To combat the coronavirus pandemic, Americans have been told to “stay home to save lives.” They’ve been counseled to stay six feet apart from others and avoid gatherings. They have been advised to get vaccinated because it’s “the unvaccinated” who are to blame for driving the pandemic and stressing health-care systems. Yes, some Americans are heeding this advice, but over time, this absolutist and judgmental approach has contributed to eroding trust in public-health institutions. It has also put local public-health practitioners and individual clinicians counseling patients in the challenging position of translating these messages into real-life recommendations.
The most effective public-health communication should embody the qualities that primary-care pediatricians like me strive to emphasize daily: empathy and nuance. We start by trying to understand families’ priorities about their children’s health and well-being. We then acknowledge ways in which the treatment may fall short, or aspects that we cannot predict. From there we lay out any potential risks and benefits with complete transparency, establish clear goals for any intervention, and support the family’s decision making with compassion.
For example, if the parents of a child with ADHD are opposed to treatment with medications, I make an effort to understand why, and explain the evidence about efficacy and safety of ADHD medications with the parents’ specific concerns in mind. I work with the family to define their goals for symptom control, discuss options for behavioral therapy, and agree on when we’ll meet again to reassess. I’m honest about not being able to predict precisely my patient’s response to treatment, and I develop with the family a shared understanding of what might prompt us to revisit the possibility of trying a medication. This approach builds trust and keeps the conversation going even when I may disagree with a family’s decision.
Understanding differences among individual families’ needs and priorities, and tailoring communication accordingly, is of course possible in a clinic visit in a way that it’s not when communicating with the general public. However, simply acknowledging and validating the varied values and priorities people hold would be helpful in framing COVID-19 guidance. One family might decide that the benefits of gathering to celebrate a milestone birthday are more important than avoiding all COVID-19 risk. A child with social or speech delay may have more difficulty communicating through a mask than other children do. Parents who have been going to in-person jobs throughout the pandemic may think differently about risk than those who have been mostly isolated at home. Those who have personally experienced the loss of a loved one to COVID-19 may have a different perspective than those who have not. Messaging that is responsive to families’ diverse needs and concerns tends to be better received.
Central to this approach are honesty and humility—not overstating benefits or understating risks of an intervention, and being direct about uncertainties and limitations in our knowledge. In November, the CDC made an appeal stating that wearing a mask could decrease the risk of COVID-19 infection by 80 percent, though a much more modest benefit is likely conferred, with the degree of benefit being related to masks’ type and fit. In some local contexts—depending on, for example, vaccination and hospitalization rates—masking, along with other interventions, may be more or less helpful. However, dramatically overstating their incremental benefit risks diminishing trust in this guidance, and potentially raises skepticism about other public-health recommendations, including those with greater benefits, such as vaccinations. Similarly, masking of children age 2 and older has been a strong recommendation in the U.S. but masking under the age of 5 has not been adopted in many other countries, based on considerations related to developmental ability and the balance of potential risks and benefits for this age group. If public-health advocates would acknowledge this difference, and explain why we have come to our own conclusion, we would instill greater public trust.
Whenever I recommend any treatment or intervention for my patients, I work with their families to establish therapeutic goals and manage expectations around factors that might prompt us to change course, including assessment of the treatment’s impact and potential side effects. During the pandemic, the goals and end points for many COVID-mitigation strategies haven’t always been clear. For example, the duration of COVID protocols (including masking and quarantine rules) in schools and day cares has generally not been linked to any clear metrics, though these policies do vary regionally. Especially now that COVID vaccines are available for school-aged children and all teachers and staff can be vaccinated and boosted, we ought to have guidance in place that dictates under what conditions restrictions will be eased. Just as, in our practice, patients and families feel anxious, confused, and frustrated if we don’t have a goal or timeline to evaluate an intervention, many parents are understandably confused and frustrated by school policies that are not tied to any particular metrics that would permit reevaluation, much less an end point.
The CDC’s recent recommendation that all vaccinated children over 12 receive a booster, and mandates from some colleges and universities requiring students to be boosted, are further examples where more detailed guidance and clearly articulated goals would be helpful. For healthy young people, the two-dose mRNA vaccine series continues to dramatically reduce the risk of severe disease and hospitalization. Broad-brushed messaging understates this enduring effectiveness of the two-dose series, but also inadequately emphasizes the importance of boosters for at-risk populations such as older adults and those who are immunocompromised, for whom the third dose is extremely important. This lack of nuance could have the unintended consequences of increasing vaccine hesitancy in people who have yet to get their first dose and decreasing the likelihood that the highest-risk populations receive a booster.
Leading with compassion when communicating with patients and families means emphasizing that we care about them unconditionally, do not judge or condescend, and seek to support them in making decisions that are right for their children and family. In clinical practice, there are times when we feel tired and frustrated, and those are the times when we need to be especially mindful about not allowing our emotions to make us come across as unkind or adversarial. Exhausted health-care providers have tried pleading with the public to get vaccinated (and also to mask and distance) to the effect of “We are tired; we are overwhelmed; we are begging for your help; we need you to care as much as we do.” The implication is that people are getting sick because they don’t care, and that getting vaccinated (and, by extension, not getting sick with COVID) is about being a good person. Unfortunately, those who are already mistrustful are especially likely to feel judged, shamed, and marginalized by this, none of which is likely to motivate them to get vaccinated or start wearing masks. Shame and blame have no place in communication between health-care providers and patients, and the same should apply to public-health messaging.
The most valuable public-health messaging channels the qualities of doctors’ best communication with individual patients and families: openness, vulnerability, compassion, and unconditional support and care. This approach also values whole health, which means understanding that health is about more than avoiding any particular disease—it’s about physical, mental, and social well-being. In this framework, we acknowledge the potential downsides of COVID restrictions, embrace the complexity of explaining nuanced information that changes over time, and trust people to use that information to make their own decisions. As all frontline health professionals can attest, this approach isn’t always simple, quick, or neat, but applying it consistently is essential for rebuilding the trust in health institutions that we will need to prepare for future pandemics, manage ongoing current health threats, and navigate the challenging recovery ahead.