Season 1 Episode 27
Oge Chigbo Welcome to a collaborative episode of From the Front Row and Share Public Health, two podcasts from the University of Iowa College of Public Health. I am Oge Chigbo, a host from From the Front Row podcast, in for Ian Buchta today. From the Front Row is a podcast produced by the College of Public Health students to share public health with everyone. By providing conversations in public health, we establish emerging leaders in the public health sector. I am thrilled to be partnering with the Midwestern Public Health Training Center’s podcast, Share Public Health, which connects you to public health topics, issues, and colleagues throughout our region and the country. One of the major competencies in public health is working in a team and interdisciplinary activities, so we always strive to share information from credible sources. Today we’re going to be interviewing Dr. Rima Afifi, who is a professor and chair of the Department of Community and Behavioral Health at the University of Iowa College of Public Health. Through her work, Dr. Afifi works to promote social, community, and policy environments conducive to well-being. She’s specifically interested in intervention and implementation science, working to encourage bridges between research and practice. So here’s the interview between me and Dr. Afifi.
Oge Chigbo Today we have Dr. Rima Afifi coming back onto the podcast to talk to us about what’s going on with this new novel coronavirus and talking about messaging from public health to the general public. So Dr. Rima Afifi, thank you so much for coming on to the podcast again, we really appreciate it, especially during this busy time.
Rima Afifi Well thank you for asking me.
Oge Chigbo Thank you. What do we need to think about when crafting a message to the general public that we want them to act upon?
Rima Afifi So that’s a really good question and I am, you know, my discipline in public health is health behavior and health education or, you know, community health. It’s often called different things, health communication, behavior change. We really focus on the science of behavior change, particularly in relation to health, and there’s a lot that the science of behavior change can provide to help us think about messaging. So there’s a few, I think, sort of key takeaways that I’d like to share. One is that we know that knowledge is really important but is totally insufficient, so sending out a message that just has a factual in it is important but will not get us to the behavior change that we really all want, particularly in this current situation of COVID-19, which I think is the focus on this. That’s one. The other takeaway is that we need to be sending different messages to different people because each person or each group’s motivations to change is very different. Each person or each groups – usually we focus more on groups than people because that would be too many messages, millions and millions of messages – but, you know, each group has certain aspects of the message that they will pay attention to or certain things that will support them to act. So sending out one message and expecting it to reach everybody is also unrealistic. That’s the second takeaway. I think the third takeaway is our, sort of, our understanding of what are the important things for behavior change, so other than knowledge what do we need to do? So I’m gonna be a little theoretical here, but only because we have tested these theories over and over and know that they’re really important in the developing of the message. The first aspect is something that we call perceived threat and that basically means that people will not change their behavior if they don’t feel personally susceptible to the particular health condition that we are talking about. So, in this case, they need to feel personally susceptible to COVID-19. That means they feel like they personally can get it. The important thing about this is it’s a perceived susceptibility, so that’s why it’s an attitude and not necessarily knowledge, which means that, you know, a health care provider could look at me and say “absolutely this person has all the characteristics that make her susceptible”, but if I don’t believe that, I’m not going to change my behavior. So it’s a perception, right, we can influence perception in a variety of ways, but really it’s the perception that matters. So perceived susceptibility is the first aspect of all this. The second is perceived severity, which means that not only do I think that I potentially could get this condition, COVID-19, but I also have to feel like if I do get it, it could potentially be serious for me or it could have a serious outcome. If I don’t have one or the other I’m unlikely to change my behavior, right, so if I don’t feel susceptible there is no need for me to change my behavior, if I don’t perceive myself to be susceptible. And, again, if I don’t perceive that it’s a serious disease there’s also no reason to change my behavior because if I get it but it’s not really going to influence me one way or another, why change, right? Behavior change is difficult, it always is difficult. So those are the first two things. We have to make sure that the messaging that goes out indicates a perceived susceptibility and a perceived severity. The combination of perceived severity and perceived susceptibility, those create a potential perceived threat, which means now as a person I feel like there’s something that you know could quote/unquote threaten my health, basically. That will get me to act, but the other things that are really important in messaging are two things. One is what we call self-efficacy, which means that whatever action we are trying to get people to do, they are confident that they have the ability to do. So self-efficacy is my confidence in my ability to undertake a particular behavior. That’s critically important. But the second part of it is what we call response efficacy and response efficacy means that I believe that if I do the behavior it will make a difference in my susceptibility or severity, right? So threat is important but then response efficacy and self-efficacy actually drive the behavior changed. So those are always sort of the things that we need to think about when crafting a particular message. I’m gonna just add one other thing that’s important to consider. There is this theory that we use most in health communication called Extended Parallel Process Model and the Extended Parallel Process Model brings together these four concepts that I’ve just been talking about and basically helps us think through it in a way that is, I think, that we’re more used to. So I think we all learn in biology that, biologically, we all have a fight-or-flight response to various environmental conditions and basically what the Extended Parallel Process Model says is that there’s two ways that our messaging can get people to go. One is fear control and one is danger control. Okay, so fear control is when I’m so scared – and this is why sometimes fear messages don’t work – I’m so scared because you haven’t given me self-efficacy or response efficacy or I feel like it’s just too scary for me that I either shut down and don’t listen to the message at all or I start to say “oh this doesn’t apply to me” or “somebody’s exaggerating” or, you know, all those things, or I use ways to sort of numb my emotions which we also know aren’t [inaudible] through substances or things like that that are also not the response that we would like people to go towards, so that’s the fear control. The danger control is when, okay, I understand this, I know that I’m susceptible and it could be severe, but I do have tools in my hands that I feel I can implement. So we really want to be messaging to get people to danger control, to be doing the things that they feel they can do and that will be able to control this threat. I think that’s sort of a broad sense of how we would message in any behavior change but now particularly for COVID-19.
