5

Coordination and Partnering Between Scientific Researchers, Policymakers, and the General Public

The workshop’s second keynote address, delivered by Saad Omer, director of the Yale Institute for Global Health (YIGH), highlighted research on public confidence in leaders and information sources during the COVID-19 pandemic, the politization of vaccine access and acceptance, and interventions shown to improve vaccine acceptance. Janet Tobias, founder and chief executive officer of Ikana Health Action Lab, moderated the session.

COMMUNICATION AND VACCINE ACCEPTANCE CONSIDERATIONS

Tobias provided context on the complexity of communication and uptake of medical interventions such as vaccines during a health emergency. She began by reviewing key takeaways highlighted by speakers during the first day of the workshop. Shah spotlighted the critical role of investment in public health and the need to rethink how health care providers communicate with both the general public and with patients, giving consideration to the incorporation of personal accounts into the narrative when appropriate. Hotez spoke of anti-vaccine activism and political groups leveraging the public’s lack of understanding and trust of vaccines for their own gains. He suggested that organizations within and beyond the federal government should focus efforts on responding to these dynamics. Graham emphasized that actions to improve pandemic response should be taken during the inter-crisis period before the next global health crisis occurs.

Much of the discussion so far has focused on vaccines and communication, noted Tobias; however, many people are concerned with multiple

health issues for which vaccines may not be relevant. For instance, a person may be worried about their teenage child’s depression, their parent’s diabetes, or their desire to lose weight. People with cancer or heart conditions may be more worried about these conditions than a pathogen that has not yet infected them. Tobias mused that if health care providers overlook these concerns to focus solely on vaccines, people may leave the encounter feeling that providers do not care about them as holistic individuals. Public health is a platform for holistic conversations with communities, she said, and this aspect of public health highlights the need for greater investment.

Tobias also noted that technology and media companies are not represented at the workshop. Although these companies can enable the spread of disinformation, their role in financing communications requires them to be as much a part of the conversation as pharmaceutical companies. Giving them a place at the table increases the likelihood of obtaining their support, Tobias suggested; for example, YouTube Health provides health information to the public and would be a suitable workshop participant.

Tobias closed her remarks with a personal anecdote to illustrate the nuanced dynamics at play in vaccine hesitancy. She recalled a friend who is a physician researcher who performed heroic work in saving and caring for patients during the pandemic. Although vaccinated and a believer in science, he voted for a candidate who did not appear to support science in the last presidential election. He explained that he “voted with [his] people,” referring to his family members who provided emotional and financial support for his education. Tobias believes that this aspect of social group affiliation should be considered in communication efforts.

COORDINATION AND PARTNERING BETWEEN SCIENTIFIC RESEARCHERS, POLICYMAKERS, AND THE GENERAL PUBLIC

Omer presented research on public confidence in pandemic information sources, the integration of vaccine hesitancy into political identity, and interventions shown to improve vaccine acceptance. He also discussed the process used to prioritize access to an initially limited vaccine supply. On January 20, 2020, when the first case of COVID-19 in the United States was confirmed, Omer was concerned that a U.S. case was confirmed within weeks of the first cases appearing in China. In his experience with other pathogens as an epidemiologist, the early emergence of severe disease that led to seeking and requiring intensive care signifies the likelihood of a substantial outbreak. This concern led him to author an op-ed that appeared on January 23, 2020, in The New York Times titled “Is America Ready for Another Outbreak?” (Omer, 2020). In the article, he maintained that the United States was not prepared for an outbreak, but that the United States need not be a helpless bystander either. The piece provided three

suggestions for responding effectively to the emerging novel virus. First, scientists—broadly defined to include those in academia and in public health agencies at the federal, state, and local levels—should lead in decision making. Outbreaks involve uncertainty and knowledge will evolve over time, Omer said, and the gap between the ability to synthesize new information and the authority to develop recommendations and decisions should be minimized. Second, he cautioned about misinformation and disinformation from both conventional and new sources. In addition to public misinformation promoted on social media, scientific misinformation can be shared via the new entity that is preprint service. Omer stated that preprint service offers benefits, but the posting of scientific work without peer review could have unintended consequences. Third, politicians instinctually try to reassure the public, but false reassurance could erode public trust. Omer lamented that all three of his warnings proved to be prescient for the pandemic response in the United States.

