Podcast: Improving health messaging in fight to slow COVID-19

Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, we focus in this episode on messaging. It’s been about a year since COVID-19 first was diagnosed in the United States, and we’ve not yet been able to agree about the best ways to communicate to help keep people safe.

Mary Politi, PhD: Everybody is trying to do the best thing for themselves. No one is purposely – I could be wrong, and there are some people willingly trying to be harmful. But I don’t really think that’s the fundamental reason. I think when people make decisions about their health and the health of society, they’re trying to make sense of this data in a way that works for them. And it’s much easier to hear a message from someone that says, “Don’t believe the numbers,” because it’s hard to hear those numbers.

Dryden: That’s Mary Politi, a professor of public health sciences at Washington University School of Medicine. This week, we speak with Politi and with Robyn LeBoeuf, a professor of marketing in the Olin Business School at Washington University. LeBoeuf says if public health messages could be crafted better, they might be more effective.

Robyn LeBoeuf, PhD: The people respond to certainty. And so when people deliver messages that are clear and certain, then sometimes those messages are very persuasive. And so, again, the challenge is for us to figure out how to deliver messages about taking precautions, about social distancing, about mask wearing, and how to deliver those messages with as much clarity and certainty as we can.

Dryden: As cases and deaths have climbed, there’s been debate about how to move forward, and there have been some very mixed messages from various government officials. During a recent Grand Rounds lecture at Washington University School of Medicine, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and one of the major figures involved in the federal response to COVID-19, talked about his surprise at how many people inside and outside of government seemed to want to ignore science.

Anthony Fauci, MD: What we’re dealing with now is an absolutely explosive outbreak that, in a very truncated period of time, has essentially immobilized the planet. We have something that I’ve never seen before in public health. Public health has been immersed in a divisive society which has made it very, very difficult to have a uniform response. I mean, I might give an example of something that I believe you all there are aware of, that there are regions of the country where hospitals are filled with people in intensive care units who are dying, and the people in the community still feel it’s fake news, it’s a hoax, and it’s a conspiracy. That, to me, is unimaginable that that is going on in the United States.

Dryden: Those who study messaging and decision-making like Politi and LaBoeuf say that although the pandemic is almost a year old, some people still don’t think it’s that big a deal. And one has to wonder what can be done to convince them. But Politi says the news isn’t all bad. She says it is clear that messages are having an effect on some people.

Politi: Everywhere I go, I see people masking. People are walking their dogs across the street from each other, and they pass each other, and they give each other space. So I think people have made a lot of behavior changes that were very, very new and unusual. Where I think the messaging has broken down and then people’s behaviors have broken down is a lack of coordinated policy and leadership that consistently sent the same message, particularly about masking. So you have some communities with mandatory mask policies and other communities that don’t, where we’ve never really had this strong reaction to data and to science, and that confused a lot of people. So although you’ve heard this message, we’ve heard this message and, probably, everyone in the public has heard this message about masking and distancing, I think there has been confusion on the ground about what that means as we live our lives, especially with mixed policy messages.

Dryden: But on the other hand, one of the more recent messages was, “Let’s not have big gatherings for Thanksgiving and Christmas. Let’s not travel. Let’s Zoom for Christmas.”

LeBoeuf: Many people are hearing the messages and are responding —

Dryden: This is Robyn LaBoeuf.

LeBoeuf: — but I think some of it, too, is that people are very influenced by what they see in front of them. People are influenced by what’s vivid and what’s concrete to them. So if they look around in their immediate family, they say, “Well, everybody I see seems healthy. I feel healthy. I don’t know of anybody” who’s maybe either had COVID, or if they’ve had COVID maybe they don’t know of anybody who has gotten severely ill. They may have known somebody who’s only had a mild case. And so, in many cases, people rely on what’s very concrete and vivid to them, what’s happened to the people around them. And so I think the challenge for the messaging is to make the message as concrete and as vivid as the anecdotal evidence that people are seeing.

Dryden: Now, you both are experts in decision-making, and I wonder about that. How do people make these kinds of decisions, whether that be about their health or about what brand of cereal they’re going to buy in the cereal aisle? And how do some of those sorts of things apply here, in this particular public health crisis?

Politi: People make decisions both on the evidence that they have, the data, and then also what’s important to them and what matters for them and their core values. And in this situation, a lot of people felt that their core values were their family, were getting together and sharing something in person, and people were tired of Zoom. The conflict between the data and their values really struck a chord, especially around the holidays. It is so painful for my mom and my in-laws to not see their grandkids. You haven’t seen them in a year, over a year, so I understand the dilemmas that people face. I think we can do a much better job pulling from communication science and decision science and sending clear, consistent messages in simple-to-understand language, but more so connecting to people’s values and helping them find a way to work within those values and make these behavior changes that align with those values and are safe.

