Well, good afternoon, everybody, and thank you so much for joining us on today's webinar focused on addressing health misinformation through health literacy. I'm Dr. Angela Michelide, the ACMPM Vice President for Programs and Education, and I'm very pleased to introduce our guest speaker, Dr. Cynthia Bauer, who is the Endowed Chair and Director of the Horwitz Center for Health Literacy at the University of Maryland. Our session today will be moderated by Dr. Kimberly McDonald, who is the Medical Director of Prime IV Hydration. The American College of Preventive Medicine is a professional medical society of more than 2,000 physicians dedicated to improving the health and quality of life of individuals, families, communities, and populations through disease prevention and health promotion. Our members are licensed medical doctors who possess expertise in a broad range of health care skills, including biostatistics, epidemiology, management of health care organizations, research, and the practice of prevention in clinical settings. Our members work in a variety of settings, including hospitals, government at the local, state, and national levels, the military, laboratories, business, and academia. Just a few housekeeping notes. At this time, the audience has been placed in listen-only mode. We will be posting a recording of this webinar on the ACPM website in a day or two after today's presentation. We ask that throughout the presentation, you type your questions into the chat box so that we can answer them in an orderly manner. And of course, we'll want to know what you think, so please complete the brief survey after the end of the webinar. It gives me great pleasure to introduce our moderator today, Dr. Kimberly McDonald. Dr. McDonald is the medical director of Prime IV Hydration. Until October of 2021, Dr. McDonald was the medical director for Wake County Human Services, and in August 2015, was given the opportunity to lead the divisions of public health, clinics, and school health as deputy for public health services. As a deputy to the human services director, she was responsible for division-level business development and strategic planning that aligned with agency mission and vision. Dr. McDonald also supervised the occupational health, HIPAA compliance program, and public health accreditation programs. Dr. McDonald arrived at Wake County from a private health information technology company where she served as physician consultant and clinical education coordinator. Previous to that, she spent six years as the director and medical epidemiologist for the North Carolina public health regional surveillance team for the eastern region. Here, she worked with state and local public health, medical, first responder, and leadership at all levels to coordinate public health emergency planning and response activities for 25 counties. During that time, she also volunteered as team physician for the eastern regional state medical assistance team. These duties included deployment with the SMAT to Waveland, MS following Hurricane Katrina. Dr. McDonald also spent 11 years in the United States Navy as a medical and preventive medicine officer. Her professional experiences include preventive medicine, ophthalmology, obstetrics and gynecology, medical disaster planning, health services administration, and health information technology for clinical practice. Dr. McDonald received a master in public health and health services degree from the Uniformed Services University of the Health Sciences, a medical degree from Eastern Virginia Medical School, and a bachelor of science in biology from the University of California, Irvine. Currently, she is a member of the American College of Preventive Medicine, the Wake County Medical Society, the North Carolina Public Health Association, the North Carolina Academy of Preventive Medicine, and the Alpha Omega Alpha Honor Medical Society. Throughout her career, Dr. McDonald has received numerous awards and commendations, including several academic honors, a health profession scholarship, the Navy Achievement Medal, Navy Commendation Medal, and the Janet M. Glasgow Award from the American Medical Women's Association. Dr. McDonald, I turn the podium over to you. Thank you so much, Dr. Michelide. Good afternoon, everyone. It's my pleasure to be here with you today as your moderator and to have the opportunity to introduce our speaker, Cynthia, Dr. Cynthia Bauer, the Endowed Chair and Director for the Horwitz Center for Health Literacy at the University of Maryland, as was mentioned earlier. Dr. Bauer is a health literacy and health communication expert focused on improving health literacy at the individual, family, community, and organizational levels. She is a professor in the Department of Behavioral and Community Health and the principal investigator on multiple projects on health literacy techniques for clear communication, digital health, diabetes, and organizational improvement. She provides expert advice to local, state, and national committees and initiatives. Before coming to the University of Maryland, she served for almost 20 years in federal health agencies. Thank you so much, and please join me in welcoming Dr. Bauer. Thank you so much, Dr. McDonald and Dr. Michelide. I'm very pleased to be here with you today. We're talking today about misinformation and how health literacy can help address misinformation challenges. I think we all wish we were talking about something other than COVID at this point. You know, it's been a long haul getting to this point, and of course, COVID has really sort of sharpened our understanding of what health misinformation is and how to address it. Many of my examples will be coming from COVID, but of course, COVID is not the only topic area in which we see this. Very happy to have you here today and welcome your questions and comments. Next slide. When I was thinking about how to approach this topic and this particular audience of preventive medicine experts, I wanted to make sure that you remember, even despite what this last year and a half, almost two years, has felt like, that you are still your patient's best source of information. We see that over and over in national surveys, in projects that we do that, you know, ask people to talk about their preferred information sources. They want to hear from their own healthcare providers. At the same time, in recent work done by the Annenberg Public Policy Center at the University of Maryland, sorry, University of Pennsylvania, only 49% of the respondents said that they'd actually discussed a COVID