UP CLOSE | Let’s talk about it: The triumphs and failures of public health messaging during COVID-19
Epidemiologists at the Yale School of Public Health, Yale faculty and a community leader comment on how the U.S. government fell short when communicating health guidance to the public during the pandemic and what lessons can be learned from the year in review.
What is the most effective method to communicate health guidance so that it prompts substantive behavioral change among the population?
This question has vexed researchers in the field of public health for decades and became increasingly relevant in March 2020, as SARS-CoV-2 began proliferating across the United States, transforming epidemiological maps of the nation from monochromatic diagrams to multicolor mosaics with emerging hotspots. As the pandemic’s spread intensified, epidemiologists at the Yale School of Public Health grappled with how to effectively communicate health messages to combat COVID-19 and keep people healthy.
For associate professor of public health Marney White — who has taught courses in epidemiology and the science of behavior change — this question became personal when she was diagnosed with a rare autoimmune disorder in December 2019 and began treatments in February 2020, causing her to be at high risk for severe COVID-19 infection when the pandemic started soon after.
“There was a member of our local board of health who posted a public Facebook post saying that she was tired of all of these people trying to control everyone else and if people are sick or immunocompromised they should just stay home, let the rest of us live our lives,” White said. White wrote in an article published by the American Journal of Public Health in October of last year that it was messages like these that made her feel like “one of the vulnerable few that some seem willing to sacrifice.”
White disagreed with the approach outlined by other academics such as David Katz SPH ’93 that came early on in the pandemic. The approach espoused by Katz called for a risk stratified plan that later became known as “focused protection.” This approach placed an emphasis on “preferentially protecting the medically frail” through methods such as building “firewalls” of protection around facilities housing the elderly or those especially vulnerable to infection while reopening the economy and permitting healthy, low-risk individuals to go back to school, work and gatherings.
White’s experience underscores the critical importance of consistent, clear and convincing health messaging to save lives and slow viral spread during a pandemic. The News spoke to five scientists at the School of Public Health, as well as other leaders and epidemiology experts, about how they crafted effective public health narratives during the pandemic and how such communication fell short — including through conflicting messaging, such as the coexisting narratives of focused protection and broad containment early on in the pandemic.
At that point, there was not yet a consensus among public health experts on how best to communicate to the public about the pandemic.
In addition to White, Dean of the Yale School of Public Health Sten Vermund, assistant professor of epidemiology Gregg Gonsalves and Director of the Yale Institute for Global Health Saad Omer, took issue with the strategies outlined in Katz’s article. White said that articles like Katz’s sent hurtful messages to people with chronic illnesses.
“It basically said, you know we’re going to slow down the economy, just to save some people who are already sick and so we shouldn’t do that,” White said. “We should just wall those people off and not have them in society. The message is basically … if you’re already weak or have an illness, to hell with you, we can’t slow down the rest of the world.”
In a response letter to Katz’s New York Times op-ed signed by Yale epidemiologists including Vermund, Gonsalves and Omer, University faculty expressed their disagreement with the “focused protection” approach outlined in Katz’s piece, titularly claiming Katz’s plan was “The Wrong Way to Fight Coronavirus.”
In an email to the News, Vermund clarified that he agreed with Katz that nursing homes were poorly managed, serving as one of the primary sources of early COVID-19 mortality when the pandemic hit the United States. Still, Vermund stated that in his view, the epidemiological flaw of the “focused protection” approach was its assumption that herd immunity could be achieved by allowing SARS-CoV-2 to infect “less vulnerable members of society.”
Katz wrote in an email to the News that regardless of how he and Vermund may differ in opinion about strategies to curb the spread of COVID-19, he agrees on the importance of protecting those most vulnerable to infection.
“We needed more [protection], not less,” Katz wrote. In an article about the “focused protection” approach, Katz stated that this plan was “not intended to discount the significance of mortality from coronavirus at any age” and aimed instead to “shelter and serve the vulnerable.”
Despite conflicting views among academics in early 2020 about how to best protect the population from COVID-19, Vermund described that public health messages about healthy behaviors, especially those coming from the government, should be consistently reinforced to promote the best pandemic response.
“When you go on safari you want to see the rhino, elephant, giraffe, hippo, lion. Those are the big five. So, I had my big five for COVID: masks, physical distancing, small groups … air quality … [and] hand hygiene.”
