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Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop (2022)

Chapter:3 Addressing Uncertainties in Pandemic Communication

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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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Suggested Citation:"3 Addressing Uncertainties in Pandemic Communication." National Academies of Sciences, Engineering, and Medicine. 2022. Toward a Post-Pandemic World: Lessons from COVID-19 for Now and the Future: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26556.
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3 Addressing Uncertainties in Pandemic Communication Communication related to coronavirus disease 2019 (COVID-19) has been a constant challenge for public health authorities and governments alike throughout the last 2 years. The rapidly evolving situations, emerging variants, and changing response actions and public health measures have resulted in much confusion for the general public and overall uncertainty about what actions to take (Porat et al., 2020; Tyson and Funk, 2022). This chapter provides various examples from the United States of community engagement and attempts to improve equity throughout the pandemic, along with case studies from different parts of the world. It concludes with a discussion on better understanding misinformation and how to dissemi- nate facts over myths so people can make the most informed decisions to maximize safe behaviors. TRUST AND ENGAGEMENT Without trust from the public and belief that implemented policies and actions will be equitable, it will continue to be difficult for the government to secure buy-in and community support. This section outlines evolving practices, existing research, and examples of ways to better engage com- munities to build the necessary trust needed for a robust response. 21 PREPUBLICATION COPY—Uncorrected Proofs

22 TOWARD A POST-PANDEMIC WORLD Engaging for Equity Presented by K. “Vish” Viswanath, Harvard T. H. Chan School of Public Health Vish Viswanath, Harvard T. H. Chan School of Public Health and Dana-Farber Cancer Institute, outlined the initial context of the problem. Although an alert to influenza-like symptoms began in December 2019, there was no discussion of how different groups were being affected differ- ently until March or April 2020. To elucidate this, Viswanath shared a few potential theories. First, he said, there is an invisibility of the underserved where social and contextual conditions of their lives are ignored. This is especially true in countries like the United States that are highly individu- alistic. There is also an issue of data absenteeism, he noted. The groups being affected and the salient factors are often not part of our routine surveillance systems. There is also a misunderstanding of what expertise is needed sometimes, as he pointed out that many people are experts in their own lives and in their communities, but their knowledge and wisdom is often devalued or ignored, and instead top-down approaches are priori- tized. When research is designed or considered, it is often in the form of randomized clinical trials in highly controlled academic settings. Rarely is community-based participatory research (CBPR) considered or offered as a method to be more equitable and engaging. CBPR can be defined as an “approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process. The partners contribute ‘unique strengths and shared responsibilities’” (Israel et al., 1998). Key principles of CBPR include draw- ing on community strengths and assets through collaboration, promoting a colearning and empowering process, and addressing health from both positive and ecological perspectives. Viswanath shared two frameworks that drive the type of work he is leading. The first, a participatory knowledge translation framework, emphasizes the importance of building trust and engaging with communi- ties over time; it is based on the understanding that the coproduction of knowledge is an iterative process.1 The other framework, he shared, is called communication inequalities, which are manifested at different levels. At the population level, there are inequalities in how health information is generated, processed, and distributed among different groups. At the individual level, there are differences in how health information is accessed, processed, and used, which leads to inequalities in how different groups 1  This work has been published, see https://doi.org/10.1007/978-0-387-93826-4_23 (ac- cessed January 24, 2022). PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 23 benefit from information. Structural determinants are key to understanding inequalities, he said. Viswanath’s research team has been looking at how different populations engage with health information, how it is accessed, and how they process it when there is a constant deluge of information. Because of the preexisting relationship the research team had built with a community, individuals within the community approached them to ask what they should do about the confusing information surrounding COVID-19. Collaborating with community members, Viswanath’s team created a COVID-19 dashboard that covered topics such as vaccines, data, and frequently asked questions. He said it is