Health Communication Messaging Is Critical to Flattening the COVID-19 Curve
By Henry I. Miller, M.S., M.D. and Sheeva Azma, MS
In spite of the wide availability of highly effective COVID-19 vaccines, only about half of eligible Americans are fully vaccinated. Partly as a result of that “vaccine hesitancy,” the United States is experiencing a fourth wave of COVID-19 cases, with over 160,000 on August 18th, more than an order of magnitude higher than in mid-June. Deaths, a lagging indicator, have more than doubled since mid-July. Hospitals and healthcare providers in the nation’s hotspots, which are mainly the Gulf Coast states, are stressed. Consequently, we are again in the position of needing to “flatten the curve” of infections, with both more-aggressive vaccination and non-pharmaceutical interventions.
How can we explain the reluctance to take vaccines that were tested in clinical trials in tens of thousands of subjects and subsequently administered to hundreds of millions of people? In surge states like Florida, Oklahoma, and Texas, political leaders have banned mask mandates and vaccination requirements out of consideration for “liberty” and “personal responsibility.” Other red states, such as Louisiana and Arkansas, are having to backtrack on mask bans in order to better protect their populations. Kay Ivey, the Republican governor of Alabama, another state experiencing an overwhelming COVID-19 Delta variant surge, has strongly encouraged constituents to get the COVID-19 vaccine, even going so far as to say, “it’s time to start blaming the unvaccinated folks.”
There is still a genuine (and troubling) red/blue divide, however: Counties that voted for Biden generally have higher vaccination rates than counties that voted for Trump. ICUs are filling up in Texas, Florida, and Oklahoma. Texas Governor Greg Abbott, who himself this week tested positive for COVID-19, said that Texas will have to use staffing agencies to find medical personnel from out-of-state to assist with the COVID-19 surge; and he requested that hospitals voluntarily postpone elective surgeries to create more space for coronavirus patients.
Medical experts are calling on the governors of Florida, Texas, and Oklahoma to declare a state of emergency and demand—or at least allow— localities to implement mask mandates. However, a longer-term COVID-19 communication ground game is also needed, as masks are only one element in prevention.
For coronavirus, the ultimate objective is minimizing the probability of serious infection—and vaccination is our most effective intervention. But as CDC Director Rochelle Walensky put it, what we are experiencing now is “a pandemic of the unvaccinated.”
CLEAR, ACCURATE, AND TIMELY INFORMATION
Vaccine hesitancy is different from hardcore anti-vaccine convictions because it stems from peoples’ natural uncertainty and fears about the vaccine (and also from the deluge of disinformation about the COVID-19 vaccines on social media), rather than from a desire to avoid vaccines entirely or outright rejection of science..
Still, vaccination campaigns are key, in order to suppress the outbreak of COVID-19 nationwide, manage the devastating, persistent effects the disease can have, and limit the emergence of new “variants of concern” that might arise. (In every infection, as the virus replicates and mutates, the probability increases that new mutants, or variants, will arise that are more transmissible and/or virulent than their predecessors.)
Vaccine-hesitant and vaccine-resistant people often cite the low mortality rate from COVID-19, while ignoring the significant likelihood of persistent symptoms following the acute infection; among others, these can include loss of taste and/or smell, shortness of breath, profound fatigue, brain fog, fever, and muscle aches. According to the results of a recent study, about 25% of COVID-19 survivors develop what is known as “long COVID,” in which their post-infection symptoms persist for months, or even indefinitely. This is consistent with an earlier report that in a “cohort of individuals with COVID-19 who were followed up for as long as nine months after illness, approximately 30% reported persistent symptoms,” and that during the original acute illness, a high proportion had had only mild disease.
Both full-blown long COVID and the long-persisting lesser symptoms have important implications both for patients’ well-being and for societal healthcare costs.
Recently, the U.S. Centers for Disease Control and Prevention said that to combat the pandemic, “the war has changed,” because “the Delta variant of the coronavirus appears to cause more severe illness than earlier variants and spreads as easily as chickenpox.” In view of that evolution, more extensive vaccination is imperative, which would have the multiple benefits of reducing the likelihood of serious illness, hospitalization, and death in individuals; and also prevent hospitals from being overwhelmed by COVID-19 patients (which, unfortunately, is already happening in various parts of the U.S.).
