Discussion

To improve the delivery of timely and accurate information and address current barriers in health communication during epidemics and pandemics, there are at least 3 broad areas to consider. These include devising of and investment in accurate, concise, and reliable public health communication frameworks; the improved and advanced use of media, and addressing misinformation by tailoring messaging to highlight facts that directly counter misinformation. Communication strategies need to be further updated to reflect nuances and requirements in the current digital era, and should be implemented more effectively during epidemics and pandemics. ^{Reference Nazir, Hussain and Tian13} A renewed investment in timely communication methods on the part of public health agencies is warranted. Addressing mistrust toward the governments and healthcare industry requires a transparent and clear information exchange with the acknowledgment of limitations without resorting to fear tactics during epidemics or pandemics. ^{Reference Han, Zikmund-Fisher and Duarte14} The status and needs of vulnerable populations should be evaluated and prioritized during epidemics and pandemics as soon as possible. ^{Reference Vraga and Jacobsen35} Tested and evidence-based guidelines on health crisis communication should be implemented with a commitment to address public mistrust. ^{Reference Reynolds and Quinn Crouse21,Reference Barrelet, Bourrier, Burton-Jeangros and Schindler22,Reference Gesser-Edelsburg, Mordini, James, Greco and Green25} During recent epidemics and pandemics, while broad aspects of the public health communication frameworks have been followed, political agendas and influences took precedence and diminished the impact of the intended health messages. ^{Reference Kim and Kreps32} Interagency cooperation needs to be re-emphasized when developing and releasing prompt press statements to improve the implementation of evidence-based frameworks and guidelines, maintain consistent messaging, and ensure that all aspects of the communication plans are followed. ^{Reference Barrelet, Bourrier, Burton-Jeangros and Schindler22,Reference Kim and Kreps32} Regional, and local governments should be regularly included in communication planning and strategizing approaches so that all stakeholders have shared goals and ownership of their implementation during epidemics and pandemics. ^{Reference Barrelet, Bourrier, Burton-Jeangros and Schindler22}

Public health communication could more effectively use clear and plain language when interacting with the public. ^{Reference Barrelet, Bourrier, Burton-Jeangros and Schindler22} The use or overuse of technical language will increase the risk of misinterpretation and decrease the likelihood of positive changes in preventative behaviors. ^{Reference Peinado, Treiman, Uhrig, Taylor and Stryker23} Public health agencies should constantly improve and update their approaches in utilizing both mass media and social media channels. While it is neither feasible nor advisable for governments and health agencies to exert complete control over what general media publishes, it is important to prioritize inputs and insights from independent scientists and experts as these direct health communicators could help improve the acceptance of the messages less affiliated with governmental instutitions. ^{Reference Finset, Bosworth and Butow9,Reference Lee and Basnyat17,Reference Leask, Hooker and King18} The relationship between healthcare delivery and public health communicators, and for all types of media sources, is vital in the dissemination of accurate and effective information to the public. Health messages that are collaboratively framed will promote knowledge and improve efficacy while avoiding media sensationalism when the facts are daunting or unclear. ^{Reference Bekalu, Bigman, McCloud, Lin and Viswanath16–Reference Leask, Hooker and King18,Reference Walker and Adukwu26} In times of information uncertainty, public health and healthcare organizations could emphasize and communicate simple evidence-based solutions that were successful in comparable situations or conditions and justify their application to the present situation while remaining truthful that more information on the specific condition may change the approach or recommendations as they become available. Moreover, promoting positive or preventative behaviors and community safety should be prioritized over fear-based approaches to engage the public. ^{Reference Han, Zikmund-Fisher and Duarte14,Reference Peinado, Treiman, Uhrig, Taylor and Stryker23,Reference Walker and Adukwu26} By providing accurate and narrative-type stories to news agencies, public health and healthcare agencies may be able to provide support for positive communication and improve the delivery of accurate information through the media.

Public health agencies often do not tailor or adapt their messages to social media networking format, but instead replicate other materials produced elsewhere, ^{Reference Sutton, Renshaw and Butts34} which will likely be less effective. Social media platforms can be effective tools. However, they require careful implementation in the right context, strategically utilized for the right audiences, and with information originating from the official public health or healthcare delivery sources. ^{Reference Anwar, Malik and Raees6,Reference Nazir, Hussain and Tian13,Reference Walker and Adukwu26} As social media continues to be 1 of the most preferred public source of information, health messages should appeal to the related audience to improve uptake and effectiveness. ^{Reference Sylvia Chou, Gaysynsky and Cappella7} The interactive nature of social media, as an accessible platform to promote 2-way dialogue with public health professionals, could be effectively utilized in health messaging. ^{Reference Anwar, Malik and Raees6,Reference Henrich24} Merely posting repeated information without addressing questions or the gaps in knowledge will not be effective use of social media and is unlikely to translate into significant behavior changes. ^{Reference Sutton, Renshaw and Butts34} Public health agencies may need to better invest in employing experts in social media utilization and adapt their communication frameworks for the high-speed nature of such platforms as the most powerful tools to directly target misinformation.