—Sten Vermund, Dean of the School of Public Health
Simple, honest and clear: Strategies for effective health messaging
Vermund emphasized that there are effective strategies for public health messaging that the government should continue to employ. Scientists and public officials should use tactics from the broader marketing and behavioral sciences fields that balance comprehensibility and detail while placing a focus on transparency.
He explained that principles of health communication are merely a subset of principles for communication in general. Thus, strategies like “social marketing” — using techniques like slogans or advertisements to design and implement programs promoting socially beneficial behavior change — are particularly important when attempting to “sell” an idea or behavior to an audience.
“Inherently you may not care about potato chips,” Vermund explained. “But if you have a slogan, ‘I bet you can’t just eat one’ or something catchy, a jingle that you can’t get out of your head, [you might start to care]. So, we like to borrow from the broader field of marketing.”
Vermund described that the most effective messages are those that are logical, easy to remember, use mnemonics and are consistently reinforced. He said that there is a fine line between overly simplistic messages that can insult the public’s intelligence versus complex jargon incapable of captivating or motivating an audience to adopt healthy behaviors.
As a result, Vermund decided at the beginning of the pandemic that to encourage people to make healthy decisions regarding COVID-19, he would use a play on words of the “big five” animals that tourists often hope to see on safari.
“When you go on safari you want to see the rhino, elephant, giraffe, hippo, lion. Those are the big five,” Vermund said, high-fiving the Zoom screen. “So, I had my big five for COVID: masks, physical distancing, small groups … air quality … [and] hand hygiene.”
Gonsalves agreed with using similar approaches to social marketing as a means to motivate behavioral change. He said that those in the field of public health could pull from lessons in the world of advertising, entertainment and pop culture.
“When we [use] messaging, our messages need to be fact-based, tailored to specific audiences and widely disseminated,” Gonsalves wrote in an email to the News. “Think of the world of advertising … how we influence each other in the broader world, we could learn a thing from those industries.”
President of the Greater New Haven NAACP Dori Dumas also championed the use of simple, memorable messages as a way to inspire people to continue to abide by public health guidelines, even if they are growing tired of following restrictive physical distancing and mask-wearing measures.
She additionally brought up the concepts of transparency from the government and open forums where community members can ask epidemiologists and virologists questions about the pandemic, vaccines or related information. She said these are invaluable methods that can bridge trust among communities that might be skeptical of vaccines.
“Speak facts. Keep it simple. But be very honest and clear.” Dumas said. “Of course … have information available for people who want to research more.”
“Speak facts. Keep it simple. But be very honest and clear.”
—Dori Dumas, President of the Greater New Haven NAACP
White explained that the science of behavior change may also afford important insights into strategies for health messaging.
She described that humans and animals tend to engage in behaviors when there is a perceived benefit to themselves. Thus, when behavioral incentives are tied immediately to the desired action, which in the context of COVID-19 might include a reward for hand washing, physical distancing or receiving the vaccine, behavior change will be more likely.
“When it comes to … trying to extend [the science of behavior change] to health messaging, instead of just saying ‘hey you should wash your hands,’ you want to frame it into some perceived benefit for the individual.” White explained. For example, “if you wash your hands, you will spare yourself the undesirable consequence of getting sick.”
Professor of marketing at the School of Management and professor of psychology Nathan Novemsky studies behavioral economics — specifically the best methods to nudge people to change their behaviors despite irrational beliefs or suboptimal habits.
Novemsky described that messages appealing to people’s altruistic or “pro-social” tendencies as well as a desire to conform to social norms can have a large impact on behavior, especially in the context of the COVID-19 pandemic.
“I don’t have hard data, but what strikes me as effective are some things like pointing to the social good,” Novemsky said. “You’re … for example wearing masks … not just to protect yourself. It’s about protecting those around you or it’s about being considerate to people and it’s rude not to wear a mask.”
When health messaging falls short
Despite the potential of health messaging to inspire behavioral change, there are examples of where the United States faltered in this effort over the course of the past year, explained Vermund. According to Vermund and Gonsalves, the inconsistent messaging and lack of a clear focus on what needed to be done to keep people healthy undermined the United States’ response to the coronavirus.
Vermund pointed specifically to inconsistencies in public health messaging from the Trump administration last year.
“Consistency of public health messaging we didn’t do well at all,” Vermund said. “If Donald Trump says, well, ‘maybe we can swallow bleach and kill the virus from the inside,’ and Debbie Birx doesn’t say anything to the contrary, I mean, that’s not consistent messaging.”
