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Public Health and Risk Communication During COVID-19—Enhancing Psychological Needs to Promote Sustainable Behavior Change

Public Health and Risk Communication During COVID-19—Enhancing Psychological Needs to Promote... ORIGINAL RESEARCH published: 27 October 2020 doi: 10.3389/fpubh.2020.573397 Public Health and Risk Communication During COVID-19—Enhancing Psychological Needs to Promote Sustainable Behavior Change 1 2 1 3 3 Talya Porat *, Rune Nyrup , Rafael A. Calvo , Priya Paudyal and Elizabeth Ford 1 2 Dyson School of Design Engineering, Imperial College London, London, United Kingdom, Leverhulme Centre for the Future of Intelligence, University of Cambridge, Cambridge, United Kingdom, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom Background: The current COVID-19 pandemic requires sustainable behavior change Edited by: to mitigate the impact of the virus. A phenomenon which has arisen in parallel with this Victoria Ann Newsom, Olympic College, United States pandemic is an infodemic—an over-abundance of information, of which some is accurate Reviewed by: and some is not, making it hard for people to find trustworthy and reliable guidance to Gregory Dore, make informed decisions. This infodemic has also been found to create distress and University of New South increase risks for mental health disorders, such as depression and anxiety. Wales, Australia Ranjeet Kumar Sinha, Aim: To propose practical guidelines for public health and risk communication that Patna Medical College, India will enhance current recommendations and will cut through the infodemic, supporting *Correspondence: accessible, reliable, actionable, and inclusive communication. The guidelines aim to Talya Porat t.porat@imperial.ac.uk support basic human psychological needs of autonomy, competence, and relatedness to support well-being and sustainable behavior change. Specialty section: This article was submitted to Method: We applied the Self-Determination Theory (SDT) and concepts from Public Health Policy, psychology, philosophy and human computer interaction to better understand a section of the journal Frontiers in Public Health human behaviors and motivations and propose practical guidelines for public health Received: 16 June 2020 communication focusing on well-being and sustainable behavior change. We then Accepted: 17 September 2020 systematically searched the literature for research on health communication strategies Published: 27 October 2020 during COVID-19 to discuss our proposed guidelines in light of the emerging literature. Citation: We illustrate the guidelines in a communication case study: wearing face-coverings. Porat T, Nyrup R, Calvo RA, Paudyal P and Ford E (2020) Public Health and Findings: We propose five practical guidelines for public health and risk Risk Communication During communication that will cut through the infodemic and support well-being and COVID-19—Enhancing Psychological Needs to Promote Sustainable sustainable behavior change: (1) create an autonomy-supportive health care Behavior Change. climate; (2) provide choice; (3) apply a bottom-up approach to communication; Front. Public Health 8:573397. doi: 10.3389/fpubh.2020.573397 (4) create solidarity; (5) be transparent and acknowledge uncertainty. Frontiers in Public Health | www.frontiersin.org 1 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Conclusion: Health communication that starts by fostering well-being and basic human psychological needs has the potential to cut through the infodemic and promote effective and sustainable behavior change during such pandemics. Our guidelines provide a starting point for developing a concrete public health communication strategy. Keywords: public health, health communication (MESH), risk communication, COVID-19, coronavirus, infodemic, behavior change, well-being BACKGROUND with the need to provide the public with actionable information for health protection (10), while taking into consideration The World Health Organization (WHO) is leading and the needs of vulnerable populations (11). Experience from coordinating the global effort to respond to the coronavirus previous pandemics may be helpful in understanding human disease (COVID-19) outbreak, however, it is also fighting a behavior in public health crises, but many things have changed second “disease” —an infodemic (1). An infodemic is an over- including the virus and its spread, the ways people collect and abundance of information, of which some is accurate and some search for information and the ways authorities such as WHO is not, making it hard for people to find trustworthy and communicate with the public via social media (9). In addition, reliable guidance to make informed decisions (2). This adds pandemics like COVID-19 are unique in the sense that face to to the natural difficulties in making decisions and adhering face interactions are limited and people have to rely on remote to recommendations, and may increase distress and the risks platforms like social media and news outlets to gain information. for common mental health disorders (3). Studies during the Thus, there is a need for enhanced communication guidelines COVID-19 outbreak already show that the high prevalence and strategies that cut through the infodemic by better of mental health problems, especially anxiety, and depression understanding human behaviors and motivations (12) and that among the general population, is positively associated with are: (1) accessible; (2) reliable; (3) useful; (4) actionable; (5) frequent social media exposure (4). acceptable; (6) inclusive; (7) consistent; (8) understandable, and In the age of social media, the infodemic phenomenon (9) promote sustainable behavior change to mitigate the impact is amplified, information spreads faster and further than of the virus. the science (1), leading even faster to information overload, Decades of research show that individuals and societies can including misinformation and myths. The COVID-19 pandemic only prosper in environments that foster basic psychological is characterized by inconsistent, ambiguous, contradicting needs, such as autonomy and competence (13). Evidence messages and absence of clear, actionable, credible, and inclusive from the Self Determination Theory [SDT: (14, 15)] shows information from authorities that people trust, leaving space for that by maximizing one’s experience of autonomy (meaning, other actors to fill the void irresponsibly. Politicians, officials, volition, choice), competence (feeling effective and mastery), media, celebrities, and even heads of state, have been elevating and relatedness (feeling cared for by others, trusted and disinformation, posing a risk to global health and safety (5). It is understood), the control of health-related behaviors is likely therefore important to understand what sources of information to be internalized, and behavior change is likely to be and modes of communication are trusted and popular among the maintained (13). population and how communicators can tap into them to make Developing a sense of autonomy, competence and sure their communication strategy is most effective. relatedness are critical for self-regulating and sustaining Health communication is an essential tool for achieving public behaviors that improve health and well-being. This means that health objectives, including facilitating and supporting behavior environments and contexts that foster autonomy, confidence, change and eliminating health discrepancies (6). Effective risk and trust are likely to enhance adherence and improve health communication is crucial for enhancing understanding of health outcomes (13). threats and to support the public in making informed decisions Previous research has shown a positive effect of meeting these for mitigating the risks (7). Poor communication is often a psychological needs (autonomy, competence and relatedness) factor in enabling public concerns to escalate and groups to on mental health (fewer depressive symptoms), physical health become polarized (8). “The public” may be accused of ignoring and quality of life, including increased physical activity, reduced scientifically sounded and sensible advice and “those in charge” smoking, and improved adherence to prescribed medications may be perceived as untrustworthy and secretive (8). (16, 17). We are not aware of previous literature in health Due to excess demand for trustworthy and timely information communication that has applied the SDT framework and about COVID-19, WHO has established the Information integrated concepts from psychology, philosophy and human Network for Epidemics (EPI-WIN), which defined “simplifying computer interaction. knowledge” as one of the strategic areas of work to respond to The COVID-19 pandemic requires long-term strategies and the infodemic—the challenge being to translate the knowledge sustainable behavior changes. Engaging the public and enhancing into actionable and behavioral change messages (2). In this intrinsic motivation is imperative for these changes to be pandemic, massive and fast behavioral change is critical (9) sustainable and foster well-being. Frontiers in Public Health | www.frontiersin.org 2 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 METHOD for these discrepancies were the limited evidence on their efficacy in preventing respiratory infections during epidemics; the need We applied the self-determination theory [SDT: (14, 15)] and to preserve limited supplies of face masks for professional use concepts from philosophy [e.g., (18–21)] and human computer in healthcare settings; the argument that face masks may create interaction [e.g., (22, 23)] to propose practical guidelines that will a false sense of security and lead to neglecting other important enhance current public health communication recommendations measures such as hand hygiene and social distancing, and that and address the above needs by fostering the basic human people may not wear them properly or repeatedly touch their psychology needs of autonomy, competence, and relatedness. mask, causing more harm than good (26, 27). Recent research has We then systematically searched the literature for research on shown that face masks could reduce the transmission of the virus health communication strategies during COVID-19 to discuss (28, 29), resulting in many governments advising or mandating our proposed guidelines in light of the emerging literature. the use of masks for healthy individuals in the community. We searched the literature in MEDLINE/PubMed and However, there are still debates on the potential risks of wearing EMBASE. The search was up to August 2020 using the terms masks, such as unintended negative consequences and the “COVID-19” (OR “corona,” “2019-nCov,” “SARS-COV-2”) AND effectiveness of different face coverings (30, 31). “communication” AND “strategy” (OR “strategies”), restricted Given the poor communication at the level of public health to studies in English. Papers were included if they related or government, particularly in some western nations on the to government communication strategy for the general public population benefit of face coverings, at the end of the Findings dealing with COVID-19. Papers relating to specific diseases, section we illustrate how the guidelines could be applied for mental health, emergency departments, and search trends encouraging people to wear face-coverings in public during this were excluded. pandemic (see Table 1). SDT was selected as a conceptual framework, since it is an empirically-validated approach to identify factors that promote FINDINGS sustained motivation, behavior change and well-being (24). In addition, compared to other motivational and behavior change In this section, we use SDT as a framework, and identify concepts theories and techniques, it is specifically focused on the processes from psychology, philosophy and HCI to foster each of the which one acquires the motivation to change his/her behavior three basic psychological needs: autonomy, competence, and and sustain it over time (16). relatedness, to propose practical guidelines for public health The domain of health communication integrates theoretical communication during pandemics such as COVID-19. For each and methodological approaches from diverse disciplines— guideline, we then discuss the emerging research from our including public health, communication, public relations, and systematic literature search. anthropology. Since insights from numerous fields may enhance The systematic literature search resulted in 253 articles (after our understanding of how people behave in crisis, what motivates removing duplicates and non-English articles). Two hundred six them, how they perceive the risk we face and how it relates papers were excluded based on title and abstract screening, and to psychological needs (9), we integrated concepts relating to 27 were excluded after reading the full paper. A total of 20 papers autonomy, competence and relatedness also from psychology, matched the inclusion criteria (36, 38–56). human computer interaction (HCI) and philosophy. Psychology Out of the 20 papers included in this overview, 12 contributes in understanding people’s behavior and motivations, papers focused on issues relating to autonomy [i.e., cultural philosophy acts as a guiding principle for behavior and brings values, voluntary adoption of preventative measures, societal considerations of ethics, such as explainability and transparency, tightness vs. looseness; (36, 38–48)]; five papers related to and HCI puts people in its center, focusing on usable, accessible issues of competence [i.e., adjusting messages to context, public and inclusive interfaces and interactions, which is very relevant involvement; (46, 49–52)] and nine addressed relatedness (sense when most of the communication is digitalised. of community, trust) (36, 38, 42, 46, 51, 53–56). Some of the papers addressed more than one issue. These findings are Case Study: Wearing Face-Coverings discussed in more detail under each of the proposed guidelines. One of the most inconsistent and ambiguous messages to the public during COVID-19 is whether the public should wear Public Health and Risk Communication face masks/face-covering and if so, which type and under Guidelines what circumstances. Only recently (June 5th), WHO revised their Fostering Autonomy recommendations advising the general public to wear fabric Behavior change is more effective and sustainable when people masks in settings where physical distancing of at least 1 m is not are autonomously motivated (17). According to the Self- possible [WHO, June 7]. This comes after recommending masks Determination Model of Health Behavior Change (16), an only for those with COVID-19 symptoms earlier this year (25). autonomy-supportive health care climate (e.g., providing choice, There was consistency in the recommendation that symptomatic taking the patients’ perspectives) facilitates satisfaction of the individuals and those in healthcare setting should wear a mask, basic psychological needs and respects patient choice. However, however discrepancies were observed in recommendations to the a controlling health care climate uses external pressure to general public and community settings (26). The main reasons move people toward desired outcomes (15). Common forms of Frontiers in Public Health | www.frontiersin.org 3 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Frontiers in Public Health | www.frontiersin.org 4 October 2020 | Volume 8 | Article 573397 TABLE 1 | A summary of the proposed guidelines for public health communication and their application to the “face-covering” case study. Guideline Description Example Case study: wearing face-covering Psychological need Create an Utilize identified regulation by providing relevant “I will adhere to the Encourage wearing masks or face covering by emphasizing Autonomy autonomy-supportive information and meaningful rationales for change, and requirements because I the rationale and value. E.g., “Your mask protects me, my health care climate not applying pressures and external controls that detract value their benefits” mask protects you” (Czech Republic Masks4All campaign) from a sense of autonomy and choice. One’s motivation (32). will reflect personal value of the behavior’s outcomes While encouraging