Misinformation has become a dangerous concurrent epidemic, and the scientific community, public health, and healthcare delivery agencies have so far struggled to manage this important challenge. Actors and stakeholders in the health communication field need to collaboratively develop strategic solutions to mitigate a continuum that includes the spread of passive misinformation to developed disinformation campaigns. ^{Reference Gesser-Edelsburg, Diamant, Hijazi and Mesch58} The primary approaches should include transparency, addressing emotions, fears, and uncertainty, and providing clear information. ^{Reference Finset, Bosworth and Butow9,Reference Han, Zikmund-Fisher and Duarte14,Reference Gesser-Edelsburg, Diamant, Hijazi and Mesch58} However, even with these strategies, public health has struggled to improve behaviors among those susceptible to misinformation. 1 of the most prominent examples is the problem of vaccine hesitancy. Vaccination is 1 of the oldest and best tools to mitigate infectious diseases and has decades of scientific research to promote its safety, feasibility, and accessibility. ^{Reference Dror, Eisenbach and Taiber3} Nevertheless, large segments of the population are still wary of vaccines and their potential side effects, largely due to decades of counter-information messaging and campaigns. ^{Reference Nowak, Sheedy, Bursey, Smith and Basket20} Due to the extent of anti-vaccination culture, strategies to increase vaccinations are an important area to test and improve health communication methods. ^{Reference Nowak, Sheedy, Bursey, Smith and Basket20,Reference Henrich24,Reference Gesser-Edelsburg, Diamant, Hijazi and Mesch58} Many of the same principles discovered in the vaccine hesitancy domain could also be applied to the misinformation regarding epidemics and pandemics. Solely highlighting the specific inaccuracies that are believed by individuals can be counterproductive, but carefully developing targeted messages that provide the concrete facts presented within the frame of open communication could help minimize the effects of misinformation. ^{Reference Gillespie, Obregon and El Asawi19,Reference Reynolds and Quinn Crouse21,Reference Henrich24,Reference Vraga and Jacobsen35,Reference Godinho, Yardley and Marcu59} Many of these population subgroups are inherently distrustful of governments and their communications, but the inclusion of trusted stakeholders, especially local healthcare providers and faith-based community leaders has been shown to improve credibility and increase the acceptance of the public health recommendations. ^{Reference Gillespie, Obregon and El Asawi19,Reference Nowak, Sheedy, Bursey, Smith and Basket20}

Once a channel of communication has been established, the focus should be on clear behavior risk-reduction messaging while refraining from blaming individuals for their beliefs. ^{Reference Nowak, Sheedy, Bursey, Smith and Basket20,Reference Godinho, Yardley and Marcu59} Additionally, communication messages should emphasize the evidence of efficacy of recommended strategies in health messages from comparable epidemics or situations to improve acceptance and build further trust compared to misinformation sources. Potential psychosocial distress, as well as reasonable questions and concerns, should be addressed rather than dismissed as anti-vaccination sentiments. ^{Reference Finset, Bosworth and Butow9,Reference Nowak, Sheedy, Bursey, Smith and Basket20,Reference Reynolds and Quinn Crouse21} Public health officials and healthcare providers must emphasize the safety and efficacy of vaccines and other preventative behaviors with evidence while concurrently addressing the fears among the target audience, all while evaluating and addressing the underlying factors. The vilification of individuals with inaccurate beliefs is often polarizing and may hinder their willingness to accept accurate information. By acknowledging the differences in baseline knowledge and communicating from a place of genuine desire to help and protect, there can be an increased uptake of protective and preventive behaviors. ^{Reference Gillespie, Obregon and El Asawi19}

Addressing specific barriers to effective health communication at healthcare delivery level would require multidisciplinary approaches to devise and tailor consistent communication frameworks based on population needs, which include collaborations among all sectors of governments, public health authorities, healthcare organizations, clinicians, and frontline providers. 2-way communication between health entities during health emergencies to develop data systems and communication strategies has been recommended by many researchers. ^{Reference Glatman-Freedman, Bromberg and Ram38,Reference Bowden, Burnham and Keniston49,Reference van Dijk, Hooiveld and Jentink53,Reference Staes, Wuthrich and Gesteland56} When medical providers provide recommendations based on experience and data from actual encounters with patients, the government and health officials should take these insights and input into consideration in creating health communication frameworks and messages. ^{Reference Wahbeh, Nasralah, Al-Ramahi and El-Gayar41} Studies have recommended using tiered systems for communicating management of disease epidemics including capacity building, containment, collaboration, and conscientious use of resources. ^{Reference Bowden, Burnham and Keniston49} Health communication at healthcare delivery level cannot follow a 1-size-fits-all approach. The target population demographics and specific needs should be considered when creating health communication messaging and related frameworks. Tailoring of messages should be based on humility and taking into account the insight, perspectives, and knowledge of the target population. ^{Reference Goldstein, Murray, Beard, Schnoes and Wang37}

To improve direct and indirect patient care, health facilities should consider differences in types and methods of health communication and counseling when providing relevant information to frontline providers. ^{Reference Klein, Cohen and Baseluos46} Medical providers can help tailor plans and information if they are provided with accurate, clear, timely information, and the needed support to deliver them. ^{Reference Bagdasarian, Cross and Fisher39,Reference Locatelli, LaVela, Hogan, Kerr and Weaver47} The input, support, and ownership from researchers, journal or magazine editors, publishers, and mass media may be needed to have consistent messaging and avoid having the medical community be an inadvertent source of misinformation. ^{Reference Bagdasarian, Cross and Fisher39} Unexpected needs or unforeseen situations will likely and frequently arise in healthcare settings during epidemics and pandemics, therefore a preparedness plan that involves a collaborative team approach can translate into better and more effective health communication that addresses uncertainties. ^{Reference Bowden, Burnham and Keniston49} Medical staff should also be trained to tailor and better disseminate accurate and consistent messages among the medical community. ^{Reference Tham, Lu and Teo50,Reference Janssen, Tardif, Landry and Warner55,Reference Scott and Van Scoy60} Additionally, in order to promote behavior changes during epidemics and pandemics, policies and infrastructure that support behaviors such as quarantining, isolating, and social distancing will also be needed in healthcare delivery settings. Communicating their importance is an important step but there also needs to be policies and structural support to promote their implementation and utilization.