Over the course of March 2020, the everyday life of most people changed from normal
to extraordinary around the globe. By the beginning of March, there had been serious
outbreaks of COVID-19 in a limited number of countries, such as China, South Korea,
Iran and Italy, while many others experienced a lull before the storm. People in unaffected
countries understood that the Corona SARS CoV-2 virus might reach their shores at
one point; the question was when and how hard it would hit. By the end of March, many
governments had ordered drastic measures. Schools and university campuses were shut
down. Shops, restaurants and companies were closed. People in many different jobs
were asked to work from home, and many were in quarantines.
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A massive flow of health information
The scale of the crisis and governments’ responses have been matched by a colossal
flow of information about COVID-19 in terms of 24/7 news coverage, televised press
conferences provided by both political leaders and health authorities, prime time
speeches to the people by kings, presidents, prime ministers and religious leaders,
as well as news analyses, debates and social media posts. This massive flow of health
information and viewpoints on the pandemic is unprecedented and varied. While young
people prefer information through social media such as Instagram or YouTube, older
adults are generally informed through national evening television and newspapers.
Migrants and refugees may be more effectively reached by migrant community leaders
and news sources from their countries of origin.
As the pandemic has developed, the need to provide clear, honest and valid information
to the public all over the world has become obvious, as expressed in a February editorial
in the Lancet, concluding that "There may be no way to prevent a COVID-19 pandemic
in this globalised time, but verified information is the most effective prevention
against the disease of panic" [1].
Political leaders and health experts have a special responsibility to provide us with
accurate information, and to implement measures that require behavior change to fight
the pandemic. However, in the near chaotic flow of information, each and every one
of us, in different roles and with different responsibilities, may contribute to improve
the flow of information and debate on COVID-19.
Health communication is a key and necessary factor in saving lives during the COVID-19
pandemic crisis. Accurate and well-developed health communication can facilitate how
societies handle uncertainty and fear, promote and accomplish adherence to necessary
behavior change, and meet individuals’ fear and foster hope in the face of a crisis.
Professionals in the fields of health communication, patient education, and health
behavior change have a special responsibility to contribute to the spread of concise
and valid information in different contexts.
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How to handle uncertainty and fear
COVID-19 is scary for many reasons. The two foremost grounds for this high rate of
fear and anxiety are how contagious and lethal this pandemic appears to be, especially
for older people [2]. The fact that the virus involves a symptom-free incubation period
of on average almost a week for the majority of those infected [3], in which contagiousness
is maybe most prominent, increases the notion that this is an invisible enemy, inducing
a feeling of losing control over ones’ lives. Consequently, both leaders and clinicians
face the difficult task of making people feel safe with uncertainty.
Uncertainty about COVID-19 and its spread is an obvious challenge for health communicators
giving information about this condition. We simply have limited experience and knowledge,
and not just about contagiousness and lethality. We know too little about the mutation
rate of the virus, if herd immunity will develop and how much that will protect us,
whether a vaccine will be efficient, and not the least, why the course of the disease
seems to vary so much, dependent on age and frailty. Furthermore, the consequences
of a societal lock down are likely disastrous for many people. The way from uncertainty
to panic may be brief.
Communication under such conditions is demanding. We will suggest four elements that
are particularly important in determining how to communicate health information to
the public effectively.
First, it is important to declare openly and honestly what is known and what is unknown
and to stick to the facts as much as possible [4]. We must also acknowledge the temporality
of ‘facts’ as a work in progress. What data we have today will be updated and perhaps
modified given new evidence related to the disease and its management. We also need
to confirm accurate sources of this information. Given how rapidly things are changing,
it is important to be clear that when recommendations change, this is based on new,
previously unknown evidence.
Second, information should be consistent and specific. Even if we acknowledge that
there is much we do not know, it is important not to get stuck in vagueness. Research
on severe diseases has shown that illness uncertainty, a patient’s inability to determine
the meaning of illness-related events, can be a result of ambiguity (conflicting,
incomplete, or inadequate information); complexity (difficult to understand information);
and unpredictability (likelihood or risk of future outcome of the disease) [[5], [6]].