Confidence in Leadership and Information Sources

Omer shared results from a national survey conducted by YIGH in February 2020 to measure trust in leadership and confidence in information sources (McFadden et al., 2020). This survey asked who should lead the U.S. COVID-19 response out of a list of options. Approximately 53 percent of respondents indicated that the director of the Centers for Disease Control and Prevention (CDC) should lead the response, followed by the director of the National Institutes of Health (NIH) (16 percent). Political leaders trailed health agencies in respondents’ preference, with the President and Congress garnering 13 percent and 1 percent, respectively. In terms of information sources, health care professionals received the highest confidence score by the respondents, followed by CDC/NIH (the survey question combined these agencies). News media sources and friends and family ranked above social media, which received the lowest confidence score. Omer stated that YIGH conducted a similar survey for mpox as news outlets began to report on the mpox outbreak during summer 2022 and found that health professionals remained the most trusted information source (Winters et al., 2022). Although confidence in the CDC had decreased since the 2020 survey, health officials—a category encompassing both local and federal levels—remained the second most trusted category. He stated that these findings indicate that reports that the overall public distrusts health officials could be misleading.

COVID-19 Vaccine Acceptance and Political Ramifications

“A vaccine that remains in a vial is 100 percent safe and zero percent effective,” said Omer, quoting his mentor and former director of

the United States’ National Immunization Program, Walter Orenstein. Drawing from his experience during the H1N1 influenza outbreak, Omer anticipated that vaccine acceptance could be an issue during the COVID-19 pandemic. In May 2020, YIGH conducted a national study on potential vaccine acceptance. At that time, most COVID-19 vaccines were in phase I, II, or early III trials. The 2020 survey data were used in a predictive model designed to identify likely determinants of vaccine acceptance (Malik et al., 2020). The model predicted age, gender, race, and education to be relevant variables in vaccine acceptance, which bore out in reality. The survey results indicated that approximately 67 percent of people would accept the vaccine (Malik et al., 2020). On December 7, 2022, the actual vaccine acceptance rate in the United States for the primary series of COVID-19 vaccine was 68.8 percent (CDC, 2022b).¹ Despite the predictions of accurate models, many experts underestimated the level of vaccine hesitancy that would emerge once COVID-19 vaccines became available, anticipating that widespread vaccine acceptance would only require photos of physicians receiving the vaccine and confirming their trust in the product. In contrast, Omer and others expressed concern months before the vaccines became available that significant levels of vaccine hesitancy could emerge. He advocated for a systematic national communications campaign before the COVID-19 vaccines rollout, a time when attitudes toward the vaccine were still forming.

The timing of the 2020 U.S. presidential election added a political dimension to the COVID-19 vaccines rollout and vaccine acceptance rates. The election was scheduled to occur on November 3, 2020, and vaccine authorizations were expected to occur in November or December. The proximity of these events gave rise to discussion of the political implications of the timing of the rollout. Omer noted that political will was exerted to alter the vaccine authorization schedule, but both career staff and politically appointed leadership at the Food and Drug Administration (FDA) resisted changing the schedule to suit the political calendar. In collaboration with colleagues in the political science and economics fields, Omer conducted a randomized study on the implications of various vaccine authorization dates (Bokemper et al., 2021b). Study participants were presented with a scenario in which the vaccine became available on a specific date and were asked how likely they were to accept the vaccine. Both confidence and predicted uptake were higher for the scenarios in which the vaccine became available in December compared to 1 week before the election. This finding indicates that changing the authorization schedule—versus insisting that it

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¹ The acceptance rate for the COVID-19 booster was much lower, at approximately 15 percent.

be determined by the scientific process—could have had real consequences, said Omer.

