health care providers, first responders, and community residents, all of whom play critical roles during crises. One

commonality across collaborative approaches is the ability to leverage shared resources and expertise (Baum et al., 2024; Brunson et al., 2021; Schuh et al., 2025). Table 1 summarizes some common types of collaborations.

Table 1 Types of Collaborations

Table 1 includes a range of possibilities for public health decision-makers to consider. One of the first decisions to make, which will be discussed later in this document, is deciding which one(s) are right for their context and for the kinds of public(s) that they need to reach. In other words, the initial question will be: What kind of unmet desire to collaborate exists?

The types of partnerships identified in Table 1 have been foundational to building and sustaining trust and ensuring that communications reflect the lived realities of different populations (NASEM, 2022, 2023b). Local and state health departments have leveraged these partnerships to increase the reach and effectiveness of numerous public health programs and interventions (Ross et al., 2020; Smith et al., 2020; Sun et al., 2019). States such as North Carolina, Oregon, Rhode Island, and Washington have developed creative approaches that encompass backbone organizations, leadership training, payment reform, interoperable data platforms, and intentional relationship-building to connect public health and primary care (Baum et al., 2024). These efforts focus on both formal and informal relationship-building, clear roles, and attention to system elements essential for change (Baum et al., 2024). Collaborations between local health departments and community-based organizations have proven vital, especially for reaching populations with limited English proficiency (Baum et al., 2024). Community-based organizations help ensure that communication is culturally relevant, trusted, and accessible (Agonafer et al., 2021; Lim et al., 2023). Sustaining these collaborations requires attention to both operational (e.g., resources, administration) and relational (e.g., trust, respect) dimensions, supported by appropriate policies and funding (Schoch-Spana et al., 2018b, 2018c; SteelFisher et al., 2024).

STRATEGIES FOR STATE AND LOCAL COLLABORATION TO SUPPORT PUBLIC HEALTH COMMUNICATION

Successful collaboration depends upon relationship-building, and it is difficult to build new collaborative relationships in the midst of a crisis. Various challenges and barriers can hinder creation of the intended relationships and/or infrastructure for effective and sustainable communication during a public health emergency. It is therefore important to address these barriers before a crisis occurs and to maintain the collaboration over time. Common challenges include structural and organizational barriers, relational issues with trust and communication among partners, struggles with effectively involving the community, and coordination difficulties. The following are strategies, with examples, that can help address these challenges by taking a strategic approach to developing and sustaining collaborations.

Assessing Unmet Desire

Before committing to collaboration, assess whether it addresses unmet needs or gaps. Table 2 summarizes the strategies in this collaboration phase.

Table 2 Assessing What Is Needed

Ask Diagnostic Questions

Decision-makers often have an unmet desire to collaborate (Kelinsky-Jones & Levine 2025; Levine, 2022; Levine & Shuman, 2025). For this reason, the key initial step is to ask questions to assess the

state of current capacity for public health communication. The answers to these questions help identify strengths, weaknesses, opportunities, and readiness.

• What are the strengths and weaknesses in current public health communication?
  Use a structured evaluation tool (e.g., the Center for Disease Control and Prevention’s [CDC’s] Program Evaluation Framework) to map communication capacity. Identify whether gaps are technical (systems, data) or relational (trust, awareness). Evaluations show that structured assessment improves alignment of goals and reduces wasted effort (CDC, 1999).
• Which of the assessed gaps and challenges could be addressed more effectively through collaboration than working alone, but without unnecessary duplication?
  Consider which of the gaps are currently stalled within the organizations currently involved in public health communications (e.g., limited reach, lack of trust, technical expertise). To identify partners who could fill those gaps, conduct a quick “network map” of partners and programs that can credibly reach the public(s) you need to reach in a public health emergency. Determine whether existing collaborations around public health preparedness or crisis communications could be expanded to include a more explicit or robust focus on community-engaged communication strategies. Identify where roles overlap and where segments of the population are missed. Analyses of chronic disease collaboratives found that uncoordinated networks duplicated outreach while leaving key populations unserved (Bevc et al., 2015; Varda et al., 2012), while partnerships that aligned institutional capacity with community assets during the COVID-19 pandemic improved vaccine uptake among people without access to vaccines (Bibbins-Domingo et al., 2021; Calo et al., 2021).
• What resources and relationships exist—or are missing—to support communication during an emergency?
  Consider barriers such as limited staffing or budget for outreach, fragmented communication systems between local and state agencies, or challenges coordinating across jurisdictions with differing political climates or priorities.
• Who is (or is not) in a position to initiate or support partnerships?
  Map decision-making authority. Ask: “Who controls funding, data, or messaging platforms?” and “Who has credibility with the community?” Studies of multisector collaborations highlight that identifying gatekeepers and informal leaders is essential for effective mobilization (Mays et al., 2010; Zahner, 2005). Identify where outreach has been difficult—for example, rural or geographically isolated communities, small businesses without dedicated public affairs staff, or civic and faith-based organizations that may have differing values or limited prior interaction with public health.
• What hesitations or power dynamics might limit participation?
  There are many reasons why potential collaborators may be uncertain about how to relate to each other (Levine, 2024). They may wonder whether others will value their expertise on the issue; they may be unsure of what is appropriate and inappropriate to say. Potential collaborators may worry that they will be criticized or that other collaborators may not have practical and trustworthy information to share. Do they really want to share decision-making authority? Create space to directly name hesitations such as these, as well as sources of inequity (financial, cultural, and/or organizational). Build feedback loops so less-resourced partners can voice concerns without penalty. Research shows that when power imbalances are ignored, collaborations often fail; when they are addressed, trust and equity improve (Innes & Booher, 2004; Lasker et al., 2001; Ostrom, 1996).

