Health communication in and out of public health emergencies: to persuade or to inform?

A scoping review of behavioural science approaches and frameworks for health protection and emergency response

AIMS

Rapid intervention development, implementation, and evaluation are required for emergency public health contexts, such as the recent COVID-19 pandemic. A novel Agile Co-production and Evaluation (ACE) framework has been developed to assist this endeavour in future public health emergencies. This scoping review aimed to map available behavioural science resources that can be used to develop and evaluate public health guidance, messaging, and interventions in emergency contexts onto components of ACE: rapid development and implementation, co-production with patients or the public including seldom heard voices from diverse communities, and inclusion of evaluation.

METHODS

A scoping review methodology was used. Searches were run on MEDLINE, EMBASE, PsycINFO, and Google, with search terms covering emergency response and behavioural science. Articles published since 2014 and which discussed a framework or guidance for using behavioural science in response to a public health emergency were included. A narrative synthesis was conducted.

RESULTS

Seventeen records were included in the synthesis. The records covered a range of emergency contexts, the most frequent of which were COVID-19 (n = 7) and non-specific emergencies (n = 4). One record evaluated existing approaches, 6 proposed new approaches, and 10 described existing approaches. Commonly used approaches included the Behavioural Change Wheel; Capability, Opportunity, and Motivation Behaviour model; and social identity theory. Three records discuss co-production with the target audience and consideration of diverse populations. Four records incorporate rapid testing, evaluation, or validation methods. Six records state that their approaches are designed to be implemented rapidly. No records cover all components of ACE.

CONCLUSION

We recommend that future research explores how to create guidance involving rapid implementation, co-production with patients or the public including seldom heard voices from diverse communities, and evaluation.

Reimagining Public Health: Mapping A Path Forward

The COVID-19 pandemic and other ongoing public health challenges have highlighted deficiencies in the US public health system. The United States is in a unique moment that calls for a transformation that builds on Public Health 3.0 and its focus on social determinants of health and partnerships with diverse sectors while also acknowledging how the pandemic altered the landscape for public health. Based on relevant literature, our experience, and interviews with public health leaders, we describe seven areas of focus within three broad categories to support transformational change. Contextual areas of focus include increasing accountability and addressing politicization and polarization. Topical areas of focus highlight prioritizing climate change and sharpening the focus on equity. Technical areas of focus include advancing data sciences, building the workforce, and enhancing communication capacity. A transformed public health system will depend highly on leadership, funding incentives, and both bottom-up and top-down approaches. A broad effort is needed by public health agencies, governments, and academia to accelerate the transition to a next phase for public health.

Moral obligation, autonomous motivation and vaccine hesitancy: Highlighting moral obligation increases reactance in hesitant individuals

Vaccine hesitancy is widespread, and developing effective communication strategies that encourage hesitant individuals to choose vaccination is essential. This pre-registered research aimed to examine associations among moral obligation, autonomous motivation, vaccination intentions and reactance, and to test messages highlighting moral obligation and autonomy support. In Study 1, participants who had not received a Covid-19 vaccine (N = 1036) completed measures of autonomous motivation, moral obligation, reactance, intentions to vaccinate and vaccine hesitancy. Autonomous motivation and moral obligation emerged as strong independent predictors of lower reactance, lower hesitancy and greater vaccination intentions. In Study 2 (N = 429), the participants received a vaccination-promoting message that highlighted moral obligation versus personal protection and used autonomy supportive versus controlling language. Messages with autonomy-supportive language and highlighting personal protection elicited lower reactance and greater perceived legitimacy compared to messages with controlling language and highlighting moral obligation. All messages elicited greater reactance and lower perceived legitimacy compared to an information-only message, and there were no effects of message type on vaccination intentions or vaccine hesitancy. The research has implications for the design of communications encouraging vaccination in hesitant individuals and suggests caution should be taken when developing messages to encourage vaccination in hesitant individuals.

Improving COVID-19 vaccine uptake: a message co-design process for a national mHealth intervention in Colombia

BACKGROUND

COVID-19 vaccination is a global priority. Latin American countries have some of the highest COVID-19 death rates worldwide with vaccination hampered by a variety of reasons, including mis- and disinformation, vaccine hesitancy, and vaccine supply constraints. Addressing vaccine hesitancy through effective messages has been found to help increase vaccine uptake. Participatory processes could be used to co-design health messages for this purpose.

