key: cord-0908592-xemoew2f
authors: Street, Jr., Richard L.; Finset, Arnstein
title: Two years with COVID-19: New - and old - challenges for health communication research
date: 2022-02-01
journal: Patient Educ Couns
DOI: 10.1016/j.pec.2022.01.006
sha: a5cffec96938791a5894ea4b5518a4d868c1650a
doc_id: 908592
cord_uid: xemoew2f

nan

Throughout the pandemic, the public has had massive information needs, both about risk to be infected, how to behave to avoid infection, and about vaccine effectiveness and side effects. Information about the pandemic on the internet and in the media has been overwhelming. In addition to scientifically grounded and useful information, social media have been overflowing with fake news, rumors and misinformation [2] . Several papers in the present issue discuss different aspects of information giving and misinformation.

For health personnel and health educators, it is important to know that some individuals are more likely to believe misinformation than others. For instance, Guidry et al. [3] report that cancer survivors currently undergoing treatment are more likely to believe misinformation related to COVID-19 than those without a cancer history. The findings indicate that some individuals may be more vulnerable to misinformation than others, due to individual factors, in this case related to undergoing treatment for cancer. Future research is needed to identify such factors.

One health communication challenge during the pandemic has been how best to persuade people to keep a social distance and to adhere to other precautionary behaviors. Kemp et al. [4] tested different strategies to promote reduction in social interaction, and put advice to abstain from social interaction up against a more moderate harm avoidance strategy (e.g, when interacting with others, wear masks, stay 6 feet apart). The authors reported that abstinence messages were perceived as 'threats to freedom' and less effective than harm reduction messages. This study highlights how effective message framing can influence behavioral intentions, yet overcoming the resistance of message recipients with strongly held negative beliefs toward the behavior remains a challenge.

The area probably most vulnerable to misinformation is related to vaccines. Evidence to date clearly indicates that people who are vaccinated against COVID-19 are significantly less likely to get infected or have serious disease if infected. Thus, getting more 'shots in arms' is paramount to ending the risks of COVID-19 infections. Effective health communication plays a central role in this endeavor through persuasive campaigns that not only promote vaccinations, but also try to mitigate vaccine hesitancy or resistance.

A number of studies have examined reasons people have for their vaccine hesitancy. In a recent systematic review, Aw et al. [5] found several cognitive factors that consistently were associated with vaccine hesitancy, such as believing that COVID-19 is not severe, lower self-perceived risk of contracting COVID-19, lesser fear of COVID-19-as well as beliefs that vaccines are not safe. Such factors would be expected from theories on health related behavior, such as the Health Belief Model. An example of how individuals weigh different cognitive factors is the study reported in the present issue by Zheng et al., [6] who found that when deciding whether to take vaccination, American adults have more concern about the probability of contracting side effects of COVID-19 vaccines than the severity of these side effects.

A number of different approaches to provide information about vaccines has been tested [7] . For instance, in an online experiment reported in this issue of PEC, Yuan et al. [8] tested different video messages (individual-centered, community-centered, country-centered) to determine whether intention to get vaccinated was related to type of appeal. The authors found that the individual-centered messages were most effective, which is not that surprising given the participants were from the United States. However, individuals who reported a more communitarian world view perceived the individual centered message less effective than did those with an individualism world view. This suggest individuals are motivated selectively to respond to claims about the vaccines that cohere with their world view.

Medical care for chronically-ill patients has been severely disrupted during the pandemic as appointments have been cancelled and treatment and other procedures have been postponed [9, 10] . In an effort to reduce COVID-19 infection risks to patients, family, and clinicians, many in person health care services have been delivered by telehealth, either with telephone or video visits [11, 12] . This includes family restrictions on visits with loved ones in hospitals or care facilities [13] . In this issue of PEC, two papers address the challenges family members faced when electronic communication (phone or video) with family members was substituted for face-toface visits with clinicians and patients. From interviews with 62 surrogates of critically ill adults, Greenberg et al. [14] extracted several themes related to communication challenges-disruptions in communicating with the medical team and with family members, keeping adequately informed about their loved one's status, and distress related to visitor restrictions. To adjust to COVID-19 restrictions, these surrogates worked with clinicians to establish routines for receiving telephone updates from the medical team, finding some comfort in at least having video calls with the patient. In the Rahul et al. [15] paper, family members of hospitalized COVID-19 patients found electronic communication acceptable in the absence of face-to-face visits, but varied in their preferences type of media (voice call, video call, or SMS text).

COVID-19 has contributed to considerable anxiety and uncertainty related to risks of infection, serious disease, and social isolation [16] . For people being treated for serious disease, COVID-19 worry can lead to poorer treatment outcomes, poorer symptom management, and poorer health-related quality of life [17, 18] , along with delays and disruptions for needed procedures and treatment [19, 20] . COVID-19 related stress and uncertainty have also complicated clinician-patient-family communication and decision-making. For example, in this issue of PEC, Spalding et al [21] report that a unique predictor of surrogates treatment preferences and accuracy (in relation to the patient) was COVID-19-related anxiety, such that surrogates with greater anxiety about COVID-19 selected more intensive treatments for patients. This was particularly true for patient-surrogate agreement on ventilation which was the lowest compared to other treatments (e.g., CPR, feeding tube). The authors speculate that this may be associated with the well-publicized concern about shortage of ventilators in hospitals treating COVID-19 patients.