Match the Collaboration Approach to Needs

Not every collaboration needs to look the same. Effective partnerships start with a shared understanding of the problem to be solved and the value each participant brings. Health departments can assess whether the need is primarily for information-sharing, coordinated outreach, or joint implementation, and then match the collaboration type accordingly. Some partnerships may remain informal and focused on situational communication, while others may require more structured governance or resource-sharing (NASEM, 2023a). Matching the approach to both current needs and the stage of the relationship allows collaborations to remain purposeful, flexible, and durable and be capable of responding not only to immediate crises but also to the evolving public health landscape.

Frameworks such as the Collaboration Continuum or social network mapping can help uncover gaps and clarify opportunities. The concept of a continuum of collaboration can help in discerning the kind of collaboration that would be helpful for creating and implementing an effective communication strategy that reaches the diverse public(s). This can include the following:

• exchanging information
• coordinating by modifying each partner’s efforts to align more closely with a common purpose
• sharing financial, human, and other resources
• merging structures, data systems, budgets, and other structures in fully integrated efforts

In practice, many collaborations involve more than two organizations. Public health departments frequently engage multiple partners simultaneously, including community groups, health systems, universities, local media, and private-sector entities—each with distinct capacities and priorities. Organizing these multipartner collaborations benefits from clarifying how each group contributes to the overall goal, establishing simple coordination mechanisms (e.g., joint briefings, shared calendars or dashboards, message maps), and designating a convener or liaison to maintain alignment across partners. Clear roles and routinized ties improve coordination and message reach (NACCHO, 2022; NASEM, 2023a).

To sustain effective collaborations, it can be valuable to assess the quality of the relationships to discern the extent to which the partners are and remain committed and aligned, and to revisit whether the breadth and composition of the partners continue to be a good fit for the purposes of the network.

Social network analysis is one tool for measuring and understanding relationships among partners. Instead of just asking whether a partnership exists, social network analysis looks at how connections actually work, who communicates, how often, and how information flows. It can show

• how connected the network is overall (density),
• which partners play a central role in sharing information (centrality), and
• how strong or weak the relationships are (tie strength).

These insights can help distinguish between networks that exist mostly on paper and those that are deeply collaborative. Research shows that when relationships move beyond surface-level contact to stronger, two-way connections, partners share resources more effectively, and their messages spread further and with greater trust (Luke & Harris, 2007; Valente, 2010; Varda et al., 2012).

Several U.S. jurisdictions have applied social network analysis to strengthen collaboration for public health communication that reached diverse audiences. In Texas, researchers mapped integrated public health networks to identify influential organizations and clarify how information flowed across partners (Wang et al., 2025). They found that effective networks relied on the quality and reciprocity of relationships rather than the number of connections (Wang et al., 2025; see also Franco et al., 2015; North Carolina Department of Health and Human Services, 2024). Research has also shown that effective partnerships depend on practices of listening, inclusion, and solidarity, especially with respect to voices that are often overlooked (Medina, 2023). Paying attention to these dynamics can help ensure that collaborations are not only efficient but also responsive to the communities they

serve (Medina, 2023).

Partnerships also evolve over time. An initiative formed in response to an acute emergency, such as a pandemic, can transition to address longer-term priorities. For example, a university that partnered with a health department for COVID-19 communication can later support workforce training, community-engaged research, data analysis, or evaluation for future response strategies. Periodically revisiting the shared purpose, updating expectations, and reaffirming mutual value helps sustain engagement beyond the original crisis (Brownson et al., 2018; NASEM, 2023b). Maintaining trust with civic, faith-based, and other social institutions, and understanding how local norms shape message uptake also supports continuity as goals shift (Southwell & Thorson, 2015).

