1 Introduction: key communication challenges

Throughout 2020 and 2021, the COVID-19 pandemic strained public health infrastructures worldwide and unearthed the social and institutional challenges of operating in a global crisis (Kim and Kreps 2020; Penninx et al. 2022; Maani and Galea 2020). This was exacerbated in the United States (U.S.), as public risk communication messages from local, state, and federal public officials were rife with conflicting information (Kim and Kreps 2020; Wang et al. 2021). In this article, we unpack the perils of flawed risk communication and how it likely puts people at greater risk associated with COVID-19 and other secondary risks, defined as novel risks that stem from risk-reducing behaviors and may stem from pandemic mitigation behaviors (Karagiannidis et al. 2023; Shin et al. 2021; Cummings et al. 2020; Rosenthal and Cummings 2021). The infrastructural and communication challenges experienced during the COVID-19 pandemic must be explored and mitigated to empower public health systems to be better prepared for future health challenges.

Risk communication is more than mass communication to the public; it occurs within and across decision-making organizations and becomes especially difficult in times of significant uncertainty. This was especially true during the first half of 2020, as early risk communication messages related to the pandemic were based on early expert understanding of the novel disease with limited information to support recommendations. Throughout 2020, poorly coordinated messaging and response activities from U.S. public officials across a wide array of governmental agencies, including the U.S. Centers for Disease Control and Prevention (CDC), resulted in conflicting and contradictory information and action plans between local, state, and federal public officials at various stages of response to the pandemic (Kim and Kreps 2020; Schiff and Mallinson 2023; Krohnert et al. 2023). These conflicting public health messages among officials across all levels of government are key factors that can trigger social disorder and chaos, and in the U.S., sparked increased ideologically driven societal hostilities and flawed efforts to mitigate health risks and avert adverse health outcomes throughout the pandemic (Kim and Kreps 2020; Nagler et al. 2020; Cherry et al. 2021).

Initial messaging on minimizing the scale of the pandemic centered on ‘flattening the curve’ with behaviors such as masking, social distancing, room ventilation, and avoiding crowded indoor spaces and non-essential travel (Sears et al. 2023; Honein et al. 2020). Compliance with preventive behaviors recommended by public health officials during the pandemic varied significantly across states and localities in the U.S.. Some of these differences were driven by the socio-demographic differences across states, urban and rural differences, and/or the prevailing political ideology of citizenry and leadership (Callaghan et al. 2021). Overall, the factors most predictive of adopting preventative health behaviors included culture, individual worldviews, personal experience, prosocial values, and social amplification through friends and family (Dryhurst et al. 2020).

The choice to engage in preventive behaviors, such as social distancing, wearing facemasks, and frequently washing hands, differed dramatically across populations. On one extreme, some individuals, which we call the under-cautious, choose not to follow or only selectively follow public health guidance regarding preventive behaviors (Urbán et al. 2021). This group includes individuals likely to hold attenuated threat severity and susceptibility beliefs toward the disease (Taylor and Asmundson 2021). Thus, their perceived risk of the virus is significantly lower than their actual risk. This group is also likely to hold low-response efficacy beliefs, noting that risk-mitigating guidance would not work and would unlikely diminish potential risk (Zhou et al. 2023).

On the opposite extreme is another group, which we call the over-cautious, who physically removed themselves from society, including friends and family in most extreme cases, even if appropriate expert recommendations were taken to mitigate risk. This group may include individuals distrustful of science/public health experts and susceptible to believing false theories, and to some extent includes immunocompromised individuals and older individuals with legitimate concerns about their risk and disease succeptibility (Plohl and Musil 2021; Freiling et al. 2023). We also argue that the over-cautious are likely hold risk beliefs antithetical to the under-cautious—their perceived risk to the virus is significantly greater than their actual risk (Liu and Liu 2023). Previous research by Freeman and colleagues suggests that such a group may have risk perception inconsistent with their actual risk (Freeman et al. 2021). Between these two polarizing groups lies the majority of people, comprised of those who follow guidance. They are most likely to follow public health guidance regarding preventive behaviors and hold threat and susceptibility beliefs that are neither overly attenuated nor amplified (Dryhurst et al. 2020).

Under-cautious behavior potentially contributed to the spread of the virus, especially in the early days of the pandemic, by refusing to engage in risk mitigation behaviors and frequently engaging in high-risk behaviors such as engaging in mass gatherings while not following public health guidance (Fischer et al. 2021; Center for Disease Control 2020). To a lesser extent, the over-cautious likely contributed to increases in secondary risks as an outcome of purposeful isolation and lack of physical, mental, and social, which potentially led to increases in obesity, cardiovascular disease, and mental health problems including depression, anxiety, stress, and a host of other psychological issues (Penninx et al. 2022; Flanagan et al. 2021).

