Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Dr. Glen Nowak, who is Professor of Advertising and Public Relations at the University of Georgia’s Grady College of Journalism and Mass Communication, and Director of Grady College’s Center for Health and Risk Communication.

He has provided senior-level leadership on communicating about topics that include infectious disease, public health risk and immunizations for government agencies, public health programs and research projects.

These organizations and projects include work for the US Centers for Disease Control, the World Health Organization and the International Association of National Public Health Institutes.

Glen Nowak has also authored or co-authored numerous peer-reviewed journal articles.

I was looking to interview someone for this podcast about how to refute myths, hype and hearsay when it comes to public health communication. Happily, our colleague Don Rubin introduced us.

Welcome, Glen, to Health Literacy Out Loud.

Dr. Glen Nowak: Thanks. Happy to be here.

Helen Osborne: I’m delighted. We are recording this in the middle of the coronavirus crisis, but I don’t want to just talk about that. I think that the issues apply to many public health issues, diseases and campaigns.

On the surface, it looks like it would be just straightforward information. But I’m thinking it’s not. What makes it so complicated to communicate a public health message?

Dr. Glen Nowak: I think coronavirus has illustrated quite well many of the challenges. They range from a great deal of uncertainty, uncertainty about whether you’re going to be exposed or infected whether it’s a new coronavirus or something more common, like influenza.

We don’t know when we go into a flu season if we individually will be infected with flu or if it will affect our lives. Uncertainty is one of the things that’s a challenge.

There are different priorities. We have seen throughout the coronavirus crisis that some people really value being able to have the freedom to live life as normal. Public health people, on the other hand, are trying to get people to take steps that will reduce their risk and prevent transmission of the disease.

Helen Osborne: I want to stop you right there, because I think there’s so much to talk about and what makes it so hard. I’m already intrigued about this issue about uncertainty.

Are you talking about uncertainty from the public’s perspective, like, “Is this really a problem? Does this really affect me?” or are you talking about uncertainty from the scientist and research perspective?

Dr. Glen Nowak: Both. It turns out that one of the things that happens with most health issues, but particularly with new infectious diseases, or even with infectious diseases, is that there is uncertainty on the side of the scientists and public health officials in terms of “How will this play out? Who will be affected? Are there people who have certain characteristics or health conditions that put them at higher risk?”

On the flipside, there are those of us, the people who are looking to health officials and doctors for advice. We want certainty, and often what we find is that they’re giving us answers that are contingent. They have to say, “We don’t know. Here’s how it could play out, but here are some other possibilities.”

I think that’s what frustrates us as consumers as well.

Helen Osborne: Uncertainty or the unknown is certainly scary and almost impossible to deal with. Thanks for clarifying. That uncertainty can come from both perspectives. We’re all uncertain about what’s going on.

Then you talked about priorities. Is that the same two-sided problem, that the officials, our government officials or our scientists have a certain set of priorities and the public might have others?

Dr. Glen Nowak: Yes. Often, if you’re in public health, your top priority is trying to prevent the spread or transmission of a health condition. That’s often your singular focus, so it’s your top priority.

What we have seen in coronavirus is that there are others, including in government, who are worried about, “What’s the economic impact of that? That should be a priority.”

Then many people are looking at the information we’re getting and saying, “Is it worth changing my life or not doing the things that I want to do?” Many people, as we’ve seen, have much different priorities there. Some are unhappy they can’t live life the way they want to live life.

Helen Osborne: Those are a couple reasons that make it hard. Are there others you want that are overriding, whether it’s this crisis or other ones, that make communicating public health messages so very hard?

Dr. Glen Nowak: I would say there are two other things that make it a challenge. One is changing recommendations and changing advice.

What we’ve seen, and again, it’s typical for a lot of infectious diseases or even things like chronic diseases, whether you’re talking about diabetes, is that science is constantly learning. As a result, recommendations and advice are often constantly changing.

That can be really difficult from a communications perspective, particularly if you convey too much certainty early on. People are going to say, “Wait a minute. You told me it was safe to do this, and now you’re telling me it’s unsafe.” I think that’s one factor.

I think the other one is risk tolerance and risk acceptance. Some people are willing to live with more risk or take more risk, and other people are more risk-averse.

When it comes to health recommendations, that can make communications challenging because you’re assuming what you’re saying is going to be equally impactful. We find that that’s not the case. People who are risk-averse will take it one way, and people who are risk-tolerant will interpret it another way.

Helen Osborne: Boy, I can relate to that certainly. In my neighborhood somebody is hearing the same messages yet we are approaching this in very different ways. I don’t know how we can come together on it. I think we just have to respect each other’s differences. Boy does that make it hard from the professional communicator’s point of view.

I want to raise another issue back to my original question when Don Rubin introduced us. I’m curious about how you would go about dealing with all the myths, hype and hearsay that’s coming out about any important public health message.

Dr. Glen Nowak: I think one of the first things you have to do is monitor. If you’re a government health agency, you want to monitor the news media. You want to monitor what people are sharing on social media.