Getting Started

Once a need has been identified and an appropriate collaboration approach determined, begin with clear, early steps. Table 3 summarizes the strategies in this collaboration phase.

Table 3 Getting Started

Define a Shared Purpose

Agree on goals that bring in missing partners, align diverse organizations, and sustain momentum. Developing a clear description of the overarching purpose of collaboration helps identify and attract the right organizations, including those that may not yet be at the table. Articulating a shared purpose also helps align diverse stakeholders, reduce fragmentation, and sustain collaboration over time (U.S. Government Accountability Office [GAO], 2023; Van Den Oord et al., 2023). During the COVID-19 pandemic, for example, the Western States Pact,⁸ a collaboration among California, Colorado, Nevada, Oregon, and Washington defined a unified purpose and provided consistent, evidence-

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based vaccine guidance across states. Similarly, the Healthiest State in the Nation Campaign⁹ in Washington used community roundtables and a leadership summit to establish shared values such as fairness, prevention, and accountability, aligning with diverse partners and sustaining statewide health improvement efforts.

Start Small, Then Scale

Begin with low-risk, achievable activities, such as joint trainings, cross-agency meetings, or information-sharing agreements, before moving toward deeper coordination or integration. Early smaller-scale efforts create trust, demonstrate value, and help identify barriers before organizations commit more resources. Evidence from some earlier U.S. public health collaborations shows why these matter:

• Pilot projects build confidence: Evaluations of local health coalitions found that partners that began with low-intensity activities, such as cohosting community forums or conducting data-sharing pilots, were more likely to sustain partnerships over the long term (Bevc et al., 2015; Zahner, 2005). Testing coordination through small-scale joint projects or tabletop exercises can reveal vulnerabilities before an emergency occurs (Lurie et al., 2013; Rutkow et al., 2015).
• Incremental progress reduces risk: Research on community health partnerships demonstrates that “small wins” create early momentum, allowing groups to expand participation and capacity over time without overcommitting (Butterfoss & Kegler, 2009; Lasker et al., 2001).
• Joint training strengthens relationships: Workforce development programs, such as the Public Health Training Center network, show that cross-sector training can function as a low-cost entry point to collaboration, building shared language and mutual awareness before moving to larger-scale integration (Leider et al., 2015; Tilson & Gebbie, 2004).
• Scaling comes after trust: Studies of preparedness coalitions illustrate that a strategy of starting with limited coordination (such as communication protocols) and gradually layering more formal structures (such as integrated data systems) is more effective than attempting deep integration at the outset (Mays et al., 2010).

Adopt a Whole-Health and a Whole-of-Society Lens

Crises produce myriad and complex challenges that are rarely limited to any single domain. Efforts to communicate what is happening, what actions to take, and what help is available will be more relevant and engender more trust if they respond to the interrelated needs of those affected instead of remaining siloed according to how systems and institutions are organized. Therefore, cross-sector coordination is critical to effective public health communication.

Networks that span public health, education, housing, emergency management, media, businesses, and other sectors have proven more resilient and effective in complex crises (NASEM, 2023a; Schoch-Spana et al., 2018a; Wolf-Fordham, 2020). During the COVID-19 pandemic, for example, various sites in California’s statewide alliance STOP COVID-19 delivered COVID-19 health-related information as one key resource among others (e.g., free groceries, free health screenings, free personal protective equipment); this engendered greater trust and improved COVID-19 vaccine uptake, by focusing on the whole-person needs of under-resourced communities (AuYoung et al., 2023).

Coordinating communication across these networks can ensure consistent messaging and maximize

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reach, but differences in sectoral priorities, fragmented systems, and challenges in data-sharing can make consensus difficult (Pratt et al., 2018; Retrum et al., 2013; Sanga et al., 2024). Even if not all sectors are directly involved in a collaboration, it is important to be aware of linkages across interdependent areas. Building communication systems across sectors (e.g., business, nonprofit, government, academic) and across relevant aspects of society (e.g., health, education, transportation, housing) strengthens resilience and broadens reach. For example, the North Carolina Emergency Management operates a business emergency operations center and invites representatives from public health and transportation to participate and liaise with businesses.¹⁰ During Hurricane Helene, business partners raised workforce health concerns (e.g., vaccine updates, water safety, sanitation). The health department provided concise guidance on tetanus vaccination, safe water, and sanitation that employers cascaded to their workforce through internal channels (e.g., shift huddles, human resources emails, union texts), aligning public and private actions to keep essential services operating while protecting workers’ health.