Yet, helping people manage COVID-19 uncertainty goes well beyond fears of infection, treatment decision-making, and social isolation. The Thompson et al. [22] paper in this issue of PEC highlights the concerns of COVID-19 'long haulers;' those who are recovering slowly from COVID-19 infections. After analyzing over 30,000 online posts, the authors extracted 16 themes reflected including the experience of heightened anxiety related to COVID-19 symptoms, immunity, challenges of symptom management, uncertainty about diagnosis, and personal identity (as a long hauler). Thompson et al. observe that one of the most important therapeutic functions of this online community was offering social support as well as validating symptoms reported by others, something which clinicians as well should do.

Two years into the pandemic, many of the communication challenges discussed in the early phase of COVID-19 [1] remain. However, as the pandemic has developed, new questions have arisen, in all of the areas mentioned above.

As we enter the third year of COVID-19, many individuals are experiencing COVID fatigue, which the World Health Organization (WHO) defines as a demotivation to follow recommended protective behaviors, as people are experiencing negative emotions and are tired of wearing face masks and keeping a distance. The challenge for health communication practice and research is how can we prevent attitudes of indifference and slack behaviors such as not wearing masks and social distancing? WHO provides several recommendations for communication policy and practice, which include being transparent (e.g., sharing reasons behind restrictions), being consistent in messaging (e.g., avoid contradictory messages such as how long should one isolate) across different experts and policymakers, and focus messaging on engagement and motivation, not judgment and blame [23] . The challenge for health communication specialists is how to best develop interventions and put these recommendations in practice.

Early in the pandemic, some research indicated that intentions to get vaccinated once vaccines was available were predicted by perceived norms and instrumental beliefs that vaccines will work [24] . While vaccine hesitancy in the early months of the pandemic was associated with the types of cognitive and emotional factors mentioned above, in the course of 2021 vaccine hesitancy has morphed into vaccine resistance and refusal, often on more ideological grounds. This is due to several factors including the appearance of conspiracy theories [25] . ideologically based responses to government efforts to encourage/require vaccinations, beliefs that vaccine messaging and policy restrict freedom of choice [26] , and an evolving information environment increasingly complicated by the complexity of a vaccine information that includes new information on COVID mutations, misinformation (false information the sender believes to be true) and disinformation (false information the sender knows to be false) [27, 28] . Hence, from a health communication perspective, the challenge for vaccine promotion has evolved from educating message recipients about vaccine effectiveness and modest side effects to overcoming hostile attitudes based on ideology and to rebuffing false information [29, 30] .

How can these cognitive and ideological barriers to accepting vaccines be overcome? First, one obvious measure is to insure that the information given is easy to understand. However, that is not always the case. In a study published in the present issue, Okuhara et al. [31] found that vaccine information supplied by health care providers is more difficult to read than recommended. Communication experts should test the readability of all information about vaccines and other aspects of the pandemic. In addition to readability of information, patient understanding can also be influenced by the quality of communication in clinical encounters. In this issue of PEC, Zheng et al. [6] reported that more patient-centered communication by clinicians moderated the relationship between vaccine knowledge and perceived risk of COVID-19 vaccine side effects.

Second, to overcome ideologically based skepticism towards vaccines, a focus on the message content is probably not enough. It may be equally important to invest in the most trusted messengers. Clinicians, typically a trusted source of information to most people, can help overcome vaccine resistance and hesitation, by strongly recommending vaccinations and the reasons why. For example, parents hesitant to have their children receive the HPV vaccine were more likely to have their child vaccinated when pediatricians made a strong recommendation for getting vaccinated and a clear rationale for why compared to parents whose doctors offered a weak recommendation [32] . To obtain maximum adherence to precautionary measures and vaccines, politicians and government agencies should employ messengers who radiate trustworthiness and are good communicators.

With respect to telehealth services, most surveys conducted during the pandemic indicate patents are relatively satisfied with telehealth alternatives [33, 34] . However, many patients also miss the 'in person' connection with health care providers and are concerned that telehealth may limit clinician's ability to show compassion, provide timely information, and address emotional distress [35, 36] . Although telehealth options for certain health care services are likely 'here to stay,' more research is needed on how to best adapt telehealth to insure quality health care [37] . We propose two lines of health communication research in the future.

First, more attention should be given to exploring patient preferences for telehealth. For example, surveys indicate that patients vary in their preferences for telehealth for certain health care services with some hoping telehealth remains an option for the future [38] ; others want to get back to normal pre-pandemic care [39] . A question to address is what health care services and for which patients should telehealth be an option? And if telehealth is a preferred option, through which medium? For example, of those patients that want telehealth as an option, some prefer the telephone whereas others think video visits are more satisfying [40] .

