Oct 04, 2021, By: Ben Olsen, Wesley Shand
Much has been written about best practices for communicating within the social media and virtual health domains. The ground is constantly shifting, and there is no manual to help guide our actions at every stage of an evolving pandemic. In fact, some strategies may be ineffective or even harmful when addressing the most troubling health issue of our generation: COVID-19 vaccine hesitancy and defiance of public health interventions.
Role of health advocacy in extending the public health message
Health advocacy and outreach play a critical role in reaching segments of society that experience systemic barriers to or face challenges in accessing information and services. The importance of health advocates such as nurses in strengthening public health messaging within the more privileged segments of society is often underestimated and underused. Consider this group as influencers on issues of public health concern and other issues pertaining to social determinants (e.g., income inequality, discrimination, food and housing insecurity).
In partnership with formal health-care entities, health advocates can work to dispel misinformation while encouraging individuals and groups to follow public health guidelines, particularly during periods of public health emergency, when health-care workers, and the system overall, are pushed to the limits.
Unlike formal health promotion and primary prevention, which take place in structured interactions between patients and providers (both virtual and real world), health advocacy and outreach happen at the grassroots level. One example occurred during early implementation of vaccine programs for the COVID-19 pandemic. As soon as vaccine supplies were widely available, individuals across Canada rallied together following a neighbour-to-neighbour approach to book appointments, arrange travel and provide other support through a social media campaign called Vaccine Hunters.
The concept of health advocacy is equally powerful when applied to communication issues, particularly when using informed leaders who are trusted and can connect on many levels. Some have argued that movements opposing public health interventions such as vaccination have taken root and grown because they connect on many areas of concern (e.g., finances, food security, child care, faith). This holistic approach is also fundamental to health promotion theory (Wills, 2014), yet we are often challenged to move beyond the narrowly focused messages in ways that can significantly influence behaviour and change outcomes in certain demographics.
Health-care workers alone cannot be expected to take on the full burden of advocacy.
Currently, health advocacy and outreach on vaccines are about connecting with individuals and groups experiencing hesitancy or resistance. There are, of course, those who dismiss scientific evidence altogether and oppose all forms of public health intervention — for example, vaccine deniers (World Health Organization [WHO], 2016). For the purpose of this discussion, however, let us consider the larger group who are yet to be vaccinated for reasons other than conspiracy theories and extremism.
Crafting the message using fundamentals of health promotion
Following the principles of health promotion and primary prevention (Wills, 2014), health-care providers and advocates can be better equipped to advance the messages of public health and engage with individuals and groups who are on the fence or non-compliant. The principles of empowerment and education are discussed here in the context of COVID-19 vaccine hesitancy and opposition to public health measures.
Empowerment refers to factors that enable individuals to take action or reduce the likelihood of inaction. In the beginning, the problem addressed by Vaccine Hunters was linking the public with appointments, arranging travel and solving other logistical issues. Currently, the factors contributing to low vaccine uptake in some demographics are much different. It is difficult to understand why individuals with privilege and opportunity should somehow need to be “empowered”; however, consider the term in a health promotion context and how it can be applied to those who are less likely to be facing systemic barriers.
The concept of an immunization plan can be helpful when addressing hesitancy in the context of empowerment. For example, what is your plan for the next 18 to 24 months? Do you plan to travel for work, school or vacation? How will you achieve your personal health goals if you can’t attend a gym or class without proof of vaccination?
For those further along the continuum, toward deeper resistance or full opposition, consider this: How attached are you to your personal feelings about mandates? Are you willing to change your job or career because of it? Are you willing to face incarceration or jeopardize your business licence?
Through the process of developing a personalized plan, it becomes increasingly obvious that vaccination is part of their personal road map for success, not a barrier. The immunization plan concept can also be applied when addressing vaccine phobia, but phobias are better dealt with as problems for behavioural psychology and psychotherapy specialists.