the public to wear face covering, (e.g., “Stay home, protect the NHS, save lives” —UK acknowledge and inform the public that some people may coronavirus campaign). not be able to wear a mask due to disability (e.g., anxiety, Rapid, clear, consistent, and repetitive messages with prior trauma, lung disease, deafness) to avoid mask-shaming meaningful rationale for change and reflecting personal situations, where mask-wearing is promoted so strongly that value has the potential to cut through the infodemic and people who do not wear masks get abused for not doing increase adherence to preventative measures. so (31). Provide choice within In addition to what the public cannot do (e.g., social “I feel helpful rather than Provide different choices: preparing a mask at home (with Autonomy the limitations interactions), provide information on what they can do in helpless” simple instructions), a home-made mask delivered to your this situation. Advise people to be proactive and take home for free, buying a fabric-mask online, option to actions that are constructive and directly relate to the personalize your mask. Volunteering to make home-made crisis they are facing. masks for others and distributing them. Prioritize the situations where masks are most important (e.g., on crowded public transport or in shops), and where they are less important (in the open air, and not in a crowd), so that individuals feel empowered to choose to wear the mask at the most appropriate time and feel able to competently decide how to prioritize its use in case of scarcity. Provide choice for people who cannot wear a mask due to disability, for example, maintain social distancing, wear a visor. Apply a bottom-up Enhance accessibility, usability and inclusiveness by “This is advice which relates Engage different audiences in co-production to understand Competence communication creating messages that are actionable and can be to my circumstances and is their needs and facilitators/barriers to acquire and wear a integrated into people’s circumstances. easy for me to follow” mask. Inclusiveness: To be inclusive, there will be a need in Engage stakeholders in a co-production process to elicit addition to preparing and distributing home-made masks, to and identify informational needs of a given audience: hand out disposable masks in the entrance of populated what decisions or inferences are important for that places (e.g., tube stations, malls, schools). This is already audience to make? And what information do they need done in several countries (e.g., China, Israel). Note that some to make those decisions/inferences successfully? Look groups will struggle with mask-wearing (hard of hearing, to the science/evidence available. neurodiverse individuals) and reassure people that if a If sufficient information is available to satisfy the majority of the community comply with mask-wearing, it does informational needs of the audience, consider how it can not matter if some individuals cannot comply. be tailored to serve those information needs. Recognize Accessibility: The way the information is communicated must cultural and age-related differences and sensitivities. be accessible (e.g., different languages, visual only, audio Recommendations should be realistic for the vulnerable, only), including clear and simple instructions on how to make, disabled and poorest in society. use and wash the masks, and the channels used (social If there is no sufficient information, consider how the media, traditional media, brochures, hotlines, information uncertainty/incompleteness can best be communicated. boards, local communities and representatives). See recent Actionable messages that can be integrated into guidelines from OCHA, 2020 (33). people’s circumstances can cut through the infodemic since they are easier to follow and adhere to, compare to ambiguous and generic guidance. (Continued) Porat et al. Public Health Communication During COVID-19 Frontiers in Public Health | www.frontiersin.org 5 October 2020 | Volume 8 | Article 573397 TABLE 1 | Continued Guideline Description Example Case study: wearing face-covering Psychological need Actionable: Consider also choices or decision trees: if you can’t buy disposable masks then make your own mask at home, or ask for a fabric-mask to be delivered to your home (via website, phone number, text message), etc. This would allow people to tailor advice to their own situation. Clarity: clear communication on the intended plan and its duration (e.g., for how long people are expected to wear masks). Create solidarity Communicate the social norm, for example that the clear “I feel part of the People of power and celebrities all wearing a mask (e.g., Relatedness majority of people are restricting themselves to protect community”; “we are all in Zuzana Caputova president of Slovakia, matching her fabric others. Avoid “us vs. them mentality.” this together” mask with her outfit) (34). Emphasize desired behaviors rather than punishment for Emphasize acts of solidarity, e.g., industries repurposing their perceived breaches. manufacturing capacity to address mask shortages (35), volunteers producing home-made masks and distributing them (32). Consider using nudges to inform the social norm (36), for example, that others within the community are wearing masks in shops. Be transparent and Communicate epistemic transparency: What is known? “I feel the authorities want Epistemic transparency: Be honest about the evidence of the Relatedness acknowledge What is still uncertain? What scientific evidence is used my best interests.” efficiency of face masks and face covering for COVID-19, and uncertainty to inform a given policy or piece of advice? And value provide the rationale for encouraging to wear them (e.g., that transparency: What political value judgements are the the wearing of masks by the general public as a form of decisions based on? What overall aim/strategy is being source control is important in severe pandemics, since even pursued? What trade-offs are being made? partial protection could have a meaningful impact on To enhance dissemination of the information, collaborate transmission) (37). Emphasize the need to continue to adhere with trusted and popular sources on social media and to the hygiene and social distancing requirements. news outlets. Value transparency: The need to preserve limited supplies of face masks for professional use in healthcare settings, is an argument that does not address the question whether a mask is recommended for use by the public. It is an argument for the need to manufacture more masks or for advocating homemade face coverings, not for denying them from the public (27). Manufacturing of face masks, both fabric masks and disposable masks is required. Research is urgently needed to determine the efficiency of disposable masks and cloth masks, including recommended fabric, thickness, closeness of fit, during this pandemic (27), and communication should be regularly updated to present the new evidence. Porat et al. Public Health Communication During COVID-19 controlled motivation are external regulation, in which one acts As part of an autonomy-supportive climate, providing choice only to avoid punishment, accord with social pressure or get a is a central requirement for autonomy perception. In HCI, reward and introjection regulation, in which one acts to receive interfaces that offer options and choices of use, and do not in approval or avoid guilt feelings. According to SDT, both of these turn demand actions from users without their consent, enhance forms of controlled regulation may improve positive outcomes feelings of autonomy (24). Therefore, to foster autonomy, health only for a short period of time [e.g., (57)]. In a meta-analysis authorities, and local governments should be encouraged to study analyzing the relationships between mental and physical create an autonomy-supportive health care climate by enhancing health and autonomy supportive and controlling healthcare autonomous motivation (Guideline 1) and providing choice climates, a clear relationship was found between introjected within the limitations (Guideline 2). regulation and negative psychological outcomes such as anxiety and depression (17). Guideline 1: create an autonomy-supportive health In contrast, autonomous motivation can result in a sustainable care climate change. Common forms of autonomous motivation are identified In dealing with the new COVID-19 pandemic, different regulation and integrated regulation. Identified regulation is countries and governments have adopted different strategies to when one supports or identifies with the virtue or importance communicate guidelines and requirements to the general public. of a behavior. Identification is facilitated when healthcare Some countries motivate the public to change behavior and professionals, local governments or health authorities provide adhere to the new requirements by using controlled motivation applicable information and meaningful rationales for change, such as external regulation, thus, through mere authority and and do not apply pressure and external controls (16). Providing coercion. Other countries use autonomous motivation, such meaningful rationales for change may also enable the public to as identified regulation—making one understand, endorse, and reason about the advice. For example, by understanding what identify with the value or importance of a behavior. it is trying to achieve and how, we might be better able to The 12 papers (36, 38–48) relating to autonomy that were think about what else can be done, when it is not feasible to identified in the systematic search, show an agreement that rapid, strictly follow the advice or how to balance it against other clear and decisive response, effective management, and public considerations. Integrated regulation is when a person not only adherence to social norms were critical to slow the trajectory of values a behavior but has adapted this behavior as part of the virus in the early stages. his/her values and lifestyle. For example, healthcare professionals Countries with high levels of cultural tightness (strict norms promote integration by supporting patients when they face and little tolerance for deviance) and government efficiency were barriers to change by identifying compatible pathways to health. found to have lower mortality rates compared with countries that According to SDT, both of these regulations enhance sustainable have only one of these factors or neither (38). People in tight behavior change and well-being (15, 16). This means that even if nations may be more willing to adhere to cooperative norms (e.g., something is not enjoyable (intrinsically motivating), we can be effective handwashing, physical distancing). In loose-nations motivated to engage with it if our motivation is autonomous (24). (weak social norms and high tolerance of deviant behavior), A recent study examining adolescents’ motivations and such as the United States, citizens expect the government to engagement in social distancing and their mental health during provide sufficient information and rationale to justify taking COVID-19, found that the common reported motivations for away their individual and social freedom (36). There is also social distancing were social responsibility and not wanting evidence that a more democratic and participative style (vs. someone to get sick. Social responsibility motivations were autocratic or directive style) was more effective in managing the associated with more social distancing. In contrast, adolescents pandemic (39). who noted that they were adhering to social distancing due to lack Taiwan is an example for effective pandemic management of alternatives reported less social distancing. Thus, adolescents because of its low COVID-19 infection and mortality rates, who are motivated by a lack of alternatives may stop social which have been partly attributed to the clear communication distancing if it will be less convenient or there will be more of appropriate behavior, efficiency of its government’s resource appealing alternatives (58). coordination, and the voluntary adherence to social norms by its This pandemic requires adherence to several measures, where citizens (38, 43). some are needed for personal protection against the infection Findings also show that to enhance effective management and (e.g., hand hygiene, avoiding direct contact with an infected adherence to social norms during this pandemic, interventions person) and some are required for the protection of the will need to be tailored to fit differences in countries’ unique society as a whole (e.g., staying at home, social distancing) circumstances, while respecting their values, cultures, and belief and depend on a strong sense of community solidarity and systems (45–48). However, there is agreement that authoritarian shared responsibility. The use of masks includes both motivations responses to COVID-19 may cause long-term damage to the (personal and courtesy to others) (59). Fostering autonomy autonomy and health of citizens, as they often reflect self- and an autonomy-supportive climate might be beneficial not serving motives, lack of transparency, and limited information only to motivate people to adhere to personal protection sharing (38). measures but also for motivating and enhancing collective Adjusting the communication strategy to the culture and responsibility to defeat the virus as a joint effort and return values is important, but this does not contrast with our to normalcy. first recommendation, that governments, particularly in loose Frontiers in Public Health | www.frontiersin.org 6 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 nations, should strive to foster an autonomy-supportive health disabled patients, from accessing a particular service or from care climate, which motivates individuals to engage in health- understanding or acting on the recommendations (64). related behaviors for their own reasons, promotes success in To design an accessible and usable interaction, HCI dealing with barriers and resistance to change, and enhances researchers and practitioners follow a user-centered design emotions of acceptance, trust, and respect. This can be approach (22). This is done by designing a system based on done by utilizing identified regulation. In addition, clear, the user’s needs and requirements and by involving users and consistent, and repetitive messages with meaningful rationale stakeholders in the design process (23). This collaboration with for change and reflecting personal value have the potential users is commonly termed “co-production” which in current to cut through the infodemic and increase adherence to policy agendas is defined as a way of incorporating people’s preventative measures. This approach is particularly important expertise into health services and research ethics in more as it becomes clear that such messaging may play a role in public meaningful and substantial ways (65, 66). This process of health for months or years, and not for a few weeks as was community engagement encourages a more equal partnership initially projected. and reinforces the importance of listening to and celebrating the voices of communities to gain deeper understanding of the issues, thus helping to create knowledge and implement the Guideline 2: provide choice within the limitations findings for transformational social change (67–69). Using a co- The COVID-19 pandemic has resulted in many constraints production approach in health research was found to identify and limitations on the public, including social distancing, stakeholders’ pain points and research ideas (70, 71), ensures requirement to stay at home, screening, testing, contact that the proposed interventions are in line with stakeholders’ tracing, and travel restrictions (60). Many of these constraints needs (72, 73) and was found to improve health and social care are counter-intuitive and difficult to comply with, such as outcomes for people with long-term conditions and resultant keeping away from grandparents, who are most vulnerable in disabilities (74, 75). Co-production is still quite limited in its use this pandemic. to produce communication tools for public health messages. In these situations, understanding what people can do in In a pandemic, where the confusion is high, actionable