vaccine with their providers. And so what we see, not just in COVID, but in many other topic areas, is that that conversation between you and your patients isn't happening. So they need to hear from you. They need, and they need to be able to understand what you're saying. And that's what we spend a lot of our time doing at the Center for Health Literacy, is working with providers who want to improve their communication with their patients and want to do so in a way that's easy for their patients to understand. And one of the consequences, when that doesn't happen, is that people will look to other sources. They do have questions. They do want information. And when they can't get it from their preferred source, which is their own provider, they will look other places. And I think we've been seeing a lot of that with the way the pandemic has played out. Next slide. I want to start with some basic communication tips. The approach that I take in health literacy is to always be very clear about what the takeaway is, that main message. And so I hope I'll give you lots of examples and other things, but I hope what you really remember are some of these common sense communication tips. And the first one is a challenge for anyone in a professional role. When you become a professional in any area, what happens is, is you build up knowledge, expertise, and a language that belongs to that professional role. And we forget that other people who don't have that same background and training don't know what we know. And so we start using jargon. Jargon is basically insider language. It's the language that you use when you're talking to people like yourself. The problem is when we take our jargon outside of that insider group, when we try and use jargon with people who don't share that same background and that same language. And that's a challenge for anybody in a healthcare provider role, is that you are very expert in what you do. You built up a lot of knowledge and skill over time. And it's challenging to remember that that everyday language is going to be more accessible to most of the patients that you deal with. Next point. The second thing that you can do is ensure that you, your colleagues, and your community leaders who are also interacting with people before they show up in your offices and facilities, that everyone in that loop has accurate and relevant information to share. One of the things that shows up repeatedly in the work that we do is people saying that they get different information from different sources. And what that leads to is that they get discouraged, they get cynical, and they kind of throw up their hands and say, well, you know, they don't know what they're talking about, right? You know, obviously, if I'm getting all these different answers, you know, none of these must be right. And so it's extremely important that the information providers in a community are all talking to each other and then making sure that each one of them, holding each other accountable to have accurate and relevant information that you're sharing with all these different ways that you're going to come in contact with the public. It may be through community meetings, it may be through social situations, it may be through visits to your office or healthcare facilities. However that's happening, people need to hear the same consistent information from all those local sources. Next point. And the last tip that I'll share sort of as an opening to the conversation is oftentimes the most difficult, particularly with what we're seeing with misinformation. We've seen leaders in various situations kind of calling out people for what they label as, you know, unhelpful or bad behavior. But from a communication perspective, what we know is that you have to maintain a stance of empathy towards people. One of the reasons that people become really tuned out and don't pay attention to what you're saying is that if they feel like they're not being heard. If you're just sort of delivering your, you know, kind of standard speech, but you're not really listening to what they have to say. And part of the way that you get there to that stance of being open and listening to what people say is by maintaining empathy. And that you have to be ready to repeat key information. In communication, we know that one time exposure isn't enough, right? In an infectious disease, one time exposure might be sufficient. But in communication, it's just the opposite. A single exposure to a message or a piece of information is rarely going to be enough to really penetrate and be fully comprehensible to people. So you have to be ready to repeat that key information, even if it feels like you've done it many times and you sense that you're getting frustrated. Maintaining that empathy, being ready to go around on that same topic over and over is really important. Next slide. So I want to ground you a little bit in what health literacy is, right? Health literacy is a term that gets used a lot in a lot of different contexts. But Healthy People 2030 has come out with this new dual definition. For a long time, when people talked about health literacy, they were talking about the first version, personal health literacy, about what individuals do when they find, understand, and use information. The new development for Healthy People 2030 is around organizational health literacy. And that's really where we come in in our various professional roles, because organizational health literacy is about what health departments, clinics, hospitals, social service agencies, health benefit exchanges, what all of these various organizations do to make it easier, more equitable for people to find, understand, and use information to make these decisions and take actions for themselves and others. And I think that's a really important distinction to maintain. Because a lot of times, the sort of easy thing is to say, well, those people over there, they just don't understand me, right? I did everything I possibly could. I explained it every way I possibly could. And they just refused to understand. And what organizational health literacy really adds to this is to say that this is a matter of health equity. It's what we do to make sure that everyone has access to the information that they need, and that the burden is really on us to do that work, to provide information and services that are helpful to people in this decision making. Next slide. So, Dr. McIlyde and I share a common background, having spent some time in the Federal Office of Disease Prevention and Health Promotion. And I've