constantly updated through working with the community. Viswanath’s team subsequently created simi- lar dashboards for other communities in various languages depending on their demographics and needs, including static infographics since not every- one has constant internet access. So, for example, he said a community partner who runs a food pantry was able to download the infographics as flyers and hand them out each week with grocery bags. Viswanath emphasized that the material they produce is constantly being updated, based on the information gathered from the community to address the most salient topics affecting each locality. Material is both coproduced with and distributed by community members. It is important to pay attention to the science of message construction, he said, but the science of engagement needs to be taken seriously also. Public health practitioners also have to learn that the expertise is diffused throughout a community, he advised; it does not just lie within the researchers or professionals in an area. Importantly, he added there is nothing deterministic about inequali- ties; they are not natural but instead are either there because of “deliberate or unintentional construction of policies.” He called for addressing not only the needs in the current pandemic but in the systems that perpetuate these inequalities. In summary, Viswanath reiterated the importance of building trust, which does not happen overnight. Every community has strengths and assets, he said, but for all the things taught in research and graduate train- ing, listening is often not one of them. But listening to the community part- ners and showing your face in the community and understanding how to involve them in the process is what will help make these lessons replicable. Science Advice and Trust in the United States Presented by Roger Pielke, Jr., University of Colorado, Boulder Roger Pielke, Jr., professor of environmental studies at the University of Colorado, Boulder, began with his conclusion, stating that the United States at the federal level “is almost alone worldwide in its lack of a PREPUBLICATION COPY—Uncorrected Proofs

24 TOWARD A POST-PANDEMIC WORLD high-level expert advisory body on COVID-19, and this matters for policy, politics, and trust.” Trust has many dimensions, he explained, which can include trust in experts and institutions, but trust between institutions is also important. He posited that the lack of such an advisory body is a core failing of intelligence in the pandemic response. He shared a project that his research group is working on, called “EScAPE (Evaluation of Science Advice in a Pandemic Emergency,”2 where they identify effective science advice for making policy. This includes generating policy options concern- ing the opening of schools, data collection, and regulatory guidance. His team has 20 case studies globally in various stages of development looking at the provision of expert scientific advice. However, he noted that provid- ing good advice to decision makers does not necessarily equate to good outcomes. Pielke presented a diagram of how the response framework was set up early on in the Trump administration, saying there was “no high-level advisory mechanism for pandemic response.” Although there were several related advisory committees, he added, nothing was at the highest level. This is in contrast to the setup in Japan, where the government overhauled its pandemic response after the 2009 H1N1 outbreak and created science advisory processes. Pielke evaluated the Japanese approach and noted that it worked fairly well, in part because of the trust that policy makers devel- oped in the expert advisers and the importance of those relationships. In the United States, Pielke said, advisers from outside the government came into the government, and many political appointees made decisions, which is generally not the best means of effectively advising policy. As another example of the potential effect an oversight body could have, he shared that throughout 2020, the U.S. government was using the COVID-19 tracking project from The Atlantic magazine as the basis for federal policy making. He shared several graphs portraying the mentions of the term pandemic in congressional legislation between 1995 and 2018, and pointed out that while there was a surge of mentions and some attention to the matter in the years following H1N1, it dropped off shortly after. While there was a lack of federal coordinated focus on pandemic planning, he continued, some efforts were at the state level. North Carolina in particular, “had a very effective high-level science advisory capability,” based on preexisting relationships between academics and government officials. One thing that has been learned in the theoretical and empirical s­ tudies of science advice said Pielke, is “If you hide political objectives behind a façade of science, that’s a really quick way to erode trust.” He provided examples such as the administration announcing the rollout of booster shots before being independently recommended by the Food and Drug 2  See https://escapecovid19.org (accessed January 24, 2022). PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 25 Administration’s advisory committee, “pitting political appointees against career officials.” Similarly, there are also ongoing debates