Potential reasons why people may hold such distinct viewpoints include anchoring heuristics and biases (Senay and Kaphingst 2009). Heuristics are mental shortcuts that enable rapid inference and decision-making and can result in biases that skew perceptions and behaviors. Anchoring bias occurs when people base subsequent beliefs and behaviors on their developing understanding of a topic under consideration (Barbosa et al. 2019). In this case, the under-cautious and over-cautious may have favored the first information they received concerning human severity and susceptibility to the virus and the efficacy of recommended risk-mitigating behaviors. This implies that the first message that the public health official or governmental agencies introduce about any issue has a prominent effect on future adherence (Azzopardi 2021).

For instance, many people first learned about the virus that causes COVID-19 when some public officials and media sources linked it to be equitable or similar to seasonal influenza. This likely minimized their threat severity perceptions of COVID-19 (Imhoff and Lamberty 2020). Similarly, yet on the other end of the spectrum, early reports of high mortality rates associated with COVID-19 that mainly were based on mortality rates in the hospitalized populations (Richardson et al. 2020) potentially maximized threat severity perceptions and skewed risk perceptions in the opposite direction. It is also essential to consider the influence of informal information sources, such as family, friends, and social networks. While some scholars have sought to overcome anchoring bias, much of the work in this area leads to strategies designed to get individuals to be willing to “consider the opposite” viewpoint—a difficult task in tumultuous times, especially in the political climate that existed in the U.S. at the time of the beginning of the pandemic and today. Thus, further theoretical and practical research should focus on improving interventions to mitigate anchoring bias in risk and health decisions for COVID-19 and future healthcare issues.

The over-cautious group also increased the probability of being susceptible to secondary health conditions by avoiding medical assistance for urgent health problems that required medical assistance from a skilled healthcare professional, thus possibly developing new health conditions or exacerbating existing ones (Maehl et al. 2021). Overcautiousness in decision-making in individual institutions may have also resulted in closing or severely limiting access to nursing homes, skilled care facilities, and subsidized apartment buildings for seniors (McGarry and Grabowski 2021). Socially isolating these vulnerable population groups was potentially increasing their risks for immobility, nutritional deficiencies, and the development or exacerbation of mental health conditions (Karagiannidis et al. 2023; Strang et al. 2020; Simard and Volicer 2020). In considering future guidelines for older people, it has been recommended to use a multifaceted approach to preserve dignity and reduce the adverse health outcomes of loneliness and social isolation that will continue long after the COVID‐19 pandemic (Rodney et al. 2021).

2 Discussion: addressing risk communication challenges to improve public health practice

The clear majority of pandemic risk communication messages focused on the under-cautious. In hindsight, this oversight may have contributed to polarizing two groups, the under-cautious and the over-cautious, who experienced greater health risks in different ways due to their beliefs. Figure 1 visually depicts the spectrum of these risk attitudes and behaviors on a continuum. This figure represents the diversity, yet similarity, in polarized risk attitude holding and decision-making regarding COVID-19, where both polarized views have the potential for individuals to develop increased morbidity and mortality.

Fig. 1
figure 1

Attitudes and behaviors of the under-cautious and over-cautious

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Limited risk communication messages to address the overly cautious resulted in “invisible victims of COVID-19” including individuals with limited access to care, children who missed school and are at greater risk of food insecurities and suicide (Kauhanen et al. 2023; Dorn et al. 2021), and older adults who face greater risks of limited physical activity and isolation, especially those in skilled care facilities who have suffered from mandated shutdown resulting in the inability to meet loved ones and frequently faced dying alone (Webb and Chen 2022; Levere et al. 2021). The remainder of this article outlines the forms and topics of public health communication messages that contributed to overly cautious behaviors of the over-cautious and suggests alternatives to these approaches to avoid future secondary risks.

