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As COVID Lingers, How Can Health Communications Be Improved?

What’s behind distrust of public health advice? Harvard's Rima Rudd, a founder of the field of health literacy, explains the ways that health messaging can go wrong.

Shop Mask Free Los Angeles rally gainst COVID-19 Vaccine
Los Angeles residents challenge the need for COVID-19 restrictions.
(Irfan Khan/TNS)
More than a century ago, the Supreme Court ruled that a mandatory smallpox vaccination policy in Massachusetts did not violate Fourteenth Amendment rights. Even so, millions of Americans view COVID-19 response measures — from vaccination to limits on gatherings — as violations of their personal liberty and beliefs, not as science-based strategies that could protect those they love.

No one would say that the rules for good health vary according to party affiliation. But when it comes to COVID-19, political persuasion makes a difference. A Monmouth University survey published this month found that 85 percent of Democrats support bringing back masking and social distancing guidelines to slow the latest surge in COVID-19 cases, while 73 percent of Republicans oppose these measures. Similarly, a POLITICO/Morning Consult poll found that more than 80 percent of Democrats are in favor of vaccination mandates, as compared to 35 percent of Republicans.

The vaccination plans of Americans vary greatly according to party affiliation.

In the 1950s, the polio vaccine was embraced by the public, a blessing from science to parents fearful the virus would strike their children. More than one factor has shaped today’s very different climate, politics mixing with conspiracy theories and fringe science, spread through social media technologies that create echo chambers for false information.

“Normally, our theories and models would say that once people are directly affected by a serious problem, they will change their beliefs and intentions and likely their actions, but COVID-19 is changing the rules,” says Cynthia Baur, director of the Horowitz Center for Health Literacy at the University of Maryland School of Public Health.

There may not be a single cure-all for the COVID-19 infodemic, but the work of health literacy researchers such as Dr. Baur has resulted in evidence-based tools that can improve consensus about what’s true and what’s not.

A Foundation of Health

Rima Rudd, senior lecturer on health literacy, education and policy at the Harvard School of Public Health, is one of the founders of the field of health literacy. “We’ve known since the first national assessment of adult literacy amongst industrialized nations in the 1990s, and through repeated assessments over the decades, that large segments of our populations cannot use commonly available materials with accuracy and consistency to accomplish everyday tasks,” she says.

The findings from early assessments were a shock, Rudd recalls. “Our assumptions about literacy were false — we had long assumed that mandatory education until at least the age of 16 would take care of the problem of low literacy. It did not.”

Faced with these findings, Rudd and others in the health sector immediately began to wonder about their implications for health. A new area of research was born, and it became apparent that literacy and health outcomes were linked.

“We found that it was definitely true that those people with limited or low literacy skills were less likely to be able to take care of a chronic disease like diabetes and maintain their well-being,” she says.

As the field progressed, more and more studies showed that the literacy skills of patients affected health outcomes in a variety of areas. Drawing on this work, Dr. Rudd drafted the nation’s first health literacy action plan.

Knowledge about best practices for achieving health literacy has continued to accumulate during the three decades since this early work. In a conversation with Governing, Rima Rudd talked about this evolution and the latest thinking about the meaning of the term “health literacy.”

Governing: How has understanding of health literacy changed over time?

Rima Rudd: There was an error that wasn't corrected until fairly recently. The mistake was that we were looking at literacy and health literacy as a characteristic of an individual, and it's not. Literacy is an interaction between a reader and a text.

I have pretty high literacy skills, but if you give me an advanced physics text and use that as a measure of my literacy skills, I would come out looking pretty poor.

Literacy is an interaction between me, my skills and the texts that I'm given. In their research studies around health literacy, people weren't including that in the equation.

Governing: How would this affect the definition of the term?

Rima Rudd: The definition of health literacy used by Healthy People 2010 and 2020 was, ‘‘Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions.’’ The focus here is on the skills and actions of individuals.

In contrast, the advisory committee for the secretary in shaping Healthy People 2030 proposed: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.”

Here, the responsibility lies with those who shape health information.

Governing: What can health professionals do to support this goal?