LeBoeuf: I think one thing that people respond to is, frankly, the norms that are set by the people around them. What they see other people doing, for lack of a better definition, right? So when people start to see other people around them wearing masks, it becomes just more comfortable to wear one, more expected that you’ll wear one, it becomes the thing to do. I think that one of the challenges, also, is to focus some of the messaging on showing other people doing the right things. Showing like, “Look how many people are wearing masks, how many people are not traveling. Look how many people are following these guidelines.” I think something like that might just set the standards, “OK, this is how we’re acting,” right? So if we want to protect our community and we want to protect ourselves, this is what everybody’s doing. So we’re all coming together to do this. This is a spirit of shared sacrifice. But not traveling doesn’t make news; traveling makes news. And so I think one of the things, in terms of just general principles, what do people respond to? People respond to norms. They respond to what other people are doing.

Politi: I also think there needs to be representation —

Dryden: Again, this is Mary Politi.

Politi: — or local community members who are trusted community members, and not just public-health experts that may be seen by people as scientists living in a bubble. We can do a lot better with connecting, on the local level, with people from the communities where we’re trying to reach.

Dryden: Now, we’re here in St. Louis. Is the sort of thing you’re talking about — I mean, should we be seeing campaigns where Ozzie Smith or Yadier Molina is wearing not just a catcher’s mask but a surgical mask? Is that the sort of thing you’re talking about?

Politi: Yeah, people do respect celebrities, and they have some pull, and people on television, anchors, news anchors. But there’s also local individuals who are part of the communities they’re serving that we’re trying to reach that I think have a lot of connection to individuals on the ground. News stories that are in papers about people you might recognize and that you might know. That can go a long way in terms of delivering a message. There is a tendency to forget that this is really hard and this isn’t something we’re asking people to do for one day. This has been going on almost a year now, and I really appreciate the fact that it’s hard for people to do this all the time and day in and day out. So we could work with people and get people who can relate and that they respect and can talk about risk reduction. I think it would be a lot easier for people to follow the guidelines and feel like they’re being heard.

Dryden: At least from my point of view on the outside, it seems like you do related work but are focusing, maybe, on different audiences and objectives. And I’m wondering if you think that the principles of good marketing and good public health messaging are at all similar?

LeBoeuf: Personally, Mary and I both have PhDs in psychology, right, so we’re both interested in human behavior and understanding human behavior. But certainly, in both cases, whether it’s marketing or public health, one of the goals is maybe to communicate an idea, whether it’s to sell an idea about a product or to sell an idea about an idea or about a policy, right? So I think there definitely are some similarities there. Mary, I don’t know what your thoughts are.

Politi: A lot of the principles of decision-making overlap between marketing and health. In fact, we look at the marketing literature to help understand, “How do we clarify people’s preferences? How do we get people to think about what’s important to them when these health-related issues tend to be new?” When someone’s newly diagnosed or, for example, with COVID there’s a new virus. And the other thing that’s interesting from both perspectives is that the biases or the shortcuts, the mental shortcuts we take when we’re making decisions and interpreting lots of data and information. We tend to look at data, and then our brain can trick us into thinking that it’s behaving rationally when it’s not. And so we tend to overlap in understanding how to work within those and overcome some of those mental shortcuts that might not serve our best interests.

Dryden: But, Mary, I wonder if there might be some people who are so convinced of their correctness that nothing’s going to get through to them?

Politi: We really need to approach this as, “Everybody is trying to do the best thing for themselves.” No one is purposely — I could be wrong, and there are some people willingly trying to be harmful to others or themselves. But I don’t really think that’s the fundamental reason people make decisions. I think when people make decisions about their health and the health of society, they’re trying to make sense of this data in a way that works for them. And it’s much easier to hear a message from someone that says, “Don’t believe the numbers,” because it’s hard to hear those numbers. It’s people that worked in the ICU that have seen COVID patients are mentally exhausted. It is very, very sad to see what’s happening to people. And it’s much easier not to think about that or to think, “That will never happen to me,” but that’s not the reality that people who are working in the health setting see. And I’m not saying that individuals need to see that, but I think we could do a better job of letting people know the seriousness of the situation rather than dismissing it. And I don’t think there’s anyone that’s wanting to contribute to that, to somebody else that could be their neighbor or their parent or their relative, potential illness.

LeBoeuf: And I would agree with what Mary said. To go back to your question, too, I think we can also focus on how far we’ve come. If you had said nine months ago, ten months ago, however long it’s been now, that mask wearing would be normalized, right, and in a relatively short amount of time, I think it would have been hard for us to believe that we would make these vast shifts in how people work and how people go to school almost overnight, right? So we’ve done a lot, and as Mary said, people have been working very hard on their ends. The people respond to certainty. And so when people deliver messages that are kind of clear and certain, then sometimes those messages are very persuasive. And so, again, the challenge is for us to figure out how to deliver messages about taking precautions, about social distancing, about mask wearing, and how to deliver those messages with as much clarity and certainty as we can. And so when people hear big numbers like that, they become numb to those numbers. And so, breaking it down to the more human level. And even thinking about 3,000 people a day, what is that? That’s 10 airplanes crashing a day, right? Those are all humans with families, with faces, right? And so trying to also just make that really vivid and remind people that — without trying to scare people unnecessarily, but really just to bring it home. That these aren’t just numbers, these are people, I think is another thing that sometimes gets lost in the focus on the numbers, is trying to actually humanize that and make everybody remember these are people who did not have to die.

