The Psychology of Public Health Messaging

Source: Salt Lake County Health Department PSA

The stark, in-your-face COVID-19 public health messaging from the Salt Lake County Health Department has begun to stir controversy. In the image above, a large, white, presumably Mormon extended family is sharing Thanksgiving dinner. They are all maskless and not socially distancing. We are told that the man at the head of the table has no symptoms of COVID-19 but has had the infection for nine days. Instead of the obligatory “cheese!” or “turkey!” the woman taking the family’s photograph says,”Everybody say: I was just exposed to COVID!”

Other public health messaging in this series targets a more racially/ethnically diverse group of young people socializing together at an indoor party, and a grandmother seeing her (unknowably COVID-positive) grandson (we are told she ends up in the ICU with COVID-19 less than a week later). This series of public health images and messages brings up fascinating issues related to the effectiveness and ethics of public health messaging. These ‘ads’ are professionally produced and appear to be well thought out in terms of target groups and influential messaging to motivate people to follow public health guidelines. Thankfully, there was thought given to avoiding reinforcing negative (and false) stereotypes as to the ‘vectors’/sources of the disease, since no person of color was labeled as the identified source.

The November issue of the American Journal of Public Health includes articles on the rise of mental distress across our country stemming from the COVID-19 pandemic, the negative health effects of COVID-19-related racial discrimination of Asian Americans, and one titled “Reimagining Public Health in the Aftermath of a Pandemic” (sources below). The authors of this latter article make the case for advances in public health infrastructure, effective ways to counter misinformation, and improvements in risk communication. They state, “We already know that researchers are adept at communicating with other researchers but less skilled in reaching non-research audiences. Skilled spokespersons are needed. Generally, the public health community can learn much from business and social marketing, which tailor messages and target audience segments.” (p. 1609)

Anxiety and fear of disability and death from contagious diseases or natural disasters can be powerful motivators for individual behavior change up to a certain point. But tapping into that anxiety and fear through targeted public health messaging can backfire when it becomes too much for people to take in or becomes nagging, nanny-state background white noise.

Sources:

“Mental Distress in the United States at the Beginning of the COVID-19 Pandemic,” by C. Holingue, et al, in the American Journal of Public Health, November 2020, vol 110:no. 11, pp. 1628-1634.

“Potential Impact of COVID-19 -Related Racial Discrimination on the Health of Asian Americans,” by J.A. Chen, et al, in the American Journal of Public Health, November 2020, vol 110:no. 11, pp. 1624-1627.

“Reimagining Public Health in the Aftermath of a Pandemic,” by R.C. Brownson, et al, in the American Journal of Public Health, November 2020, vol 110:no. 11, pp. 1605-1610.

Nurses, Vaccine Hesitancy, and the COVID-19 Pandemic

University of Washington Special Collections “Pioneering Medicine” exhibit, 2016

Nurses are the most trusted healthcare professionals in our country. Nurses are the largest component of the healthcare system here in the United States and worldwide. Nurses have an enormous ethical responsibility to keep up to date on and apply evidence-based practice in their work and in their personal lives.

The American Nurses Association (ANA) recently released results of a study from October, 2020 showing that only thirty-four percent of nurse members surveyed said they were willing to receive the COVID-19 vaccine once it is approved for use. Seventy percent of nurses reported that they had mistrust in the COVID-19 vaccine approval process, and sixty-three percent said their main source of information about the vaccine was from mainstream media. (source: American Nurses Foundation, Pulse on the Nation’s Nurses COVID-19 Survey Series: COVID-19 Vaccine, October 2020.) With the first COVID-19 vaccine due to be released for nurses and other frontline workers as early as next month, clearly, we have a problem.

We all need to work to repair the erosion of respect and trust in our public health system, including vaccine research, development, and safe, equitable distribution. Nurses can and should be at the forefront of that work and should be included on President-Elect Biden’s COVID-19 Advisory Board.

Not Playing Indian

November is both Native American Heritage Month and National Homeless Youth Awareness Month. This week (November 15-22, 2020) is Hunger and Homelessness Awareness Week. Especially this year, in the midst of the pandemic disproportionately affecting Native Americans and other BIPOC people, rising joblessness, increasing evictions (despite CDC and other anti-eviction mandates), increasing domestic violence, increasing social isolation and depression among our teens/young adults, increased attention and action related to these social and health issues are important. There are many things we can all do to help. Here is my list of actions for you and your family members to consider doing—not only during November:

1. Become better informed about these national and local issues by reading through the resources included in the links above.