addition to what they cannot do is important. It is useful to advise messages supporting decision making are required, and people people to be proactive and do things that are constructive and need the competence or the capability to act on these messages. directly relate to the crisis they are facing (61). Taking action and High level requirements or guidelines will be dismissed if one being proactive during a crisis can help to redevelop a sense of cannot adhere to the requirement or does not know how control and overcome emotions of helplessness and hopelessness (62). Helping the public feel in control and empowered on some to comply. Recommendations should be concrete, localized, accessible (e.g., in accessible formats), actionable and inclusive— parts of their lives may also decrease fear (61). One paper from tailored to different audiences and linguistically and culturally the systematic search related to this aspect (46) emphasized the appropriate (60, 76), and adaptable to their context and tensions importance of understanding one’s limitations (making changes with real life. For example, if an individual has COVID-19 that are possible and accepting what cannot be changed), symptoms, the UK advice is to isolate from members of their reversing negative thoughts and knowing one’s strengths during household—sleep in a spare room and use a second bathroom. this pandemic. This can be supported by resilience training, This type of advice is not actionable for those who live as a which could enhance health ownership and self-efficacy (46). family of five in a one bedroom flat. Other advice has been to Fostering Competence work from home, again this is not actionable for individuals who Internalization requires experiencing the competence and work as cleaners or construction workers. This type of advice confidence to change. In healthcare, competence is fostered from public health authorities appears to be applicable only to when professionals provide relevant information and feedback a wealthier section of society, and falls wide of the mark for (16). The patient is given the skills and tools for change, much of the population (76). If it had been end-user tested before and is supported when barriers arise (16). Acquiring a feeling being released, it could have avoided the disdain with which it of competence is promoted by autonomy. Once people are was received. autonomously engaged and have high willingness to act, they When planning a public health communication strategy, are then most inclined to learn and apply new methods and special attention should be given to vulnerable groups, including competencies (63). homeless people, people without adequate employment, Competence, or feeling capable and effective, is a familiar need immigrants, communities of color, people with disabilities, to HCI and usability experts, as usability heuristics are based certain frontline workers (60). It is important to engage these on the needs for competence and autonomy (24). For example, groups and organizations that represent vulnerable and disabled the amount, type and clarity of the feedback provided and the people in decision making to understand their needs and how intuitive design of the interface and controls, all impact the best to communicate and disseminate information. Failure users’ empowerment and engagement via increased competence to respect their needs will seriously undermine response (24). Accessibility, which is an important requirement for feeling efforts (60). A concern over the disproportionate impact competent, is a major concern in health technologies, which of COVID-19 on the Black, Asian and minority ethnic may include poor interface design or complex information (BAME) communities in the UK and US has already been that excludes parts of the population, such as elderly or raised (76, 77). Frontiers in Public Health | www.frontiersin.org 7 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Community engagement is important not just for formulating the main rationale for seeking out information is to reduce and communicating the messages but also on implementing uncertainty about a decision (82) and information seeking in the these messages, as risk communication messages not only have health context is an important element in coping with a disease personal implications but also have significant implications at and health-related uncertainty. community level (for example, closure of religious places, parks, Once the informational needs of a given audience have been and shops). identified, then we can look to the science or evidence available. Thus, engaging users and taking their perspective (bottom- Is sufficient information available to satisfy the informational up approach) to design an intervention that is actionable and needs of the audience? If it is, consider how information can tailored to their values and needs (while removing obstacles), be tailored to serve those information needs. If not, consider results in an intervention that is usable, accessible and inclusive how the uncertainty/incompleteness can best be communicated. (Guideline 3). This enhances their autonomy and competence, Again, the aim is to tailor the communication based on how it making users feel understood and enables them to perform their will impact the ability of the audience to take competent action. tasks effectively and efficiently, with increased satisfaction (22). Rather than thinking (primarily) about how information can be tailored to the cognitive limitations of the audience (simplifying Guideline 3: apply a bottom-up (vs. top-down) knowledge), focus on how the information can be tailored to communication using principles of co-production serve their needs. Rather than (or in addition to) thinking about WHO EPI-WIN defined “simplifying knowledge” as one of the the cognitive limitations of the audience, think (also) about the strategic areas of work to respond to the infodemic, defining it limitations of the available science/evidence and translating the as “ways of interpreting and explaining the science to different science into meaningful messages that resonate with the realities audiences” (2). This implies a top-down model of science of people’s circumstances. communication—we have “the science” or “the evidence” and the Five papers relating to a bottom-up approach were identified aim is to “simplify,” “explain,” or “interpret” it so that a given in the systematic literature search (46, 49–52). All papers audience understands it. This seems related to the “information emphasized the importance of contextualizing communication deficit model” (78), which is associated with a defined separation strategies to different populations and engaging communities and between experts who have the information and non-experts the public in decision making. who do not, and suggests that communication should focus Taiwan was given as an example for its human-centric on enhancing the transfer of information from experts to non- approach by understanding that successful management of the experts (79). This model has been criticized on theoretical and virus requires cooperation and trust from the public (50). pragmatic grounds (80). The government has engaged with various sectors of the Within this top-down framing, normative analysis starts from society, enhancing public support, and instead of forcing laws “the science/evidence.” It suggests that the ideal is for the to ban religious mass gatherings, the government reached an audience to understand all of it perfectly but that we have to understanding with local religious leaders which resulted in simplify the information because of the audience limitations. postponing mass events voluntarily. It also assumes that as long as the audience have understood Therefore, our third recommendation is to use a bottom- it correctly, they will definitely act on its meaning, and there up communication approach by engaging stakeholders, to will be no other barriers to them acting on it. There are enhance accessibility, usability, and inclusiveness by creating two main problems with this approach: (1) it suggests that messages that are actionable and can be integrated into people’s understanding the science is valuable for its own sake, that circumstances. These messages can cut through the infodemic the default aim is for the audience to understand as much since they are easier to follow and adhere to compare to as possible. Constraints to this aim stem from the limited ambiguous and generic guidance. ability of the audience to understand. The specific purposes or values of a given audience are not foregrounded by default; Fostering Relatedness (2) it suggests that the science/evidence is unproblematic or According to SDT, relatedness is the feeling of being understood, complete and uncontested. It does not foreground (by default) trusted, and cared for by others. It also relates to belonging, the possibility that the science/evidence might be uncertain or trusting others and contributing to others (13). In healthcare, the incomplete, might change in future, or might implicitly encode relationship between the practitioner and the patient is critical for value assumptions that are not shared by a given audience enhancing change. Patients look for the guidance and feedback (20, 81). of professionals and therefore a sense of being understood, An alternative framing would start bottom-up, from the respected and cared for is necessary to form an experience of trust informational needs of a given audience: What decisions or and connection that will allow internalization to happen (16). inferences are important for that audience to make in order Health communication is similar in this respect, the relationship to stay safe and healthy (given their specific values and between local governments and health authorities to the public is context)? And what information do they need to make those crucial for behavior change. People need to feel respected, cared decisions/inferences successfully? Philosophers have defended for and understood for trust to occur. In addition, they would like bottom-up approaches to explanation [e.g., (18, 19)]. Here we to feel part of a community. propose that this approach should be adopted for public health Trust in health authorities is linked to attitudes and behaviors communication as well. This is particularly important since in many aspects, having implications on vaccination adherence, Frontiers in Public Health | www.frontiersin.org 8 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 clinician-patient relationships, treatment adherence, and seeking whether individuals believe that official authorities are capable care (83). Underserved communities, such as people with of providing relevant health information and whether the disabilities and communities of color, are particularly distrustful health information can solve the health-related issues. If the of public health authorities and institutions, since they have been public feels that the authorities are competent, the trust in historically abused and undertreated in the healthcare system such information may be high. This might not be the case in (60). When the government credibility is low, people question developing countries where governments are corrupt and their the reliability of the official information and the ability of the motives are often questionable. authorities to handle the outbreak situation. Integrity trust is defined as the degree of trustees’ reliability A recent survey (84) suggests that UK citizens are more likely and honesty (87) and indicate whether individuals believe that to trust COVID-19 information from their workplace than from official authorities are honest in what they know and what they the government and official sources. The survey also implies that don’t know and in their motivations. When people feel that they people in the US and UK are less trusting of official information interact with others that honestly care about their health and on the pandemic than in other countries such as Germany. WHO well-being and do not have other agendas such as promoting and local scientific advisors are shown to be a trusted source of certain health services or gaining money then their perceived information by almost all countries. The recent decision of the US relatedness increases (90). to withdrawal from WHO (85), might influence the trust people The authorities’ response to an outbreak can enhance morale have toward WHO, perhaps in a negative way. and spirit of public solidarity that contributes to outbreak control A study on popular tweets following a case of diphtheria (59). However, if scientific uncertainty is not communicated in Spain (86) found that individual journalists and authors of properly to the public, it can aggravate the situation making it popular science were the most popular sources for disseminating difficult for solidarity. In addition, during outbreaks, such as health information on Twitter, tweeting mainly personal COVID-19, the advice needs to be based on emerging facts rather opinionated messages and engaging with followers, leading than established facts (for example, a loss or change to your sense journalists and the public to be more interconnected in real time. of smell or taste was added to the symptom list later on during Furthermore, the authors found that health organizations did not the outbreak in the UK). publish any of the popular tweets. This could suggest that it could Thus, for people to feel relatedness and trust in be useful for healthcare organizations to collaborate with popular local governments and health authorities, they need journalists and authors of popular science to disseminate health to feel part of the society and community (Guideline information on social media, while addressing misinformation 4) and perceive the communication as transparent and and public concerns in accessible ways (86). honest (Guideline 5). Previous research has shown that trust leads to trust- related behaviors such as making a purchase, sharing personal Guideline 4: create solidarity (we are all in this together) information, or performing an action on a website (87). In HCI, A key strategy in health communication is communicating the particularly in designing decision support systems (DSS), trust in social norm. A recent study (9) found that people are willing to the knowledge base is an enabler of DSS use. When healthcare restrict their everyday life to “flatten the curve” and decrease the professionals trust the system, they will use it, but when they do burden for the healthcare system. However, their motivation to not trust the system, it would not be used (88). restrict their everyday life was even higher when the need was to Trust begins with communication, and communicating protect vulnerable others. Communicating the social norm, that information during outbreaks is challenging, particularly as our the vast majority of people are restricting themselves to protect knowledge of a virus or a disease evolves (89). This emphasizes others, encourages others to do the same. It creates solidarity at the importance of building trust and respect well in advance, a time when everybody needs it and people may suffer from the rather than at the time of the outbreak. Trust is identified as a non-health-related issues of the pandemic (9). multidimensional concept including three types of trust beliefs: Six papers from the systematic search related to solidarity benevolence, competence and integrity (90). and sense of community (36, 38, 46, 51, 53, 54). Findings Benevolence trust is the degree to which trustees act in trustors’ showed that communicating the social norm during COVID- interests based on altruism (87, 91). This means that benevolent 19 could improve adherence (36, 38, 53). For example, nudges trustees select to help trustors even without a requirement or that inform what others within the community are doing had a reward to do so. In the context of public health communication, positive influence on citizens’ behavior (36) and are particularly benevolence trust indicates how much the public perceives health important in loose cultures, which are more likely to resist and official authorities to act in their interests, such as caring increased constraint. However, such nudges need to maintain about their