You’re doing that for a couple reasons. One is you’re trying to find out what the myths and misinformation are that are being shared. Then the second thing you’re trying to find out is you need perspective and context. How widely is it being shared, and who does it seem to be affecting?

Often, you would find, and I found this when I was working at the CDC in the immunization program, that misinformation wasn’t being as widely shared as one would assume, or there wasn’t as much of the information out there that you would believe.

For instance, I would often have people at CDC walk into my office and show me negative news stories about vaccines. They would never bring positive stories.

It turns out when you looked at the media landscape, the vast majority of stories were either positive or they were neutral in the sense that the story, as a result of journalism practice, quoted people who were saying good things about vaccines and then maybe at the bottom of the story there was someone who said something negative about vaccines. But generally, it was rare to find a negative story.

In today’s social media world, most people don’t realize that every single day there are 450 to 500 million tweets that go out.

Helen Osborne: Really? I can’t get my brain around that big a number.

Dr. Glen Nowak: Right. When people say, “I found 100 tweets that have misinformation about coronavirus,” it’s like, “That’s not terribly surprising if there are 450 to 500 million tweets going out each day.”

The question really becomes “How influential is that misinformation? Who is it impacting?” If it is showing that it’s changing people’s beliefs or making them make bad decisions, then we have to focus on those people more so than the information.

Helen Osborne: Glen, what about the role of hearsay, just what one neighbor or one family member says to another? Like, “I really think that this happens because of that,” and that information might not be scientifically sound. You would never find out about that, would you, the word-of-mouth communication?

Dr. Glen Nowak: Word-of-mouth communication is much more difficult. One of the weaknesses in a lot of the social media monitoring that goes on is that it doesn’t get into a lot of the channels that people are really using.

For instance, private Facebook pages. You don’t have access to what people are sharing on their private Facebook pages.

In a lot of parts of the world, people communicate using WhatsApp. Again, you can’t get into WhatsApp and look at what’s being shared, so you don’t necessarily have in a lot of instances what information or hearsay people are sharing.

I think the other challenge with hearsay is that even though hearsay clearly exists and people do cite it . . . I have relatives who would fall into that category who have extreme beliefs. But I guess I learned from my conversations with them that I’m not convinced so much that the information matters.

I think what they’re reacting to is they want to believe something, and they grab pieces of information that are floating out there in the world and they cite it as the basis for their belief.

I don’t know that you could ever change their belief because it’s part and parcel of their value.

Helen Osborne: These are hard problems. These are complicated messages. We’re living in a complicated world right now with so much flying around us at an incredible rate. What do you recommend for listeners of Health Literacy Out Loud?

Let me describe the listeners a little bit. We might be working in public health. We might be clinicians. We are communicating health messages and want to do it clearly and in ways that people can understand and follow. We come from all walks of life and work in all kinds of settings.

What have you learned that we could take from you about communicating these public health messages, even given the problems and realities of uncertainty, conflicting priorities, different risk tolerances, hearsay, hype and all of that? What can we do?

Dr. Glen Nowak: The first thing is to look at your assumptions. One of the assumptions you probably can’t make, and you probably could never make but I think people would like to make in public health and other places, is that persuasion is difficult. A lot of what we’re doing is persuasion. I think that’s often unrecognized.

People believe, “All I have to do is put out information and I have to pay attention to how it’s phrased and worded so it’s understandable.” That is important. However, it’s probably not the most important thing.

The first thing is that there are different groups of people out there in your population, and one size is not going to fit all. You have to realize and think about, “How might this larger group of people differ? Which ones are already on board?”

For those people who are already on board, they probably would welcome supporting information, information that reaffirms what they’re doing and what they believe.

If you’re talking about people who disagree with you, you’re in the realm of persuasion and it’s going to be much more difficult.

Helen Osborne: My background is clinical. In the health literacy world, we talked about things like informed consent for a long time and how that is hard to communicate. But there, the purpose is to inform, not to persuade. It’s to give information very neutrally.

When you do public health information, is it different because now your mission is really to persuade and not just to inform?

Dr. Glen Nowak: I don’t know that often our intent is just to inform. Sometimes we are giving information to educate and to help people make a better decision. I think I’d put informed consent in that category. What we’re trying to do is educate people so that they make a good decision regarding a medical treatment.

But in a lot of what we’re doing, we’re trying to persuade some people. Some people will readily agree with us and say, “Yes, thank you for that information. That’s what I believe. You reaffirmed that that’s what I want to do.”

I think what we’re seeing with coronavirus, and it’s certainly been there on a lot of public health issues, whether you’re talking about HIV prevention or trying to get people to get an influenza vaccine, is there are people we are now in the realm of trying to influence and convince. For those people, it’s going to be much more difficult. Persuasion is not easy to do.

Helen Osborne: All right. So, acknowledging the persuasion. What other lessons learned or tips do you have for all of us, whatever our settings?

Dr. Glen Nowak: Again, one would be trying to figure out what the different groups are that exist among a broader audience. Which ones are you going to have to persuade?