2. Read more books by Native Americans. My current favorites include Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teachings of Plants by Robin Wall Kimmerer; There There by Tommy Orange, and An Indigenous Peoples’ History of the United States by Roxanne Dunbar-Ortiz.

3. Support Native American/Indigenous owned and run social service programs, such as Chief Seattle here in Seattle. They have health and social services (including supportive housing) for urban Native Americans/Native Alaskans/Indigenous people experiencing homelessness.

4. Support Native American/Indigenous owned and run arts and crafts stores, such as the “Inspired Natives, Not Native Inspired” Eighth Generation located in Pike Place Market, Seattle.

5. Support the expansion of school nurses and mental health counselors in all of our schools.

6. Support upstream policy efforts to prevent homelessness and hunger in our country. National Low Income Housing Coalition is one source of information on these issues. Likewise, for health and homelessness national policy issues, the National Health Care for the Homeless Council is an excellent resource.

Here is a digital storytelling video I made this summer in a StoryCenter workshop. “Honor Their Stories” is about my experience researching and writing a book chapter (in Skid Road: On the Frontier of Health and Homelessness in an American City, JHU Press, 2021) on Kikisoblu, also known as Princess Angeline, who was the daughter of Chief Seattle for whom Seattle is named. In this video, I explore the ethical issues I encountered as a white woman trying to understand more of the life, and death, of a Native American woman.

Healing. But First, Grieving

Individually and collectively we need a time of healing, physically, emotionally, and spiritually. 2020, the Year of the Metal Rat, has been a year like no other. The multiple upheavals and uncertainties have taken a large toll on us. We need a time for grieving all that we have lost and continue to lose. Not only the hundreds of thousands of Americans who have already died of COVID-19, but also the mounting job losses, increases in domestic violence, gun-related violence, and social isolation, especially for our elderly and other high-risk people. As we enter the darkest days of the year here in the Northern Hemisphere, alongside a second wave of COVID-19 infections and deaths, we need ways of staying hopeful, strong, resilient, and resistant.

What we are experiencing is not simple grief. It is complicated grief. As the Mayo Clinic writers put it, “Complicated grief is like being in an ongoing, heightened state of mourning that keeps you from healing.” Risk factors for complicated grief include social isolation, past history of depression and PTSD, adverse childhood experiences, and other stressors like financial hardships. Medical treatment for complicated grief includes, not surprisingly, grief counseling and cognitive-behavioral counseling. But other treatment interventions known to build resilience and lessen the negative effects of complicated grief are arts-based therapies, narrative storytelling, and other meaning-making activities.

The feminist environmental health and justice writer Terry Tempest Williams, said recently in an interview with Pam Houston, referring to both the very real effects from climate collapse (fires in the West and unrelenting hurricanes in the South) and the pandemic, “We haven’t grieved for it, for the people lost, and if you don’t think that won’t come back at us sideways (well, you’re wrong).”

Key references/sources:

Martha Kent , Mary C. Davies, “Resilience Training for Action and Agency to Stress and Trauma: Becoming the Hero of Your Own Life,” in The Resilience Handbook, eds. Kent, Davies, and Reich, (Routledge, 2013), 227-44.

Josephine Ensign, Soul Stories: Voices from the Margins, (University of California Medical Humanities Press, 2018).

Nursing and Advocacy and Voting

Thank you University of Washington Continuing Nursing Education for the opportunity to share my ZOOM videotaped thoughts on all things nursing advocacy, activism, civic engagement and voting. And I meant what I said towards the end of my remarks: my nursing students give me great hope for our collective future. Most of them already understand the importance of this, are doing this work, and are keen to hone their advocacy, activism, and civic engagement skills. I’d also add here that we need to stand up against voter suppression and intimidation.

Stay strong and vote!

Past Presidents of the ANA Endorse Biden-Harris

Note: The following is a letter from eight past presidents of the American Nurses Association in support and endorsement of Biden-Harris in the 2020 election. It was shared with me today by past ANA president, Virginia Trotter Betts who asked that I share it widely. Nurses, nursing students, and everyone whose lives have been/are/will be impacted by a nurse need to read this. And vote for Biden-Harris in the November election.