health, trying their best to solve their health issues people’s sense of autonomy or they may backfire and elicit and keeping personal information safe. When benevolence trust psychological reaction (38). beliefs are high, people are more likely to feel cared for and In contrast, political communication, as was seen in the seek health information. Both autonomy and relatedness are US (i.e., propagating conspiracy beliefs, using war language) important to support benevolence trust beliefs (90). contributes to “us vs. them” mentality, which may undermine Competence trust is the degree to which trustees are capable people’s sense of collective support and care and lead to of meeting trustors’ needs (87). In relation to public health individualistic behaviors such as hoarding, which was seen in communication, individuals’ competence trust depends on this pandemic (46, 54). Furthermore, messages that emphasize Frontiers in Public Health | www.frontiersin.org 9 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 desired behaviors are likely to lead to higher adherence than those preventative measures during COVID-19. For example, the that emphasizes punishment for perceived breaches (46). Romanian public lost trust in its healthcare system after years of corruption, which resulted in citizens not reporting truthfully Guideline 5: be transparent and acknowledge uncertainty about their travels and disregarding the government’s restrictions Public trust is injured when governments or health authorities (55). In the US, individuals interpreted the COVID-19 threat downplay the true risk posed by a crisis or have caused panic by in partisan-patterned ways, with Republicans following party leaders in dismissing the threat and taking less actions than overstating a potential threat. Honesty about what is known and what is unknown is a critical component of transparency (92), did Democrats (54). In a recent survey in the US, only 23% of respondents expressed high levels of trust in COVID-19 and the ability of authorities to apologize frankly if a mistake was made. information given by the President, where in Australia, the government’s response was rated highly (42). This could explain Lack of transparency breeds rumors, confusion, speculations, and engenders mistrust leading people to seek information from the higher adherence of preventative measures in Australia vs. the US, and the more effective management of the pandemic. unreliable sources (60). Social media offers a fruitful platform for misinformation to be disseminated. Accurate information Thus, our last recommendation is to communicate with both epistemic and value transparency, while acknowledging provided by trusted clinicians and scientists that emphasize the facts and not the myth (93) can help mitigate the spread uncertainty. Trust is probably the most important criterion in fighting the infodemic. Trusted sources have the power of misinformation. Health communication experts can directly to influence people, however there is no trust without counter false information and narratives while promoting reliable sources of health information (92). trustworthiness, and governments and other authorities should strive to gain the public’s trust by being honest, transparent, Philosophers of science have emphasized the importance of transparency for creating (ethically well-placed) trust in informing early in the outbreak and acknowledging uncertainty and mistakes. science-informed policy (20, 21, 81, 94). They highlight the importance of both epistemic and value transparency (95) in communications by local governments and health authorities. DISCUSSION Epistemic transparency: What is known? What is still uncertain? What scientific evidence is used to inform a given policy or piece This paper proposes practical guidelines for public health and of advice? Value transparency: What political value judgements risk communication, starting from addressing humans’ basic are the decisions based on? What overall aim/strategy is being psychological needs of autonomy, competence, and relatedness. pursued? What trade-offs are being made? Fostering these needs during this pandemic has the potential to In addition to public trust, transparency could enforce careful cut through the infodemic and maintain our well-being, while and accountable decision making as the shortcomings are likely enhancing our intrinsic motivation to adhere to the required to be revealed. This is particularly important in the context behavior change (e.g., staying at home, social distancing, hand of a global crisis, where many governments are simultaneously hygiene) for longer periods of time. seeking to address the same problem. Individual governments The COVID-19 pandemic requires long-term strategies and may feel incentivised to present policy as purely evidence- sustainable behavior changes. The requirements and expectations based, to avoid taking responsibility for potentially controversial from the public during this long period are extreme (i.e., staying political judgements. However, if governments pursue different at home, social distancing), and have serious implications for policies, the public will notice the discrepancy and start asking the privacy, freedom and wellbeing of citizens (97). Restrictive questions. If good answers are not forthcoming, this can or mandatory measures need to be proportionate and well- breed distrust and lead people to start speculating about what explained and justified, if they are to be effective and to receive the “real” motives behind the policies are and to seek out the support and trust of the public (97). alternative sources of information. For example, there has been Health communication has an important role in influencing, widespread confusion as to whether the UK government is supporting and engaging individuals, communities, healthcare pursuing (or has pursued) a “herd immunity” strategy, fuelling professionals, policymakers, and the public to adopt and speculation that this was a deliberate “cold-blooded experiment sustain a behavioral practice that will ultimately improve health in social engineering” (96). Apparently, the term was used in outcomes (98). When the restrictions on the public are so early messaging to help justify their proposed social distancing extreme and limiting, health communication strategies that focus measures. Though the government has since disavowed the use of on enhancing basic psychological needs such as autonomy, this term, there is speculation that the government continues to competence and relatedness (within the limitations) are critical pursue the herd immunity strategy. This is arguably reinforced by for maintaining well-being and motivation to adhere to these the fact that other governments have adopted different strategies requirements for a long period of time. for managing the pandemic, highlighting that the UK’s approach To cut through the infodemic and support wellness and was not the only one possible. A clearer and more transparent sustainable behavior change, we applied the SDT as a framework account of the overall strategy would have helped avoid the and used concepts from philosophy, psychology and HCI resulting distrust. to discuss how these concepts can be applied to health Five papers relating to transparency and trust were identified communication during the COVID-19 pandemic to enhance in our systematic search (42, 46, 54–56). Findings show that human’s basic psychological needs of autonomy, competence and trust is a critical factor influencing the public’s adherence to relatedness. These three needs are linked together and are all Frontiers in Public Health | www.frontiersin.org 10 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 essential for ongoing psychological growth and well-being (14). decisions (105). Explainable recommendations help to improve This resulted in proposing five practical guidelines, which gained the transparency, effectiveness, trustworthiness and satisfaction initial support from the emerging literature on the effectiveness of recommendation systems (106). According to Miller (107) of different communication strategies during COVID-19. the main reason that people want explanations is to facilitate To foster autonomy, we propose to (1) create an autonomy- learning, enabling them to create a conceptual model where supportive health care climate and (2) provide choice within they can predict and control future phenomena (105). Thus, the limitations. this bottom-up approach will enable providing messages that are A common concern across disciplines such as public health inclusive, actionable, and integrated into people’s circumstances and philosophy, is the tension and balance between ensuring the and hence have better chances to cut through the infodemic. safety of people and respecting their right to autonomy (64, 99). Furthermore, a bottom-up approach which engages the public As the findings show, communication strategy should be tailored enhances trust which builds confidence in the authorities’ ability to the culture, values and context, and therefore one may argue to manage and control the situation (7). that an autonomy-supportive healthcare culture may not “work” Engaging different audiences and understanding their specific in some cultures or countries and that without external regulation circumstances and needs is critical in designing interventions (e.g., enforceable legislation), the adherence might be low. For that will be inclusive and address those needs. Historically, risk example, the message might not get through the infodemic, might communication during crisis has been inaccessible to vulnerable not be trusted, people might not find it actionable if it is in conflict people, including people with disabilities, cognitive limitations with other things that are important to them, or they might find or low literacy levels (108) resulting in them not receiving it hard to prioritize it (e.g., stay at home vs. going to work and information and being able to act in a timely manner (11). earning money to feed their family). In the short-term controlled Initiatives such as Community Citizen Science (CCS) which motivation by external regulation may be effective (people may embraces participatory democracy to influence policymaking and obey), if the rationale is explained transparently. In the longer address local concerns, should be encouraged and applied (104). term, people may get tired from the strict measures, resulting, as To foster relatedness, we propose to (4) create solidarity and is already evidenced in this pandemic, in breaches of lockdowns, (5) be transparent and acknowledge uncertainty. Community domestic violence (100), street violence and demonstrations activism evidenced in the current COVID-19 emphasizes the (101), police brutality (102), and “quarantine fatigue” (48). critical and impactful role of the public and the importance Furthermore, a strict and closed list of “essential” reasons of the bottom-up approach in engaging the public in decision that people may go out of their house for (e.g., buying food, making which enhances the understanding of the experiences doctor appointment), cannot cover all the needs of individual and concerns of those affected. Engaging the public and being cases, particularly when it relates to mental health. Whilst we transparent and honest about the decision making process is may be able to identify what is “essential” to us on an individual critical for changing behavior and community initiatives such basis, it is impossible to define what is essential to someone as the above. Governments cannot just ask for people to trust else (103). Measures to respond to COVID-19 are essential. them, they have to earn trust and do so in the right ways. However, they should also be ethical, proportionate, and subject They should not just be trusted but also be trustworthy. Trust to robust democratic accountability (97). There should be strong and transparency go together: we can only trust if we are well- countervailing arguments to denying people, properly informed informed and understand what is being asked from us (109). about the risks, to make choices about how to live their lives (97). The proposed guidelines are a starting point for developing To foster competence, we propose to (3) apply a bottom-up a multidisciplinary comprehensive public health communication communication. Conventionally, scientists and decision-makers strategy that fosters well-being and sustainable behavior change apply top-down approaches to communicate and engage with at its core. While some of the guidelines we propose the public (104). At the current time, organizations such as have been discussed previously in the context of health WHO look for ways to address the infodemic by “simplifying communication, such as transparency and trust [e.g., (59)], these knowledge,” thus, applying a top-down approach where the aim guidelines enhance and strengthen their importance by providing is to take the existing science and simplifying it so the public supporting evidence from a different perspective and practical (different audiences) will understand. We propose to apply a and actionable ways to act on them. Other proposed guidelines bottom-up approach that will start from understanding the such as fostering an autonomy-supportive climate and applying informational needs of a given audience based on the decisions a bottom-up approach are unique and novel in this context. they have to make in their specific context and circumstances, While these guidelines are based on evidence from other and tailor the information to satisfy these informational needs. domains, and gained initial supporting evidence from this This means that some communication strategies would have to pandemic, they will need to be validated in the context of be formulated locally to take into account local demographics public health communication during such pandemics. The and needs, devolved to e.g., city councils. This is in line with factors affecting the pandemic outcomes in different countries is “explainability,” a concept in philosophy and HCI, that has complex, and their medium and long-term social, psychological, been recently discussed extensively in the context of Artificial and economic costs are far from being understood. Thus, part Intelligence (Explainable AI). Explanations are provided to of the preparedness for future health crises should include a support transparency, where users can see aspects of the robust analysis of the best strategies for public cooperation and inner state of the AI system and support them in making communication (12). Frontiers in Public Health | www.frontiersin.org 11 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 CONCLUSION AUTHOR CONTRIBUTIONS Health communication that starts by fostering well-being and TP and RN: conception of the study. TP, RN, RC, PP, and EF: basic human psychological needs, has the potential to cut review of the literature, analysis, interpretation of themes and through the infodemic and promote effective and sustainable guidelines, revising the paper critically for important intellectual behavior change during such pandemics. Our guidelines provide content, and sign-off final version of manuscript. TP: initial a starting point for developing a concrete public health draft of manuscript. All authors contributed to the article and communication strategy. approved the submitted version. FUNDING DATA AVAILABILITY STATEMENT RN was funded by Wellcome Trust [213660/Z/18/Z] and by the The original contributions presented in the study are included Leverhulme Trust through the Leverhulme Center for the Future in the article/supplementary material, further inquiries can be of Intelligence. directed to the corresponding author/s. REFERENCES 15. Ryan RM, Deci EL. 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This is an open-access responding to pandemic influenza: implications for people with disabilities. article distributed under the terms of the Creative Commons Attribution License (CC Am J Public Health. (2009) 99:S294–300. doi: 10.2105/AJPH.2009.1 BY). The use, distribution or reproduction in other forums is permitted, provided 62677 the original author(s) and the copyright owner(s) are credited and that the original 109. Whittall H. COVID, Transparency and trust. Nuffield Council on Bioethics. publication in this journal is cited, in accordance with accepted academic practice. (2020) Available online at: https://www.nuffieldbioethics.org/blog/covid- No use, distribution or reproduction is permitted which does not comply with these transparency-and-trust (accessed April 16, 2020). terms. Frontiers in Public Health | www.frontiersin.org 15 October 2020 | Volume 8 | Article 573397 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Frontiers in Public Health Pubmed Central