always seen health literacy as a key prevention strategy. The majority of our work is in primary and secondary prevention, because I believe it is much better if we can help prevent health and safety problems than it is to try and come in after the fact and try and teach people how to manage their situation, their chronic disease or disability or whatever the situation is. So, I've always seen health literacy as really key to a prevention strategy. And I think there's sort of two dimensions to that. The first one is from that individual level, from what people know and are able to do to respond to both the routine and the extraordinary health issues. So, from a prevention perspective, there's micro decisions that we all make every day, right? What to eat, how much physical activity to get, tobacco use, how much sleep we get, what the quality of our relationships are, right? All of those are micro things that go on all day long, oftentimes without our conscious awareness, right? Because they're part of our habits. But then there's these extraordinary moments, you know, like COVID or like a natural disaster in which the situation may change, but people still want to come back to, you know, what can I do to protect my health and my family's health? At the same time that this sort of individual level assessment of the situation is going on, there's the organizational piece, right? So, how prepared are local and state health departments? How prepared are hospitals and clinics? How prepared are our social service providers to make sure the resources are there so that people can identify and respond to these routine and extraordinary health questions and issues? And health information has a lot to do with how people feel about those situations and how ready they are to respond. Next slide. For me, COVID-19 is an extreme but not an example. So, the reference in my biography was to having spent time at federal health agencies. I was at CDC for 10 years before I came to the University of Maryland and was involved in helping craft the information for a number of different responses. And so, there are some common themes that you always have to deal with in these emergency and crisis communication situations. But the reality is that no matter what health topic you work on and no matter what your patients come to see you for, the harsh reality is that public knowledge is low about many health issues and topics. And there's plenty of research to back that up, whether you're looking at diabetes or heart disease or asthma or any other issue. You know, public knowledge about the disease, about their body, about how those diseases work in their bodies, all of that is pretty low. At the same time, what we see are that both mass and social media sources amplify misinformation to just enough people. Misinformation doesn't have to work for everybody. It just has to work for enough people that they then share it with others. Right? There's research that shows, you know, that looks at what are those things that take off and, you know, as they say, go viral or become a meme, and those things that just sort of die off. Right? So not every piece of misinformation is going to become, you know, harmful to a large number of people. But it is important to recognize that there's just enough people oftentimes who are susceptible to this misinformation that it ends up causing a more widespread problem. And the other thing that we're dealing with, again, that makes COVID extreme but not unique, is that very few people understand what science is, right, as a method. And I know that there's been a lot of talk about trust the science or believe the science without really explaining what that means. What is science? What is that process of knowing? And how does that contrast with other ways of knowing? And I think that's what we're seeing is people are kind of saying, well, my personal experience is just as valid as your clinical study. And I think that burden is really on us to help break down what the scientific method is and why it's a different way of knowing and coming to an answer than other ways. We do a lot with numeracy and how to explain different kinds of numerical expressions to people. And so data of all types are extremely challenging for people who are not trained in statistics or similar areas, epidemiology, to really understand data. So again, you have to start from that perspective that data are going to be challenging for most people. And then policymaking is a process. So I know before the webinar began, Dr. McDonald and I were talking about her time as a local health officer during COVID. And a lot of the policies that have been put forward during COVID, people had no background in how does a policy like this even get made? Why is this person standing up and announcing this policy? Where did this come from? So all of these things really came together in this very combustible situation of this unknown virus that was easily transmissible. And we just had all these other factors kind of layered into that. Next slide. So the term misinformation does get thrown around a lot. I mean, misinformation is pretty much in most headlines every day and in a lot of academic publishing that's going on right now. Sometimes misinformation and disinformation as terms get used interchangeably. Sometimes people distinguish between whether there's a specific economic or political agenda behind the information or whether it's just information that somebody shares and never bothered to validate, but there's no intent to harm. But the kind of general definition for misinformation and disinformation is that it's harmful, false, misleading information. And, you know, it's up to you whether you want to distinguish the motivation or not. The World Health Organization really elevated this focus on misinformation by starting to talk about an infodemic. So in the same way that diseases can spread and, you know, harm people, WHO said we need to introduce this notion of an infodemic so that information, and in this case too much information, so it's not just a small amount. We're talking about a very large volume of information, including false and misleading information, spreads through digital and physical means during a disease outbreak. And so by kind of elevating our attention to the role that information plays in a pandemic and how we respond, there's really just been an extraordinary amount of interest in trying to figure out why does misinformation happen and how do we deal with it. Next slide. What we see then is misinformation, one of its many