Blog Blog Post by Topic COVID-19

Messaging matters: Developing quality COVID-19 health messaging to reach across the rural-urban divide

Written by Sienna Ruiz, public health research coordinator at the Washington University School of Medicine & Ashley Housten OTD, MSCI, assistant professor in the Division of Public Health Sciences & faculty scholar at the Institute for Public Health

Photo: Nathan Dumlao, Unsplash

“Mike”* is a white man in his 20’s who participated in our study on the public’s opinion of COVID-19 messaging, and he lives in the largely rural region of Southeast Missouri known as the “Bootheel.” He told us that he believes that politics, the U.S./China trade war, and the 2020 U.S. presidential election were the three most important factors that led to COVID-19’s appearance in the world. In contrast, “Tania”, an African American woman in her 60’s who lives in the urban city of St. Louis, believes the spread of COVID-19 to be a result of overseas travel, misinformation, and lack of compliance with protocol such as hand-washing and mask-wearing. Despite these differences, both participants want COVID-19 messages to include understandable language, eye-catching colors, emotional appeals, and clear depiction of the source of the message.

The common desires of these participants paralleled the similar suggestions given by both groups of participants in the Bootheel and St. Louis. We expected to find different recommendations for messaging from each group, but while participants in the Bootheel were more likely to give politically-motivated responses to the causes of the pandemic than the sample in St. Louis, their feedback on COVID-19 messages was largely the same as the St. Louisans’. This begs the question: are we overly focused on creating messages based on regional differences, when what we really need is higher quality, broadly applicable health messaging?          

Ever since COVID-19 cases shifted from urban regions to more rural areas in late spring 2020, journalists, public health officials, and politicians have worked to identify the unique beliefs and cultural practices of rural residents that could direct their approach. Articles have reported differences in mask-wearing, social distancing, and vaccine hesitance between rural and urban areas, with rural populations less likely to adhere to COVID-19 prevention behaviors and more likely to refuse vaccines than their urban counterparts. Furthermore, politicians who made the pandemic a partisan issue, exacerbated political polarization between liberal urban areas and more conservative rural areas; meaning that individuals’ political beliefs influenced their actions related to the pandemic. Such differences have left public health messaging fragmented across different regions and have led scholars to advise specific methods of communication with rural residents about behaviors to prevent COVID-19 and vaccines.

However, in our joint research project by Washington University in St. Louis and the nonprofit Health Literacy Media, we found that creating region-specific health messages may be less important than previously thought. The research team interviewed residents of the Bootheel and St. Louis. The team asked about their beliefs on COVID-19 and their thoughts on the language and design of four COVID-19- public health messages. While samples differed in beliefs surrounding COVID-19, both groups suggested adjustments to messages including: using large logos from well-known organizations like the World Health Organization (WHO); re-affirming the importance of basic COVID-19 protocols; cutting out unnecessary information; and, depicting realistic images of people. Such changes have been missing from many COVID-19 campaigns, which have struggled to successfully emphasize consistent preventive practices during a crisis in which protocols seem to constantly shift. An example of this shift is the CDC’s July 27 reversal of mask guidelines, which advised masks for vaccinated and unvaccinated residents only “in areas of high numbers of COVID-19 cases”. They released a map showcasing such areas, a message that has again, geographically divided Americans and has left many uncertain about how to keep themselves safe.

Rather than reinventing the wheel to create COVID-19 public health messages for different regions, we must use approaches to health messaging that apply to everyone. These approaches include using plain language to be concise and conversational; visually highlighting a well-known source so those seeking additional information can learn more; consistently endorsing evidence-based health practices; and, simply communicating why evidence may compel changes to these practices. This does not mean that differences between urban and rural populations should be ignored-there are real socioeconomic, cultural, and health differences between rural and urban communities-health officials should consider using unique channels of communication to reach rural residents.

We also collected data before the widespread vaccine rollout, and found that segmented approaches to messaging specifically targeted to people who are unvaccinated may prove critical to mitigating disease spread. However, these considerations do not preclude ensuring that health messaging is consistent, attractive, reliable and accessible. When developing public health messaging, it is imperative that we do not lose sight of what works for all of us: well-designed, comprehensible messages.

*All names are pseudonyms for study participants

This op-ed was written with the support of Uzoma C. Okere, MD, MPH; Michelle Eggers, MA; Melanie Schwartz, MA; and Catina O’Leary, PhD.