A ‘cow length’ of distance

The factor that causes us most anxiety is uncertainty. Not understanding what is happening, not knowing where things go from here or what we are supposed to do can paralyse us or cause us to take the wrong action. On the other hand, if we have more clarity, we see things differently: we are proactive, we make better decisions and we find solutions for whatever situation we find ourselves in.

 
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This is particularly so with regards to health, where we have to bridge the knowledge gap and seek to find a common identity and solidarity between those sending and those receiving health messages. It goes beyond mere communication. It is very simple: all information that the audience does not manage to understand is not only useless, but counterproductive.

Writing specifically about Covid-19, there are many examples of poor presentation and mixed messaging in health campaigns that have caused confusion on the part of the target population, i.e. all of us. For example, at the same time when some health authorities were clearly advising that fever and/or cough were not sufficient reasons to go to a health center or hospital, a message from UNICEF suggested seeking medical assistance immediately if a person presented fever, coughing or breathing difficulties. How much unnecessary confusion was caused by something as simple as the conjunction ‘or’ in this case?

On the other hand, we also see the messages that many people do not understand and that, clearly, many more will not be able to comply with. Physical or social distancing is the best public health measure to impede the progress of an infectious disease. Yet, for many, distancing is a new concept and if we insist on using this terminology in public health campaigns, there is no doubt that we will not reap as much success as we would like to. It is vitally important to explain public health issues in a manner that is much simpler and appropriate to the target audience. In many public health campaigns, even when attempting to explain the reasons behind a measure being taken,  we find the same errors: extensive texts, inadequate size of print and poor design of the information as a whole that confuse the message. They can even be contradictory, frequently ambiguous or elaborate in style, rather than using more familiar or informal examples. The title of this article, however infantile it may sound is an appropriate illustration of this. It would not hurt to have health messages that draw attention and are understood by both children and adults alike.

This was one of the strategies implemented in Australia with the use of the iconic kangaroo, in Canada with the caboose and in northern Sweden with the elk to demonstrate what social distance means. Public health messages should use examples that are adapted geographically and culturally, not a one-size-fits-all approach. One example or image can mean different things to people in diverse geographic and cultural settings.

Pictograms do not always have to be accompanied by text to explain what they mean. In fact, the ideal would be to have a single image that expresses what the communicator wants to convey.  We keep hearing the well-worn cliché that a picture is worth more than a thousand words. Steer clear of any health communicator who mindlessly repeats this mantra, as it is an indication that they do not understand the complexity of the use, design and interpretation of pictograms in health communication. In Crisis Emergency and Risk Communication, using an image that expresses more than a thousand words (with possibly more than a thousand interpretations) is a very wrong choice indeed.

In such situations, an image must not leave room for ambiguity. It must be explicit and specific. It must not be open to subjective interpretation and, as far as this is possible, must be universally understood in the same way. This is not easy to achieve. Pre-testing of candidate pictograms with participants from diverse cultural, linguistic, age and socio-economic backgrounds can provide insights into how far universal interpretation is feasible.

If we are shown an image of two people separated from one another, we could interpret that there is no physical contact between them, but how close can they be? In some countries, it is 1 meter (France), for others, 1.5 meters (Germany) and others still, 2 meters (UK). If we remember what the correct physical distance is in a locality, how do we calculate it in practice? Here, again, the example of using something concrete, such as a kangaroo, a cow, a bed, a surf board, is useful to demonstrate how, instead of measurements in meters or feet, it might be more effective to illustrate the advice with something more relatable, such as animals or objects that are well known in the target culture.

An image also has the quality of conveying friendliness and empathy, generating trust and, at the same time, arousing curiosity and the desire the learn more about the health topic in question. In health promotion, this is an ideal outcome: positive behavior change that is initiated by an individual feeling motivated to find out more, to become informed, to educate oneself and to learn to rid oneself of false and alarmist information. Images are also a powerful tool to personalise and localise the message, to adapt each message, such as according to the age, ethnicity, and language of the audience. This means that the image can help the recipient of the message feel an identity and can take ownership of the information. The following examples are from Bolivia (in Spanish) and Guatemala (in K’iche’) where the images have been adapted to resemble people in both countries, respectively:

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In crises or emergencies, our capacity to process information that is complex or that is constantly changing according to new evidence, such as with the current pandemic, is affected and even reduced. We do not deal well with information that is uncertain or ambiguous. It becomes difficult to assimilate risk information in particular and we tend to hold onto the first thing we hear. For this reason, in many countries, rumours, conspiracy theories and disinformation have filled in all the information voids where health authorities and governments have been late to address. All this false information that has been virally shared becomes rooted in the minds and the belief systems of people. It becomes difficult to distinguish information that is false or out of context from what is reality and backed up by science. It then becomes impossible to dislodge these views once they´ve been established. All this can produce negative and very grave health outcomes.

With this famous ‘new normal’, will we always have to put signs on the seats of public transport, put markings on the ground to show how to queue, how to enter and exit buildings or paint white circles on lawns as they did in the public parks of New York? With these in place, the likelihood is that people will comply and stay within those markings and understand why they are supposed to do it. But what happens if there are no markings? Do we as individuals have to work out where the responsibilities of local health authorities end and where those of the independent, responsible citizen begin? However, before citizens can take personal responsibility, there needs to be clear and accessible information for all. It is important to understand what we need to be responsible for and why.