OBJECTIVE

This article describes the methodology used to co-design evidence-based audio messages to be deployed in a cohort of individuals through an interactive voice response (IVR) mobile phone survey intervention, aimed towards increasing vaccination uptake in an adult population in Colombia.

METHODS

Participants of the COVID-19 vaccination message co-design process included a sample of the general population of the country, representatives of the funder organisation, and research team members. The co-design process consisted of four phases: (1) formative quantitative and qualitative research, (2) message drafting based on the results of the formative research, (3) message content evaluation, and (4) evaluation of the voices to deliver the audio messages; and was informed by reflexive meetings.

RESULTS

Three categories of evidence-based audio messages were co-designed, each corresponding to an arm of the mHealth intervention: (1) factual messages, (2) narrative messages, and (3) mixed messages. An additional fourth arm with no message was proposed for control. The iterative co-design process ended with a total of 14 audio messages recorded to be deployed via the intervention.

CONCLUSIONS

Co-developing health messages in response to health emergencies is possible. Adopting more context-relevant, participatory, people-centred, and reflexive multidisciplinary approaches could help develop solutions that are more responsive to the needs of populations and public health priorities. Investing resources in message co-design is deemed to have a greater potential for influencing behaviours and improving health outcomes.

Rural adults' perceptions of nutrition recommendations for cancer prevention: Contradictory and conflicting messages

Despite robust evidence linking alcohol, processed meat, and red meat to colorectal cancer (CRC), public awareness of nutrition recommendations for CRC prevention is low. Marginalized populations, including those in rural areas, experience high CRC burden and may benefit from culturally tailored health information technologies. This study explored perceptions of web-based health messages iteratively in focus groups and interviews with 48 adults as part of a CRC prevention intervention. We analyzed transcripts for message perceptions and identified three main themes with subthemes: (1) Contradictory recommendations, between the intervention's nutrition risk messages and recommendations for other health conditions, from other sources, or based on cultural or personal diets; (2) reactions to nutrition risk messages, ranging from aversion (e.g., "avoid alcohol" considered "preachy") to appreciation, with suggestions for improving messages; and (3) information gaps. We discuss these themes, translational impact, and considerations for future research and communication strategies for delivering web-based cancer prevention messages.

Overview of the Health Communication Curriculum in Canadian Master of Public Health Programs

CONTEXT

Competency-based public health education ensures practitioners are well equipped to positively influence the health of the public. The Public Health Agency of Canada's Core Competencies for Public Health has named communication as an essential competency area for practitioners. However, little is known about how Master of Public Health (MPH) programs in Canada support trainees in developing the recommended core competencies in communication.

OBJECTIVE

Our research aims to provide an overview of the extent to which communication is embedded in the curriculum of MPH programs in Canada.

DESIGN

We conducted an online scan of Canadian MPH course titles and descriptions to determine how many MPH programs offer communication-focused courses (ie, health communication), knowledge mobilization courses (eg, knowledge translation), and other courses that may support communication skills. Two researchers coded the data; discrepancies were resolved via discussion.

RESULTS

Of the 19 MPH programs in Canada, less than half (n = 9) offer courses specifically focused on communication (ie, health communication); these courses are mandatory in only 4 programs. Seven programs offer knowledge mobilization courses; none are mandatory. Sixteen MPH programs offer a total of 63 other public health courses that are not focused on communication but contain communication terms (eg, marketing, literacy) in their course descriptions. No Canadian MPH program has a communication-focused stream or option.

CONCLUSION

Canadian-trained MPH graduates may not be receiving sufficient communication training to equip them for effective and precise public health practice. This is particularly concerning, given that current events have underlined the importance of health, risk, and crisis communication.

Assessing the Effect of Nonvisual Information Factors in Pandemic-Related Video Communication: Randomized Controlled Between-Subjects Experiment

BACKGROUND

Videos have been an important medium for providing health and risk communication to the public during the COVID-19 pandemic. Public health officials, health care professionals, and policy makers have used videos to communicate pandemic-related content to large parts of the population. Evidence regarding the outcomes of such communication, along with their determinants, is however limited.