When it comes to giving information, it’s looking at the world through the eyes of your audience or the individuals that you’re trying to communicate. What are their priorities, beliefs, concerns and questions? Your information is tailored to address those.

Helen Osborne: That’s interesting. I like that phrase, “the world through the eyes of your audience.”

Getting back to my interest in hearsay, hype and myths, what would you recommend that we do about that on an everyday basis as we’re communicating health messages?

Dr. Glen Nowak: I think some of it, which is being done, is trying to limit the sources or the presence of that.

You see a lot of agencies, like the Centers for Disease Control and World Health Organization, working with Facebook and Google to take steps that when it comes to clearly false information, that information either isn’t readily accessible or that information has warning labels stuck on it. Some of those efforts are taking place at the broader level.

I think in terms of when you get down to the more individual level, it’s trying to understand why that person holds the belief in the first place. What’s motivating them? What are their real concerns?

There have been some efforts in the world of health to do something called motivational interviewing.

Helen Osborne: I’ve heard that term.

Dr. Glen Nowak: It’s trying to ask questions that are going to surface the true concerns that a person has for not doing a behavior.

Helen Osborne: It’s interesting. You’re doing the work and you work for great big organizations. You’re really not dealing with that one-to-one communication.

It sounds like some of these tips, and they’re wonderful and thank you so much for sharing them, can be used more effectively on a one-to-one or small group method, when you really do know your audience, versus giving a national or international message very broadly.

It sounds like two very different kinds of communication. Same underlying principles, but different in how you’d approach some of these hurdles.

Dr. Glen Nowak: Yes. It’s very hard if you’re at a government agency like the Centers for Disease Control. You do have to put out broad messages, and those are essential, but you also know that one-size-fits-all messaging isn’t going to cause everybody to be on board.

One of the things that the Centers for Disease Control has done, and it started when I was there, was we would do research to find out what the concerns were that parents had about vaccines. What were the questions that they wanted answered?

We would make that information available to healthcare providers, because they were part of the public health network. We would say, “These are the kinds of questions you need to be ready to answer.”

In the last five or six years, the CDC has gone one step further. HPV vaccine, which is a vaccine that some parents have had concern about, not only has CDC said to healthcare providers, “Here are the questions you need to answer,” they’ve said, “Here are some really good ways to answer those questions.” They’ve gone one more step and said, “Here are some suggested answers that are better than others.”

They also undertook a campaign about six or seven years ago to tell nurses, “Our research shows that you’re going to be asked these questions, so be ready to answer them. Don’t act surprised when you get them.”

Helen Osborne: I know I recommend that in healthcare, too. If you’re working in a setting and you know patients always have the same kinds of questions, rather than saying, “What questions do you have?” you might say, “Many people want to know this. Is that something you want to talk about?” It’s kind of taking the lead in the known hurdles in there.

Putting on your magical hat, let’s fast forward to the future. What do you think health communication about public health will look like in a number of years? Let’s say this crisis is done. What do you think it would look like five or 10 years out?

Dr. Glen Nowak: A lot of it depends on the commitment of politicians and society to fund public health. I think a lot of the challenges we’ve seen recently under public health at all levels is it doesn’t have enough money and people to do a lot of things, including educate and communicate well.

Assuming we address that problem of funding, I think one of the areas that needs more resources is communications and education.

As I mentioned, people now have more sources of information. They can find information that fits their preexisting beliefs. If you’re going to address that, you’re going to have to do more listening and customization or tailoring of messages to different groups, and you’re probably going to have to have more patience.

You’re going to have to be willing to engage for longer periods of time to achieve your goals in terms of the communications front or in terms of the behavior change front.

Helen Osborne: Are you optimistic?

Dr. Glen Nowak: I’m cautiously optimistic. We are seeing with coronavirus . . . and we’re not done with coronavirus. We’re entering a period over the next year or two where we don’t know, but we do know that we may have coronavirus and a flu season at least once.

I think that may, again, help persuade people that it is important that we understand public health actions and recommendations and we have access to good information.

Helen Osborne: Thank you for making clear what the problems are, as discouraging as it sounds. And giving us some tips and strategies that I think we can all put into place, and looking ahead with even guarded optimism.

Glen, thank you so much for all you do and for sharing it with us on Health Literacy Out Loud.

Dr. Glen Nowak: You’re very welcome, and thanks for the invitation.

Helen Osborne: As we just heard from Professor Glen Nowak, it is important to communicate about public health issues. But in this complicated world of so much information, misinformation, beliefs and values, this is hard to do.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. You might be especially interested in Chapter 13, “Talking with Patients About What They Learn from the Media.”

Feel free to also explore my website, www.HealthLiteracy.com, and contact me directly at helen@healthliteracy.com.

Health Literacy Out Loud podcasts come out every few weeks. You can get all the episodes automatically, for free, by subscribing at www.HealthLiteracyOutLoud.com. You can also find us on Apple Podcasts, Google Play, Spotify, iHeartRadio, Stitcher and probably a whole lot of other podcast apps.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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