Rima Rudd: If we continue to focus on the skills or deficits of the public, there is no action we can take other than wait for the education systems to improve. Instead, we have a responsibility to improve our own communication skills, make our information and texts more accessible, ease the tasks that people need to undertake, and remove existing barriers in our health institutions and systems.

Rima Rudd: "Health literacy offers us insight to remove barriers to information. It offers us insight to increase dialogue, because health literacy, at the base of it, really focuses on a dignified exchange. We lay the foundation stone for respectful exchange, respectful dialogue. Without that nothing could move forward." (Harvard)
Those of us in science, public health, medicine, nursing, pharmacy, dentistry and all the allied health professions have a responsibility to policymakers and to the public to be sure to translate our findings and advice into everyday terms so that we literally share our information. We must all become bilingual — skilled in the language of our specialties but also fluent in everyday ‘kitchen table’ talk.

Governing: What kinds of techniques can help health communications arrive as intended?

Rima Rudd: Several thousand peer review studies indicate that health texts are provided at levels of difficulty that far exceed the known skills of most adults in our society. Written, posted or spoken information can be compromised by the use of jargon or unfamiliar concepts, a lack of organization, or insufficient emphasis or relevance.

A long sentence confuses a poor reader because a long sentence is likely to have different clauses in it, many things set off by commas. I don't know if you've seen these brochures where it takes seven lines before a sentence is completed. People get lost by line two.

Communication should be consistent; always tell people what we know, what we don't know and what we're doing to find out more.

The CDC’s guidelines on risk communication, Crisis and Emergency Risk Communication, don’t mention health literacy, but draw from really good communication theory. Even people at CDC are not always following the guidelines that they themselves promulgated.

When I talk about literacy, by the way, I'm also including numeracy. We know what those skills are, and we know that they're poorer than we would want.

Governing: How do you take numeracy into account in communications?

Rima Rudd: If you start talking to people and within the same message you're talking about numbers with decimal points, talking about fractions and talking about percentages, you're asking people to do calculations. It’s a very difficult task to transfer a number with a decimal point into a fraction or a percentage. People cannot do that.

Governing: What’s the right tone for communications? We’re at a point where all sides can get overheated.

Rima Rudd: Engaging in this kind of dialog is respectful. It carries a level of dignity, that you really are knowledgeable about and concerned about the target audience. You know who they are, you know what they need. You're not talking down to them.

You want people to have access to information, so you start taking away all the barriers to access information — a barrier that has to do with foreign language, scientific jargon, medical jargon. A barrier that has to do with the use of confusing numbers, a barrier that has to do with unnecessarily complex, long sentences.

Governing: How can communicators maintain discipline in regard to these practices?

Rima Rudd: We've long known that we should apply the same scientific rigor to our communication as we apply to medical devices. We would never allow a medical device to come on the market without having carefully tested it and tested its use with members of the intended users. Medicines have always followed a rigorous scientific process, which involves pilot testing with members of the intended audience.

We should do that with words as well; words have equal weight. No one should be able to sit at a computer and press the “print” button and send a message to the world.

There are existing and well-tested assessment tools that are freely available to people, as well as focus groups and pilot testing.

Is this understandable? Would your neighbor, who perhaps doesn't read well, understand this? Is information missing? That is applying good scientific processes to communication.

Governing: Is better communication about COVID enough, in itself, to change the minds of those who are rejecting guidance from public health officials?

Rima Rudd: We're assuming that access to information or knowledge leads to behavior change. That's a whole different realm — knowing something doesn't mean that you're going to do something.

So now we have a need for persuasive communication. We have a need to counterbalance to the purposeful, misguided lies that are perpetuated by who knows whom on a political agenda, telling people that the vaccine is going to change your DNA.

Health literacy doesn't have an answer for that. That's where you're looking at persuasive communication, how to counter propaganda. You have to match what we know with health literacy and bring in other forces as well.

Governing: Would it be fair to say that the success of health literacy and counterpropaganda efforts are intertwined at this time?

Rima Rudd: Health literacy offers us insight to remove barriers to information. It offers us insight to increase dialog, because health literacy, at the base of it, really focuses on a dignified exchange.

We lay the foundation stone for respectful exchange, respectful dialog. Without that nothing could move forward.
Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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