In addition to the political ramifications of vaccine rollout, Omer examined the effect of endorsements from various leaders on vaccine acceptance (Bokemper et al., 2021b). Study participants were presented with a statement that either endorsed a positive (i.e., the leader believed the vaccine to be safe and effective) or negative (i.e., the leader was not convinced that the vaccine was safe and effective) view of the vaccine. The randomly selected endorsement was attributed to one of three leaders: Anthony Fauci, then-director of the National Institute of Allergy and Infectious Diseases (NIAID); then-President Donald Trump, a Republican; and then-Speaker of the House Nancy Pelosi, a Democrat. Omer emphasized that in fall 2020, attitudes about vaccines were still forming and had not yet become as entrenched in political identity as they were in December 2022, at the time of the workshop. The study found that endorsement statements attributed to Fauci were the most influential of the three leaders. This finding held across party lines, although Democrats generally had higher confidence levels in Fauci than did Republicans. President Trump’s endorsement of vaccines influenced Republicans but had a “backfire effect” on Democrats. A similarly polarizing dynamic was at play for Speaker Pelosi. In surveys in which a positive or a negative endorsement was attributed to both President Trump and Speaker Pelosi, participants from both political parties were influenced. However, the effect of a joint endorsement from the two politicians did not alter confidence in vaccines to the degree that a statement attributed to Fauci did.

Omer and colleagues conducted a follow-up study to better understand the effect of political and religious identity on vaccine acceptance (Bokemper et al., 2021a). They found that Republicans were less likely to be vaccinated, with white evangelicals demonstrating the most intractable attitudes.² The study examined determinants of vaccine acceptance within the white evangelical population, including through a series of experiments involving precision community-focused interventions. He noted that at the time of this research, uncertainty remained about whether any indirect effects of the vaccines were at play. The study indicated that by spring 2021, conventional messages lost all potency with this population. He attributed this outcome to the integration of vaccination status into political identity between fall 2020 and spring 2021, a dynamic he likened to the effect of party affiliation on perceptions of global climate change.

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² A majority of white evangelicals also identify as Republicans. See https://www.pewresearch.org/religion/religious-landscape-study/religious-tradition/evangelical-protestant/party-affiliation/ (accessed April 30, 2023).

Global Vaccine Acceptance

In an effort to understand vaccine acceptance at the global level, Omer’s group partnered with economists and scientists around the world to examine data from 12 countries, including the United States, Russia, and 10 low- to middle-income countries (LMICs). Although some variation emerged among the LMICs, the baseline vaccine acceptance rate in all 10 nations was higher than that of Russia or the United States (Solís Arce et al., 2021). Referring to his work with the United Nations Children’s Fund (UNICEF) and other partners, Omer recounted that many countries expressed ambivalence about aggressive promotion of vaccines because of the low supply levels available to LMICs. He added that such comments have been used to justify global vaccine distribution patterns through claims that the nations do not want the vaccines. However, the dynamics affecting vaccine promotion are nuanced, he added, and many LMICs aspired to the goal of vaccinating their populations.

Vaccine Acceptance Interventions

Shortly before the COVID-19 pandemic, the Bill and Melinda Gates Foundation approached YIGH about conducting a massive review and meta-analysis of interventions to increase vaccine acceptance, said Omer. The review identified several strategies that showed evidence of effectiveness, yet many of these strategies were absent in the national efforts deployed in the United States. Thus, Omer believed that the federal plan to promote vaccine acceptance was not entirely evidence-based. Omer explained that while U.S. health departments and public health officials have engaged in heroic efforts to increase vaccine uptake, not all available evidence-based interventions were used at the federal level.