around the origin of the virus, which sets up difficulties with geopolitics and working with multilateral institutions to coordinate response and messaging. Case Studies on Establishing and Sustaining Trust To understand a fuller picture of establishing and sustaining trust throughout the dynamic environment of COVID-19, three speakers shared their experiences from different countries in engaging people within their communities. Using Graphics in New Zealand Siouxsie Wiles, University of Auckland in New Zealand, shared her country’s experience with COVID-19, saying the highest daily number of cases it has had was around 80, during the first wave back in March 2020. New Zealand decided to take an elimination strategy, including closing borders and strict lockdown. Only essential businesses were open, she said. Schools were closed, and businesses were provided financial support. Since then, the country has been able to operate much more freely, with just limits on borders. She said one of the keys to success has been the elimination strategy, but also the way it has been portrayed to New Zealand residents. The slogan and messaging have been focused on uniting together as a team and providing a human response to the health crisis. She also credited the leadership of Prime Minister Jacinda Arden and the director general of health, Ashley Bloomfield, who gave briefings almost daily during out- breaks to provide updates on decisions the government was making. “When we panic, we don’t act in our best interests,” Wiles said. The communities that come together in times of disaster are usually the ones that come through that disaster with more resilience and a stronger recov- ery. She wanted to help New Zealanders understand those two principles. As she was targeted for many interviews and writing outlets, Wiles said her goals were to be calm, transparent, and accessible, and to explain the evi- dence so people can understand how her values interact with the interpreta- tion of the available evidence to develop conclusions without stigmatizing. When the concept of “flattening the curve” first emerged, she teamed up with an animator to create a graphic that could be easily understood and shared. While they initially used it to show how an individual’s choices could contribute to a response, they changed course quickly to make it a graphic demonstrating the collective response based in the elimination strategy, and emphasizing the importance of a long-term response, and not letting up on the public health measures too soon. They developed PREPUBLICATION COPY—Uncorrected Proofs

26 TOWARD A POST-PANDEMIC WORLD upwards of 40 more graphics to better explain some of the complex con- cepts throughout the response. She said what was really important was to release them under Creative Commons license so others could easily use them and repurpose them for their own needs.3 As she spoke, she said New Zealand was in a very delicate situation regarding an outbreak of the Delta variant, with higher numbers of cases and hospitalizations. While this is going on, she said they have been dealing with critics both within and outside the country, saying that their elimination strategy was the wrong approach, and disrupting the country’s response. She noted some initial mistakes in terms of equity as they work to roll out vaccines, most especially not engaging some of their indigenous community leaders and failing to intentionally address needs for vaccine access. The government is now taking a much more intentional approach to meeting indigenous communities and helping them get equal access to the vaccines. Trust and Engagement During Outbreaks in Sierra Leone Lawrence Sao Babawo, School of Community Health Sciences in the Department of Nursing at Njala University, focused his remarks on his experiences during the Ebola outbreak in West Africa in 2014–2015. Going back to that time, he said the mistrust in the Ebola response was likely caused by several factors. Because people’s understanding of the disease was very narrow, and because the disease was new to that region, it caused a great deal of panic. International organizations who came in to assist in the response also had differing case definitions, leading to confusion and even doubt of the disease’s existence. Then, one of the only virologists in Sierra Leone who was treating people contracted Ebola and died, leading to even more doubt about available treatments and expertise. There was also a “thin line of demarcation between governance of the health system and that of the political system,” he said. Politicians or military officers were appointed to response positions instead of experienced professionals, so there was skepticism about the sincerity of the government’s response. He stated that some people were worried the government was just trying to make money or gain political prominence. Looking at a different angle, Sao Babawo said, there was also a lack of trust in community members by the medical staff; many cases were hid- den by community members, which may have led to sick people dying and being buried without following proper protocols. Community members also lacked trust in the medical staff, sometimes believing that the health system had introduced the disease. 