Integrated data platforms allow agencies to coordinate services in real time. In Allegheny County, Pennsylvania, the Department of Human Services Data Warehouse consolidates person- and service-level data across behavioral health, child welfare, homelessness and aging services, and more; it supports case management tools, dashboards, predictive models, and community access while respecting privacy protocols. New York City’s HHS-Connect/Worker Connect component grant authorized caseworkers for near-real-time access to client data across multiple human services agencies (Gill et al., 2014; Yaroni et al., 2015). These examples demonstrate how interoperable data infrastructure, underpinned by enterprise memorandums of understanding and secure data agreements, enhances coordination and reduces fragmentation.

Establish Governance Early

Shared committees or agreements clarify roles and expectations from the outset. Joint governance and shared structures can reduce fragmentation and strengthen coordination. Steering committees and interlocal agreements help align priorities and clarify roles. For example, the Tacoma-Pierce County Health Department in Washington was formed through an interlocal agreement that shared governance and resources between city and county entities (Liss-Levinson et al., 2020). Another long-standing interlocal agreement is the Mecklenburg County Interlocal Agreement in North Carolina, which established a collaborative model in which a major health system operates public health services under county oversight. For nearly 2 decades, this joint governance structure has enhanced service coordination, leveraged clinical resources, and improved access (Piper et al., 2018). Formal frameworks such as memorandums of understanding or charters can draw from established playbooks such as the Government Accountability Office’s (GAO’s) leading practices for interagency collaboration, the Association of State and Territorial Health Officials’s (ASTHO’s) multisector partnership toolkit, and the National Association of County and City Health Officials’s (NACCHO’s) data-sharing resources. These frameworks can specify roles, decision rights, data governance, and (where feasible) fairness or equity requirements (ASTHO, 2024; GAO, 2023; NACCHO, 2014).

Identifying Whom to Engage

Collaboration is needed not just among institutions—community partners are essential. Table 4 summarizes the strategies in this collaboration phase.

Health department readiness for effective communication is advanced by an organizational culture of collaboration that includes, but goes beyond, top leadership and times of crisis. Meaningful engagement positions community-based organizations and trusted leaders as cocreators in public

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health communication. Their local knowledge and social capital are not just resources to draw upon but essential expertise that guides shared planning, decision-making, and implementation, especially in linguistically and culturally diverse communities (Schoch-Spana et al., 2018a; SteelFisher et al., 2024).

Table 4 Identifying Whom to Engage

Identify Partners Broadly

Think beyond formal organizations to include community groups, local leaders, and informal networks. Public trust during emergencies is often not anchored in government agencies but in individuals embedded in community life, including community health workers; faith networks; and frontline workers, such as pharmacists, social workers, and promotors, who play critical roles in building trust (NASEM, 2022, 2023a). Examples from the COVID-19 pandemic demonstrate how collaborating with local communities, incorporating their lived experiences, and leveraging these insights can enhance the adoption of public health measures (Oliver et al., 2024).

Key actions can include collaborating with high-trust and high-reach messengers, thereby enabling public health messages to resonate where institutional voices might fail (Schoch-Spana et al., 2018a; SteelFisher et al., 2024). State-level trusted messenger initiatives, such as those in Ramsey County, Minnesota,¹¹ and the Minnesota Department of Health,¹² have reinforced this model by leveraging culturally tailored communication and providing ongoing training for community-based ambassadors.

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Moreover, public health communication becomes more meaningful and relevant when shared by trusted messengers in a cultural community’s “sacred spaces,” such as barbershops and hair salons, which served as de facto health hubs for some African Americans during the COVID-19 vaccination campaign (Linnan et al., 2022; Mundagowa et al., 2024). The iHeard project¹³ is an example of a collaboration that not only leverages trusted messengers but also builds trust through community involvement in identifying information that might need to be corrected via public or clinical communication.

Recognize Power Differentials

Research shows that ignoring power imbalances can reinforce inequities and undermine collaboration. For example, framing the goal as community “resilience” may seem productive; but for partners whose experience of resilience means maintaining systems built on poorly paid, insecure labor, it can be counterproductive and deepen mistrust (Lansing et al., 2023; Pascoe & Stripling, 2020). Ahead of a national convening on mpox diagnostics, the New York City (NYC) Preparedness & Recovery Institute held separate focus group conversations with advocates, federal leaders, and business executives to surface differing perspectives and ease tensions, which led to more meaningful outcomes (NYC Pandemic Response Institute & The Foundation for AIDS Research, 2023). Similarly, to engage Maryland residents in a deliberation about which community values should inform the ethically complex decision of how to allocate scarce lifesaving medical resources in a disaster (e.g., mechanical ventilators during an influenza pandemic), a Johns Hopkins University team advising the state health department held community forums separate from discussions with emergency managers and health professionals, to overcome some participants’ inclination to defer to the “experts” and downgrade their own opinions and to avoid the potential for specialists to drown out community voices (Daugherty Biddison et al., 2014). These cases highlight why understanding differences in perspective and addressing inequities directly is essential groundwork for building trust (Gorman, 2024).