Second, electronic communication (through phone or videoconferencing) can limit the spontaneity of interaction and nonverbal cues necessary when clinicians are trying to establish rapport, be compassionate, reassure, and show empathy. Thus, future research needs to help clinicians acquire communication skills that will enhance their 'webside manner' to learn communication techniques (e.g., more reliance on talk, using gestures, adjusting camera angle and closeness) for building rapport, signaling attentiveness, and showing care and concern through various media platforms (e.g., video, phone, SMS text) [41] .

COVID-related uncertainty and anxiety will remain an issue that policy-makers, political institutions, clinicians, and the general public must contend with for the foreseeable future. Effective health communication must play a central role in helping the world cope with and manage the lingering, evolving effects of COVID-19. Effective clinician-patient information-exchange and relationshipbuilding, two domains of patient-centered communication that patients value most, can help patients and family deal with stress associated with uncertainty related to the unknown of the pandemic [42] . However, there will also be a need to have clinicians fine tune skills in two other domains of communication, such as responding to difficult feelings and managing uncertainty, which clinicians often score less well on compared to information-giving and decisionmaking [43] .

In many ways, the biomedical science associated with testing for infection, identifying virus mutations, and developing effective vaccines against COVID-19 has been remarkable. As of today, those vaccinated and boosted are significantly less likely to get infected or have serious disease relative to the unvaccinated. Yet, biomedical science cannot solve vaccine hesitancy, misinformation, ideological resistance to vaccination, disruptions in health care, and how best to cope with the lingering uncertainty and anxiety of living with the pandemic. These tasks fall on the shoulders of communication scientists and professional communicators. In this editorial, we offer ideas for where future research can address these challenges; in this issue of PEC, several papers are presented embracing this charge.

Effective health communication -a key factor in fighting the COVID-19 pandemic

Impact of rumors and misinformation on COVID-19 in social media

Endorsement of COVID-19 related misinformation among cancer survivors

Applying harm reduction to COVID-19 prevention: The influence of moderation messages and risk infographics

COVID-19 Vaccine hesitancy-A scoping review of literature in high-income countries

Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication

Assessment of communication strategies for mitigating COVID-19 vaccine-specific hesitancy in Canada

Vaccine for yourself, your community, or your country? Examining audiences' response to distance framing of COVID-19 vaccine messages

Impact of COVID-19 on cancer care: How the pandemic Is delaying cancer diagnosis and treatment for American seniors

The impact of COVID-19 pandemic on patients with ANCA associated vasculitis

Rapid utilization of telehealth in a comprehensive cancer center as a response to COVID-19: Cross-sectional analysis

Impact of the COVID-19 pandemic and lockdown restrictions on psychosocial and behavioural outcomes among Australian adults with type 2 diabetes: Findings from the PREDICT cohort study

Care partners reading patients' visit notes via patient portals: Characteristics and perceptions

Challenges faced by families of critically ill patients during the first wave of the COVID-19 pandemic

A questionnairebased study on quality and adequacy of clinical communication between physician and family members of admitted Covid-19 patients

The psychological impact of COVID-19 on the mental health in the general population

Perspectives of cancer patients and their health during the COVID-19 pandemic

Hepatic complications of COVID-19 and its treatment

The impact of coronavirus disease 2019 on the quality of life and treatment disruption of patients with breast cancer in a multiethnic cohort

Challenges of non-COVID-19 patients with chronic illness during the pandemic

Exploring variables related to medical surrogate decision-making accuracy during the COVID-19 pandemic

Using crowdsourced medicine to manage uncertainty on Reddit: The case of COVID-19 longhaulers

Pandemic fatigue -reinvigorating the public to prevent COVID-19. Policy framework for supporting pandemic prevention and management. Copenhagen: WHO Regional Office for Europe

Which beliefs predict intention to get vaccinated against COVID-19? A mixed-methods reasoned action approach applied to health communication

Conspiracy theories as barriers to controlling the spread of COVID-19 in the U

Walking the party line: The growing role of political ideology in shaping health behavior in the United States

Public perceptions of conflicting information surrounding COVID-19: Results from a nationally representative survey of U.S. adults

Susceptibility to misinformation about COVID-19 around the world

Combatting against Covid-19 & misinformation: A systematic review

Vaccine hesitancy: The next challenge in the fight against COVID-19

Readability assessment of vaccine information: A systematic review for addressing vaccine hesitancy

Characterizing safety-net providers' HPV vaccine recommendations to undecided parents: A pilot study

Patient satisfaction with telemedicine during the COVID-19 pandemic: Retrospective cohort study

Virtual oncology appointments during the initial wave of the COVID-19 pandemic: An international survey of patient perspectives

Bridging the distance: Continuing psychooncological care via video-consults during the COVID-19 pandemic

Strategies for digital care of vulnerable patients in a COVID-19 world-Keeping in touch

Covid-19 and the 'new normal': are remote video consultations here to stay

Telehealth consultations in general practice during a pandemic lockdown: Survey and interviews on patient experiences and preferences

How did women with breast cancer experience the first wave of the COVID-19 pandemic? A qualitative study

Patient preferences for telehealth services in a large multispecialty practice

Webside manner during the COVID-19 pandemic: Maintaining human connection during virtual visits

Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind

Factors affecting the communication experiences of newly diagnosed colorectal cancer patients