3  The collection of graphics can be found here https://thespinoff.co.nz/media/07-09-2021/ the-great-toby-morris-siouxsie-wiles-covid-19-omnibus (accessed January 24, 2022). PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 27 Something that could have helped this situation was the press, Sao Babawo noted, but they were censored as to what they could present publicly. This led to many rumors about the disease and what information was true. All of these factors converged to create a resistance in some com- munities; people refused to go to health centers. Historical conflicts and political tensions also fueled this distrust from the communities, as well as the top-down response approach that failed to engage local community leaders, especially in social mobilization and messaging. Without commu- nity members having any ownership in the response or health prevention effort, he said, it was difficult to succeed, and people resisted even more. To combat these issues, he said, the government developed a new communication strategy that involved the local people and local leaders, including top community leaders such as the paramount chiefs, who are very powerful in the country. Employment of those in strategic posi- tions was also done in consultation with the community. The govern- ment re­distributed the “Ebola economy,” hiring local people as part of the response. All of this helped to increase trust from the community in the response effort, and the government was able to bring down case numbers and eventually end the outbreak. Sao Babawo believed that experience helped to influence the current response to the COVID-19 pandemic in Sierra Leone, saying that they now have trained surveillance officers who were sent to the national borders, quarantine centers that could be identified, and other systems in place to allow the government to respond. Luckily, Sierra Leone has not experienced as many cases as some neighboring countries thus far. Addressing Racial and Ethnic Disparities to Achieve Health Equity Stephen B. Thomas, Center for Health Equity at the University of Maryland, set the stage for his presentation by saying health disparities and underlying chronic disease conditions must continue to be a priority effort to reduce and ultimately eliminate racial and ethnic health disparities. Additionally, the equity approach means addressing the social, cultural, and environmental factors beyond the biomedical model. His approach includes “breaking the cycle of poverty, increasing access to quality health care, eliminating environmental hazards in homes and neighborhoods, and implementing effective prevention programs tailored to community needs.” Intervention programs cannot be colorized stock images copied and pasted to different demographics or population groups, he said. The pandemic has highlighted the value of hyperlocal strategies to engage those who are most vulnerable. There has been plenty of evidence that the morbidity and mortality caused by the pandemic has disproportionately affected racial and ethnic minority populations. PREPUBLICATION COPY—Uncorrected Proofs

28 TOWARD A POST-PANDEMIC WORLD Thomas also pointed to the historical importance of the U.S. Public Health Services Syphilis Study done at Tuskegee University (1932–1972) as legitimate reason for vaccine hesitancy. This 40-year experiment is egre- gious because once penicillin was widely available, treatment was denied to the men in the Tuskegee Study.4 Today the public health community is faced with that legacy, Thomas said, and needs to use every government lever to ensure people of color and minorities actually obtain needed treatment. Following the Tuskegee Study, the Belmont Report emerged in 1978 that guides ethical engagement for human subjects research.5 This includes the principle of justice, he added, which states that those who bear the burden of research should not be denied the benefits of research. So, for the very population suffering the greatest burden of an infectious disease, it is a violation of the Belmont principle of justice if they do not have access to the available preventative measure. Many black people don’t even need to go back to the Tuskegee Study, Thomas continued, they can look to how their loved ones were treated in the health care system more recently. Because trust matters, Thomas, working through the University of Maryland, is working on building trust between minorities and researchers through an online interactive training program with the National Institutes of Health. He shared a recent report from Prince George’s County that recommended using the “COVID-19 vac- cination campaign as a foundation for sustained health promotion activi- ties” in the community (CommuniVax Coalition, 2021). The report also called for humanizing the delivery and communication of vaccines, invest- ing in a strong public health infrastructure for sustained community engage- ment, and “strengthen[ing] the community health system as the backbone for equity, resilience, and recovery.” Too many solutions are only found in journals and scientific meetings, he said, and are never implemented. Instead, he called for building on previous generations of research and tak- ing action, while being intentional about race and structural determinants that still must be addressed. To demonstrate how the University of Maryland has been putting such solutions into action, Thomas shared a short video on how his study team is getting messages into the community, specifically through area Black barbershops and salons. Before the pandemic, his team started a program in barbershops focusing on colon cancer, but once COVID-19 became a clear 4  Now known as the USPHS (U.S. Public Health Service) Syphilis Study at Tuskegee. See sum- mary from the U.S. Centers for Disease Control and Prevention: https://www.cdc.gov/tuskegee/ index.html (accessed January 24, 2022) and more information here: https://www.tuskegee.edu/ about-us/centers-of-excellence/bioethics-center/about-the-usphs-syphilis-study (accessed Janu- ary 24, 2022). 