OBJECTIVE

The aim of this study was to test the impact of nonvisual information factors of video communication on 4 outcomes: trust, comprehension, intentions, and behavior.

METHODS

Twelve short health communication videos related to pandemics were produced and shown to a large sample of participants, applying a randomized controlled between-subjects design. Three factors were included in the creation of the videos: the topic (exponential growth, handwashing, and burden of pandemics on the health care system), the source (expert and nonexpert), and a call to action (present or absent). Participants were randomly assigned to 1 video intervention, and 1194 valid replies were collected. The data were analyzed using factorial ANOVA.

RESULTS

The 3 pandemic-related topics did not affect trust, comprehension, intentions, or behavior. Trust was positively influenced by an expert source (2.5%), whereas a nonexpert source instead had a positive effect on the proxy for behavior (5.7%) compared with the expert source. The inclusion of a call to action had a positive effect on both trust (4.1%) and comprehension (15%).

CONCLUSIONS

Trust and comprehension in pandemic-related video communication can be enhanced by using expert sources and by including a call to action, irrespective of the topic being communicated. Intentions and behavior appear to be affected to a small extent by the 3 factors tested in this study.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/34275.

Impact of intensive adherence counseling on viral load suppression and mortality among people living with HIV in Kampala, Uganda: A regression discontinuity design

Intensive adherence counseling (IAC) is recommended for people living with HIV (PLHIV) with viral load (VL) ≥1,000 copies/ml after ≥6 months of anti-retroviral therapy (ART). We evaluated the effect of IAC on VL suppression and all-cause mortality among PLHIV on first-line ART with VL ≥1,000 copies/ml after ≥6 months of ART in Kampala, Uganda using regression discontinuity design, a quasi-experimental method for effect estimation when interventions depend on a cut-off. PLHIV just above VL ≥1,000 copies/ml cut-off who received ≥3 IAC sessions formed the intervention group while those just below the cut-off who received routine psychosocial support constituted the control group. Primary outcome was repeat VL suppression defined as VL <1,000 copies/ml approximately 9-12 months following initial VL assessment. Secondary outcome was all-cause mortality. We used logistic regression for causal-effect analysis, reported as odds ratio (OR) with a 95% confidence interval (CI). We performed sensitivity analyses to assess the robustness of findings to varying bandwidths at the cut-off. We found 3,735 PLHIV were started on ART between Nov 2020 and Nov 2021 of whom 3,199 were included in the analysis (3,085 control, 114 intervention). Within an optimal bandwidth, there were 236 participants (222 control, 14 intervention) with similar demographic and clinical characteristics. Repeat VL suppression was lower in the intervention than in the control group (85.7% versus 98.6%, p = 0.021) while all-cause mortality was similar (0% versus 0.5%, p = 1.000). In multivariable analysis, the odds of repeat VL suppression were 91% lower in the intervention than control group (OR = 0.09; 95% CI, 0.01-0.66). Findings are robust to varying bandwidths around the cut-off. We concluded IAC is ineffective in suppressing VL among PLHIV on first-line ART in Kampala, Uganda. Findings suggest a need to investigate the IAC implementation fidelity for successful translation in practice and the reasons for VL persistence beyond the suppression threshold.

Essential Skills for Health Communication, Barriers, Facilitators and the Need for Training: Perceptions of Healthcare Professionals from Seven European Countries

Many healthcare professionals are unaware of the necessary skills and barriers hindering interpersonal health communication. This study aimed to evaluate the healthcare professional's perception regarding health communication training's necessity, barriers, facilitators and critical skills in health communication. Data from a cross-sectional online survey in the framework of the H-Com project were utilized. The study included 691 healthcare professionals (physicians, nurses, students and allied health professionals) from seven European countries. Only 57% of participants had participated in health communication training, while 88.1% of them indicated a willingness to be trained in health communication. Nurses were more likely (OR = 1.84; 95% CI 1.16, 2.91) to have received such training, compared to physicians. Most examined communication skills, barriers and facilitators of effective communication, and perceived outcomes of successful communication were considered crucial for most participants, although physicians overall seemed to be less concerned. Most agreed perceived outcomes were improved professional-patient relations, patient and professional satisfaction, physical and psychological health amelioration and patients' trust. Nurses evaluated the importance of these communication skills and communication barriers, facilitators and outcomes higher than physicians. Physicians may underestimate the importance of communication skills more than nurses. Health communication should become an integral part of training for all health professionals.