effects is that it distorts the broader information environment. So again, back to this October Annenberg Public Policy Center research, the good news was that 75% of the respondents in that national study reported being vaccinated, right, so that's the positive news. The unfortunate news is that 79% of those who are unvaccinated say they already have enough information, right, so their decision not to get vaccinated is not in that category of I'm still waiting to see or I need to know more, but 79% of those who are unvaccinated say they already have enough information to make their decision. And we know from a psychological perspective, there's different things that we do to reinforce a decision once we've made it, right. It's psychologically very uncomfortable to change our minds about things. We get very invested in the decisions that we make. And so what happens is once we've decided something, right, I'm not going to get vaccinated or whatever it is, then we gather more information to support that position and we actively avoid anything that's going to challenge that. And a very large proportion, right, not surprisingly said that nothing could change their mind, right, there's no information that they could see, no conversation that they could have that would change their mind. And so of course that's very worrisome because if that decision to remain unvaccinated is based on a lot of inaccurate or false information, then that's a reflection of how distorted that environment is, is that what they've been exposed to and what they use to reinforce their opinions is, you know, very well aligned and will remain aligned because that's what they will continue to look for. The same study also found that a large proportion of conservative media consumers were more likely to believe in these non-approved, I guess, solutions for, or prevention steps for pandemic or treatments for COVID-19. And they also reported distrusting Dr. Anthony Fauci. So again, what we see is that you don't need everyone to believe these things, you just need a large enough number of people in certain groups who believe certain things and then share that information with each other and continue to reinforce those beliefs. Next slide. So how do we use health literacy then to address these many challenges that I've just laid out for you? As I indicated in the health literacy definition, there's really three components that we're interested in. We're interested in how people find information, you know, and that can be active or that can be passive. You can be exposed to information even if you're not actively seeking it. How you make sense of, how you understand what that information is. And in the case of COVID, we know that the newness of the virus, issues of trust, some longstanding and some more recent, and then people's risk perceptions really came into play in terms of how they understood the information that they were either looking for or being exposed to. And then finally, this issue of choice, right, how people use information and how they use it to construct what their choices are in a particular situation. So I'm going to run through each of these three briefly with some examples. Next slide. So the top reasons that people are unlikely to be vaccinated at this stage in the pandemic is that 61% say it's still too untested and they're waiting to see what happens. But the really worrisome thing, so not only is that a large proportion of people, but that it's an increase from April. So what that says to me is that our information environment is becoming even more problematic than where we were in the spring, right? If more people are feeling like, even after all the vaccinations that have been given, all of the information that's been provided, they still say their number one reason is that these vaccines are too untested and they want to wait and see what happens. I think that's a very strong indicator of how, you know, how much we have really failed in penetrating, you know, people's information shield, so to speak, right? The way that they've sort of protected themselves from information that might be challenging to the beliefs that they hold. Next point. Not far behind is really one of, again, trust, right? So 53% said that they don't trust the government, again, up significantly from 40% in April. So this is highly problematic if you're a public official, right? Because instead of chipping away at and really providing reassurance and information that is credible to people, the trend is definitely in the wrong direction, and even fewer people trust the government now than they did in the spring. Next point. Very similarly, 51% said they don't trust the scientists and the companies that make the vaccine. So really what we're seeing here, you know, is the number one reason they don't trust the science. The number one reason they don't trust the science. Number two and three, they don't trust the source. And as a communicator, I can tell you when people don't trust the source of the information and they don't trust how it's being delivered, it's very unlikely you're going to be able to write through. And again, this number about not trusting scientists and companies is up from earlier in the spring. So these three numbers, I think, really tell the story about why we are where we are in the pandemic, you know, in the fall of 2021, is that these key components that really would make a difference if people perceived the evidence to be strong and the sources to be credible, we'd be looking at a very different picture in the pandemic. Next point. Then you start to see things that are sort of more specific to their own health concerns, right? Worried about allergies and side effects. Next point. Not concerned, right? Low risk perception, but see that that's significantly less than any of these top three reasons really related to science and the source of information. Next point. Never got vaccines generally, right? So again, low interest, right? What we would call low perceived susceptibility to vaccine preventable diseases. Next point. And then 15% thinking that they already have enough immunity. So you can see really here, this is a very challenging information picture because of where people have been getting their information and how their beliefs have been reinforced over time so that the trends are really going the wrong direction. Next slide. So what we see is that the people's fears of the government of pharma and their beliefs about the coronavirus and its source really are outweighing their fear of COVID, right? Because very early