5  See https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html (accessed January 24, 2022). PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 29 threat, they were able to pivot and focus the platform on those messages instead. They developed rapid response trainings for stylists and barbers to help them become certified as community health workers within Maryland. Thomas described his team’s first major campaign that was just completed, where they embedded vaccination clinics inside of barbershops and salons. They asked each attendee about their motivation to get vaccinated, and his team used that information to tailor the program and understand how to help people move from vaccine hesitancy to vaccine confidence through community listening and concerns. Summarizing some of the responses, Thomas said the main categories of motivation included keeping family safe, keeping themselves safe, and keeping the community safe. Concluding, he added that his team’s rapid response training program is currently being delivered to more than 936 barbershops and salons across the country, where they are also hosting vaccine clinics. Thomas was optimistic about the effect the program could have and the potential for sustainable, outside- the-box health programming in the community. Discussion Related to the call for a higher-level advisory committee, a participant asked Pielke how to infuse health equity into that type of oversight. He responded that one important task could be to identify the data that is needed in order to manage and evaluate the pandemic response. If there are equity issues at a high level, it would be helpful to outline the data needed early in the response to help track those issues. He also used Italy as an example to consider, as it has parallel social sciences, public health, and ethics committees guiding their decisions. However, during interviews, experts on some of these committees were unaware of the existence of the other committees. He noted the global “political fault line” between public health and economic policies, saying that some advisory bodies have no capability to integrate public health and economics through policy options. But having input from multiple sectors can often allow for more nuanced options in between extremes. However, he also pointed out that advisors on these types of committees do not always agree, especially across disciplines, so handling that for a complicated, fast-moving topic with knowledge that is constantly emerging is difficult. With the amount of information available on numerous topics, it is understandable why there is confusion among both decision makers and the public, he said. In response to a question around the roles of communication and trans- parency in combating mistrust, Sao Babawo said there was little account- ability on the part of the government in terms of people dying each day. The people of Sierra Leone also were not clear about how much money PREPUBLICATION COPY—Uncorrected Proofs

30 TOWARD A POST-PANDEMIC WORLD the country was receiving from international organizations for various purposes, which led to people thinking the government of Sierra Leone was hiding things. At the beginning of the response, as it was a new disease, there was a lot of confusion about how best to approach it, and several things went wrong, he noted. But as the response continued, the govern- ment established accountability mechanisms and began to take on a central coordinating role. Another participant asked how efforts to establish trust in COVID-19 vaccines can be used to address other areas of health inequity in the United States, such as maternal health. Thomas commented on the growing body of evidence that a disproportionate burden of the inequity is related to persistent racism. When you experience it day in and day out, he said, it is called weathering, and theories around this are increasingly being validated. He advocated for meeting people where they are, including addressing their needs. For example, if a person seeks out a doctor for help with varicose veins, that issue needs to be addressed first before you can talk to them about colon cancer screenings or mental health. But the medical system is not set up for these types of longer interactions, so he suggested transform- ing more types of trusted businesses into trusted information sites—for all health disparities facing minority communities. Health professionals should not be threatened by this, Thomas noted, as they are still needed to deliver medical services in nonclinical settings. In their program’s model, they bring in cardiologists, gastroenterologists, and other specialists to their barbershop and salon