Paternalistic persuasion: are doctors paternalistic when persuading patients, and how does persuasion differ from convincing and recommending?

In contemporary paternalism literature, persuasion is commonly not considered paternalistic. Moreover, paternalism is typically understood to be problematic either because it is seen as coercive, or because of the insult of the paternalist considering herself superior. In this paper, I argue that doctors who persuade patients act paternalistically. Specifically, I argue that trying to persuade a patient (here understood as aiming for the patient to consent to a certain treatment, although he prefers not to) should be differentiated from trying to convince him (here understood as aiming for the patient to want the treatment) and recommending (the doctor merely providing her professional opinion). These three forms of influence are illustrated by summaries of video-recorded hospital encounters. While convincing and recommending are generally not paternalistic, I argue that persuasion is what I call communicative paternalism and that it is problematic for two reasons. First, the patient's preferences are dismissed as unimportant. Second, the patient might wind up undergoing treatment against his preferences. This does not mean that persuasion always should be avoided, but it should not be undertaken lightly, and doctors should be aware of the fine line between non-paternalism and paternalism. The fact that my analysis of paternalism differs from traditional accounts does not imply that I deem these to be wrong, but rather that paternalism should be considered as a more multi-faceted concept than previous accounts allow for.

Determinants of COVID Vaccination Willingness among Health and Non-Health Studies Students: A Cross-Sectional Study

Students, as a relatively health-informed population group, may still have limitations in health literacy, which is a concern as students take increasing responsibility for their health and make independent health decisions. The aim of this study was to evaluate the overall attitudes towards COVID vaccination among university students and to investigate various factors contributing to vaccination willingness among health and non-health studies students. A total of 752 students from the University of Split were included in this cross-sectional study and completed a questionnaire that consisted of three sections: socio-demographic data, health status information, and information on vaccination against COVID-19. Results show that the majority of students of health and natural sciences were willing to be vaccinated, but the majority of students of social sciences were not (p < 0.001). Students who used credible sources of information had a more significant proportion of those willing to be vaccinated and the majority of students who used less credible sources (79%) or did not think about it (68.8%) were unwilling to be vaccinated (p < 0.001). Multiple binary logistic regression modeling shows that female gender, younger age, studying social sciences, negative opinion about the need to reintroduce lockdown and the effectiveness of epidemiological measures, and usage of less credible sources of information were the most important factors contributing to increased vaccination hesitancy. Therefore, improving health literacy and restoring trust in relevant institutions can be critical in health promotion and COVID-19 prevention.

Public Engagement with Romanian Government Social Media Accounts during the COVID-19 Pandemic

Following international best practice examples, the Romanian government resorted to its social media accounts to disseminate information and unfold an awareness and persuasion campaign to fight the COVID-19 pandemic. The article focuses on the use of the government's YouTube and Facebook accounts to persuade the population to get vaccinated in 2021 via video messages tailored for this purpose. The research quantified the volume of public engagement with the two waves of the persuasive campaign, finding that, while click-based reactions tended to show a positive attitude toward the campaign, the comments mainly denoted frustration, anger, and anxiety on the part of the public. Moreover, the citizens' engagement with the campaign messages was by far lower than the number of subscribers and followers of the analyzed social media accounts. The goal of the COVID-19 public health persuasion campaign was to build support for the governmental policy and minimize the risks of the pandemic while vaccination was being rolled out. The public reaction to the governmental campaign showed that a finer and more adapted approach was necessary. This study offers a qualitative basis for informing health communication strategies of the challenges posed by social media platforms used in crisis times.

Digital dashboards visualizing public health data: a systematic review

Introduction

Public health is not only threatened by diseases, pandemics, or epidemics. It is also challenged by deficits in the communication of health information. The current COVID-19 pandemic demonstrates that impressively. One way to deliver scientific data such as epidemiological findings and forecasts on disease spread are dashboards. Considering the current relevance of dashboards for public risk and crisis communication, this systematic review examines the state of research on dashboards in the context of public health risks and diseases.