Support Capacity for Engagement

Collaboration approaches in which community members can actively contribute their knowledge and expertise have demonstrated success in enhancing the trust, uptake, and sustainability of health messages (Brunson et al., 2021; Jagosh et al., 2015; NASEM, 2023b; Wallerstein & Duran, 2010). Community-based participatory research, for example, fosters a long-term perspective, shifting power toward communities while increasing message resonance, trust, and behavior change. These approaches have been applied successfully to design culturally tailored campaigns for infectious diseases, maternal health, and disaster preparedness (Schoch-Spana et al., 2018a). For example, the Strong Heart Study¹⁴ is a multidecade community-based participatory research effort with American Indian communities across multiple states. It involves community members in designing surveys, choosing examination sites, and conducting recruitment. The initiative has resulted in health data and findings that are culturally aligned, locally relevant, and used actively in community health planning. Similarly, Chicago’s Population Study of ChINese Elderly (PINE Study) worked with community partners to create linguistically appropriate surveys for Chinese American seniors, boosting participation and relevance (Dong, 2014). These examples show how community-based participatory research approaches can foster long-term engagement and more effective communication strategies.

In parallel, most institutional partners involved in a whole-of-society approach to public health collaboration have limited staff with deep experience in community engagement, a capacity gap that weakens their ability to build authentic, trusted relationships (Chen et al., 2024). To address this gap,

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institutions can recruit individuals with engagement expertise, incorporate community-based methods into ongoing training, and encourage staff to adopt participatory approaches. Some public health departments are already experimenting with innovative hiring and retention models to expand their workforce’s capacity in this area. Local examples include the Connecticut Public Health Fellowship Program,¹⁵ which places students in mentored positions across the state’s health agencies, and the Population Health Fellows program¹⁶ in the San Francisco Department of Public Health, which offers 2-year paid placements with structured training and mentorship.

Combining funding or infrastructure can avoid waste and extend reach. Crises often strain funding, staffing, and training capacity (Errecaborde et al., 2019; Sanga et al., 2024). Braiding and blending funds across agencies can align streams around shared goals while allowing individual sources to retain accountability (DeSalvo et al., 2017; NACCHO, 2021; Trust for America’s Health, 2018).

Value Community Expertise

Evidence from the COVID-19 pandemic and earlier emergencies shows that trust increases when communities are involved in decision-making processes through participatory advisory boards, codesigned messages, or shared ownership of dissemination plans (Schoch-Spana et al., 2018a; SteelFisher et al., 2024). Embedding communities in decision-making can include establishing collaborative governance structures, such as participatory advisory boards or codesigned communications, to help align public health strategies with local needs. In addition, evaluations have shown that integrating community-based organizations in planning and funding their participation can improve the reach and implementation of vaccination and related public health efforts (Heinrichs et al., 2023). Local-level examples of embedding communities in decision-making include the Greater Sullivan County Public Health Network¹⁷ in New Hampshire, which brought together a regional coordination committee comprising schools, nonprofits, community groups, and faith groups to jointly plan communications, run vaccine clinics, and guide emergency strategy during the 2009/10 H1N1 outbreak.

Coleading and Sustaining Public Health Collaborations

Sustaining collaboration requires intentional relationship-building and coordination. Table 5 summarizes the strategies in this collaboration phase.

Table 5 Coleading and Sustaining Collaborations

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Build and Maintain Trust

Trust grows over time through joint activities, not during crises alone. Few actors and organizations will successfully build trust or rapport during a crisis; sustained collaboration facilitates interactions that can in turn help build and sustain trust (MacKay et al., 2022; Schuh et al., 2025). Formal or informal relationship-building activities, such as cross-training, job rotation, retreats, and community forums, can improve trust (Baum et al., 2024; Krczal & Behrens, 2024). Additionally, trust can be built and sustained through flat hierarchies, shared decision-making, and open communication channels (Aunger et al., 2021). Live Well San Diego,¹⁸ a countywide partner network, utilizes community leadership teams, a shared partner portal for meetings and trainings, and routine cross-partner convenings to maintain relationships. Another example is the Rhode Island Health Equity Zones,¹⁹ which fund local collaboratives to hold community forums, codesign priorities, and use shared measures to keep partners aligned (Alexander-Scott et al., 2016). Additionally, the collaboratives use community feedback loops to flag implementation barriers and adjust strategies with community members and partner organizations (Alexander-Scott et al., 2016).