pop-up clinics to take vitals or answer important medical questions. This is a win on both sides, he said, as it is often the first-time people in the community have met such an expert, and the specialists are thrilled to finally be reaching the population before its constituents end up in the emergency room. They have been very successful thus far, but most of the program is run through various grant funding, so Thomas hoped for more sustainable funding mechanisms to be able to expand and continue the program to help more in need. UNDERSTANDING MISINFORMATION Part of the challenge with influencing healthy behaviors and success- fully implementing public health measures is the variability in available and verifiable information. In some cases, a dearth of data and direction from professionals and scientific organizations led to other groups filling the void. Other times, the source of information was unclear, which, coupled with the ease of sharing on social media platforms, led to much confusion about actions. This section explores these issues and what existing evidence and best practices can inform. PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 31 Facts and Myths Presented by Brendan Nyhan, Dartmouth College Brendan Nyhan, Dartmouth College, sought to introduce the core ideas and findings within research on misperceptions and misinformation and offer suggestions on how to apply those findings to current pan- demic and other health-related concerns. He emphasized the importance of using clear and careful language regarding claims of misinformation. Misinformation in the United States is a key area of vulnerability for our democracy, he said, particularly surrounding the legitimacy of elections. He walked through how misinformation fits into existing knowledge about how beliefs and opinions are formed, and ultimately how people make decisions about behavior. An especially important concern, beyond simple knowledge or ignorance, is misperception—when someone believes they know something but in fact do not. He said this has been very important with the increase in partisan polarization. He defined misperception as “cases in which people’s beliefs about factual matters are not supported by clear evidence and expert opinion” (Nyhan and Reifler, 2010). Nyhan outlined four key human vulnerabilities to misinformation: sim- ple exposure, lack of scrutiny or analytical thinking, selective exposure, and directionally motivated reasoning. But in addition to this “demand” side of misinformation, he said there also needs to be consideration of the supply side. The psychological factors of human beings are not changing anytime soon, claimed Nyhan, so there is much more leverage for intervention on the supply side. Factors that may play a role include reduced distribution, reduced cost of producing and distributing information—including false information—and the incentives to spread that information for political or economic gain. Additionally, there is the challenge of the speed with which that distribution can outrun counterefforts. Misinformation Myths Nyhan described three common myths about misinformation that are especially prevalent today: 1. Most Americans are in online echo chambers. 2. Consumption of false news is common. 3. Fact-checks usually backfire. Together, these myths lead to a different understanding of the problem, he said, as well as the types of solutions needed. But none of these are true when thinking about a typical person, he said, as these statements are only PREPUBLICATION COPY—Uncorrected Proofs

32 TOWARD A POST-PANDEMIC WORLD true for a small minority of Americans. Regarding the first myth on the echo chamber, Nyhan said that there is behavioral data now that can go beyond simple surveys asking “Where do you get your news?” Researchers can now see in certain contexts for certain platforms what kind of information people are being exposed to. He also shared web browsing data that has been replicated numerous times, demonstrating the estimated slant of the media and websites visited by representative samples of Americans, show- ing media diets are typically reasonably balanced (Guess, 2021). Nyhan then addressed the second myth of widespread consumption of false news, clarifying that while this is a problem, it is generally con- centrated among a small percentage of the population. In reality, exposure to untrustworthy news is low, and those websites make up a small share of people’s general information diets on average (Guess et al., 2020). For example, during the 2016 election cycle in the United States, only one percent of Twitter users were exposed to 80 percent of false news stories (Grinberg et al., 2019). So, this generally does not apply to the person in the middle of the information distribution, he noted. Finally, for the myth on fact-checks backfiring, he said this effect is generally very rare. More often, fact-checks are effective in the moment at driving down the misinformed belief, but after time elapses, beliefs revert to their prior state. Nyhan commented on the significant partisan divide over the COVID-19 pandemic response, saying that many people think misinformation is a key contributor to this, but there are numerous aspects to it. When thinking about misinformation as something to address to affect behaviors like vac- cine hesitancy, he