Open Letter from American Nurses Association Past Presidents as signed below

The 2020 presidential election will be one of the most consequential decisions our nation has ever faced. Over the course of more than four decades, we, the undersigned past presidents of the American Nurses Association (ANA), led the nation’s nurses without deference to specialty or affiliation on matters of policy and politics. Instead, our work was grounded in the tenets of the ANA’s Code of Ethics for Nurses and the principles of its Social Policy Statement, venerated guideposts that establish nurses’ professional values and direct their practice, embodied in a commitment to serve all society. Our body of work compels us to speak out and express our support for the presidential candidate who we believe will best serve the people of this nation—Joe Biden.

We believe that Americans have a choice on the ballot this year between a candidate who will be inclusive and restore a moral compass with empathy for human beings or a candidate who has sewn chaos and division while showing no compassion for the American people. The Trump administration has us literally fighting for our lives as we face down the Coronavirus pandemic while sparring over our economic futures; access to affordable and equitable health care; racial equality; social justice; and immigration policy.

From bedsides to boardrooms, professional nurses across this country have always served the healthcare needs of our people. We know firsthand the value, knowledge, and skills nurses bring to the care of others. Perhaps more than at any other time over the past century, the COVID-19 pandemic has brought into focus the essential nature of nurses’ contributions to the health promotion, illness prevention, and compassionate healing of all people in need. It has also laid bare the lack of a coordinated national response to COVID-19, which has failed nurses and all Americans. A failure to promote and enforce life-saving coronavirus mitigation strategies through organized, consistent, and evidence-based guidelines and the silencing or denigrating of scientific and medical experts and institutions has denied critical public health safeguards for us all.

Utilizing nursing’s core principles, the eight of us have analyzed the positions of each party’s presidential candidate. Without question, the Democratic Party platform aligns best with nurses’ ethical values and numerous ANA positions on important issues such as promoting public health, healthcare access, ensuring racial equality and social justice, ending the epidemic of gun violence, providing humane treatment for those seeking refuge from danger, and securing a clean energy future, among others.

The choice is clear. As national nurse leaders, we strongly support Vice President Joe Biden for President. He will safeguard the future and health of our nation. Join us in support of the Biden-Harris ticket!

Signed, Past Presidents of the American Nurses Association in Support of Biden-Harris

Pamela Cipriano, RN, 2014-2018 Virginia
Karen Daley, RN, 2010-2014 Massachusetts

Rebecca Patton, RN, 2006-2010 Ohio
Barbara Blakeney, RN, 2002-2006 Massachusetts

Mary Foley, RN, 1999-2002 California
Virginia Trotter Betts, RN, 1992-1996 Tennessee

Eunice Cole, RN, 1982-1986, California
Barbara Nichols, RN, 1978-1982 Wisconsin

Teaching in the Time of Trump

As I prepare to teach public health to nursing students this fall, I am mystified by and angry at the absolute wreckage Trump has made of our public health system and of our country. How to teach in the climate of hate and discord and blatant disregard for basic human rights, for human lives, for the lives of our COVD-19 pandemic frontline nurses and other healthcare providers, for scientific evidence? How to teach in the time of Trump?

Back in January 2017, as Trump was being inaugurated President of the United States, white supremacist hate groups infiltrated our university campus. They spread virulent racism, hatred, violence, and intimidation across our campus, including inside our health sciences/hospital buildings. In some cases, they attached razor blades to the backs of flyers they posted in classrooms so that people who removed the flyers could be cut in the process. Two of our university students brought weapons–including a gun–to campus and shot and seriously injured a protestor at the ill-advised Milo event sponsored by the Republican student group–an event that was allowed to happen by our university administration. I wrote about this and subsequent white supremacist group activity on our campus in a previous blog post, “Teaching in a Time of Hate and Violence.”

I thought it couldn’t get much worse than that, but, of course, it has. Trump’s complete bungling of our country’s response to the COVID-19 pandemic has led to the deaths of over 200,000 people in the US and to the deaths of over 2,000 frontline nurses and other healthcare workers who were denied proper personal protective equipment in caring for patients with COVID-19. And, with Trump and Trump appointees politicizing/meddling with public health institutions including the Centers for Disease Control, there is now even more public distrust of and confusion over scientific, evidence-based public health individual and community level recommendations. Public health officials across the country are receiving death threats from Trump supporters.

I am dismayed by the decision by the current leadership of the American Nurses Association (ANA) in deciding to ‘sit out’ this election, in pretending to be politically neutral by not endorsing the clear choice of Biden-Harris to lead our country out of the current public health, economic, and social mess Trump has made. Shame on you ANA for being so spineless. History will not be kind to your choice.