Vermund was referring to a White House coronavirus task force briefing on April 23 of last year, where the former White House Coronavirus Coordinator Deborah Birx, journalists and other members of the Trump administration were in attendance. During the press conference, former President Donald Trump suggested that further research should examine whether COVID-19 could be treated by injecting disinfectant into the body, an idea immediately debunked and lambasted by medical experts.
Vermund explained that distracting public health messages that focus on largely irrelevant details can also undermine successful public health campaigns and draw attention away from the issues that matter.
“It’s really not important if the virus jumped out of a lab or the virus jumped out of an animal,” Vermund said. “[The virus’ origin] is not a public health interest because it doesn’t matter … If you then focus attention on something like that, you’re distracting people from what’s really important. The pandemic has swept across the world.”
Gonsalves added that “deliberate misinformation” disseminated by the Trump administration contributed to the ineffectiveness of the government’s pandemic response in 2020.
“We need an autopsy, a thorough investigation of how facts were twisted in 2020. How did our nation’s prized health agencies get silenced, how did officials get driven to repeat falsehoods they knew to be untrue, how did data get suppressed and manipulated? We need to know in detail how this all went wrong, how it happened, who was involved and when.”
—Gregg Gonsalves, assistant professor of epidemiology
Gonsalves contrasted this to the current administration, saying that the Biden Administration has “re-centered public health messaging around science, expertise and evidence,” although there remain “missteps here and there.”
Still, Gonsalves emphasized that historically, promoting healthy behavioral changes has been challenging in nearly all realms of public health, including campaigns focused on healthy eating, smoking cessation or limiting substance use.
He said that relying on health communications alone is not sufficient to promote significant behavioral change and that the government should focus on providing people with tools — such as masks and universal paid sick leave — to make healthy decisions.
“We need to incentivize better choices, by making it easier for people to do the right thing … so that people don’t have to choose between their livelihoods and safety,” Gonsalves said.
Lessons from a past health crisis
“We don’t have to always reinvent the wheel in public health messaging,” Vermund said, citing the “tried-and-true” strategies of consistent messaging driven by science, interpretable by the general public and tailored for select sub-audiences. To develop public health messaging for the coronavirus pandemic and other future pandemics, scientists drew on lessons learned from the HIV/AIDS epidemic in the 1980s and 1990s: the needs for clarity, depolarization and removal of stigma around a sickness, as well as the role of popular spokespeople in promoting behavioral change.
During the HIV/AIDS epidemic, Vermund remembered observing “abysmal” and ineffective communications coming from the CDC as well as other administrative agencies of the United States government.
“The messaging that came out of CDC and other government sources for HIV was embarrassing,” Vermund said. “It was hard to understand, they bent over backwards never to talk about sex, never to talk about injecting a needle in your arm. It was so constrained by the political points of view of the government at the time, the Reagan administration, that it was just awful.”
Vermund related the examples of the politicization of health messages during the Reagan administration to similar politicization surrounding COVID-19 public health messaging that he observed during 2020.
An August 2020 study published in the SAGE Public Health Emergency Collection suggested “that the high degree of politicization and polarization in initial COVID-19 coverage may have contributed to polarization in U.S. COVID-19 attitudes.”
Specifically, Vermund pointed to how Dan Patrick, the lieutenant governor of Texas, told Fox News in March of last year that senior citizens should “take a chance on your survival” to reopen the economy. Vermund classified this as a troubling example of how talk of letting the virus run rampant, as well as politicization of health messages, could be damaging to public health campaigns.
Vermund explained that a similar approach of “letting the virus run its course” was adopted in Sweden, a nation that never implemented a full lockdown, allowed restaurants and bars to remain open in 2020, refused to institute legal sanctions or mask mandates and instead appealed to its citizens’ sense of civic duty to practice healthy behaviors. Sweden had more fatalities from COVID-19 than all of the other Nordic countries combined by the end of 2020.
“The point is that you can lead people astray with false promises that may look convenient, because, conveniently we are not going to shut schools, conveniently we are going to keep businesses open, conveniently we’re going to just thrive in our society,” Vermund said. “[The United States] would have had over a million deaths from COVID if that point of view had been embraced.”
The United States should also reflect on the forms of stigma and discrimination displayed during the HIV/AIDS epidemic when working to craft better public health campaigns going forward, Gonsalves said. He is one of the co-founders of Treatment Action Group, an organization established in 1992 to advocate for better treatment and a cure for AIDS.