emphasized one of the key findings of communications research: the importance of using trusted sources. Having trusted figures say and demonstrate that they were getting vaccinated is much more effec- tive than pointing to studies of efficacy, he said. This principle also applies to marginalized communities and groups that have faced discrimination, who might still have distrust in institutions delivering the vaccine or health intervention. In conclusion, he said that preventing myths is easier and more effective than correcting them, and stakeholders should differentiate extremists from ordinary people when seeking to understand behavior or decision making among the general public. Panel Discussion Renée DiResta, research manager at Stanford University, shared her work on the Virality Project through a research consortium with Stanford Internet Observatory.6 Her team noticed a proliferation of false narratives about COVID-19 even in early 2020, with many topics emerging from 6  See https://www.viralityproject.org (accessed January 24, 2022). PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 33 media, especially related to conspiracy theories around the origination of the virus. There was also a significant disagreement about mask wearing and potential cures and treatments. She noticed a continued discrepancy between the speed of conversation on the internet and the time it takes to actually arrive at a scientific consensus, leading to a constant dearth of information where people would go looking for information to fill the voids related to a particular topic. What they would find was information created by influencers with large audiences, or those who were most adept at pro- ducing content that incorporated the term that people were searching for. So, there was a unique dynamic, she explained, where influence and expertise were actually decoupled. The authoritative institutional voices were not communicating and did not want to put facts out without com- plete certainty, but influencers with varying motivations were contributing to narratives and shaping public opinion—especially about things such as the COVID-19 vaccine. DiResta also noted this was not unique to the United States; it was happening globally. She added that while much of the antivaccine conversation was not new and built off of previous vac- cine narratives present on social media over the last decade, the rhetoric and framing began to find its way into new communities that were not antivaccine, but that were seemingly sympathetic to specific antivaccine narratives, such as right-leaning communities or wellness influencers. There was cross-­pollination of narratives from antivaccine communities to other communities that had not previously focused on vaccines. So, Stanford sought to study the prevalence of how disinformation was moving through communities, particularly within subcommunities with a high degree of engagement and sharing behaviors. Christine Prue, associate director for Behavioral Science at the National Center for Emerging and Zoonotic Infectious Diseases, within the U.S. Centers for Disease Control and Prevention, emphasized the role of social and behavioral scientists.7 Social and behavioral scientists are important in helping communities understand scientific information by contextualizing it. Additionally, social and behavioral scientists also provide feedback to public health officials on what interventions are and are not effective within various contexts. However, Prue noted that social and behavioral scientists are not always integrated and used to the necessary extent, creating fragmentation in communication with the public, ineffective engagement with communi- ties, and lack of feedback on intervention acceptability and effectiveness. 7  Social sciences relate to studies of human society and individual relationships to and within a society, while behavioral sciences pertain to human actions, with the goal of understanding, pre- dicting, or influencing behavior. See McQueen, 2022. https://www.encyclopedia.com/­education/ encyclopedias-almanacs-transcripts-and-maps/social-and-behavioral-sciences (accessed Febru- ary 16, 2022). PREPUBLICATION COPY—Uncorrected Proofs

34 TOWARD A POST-PANDEMIC WORLD Prue highlighted that these experts are uniquely poised to understand social determinants of health as they are trained to gain an understanding of the mindsets, skill sets, and contexts that affect health. She added that social and behavioral scientists are instrumental in contextualizing information to foster conversations and develop community-based solutions. Brian Southwell, senior director of science in the Public Sphere pro- gram at RTI International and professor at Duke University, discussed the interplay between misinformation and trust in science. He noted that the perception and meaning of the term misinformation is important to con- sider. More specifically, misinformation is often incorrectly thought of as monolithic and pervasive, he said. However, misinformation can encompass various types of false information, some of which may be more harmful than others, and some may spread faster than others. However, aiming to increase trust in science is much more effective and productive than trying to eliminate misinformation, Southwell explained. Health care professionals