Interventions found to increase vaccine coverage include education campaigns, on-site vaccination (e.g., in workplaces), incentive programs, free vaccination, recommendations from trusted institutions and providers, appointment reminders, message framing, vaccine champions in local communities, and others (see Figure 5-1) (Yale Institute for Global Health, 2022). Omer briefly discussed each intervention. He noted that free vaccination has been an important component of the U.S. vaccination coverage effort, and on-site vaccination has been deployed. Use of incentives has been nuanced, and institutional recommendations have a mixed record, he added. Provider recommendation demonstrated one of the strongest effect sizes in the review, yet this intervention has not been fully utilized in the United States. Although many U.S. health providers have recommended the COVID-19 vaccine, the country has not trained its health care professionals on effective communication of vaccine recommendations in the clinic. Vaccine champions

have also been underutilized in the U.S. vaccination effort. The review also identified interventions that demonstrated limited effect across multiple studies. Omer noted a minimal difference in the effect of positive and negative message framing on individual vaccine uptake. Although incentives for vaccine recipients are effective—provided the incentives are valued by the recipients—incentives for health care workers are less effective. Decision aids and self-assessments also have limited effect.

Data from multiple countries indicate that health care providers are consistently consider to be the most trustworthy source for vaccine information (Solís Arce et al., 2021). Omer advocated for training health care providers on effective vaccine acceptance communication strategies (Omer, 2021). He was involved in the creation of a continuing medical education (CME) module about evidence-based methods to communicate COVID-19 vaccine information in the clinic.³ These methods were originally evaluated through research on a novel maternal H1N1 immunization strategy funded by NIAID. Omer believes that a national CME program should be instated for health care provider vaccine communications in the clinic.

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³ More information about the “COVID-19 Vaccination: A Communication Guide for Providers” module from the Yale School of Medicine is available at https://yale.cloud-cme.com/course/courseoverview?P=3000&EID=24141 (accessed January 31, 2023).

Omer noted that YIGH collaborated with WHO, UNICEF, Meta (i.e., the conglomerate that owns Facebook, Instagram, and WhatsApp, among other products and services), and other partners to develop a series of tools that were deployed in multiple countries. For example, they developed the “Vaccine Misinformation Management Field Guide” that has been translated into five languages, a “Vaccine Messaging Guide” used by UNICEF country offices, and the whitepaper “Behavioural Considerations for Acceptance and Uptake of COVID-19 Vaccines” published by WHO (UNICEF, 2020; WHO, 2020a; Yale Institute for Global Health and UNICEF, 2020). Omer also co-chaired the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA, which addressed SARS-CoV-2 within a broader scope that included other pathogens (Omer et al., 2021).

In collaboration with The Public Good Projects, Meta, and UNICEF, YIGH conducted multiple randomized trials of social media messaging in five countries outside of the United States, Omer explained. Via the design and launch of 27 campaigns, they found social media to be an effective platform for deploying messaging that generated positive shifts in attitudes toward vaccines. Omer summarized that these test campaigns revealed that (1) partnership works, (2) use of local language(s) is needed, (3) communication should focus on values-based messaging, and (4) international and domestic context is helpful. YIGH, Meta, the Ad Council, UNICEF, and other partners are developing a course on digital media for health outcomes to train ministries of health on how to deploy these learnings.

Non-Pharmaceutical Interventions

Non-pharmaceutical interventions are essentially behavioral interventions, Omer explained. In spring 2020, he and his colleagues used anonymized cellphone data to track adherence to stay-at-home orders and found a substantial and consistent increase in at-home phone usage across counties, indicating adherence (Yan et al., 2021). Because not all counties issued stay-at-home orders, this finding led the researchers to further investigate whether people would have changed their behavior in the absence of imposed restrictions. They found that people changed their mobility habits in response to policy and information gleaned from local and national news sources. Regardless of whether stay-at-home orders were issued in their locality, people spent more time at home, although this behavior change happened earlier in counties that imposed restrictions. They calculated that the adherence to a stay-at-home order tends to occur when news of 20 or more COVID-19 deaths in a county is made public. That is, higher death counts within a county correlated with greater average behavioral effect. Omer added that people reduced their mobility (which had implications for economic activity) in the absence of shelter-in-place restrictions. He

specified that this finding applies to the early stage of the pandemic when much was unknown about the pathogen. In another study on “pandemic fatigue,” Omer and colleagues found that public adherence to various nonpharmaceutical interventions declined in July 2020 (Crane et al., 2021).