“Last year, we saw a rise in violence and harassment of Asian-Americans due to President Trump’s insistence on calling SARS-CoV-2, not by its proper name, but as the ‘China virus,” Gonsalves wrote. “This was a deliberate attempt to scapegoat a set of Americans for the pandemic. It is reminiscent of the scapegoating of gay men, people who use drugs, Haitians and others in the early years of the AIDS epidemic.”
Vermund added that one of the most poignant lessons for public health messaging to be learned from the HIV/AIDS epidemic is the role that celebrity and popular spokespeople can play in influencing the public to adopt healthy behaviors.
Vermund explained that when Magic Johnson — an NBA superstar who led the Los Angeles Lakers to five championships over the course of his career — tested positive for HIV, it had a huge impact on the general public’s perception of HIV/AIDS testing and alleviating the stigma surrounding HIV/AIDS.
“When I was working in HIV, back years ago when Magic Johnson got an HIV test, he tested positive, turned out he had HIV, and he told everybody,” Vermund said. “We saw an uptick in testing in minority communities after his testing and his going public which was very dramatic. Everybody knows it’s the ‘Magic Johnson’ effect.”
Vermund added that more research should be conducted on the effectiveness of using popular spokespersons to pivot perspectives, but he remains optimistic that continued celebrity endorsement of COVID-19 vaccines will help to improve vaccine uptake in the months to come. Vermund cited Dolly Parton’s twitter video of herself receiving the first dose of the Moderna vaccine as an example of powerful messaging.
Vermund is currently working with the Creative Coalition — a Hollywood nonprofit that has collaborated with celebrities including Morgan Freeman — to transmit messages of COVID-19 health and hygiene to the greater public.
Novemsky added that spokesperson endorsements, particularly when these figures are some sort of expert, doctor or celebrity, are often quite powerful, particularly in the context of changing health behaviors and countering false or misinformed beliefs.
Courtesy of the KFF COVID-19 Vaccine Monitor
Data from the KFF COVID-19 Vaccine Monitor (Zully Arias, Production and Design Editor)
‘Four phenotypes’ of attitudes toward COVID-19 vaccines
Vermund explained that academics and public health officials engaging in health communications are contending with “four phenotypes” of people when it comes to vaccine uptake, ranging from those who closely follow public health guidelines to those who will not take the vaccine under any condition.
The first group of individuals consists of doctors, nurses and members of the general public who largely heed the advice of public health experts to get the COVID-19 vaccine.
(Zully Arias, Production and Design Editor)
The second group, Vermund described, is composed of people who may be skeptical of the government or of the medical establishment, but do not have a fundamental distrust of vaccines in general — a group that the Kaiser Family Foundation, or KFF, has termed as the “wait and see” cohort.
“Since September until now, [the KFF] surveys of such individuals have shown a halving of the number,” Vermund said. “60 percent were ‘wait and see’ back in September. Now it’s only 30 percent. So there’s been an absolutely consistent shift from the ‘wait and see’ to the ‘I want to get vaccinated group.’ So that’s wonderful. There are many people in communities of color that are in that category.”
The KFF reported that the two groups with the highest proportion of survey respondents in the “wait and see” category are currently Black people and individuals the ages of 18 to 25.
(Zully Arias, Production and Design Editor)
The third group includes individuals who will only consider getting vaccinated if it is necessary to participate in activities like flying on airplanes, or going to work or school, Vermund said. The fourth and final category includes people who will not get the vaccine, “end of subject,” he explained.
‘Start with the evidence’: Messaging around vaccine hesitancy
As the president of the Greater New Haven NAACP, Dumas has been working over the past year to encourage communities of color to get the COVID-19 vaccine.
(Zully Arias, Production and Design Editor)
Dumas explained that through collaboration with local clergy members and the use of churches as vaccine pop-up centers, the NAACP has made strides in promoting vaccine uptake in New Haven. Federal Emergency Management Agency mobile clinics as well as Fair Haven Community Health Care have aimed to do the same.
“There’s still far too many people who have not been vaccinated but more and more are talking about it and more people in their own circle are starting to say you know, it’s not that bad, here’s the facts, here’s some straight information,” Dumas said. “I think those kinds of things have been helpful. I’m hoping that more and more people in the Black and brown communities will get the vaccine and more and more people will share why it’s so important. In order for us to get herd immunity, we need more people to advocate.”
Vermund said that consistent messaging will continue to be the key to counter vaccine hesitancy, bridge trust among skeptical communities and build confidence in what have been “among the safest and most efficacious vaccines ever developed in the history of vaccinology.”