However, getting the remaining eligible Americans vaccinated is not easy, in large part because of the “infodemic“—”too much information including false or misleading information in digital and physical environments”—that has accompanied the pandemic. Some of that false or misleading information comes from ignorance; much of the rest comes from more nefarious sources, such as “the Russian government’s propaganda apparatus, which cultivates and exploits foreign anti-vaccine “useful idiots,” causing palpable harm to Americans and citizens of other Western countries.
How can we counteract that? According to MIT research, “clear, accurate, and timely” information can help dispel vaccine hesitancy. In other words, effective science and health communication may convince many of the unvaccinated.
A WELL ORGANIZED GROUND GAME
A June 2021 Kaiser Family Foundation survey examined the views of people in various U.S. demographic groups toward COVID-19 vaccines and found that vaccine hesitancy is widely distributed among various demographics. (See the figure, labeled “Figure 2” here.) Uninsured people under age 65 have the lowest vaccination rates of all, followed by Republicans, rural residents, and people aged 18-29. Yet, 15% of the uninsured under age 65, as well as 15% of Black adults, and 14% of Hispanic adults say they’ll “wait and see” to get a COVID-19 vaccine. Therefore, the problem is not only a partisan political one; it cuts across many demographics.
While the KFF survey identifies many people as a “definitely not” when it comes to vaccinations, there are also many others in the “wait and see” or “only if required” categories who, if persuaded by effective health communication, could help to flatten the curve.
Effective health communication about the pandemic requires a well-organized ‘ground game,’ which can be likened to a political campaign.
There are many different reasons people cite for their reluctance to get the COVID-19 vaccine, including concerns about efficacy, safety and side effects, the speed with which the vaccines were developed, and a distrust of vaccines and the government, in general. Simply telling them that they are selfish doesn’t work, according to experts cited in a recent article in the New York Times.
Effective health communication about the pandemic requires a well-organized “ground game,” which can be likened to a political campaign. When people vote, there are generally a variety of issues they care about, and they try to align themselves with leaders who share their views on the issues. The vaccination ground game should be similar, which is why political leaders must be prominent in the effort.
A good example of the health communication “ground game” was the local, personal touch of Republican State Sen. Roger Thompson, who earlier this month attended a vaccination truck event in Okemah, Oklahoma. It served both to show that he was willing to be vaccinated and featured the “Free COVID-19 Vaccine Clinic.” Events with national politicians were less down-home but also very important. Louisiana congressman Steve Scalise, the House’s No. 2 Republican, posed for a photo of himself getting a vaccine, and urged others to do the same. “Get the vaccine,” he said. “I have high confidence in it. I got it myself.” Senate Minority Leader Mitch McConnell, a polio survivor who has been a constant critic of his party’s vaccine resisters and anti-maskers, warned bluntly: either get vaccinated or get ready for more lockdowns.
In the current wave of COVID-19, a health communication “ground game” is needed that can:
- Be nonpartisan, with a focus on improving constituents’ health.
- Align with peoples’ values, including red-state values such as freedom (to return to pre-pandemic normalcy, and of local governments to make policy decisions), bodily autonomy, etc.
- Meet people where they are. COVID-19 health communicators must answer questions, acknowledge that people’s concerns are valid, and help facilitate understanding of the ways that vaccines help reduce severe hospitalization and death due to COVID-19.
- Help people to understand that the risks of a COVID-19 infection far outweigh the risks of being vaccinated.
- Share personal stories that will resonate with vaccine-hesitant groups. There are innumerable stories in the mainstream and local media about people on their deathbeds wishing they had gotten the COVID-19 vaccine. Such sagas can be avoided if vaccinated people talk to their unvaccinated friends, family, church members, etc., about what their experiences were like when they got vaccinated. Many people want to get the vaccine but have questions before taking the plunge.
- Reduce barriers to vaccination for vaccine-hesitant groups, particularly the uninsured and other groups (with mobile vaccination units, for example), emphasizing that vaccines are available without cost, regardless of insurance status (and that there may be perks with vaccination, such as cash payments, tickets to sports events, etc.)
The emergence of new, more infectious and virulent “variants of concern” of SARS-CoV-2 (the virus that causes COVID-19), such as the Delta variant, reinforces the point that every new infection provides opportunities for new, more dangerous mutants. That serves as a reminder of the validity of the cliché that none of us is safe until we’re all safe. Which is why we need to redouble our efforts to persuade the undecided to get vaccinated.