Vaccine Allocation and Distribution

National responses are inadequate for global pandemics, Omer maintained. The United States pulled out from the multilateral global health system in early 2020, resulting in decreased resources for the COVID-19 Vaccines Global Access (COVAX) Facility—an international initiative to establish equitable COVID-19 vaccine access. Lacking adequate resources, COVAX could not place orders in time to avoid supply shortages (COVAX, 2021). Research indicates that robust, worldwide vaccine access would benefit U.S. national interests (Rotesi et al., 2021). In September 2021, Omer proposed the establishment of a pandemic trust fund, which varied slightly from the pandemic fund the World Bank later established (Heinrich and Omer, 2021).

Ethics are relevant in determining pandemic response policy, said Omer. For example, scientific and ethical aspects were considered in prioritizing subpopulations for vaccination. He served on two committees tasked with designing a framework for equitable allocation of the COVID-19 vaccine in the context of limited supply: the National Academies of Sciences, Engineering, and Medicine Committee on Equitable Allocation of Vaccine for the Novel Coronavirus and the WHO Strategic Advisory Group of Experts on Immunization. Ethicists were included in the latter group, highlighting the emphasis placed on ethics in prioritizing groups for vaccination.⁴ Each committee developed a strategy that prioritized reducing mortality rates over interrupting transmission (NASEM, 2020b; WHO, 2020c). The strategy afforded health care providers top priority in vaccine distribution in order to maintain functioning health systems and offer lifesaving interventions. The general population was prioritized for vaccine distribution according to mortality risk factors such as older age and significant comorbid conditions. Omer noted an evaluation of the vaccine distribution plans found that states that enacted age-based prioritization for vaccination had fewer deaths due to COVID-19. This finding demonstrates the consequences of policy, Omer remarked, adding that policy decisions such as vaccine prioritization should be considered in advance of a crisis rather than during a pandemic.

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⁴ Omer co-authored an article describing the factors and processes utilized by the WHO Strategic Advisory Group of Experts on Immunization in determining a framework for vaccination prioritization (Faden et al., 2022).

Consequentialist Approach to Novel Surveillance and COVID-19 Research

A consequentialist approach to research leads to interdisciplinary efforts and is appropriate for outbreak science, said Omer.⁵ Deploying such an approach involves starting with the desired outcome and then working backward to determine which disciplines are needed to achieve the outcome. He has worked with cohorts spanning epidemiology, immunology, clinical science, and virology in order to address policy-relevant questions and design new testing methods. These interdisciplinary teams have researched the impact of variants on vaccine immunity, heterologous boosters with mRNA vaccine, a layered public health approach featuring booster vaccination, and detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via saliva or nasopharyngeal swab specimens (Lucas et al., 2021; Omer and Malani, 2022; Pérez-Then et al., 2022; Wyllie et al., 2020).

Omer collaborated with Jordan Peccia, professor of environmental engineering at the Yale School of Public Health, to develop novel surveillance methods. They demonstrated that wastewater surveillance not only can serve as a tool in identifying the presence of SARS-CoV-2 RNA, but also can be used to predict outbreaks with a lead time of 1–7 days (Peccia et al., 2020). Exploring the deployment of this method in locations where wastewater is untreated, Omer has shown that surveillance of untreated sewage in Karachi, Pakistan, is predictive of outbreaks. He has also surveilled graveyards, using remote sensing technology to detect freshly dug graves, to estimate excess mortality. Karachi, a major metropolitan area, has less documentation of COVID-19 data than some other populous cities, and graveyard surveillance indicates that only a fraction of the excess mortality in 2020 and 2021 was documented.⁶

Lessons Learned from the COVID-19 Response

Omer concluded by outlining lessons he has gleaned from his research during the COVID-19 pandemic, emphasizing that the list is selective and incomplete (see Box 5-1).