Dumas said that she is continuing to encourage the city of New Haven, Hamden and other localities, as well as hospitals, to supply communities with basic information on vaccines by spending money on marketing and information campaigns that will provide people with links or phone numbers to call if they have questions about vaccines.
In an attempt to promote vaccine uptake around the world, Omer has also been collaborating with Facebook on a social media campaign to convey evidence-based messages on the vaccines in low- and middle-income countries.
“We have learned again and again, start with the evidence,” Omer said. “You start with the evidence and you start with the reassurance that these vaccines are safe.”
Despite efforts to increase vaccine uptake on local, national and international scales, on April 13, 2021, the CDC and U.S. Food and Drug Administration called for a pause in the use of Johnson & Johnson’s Janssen COVID-19 Vaccine in response to six reports of cerebral sinus vein thrombosis — blood clotting in the brain — among women aged 18 to 48, out of more than seven million doses administered. Symptoms were reported by these patients six to 13 days after receiving the shot, and one of the cases was fatal. Following this announcement, Yale New Haven Health System suspended use of the J&J vaccine on April 13.
When asked about how this pause on the J&J vaccine will impact the public’s trust in vaccines, Novemsky pointed to a principle in psychology called the “availability heuristic.” This idea says that when it is easy to bring examples of a tragedy to mind, people have a tendency to overestimate the actual probability of the threat.
For example, even though more than 7.2 million doses of the J&J vaccine had been administered in the United States, and only six cases of severe blood clotting were reported — constituting less than approximately 0.0009 percent of the population that received the J&J vaccine — Novemsky explained that these few cases might have a “disproportionate impact” on levels of vaccine hesitancy.
“You know, death by omission, by not getting the vaccine and dying of COVID is something people worry about a lot less than errors of commission, ‘I take the vaccine and that kills me,” Novemsky explained. “Getting people to make a rational calculus is really very hard in these situations because of availability [heuristics] and the omission, commission bias that keep people from doing the right thing.”
Omer said that the argument that the pause on the J&J vaccine may impact vaccine acceptance negatively is a reasonable one. Still, Omer considered an alternative view.
“In the short run, [the pause on the J&J vaccine] may actually increase the confidence of people in vaccine safety” he said. “It’s not guaranteed. But if you have good messaging saying, look the CDC are being prudent about safety, that sends the message that they are not kidding around.”
A year of health messaging in review
When asked to reflect on the successes and failures of public health messaging from the past year of the pandemic, Vermund said that many policies from the last year have been suboptimal and that it is up to the public health community to fix these mistakes.
“I do feel like all of us in the public health community need to learn how to better communicate to lay audiences and how to better communicate to policy makers,” Vermund said.
Department chair of epidemiology Albert Ko added that inconsistent information from the CDC in the early days of the pandemic exacerbated already poor public health messaging.
Gonsalves similarly described that last year’s events caught many public health leaders off-guard.
“2020 in the U.S. was a lesson, a master class, in how to confuse, mislead the public, pit public health experts and scientists against ordinary Americans,” Gonsalves wrote. “Those of us working in public health need to up our game.”
Omer noted that public health officials should work harder at communicating information about vaccine safety, especially as the rollout in the United States and abroad hastens.
He described that the best way to convey messages moving forward is in a manner that is clear cut and rooted in science. He emphasized that the most important point when it comes to vaccines is that nothing is 100 percent safe, but that the vaccines are “incredibly safe” and the benefits on both an individual and collective scale far outweigh the risks.
Ko acknowledged that unlike nations like Brazil — which has a universal healthcare system — the United States’ fragmented public health system merely compounded failures in public health messaging in the past year.
“We need an autopsy, a thorough investigation of how facts were twisted in 2020,” Gonsalves wrote. “How did our nation’s prized health agencies get silenced, how did officials get driven to repeat falsehoods they knew to be untrue, how did data get suppressed and manipulated? We need to know in detail how this all went wrong, how it happened, who was involved and when.”
The CDC reports 3,484,148 total cases of COVID-19 in the United States, while the World Health Organization reports over 141,057,106 confirmed cases of COVID-19 globally.
Sydney Gray | firstname.lastname@example.org
Correction, Apr. 21: An earlier version misstated that White “supports the implementation of broad containment policies on the entire population that do not consider the relative risks of severe infection.” That sentence has been removed. The story has been updated.