Method

Nine electronic databases where searched for peer-reviewed journal articles and conference proceedings. Included articles (n = 65) were screened and assessed by three independent reviewers. Through a methodological informed differentiation between descriptive studies and user studies, the review also assessed the quality of included user studies (n = 18) by use of the Mixed Methods Appraisal Tool (MMAT).

Results

65 articles were assessed in regards to the public health issues addressed by the respective dashboards, as well as the data sources, functions and information visualizations employed by the different dashboards. Furthermore, the literature review sheds light on public health challenges and objectives and analyzes the extent to which user needs play a role in the development and evaluation of a dashboard. Overall, the literature review shows that studies that do not only describe the construction of a specific dashboard, but also evaluate its content in terms of different risk communication models or constructs (e.g., risk perception or health literacy) are comparatively rare. Furthermore, while some of the studies evaluate usability and corresponding metrics from the perspective of potential users, many of the studies are limited to a purely functionalistic evaluation of the dashboard by the respective development teams.

Conclusion

The results suggest that applied research on public health intervention tools like dashboards would gain in complexity through a theory-based integration of user-specific risk information needs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=200178, identifier: CRD42020200178.

Transparent communication of evidence does not undermine public trust in evidence

Does clear and transparent communication of risks, benefits, and uncertainties increase or undermine public trust in scientific information that people use to guide their decision-making? We examined the impact of reframing messages written in traditional persuasive style to align instead with recent "evidence communication" principles, aiming to inform decision-making: communicating a balance of risks and benefits, disclosing uncertainties and evidence quality, and prebunking misperceptions. In two pre-registered experiments, UK participants read either a persuasive message or a balanced and informative message adhering to evidence communication recommendations about COVID-19 vaccines (Study 1) or nuclear power plants (Study 2). We find that balanced messages are either perceived as trustworthy as persuasive messages (Study 1), or more so (Study 2). However, we note a moderating role of prior beliefs such that balanced messages were consistently perceived as more trustworthy among those with negative or neutral prior beliefs about the message content. We furthermore note that participants who had read the persuasive message on nuclear power plants voiced significantly stronger support for nuclear power than those who had read the balanced message, despite rating the information as less trustworthy. There was no difference in vaccination intentions between groups reading the different vaccine messages.

Differences in comprehending and acting on pandemic health risk information: a qualitative study using mental models

Background

A worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions. This study explored how people use mental models to make sense of scientific information and apply it to their lives and behaviour in the context of COVID-19.

Methods

This qualitative study enrolled 15 male and female participants of different ages, with different levels of education and occupational backgrounds and from different geographical regions of Norway. The participants were interviewed individually, and the interview data were subjected to thematic analysis. The interview data were compared to a expert model of COVID-19 health risk communication based on online information from the Norwegian Institute of Public Health. Materials in the interview data not represented by expert model codes were coded inductively. The participants’ perceptions of and behaviours related to health risk information were analysed across three themes: virus transmission, risk mitigation and consequences of COVID-19.

Results

The results indicate that people placed different meanings on the medical and scientific words used by experts to explain the pandemic (e.g., virus transmission and the reproduction number). While some people wanted to understand why certain behaviour and activities were considered high risk, others preferred simple, clear messages explaining what to do and how to protect themselves. Similarly, information about health consequences produced panic in some interviewees and awareness in others.

Conclusion

There is no one-size-fits-all approach to public health risk communication. Empowering people with decision-relevant information necessitates targeted and balanced risk communication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13853-y.

"You Know Nothing about How Alcohol Might Lead to Cancer!" Effects of Threatening and Hedging Languages on Intentions to Reduce and Stop Drinking

Alcohol causes cancer, but many alcohol consumers are not aware of this risk. Research is needed to identify effective communication strategies to increase risk perceptions and decrease alcohol consumption. This study examined the effects of threatening and hedging languages in communicating the cancer risk associated with alcohol use. Results from a between-subjects experiment (N = 584) revealed a significant interaction effect: Threatening language combined with lexical hedges led to a higher perceived threat to drinker identity competence, which predicted higher intentions to reduce and stop drinking. Moreover, threatening language increased perceived threat to freedom, predicting greater reactance and lower behavioral intentions. Lastly, hedging increased perceived message tentativeness, predicting lower risk perceptions and behavioral intentions. Implications of our study were discussed.