The pandemic resulted in fertile ground for the emergence of a large amount of erroneous and misleading information about the virus (Wang et al. 2021). The situation became so dire that the World Health Organization (WHO) declared an “infodemic” of incorrect information about the virus and discussed its risks to global health (Cucinotta and Vanelli 2020; Ahmed et al. 2020). Table 1 outlines the different types of incorrect messages that were prominent during the pandemic and describes how these types of incorrect messages differ in purpose and intent. Misinformation is incorrect information unintentionally spread by individuals without appropriate knowledge and can be the product of misjudgment, outdated knowledge, or even typographical errors (Cummings and Kong 2020). Rumors are unsubstantiated claims that reduce uncertainty and provide a potentially plausible rationale for a topic (Cummings and Kong 2020). Disinformation intentionally distorts information to manipulate or obfuscate facts and influence behavior (Cummings et al. 2021). Similarly, propaganda is the coordinated and systemic effort to influence others through disinformation strategies (Cummings and Kong 2020). Disinformation was used by politicians and interest groups around the world for political purposes, including avoiding responsibility, scapegoating others, or avoiding criticism for questionable decisions (Recuero and Soares 2022). In such conditions, many fraud products, remedies, and myths have come onto the market, which are falsely claimed to be effective for the disease and can harm the patients (Chavda et al. 2022). The COVID-19 pandemic has been marked by various risk communication messages and topics, which we argue have contributed to overly cautious behavior likely to exacerbate secondary risks like isolation and lack of physical, mental, and social activity.

Table 1 Different types of incorrect messages
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2.1 Confusion about the purpose and timing of movement restrictions

In March and April 2020, many communities in the U.S. began mandated shutdowns of dense gathering locations likely to worsen viral contagion. While such measures effectively suppressed the disease, allowing for public health interventions to occur, the lockdown’s purpose and duration could have been communicated more effectively to the public. Official communication often missed the concept that shutdowns are meant to be temporary measures and are not designed to be implemented for the duration of the period until vaccine discovery. With extended shutdowns (government or self-imposed), populations are likely to experience “quarantine fatigue” in which social distancing may be done with little to no familiarity of risk, resulting in real economic and health consequences due to secondary risks associated with the pandemic (Goldstein et al. 2021). The optimal policy reflects the rate of time preference, epidemiological factors, vaccine discovery hazard rate, healthcare sector learning effects, and the severity of output losses due to lockdown. The policy behind implementing lockdowns in 2020–2021 has rarely been evidence-based (Yanovskiy and Socol 2022).

2.2 Exaggerated risk of contracting the virus while outdoors

Some areas in the U.S. have maintained mask mandates for public activities even though scientists note the low possibility of COVID-19 spreading outdoors, especially for individuals who are away from others or with members of their households. Such mandates may exaggerate the risk of contracting the virus outdoors, creating amplified risk perceptions and stress—a systematic review by Bulfone et al. supported the understanding that the risk of outdoor transmission of COVID-19 is much lower than indoors. In this review, five studies found a low proportion of reported global SARS-CoV-2 infections occurred outdoors (< 10%), and the odds of indoor transmission were very high compared to outdoors (18.7 times; 95% confidence interval, 6.0–57.9) (Bulfone et al. 2021).

2.3 Exaggerated case fatality rate (CFR)

Many COVID-19 infections are asymptomatic and spread by asymptomatic carriers (Shang et al. 2022). Early reports about the CFR rate of COVID-19 did not consider asymptomatic cases (estimated at 25% of all COVID-19 infections) and cases with mild symptoms and primarily focused on severe cases that ended up in hospitalizations (Alene et al. 2021). Incomplete and much smaller estimation of the denominator during the early stages of the pandemic resulted in expert estimates of CFR (such as 3.4%, reported by WHO) that were much higher than our revised contemporary understanding. In testimony before U.S. Congress on March 11, 2020, House Oversight and Reform Committee members were informed that the estimated mortality for the novel coronavirus was ten times higher than for seasonal influenza (Ioannidis 2020). Additional evidence, however, suggests the validity of this estimation could benefit from vetting for biases and miscalculations (Brown 2020). These early mortality rates were a likely salient “anchor” from which the overly cautious group based their understanding of the disease and chose to engage in overly cautious behaviors potentially putting them at higher risks to secondary risks. Classification challenges associated with correctly attributing death to COVID-19 was also a concern, as varous countries also use different processes to test and report COVID-19 deaths, making comparisons difficult, especially during early stages of the pandemic there were issues with over-classification and under-classification of mortality related to infection (World Health Organization 2024).