on, if you go back and look at what we were saying, what the collective was saying back in early 2020 and even through the summer of 2020, but very early on COVID was presented as low risk and primarily a threat to older people. And that has not really changed for a lot of people whose beliefs now are that the government and pharma and that science are the problem, not the disease itself. Next slide. So what can we do about this? We've been doing a lot of projects really focused on local communication. One of the challenges is how nationalized the information environment has become. But all of you represent local information sources, you and your colleagues and the other organizations that you're networked with in your communities, you have that opportunity to counter those national narratives, to be that informed, credible local alternative just to what people are seeing on their social media feeds. I loop back to what I said in the beginning. People still, despite how much time and how much information they get from social media, they do want to hear from their providers. That may not seem as believable to you, but that is what the data show consistently that people really do want to hear from you. It may not be that they take your advice the first time, but you are a very important source for them. And I think offering these local alternatives to this highly nationalized environment that we see in social media is a really important strategy. The second thing that I talk to a lot of people about is just how much more we have to do in communication. I would say it's virtually impossible to over communicate at this point in terms of fact-based alternatives. A lot of times people think, well, I said it once, or I said it twice, or I even said it three times, or we ran a campaign, or we put out posters, or we mailed out postcards, we put it on our Facebook page. What else do you want us to do? And I think what you have to be mindful of is just the volume of information coming from these misinformation sources. It is so easy for people to be exposed to the non-credible sources that we really have to mount a very high volume of counter-messaging effort to make sure that we have just as many messages out there that are coming from a fact-based perspective. People have to perceive that there's an alternative to even entertain the idea of reconsidering their beliefs. And like I said, it's not an easy thing to do. People don't naturally want to examine their beliefs, but there has to be enough counter-messaging out there for them to even entertain that possibility. Next slide. The other challenge that we have been up against with COVID specifically is just how new this has been, right? We know that anytime you're dealing with a new situation, that creates what's called high cognitive demand. And that means that it requires more from us as humans in terms of information processing, right? We fill in with incorrect comparisons. We saw that a lot, right? People kept bringing up seasonal flu in the beginning, and that laid down this framework for which people said, well, I'm not afraid of the seasonal flu, and that's not a big deal. I don't worry about it. I never get a shot for the flu. Like, why are we even talking about this if this is like the flu, right? So right from the beginning, it was very problematic in terms of some of the comparisons that were being made. And as I've said before, what happens is if people don't understand what you're saying to them, they just fill in with what they already know and believe. So again, back to the empathy, right? We have to empathize, say, I know this is new. I know this is hard to understand. I know this is a lot of information, but we are going to, you know, stick with this. We're going to answer as many questions. We're going to do whatever it takes to make sure that you're comfortable with this information that we're providing, but you've got to do it in a jargon-free way. There's research that shows that if people don't understand what you're saying to them, they find you less credible, right? And that's one of the things that jargon does. It gets in the way of your credibility as an information source. Next slide. So here's some sample language that is based on these health literacy best practices to say that, you know, here's what we know, here's what we don't know about that, and here's what we're doing to find out. We expect that we're going to know it next week, next month, right? And then we'll come back and we'll be able to tell you that, right? Making things as concrete for people as possible. This other example is about, you know, offering an empathetic stance, right? We understand you have many questions about the vaccine development process, and we want to explain that, right? We want to understand what we've learned about this, and here's how we've gone about testing to develop these vaccines. Again, this is not going to allay every fear, and one time, doing this one time, you're going to be able to do it. You're going to be able to do it and one time, doing this one time is not going to solve all your problems, but, you know, if we had taken some of these stances very early on in the response, it would have laid down a very different track to build on as our knowledge about the pandemic and COVID-19 expanded. Next slide. The novelty introduces a lot of whys, right? People have a lot of questions that have to be answered, you know, why is the vaccine safe given how it was developed? Next question. Why risk a new vaccine if we don't even know how well it protects? Next one. Why am I or we suddenly a priority for vaccination when we haven't been priorities for health before? So, the health disparities challenge that we've seen, people being suspicious, like, well, the medical, you know, establishment has never had our best interest at heart before, so now why suddenly are you putting us at the front of the line for the vaccine? Next point. So, here's a way that we can potentially start to address some of those questions, right? We included people of all races and ages in the vaccine test. We found it worked equally well, or it worked differently for everyone, and here are what some of them said about the experience. I know that when the vaccine was first rolling out, there was a big push to get a lot of testimonials out there of people who were getting vaccinated, but what we didn't see were people standing up and saying, here's why I volunteered to be in the vaccine trials. Here's why I overcame my concerns and my fears to be part of this process. Here are