For those who are taking a “wait and see” approach, addressing misconceptions and disinformation can be effective (Shen & Dubey, 2019). This is challenging when the individuals and groups are not undereducated but are equating the information they have gathered or been exposed to with scientific inquiry and clinical research. They consider themselves to be capable of using critical thinking to guide their behaviour, regardless of how off-course it will take them.
As a starting point, remind them that effective scientific discourse requires that all parties are willing to consider the larger body of evidence and that increasing knowledge is the primary objective for discussion (WHO, 2016). Take opportunities to engage constructively and remember that you are representing the consensus that scientists and clinicians overwhelmingly agree with. Avoid being trapped into a debate on one study or another; this can create doubt and skepticism. Be aware that often those who are knowledgeable or in a position of influence are more likely to be targeted to make them look less credible. Remember that your advanced level of knowledge does not necessarily make you an effective speaker or educator; it takes practice and experience in different settings and circumstances.
Delivering your messaging effectively
Many social media users lack basic understanding of the functionality and pitfalls to avoid when communicating on social media and using other virtual tools. The following are sound practices in general, but especially when engaging as professionals, advocates or anyone looking to advance public health messaging in constructive ways. As troubling as they are, threats against health-care workers and advocates are real and increasingly prevalent; always be aware of the risks and precautions to protect yourself both mentally and physically.
Consider the audience
Conversations that happen on social media and other virtual spaces are usually not private. Your target audience is not the individual but a larger group or the general public. These interactions are an opportunity to inform the undecided (Leask, 2011), convince skeptics (WHO, 2013) and strengthen arguments opposing anti-vaccine rhetoric. Remember that your messaging is dual purpose, countering opposing views while further strengthening supporting ones.
Decide who sees your content, including all reactions and responses. Some platforms allow the user to decide if posts default to private, contacts only or selected contacts . Privacy settings can often be set up separately for content and discussion. For example, a message can be posted publicly to share with a wider audience, with the comments restricted to contacts only. This can prevent anyone from hijacking the discussion outside the circle you have selected for engagement.
Let contacts know what settings are used or employ hashtags that are recognized by your audience — for example, #pubconfof (public content, friends of friends can comment) or #pubconfriendsonly (public content, friends only can comment). Depending on the application, these settings may behave globally rather than be applied to specific messages. Confirm all of your privacy and engagement settings separately for each application and be aware that some interrelated applications inherit settings from a parent application.
Nested focus groups
Test your messaging with a small but informed audience. Start with a few individuals, gradually adding others who can contribute different perspectives while developing your ideas and counterpoints. Identify concepts that could be misinterpreted and incorporate the feedback from many perspectives. Although it goes without saying, create messaging that aligns with your employer and public health agency, but don’t stop there. Be creative and use an approach that does more than resonate with your audience; it needs to motivate to effect real change.
It is normal and expected to associate with groups with aligning views. However, exposure to other sources is also helpful to understand the ideas being presented and develop messages that address the concerns of those experiencing resistance. Use discretion as conversations can quickly digress into hearsay and conspiracies. Avoid engaging if there is a risk of creating a platform for extremists; focus on areas where there is an opportunity to address logical arguments and validate rational concerns. Discuss next steps and don’t expect wholesale change to occur immediately or at all.
Immunization is the overwhelmingly supported measure for addressing the COVID-19 pandemic. Anti-vaccine rhetoric is real and extremely dangerous; there is no grey area here either. The false dichotomy relates to individuals (i.e., anti-vaxxers) because the number of individuals who reject immunization is small compared to those who eventually follow the evidence or comply with requirements. Even though stronger requirements would be effective, few jurisdictions have imposed widespread mandates beyond non-essential activities. Instead, outcomes are subject to the propensity for change on an individual basis, ranging from early adopters to extreme laggards. Those who can be influenced in either direction hold the balance of power, not the vocal minority at the one extreme. Forcing individuals into a false dichotomy (e.g., pro-vaccine, anti-vaccine) is problematic because it discounts the opportunity to correct behaviour and creates a false sense of certainty that individuals will always comply, creating dangerous conditions for complacency and overestimating support as interventions evolve and adapt to dynamic situations.