Thus, it is important to provide information in clear, specific, unambiguous, and
consistent lay language. Beyond keeping the messages consistent and specific, also
the number of spokespersons should be limited and consistent.
Third, we suggest that it is important to demonstrate ability to make decisions in
a situation characterized by uncertainty, with confidence (signaling ability to feel
safe in the situation) and honesty (that the decision might prove wrong). From a health
communication perspective, part of this leadership might be to publically acknowledge
and praise those politicians, scientists, and health care providers at the front line
working to solve immediate problems for the benefit of all.
Fourth, we should acknowledge emotions. Uncertainty in illness has been associated
with anxiety, depression and distress [3,7,8], all of which can result in panic and
passivity, rather than the community working together to change behavior in ways that
will reduce the COVID-19 risk. Information should therefore be empathic, by demonstrating
concern and by acknowledge the impact of the situation for the individual and their
lives, and not by being aloof or too factual [9,10]. Clinicians will know that this
is a challenging task, often helped by reciprocal trust.
Fear is a natural response in the face of the pandemic. Fear does not go away by being
ignored. Rather the opposite, fear is easier to handle when it is acknowledged [11].
Petersen has coined a term, “optimistic anxiety”, suggesting that “citizens must be
anxious enough to take the advice from the authorities to heart and optimistic enough
as to feel that their actions make a difference” [12].
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How to promote behavior change: lessons from health communication research
To reduce the risk of COVID-19 in the community, it is critical that we pay attention
to optimal methods to ensure behavior change, both on the individual as well as on
the community level. How recommendations are framed is important to secure adherence.
We know from research on previous pandemics that official recommendations are met
with skepticism by many [13].
The relevant behavior changes to fight the pandemic are well known by now: Wash your
hands regularly! Cough in a tissue or in your elbow! Keep distance - Social distancing!
Clean surfaces! Do not touch your face! The messages are simple, but are not necessarily
simple to implement for all. Even if everybody had the correct and the same information,
behavior change would still be a challenge. Many of these recommendations require
changing subconsciously deployed behavioral routines. This will require communication
raising to awareness actions that are mindlessly habitual. As we all know, the way
from knowing to doing is not easy; the intention-behavior gap has been well documented.
Knowing is not the same as doing.
In the last few weeks, a number of papers and websites have been produced, which may
serve as helpful resources for everyone engaged in health communication [10,[14],
[15], [16], [17]]. We will briefly mention four recommendations regarding behavior
change.
First, Michie and colleagues have suggested the usefulness of creating a mental model
about how contamination works and how this can be prevented [16]. The better inner
picture you have of how the virus gets into the environment and is then inhaled, the
better you understand and remember how its route to transmission may be blocked. While
much of the general public has a mental model of COVID-19 as a scary and disruptive
disease, other sectors of a population may not share that sense of urgency and thus
may ignore behaviors, such as social distancing, that can help stop the spread. Another
obvious challenge here is that the mental model of experts is not even yet settled,
as we learn more and more along the way and need to wait for reliable evidence to
be collected and shared.
Second, behavior change requires not only verbal recommendations, but also real interventions
in the environment and even legislation. Lunn et al. point out that it is not enough
to advise individuals to wash hands and cough in the elbow. It is just as important
to change the environment in a way that facilitates the new behavior, in this case
for instance by placing alcohol-based hand sanitizer (AHS) in highly visible locations
[10]. Moreover, it is important not only to say “Don’t!”, but rather to replace one
behavior with another and make the behavior easy, for instance by building it into
existing behavioral routines. The norm of not shaking hands as part of social distancing
e.g., may lead to awkward, uncomfortable situations as we have to change routines.
