Messages to Increase COVID-19 Knowledge in Communities of Color: What Matters Most?
Authors: Lisa A. Cooper, Catherine M. Stoney
Journal: Annals of Internal Medicine (2020)

Editorials21 December 2020Messages to Increase COVID-19 Knowledge in Communities of Color: What Matters Most?FREELisa A. Cooper, MD, MPH and Catherine M. Stoney, PhDLisa A. Cooper, MD, MPHJohns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, and Johns Hopkins University School of Nursing, Baltimore, Maryland and Catherine M. Stoney, PhDNational Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MarylandAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-8057 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Disparities in coronavirus disease 2019 (COVID-19) outcomes in the United States are irrefutable. Non-Hispanic Black people make up 12% of the U.S. population but account for 13.5% of cases and 26.4% of (age-adjusted) deaths. Hispanic/Latinx persons make up 18% of the U.S. population but account for 23.8% of cases and 38.8% of (age-adjusted) deaths (1). Addressing systemic racism, health care access, and inequalities in socioeconomic status is fundamentally important in eliminating health disparities. Understanding how best to communicate COVID-19 messages also may help narrow these gaps.In their recent study, Alsan and colleagues (2) explored the relationship between aspects of COVID-19 messaging and African American and Latinx participants' knowledge and information-seeking behavior (2). Video messages about COVID-19, delivered by physicians, were viewed by more than 14 000 African American and Latinx participants. Videos varied by the race/ethnicity of the messenger and acknowledgment of racial inequities and community perceptions about masks. In addition to determining whether message characteristics were related to viewers' subsequent knowledge, the authors investigated whether they had an effect on subsequent information seeking in this simulated environment.This study demonstrated a small but statistically significant increase in COVID-19 knowledge that did not differ by racial concordance between the physician messenger and the viewer. However, information seeking was higher among African American participants after they viewed messages from African American physicians. Previous research has documented the benefits of patient–physician racial concordance on communication and health outcomes (3, 4), underscoring the importance of a diverse workforce to care for a diverse population. However, in 2018 only 5% and 5.8% of U.S. physicians were African American and Hispanic, respectively (5). Finally, the study provides further support for the important role that health professionals and other leaders in communities of color play in enhancing the acceptance of COVID-19 vaccination and other interventions.The COVID-19 pandemic demands approaches that draw on evidence and resources from a range of academic disciplines and societal sectors. Racial concordance of messengers and receivers of information may be particularly important in communicating about emotionally charged, politicized issues, such as COVID-19. Yet, race is only one dimension of concordance. An array of other demographic characteristics, including age, sex, socioeconomic status, and language (6), also may be important. Because information seeking among Latinx participants did not increase after they viewed a message from a Latinx physician, concordance across dimensions other than ethnicity may be more important for Latinx patients. In addition, this study did not examine whether racial concordance matters as much when communicating about COVID-19 to White persons. Subgroups exist, defined by education, religion, or political views regardless of race or ethnicity, in which persons are skeptical of COVID-19 recommendations. Research should examine whether different types of messenger–recipient concordance influence the effectiveness of public health messages.The literature also documents the importance of trust when communicating health care information. Although Alsan and colleagues measured respondents' trust in health professionals, they did not report those findings. Studies document lower trust in health professionals and health care institutions among patients of color, which may influence receptivity to health care advice (7, 8). Ensuring that messages are accurate, available, and comprehensible is insufficient—recipients must also trust the messenger. Trust is most likely when information is delivered by a messenger who is known and has a positive relationship with the community. The National Institutes of Health Community Engagement Alliance (CEAL) Against COVID-19 Disparities (https://covid19community.nih.gov) has embraced this concept. One of CEAL's goals is active community engagement with, investment in, and outreach to underserved communities to build partnerships to improve diversity and inclusion in the scientific response to the COVID-19 pandemic. Trusted messengers often include health care professionals well known to patients and their families, faith or community leaders (9), and other influential persons.Alsan and colleagues used requests for information as the behavioral outcome of interest, leaving the potential effect of message characteristics on actual patient behaviors undetermined. Attitudes, as well as abilities and resources, may be more important to behavior change than to knowledge itself. Thus, querying research participants on actual or intended behaviors regarding COVID-19 on the basis of new knowledge obtained from the videos may have provided a richer picture of the impact of the interventions. In fact, querying about intended behaviors may have a small but positive effect on the uptake of those behaviors (10).Questions also remain about the information resources most likely to be used. What were the features of the webpages and videos that research participants requested most frequently? Did these requests differ by participant attributes? Also unknown is whether the public in general and persons in communities of color specifically desire information about topics not included in the 10 resources provided in this study. Communications research continues to grapple with questions about the effectiveness of messages targeted to demographic groups versus those