the questions I asked to make sure that I was satisfied that I was being treated with respect, right? That kind of personal testimonial would have been extremely powerful in terms of trying to address people's fears about the way the vaccine testing was done. Next slide. Here's another example. We will show and explain any data we have about how the vaccines were developed. You know, the assuming that people don't want the data because it's too hard to understand is also problematic, right? So, people say, well, if you're telling me that people's numeracy skills are weak, well, we just won't provide any of the numbers. That's oftentimes not the solution because people may be suspicious of statements of like low risk, right? What does low risk mean? Exactly how is low? I had a clinician not too long ago tell me that if I started taking this new medicine, there was a low risk of stroke in the first three days of starting to take this. And I said, well, exactly what is low, right? Low to you may be high to me, especially if we're talking about something like a stroke. So, I think, you know, it's not easy to explain data in plain language, but oftentimes the data are those signals to people that we really have done the hard work and the data are those validators of the statements we're making about whether something is low risk or high risk. Next slide. The way mRNA, and again, showing people how that's pronounced, a lot of people don't know, for example, when they see the letter COPD that you spell that out, right? So, giving people those little clues to help them understand what these terms are. So, the way mRNA vaccines protect our bodies is by teaching our own cells to fight off the coronavirus, right? There's been a lot of talk, people throwing around notions about immunity, what it is, how it works. And I think this is really an interesting moment to help people understand what an immune system is and how it works. And we can do that in plain language, but it will take some effort to get there. Next slide. So, finally, this issue of choice, which has been so central to how people have perceived the vaccines, right? There's been both individual and collective level choices. You know, we had the choice to let the virus spread with no protection, right? And there was a lot of talk early on about what the number of cases and deaths would be. And I think, you know, certainly the number of deaths has gone beyond what a lot of people thought we would all tolerate. But the reality is, is that we are a society that has a pretty high tolerance for death. We tolerate a lot of deaths every year from things that are highly preventable, as you all know. So, you know, that, I think, you know, we could have been even more stark, I think, about what this choice was. We could have been more clear that if we just let the virus get uncontrolled in the way that it has in some places, there would definitely not be enough resources to treat everybody. And also that, you know, there's been a lot of assertions of beliefs and values around freedom, is that there's also freedom to live without virus exposure. And you've not, you've seen some of that, but not nearly as much kind of counter-messaging on that to offer an alternative point of view. Next point. So I think we could have, you know, contrasted that a little more clearly with what the range of protective options were, right? I think, you know, the lockdown last spring was in many ways kind of presented as the opportunity to get things under control, and they set expectations in a certain way. And when that didn't happen, you know, we've seen a kind of a steady erosion of trust in that the virus could even be controlled. So I think these choices have been implicit and explicit at different points in time, but they've not always been kind of clearly contrasted with each other that, you know, what those trade-offs were and what we would get if we went one way or the other. Because people are right, all of these things have been choices at every step of the way, but we've always not been clear enough, I think, about what the nature of those choices are. Next slide. So here's some sample language about that. The coronavirus is real, and our county has to choose how to respond. You know, we have X choices, right, and this would be depending on what stage of the response that you're at. Here are the pros and cons of each, and this is why we think this choice will protect the most people. You know, that's not to say that everybody's going to agree with the recommended choice, but that is being very clear in the steps in terms of how you got to that recommendation about why that would protect the most people. And then people can argue with you, as they have, right? You know, oh, the economy has to be the priority, or keeping kids in school has to be the priority, or whatever people argue the counter-priority is. But at least we're clear about the value being protecting the most people, and then we can say, well, is that really what we value the most or not, or are we going to put something else ahead of protecting the greatest number of people? Next slide. Here's another example. If we let the virus spread without using any protections, you and your family may get sick, have lifelong health problems, or die. We can't promise a hospital bed if you or your family gets sick. You know, what I saw a lot was reporting of, you know, ICU capacity, a number of beds. That's very abstract for most people. It's not to say that that's not useful information for policy makers or for, you know, health economists or other people interested in that data. But what, you know, people started to experience on the ground was, is if their family member was having a heart attack, or their diabetes was out of control, or somebody was having an asthma attack, they couldn't necessarily get treatment or services where they would otherwise, because the facilities were so busy with COVID. And we could have been on the And we could have been a lot more direct and concrete about what the consequences of this would have been earlier on. Next slide. So here's, you know, what we can do regardless of what the topic is, we can always talk to people about the steps they can take to find accurate information and why that is such an important thing for them to invest their time in, to question the source and compare sources. Oftentimes, when people are kind of step out of that source, and, you know, start looking and saying, you know, oh, what did this person say, or what did this person say, if they're in their information