Demonstrations on TV by role models of touching elbows or a Japanese style bow or
nod of the head are examples of suggesting an easy, alternative behavior for shaking
hand. This will increase self-efficacy, which is an important determinant of behavior
change. Restrictive legislation may also be required. It is interesting to see that
the road of restrictive legislation is increasingly being used to promote health behavior
change. This route is observed in recent years in the prevention of smoking and also
now used in many countries to reinforce adherence to social distancing.
Third, even if citizens are more isolated than ever, in more or less self-imposed
quarantines, appeals to collective action and a spirit of we-are-in-it-together are
very important to flatten the curve and reduce the rate of infection [10]. The attitude
and behavior of leaders at all levels are important. For instance, in Norway politicians
appeal to the Norwegian tradition of “dugnad”, a word for joint action on family or
community level. In several countries politicians and heads of state have given national
speeches acknowledging how the pandemic creates fear, and with appeals to solidarity
and shared responsibilities. A demonstration of concern from role models may have
a role in persuading the public to adhere to recommendations.
Fourth, maintaining behavior change over time, including washing hands, maintain social
distance, sneezing into one’s elbow and not touching one’s face are important, in
particular when restrictions have lasted for several weeks or even months [[18], [19],
[20]]. It is important to acknowledge that transition of initiation of behavior to
maintenance requires a change in the self-regulation of the behavior. Behavior initiation
requires intentional behavior planning whereas maintenance becomes more habitual and
requires less self-regulation. Self-efficacy is relevant in the motivational phase
of behavior, when behavior intentions are being formulated. To initiate a new health
behavior, individuals must be confident in their ability and skills to perform that
behavior (action self-efficacy). To maintain behavior, individuals must be repetitive
in their performance of the desired behaviors and confident in their ability to overcome
barriers in order to continue that behavior (maintenance self-efficacy).
4
Challenges for the clinician
A final important area for implementation of health communication in the COVID-19
crisis is to consider the challenges clinicians face in clinical encounters with patients
whether in person or to an increasing extent virtual encounters. Net-based manuals
have been developed, for instance by VitalTalk [21] and the Association for Palliative
Medicine of Great Britain and Ireland [22]. These web sites are valuable resources
for clinicians on how to tailor communication skills to the needs of patients with
COVID-19.
Important decisions are to be made with the patient and the family about the pros
and cons of staying at the ICU and its impact on the quality of life in the long run.
Serious infections with COVID-19 require a long stay at the ICU with mechanical ventilation
which is highly invasive. For some patients, the physical impact both of the disease
itself and invasive treatment can be huge. A study by Udelsman et al. among older,
higher-risk patients presenting for elective procedures showed that most patients
chose limitations to life-sustaining treatments [23]. This finding highlights the
need for in-depth goals of care discussion and establishment of advance care preferences
before any procedure or operative intervention, preferable even before one is affected
with COVID-19.
We also need to acknowledge the mental health effects of extended social isolation
for many vulnerable individuals [18,19,24]. For example, social isolation is one of
the most important contributors to all-cause mortality in older adults. On the one
hand, if we are unable to decrease the rate of progression of the pandemic (“flatten
the curve”), the healthcare system will become overwhelmed, and older adults are those
at greatest risk for death from the direct effects of infection. Yet, on the other
hand, social isolation puts older adults at risk for mental and physical adverse effects.
The current COVID-19 crisis is a unique situation. Not in the history of mankind has
a widespread pandemic been met with such extensive and invasive action from political
authorities and the healthcare community. However, the communication around the measures
taken can be improved in many cases. The academic fields we discussed here offer many
important insights for anybody with a need to advise leaders or communicate directly
with their local communities or the public at large.
A situation like this requires a broad, interdisciplinary response from the research
community [25]. Professionals in the fields of communication, education, and health
behavior change need to take responsibility for carefully evaluating what is known
and insights currently emerging. We are in a position to use their expertise to counsel
others to adjust their strategies to fit the new and largely unknown situation, and
heeding the call to action can play a significant part in guiding our societies through
these challenging times. Effective health communication is a key factor in fighting
the COVID-19 pandemic.