Oge Chigbo Yeah. How do you think public health as a whole has done with messaging around the novel coronavirus so far?
Rima Afifi So I first have to say that, you know, that the CDC particularly and then,, globally, the WHO and the NIH and all these excellent, just really amazing public health structures have done an amazing job at getting the information out there. In many ways, if you look at the extended, sort of, information that’s being provided on those webpages, they are tailored. So if you go into the CDC you can sort of click on a button that tells you who’s at risk and then they have different messages for people depending on risk level. So I mean, I think they’re absolutely trying to implement the types of messaging that we are talking about. I also think, though, that in an effort to control panic, some of the early messaging – and we’re also seeing this change. One, I think we’ve been trying to send out general messages to everybody rather than tailored messages to particular groups in general. The shorter messages, right, if you don’t want to read pages and pages of stuff. So that’s one, but then even when we are tailoring messages, because we’re trying to control panic we have missed out on the perceived severity. For a very very long time the message that young people were getting was yes, absolutely, you could get this but really, it’s not a big deal for you in general. If you’re a healthy young person and don’t have an underlying health condition and are not immunocompromised, you don’t really have to worry about this. It’s not going to be bad for you. And in that messaging – which I totally understand because I think we were trying to not create panic – but I do think that we have sent a message that will not lead to behavior change because, as we talked earlier, even if they feel susceptible – that’s a question mark but I think most people feel susceptible, they just don’t think it’s a big deal. So, it’s okay, I can get this, I’m gonna survive, it’s alright, I don’t have to worry about it, why do I need to change my behavior? We are starting to see a little bit of that changing in the recent messaging over the last two days, so things are coming out that are basically . . . I mean there’s two levels of change that are happening around this messaging. One is the understanding that for people who are immunocompromised or have health conditions or are older, this is in fact a very serious condition. So therefore everybody needs to act, if not for yourself for others around you, so that’s a message that’s been coming out that I think is helpful. Although that still doesn’t necessarily have the self-efficacy in it, you know, can you do this, which I think we need to focus on. But then recently in the last two days we’ve also seen messages particularly to young people that say listen, even some young people are having serious negative consequences. So I think, again, they’re starting to change the messaging for young people but that’s the, I think, the demographic that we most need to think very seriously about messaging to is people that are like young adolescents, youth, and young adults because I think they are a big part of the potential solution or our potential ability to flatten that curve.
Oge Chigbo So, what needs to be done better to help people understand the importance of listening to public health messaging?
Rima Afifi Yeah so that’s a big question and maybe, I mean, maybe again just to go back again to what do we need to do better, I think that, you know, as I said, susceptibility and severity are important but those other two things are very important. So messaging that is you can do it, you need to do it now. So first the way that we send that message is important, being very it’s not “people should” because “people should” doesn’t mean me, right? “You should” is what I like, “you should be able to do this”. That’s one. The time aspect of a message is really important, so we need to say “now”, right, so “you should do this now” is really important. “You can do it”, so that’s the self-efficacy and “it will make a difference”. So those are the types of words that we need to be using in our messaging so that we’re most effective at trying to get to behavior change. In terms of what we need to do better to help people understand public health messaging, I think that in general there is less understanding and awareness about the complexity of communication and health communication. So a lot of people think that it’s enough to send out knowledge and that it’s a no-brainer, you know, hey if I tell people that this is dangerous then people are gonna change their behavior. And I just . . . I think I need to remind us all because it, for me, it’s always helpful to think about myself and how I react in terms of how others would react. A lot of us are in the health sciences, we know absolutely what’s important for us to do for our health. I mean even putting COVID-19 aside right now, just in general like recommendations about exercising, recommendations about sleep, recommendations about eating, all these recommendations. We are in the health field. We know absolutely what we are supposed to do. We have the knowledge. Many of us, I would argue, are not doing all the things that we know we should do. I know that I often don’t sleep the recommended number of hours. I can tell you a variety of reasons why I don’t, but just to make the point that knowledge is necessary but absolutely not sufficient and that we need to be thinking about creating healthy environments that support all of our ability to put our knowledge into action and that’s difficult. But the important thing about this is also – and I’m not getting quite to your question but I will – is not to victim blame. I mean once we understand that knowledge is not sufficient then that helps us not victim blame and that helps us not get upset at people because they’re not acting in a particular way. Once we understand that there are so many facilitators and barriers in the environment that either allow us to act on our knowledge or don’t allow us to act on the knowledge. So I think the first thing is, one, to understand that health messaging is very complex, takes a lot of effort, isn’t something that we can just sit around and just like throw out a message without very carefully thinking about . . . even sort of a checklist. We’re now starting to do this in public health like, okay, the message that we want to send out has to have aspects