Recent national surveys indicate that confidence in public health and government institutions has declined in many communities, often along social, political, and geographic lines (Kennedy & Tyson, 2023; Kirzinger et al., 2023; NASEM, 2023a; 2023b). These patterns underscore the importance of tailoring messages to local contexts and using trusted community intermediaries to help bridge divides. Recognizing that trust is socially patterned can help communicators anticipate barriers and design strategies that strengthen credibility across diverse audiences. Practical tools are available to help organizations translate these principles into action. The American Association of Medical Colleges’ Principles of Trustworthiness Toolkit offers community-tested guidance for institutions seeking to build or repair trust with historically marginalized communities.

Proactively identifying and addressing barriers is one of the most effective ways to build and sustain trust (Alderwick et al., 2021; Valaitis et al., 2020). These barriers can take many forms, such as organizational, linguistic, or financial, and recognizing them is key to meaningful collaboration. An example comes from Johns Hopkins’s TRUST²⁰ checklist, which recommends routine partner debriefs, after-action check-ins, and transparent updates during evolving events to maintain trust and steer efforts in real time (Potter et al., 2025). Another practical framework comes from the National Alliance to End Homelessness. Its Housing-Focused Outreach model tackles barriers directly by building collaborative governance, workgroups, and case conferencing into its processes (National

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Alliance to End Homelessness, 2023).

Communicate Consistently

Fostering open and frequent bidirectional, reliable, and accessible health communication, such as by holding meetings, establishing shared protocols, and utilizing interoperable information systems, can help strengthen understanding, coordination, and cooperation among partners (Alderwick et al., 2021). Transparency is also important to open communication in the face of uncertain public health risks and crises (Lowe et al., 2022). To put this principle into practice, Allegheny County, Pennsylvania, and Washington County, Oregon, use weekly cross-partner meetings guided by shared protocols and common data to improve coordination in their homelessness responses (Allegheny County Continuum of Care, 2022; Washington County Continuum of Care, 2020).

Aligning communication across partners using joint information systems, templates preapproved among the partners, and culturally responsive practices can be effective for creating consistent, tailored communication during emergencies. Federal doctrine; the CDC’s Crisis and Emergency Risk Communication framework; and local examples such as New York State, San Diego (California), and Denver (Colorado) illustrate how practices such as rumor control and clear pathways for approving messages support effective public communication (City and County of Denver, Office of Emergency Management, 2022; Federal Emergency Management Agency, 2020; New York State Division of Homeland Security and Emergency Services, 2025; Reynolds & Seeger, 2014; Unified San Diego County Emergency Services Organization & County of San Diego, 2022).

Social media can facilitate rapid information exchange, guide citizens in real time, and mobilize community support through donations or service coordination (Nielsen et al., 2024). Dashboards, such as the Johns Hopkins COVID-19 tracker, can provide situational awareness and adaptability during crises (Dong et al., 2020). Emerging technologies, including AI-based monitoring and crowdsourced citizen data, can further strengthen early detection and response optimization (Cheng et al., 2024).

Develop Shared Leadership

Encourage leadership that is accountable, culturally aware, and collective rather than hierarchical. Targeted leadership development that emphasizes respect, accountability, and shared responsibility can reduce power imbalances, strengthen trust, and improve collaboration quality. Programs that pair technical leadership skills with practices that encourage openness, transparency, and effective communication show gains in team functioning and cross-sector problem-solving (Martsolf et al., 2018; Murray-García et al., 2021). Local health department leaders who are actively present in the community and committed to fostering partnerships are key to an organizational ethos in which community engagement is a strategic objective rather than a discrete activity (Schoch-Spana et al., 2018c). Some jurisdictions, such as Kent County, Michigan, and Kentucky local health departments, have long-standing cultural competency policies and resources that are utilized when working with communities and coalitions (Kent County Connect, 2024; Robinson et al., 2021). Other programs have created centralized leadership training programs. For example, the Community Scientists Program, part of the New Jersey Alliance for Clinical and Translational Science²¹ at Rutgers University, actively invested in building the capacity of community partners by providing leadership training experience to people involved in public health organizations.