Dryden: We’ve been talking about people’s beliefs and some of their implicit assumptions about this, and, I mean, I admit, part of my implicit assumption in this interview is that maybe this didn’t have to be this bad. That with better messaging, better public cooperation, we’d look more like some other countries. Still not safe or normal, but way fewer infections and deaths. But I wonder about that assumption of mine. Do you think some of what we’ve experienced in these months might have been avoided? And if so, how?

Politi: Yes, I absolutely agree. You can use cognitive biases that we have or these mental shortcuts that trick us into thinking things for positive reasons or for negative reasons. I think that there are a lot of messages that were sent by some who didn’t want to believe the message, some in leadership positions, that were really manipulative and played on people’s fears, and then played on the fact that we might trick ourselves into numbing ourselves to the vast number of deaths because it’s much easier not to have to think about that. And connecting on a personal level and having people be seen as people and not as these large collections of a number that doesn’t have meaning might be useful.

LeBoeuf: And one thing I think that may make it a challenge, maybe, in the U.S. compared to some other countries is just the vastness of the country. And so the pandemic rolled out at different times, and crisis levels even continue to be hit at different times in different places. And so, for some people, the initial messaging about, “Stay home. Don’t go anywhere. Keep apart from everyone,” may have hit them before it was really a problem in their community. And so they then thought, “Well, nothing’s happening. No one’s getting it. It must be over, right? So we can go back to normal life, right?” And so I think even now, though, we’re seeing that still playing out, where some areas of this country are in crisis right now and others are in — things are bad, but not nearly as dire.

Dryden: It’s that everybody needs to mask. Everybody needs to social distance. And, as soon as possible, everybody needs to get vaccinated, right? So that’s another layer of, “How do we convince people to do something?” Because some folks aren’t convinced it’s going to be safe. So are there lessons we can learn from what has happened with masking and social distancing and travel, things like that, that might be applied to the vaccine as it rolls out around the country?

Politi: And there is a lot of data on how to communicate about vaccines. Lots of other vaccines that are developed for other illnesses, it’s already being applied to this vaccine, the SARS-CoV-2 vaccine. And so I’m hoping we will learn a lot from those messages. There are a lot of biases that impact people’s decisions to get a vaccine or not. One of the biggest ones is called the omission bias, where, if you fail to do something and a bad outcome happens, you feel less guilty than if you do something then a bad outcome happens. It’s a flaw in our thinking because the vaccines protect people from diseases, and when there are mild side effects, they’re mild and treatable. Most vaccines, including this one, have transient short-term side effects that are manageable with over-the-counter medication or rest, and they go away within a day or so. But people often feel this intense fear and guilt if something happens, where they felt they contributed to it by doing something as opposed to failing to do something.

LeBoeuf: I think for the vaccine, again, we can think also about leveraging the power of social norms, and there’s times that we’ve seen that. We’ve seen politicians getting it publicly, right, showing that people are getting it, right? And so focusing on the idea that this is being accepted by major figures, whether it’s politicians, whether it’s celebrities, whether it’s people on the news, right? And so trying to emphasize that, too. To show that this is something that people are doing, that people are regarding as safe, and not necessarily giving more oxygen to somewhat specious claims about the vaccine. I think, at the same time, we do need to take people’s concerns seriously and understand what they’re concerned about and talk about what kinds of long-term effects would it be possible to — would it be expected to see from the vaccine and have we looked for those, right? And so, has the time horizon been long enough? And talk about, “Well, like with most vaccines, we would have seen any sort of effects by now,” so the fact that we haven’t is relatively reassuring. But understand that when people hear “long-term effects,” they’re thinking on the order of 20, 30 years down the line. And so trying to find a way to tell people, “No, that’s not what happened with vaccines. We shouldn’t expect any long long-term consequence.”

Politi: A lot of people in the communities that are hesitant about vaccine feel like they’re not listened to; they’re just dismissed. I completely understand why people have questions about anything in health. And I think people’s questions deserve to be answered, and they need to find people that they trust who can answer their questions.

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Dryden: Politi and LeBoeuf say continuing to address concerns and questions is key moving forward. And although both say that we’ve come a long way since last year when COVID-19 first started infecting Americans, they admit that with high post-holiday infection rates and millions of people to vaccinate, finding the best messages to convince people to behave safely and to get vaccinated when they become eligible will be vital to any future return to normal life. Show Me the Science is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. Thank you for tuning in. I’m Jim Dryden. Stay safe.