Health Communication in and out of Public Health Emergencies: To Persuade or to Inform?

"Health authorities and others responsible for communicating health information to the public should reflect carefully on the purpose of the information they communicate to the public - whether it is intended primarily to persuade people or to inform them."

Much health communication during the COVID-19 pandemic was designed to persuade people to take up behaviours, such as wearing masks, more than to enable them to make an informed decision (e.g., about whether to wear a face mask). This article discusses potential conflicts between seeking to persuade or to inform people, the use of spin to persuade people, the ethics of persuasion, and implications for health communication in the context of the pandemic and generally. It offers nine principles to guide decisions by authorities about whether to try to persuade people in public health emergencies.

As noted here, messages designed to persuade people to follow infection prevention and control measures can limit their ability to make informed choices and may erode public trust in authorities, which in turn can negatively impact compliance. Conversely, health authorities aiming to enable people to make informed choices (or to be transparent about the reasons for a mandate) are more likely to include what is known about the pros and cons of interventions and the reasons for recommendations or policies. However, this approach could reduce compliance (e.g., communication of uncertainty might reduce the perception of effectiveness) and could also increase inequities (e.g., if some people are less likely to have access to candid information, to understand it, or to be able to use it as intended).

When there is compelling evidence that the advantages far outweigh the disadvantages, the difference between persuading and informing people may be small. For example, the advantages of vaccines for measles, mumps and rubella clearly outweigh the disadvantages. Parents want balanced information about the benefits and harms of childhood vaccination, and providing them with clear, concise, evidence-based information may both build trust and persuade them to consider the evidence when deciding.

On the other hand, influencing people to behave in a desired way may take the form of "spin", which means emphasising the advantages of a desired behaviour and ignoring or downplaying its disadvantages or uncertainties. Spin strategies, used either intentionally or unintentionally, include using words and hyperbolic or alarming language without including numbers, presenting risk ratios for benefits and absolute effects for harms, leaving out the denominator, arousing fear or a sense of urgency, using narratives, and using expert sources to support otherwise unsubstantiated claims.

Health authorities who communicate to the public in the context of health emergencies must take account of ethical considerations and the extent to which persuasion is justified. As outlined in the paper, there is a continuum from information to coercion that may be helpful in considering the ethics of information designed to persuade:

The types of information that may be deemed ethically permissible include:

• Information that respects individual autonomy but considers collective burden (e.g., on healthcare systems).
• Information that is not manipulative - Withholding important information about a well-documented, serious vaccine side effect would be manipulative, even if there is compelling evidence that vaccine's benefits far outweigh the harms
• Information that is honest and transparent - Changes in policies because of changes in the evidence are likely to be more acceptable to the public if the authorities were transparent about the uncertainties of the evidence when the original policy was made);
• Information that does not "blame the victim" - Use of threats or scare tactics can stigmatise those with a condition or disease.
• Information that is "actionable" - Not everyone is interested in the justification for every recommendation, but the justification should be reasonable and should be available to anyone who is interested.
• Information that is developed through systematic, transparent, and evidence-informed processes (i.e., to ensure accountability and reasonableness).

"Generally, the more uncertainty there is about the balance between the advantages and disadvantages of a behaviour, the less likely it is that it is justified to try to persuade people to behave in that way....On the other hand, the greater the potential impacts of a behaviour are on others (e.g. transmission of infectious diseases or drunk driving), the more likely it is that persuasion is justified....Similarly, the greater the risk, the more likely it is that persuasion is justified."

Principles that can help guide health authorities' decisions about when it is justifiable to try to persuade people to behave in a certain way are summarised in Table 2 of the paper. To cite only one of the principles: flexibility, which calls on authorities to pay attention to minority groups, their ability to access and understand messages, and their ability to act on messages. This principle also entails tailoring choice of communication channels to particular audiences, as well as reconsidering messages and how they are communicated in response to changing conditions or new evidence. Answering the questions posed for each of the nine principles (e.g., in the case of flexibility: is the message tailored to key audiences and their contexts, and can it be modified as new information becomes available?) requires evidence, interpretation of the evidence, and judgments. The researchers recommend having in place an efficient system for summarising the evidence, involving stakeholders, and making transparent judgments about how to communicate decisions and whether to persuade people.

In conclusion: "When there is a public health emergency, persuasion may be justified despite important uncertainties about the balance between the potential benefits and harms. However, when there are important uncertainties, they should be acknowledged. Not disclosing uncertainties distorts what is known, inhibits research to reduce important uncertainties, and can undermine public trust in health authorities."