Trump is now doing the theater piece of establishing the 1776 Patriotism in Education Presidential Commission to push for revisionist and white supremacist education throughout our country. Trump does not want the history of slavery in our country taught or anything else resembling (the truth) and having to do with anti-racism.

In addition to teaching the basic principles and practices of public health nursing, this year I will teach even more to civic engagement, the importance of being an informed citizen, of voting, of speaking up for what’s right–not only for individual patients our nursing students will care for, but also communities, our entire country, and our world. The two required textbooks will include one basic textbook on public health nursing and How to be and Antiracist by Ibram Kendi.

Nurses: Please Vote

Nurses in the United States: Please do not sit this election out. Do your duty as an American citizen and as a nurse. Make informed decisions about candidates and issues and cast your ballot (just once, that is—don’t listen to our current president, silly man that he is, only vote once, whether it is by mail or in person or via e-mail for oversees folks). Voting is always important and is a sacred civic duty. This year, it is especially crucial for the health and future of our country. And do whatever you can to encourage and enable other people to vote, including your patients and your community members.

If you happen to be a nurse educator as I am, remember that you can and should provide course content on the importance of political knowledge and advocacy for nursing. It seems to be a common misperception among nurse educators that political content is somehow a no-no and that it can get them in trouble with their employers. Providing non-partisan information on being an informed voter is never a no-no. And, our nursing students need to be exposed to nursing faculty and other mentors who are politically engaged—including nurses who run for political office at the local, state, and national levels. A great non-partisan resource is the All In Campus Democracy Challenge. Check to see if your college/university has signed on to this challenge and what resources and activities you can tap into.

In just a few weeks, I will cast my ballot here in Seattle, King County, Washington. I am proud of our state and county for ensuring that our elections are safe and open to every eligible voter, no matter their race/ethnicity, country of origin, language, able-ness, and political affiliation. I am proud to be part of the grassroots Nurses for Biden-Harris group, working to promote information on the reasons why nurses should strongly consider voting for the Biden-Harris ticket: compassion, faith, resilience, empathy, kindness, humility, joy, respect, inclusion, and dignity. Those are the core values of Joe Biden and Kamala Harris. They also happen to be core values and part of the Nursing Code of Ethics of the American Nursing Association.

Overdue Reckoning on Racism in Nursing

An excellent series of online webinars to consider signing up for.

NurseManifest

We are excited to announce a series of web discussions “Overdue Reckoning on Racism in Nursing” starting on September 12th, and every week through October 10th! This initiative is in part an outgrowth of our 2018 Nursing Activism Think Tank and inspired by recent spotlights on the killing of Black Americans by police, and the inequitable devastation for people of color caused by the COVID-19 pandemic.

Racism in nursing has persisted far too long, sustained in large part by our collective failure to acknowledge the contributions and experiences of nurses of color. The intention of each session is to bring the voices of BILNOC (Black, Indigenous, Latinx and other Nurses Of Color) to the center, to explore from that center the persistence of racism in nursing, and to inspire/form actions to finally reckon with racism in nursing.

Lucinda Canty, Christina Nyirati and I (Peggy Chinn) have teamed up…

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Racism and Nursing

Bandaging a patient’s hand, Cross-Over Clinic, 1986. Richmond Times-Dispatch

Ibram Kendi writes, “We are surrounded by racial inequity, as visible as the law, as hidden as our private thoughts. The question for each of us is: What side of history will we stand on?” (How to Be an Antiracist, p. 22).

In preparing to teach population health nursing and health policy and politics again this coming academic year, I am working with the good folks at StoryCenter to develop media literacy content utilizing digital storytelling videos. And, since our University of Washington Health Sciences Common book will be Kendi’s How to Be and Antiracist (not to mention the current moment in terms of racism in our country), I plan to use digital storytelling focusing on racism and bias in nursing and health care.

Nurstory, working with StoryCenter, has some excellent digital storytelling videos by nurses across the country, including nurses with the Nurse Family Partnership. Dr. Raeanne Leblanc and her colleagues at University of Massachusetts, Amherst, completed a Nurstory project on social justice. My plan is to work with our students on the use and making of digital stories related to racism and bias. Since I believe that I should practice what I preach (or teach in this case), I recently made a digital storytelling video on my experience of racism in various aspects of nursing, including nurse education. Titled “Relics,” here it is:

Relics, Josephine Ensign, August 2020