bubble, of course, then they're going to, you know, continually find that reinforcing information. But, you know, we can always talk to people about the steps they can take to find accurate information and why that is such an important thing for them to invest their time in, to question the source and compare sources. Oftentimes, when people are kind of step out of that source, and, you know, start looking and saying, you know, oh, what did this person say, or what did this person say, if they're in their information bubble, of course, then they're going to, you know, continually find that reinforcing information. But asking people to always compare sources is one way to kind of break that train that they have, where they're sort of locked into that one point of view. Next point. To really scrutinize their search results and be choosy, right, that they should not, just because something shows up in a list of search engine results doesn't mean that it's credible. That the responsibility is still on them as an information consumer to look at those results and be very picky about what they consume in their information diet. Next point. As professionals, we can always refer people to credible sources. The National Library of Medicine had an initiative for a long time with an information prescription. So in the same way that you would give people a script for a medicine or refer them for a test, you also could refer them to credible information sources. Next slide. So these are a couple of sources that have really been tracking not just COVID, but misinformation in a lot of different areas. So First Draft is a global nonprofit out of an institute at Harvard and factcheck.org and SciCheck are based on the Annenberg School of Public Policy. Both of them do a great job covering misinformation coming out of, you know, not just the US, but globally and showing, you know, what the, you know, what the motivations are, where all of this misinformation is coming from and really offering people this you know, accurate fact-based approach. And so if you yourself are wondering, like, how do I confirm, you know, things that I'm hearing from my patients or things that my relatives or my friends are sharing with me, these are two great places to always check out. Last slide. So if you're looking for more resources on health literacy, I would refer you to our website, to the health literacy website at CDC. The Clear Communication Index is a tool that I helped co-create with a colleague that provides criteria, health literacy criteria for evaluating health information. And then CDC has a number of communication resources on crisis and emergency response. And then the federal government has a wide range of resources on how to communicate using plain language. So thank you for your time today. And I believe there was one question in the chat, but I think, you know, hopefully a few more will come in. And I think we're on to the Q&A. Is that right, Dr. McDonald? That's correct. Thank you so much, Dr. Bauer. That was a great presentation. Lots of good information. One quick question from me. I'll take that liberty as the moderator. Given that there are so many pieces of misinformation out there, how can a busy provider have the most impactful conversation in the short period of time that we spend with our patients? Yeah, that's a great question, right? Because time is always, you know, one of those constraints, right, regardless of the topic. And so I think it's letting the patient tell you what is the thing that's most concerning to them, right? Because you know that they'll grab you as you're walking out the door anyway, right? You know, if it's something that's bugging them that they haven't had a chance to bring up, and that's usually the worst time. So I think really letting them offer that thing that's most concerning to them. I know there was, I think it was actually in North Carolina, a physician who himself got very severely ill with COVID. And then when he recovered, he became a big proponent of, you know, vaccination, and they have featured him talking to different patients. And, you know, there was one video that I saw. And, you know, he was just, he really had to sit there very patiently and just answer, you know, they kind of ticked off all the things that we've heard that are, you know, coming from the rumor mill about the vaccine. And he had to sit there one by one, you know, but that was, he was letting the patient really, this couple really drive the agenda in terms of letting them get all of those rumors, all of those fears out there, and just responding to them rather than him trying to say, here's what I want to talk to you about. He was really letting them set the agenda and then responding to that. Thank you so much. That makes absolute sense. The next question from Dr. Michelide, many physicians treat patients whose first language is not English. What can be done to ensure that materials written in other languages comply with low literacy guidelines? Well, that's really interesting because the Federal Office of Minority Health has been, has funded quite a few sites around the country to do that work. And what they're asking the sites to do is create health materials with both health literacy standards and the culturally and linguistically appropriate services standards in mind. So I think, Dr. Michelide, the answer to your question will be forthcoming over the next year or two, as we start to see how you do this at scale, right? Because I think one of the biggest challenges, you know, in the 25 or 30 years I've been working on these questions is, how do you, first of all, get resources in multiple languages? And then second, you use them effectively. And I think that's what these new federal grants are designed to do is really see how do you do that at scale, you know, with like within a city or within a county, and then how do you build an infrastructure that will help you maintain that over time? So I think that's a to be determined sort of question. Very good. Would you be able to comment on some of the best practices that you've seen come out of the COVID response thus far in terms of developing health literacy programs? Well, I think, you know, I'll kind of answer that on two levels, right? So there's sort of just at the messaging level, I think there's been some interesting things like, for example, the Baltimore City Health Department has got a lot of kudos for like their social media feeds. They've been a little bit cheeky in some of their posts, you know, that they've done. And some people have