Public Health and Risk Communication During COVID-19—Enhancing Psychological Needs to Promote Sustainable Behavior Change

Frontiers in Public Health , Volume 8 – Oct 27, 2020

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ORIGINAL RESEARCH published: 27 October 2020 doi: 10.3389/fpubh.2020.573397 Public Health and Risk Communication During COVID-19—Enhancing Psychological Needs to Promote Sustainable Behavior Change 1 2 1 3 3 Talya Porat *, Rune Nyrup , Rafael A. Calvo , Priya Paudyal and Elizabeth Ford 1 2 Dyson School of Design Engineering, Imperial College London, London, United Kingdom, Leverhulme Centre for the Future of Intelligence, University of Cambridge, Cambridge, United Kingdom, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom Background: The current COVID-19 pandemic requires sustainable behavior change Edited by: to mitigate the impact of the virus. A phenomenon which has arisen in parallel with this Victoria Ann Newsom, Olympic College, United States pandemic is an infodemic—an over-abundance of information, of which some is accurate Reviewed by: and some is not, making it hard for people to find trustworthy and reliable guidance to Gregory Dore, make informed decisions. This infodemic has also been found to create distress and University of New South increase risks for mental health disorders, such as depression and anxiety. Wales, Australia Ranjeet Kumar Sinha, Aim: To propose practical guidelines for public health and risk communication that Patna Medical College, India will enhance current recommendations and will cut through the infodemic, supporting *Correspondence: accessible, reliable, actionable, and inclusive communication. The guidelines aim to Talya Porat t.porat@imperial.ac.uk support basic human psychological needs of autonomy, competence, and relatedness to support well-being and sustainable behavior change. Specialty section: This article was submitted to Method: We applied the Self-Determination Theory (SDT) and concepts from Public Health Policy, psychology, philosophy and human computer interaction to better understand a section of the journal Frontiers in Public Health human behaviors and motivations and propose practical guidelines for public health Received: 16 June 2020 communication focusing on well-being and sustainable behavior change. We then Accepted: 17 September 2020 systematically searched the literature for research on health communication strategies Published: 27 October 2020 during COVID-19 to discuss our proposed guidelines in light of the emerging literature. Citation: We illustrate the guidelines in a communication case study: wearing face-coverings. Porat T, Nyrup R, Calvo RA, Paudyal P and Ford E (2020) Public Health and Findings: We propose five practical guidelines for public health and risk Risk Communication During communication that will cut through the infodemic and support well-being and COVID-19—Enhancing Psychological Needs to Promote Sustainable sustainable behavior change: (1) create an autonomy-supportive health care Behavior Change. climate; (2) provide choice; (3) apply a bottom-up approach to communication; Front. Public Health 8:573397. doi: 10.3389/fpubh.2020.573397 (4) create solidarity; (5) be transparent and acknowledge uncertainty. Frontiers in Public Health | www.frontiersin.org 1 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Conclusion: Health communication that starts by fostering well-being and basic human psychological needs has the potential to cut through the infodemic and promote effective and sustainable behavior change during such pandemics. Our guidelines provide a starting point for developing a concrete public health communication strategy. Keywords: public health, health communication (MESH), risk communication, COVID-19, coronavirus, infodemic, behavior change, well-being BACKGROUND with the need to provide the public with actionable information for health protection (10), while taking into consideration The World Health Organization (WHO) is leading and the needs of vulnerable populations (11). Experience from coordinating the global effort to respond to the coronavirus previous pandemics may be helpful in understanding human disease (COVID-19) outbreak, however, it is also fighting a behavior in public health crises, but many things have changed second “disease” —an infodemic (1). An infodemic is an over- including the virus and its spread, the ways people collect and abundance of information, of which some is accurate and some search for information and the ways authorities such as WHO is not, making it hard for people to find trustworthy and communicate with the public via social media (9). In addition, reliable guidance to make informed decisions (2). This adds pandemics like COVID-19 are unique in the sense that face to to the natural difficulties in making decisions and adhering face interactions are limited and people have to rely on remote to recommendations, and may increase distress and the risks platforms like social media and news outlets to gain information. for common mental health disorders (3). Studies during the Thus, there is a need for enhanced communication guidelines COVID-19 outbreak already show that the high prevalence and strategies that cut through the infodemic by better of mental health problems, especially anxiety, and depression understanding human behaviors and motivations (12) and that among the general population, is positively associated with are: (1) accessible; (2) reliable; (3) useful; (4) actionable; (5) frequent social media exposure (4). acceptable; (6) inclusive; (7) consistent; (8) understandable, and In the age of social media, the infodemic phenomenon (9) promote sustainable behavior change to mitigate the impact is amplified, information spreads faster and further than of the virus. the science (1), leading even faster to information overload, Decades of research show that individuals and societies can including misinformation and myths. The COVID-19 pandemic only prosper in environments that foster basic psychological is characterized by inconsistent, ambiguous, contradicting needs, such as autonomy and competence (13). Evidence messages and absence of clear, actionable, credible, and inclusive from the Self Determination Theory [SDT: (14, 15)] shows information from authorities that people trust, leaving space for that by maximizing one’s experience of autonomy (meaning, other actors to fill the void irresponsibly. Politicians, officials, volition, choice), competence (feeling effective and mastery), media, celebrities, and even heads of state, have been elevating and relatedness (feeling cared for by others, trusted and disinformation, posing a risk to global health and safety (5). It is understood), the control of health-related behaviors is likely therefore important to understand what sources of information to be internalized, and behavior change is likely to be and modes of communication are trusted and popular among the maintained (13). population and how communicators can tap into them to make Developing a sense of autonomy, competence and sure their communication strategy is most effective. relatedness are critical for self-regulating and sustaining Health communication is an essential tool for achieving public behaviors that improve health and well-being. This means that health objectives, including facilitating and supporting behavior environments and contexts that foster autonomy, confidence, change and eliminating health discrepancies (6). Effective risk and trust are likely to enhance adherence and improve health communication is crucial for enhancing understanding of health outcomes (13). threats and to support the public in making informed decisions Previous research has shown a positive effect of meeting these for mitigating the risks (7). Poor communication is often a psychological needs (autonomy, competence and relatedness) factor in enabling public concerns to escalate and groups to on mental health (fewer depressive symptoms), physical health become polarized (8). “The public” may be accused of ignoring and quality of life, including increased physical activity, reduced scientifically sounded and sensible advice and “those in charge” smoking, and improved adherence to prescribed medications may be perceived as untrustworthy and secretive (8). (16, 17). We are not aware of previous literature in health Due to excess demand for trustworthy and timely information communication that has applied the SDT framework and about COVID-19, WHO has established the Information integrated concepts from psychology, philosophy and human Network for Epidemics (EPI-WIN), which defined “simplifying computer interaction. knowledge” as one of the strategic areas of work to respond to The COVID-19 pandemic requires long-term strategies and the infodemic—the challenge being to translate the knowledge sustainable behavior changes. Engaging the public and enhancing into actionable and behavioral change messages (2). In this intrinsic motivation is imperative for these changes to be pandemic, massive and fast behavioral change is critical (9) sustainable and foster well-being. Frontiers in Public Health | www.frontiersin.org 2 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 METHOD for these discrepancies were the limited evidence on their efficacy in preventing respiratory infections during epidemics; the need We applied the self-determination theory [SDT: (14, 15)] and to preserve limited supplies of face masks for professional use concepts from philosophy [e.g., (18–21)] and human computer in healthcare settings; the argument that face masks may create interaction [e.g., (22, 23)] to propose practical guidelines that will a false sense of security and lead to neglecting other important enhance current public health communication recommendations measures such as hand hygiene and social distancing, and that and address the above needs by fostering the basic human people may not wear them properly or repeatedly touch their psychology needs of autonomy, competence, and relatedness. mask, causing more harm than good (26, 27). Recent research has We then systematically searched the literature for research on shown that face masks could reduce the transmission of the virus health communication strategies during COVID-19 to discuss (28, 29), resulting in many governments advising or mandating our proposed guidelines in light of the emerging literature. the use of masks for healthy individuals in the community. We searched the literature in MEDLINE/PubMed and However, there are still debates on the potential risks of wearing EMBASE. The search was up to August 2020 using the terms masks, such as unintended negative consequences and the “COVID-19” (OR “corona,” “2019-nCov,” “SARS-COV-2”) AND effectiveness of different face coverings (30, 31). “communication” AND “strategy” (OR “strategies”), restricted Given the poor communication at the level of public health to studies in English. Papers were included if they related or government, particularly in some western nations on the to government communication strategy for the general public population benefit of face coverings, at the end of the Findings dealing with COVID-19. Papers relating to specific diseases, section we illustrate how the guidelines could be applied for mental health, emergency departments, and search trends encouraging people to wear face-coverings in public during this were excluded. pandemic (see Table 1). SDT was selected as a conceptual framework, since it is an empirically-validated approach to identify factors that promote FINDINGS sustained motivation, behavior change and well-being (24). In addition, compared to other motivational and behavior change In this section, we use SDT as a framework, and identify concepts theories and techniques, it is specifically focused on the processes from psychology, philosophy and HCI to foster each of the which one acquires the motivation to change his/her behavior three basic psychological needs: autonomy, competence, and and sustain it over time (16). relatedness, to propose practical guidelines for public health The domain of health communication integrates theoretical communication during pandemics such as COVID-19. For each and methodological approaches from diverse disciplines— guideline, we then discuss the emerging research from our including public health, communication, public relations, and systematic literature search. anthropology. Since insights from numerous fields may enhance The systematic literature search resulted in 253 articles (after our understanding of how people behave in crisis, what motivates removing duplicates and non-English articles). Two hundred six them, how they perceive the risk we face and how it relates papers were excluded based on title and abstract screening, and to psychological needs (9), we integrated concepts relating to 27 were excluded after reading the full paper. A total of 20 papers autonomy, competence and relatedness also from psychology, matched the inclusion criteria (36, 38–56). human computer interaction (HCI) and philosophy. Psychology Out of the 20 papers included in this overview, 12 contributes in understanding people’s behavior and motivations, papers focused on issues relating to autonomy [i.e., cultural philosophy acts as a guiding principle for behavior and brings values, voluntary adoption of preventative measures, societal considerations of ethics, such as explainability and transparency, tightness vs. looseness; (36, 38–48)]; five papers related to and HCI puts people in its center, focusing on usable, accessible issues of competence [i.e., adjusting messages to context, public and inclusive interfaces and interactions, which is very relevant involvement; (46, 49–52)] and nine addressed relatedness (sense when most of the communication is digitalised. of community, trust) (36, 38, 42, 46, 51, 53–56). Some of the papers addressed more than one issue. These findings are Case Study: Wearing Face-Coverings discussed in more detail under each of the proposed guidelines. One of the most inconsistent and ambiguous messages to the public during COVID-19 is whether the public should wear Public Health and Risk Communication face masks/face-covering and if so, which type and under Guidelines what circumstances. Only recently (June 5th), WHO revised their Fostering Autonomy recommendations advising the general public to wear fabric Behavior change is more effective and sustainable when people masks in settings where physical distancing of at least 1 m is not are autonomously motivated (17). According to the Self- possible [WHO, June 7]. This comes after recommending masks Determination Model of Health Behavior Change (16), an only for those with COVID-19 symptoms earlier this year (25). autonomy-supportive health care climate (e.g., providing choice, There was consistency in the recommendation that symptomatic taking the patients’ perspectives) facilitates satisfaction of the individuals and those in healthcare setting should wear a mask, basic psychological needs and respects patient choice. However, however discrepancies were observed in recommendations to the a controlling health care climate uses external pressure to general public and community settings (26). The main reasons move people toward desired outcomes (15). Common forms of Frontiers in Public Health | www.frontiersin.org 3 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Frontiers in Public Health | www.frontiersin.org 4 October 2020 | Volume 8 | Article 573397 TABLE 1 | A summary of the proposed guidelines for public health communication and their application to the “face-covering” case study. Guideline Description Example Case study: wearing face-covering Psychological need Create an Utilize identified regulation by providing relevant “I will adhere to the Encourage wearing masks or face covering by emphasizing