Create Feedback Loops

Use dashboards, listening sessions, or scorecards to ensure that community input is heard and acted upon. As with all partnerships, collaboration with communities is sustained by mutual accountability

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and continuous responsiveness. Experience with community-based organizations underscores that public health involvement is strengthened when health departments welcome feedback and explain their decisions openly (SteelFisher et al., 2024). Feedback loops, whether through community scorecards, community-facing dashboards, social media monitoring, or listening sessions, ensure that evolving concerns and unmet needs are identified and addressed in real time. In one example, feedback from community-based organizations led to changes in the tone and timing of health messages to better reflect community schedules, literacy levels, and concerns about stigmatization (SteelFisher et al., 2024). In Alameda County, California, a public health scorecard improved transparency and guided continual program enhancement.²² In Lubbock, Texas, listening sessions shaped health departments’ understanding of local needs and informed messaging strategies (Lubbock Public Health & Initium Health, 2024).

Plan for the Long Term

Secure agreements, recurring funding, and preparedness activities sustain collaboration beyond a single emergency. Communicating through brand-new and short-term relationships rarely fosters trust or community participation. Public health agencies need to cultivate long-term partnerships with community-based organizations that extend beyond a single emergency. These relationships can be formalized through memorandums of understanding, recurring funding streams, or joint participation in ongoing preparedness initiatives (Schoch-Spana et al., 2018a, 2021; Wolf-Fordham, 2020). Where possible, align these efforts with existing structures—such as Public Health Accreditation Board (PHAB, 2022) accreditation requirements to maintain state health improvement plans—so collaboration and communication networks are embedded in routine planning, not just crisis response. Ongoing collaboration also counters the “boom and bust” cycles of public health funding, which leave communities at risk when the next crisis arises (SteelFisher et al., 2024). Some examples include the NOLA Ready Volunteer Corps²³ in New Orleans, a preparedness system that remains active year-round, not just during crises, reinforcing community trust and readiness. Similarly, New Hampshire’s regional public health networks, funded and coordinated through continued agreements with state and federal agencies, ensure that municipalities, health care providers, schools, and community groups maintain readiness and alignment over time.²⁴ North Carolina offers a related model: a standing community council convened around state health improvement plan priorities that, during events such as Hurricane Helene, surfaced local concerns and cascaded health information through trusted channels, illustrating how anchoring partnerships in existing governance can accelerate emergency communication.²⁵

GUIDING PRINCIPLES FOR ENABLING EFFECTIVE PARTNERSHIPS

While potential types of collaborations for public health communication vary widely, certain common factors support their effectiveness and sustainability across this diversity. The following guiding principles, based on research and practical experience, can help establish collaborations that provide lasting and successful support for public health communication.

• Create the right conditions: Effective collaborations depend on making the effort to understand partners and their diverse needs. Research shows that strong partnerships depend on integrative capacity, which includes shared mental models—common understandings of goals, roles, and processes that enable partners to anticipate each other’s actions and coordinate effectively—along with coordination processes and

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relationship-building practices developed over time (Im et al., 2023; NASEM, 2025).

Communities are made up of many groups with different perspectives and priorities, often shaped by mistrust (Stout et al., 2019). Building trust requires institutions and funders to understand their contexts well enough to create the right mix of support and structure, including shared goals, clear roles, adequate resources, cultural competence, and leadership that champions collaboration (Schoch-Spana et al., 2018b, 2018c).

• Build before and stay after: Collaborations are most effective when relationships, outreach, and coplanning happen before a crisis occurs, and when those relationships are maintained afterwards. An analysis of interviews with local health department staff identified preexisting relationships with community messengers—and the logistical supports provided to them, such as materials, stipends, and technical assistance—as key factors that appeared to support faster and more consistent message dissemination (SteelFisher et al., 2024). Complementary network-level analyses, such as Bevc et al. (2015), describe how interorganizational ties are structured and where collaboration gaps may exist. These social network studies are primarily descriptive, providing insight into partnership configurations rather than experimental evidence of effectiveness. Taken together, these qualitative and network approaches highlight promising avenues for further, system-level research on how communication networks influence preparedness and trust. After a crisis, it is critical not to dismantle partnerships but to continue to invest in them to improve community health and well-being (Schoch-Spana et al., 2021). Unlike short-term task forces, these partnerships are ongoing and typically anchored in broader community priorities—such as health equity, chronic disease prevention, or local economic development—that can pivot toward emergency response when needed. By connecting preparedness teams with those already engaged in core public health and community initiatives, agencies can “de-silo” preparedness work and sustain relationships that make response more coordinated and trusted (NASEM, 2023a; PHAB, 2022).
• Promote fairness in practices: Achieving sustainable results requires a consistent commitment to fairness across funding, leadership, and evaluation. It also involves compensating organizations or individuals for their time and expertise, providing visible credit through cobranding or acknowledgments, and including partners as speakers or coauthors in public or professional forums. These actions demonstrate respect for shared ownership and accountability, reinforcing the authenticity of partnerships (NASEM, 2023a; Plough, 2013). Promoting health for all means ensuring that the approach to communication takes into account disparities rooted in the social determinants of health and the policies that created them (Yearby, 2020). This is not easy in emergencies. In practice, promoting health for all involves aligning incentives and grants with approaches that broaden participation. Ensure that resources, decision-making, and credit are shared; are supported by flexible funding; and employ coordinated mechanisms for accountability and evaluation (Klepac et al., 2025; NASEM, 2025). Framing these goals as fairness and inclusion may aid in their being readily adopted across a wide range of organizational and political contexts.
• Work with communities, not just for them: Sustainable partnerships are built by intentionally involving communities in decision-making. Research on community–academic partnerships has found that sustainable collaboration depends on intentionally involving communities in decision-making, valuing local expertise, addressing barriers to the collaboration, and embedding culturally aware practices (Jagosh et al., 2015; Pandya et al., 2025).
• Lead with humility and respect: Trusting exchanges are built when partnerships embrace intellectual humility and ongoing reflection and adapt strategies to community needs and contexts (Lansing et al., 2023; Naumova, 2023). Relational approaches, such as