Work smarter, not harder
The advocacy-engagement matrix in Table 1 has been adapted from change management theory and can be useful in determining how to optimize efforts and resources in the context of a discrete group — for example, a religious group or sports team. The primary axis identifies positions on the issue (A: in favour, B: opposed). The secondary axis is the level of influence (1: highly influential, 2: non-influential). For successful adoption with the lowest resource inputs, focus on individuals who are highly influential and opposed (B1) using highly influential allies (A1). Do not neglect the majority of supporters (A2); a pyramid stands because of its strong base. Every eligible individual has an opportunity to grow population immunity through vaccination; the rate and degree to which that is achievable depends on how effectively the B2s can be influenced
Table 1. Advocacy-engagement matrix
Position on the Issue
In favour (A)
Influence on others
(Tables are best viewed on a desktop computer.)
Slippery slopes are arguments that aren’t borne out when followed through to their conclusion. At the height of pandemic resistance, Darwinism was frequently invoked as a way of implying, or directly stating, that “those people don’t deserve care because they did it to themselves.” However, a large segment of the population may not have been vaccinated because they were not eligible (e.g., under 12 years) or have a medical condition. When communicating as a health advocate, avoid arguments that are inconsistent with the larger public health goal, which is to achieve population protection through vaccination, not herd immunity.
Diffuse the bomb
For many, social media is a personal journal and place to reflect on how they are feeling at the time. Don’t deny your feelings; include them as part of an introspective practice that includes reflection. Write exactly how you feel and save it as a private message. Take a deep breath and talk to someone about it. You will feel better and potentially avoid any negative consequences or retaliation by the intended or unintended target.
Health-care workers and those who engage in health advocacy are susceptible to burnout and compassion fatigue. It is important to identify your personal triggers and coping mechanisms. When embarking on a long period of engagement or stressful confrontation, develop a plan that includes downtime (rest, recreation and relationships), a healthy diet, sleep hygiene and strategies to improve and maintain mental health.
Two case studies
What follows are two hypothetical scenarios — a health-care provider and a citizen advocate — based on lived experiences. Instructors might consider adapting the scenarios for a care-planning exercise applicable to their specific discipline or clinical context. Non-governmental organizations might use them as part of an orientation activity to reinforce strategies that are based on principles of health promotion and the communication tips discussed here.
Case study 1 of 2: Sam (a health-care provider)
Sam is a nurse in the outpatient IV clinic at a small rural hospital. All health services are aggregated there; it is a hub for wellness, social and physical activities beyond medicine. The hospital is deeply rooted in the community, a place where members of the community frequently participate in volunteering and fundraising. Among the population, however, there is resistance to public health measures, and vaccination rates are much lower than the provincial average. This is an issue for Sam as she has been restricting activities for her children, who are not eligible to be vaccinated due to age restrictions. Even though there are no public health orders in place, she is encouraging others to also limit social contact. Her stance has created a rift among friends and the farming community her family has been a part of for generations.
At work, Sam is under pressure for spending extra time addressing concerns about vaccine hesitancy, which is impacting clinic productivity. She has also observed increasing discrimination toward patients and families who are assumed to be unvaccinated. Sam has experienced microaggressions from a co-worker, who has accused her of “pandering to anti-vaxxers.” Outside work, she is worried about threats from community members protesting public health measures such as masking and curfews at bars and restaurants. Eventually, the stress becomes so overwhelming that Sam has to take time away from her job, leaving the hospital short-staffed. The manager has no choice but to reduce weekend hours, leaving patients to receive IV treatment in the emergency department, where the exposure risk is much higher, and putting additional strain on resources for urgent and emergent care.
How can we help Sam?
- Provide emotional support and direct Sam to the employee and family assistance program available through her employer.
- Create space (virtually or in person) for Sam to engage constructively on all domains of concern for her patients and their families.
- Provide resources for staff so that Sam is not alone in providing outreach on vaccine hesitancy at the clinic.
- Encourage Sam’s managers to address the extra workload by providing staff, such as health navigators and care aides, to support advocacy and outreach.