of at least susceptibility or severity or self-efficacy or response efficacy, like just putting that in front of because it’s so easy to just, you know, be sending out a message that’s a knowledge message only. The other thing is I think that when people think about public health, they think mostly about two things. They think about epidemiology and biostatistics, which are the basic sciences of public health and critical to everything that’s happened so far. Epidemiology and biostatistics have been on the front lines of trying to figure out what is this and showing us numbers and graphs and simulations that we can understand, providing us really concrete knowledge. People also often think about health management, health policy, those types of things, what happens in the healthcare system. Also, I think we need to be very clear that the people that are on the frontlines of this particular epidemic, in any epidemic, are heroes, as we all are, are exposing themselves and their families in ways that not all of us are doing. So just to be super thankful about all the work that’s happening there, but they often forget about the two other parts of public health, which is occupational and environmental health and community and behavioral health, which I’ll talk about in a minute. So often people around will sort of automatically turn to our colleagues and experts in epidemiology and health services and that is absolutely an important component of this response, but also thinking about those other aspects of public health are really important. Reaching out to people in health behavior to understand what is important in messaging is critically important, and also occupational and environmental health because so many of our health problems are quite based in creating healthy occupational environments in general. So to think about the broadness of public health and that’s the beauty, I think, of public health. We often say public health is everywhere, right, and there’s skills that we each bring to the table, which is why, as a College of Public Health, we work very closely together in thinking about any problem because every one of us has a particular part of the solution as well.
Oge Chigbo Do you have any other thing you’d like to add?
Rima Afifi Yes, I know that we’ve been focusing a lot on what does it take to change behaviors and that, as we’ve said, is a really critical component of our ability to be able to manage this particular epidemic, COVID-19. Just to reiterate, I think people know what the behaviors are that we really need people to apply. What we mean when we say social distancing is more physical distancing and it is not social disengagement. In fact we need to continue to remain socially connected even more in situations like this. So I would urge people to, you know, to just get up to speed on those. I think people know by now, have heard the recommendations and, of course we need to get better at messaging but I think people know the recommendations. But what we often don’t talk about is that not every group of people or not everybody has the same facilitating environment in which to implement these interventions. So whether it’s groups that may not have access to soap and water, whether it’s in the United States or internationally, people who have particular mental distress for which the social distancing recommendation becomes particularly difficult, and how do we create opportunities, tools, messages to actually ensure that we are keeping connected and have the tools in our hands that we can support everybody. Many of these recommendations are gendered in that, particularly, the shut down now that we’re seeing all over the world and in the United States of schools and daycares often adds burden to women more than men, so just to keep that in mind. Of course not in all families, but in some families. The shutting down now of restaurants and bars are particularly painful, I guess, or difficult for many of us that work on hourly basis and need that income desperately. So, again, to think through what are some of these basic needs that we also need to be paying attention to as we’re sending through these messages? What are the potential disparities that may occur during this period based on some of these messages? We do have families that, or people that are living in famine situations that are not ideal and being in the same space for a very long time is difficult and may also increase the rates of domestic violence etc., so that is not to take away from the critical importance of these behaviors that will be critically important to flattening the curve and even, hopefully, not just to flatten the curve. Flattening curve means we have the same number of cases but just over a longer period of time, which is very important for our ability to manage them, but we hopefully can also decrease the number of cases. Both of those things I think are important, but in the messaging to continue to think about, you know, how do we create environments that continue to uphold health and well-being of everybody in this process and think about strategies to support even further those of us that have particular circumstances that make it difficult for them to implement these behaviors.
Oge Chigbo Alright, thank you so much. Thank you.
Oge Chigbo So I hope you guys really liked this interview. Thank you to everyone who keeps the economy going from those who stock food, drive trucks to those who work in hospitals, our health professionals, home health aides, people who work with their hands, first responders or are in public health, and many more who I haven’t called out, but all of you are heroes and we appreciate you. From all of us to you, we say a huge thank you. So thank you for joining us today. Special thanks to our guest, Dr. Rima Afifi and to members of our planning committee. This episode of From the Front Row and Share Public Health was hosted by Oge Chigbo. You can let us know what you thought about this episode and series at cph-gradambassador@uioewa.edu. That is cph-gradambassador@uiowa.edu. You can find us on Facebook at the University of Iowa College of Public Health. We are on iTunes and Spotify, as well as the University of Iowa College of Public Health. Funding for this podcast is provided by the Health Resources and Services Administration. Please see the podcast notes for an evaluation and transcript. This podcast is brought to you by the University of Iowa College of Public Health. See you next week.