Autonomy autonomy-supportive information and meaningful rationales for change, and requirements because I the rationale and value. E.g., “Your mask protects me, my health care climate not applying pressures and external controls that detract value their benefits” mask protects you” (Czech Republic Masks4All campaign) from a sense of autonomy and choice. One’s motivation (32). will reflect personal value of the behavior’s outcomes While encouraging the public to wear face covering, (e.g., “Stay home, protect the NHS, save lives” —UK acknowledge and inform the public that some people may coronavirus campaign). not be able to wear a mask due to disability (e.g., anxiety, Rapid, clear, consistent, and repetitive messages with prior trauma, lung disease, deafness) to avoid mask-shaming meaningful rationale for change and reflecting personal situations, where mask-wearing is promoted so strongly that value has the potential to cut through the infodemic and people who do not wear masks get abused for not doing increase adherence to preventative measures. so (31). Provide choice within In addition to what the public cannot do (e.g., social “I feel helpful rather than Provide different choices: preparing a mask at home (with Autonomy the limitations interactions), provide information on what they can do in helpless” simple instructions), a home-made mask delivered to your this situation. Advise people to be proactive and take home for free, buying a fabric-mask online, option to actions that are constructive and directly relate to the personalize your mask. Volunteering to make home-made crisis they are facing. masks for others and distributing them. Prioritize the situations where masks are most important (e.g., on crowded public transport or in shops), and where they are less important (in the open air, and not in a crowd), so that individuals feel empowered to choose to wear the mask at the most appropriate time and feel able to competently decide how to prioritize its use in case of scarcity. Provide choice for people who cannot wear a mask due to disability, for example, maintain social distancing, wear a visor. Apply a bottom-up Enhance accessibility, usability and inclusiveness by “This is advice which relates Engage different audiences in co-production to understand Competence communication creating messages that are actionable and can be to my circumstances and is their needs and facilitators/barriers to acquire and wear a integrated into people’s circumstances. easy for me to follow” mask. Inclusiveness: To be inclusive, there will be a need in Engage stakeholders in a co-production process to elicit addition to preparing and distributing home-made masks, to and identify informational needs of a given audience: hand out disposable masks in the entrance of populated what decisions or inferences are important for that places (e.g., tube stations, malls, schools). This is already audience to make? And what information do they need done in several countries (e.g., China, Israel). Note that some to make those decisions/inferences successfully? Look groups will struggle with mask-wearing (hard of hearing, to the science/evidence available. neurodiverse individuals) and reassure people that if a If sufficient information is available to satisfy the majority of the community comply with mask-wearing, it does informational needs of the audience, consider how it can not matter if some individuals cannot comply. be tailored to serve those information needs. Recognize Accessibility: The way the information is communicated must cultural and age-related differences and sensitivities. be accessible (e.g., different languages, visual only, audio Recommendations should be realistic for the vulnerable, only), including clear and simple instructions on how to make, disabled and poorest in society. use and wash the masks, and the channels used (social If there is no sufficient information, consider how the media, traditional media, brochures, hotlines, information uncertainty/incompleteness can best be communicated. boards, local communities and representatives). See recent Actionable messages that can be integrated into guidelines from OCHA, 2020 (33). people’s circumstances can cut through the infodemic since they are easier to follow and adhere to, compare to ambiguous and generic guidance. (Continued) Porat et al. Public Health Communication During COVID-19 Frontiers in Public Health | www.frontiersin.org 5 October 2020 | Volume 8 | Article 573397 TABLE 1 | Continued Guideline Description Example Case study: wearing face-covering Psychological need Actionable: Consider also choices or decision trees: if you can’t buy disposable masks then make your own mask at home, or ask for a fabric-mask to be delivered to your home (via website, phone number, text message), etc. This would allow people to tailor advice to their own situation. Clarity: clear communication on the intended plan and its duration (e.g., for how long people are expected to wear masks). Create solidarity Communicate the social norm, for example that the clear “I feel part of the People of power and celebrities all wearing a mask (e.g., Relatedness majority of people are restricting themselves to protect community”; “we are all in Zuzana Caputova president of Slovakia, matching her fabric others. Avoid “us vs. them mentality.” this together” mask with her outfit) (34). Emphasize desired behaviors rather than punishment for Emphasize acts of solidarity, e.g., industries repurposing their perceived breaches. manufacturing capacity to address mask shortages (35), volunteers producing home-made masks and distributing them (32). Consider using nudges to inform the social norm (36), for example, that others within the community are wearing masks in shops. Be transparent and Communicate epistemic transparency: What is known? “I feel the authorities want Epistemic transparency: Be honest about the evidence of the Relatedness acknowledge What is still uncertain? What scientific evidence is used my best interests.” efficiency of face masks and face covering for COVID-19, and uncertainty to inform a given policy or piece of advice? And value provide the rationale for encouraging to wear them (e.g., that transparency: What political value judgements are the the wearing of masks by the general public as a form of decisions based on? What overall aim/strategy is being source control is important in severe pandemics, since even pursued? What trade-offs are being made? partial protection could have a meaningful impact on To enhance dissemination of the information, collaborate transmission) (37). Emphasize the need to continue to adhere with trusted and popular sources on social media and to the hygiene and social distancing requirements. news outlets. Value transparency: The need to preserve limited supplies of face masks for professional use in healthcare settings, is an argument that does not address the question whether a mask is recommended for use by the public. It is an argument for the need to manufacture more masks or for advocating homemade face coverings, not for denying them from the public (27). Manufacturing of face masks, both fabric masks and disposable masks is required. Research is urgently needed to determine the efficiency of disposable masks and cloth masks, including recommended fabric, thickness, closeness of fit, during this pandemic (27), and communication should be regularly updated to present the new evidence. Porat et al. Public Health Communication During COVID-19 controlled motivation are external regulation, in which one acts As part of an autonomy-supportive climate, providing choice only to avoid punishment, accord with social pressure or get a is a central requirement for autonomy perception. In HCI, reward and introjection regulation, in which one acts to receive interfaces that offer options and choices of use, and do not in approval or avoid guilt feelings. According to SDT, both of these turn demand actions from users without their consent, enhance forms of controlled regulation may improve positive outcomes feelings of autonomy (24). Therefore, to foster autonomy, health only for a short period of time [e.g., (57)]. In a meta-analysis authorities, and local governments should be encouraged to study analyzing the relationships between mental and physical create an autonomy-supportive health care climate by enhancing health and autonomy supportive and controlling healthcare autonomous motivation (Guideline 1) and providing choice climates, a clear relationship was found between introjected within the limitations (Guideline 2). regulation and negative psychological outcomes such as anxiety and depression (17). Guideline 1: create an autonomy-supportive health In contrast, autonomous motivation can result in a sustainable care climate change. Common forms of autonomous motivation are identified In dealing with the new COVID-19 pandemic, different regulation and integrated regulation. Identified regulation is countries and governments have adopted different strategies to when one supports or identifies with the virtue or importance communicate guidelines and requirements to the general public. of a behavior. Identification is facilitated when healthcare Some countries motivate the public to change behavior and professionals, local governments or health authorities provide adhere to the new requirements by using controlled motivation applicable information and meaningful rationales for change, such as external regulation, thus, through mere authority and and do not apply pressure and external controls (16). Providing coercion. Other countries use autonomous motivation, such meaningful rationales for change may also enable the public to as identified regulation—making one understand, endorse, and reason about the advice. For example, by understanding what identify with the value or importance of a behavior. it is trying to achieve and how, we might be better able to The 12 papers (36, 38–48) relating to autonomy that were think about what else can be done, when it is not feasible to identified in the systematic search, show an agreement that rapid, strictly follow the advice or how to balance it against other clear and decisive response, effective management, and public considerations. Integrated regulation is when a person not only adherence to social norms were critical to slow the trajectory of values a behavior but has adapted this behavior as part of the virus in the early stages. his/her values and lifestyle. For example, healthcare professionals Countries with high levels of cultural tightness (strict norms promote integration by supporting patients when they face and little tolerance for deviance) and government efficiency were barriers to change by identifying compatible pathways to health. found to have lower mortality rates compared with countries that According to SDT, both of these regulations enhance sustainable have only one of these factors or neither (38). People in tight behavior change and well-being (15, 16). This means that even if nations may be more willing to adhere to cooperative norms (e.g., something is not enjoyable (intrinsically motivating), we can be effective handwashing, physical distancing). In loose-nations motivated to engage with it if our motivation is autonomous (24). (weak social norms and high tolerance of deviant behavior), A recent study examining adolescents’ motivations and such as the United States, citizens expect the government to engagement in social distancing and their mental health during provide sufficient information and rationale to justify taking COVID-19, found that the common reported motivations for away their individual and social freedom (36). There is also social distancing were social responsibility and not wanting evidence that a more democratic and participative style (vs. someone to get sick. Social responsibility motivations were autocratic or directive style) was more effective in managing the associated with more social distancing. In contrast, adolescents pandemic (39). who noted that they were adhering to social distancing due to lack Taiwan is an example for effective pandemic management of alternatives reported less social distancing. Thus, adolescents because of its low COVID-19 infection and mortality rates, who are motivated by a lack of alternatives may stop social which have been partly attributed to the clear communication distancing if it will be less convenient or there will be more of appropriate behavior, efficiency of its government’s resource appealing alternatives (58). coordination, and the voluntary adherence to social norms by its This pandemic requires adherence to several measures, where citizens (38, 43). some are needed for personal protection against the infection Findings also show that to enhance effective management and (e.g., hand hygiene, avoiding direct contact with an infected adherence to social norms during this pandemic, interventions person) and some are required for the protection of the will need to be tailored to fit differences in countries’ unique society as a whole (e.g., staying at home, social distancing) circumstances, while respecting their values, cultures, and belief and depend on a strong sense of community solidarity and systems (45–48). However, there is agreement that authoritarian shared responsibility. The use of masks includes both motivations responses to COVID-19 may cause long-term damage to the (personal and courtesy to others) (59). Fostering autonomy autonomy and health of citizens, as they often reflect self- and an autonomy-supportive climate might be beneficial not serving motives, lack of transparency, and limited information only to motivate people to adhere to personal protection sharing (38). measures but also for motivating and enhancing collective Adjusting the communication strategy to the culture and responsibility to defeat the virus as a joint effort and return values is important, but this does not contrast with our to normalcy. first recommendation, that governments, particularly in loose Frontiers in Public Health | www.frontiersin.org 6 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 nations, should strive to foster an autonomy-supportive health disabled patients, from accessing a particular service or from care climate, which motivates individuals to engage in health- understanding or acting on the recommendations (64). related behaviors for their own reasons, promotes success in To design an accessible and usable interaction, HCI dealing with barriers and resistance to change, and enhances researchers and practitioners follow a user-centered design emotions of acceptance, trust, and respect. This can be approach (22). This is done by designing a system based on done by utilizing identified regulation. In addition, clear, the user’s needs and requirements and by involving users and consistent, and repetitive messages with meaningful rationale stakeholders in the design process (23). This collaboration with for change and reflecting personal value have the potential users is commonly termed “co-production” which in current to cut through the infodemic and increase adherence to policy agendas is defined as a way of incorporating people’s preventative measures. This approach is particularly important expertise into health services and research ethics in more as it becomes clear that such messaging may play a role in public meaningful and substantial ways (65, 66). This process of health for months or years, and not for a few weeks as was community engagement encourages a more equal partnership initially projected. and reinforces the importance of listening to and celebrating the voices of communities to gain deeper understanding of the issues, thus helping to create knowledge and implement the Guideline 2: provide choice within the limitations findings for transformational social change (67–69). Using a co- The COVID-19 pandemic has resulted in many constraints production approach in health research was found to identify and limitations on the public, including social distancing, stakeholders’ pain points and research ideas (70, 71), ensures requirement to stay at home, screening, testing, contact that the proposed interventions are in line with stakeholders’ tracing, and travel restrictions (60). Many of these constraints needs (72, 73) and was found to improve