community-based participatory research, reinforce empowerment through iterative processes, colearning, and shared decision-making across different scales (Hoerger et al., 2023; Redvers et al., 2024).

• Stay flexible and adaptive: Conditions will inevitably change; a strong collaboration is made up of partners who are able to acknowledge uncertainty, recognize changes when they occur, and be flexible enough to adjust as needed (Naumova, 2023). Implementation science frameworks offer tools for assessing the reach and fidelity of communication strategies, enabling public health practitioners to refine their messaging in real time and adjust interventions across cultural, political, and geographic contexts (NASEM, 2025; Schoch-Spana et al., 2018a). Frameworks also exist for guiding assessment and improvement of partnerships (Brinkerhoff, 2002; NACCHO, 2021).

Key Questions to Inform Future Policy and Research

Evidence to date demonstrates that trusted relationships, sustained collaboration, and consistent communication are critical to effective emergency response. Most available studies are qualitative, descriptive, or case-based, offering valuable insights into how partnerships work. Less evidence is available on the extent to which these efforts achieved the desired communications outcomes at the level of systems and communities. To strengthen the evidence base and inform future policy, several key questions emerge:

• Effectiveness and Outcomes
  • How do different collaboration models (e.g., standing community networks, business councils, academic partnerships) influence response speed, message reach, and community outcomes during emergencies?
  • Which specific practices—such as compensating community messengers, using preapproved templates, or cobranding materials—produce measurable improvements in communication effectiveness?
• Equity and Reach
  • How do collaboration structures affect trust and participation among historically marginalized, rural, or politically diverse communities?
  • What mechanisms help ensure that benefits of communication partnerships are distributed equitably across populations?
• Sustainability and Resources
  • What funding and governance models best sustain cross-sector partnerships between emergencies?
  • How can accreditation and planning processes (e.g., PHAB, state or community health improvement plans) be leveraged to maintain communication capacity and readiness over time?
• Measurement and Data
  • What metrics and data systems are needed to evaluate partnership performance and communication outcomes at the system level?
  • How can qualitative and network-based insights be integrated with quantitative outcome measures to assess long-term impact?
• Learning and Adaptation

• What processes allow health departments and community-based organizations to document, share, and institutionalize lessons from communication successes and failures?
• How can ongoing evaluation be embedded into preparedness funding streams and partnership agreements?

Addressing these questions would advance both the evidence base and the policy infrastructure necessary to sustain equitable, trusted, and effective communication partnerships (Bevc et al., 2015; Brownson et al., 2018; NASEM, 2023a; SteelFisher et al., 2024).

CONCLUSION

Sustaining effective public health communication needs to engage diverse audiences, in which no single organization or decision-maker is likely to be credible on their own. This is why investment in collaborations to design and implement communication is needed. Collaboration across government agencies, community-based organizations, universities, and private entities—which can be informal and/or more formal—is an essential path forward for avoiding fragmentation and closing gaps in communication and trust. Collaboration for public health communication works best when both operational and relational dimensions are supported by policies and funding that help sustain them beyond a single crisis.

The principles and strategies outlined in this consultation offer a path forward. Following these principles and strategies can establish relationships and trust between collaborative partners, build capacity, and ultimately create and implement communication systems that are responsive and viewed as credible in the face of future emergencies. Mechanisms to demonstrate their value across times of shifting priorities are essential to prevent disinvestment. Strengthening collaboration is the cornerstone of preparing to successfully communicate in the face of public health emergencies.

SEAN is interested in your feedback. Was this rapid expert consultation useful? Send comments to sean@nas.edu or (202) 334-3440.