are often trusted sources of scientific information. Interventions that sup- port and train physicians on how to have conversations regarding misin- formation and on how to foster trust within the community are important, Southwell said. Rather than having national announcements or efforts to eradicate misinformation, Southwell suggested small-scale conversations that can be scaled up to increase trust in science on higher levels. The panelists discussed what conditions brought about the global wave of misinformation during COVID-19. Southwell noted that the global nature of COVID-19 made relevant misinformation more prevalent. Infor- mation vacuums and uncertainties from the scientific community also helped spread misinformation, he added. Prue noted that lack of transpar- ency in policy making and clarity in public communication also fueled misinformation during COVID-19. DiResta explained that low trust in authorities and science contributed to this trend. She added that public nar- ratives, which were often provocative and accusatory, accelerated existing conspiracy theories. Similarly, Nyhan surmised that polarizing narratives from various political parties helped spread misinformation. The panel discussed the importance of local news sources. Nyhan explained that a shift away from local and trusted news sources and toward national-level news, which tends to highlight controversy, has increased polarization and a lack of reciprocal relationships between media outlets and the community. He added that public health organizations are over­ relying on their social media accounts with very few followers. Instead, he highlighted the need for new communication methods that involve inter­mediary stakeholders who are already trusted within communities. ­Southwell echoed the importance of local news sources. The panel also explored the relationship between scientific uncertainty, what is defined as “false information,” and how scientific uncertainty can PREPUBLICATION COPY—Uncorrected Proofs

UNCERTAINTIES IN PANDEMIC COMMUNICATION 35 best be communicated to the public. Southwell explained that it is impor- tant for the public to understand that scientists do not have the absolute truth but instead go through a process to achieve knowledge, which can change as new information emerges. He explained that transparency about current, past, and potential future changes in scientific consensus is impor- tant so the public can trust the scientific process. Southwell proposed a Wikipedia-like online platform with version control where different sci- entific institutions can update and keep track of scientific information as it changes. Prue emphasized the importance of involving people from the community in the scientific process: receiving and incorporating dif- ferent perspectives from the community is an important part of research. Scientists should position themselves as learners within a community. This bidirectional learning process would lead to, she explained, increased trust in science and stronger relationships between scientists and the community. Finally, the panel explored the difference between a centralized com- mittee versus local communications channels. DiResta said that people no longer trust top-down scientific communication methods, and instead using local entities or civil society groups that rely on scientists as a source would be more efficient. Prue agreed and added that establishing these local com- munication pathways would be best achieved by incorporating social and behavioral science in organizations. Prue also noted that social and behav- ioral sciences need to be applied beyond communications. These inputs are necessary for the implementation of policies and programs, especially as they facilitate incorporating the expertise of community members’ lived experiences in the development and implementation process. She explained that because infectious diseases begin locally, local solutions should be considered and prioritized. PREPUBLICATION COPY—Uncorrected Proofs

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To take stock of lessons learned from COVID-19 around the world and in the United States, the Forum on Microbial Threats held two virtual workshops during 2021. The first workshop focused on what it means to frame the response to COVID-19 through a "syndemic" approach, and what the implications would be for global recovery. The second workshop focused more broadly on key lessons and emerging data from ongoing pandemic response efforts that can be incorporated into current health systems to improve resilience and preparedness for future outbreaks.

This workshop explored the long-term effects of COVID-19 on health equity, including considerations for mental health and social determinants of health. It also addressed uncertainties during a pandemic, such as trust, communication, and engagement and explored approaches to systematize recovery efforts to improve the ongoing responses and prepare for the next pandemic. Experts discussed possibilities for a post-pandemic world and a response strategy for stakeholders that ensures sustained community partnerships and prioritization of health equity. This Proceedings of a Workshop summarizes the presentations and discussions from the second workshop.

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