health and social care are counter-intuitive and difficult to comply with, such as outcomes for people with long-term conditions and resultant keeping away from grandparents, who are most vulnerable in disabilities (74, 75). Co-production is still quite limited in its use this pandemic. to produce communication tools for public health messages. In these situations, understanding what people can do in In a pandemic, where the confusion is high, actionable addition to what they cannot do is important. It is useful to advise messages supporting decision making are required, and people people to be proactive and do things that are constructive and need the competence or the capability to act on these messages. directly relate to the crisis they are facing (61). Taking action and High level requirements or guidelines will be dismissed if one being proactive during a crisis can help to redevelop a sense of cannot adhere to the requirement or does not know how control and overcome emotions of helplessness and hopelessness (62). Helping the public feel in control and empowered on some to comply. Recommendations should be concrete, localized, accessible (e.g., in accessible formats), actionable and inclusive— parts of their lives may also decrease fear (61). One paper from tailored to different audiences and linguistically and culturally the systematic search related to this aspect (46) emphasized the appropriate (60, 76), and adaptable to their context and tensions importance of understanding one’s limitations (making changes with real life. For example, if an individual has COVID-19 that are possible and accepting what cannot be changed), symptoms, the UK advice is to isolate from members of their reversing negative thoughts and knowing one’s strengths during household—sleep in a spare room and use a second bathroom. this pandemic. This can be supported by resilience training, This type of advice is not actionable for those who live as a which could enhance health ownership and self-efficacy (46). family of five in a one bedroom flat. Other advice has been to Fostering Competence work from home, again this is not actionable for individuals who Internalization requires experiencing the competence and work as cleaners or construction workers. This type of advice confidence to change. In healthcare, competence is fostered from public health authorities appears to be applicable only to when professionals provide relevant information and feedback a wealthier section of society, and falls wide of the mark for (16). The patient is given the skills and tools for change, much of the population (76). If it had been end-user tested before and is supported when barriers arise (16). Acquiring a feeling being released, it could have avoided the disdain with which it of competence is promoted by autonomy. Once people are was received. autonomously engaged and have high willingness to act, they When planning a public health communication strategy, are then most inclined to learn and apply new methods and special attention should be given to vulnerable groups, including competencies (63). homeless people, people without adequate employment, Competence, or feeling capable and effective, is a familiar need immigrants, communities of color, people with disabilities, to HCI and usability experts, as usability heuristics are based certain frontline workers (60). It is important to engage these on the needs for competence and autonomy (24). For example, groups and organizations that represent vulnerable and disabled the amount, type and clarity of the feedback provided and the people in decision making to understand their needs and how intuitive design of the interface and controls, all impact the best to communicate and disseminate information. Failure users’ empowerment and engagement via increased competence to respect their needs will seriously undermine response (24). Accessibility, which is an important requirement for feeling efforts (60). A concern over the disproportionate impact competent, is a major concern in health technologies, which of COVID-19 on the Black, Asian and minority ethnic may include poor interface design or complex information (BAME) communities in the UK and US has already been that excludes parts of the population, such as elderly or raised (76, 77). Frontiers in Public Health | www.frontiersin.org 7 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 Community engagement is important not just for formulating the main rationale for seeking out information is to reduce and communicating the messages but also on implementing uncertainty about a decision (82) and information seeking in the these messages, as risk communication messages not only have health context is an important element in coping with a disease personal implications but also have significant implications at and health-related uncertainty. community level (for example, closure of religious places, parks, Once the informational needs of a given audience have been and shops). identified, then we can look to the science or evidence available. Thus, engaging users and taking their perspective (bottom- Is sufficient information available to satisfy the informational up approach) to design an intervention that is actionable and needs of the audience? If it is, consider how information can tailored to their values and needs (while removing obstacles), be tailored to serve those information needs. If not, consider results in an intervention that is usable, accessible and inclusive how the uncertainty/incompleteness can best be communicated. (Guideline 3). This enhances their autonomy and competence, Again, the aim is to tailor the communication based on how it making users feel understood and enables them to perform their will impact the ability of the audience to take competent action. tasks effectively and efficiently, with increased satisfaction (22). Rather than thinking (primarily) about how information can be tailored to the cognitive limitations of the audience (simplifying Guideline 3: apply a bottom-up (vs. top-down) knowledge), focus on how the information can be tailored to communication using principles of co-production serve their needs. Rather than (or in addition to) thinking about WHO EPI-WIN defined “simplifying knowledge” as one of the the cognitive limitations of the audience, think (also) about the strategic areas of work to respond to the infodemic, defining it limitations of the available science/evidence and translating the as “ways of interpreting and explaining the science to different science into meaningful messages that resonate with the realities audiences” (2). This implies a top-down model of science of people’s circumstances. communication—we have “the science” or “the evidence” and the Five papers relating to a bottom-up approach were identified aim is to “simplify,” “explain,” or “interpret” it so that a given in the systematic literature search (46, 49–52). All papers audience understands it. This seems related to the “information emphasized the importance of contextualizing communication deficit model” (78), which is associated with a defined separation strategies to different populations and engaging communities and between experts who have the information and non-experts the public in decision making. who do not, and suggests that communication should focus Taiwan was given as an example for its human-centric on enhancing the transfer of information from experts to non- approach by understanding that successful management of the experts (79). This model has been criticized on theoretical and virus requires cooperation and trust from the public (50). pragmatic grounds (80). The government has engaged with various sectors of the Within this top-down framing, normative analysis starts from society, enhancing public support, and instead of forcing laws “the science/evidence.” It suggests that the ideal is for the to ban religious mass gatherings, the government reached an audience to understand all of it perfectly but that we have to understanding with local religious leaders which resulted in simplify the information because of the audience limitations. postponing mass events voluntarily. It also assumes that as long as the audience have understood Therefore, our third recommendation is to use a bottom- it correctly, they will definitely act on its meaning, and there up communication approach by engaging stakeholders, to will be no other barriers to them acting on it. There are enhance accessibility, usability, and inclusiveness by creating two main problems with this approach: (1) it suggests that messages that are actionable and can be integrated into people’s understanding the science is valuable for its own sake, that circumstances. These messages can cut through the infodemic the default aim is for the audience to understand as much since they are easier to follow and adhere to compare to as possible. Constraints to this aim stem from the limited ambiguous and generic guidance. ability of the audience to understand. The specific purposes or values of a given audience are not foregrounded by default; Fostering Relatedness (2) it suggests that the science/evidence is unproblematic or According to SDT, relatedness is the feeling of being understood, complete and uncontested. It does not foreground (by default) trusted, and cared for by others. It also relates to belonging, the possibility that the science/evidence might be uncertain or trusting others and contributing to others (13). In healthcare, the incomplete, might change in future, or might implicitly encode relationship between the practitioner and the patient is critical for value assumptions that are not shared by a given audience enhancing change. Patients look for the guidance and feedback (20, 81). of professionals and therefore a sense of being understood, An alternative framing would start bottom-up, from the respected and cared for is necessary to form an experience of trust informational needs of a given audience: What decisions or and connection that will allow internalization to happen (16). inferences are important for that audience to make in order Health communication is similar in this respect, the relationship to stay safe and healthy (given their specific values and between local governments and health authorities to the public is context)? And what information do they need to make those crucial for behavior change. People need to feel respected, cared decisions/inferences successfully? Philosophers have defended for and understood for trust to occur. In addition, they would like bottom-up approaches to explanation [e.g., (18, 19)]. Here we to feel part of a community. propose that this approach should be adopted for public health Trust in health authorities is linked to attitudes and behaviors communication as well. This is particularly important since in many aspects, having implications on vaccination adherence, Frontiers in Public Health | www.frontiersin.org 8 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 clinician-patient relationships, treatment adherence, and seeking whether individuals believe that official authorities are capable care (83). Underserved communities, such as people with of providing relevant health information and whether the disabilities and communities of color, are particularly distrustful health information can solve the health-related issues. If the of public health authorities and institutions, since they have been public feels that the authorities are competent, the trust in historically abused and undertreated in the healthcare system such information may be high. This might not be the case in (60). When the government credibility is low, people question developing countries where governments are corrupt and their the reliability of the official information and the ability of the motives are often questionable. authorities to handle the outbreak situation. Integrity trust is defined as the degree of trustees’ reliability A recent survey (84) suggests that UK citizens are more likely and honesty (87) and indicate whether individuals believe that to trust COVID-19 information from their workplace than from official authorities are honest in what they know and what they the government and official sources. The survey also implies that don’t know and in their motivations. When people feel that they people in the US and UK are less trusting of official information interact with others that honestly care about their health and on the pandemic than in other countries such as Germany. WHO well-being and do not have other agendas such as promoting and local scientific advisors are shown to be a trusted source of certain health services or gaining money then their perceived information by almost all countries. The recent decision of the US relatedness increases (90). to withdrawal from WHO (85), might influence the trust people The authorities’ response to an outbreak can enhance morale have toward WHO, perhaps in a negative way. and spirit of public solidarity that contributes to outbreak control A study on popular tweets following a case of diphtheria (59). However, if scientific uncertainty is not communicated in Spain (86) found that individual journalists and authors of properly to the public, it can aggravate the situation making it popular science were the most popular sources for disseminating difficult for solidarity. In addition, during outbreaks, such as health information on Twitter, tweeting mainly personal COVID-19, the advice needs to be based on emerging facts rather opinionated messages and engaging with followers, leading than established facts (for example, a loss or change to your sense journalists and the public to be more interconnected in real time. of smell or taste was added to the symptom list later on during Furthermore, the authors found that health organizations did not the outbreak in the UK). publish any of the popular tweets. This could suggest that it could Thus, for people to feel relatedness and trust in be useful for healthcare organizations to collaborate with popular local governments and health authorities, they need journalists and authors of popular science to disseminate health to feel part of the society and community (Guideline information on social media, while addressing misinformation 4) and perceive the communication as transparent and and public concerns in accessible ways (86). honest (Guideline 5). Previous research has shown that trust leads to trust- related behaviors such as making a purchase, sharing personal Guideline 4: create solidarity (we are all in this together) information, or performing an action on a website (87). In HCI, A key strategy in health communication is communicating the particularly in designing decision support systems (DSS), trust in social norm. A recent study (9) found that people are willing to the knowledge base is an enabler of DSS use. When healthcare restrict their everyday life to “flatten the curve” and decrease the professionals trust the system, they will use it, but when they do burden for the healthcare system. However, their motivation to not trust the system, it would not be used (88). restrict their everyday life was even higher when the need was to Trust begins with communication, and communicating protect vulnerable others. Communicating the social norm, that information during outbreaks is challenging, particularly as our the vast majority of people are restricting themselves to protect knowledge of a virus or a disease evolves (89). This emphasizes others, encourages others to do the same. It creates solidarity at the importance of building trust and respect well in advance, a time when everybody needs it and people may suffer from the rather than at the time of the outbreak. Trust is identified as a non-health-related issues of the pandemic (9). multidimensional concept including three types of trust beliefs: Six papers from the systematic search related to solidarity benevolence, competence and integrity (90). and sense of community (36, 38, 46, 51, 53, 54). Findings Benevolence trust is the degree to which trustees act in trustors’ showed that communicating the social norm during COVID- interests based on altruism (87, 91). This means that benevolent 19 could improve adherence (36, 38, 53). For example, nudges trustees select to help trustors even without a requirement or that inform