- Help Sam manage her time better to achieve the operational goals of the clinic, within the larger context of the public health goals of the health authority.
- Advise co-workers that actions to make a connection with patients are based on the principles of health promotion theory; criticizing them for doing so does not contribute to the larger public health goal.
- Advise Sam to review her privacy settings so that she is more in control of who can view and comment on her social media platform.
Case study 2 of 2: Gerry (a citizen advocate)
Gerry is an engineer who works for the city. He supports many social issues opposing racism and discrimination and has participated in activism formally and informally most of his life. At work, he manages a team and has been experiencing a lack of engagement and reduced productivity among a group of employees who have expressed concerns about vaccine mandates.
Gerry is highly influential because of his position at work and as a member of an ethnic minority in which he is considered a leader and mentor. He is outspoken about his views on public health recommendations and is angered that the messaging is not effecting change in his community. In frustration, Gerry regularly posts on social media about anti-vaxxers and has been targeting individuals implying, or directly stating, that they deserve to die. Gerry is contacted by the HR department regarding a complaint that his posts are threatening to someone who reports to him, who has asked to be assigned to another manager. Even though the employee wasn’t explicitly “tagged,” they are part of the same circle of contacts on the platform where the messages were posted.
How can we help Gerry?
- Provide Gerry with resources for engaging in health advocacy that are grounded in the fundamentals of health promotion to influence change in his community and at work.
- Make him aware that common ground is a good starting point for initiating constructive dialogue on important issues.
- Support his engagement in health advocacy using approaches that are most effective in his ethnic community. Accept that the approach he takes within his community won’t always align with conventional messaging from health authorities or his employer.
- Advise him to consider both his content and audience on social media. Instruct him to review how he uses his platform, including his options for selecting an audience for personal contacts separately from his contacts through work.
- Encourage him to help other individuals to use their own platforms to influence change.
Health-care workers alone cannot be expected to take on the full burden of advocacy. All citizens have a responsibility to identify misinformation where it exists and direct the public to resources and services that provide support through their health system. At the same time, health-care providers need to be aware of the role they can play in communicating effectively to extend the public health message. Together, health-care providers and the general public can serve as a voice that is deeply immersed in many communities. Pragmatic approaches are needed to advance health literacy and better protect those who engage in educating individuals and society at large. If we do not adopt such approaches, the road to adherence will be fraught with challenges and barriers that limit our ability to achieve public health goals and reverse the largest health threat to humanity today.
Leask, J. (2011). Target the fence-sitters. Nature, 473(7348), 443-445.
Shen, S., & Dubey, V. (2019). Addressing vaccine hesitancy. Clinical guidance for primary care physicians working with parents. Canadian Family Physician, 65(3): 175-181.
Wills, J. (Ed.). (2014). Fundamentals of health promotion for nurses (2nd ed.). Malden, MA: Wiley-Blackwell.
World Health Organization. (2013).The guide to tailoring immunization programmes (TIP). Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0003/187347/The-Guide-to-Tailoring-Immunization-Programmes-TIP.pdf
World Health Organization. (2016). Best practice guidance: How to respond to vocal vaccine deniers in public. Retrieved from https://www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidance-respond-vocal-vaccine-deniers-public.pdf
Ben Olsen has a baccalaureate degree in nursing and 15 years’ experience in British Columbia and Alberta. He is affiliated with the University of Alberta and facilitates courses in communication and collaborative practice for students in nursing, medicine and other health disciplines His other role is with Alberta Health Services, where he manages a team that supports clinical workforce planning for nursing and other health disciplines in all sectors across the province.
Wesley Shand has been a full-time nurse practitioner at the Strathcona Community Hospital in Sherwood Park, Alberta, in the emergency department, IV clinic and emergency transition clinic for seven years. He has also spent two years facilitating a biweekly medical clinic at Fort Saskatchewan Correctional Centre. Prior to his work as a nurse practitioner, he was a bedside registered nurse for 10 years in several intensive care units, with the majority of time in the cardiovascular ICU at the University of Alberta/Mazankowski Alberta Heart Institute.