tailored to the concerns of the public regardless of demographic characteristics.This innovative study provides insight and generates important questions during this critical time. As new vaccines against COVID-19 become available, and when so many lives are at stake, mistrust of institutions and science remains high. This mistrust is especially high in U.S. communities of color, which have borne the greatest burden during the pandemic. The study by Alsan and colleagues validates previous research documenting the importance of racial concordance between patients and their physicians. However, the small differences observed suggest that trust and concordance of factors other than race/ethnicity also may need to be considered in developing effective communication strategies for COVID-19 prevention and treatment. Further study should examine whether COVID-19 information seeking is a predictor of actual behavior change. Messages that promote behavior change in diverse groups are essential to save lives and facilitate economic and psychological recovery from the devastation of the COVID-19 pandemic.References1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. COVID-19 Racial and Ethnic Health Disparities. Accessed at www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-deaths.html on 15 December 2020. Google Scholar2. Alsan M, Stanford FC, Banerjee A, et al. Comparison of knowledge and information-seeking behavior after general COVID-19 public health messages and messages tailored for Black and Latinx communities. A randomized controlled trial. Ann Intern Med. 2021;174:484-92. doi:10.7326/M20-6141 Google Scholar3. Shen MJ, Peterson EB, Costas-Muñiz R, et al. The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. J Racial Ethn Health Disparities. 2018;5:117-40. [PMID: 28275996] doi:10.1007/s40615-017-0350-4 CrossrefMedlineGoogle Scholar4. Greenwood BN, Hardeman RR, Huang L, et al. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020;117:21194-200. [PMID: 32817561] doi:10.1073/pnas.1913405117 CrossrefMedlineGoogle Scholar5. Association of American Medical Colleges. Diversity in Medicine: Facts and Figures 2019. Accessed at www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 on 15 December 2020. Google Scholar6. Cooper LA, Beach MC, Johnson RL, et al. Delving below the surface. Understanding how race and ethnicity influence relationships in health care. J Gen Intern Med. 2006;21 Suppl 1:S21-7. [PMID: 16405705] CrossrefMedlineGoogle Scholar7. Boulware LE, Cooper LA, Ratner LE, et al. Race and trust in the health care system. Public Health Rep. 2003;118:358-65. [PMID: 12815085] CrossrefMedlineGoogle Scholar8. Birkhäuer J, Gaab J, Kossowsky J, et al. Trust in the health care professional and health outcome: a meta-analysis. PLoS One. 2017;12:e0170988. [PMID: 28170443] doi:10.1371/journal.pone.0170988 CrossrefMedlineGoogle Scholar9. Schoch-Spana M, Brunson EK, Long R, et al. The public's role in COVID-19 vaccination: human-centered recommendations to enhance pandemic vaccine awareness, access, and acceptance in the United States. Vaccine. 2020. [PMID: 33160755] doi:10.1016/j.vaccine.2020.10.059 CrossrefMedlineGoogle Scholar10. Wood C, Conner M, Miles E, et al. The impact of asking intention or self-prediction questions on subsequent behavior: a meta-analysis. Pers Soc Psychol Rev. 2016;20:245-68. [PMID: 26162771] doi:10.1177/1088868315592334 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Lisa A. Cooper, MD, MPH; Catherine M. Stoney, PhDAffiliations: Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, and Johns Hopkins University School of Nursing, Baltimore, MarylandNational Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MarylandDisclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-8057.Corresponding Author: Lisa A. Cooper, MD, MPH, Johns Hopkins Center for Health Equity, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21287; e-mail, lisa.cooper@jhmi.edu.Current Author Addresses: Dr. Cooper: Johns Hopkins Center for Health Equity, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21287.Dr. Stoney: National Institutes of Health, 6701 Rockledge Drive, Bethesda, MD 20892.This article was published at Annals.org on 21 December 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoComparison of Knowledge and Information-Seeking Behavior After General COVID-19 Public Health Messages and Messages Tailored for Black and Latinx Communities Marcella Alsan , Fatima Cody Stanford , Abhijit Banerjee , Emily Breza , Arun G. Chandrasekhar , Sarah Eichmeyer , Paul Goldsmith-Pinkham , Lucy Ogbu-Nwobodo , Benjamin A. Olken , Carlos Torres , Anirudh Sankar , Pierre-Luc Vautrey , and Esther Duflo Metrics Cited byHealth Messaging and the Black Community: Analysis of Rhetoric in Michelle Obama’s Social Media’s Posts Announcing Her COVID-19 Vaccination StatusPaying Attention to the Pandemic: Knowledge of COVID-19 Facts by News Source and DemographicsImplementation of the Texas Community-Engaged Statewide Consortium for the Prevention of COVID-19What message appeal and messenger are most persuasive for COVID-19 vaccine uptake: Results from a 5-country survey in India, Indonesia, Kenya, Nigeria, and UkraineThe Frank Michota Memorial Lecture 2022: “Health Disparities in PeriOperative Medicine: The Urgent Need for Diversity in Healthcare” By William McDade MD, PhDRacial/Ethnic Variances in COVID-19 Inoculation among Southern California Healthcare WorkersRapid Implementation of a Community–Academic Partnership Model to Promote COVID-19 Vaccine Equity within Racially and Ethnically Minoritized CommunitiesListening to Voices from African American Communities in the Southern States about COVID-19 Vaccine Information and Communication: A Qualitative StudyDevelopment of a Theory-Based, Culturally Appropriate Message Library for Use in Interventions to Promote COVID-19 Vaccination Among African Americans: Formative Research April 2021Volume 174, Issue 4 Page: 554-555 Keywords African American people Behavior Communication in health care COVID-19 Health care Health equity Prevention, policy, and public health Racial and ethnic issues Socioeconomic status Vaccines ePublished: 21 December 2020 Issue Published: April 2021 Copyright & PermissionsCopyright © 2020 by American College of Physicians. 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