responded positively to that. I know that when ivermectin was like at the top of everybody's news feeds, FDA came out with a tweet that said, you're not a horse, you're not a cow. Come on, you all just stop it. And then the comments in that in that post were just like all over the place. Some people were like, go FDA, great job on the plain language. And other people were like, wow, you're really all fed up with us, aren't you? You know, so people, I think, you know, you have to be careful, right? This is a serious situation. And I don't, you know, sometimes people think, well, humor is like, you know, it's going to be attention getting, it will get you attention, but maybe not always the attention that you want. So I think that's at the message level, that's one thing to kind of be mindful of. But you know, I think the most effective has still been kind of at the interpersonal level. And I think that's why I was recommending that people really stick with a lot of local communication at this point, right, to counteract the effects of mass communication. Normally, we rely on mass communication, because we want to message out to like millions and millions of people, right? That's what mass communication does for you. But at the same time, if you're dealing with an environment that's super tainted by rumor and misinformation, you've got to have some way to counteract that. And I think this local approach is really important at this stage, because that is where you're going to find people who are communicating in the context of a relationship. And it's the context of that relationship that will make the information most powerful. Thank you. Yeah. And I think that what I saw at the local level is that the rapid change of information at the beginning of the response really led some people locally to not trust, you know, they felt like we continually changed our mind in terms of managing the situation. And I think that that's extremely challenging to come back from. It is. Yeah. I mean, you know, there's there's a lot of polling and public opinion work that's just done on science literacy, right? So literacy is attached to all kinds of things. There's digital literacy and health literacy and science literacy and information literacy. But in science literacy, what they look at is, you know, people's kind of basic knowledge about different scientific concepts and practices. And, you know, we just started from a very weak position in terms of people's understanding of science as a practice. What does, you know, I mean, we kind of jumped into discussions of clinical trials without ever asking, like, how many people actually know what a clinical trial is, right? You know, how many people know what flatten the curve is, right? That's epidemiology. And everybody, yeah, was screaming about flatten the curve last spring. So, you know, I think we just started a whole bunch of conversations as if we were like five miles down the road. And, you know, I think that just really set us back a lot, a long way. Yeah, I mean, I guess the one good thing that comes out of it is that now we know more specifically what some of the issues are and how we might strategize around addressing them. Yeah. Yeah. Okay, another question for you. How can people get better at discerning reliable versus unreliable information? Well, some of those strategies I talked about at the end come from some work that a colleague here at Maryland has done from, you know, there's a long history of something called media literacy, as Dr. McElyde knows. And so that's kind of morphed into information literacy and, you know, people applying these strategies to try and evaluate information in a digital environment. And so my colleague had done some tests where she had shown that if you're like a professional fact checker, one of the things you do when you encounter a new piece of information is you immediately leave that and go looking to see who else is saying that same thing. So they would do something like go off to Wikipedia, for example. And she said, normally, she said, the last thing I would do is send people to Wikipedia. But she said, in this case, it was actually a pretty decent strategy. Because if there was something really crazy about the first piece of information, Wikipedia was immediately something that was kind of like highlighting, hey, that's not right, that's kind of off. And so that sent the person like on this kind of chain to say, oh, okay, I got two things, they look really different. What else is out there? And what they had done this test with professional fact checkers, and college students, and the college students would be just like tunnel vision, they would look at what they found, they'd evaluate just what they found, it never occurred to them to like, leave that and go look for something else. And so that's why I think this notion of getting people to kind of break that stride, like, I'm looking at this, I'm just going to evaluate this piece of information. But getting them think, I'm going to look at this and this and this. And then I'm going to kind of reframe my thinking about this topic. Based on her research, that's one of the best things we can do. Great. And Dr. Armstrong made a comment that I think is a good one for us to close out on. And that is that it's always important to set expectations for people. And we didn't do a very good job of that. He said failed. So I'm paraphrasing, didn't do a very good job at the beginning, letting folks know that recommendations will change as more information becomes available. So that's a good piece of information for us to keep in mind going forward. Yeah, well, you guys have all been doing, you know, a great job on the front line. So, you know, I know it's been hard, but you know, please hang in there. People need to hear from you. Appreciate you and thank you so much for the support that you're providing to this effort. Okay, great to be with you all. And let me join Dr. McDonald in thanking Dr. Bauer and Dr. McDonald for excellent moderation of this session. Please look out for the event survey. And if you'd like to share this webinar with your colleagues and approximately 300 other educational offerings, please log on to the acpm.org education events section of our website and have access to so many more things of importance in preventive medicine. So I bid you all a very good day. Thank you for attending. Thank you.

webinar

health literacy

COVID-19 pandemic

clear communication

trusted sources

health misinformation

government trust

communication efforts

addressing concerns