what others within the community are doing had a reward to do so. In the context of public health communication, positive influence on citizens’ behavior (36) and are particularly benevolence trust indicates how much the public perceives health important in loose cultures, which are more likely to resist and official authorities to act in their interests, such as caring increased constraint. However, such nudges need to maintain about their health, trying their best to solve their health issues people’s sense of autonomy or they may backfire and elicit and keeping personal information safe. When benevolence trust psychological reaction (38). beliefs are high, people are more likely to feel cared for and In contrast, political communication, as was seen in the seek health information. Both autonomy and relatedness are US (i.e., propagating conspiracy beliefs, using war language) important to support benevolence trust beliefs (90). contributes to “us vs. them” mentality, which may undermine Competence trust is the degree to which trustees are capable people’s sense of collective support and care and lead to of meeting trustors’ needs (87). In relation to public health individualistic behaviors such as hoarding, which was seen in communication, individuals’ competence trust depends on this pandemic (46, 54). Furthermore, messages that emphasize Frontiers in Public Health | www.frontiersin.org 9 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 desired behaviors are likely to lead to higher adherence than those preventative measures during COVID-19. For example, the that emphasizes punishment for perceived breaches (46). Romanian public lost trust in its healthcare system after years of corruption, which resulted in citizens not reporting truthfully Guideline 5: be transparent and acknowledge uncertainty about their travels and disregarding the government’s restrictions Public trust is injured when governments or health authorities (55). In the US, individuals interpreted the COVID-19 threat downplay the true risk posed by a crisis or have caused panic by in partisan-patterned ways, with Republicans following party leaders in dismissing the threat and taking less actions than overstating a potential threat. Honesty about what is known and what is unknown is a critical component of transparency (92), did Democrats (54). In a recent survey in the US, only 23% of respondents expressed high levels of trust in COVID-19 and the ability of authorities to apologize frankly if a mistake was made. information given by the President, where in Australia, the government’s response was rated highly (42). This could explain Lack of transparency breeds rumors, confusion, speculations, and engenders mistrust leading people to seek information from the higher adherence of preventative measures in Australia vs. the US, and the more effective management of the pandemic. unreliable sources (60). Social media offers a fruitful platform for misinformation to be disseminated. Accurate information Thus, our last recommendation is to communicate with both epistemic and value transparency, while acknowledging provided by trusted clinicians and scientists that emphasize the facts and not the myth (93) can help mitigate the spread uncertainty. Trust is probably the most important criterion in fighting the infodemic. Trusted sources have the power of misinformation. Health communication experts can directly to influence people, however there is no trust without counter false information and narratives while promoting reliable sources of health information (92). trustworthiness, and governments and other authorities should strive to gain the public’s trust by being honest, transparent, Philosophers of science have emphasized the importance of transparency for creating (ethically well-placed) trust in informing early in the outbreak and acknowledging uncertainty and mistakes. science-informed policy (20, 21, 81, 94). They highlight the importance of both epistemic and value transparency (95) in communications by local governments and health authorities. DISCUSSION Epistemic transparency: What is known? What is still uncertain? What scientific evidence is used to inform a given policy or piece This paper proposes practical guidelines for public health and of advice? Value transparency: What political value judgements risk communication, starting from addressing humans’ basic are the decisions based on? What overall aim/strategy is being psychological needs of autonomy, competence, and relatedness. pursued? What trade-offs are being made? Fostering these needs during this pandemic has the potential to In addition to public trust, transparency could enforce careful cut through the infodemic and maintain our well-being, while and accountable decision making as the shortcomings are likely enhancing our intrinsic motivation to adhere to the required to be revealed. This is particularly important in the context behavior change (e.g., staying at home, social distancing, hand of a global crisis, where many governments are simultaneously hygiene) for longer periods of time. seeking to address the same problem. Individual governments The COVID-19 pandemic requires long-term strategies and may feel incentivised to present policy as purely evidence- sustainable behavior changes. The requirements and expectations based, to avoid taking responsibility for potentially controversial from the public during this long period are extreme (i.e., staying political judgements. However, if governments pursue different at home, social distancing), and have serious implications for policies, the public will notice the discrepancy and start asking the privacy, freedom and wellbeing of citizens (97). Restrictive questions. If good answers are not forthcoming, this can or mandatory measures need to be proportionate and well- breed distrust and lead people to start speculating about what explained and justified, if they are to be effective and to receive the “real” motives behind the policies are and to seek out the support and trust of the public (97). alternative sources of information. For example, there has been Health communication has an important role in influencing, widespread confusion as to whether the UK government is supporting and engaging individuals, communities, healthcare pursuing (or has pursued) a “herd immunity” strategy, fuelling professionals, policymakers, and the public to adopt and speculation that this was a deliberate “cold-blooded experiment sustain a behavioral practice that will ultimately improve health in social engineering” (96). Apparently, the term was used in outcomes (98). When the restrictions on the public are so early messaging to help justify their proposed social distancing extreme and limiting, health communication strategies that focus measures. Though the government has since disavowed the use of on enhancing basic psychological needs such as autonomy, this term, there is speculation that the government continues to competence and relatedness (within the limitations) are critical pursue the herd immunity strategy. This is arguably reinforced by for maintaining well-being and motivation to adhere to these the fact that other governments have adopted different strategies requirements for a long period of time. for managing the pandemic, highlighting that the UK’s approach To cut through the infodemic and support wellness and was not the only one possible. A clearer and more transparent sustainable behavior change, we applied the SDT as a framework account of the overall strategy would have helped avoid the and used concepts from philosophy, psychology and HCI resulting distrust. to discuss how these concepts can be applied to health Five papers relating to transparency and trust were identified communication during the COVID-19 pandemic to enhance in our systematic search (42, 46, 54–56). Findings show that human’s basic psychological needs of autonomy, competence and trust is a critical factor influencing the public’s adherence to relatedness. These three needs are linked together and are all Frontiers in Public Health | www.frontiersin.org 10 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 essential for ongoing psychological growth and well-being (14). decisions (105). Explainable recommendations help to improve This resulted in proposing five practical guidelines, which gained the transparency, effectiveness, trustworthiness and satisfaction initial support from the emerging literature on the effectiveness of recommendation systems (106). According to Miller (107) of different communication strategies during COVID-19. the main reason that people want explanations is to facilitate To foster autonomy, we propose to (1) create an autonomy- learning, enabling them to create a conceptual model where supportive health care climate and (2) provide choice within they can predict and control future phenomena (105). Thus, the limitations. this bottom-up approach will enable providing messages that are A common concern across disciplines such as public health inclusive, actionable, and integrated into people’s circumstances and philosophy, is the tension and balance between ensuring the and hence have better chances to cut through the infodemic. safety of people and respecting their right to autonomy (64, 99). Furthermore, a bottom-up approach which engages the public As the findings show, communication strategy should be tailored enhances trust which builds confidence in the authorities’ ability to the culture, values and context, and therefore one may argue to manage and control the situation (7). that an autonomy-supportive healthcare culture may not “work” Engaging different audiences and understanding their specific in some cultures or countries and that without external regulation circumstances and needs is critical in designing interventions (e.g., enforceable legislation), the adherence might be low. For that will be inclusive and address those needs. Historically, risk example, the message might not get through the infodemic, might communication during crisis has been inaccessible to vulnerable not be trusted, people might not find it actionable if it is in conflict people, including people with disabilities, cognitive limitations with other things that are important to them, or they might find or low literacy levels (108) resulting in them not receiving it hard to prioritize it (e.g., stay at home vs. going to work and information and being able to act in a timely manner (11). earning money to feed their family). In the short-term controlled Initiatives such as Community Citizen Science (CCS) which motivation by external regulation may be effective (people may embraces participatory democracy to influence policymaking and obey), if the rationale is explained transparently. In the longer address local concerns, should be encouraged and applied (104). term, people may get tired from the strict measures, resulting, as To foster relatedness, we propose to (4) create solidarity and is already evidenced in this pandemic, in breaches of lockdowns, (5) be transparent and acknowledge uncertainty. Community domestic violence (100), street violence and demonstrations activism evidenced in the current COVID-19 emphasizes the (101), police brutality (102), and “quarantine fatigue” (48). critical and impactful role of the public and the importance Furthermore, a strict and closed list of “essential” reasons of the bottom-up approach in engaging the public in decision that people may go out of their house for (e.g., buying food, making which enhances the understanding of the experiences doctor appointment), cannot cover all the needs of individual and concerns of those affected. Engaging the public and being cases, particularly when it relates to mental health. Whilst we transparent and honest about the decision making process is may be able to identify what is “essential” to us on an individual critical for changing behavior and community initiatives such basis, it is impossible to define what is essential to someone as the above. Governments cannot just ask for people to trust else (103). Measures to respond to COVID-19 are essential. them, they have to earn trust and do so in the right ways. However, they should also be ethical, proportionate, and subject They should not just be trusted but also be trustworthy. Trust to robust democratic accountability (97). There should be strong and transparency go together: we can only trust if we are well- countervailing arguments to denying people, properly informed informed and understand what is being asked from us (109). about the risks, to make choices about how to live their lives (97). The proposed guidelines are a starting point for developing To foster competence, we propose to (3) apply a bottom-up a multidisciplinary comprehensive public health communication communication. Conventionally, scientists and decision-makers strategy that fosters well-being and sustainable behavior change apply top-down approaches to communicate and engage with at its core. While some of the guidelines we propose the public (104). At the current time, organizations such as have been discussed previously in the context of health WHO look for ways to address the infodemic by “simplifying communication, such as transparency and trust [e.g., (59)], these knowledge,” thus, applying a top-down approach where the aim guidelines enhance and strengthen their importance by providing is to take the existing science and simplifying it so the public supporting evidence from a different perspective and practical (different audiences) will understand. We propose to apply a and actionable ways to act on them. Other proposed guidelines bottom-up approach that will start from understanding the such as fostering an autonomy-supportive climate and applying informational needs of a given audience based on the decisions a bottom-up approach are unique and novel in this context. they have to make in their specific context and circumstances, While these guidelines are based on evidence from other and tailor the information to satisfy these informational needs. domains, and gained initial supporting evidence from this This means that some communication strategies would have to pandemic, they will need to be validated in the context of be formulated locally to take into account local demographics public health communication during such pandemics. The and needs, devolved to e.g., city councils. This is in line with factors affecting the pandemic outcomes in different countries is “explainability,” a concept in philosophy and HCI, that has complex, and their medium and long-term social, psychological, been recently discussed extensively in the context of Artificial and economic costs are far from being understood. Thus, part Intelligence (Explainable AI). Explanations are provided to of the preparedness for future health crises should include a support transparency, where users can see aspects of the robust analysis of the best strategies for public cooperation and inner state of the AI system and support them in making communication (12). Frontiers in Public Health | www.frontiersin.org 11 October 2020 | Volume 8 | Article 573397 Porat et al. Public Health Communication During COVID-19 CONCLUSION AUTHOR CONTRIBUTIONS Health communication that starts by fostering well-being and TP and RN: conception of the study. TP, RN, RC, PP, and EF: basic human psychological needs, has the potential to cut review of the literature, analysis, interpretation of themes and through the infodemic and promote effective and sustainable guidelines, revising the paper critically for important intellectual behavior change during such pandemics. Our guidelines provide content, and sign-off final version of manuscript. TP: initial a starting point for developing a concrete public health draft of manuscript. All authors contributed to the article and communication strategy. approved the submitted version. FUNDING DATA AVAILABILITY STATEMENT RN was funded by Wellcome Trust [213660/Z/18/Z] and by the The original contributions presented in the study are included Leverhulme Trust through the Leverhulme Center for the Future in the article/supplementary material, further inquiries can be of Intelligence. directed to the corresponding author/s. REFERENCES 15. Ryan RM, Deci EL. 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