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⁵ Consequentialism is an ethical theory that can be used to judge whether actions are right or wrong by evaluating the resulting consequences. See https://plato.stanford.edu/entries/consequentialism/ (accessed June 12, 2023).

⁶ “COVID-19, Burial Site Surveillance to Measure Excess Mortality—Pakistan” is an ongoing research project. See https://medicine.yale.edu/yigh/ghes/research-training-sites/karachi-pakistan/ (accessed June 12, 2023).

DISCUSSION

Investing in Research to Promote Vaccine Acceptance

Noting an apparent hierarchy in pandemic response and science that prioritizes translational research above behavioral science, Tobias asked how future investments can address the need for behavioral science research. Funding is often awarded for the next incremental step of existing research, rather than for groundbreaking work—this tendency needs to shift, Omer remarked. He described that for many years, much of his work and funding were in vaccine trials, vaccine epidemiology, and other related areas, whereas his work on vaccine acceptance science was “a labor of love” that did not garner significant funding support. However, now that his research has demonstrated the effects of vaccine acceptance,

he was able to secure funding for additional research in this area. Omer added that despite evidence that public acceptance of the COVID-19 vaccine could not be assumed, many well-respected leaders were surprised by the level of vaccine hesitancy that emerged. Moving forward, Omer stressed that the field would benefit from recognizing the ramifications of vaccine acceptance. For example, he said, basic mechanics to encourage this type of science are not currently in place. He recalled that a reviewer objected to the first sentence of a proposal that he submitted to NIAID, wherein he stated that vaccines are one of the most effective public health interventions. This fundamental disagreement on the use of vaccines indicated that the application was directed to a study section without the appropriate expertise to understand and evaluate the proposal’s subject matter, said Omer. As the largest biomedical funding agency in the world, NIH has influence on what research is conducted. He noted that NIH does conduct and fund behavioral science for HIV and that the National Cancer Institute, which is part of NIH, funds some of the best behavioral science research being carried out. Omer believes that NIAID leaders reconsidered the role of social and behavioral sciences as they convened during the COVID-19 pandemic, but that it takes time for policy documents to be translated into action.

Vaccine Acceptance Training in Medical Schools

Because health care professionals are among the most trusted communicators on vaccines, Tobias asked whether medical and nursing students are educated about communicating about health issues with patients. She expressed support for a national education campaign on communication for health care practitioners. Omer referenced research from 2005 that indicated a cohort effect on health care providers’ views regarding vaccines: health care providers who graduated within the past 5 years were 15 percent less likely to believe vaccines are efficacious than those who graduated more than 5 years prior (Mergler et al., 2013). This study worked from the hypothesis that physicians who were in residency in the 1980s were more likely to have firsthand experience with serious cases of preventable diseases, such as Haemophilus influenzae type b infections, compared with those who completed medical school after the turn of the century. Physicians have a high rate of vaccine acceptance, both in terms of vaccinating their own children and of recommending vaccination to others, Omer said. However, vaccines have become “victims of their own success;” people who never witnessed the manifestation of now-preventable diseases may downplay the effects of vaccines, having no personal context for comparison. Acknowledging model curricula that have been developed over the past 10–12 years, Omer stated that increased efforts are needed to train physi-

cians to communicate with patients about vaccines. He said that teaching vaccine acceptance science should be approached with the same evidence-based rigor as that for pathology.