2.4 Lack of identifying and communicating appropriate low-risk activities

The public was bombarded with information about high-risk activities throughout the pandemic. In contrast, little information was available on the low-risk activities outside of staying at home. Overall, there has been a lack of emphasis and information on minimizing risks if you have to engage in social activities. This may be due to long-standing media effects, where low-risk activities are not as eye-catching or “newsworthy” as other narratives regarding high-risk events and are thus not communicated as widely to the public. As one study noted of COVID-19, “mainstream media tend to rely on news content that will increase risk perceptions of pandemic outbreaks.” (Olagoke et al. 2020, p. 865). This follows a traditional media rubric that scholars have criticized for decades, where mainstream media prioritize highly selective, often sensational, and sometimes inaccurate reporting of risks (Fog 2004). Due to the vacuum of balanced reporting, officials have prioritized emphasizing the message of “staying home” without considering secondary risks caused by reduced physical activity.

2.5 Excess morbidity and mortality during COVID-19 pandemic in the U.S.: underlying causes?

According to the recent CDC report, 63,700–162,400 excess deaths in the U.S. occurred during the first year of the COVID-19 pandemic (Center for Disease Control 2021). Up to 25% of these excess deaths (especially in the age group of 75 and under) were likely due to non-COVID causes. The fundamental non-COVID-19-related causes are outlined in Table 2. We would like to hypothesize that many of these excess mortalities that are not COVID-related are potentially preventable with appropriate risk communication and disaster response (Fog 2004).

Table 2 Key causes of non-COVID-19-related mortalities in the US (based on CDC data, January 26, 2020–February 27, 2021, Center for Disease Control 2021)
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3 Conclusion

COVID-19 communication has been challenging, and a large amount of information that served as a foundation for many COVID-19-associated policies needs to be more evidence-based. Many ethical issues arose due to the pandemic, including our response to protecting older people, children, and those at increased secondary risks. Our reflection on these forms and types of communication strategies as they have developed for COVID-19 can help with planning for more successful future pandemic and disaster communication.

With the emergence of safe and efficacious vaccines at the end of 2020, public officials attempted to communicate messages that emphasized the need for the population to get vaccines and that the vaccines were safe and effective. Early communications from the CDC and other agencies about the vaccines focused on the importance of social distancing and avoiding crowds, even for individuals who received vaccines, potentially raising the question of why somebody would want to get vaccinated. Effective risk communication can only happen with experts trained in communication, and there needs to be an emphasis on having communication experts involved in handling the COVID-19 pandemic.

As we continue COVID-19 management and anticipate improved planning for future challenges, we advocate for greater formative evaluation and evidence-based research on effective communication strategies. This would include invigorated efforts to understand public risk perceptions and behaviors while identifying higher-risk groups’ needs and motivating factors. This can be done through systematic efforts to assess risk messages and improve our understanding of risk communications by conducting focus groups and surveys. With the new report from Japan describing excess mortalities observed for all cancers and some specific types of cancer (including ovarian cancer, leukemia, prostate cancer, lip/oral/pharyngeal cancer, pancreatic cancer, and breast cancer) after mass vaccination with the third COVID vaccine dose in 2022, evidence needs to be carefully evaluated and effectively shared with the public with emphasis on what groups will benefit from the vaccines (Gibo et al. 2024).

Through robust and granular formative analysis of the public’s understanding of risk, we can provide an empirical baseline from which more nuanced and targeted risk messaging strategies can be developed. Additionally, with further knowledge of COVID-19 risk to society and secondary risks associated with virus control measures, public health officials need to focus on minimizing the spread of COVID-19 and minimizing the general damage to public health by the pandemic. Recent review suggested the following essential features of effective communication to enhance adherence to public health behavioral interventions (i) information should be conveyed clearly, and conflicting (mixed) messages should be avoided; (ii) information should be conveyed by trusted sources (e.g., health authorities); and (iii) communication should strike a balance between being authoritative but avoiding language seen as controlling (Williams et al. 2023).

We need to harness the knowledge in health communications to craft public health campaigns to help our societies engage in health behaviors most conducive to improving health. Individuals’ risk perception level will be affected by many factors such as psychology, society, culture, system, and oneself, which play an essential role in disseminating risk information (Wang et al. 2022). With appropriate information access, the level of uncertainty about COVID-19 and similar conditions might decrease over time, and evidence-based public information might provide solid mitigation measures for society. Since risk perception may be easily affected by factors such as household prosperity, work conditions, social capital, and trust in authorities, more research on risk perception should be done to mitigate future pandemics.

By focusing on evidence-based information from the onset of pandemics and other public health challenges, we can better communicate risks so that the public will understand and avoid deleterious “anchoring points” that may skew responsible behavior. Such efforts can also help to identify the secondary risks of advocated risk mitigation strategies, which, with proper anticipation and response, can help curb some of the extraneous risks sometimes assumed by the public during this COVID-19 pandemic.