Humans are very adaptable, but it is much easier to adapt to something that we understand. Why are we doing it? What is the end game? What would happen if I decide to do my own thing? What would happen if I don’t do what the government is advising? Is it just advice or do I have to do it? If it is not an imposition or an order, how can people be encouraged to act voluntarily, as individuals and as a collective? This time of lockdown should also be used as a period of preparation so that all of us know how to reintegrate ourselves appropriately in what we will soon call ‘routine’.

According to best practices set out by the US CDC and WHO, it is recommended to present messages that do not contain medical jargon, use short sentences in the active voice, use everyday words, provide facts and not opinions. They recommend to state what is known and what it is not yet known, what is being done to gather more information and to tackle head-on any worries that people may have.

One commonly recommended device is to present health advice in ‘threes’. This means three messages or three simple elements to one key message, emphasising essential points or presenting a formula of action and consequence. A hugely effective example of this was the British government’s exhortation to its citizens at the beginning of lockdown in March:  

Stay Home. Protect the NHS. Save Lives

Here, we can see a completely logical flow of individual action and collective outcome: staying home = less risk of infection = the UK health service will not be over-burdened = lives will be saved. It is arguably the most effective public health message in British history, not only because of the message, but the use of color (to be explored in a forthcoming article). The measurable effect was that British residents largely understood the severity of the situation, complied and stayed at home.

However, if a message is not well presented or its meaning is not obvious, it can have the opposite effect: it can cause confusion and fail to motivate and persuade the intended audience. For example, in UK in early May, that hugely successful message was replaced by the following:

Stay alert. Control the virus. Save lives

How this slogan was received by the British public deserves another article. Suffice it to say that it fell flat. Nobody knew what ‘staying alert’ meant exactly or ‘controlling the virus’. These instructions were too abstract for anybody to commit concrete action to. It was even rejected by other Home Nations, who stuck with the original, clearer message.

This ‘triple enumeration’ is a device that has been used to great effect in literature for millennia – think ‘vini vidi vici’ or ‘I am the way, the truth, the life’ – and has the potential of reaping success in public health campaigns and emergency communications. But this cannot happen if the register of the text used is too high for universal comprehension, as can be seen in the following two examples from Chile and Guatemala, respectively, where clear communication is hindered by higher register verbiage, such as ‘ubique el establecimiento de salud más cercano al lugar donde se hospedará’ (‘Locate the closest health establishment in the place where you will be lodging’) and ‘realice previamente un chequeo médico si padece alguna enfermedad crónica’ (‘conduct a medical check-up beforehand if you suffer from any chronic illness’.)

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In the USA, a high percentage of Covid-19 patients did not have functional knowledge of English, many of them unable to communicate in English at all. From mid-May 2020, 22% of people who tested positive in hospitals in Minnesota alone required an interpreter to be present when being spoken to by a doctor. Thousands of undocumented immigrants in the USA avoid seeking medical help for fear of being reported to authorities. These are vulnerable people, whose fates are in the hands of their employers, as in the case of factory and food processing plants, where there continues to be spikes in infections, due to working in close quarters with other people on the production line.

Indigenous peoples make up 6% of the global population. The UN is committed to making all coronavirus information relating to hygiene, physical distancing, quarantine and prevention available in indigenous languages. Unfortunately, the quantity and quality of health information in these languages fall short in terms of how the messages are disseminated without taking into account how people prefer to receive information, e.g. text versus audiovisual. In addition, how the messages are constructed is sometimes problematic, such as use of the majority language, such as Spanish, to fill in lexical gaps in the indigenous language. For example, terms like ‘social distancing’ and even ‘virus’ have been inserted into indigenous language information in Latin America. It might have been better to explain these terms in those languages by means of circumlocution, rather than shoe-horning in utterly foreign concepts in, what is for some, utterly foreign languages, such as Spanish or Portuguese. Again, pre-testing might have been a sensible idea.

Who the messenger is has importance too. Has the public health message been developed and disseminated by central government or an NGO - who make too many wrong assumptions about local language content - or has there been local input in the design of the information? Community engagement in a fast-moving crisis is vital, but around the world, as far as minority communities are concerned, little of this seems to have happened during this pandemic.  

These are just some examples of the varying quality of public health messaging in this crisis. As we have seen, some have worked because the messages are accessible and relatable, while others fail because they are poorly constructed and incongruous. Prevention measures, social assistance, how to deal with coronavirus at home, lockdown and navigating ourselves out of lockdown, all these are basic themes during this crisis. However, many people have struggled to cut through the fog of information, what is still not known about the disease and how to distinguish between fact and fiction.

Disinformation in this crisis has had a tangible and negative effect on public health in all countries. In a crisis, where rumour and false information have reached people before the facts have is a complete failure on the part of governments. And when the facts do arrive and they are often inaccessible due to information that is poorly designed and full of jargon, that is a double failure. Add this to the mixed-messaging from governments, missteps from our leaders and the net result is a thick soup of confusion. This is where people’s trust and confidence are lost.

What happens now when the much-feared second wave hits us or there are local surges in cases? Will we, in our respective countries, decide to isolate ourselves again, to count the dead again, to attend even more Zoom funerals, to wreak further damage to our economies, to face starvation? Next time will we comply with what our leaders are telling us to do? Trust has been so massively eroded, people have preferred to hold onto disinformation and conspiracy theories. Huge changes will be required to win back people’s trust and for all of us to work together for the common good. And the key to all this is so very simple: timely, honest and clear information.  

Alejandra Contreras, Health Information Linguist

10th June 2020, Guatemala

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© 2020 Alejandra Contreras, protected under British Copyright Law 1988. 

 
 
Health Communication, Health PromotionGibson Research ConsultancyA cow length of distance, health information