Shifts in Vaccine Acceptance and Expert Opinion

Barouch noted that Omer described a shift in vaccine acceptance attitudes from the beginning of the COVID-19 pandemic to the vaccine rollout 1 year later. He observed that expert opinion also seems to become less united as time passes. For instance, some pro-vaccine experts on prominent media outlets have objected to government policy, and messaging from the CDC, FDA, and NIH does not always align. He asked about the reasons for this shift in attitude among the general public and experts and about the effect of discord within the expert community on the vaccine debate. In terms of shifting public sentiments, Omer replied that more recent data have indicated continuing decrease in vaccine acceptance rates as this issue has become entrenched in political identity. Understanding of this dynamic should be applied to future vaccine rollouts to ensure their promotion as independent of political administration, he stated. Although political accountability and political credit are realities of living within a democratic society, Omer cautioned that a political party taking credit too early in a vaccination effort can alienate the opposing party’s members. He also observed that numerous social and behavioral interventions were being tested in randomized trials by spring 2021, but none had a significant effect on groups with the most entrenched views. The evidence base on vaccine acceptance can be leveraged before the next health crisis to address some of these issues, Omer said. For example, vaccination could be incorporated into a wider array of medical encounters; for example, a cardiologist visit could double as a vaccination visit. In addition, to avoid associations between vaccination and political identity, future efforts could center messaging directly from CDC personnel. Omer recalled that in the responses to outbreaks of anthrax, Zika, and Ebola, more information came from career public health personnel than from politicians, which decreased political partisanship in these efforts.

Regarding discord among experts, Omer stated that disagreement is part of healthy debate and that all scientists’ views evolve over time. He noted that during the COVID-19 pandemic, this disagreement was brought forth to public media forums more often than prior to the pandemic. Scientific debate in open conversation is part of the process and should not be eliminated, he maintained, adding that the open committee laws require this type of conversation in some settings. However, messaging around this discourse could improve by explicitly acknowledging scientific uncertainty. Humility can serve a role in public messaging, particularly during uncertain

times. Omer added that he participates in weekly calls held by the WHO COVID-19 Vaccine Working Group; each call involves back-and-forth discussion among participants that eventually results in consensus that is communicated through a public statement.

Tools for Effective Communication

Matthew Zahn, deputy health officer for the Orange County Health Care Agency, asked about resources available to guide public health in communicating with local communities, particularly in terms of addressing uncertainty, shortage of materials, and communication pitfalls. Omer replied that a set of documents is currently being developed for this purpose. Much of this work has been done in partnership with UNICEF because of its strong presence in many countries outside of the United States, including within the European Union. He wants these tools to be translatable to a variety of situations, and where there is insufficient evidence to speak with certainty, he hopes there will be humility, with admissions that the evidence is still developing. Omer also believes that public health and health care providers can play a role in helping people understand scientific research. He described results from recent research where people who claimed they researched information about vaccines independently were challenged with information that proved their research was wrong. People who were vaccine-hesitant shifted their views toward acceptance, and people who were already pro-public health further increased their trust in vaccines. Values-based messaging is another promising area, Omer stated. Although Omer does not believe that a health provider should try to change patients’ values, communication to encourage behavior change or understanding can be framed in the context of the individual’s values, such as liberty or purity.

Decreased Trust in Public Health

Omer highlighted factors that have contributed to an erosion of trust in U.S. health agencies during the COVID-19 pandemic. Whereas public health entities should be trustworthy and operate based on the best science, he contended, some guidance issued during the pandemic appeared to be at odds with scientific evidence. For example, the isolation guidelines for people who test positive for COVID-19 were shortened from 10 days to 5 days in December 2021, 3 weeks after the emergence of the Omicron variant. However, evidence from early 2022 did not support this shortened isolation period. In March, April, and May 2020, guidelines on masks and modes of transmission shifted as scientific understanding of the novel virus increased. Omer noted that these determinations were made in the absence of a mechanism for conducting adequately large trials of masking. Accord-

ing to his sample size calculations, such trials would require tens of thousands of people. Nonetheless, prior coronavirus and flu outbreaks offered opportunities to conduct large surgical mask trials. Failure to capitalize on these opportunities resulted in limited evidence on masking to inform the COVID-19 response.

In order to be trusted, the field must first be trustworthy, said Omer. Although his current research efforts are identifying promising tools, transparency and trusted messengers are in short supply. Research indicates that, irrespective of who they are, messengers lose trust when they perform certain actions. However, noting the emerging nature of this evidence, Omer did not specify those actions. He stated that he plans to focus his research efforts specifically on interventions to increase trust in public health.

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