The current analysis is informed by the literature on effective communication, summarized above and corroborated by interview participants. Having regard to the qualities of effective communication, we identified three characteristics in the communications examined: (1) inconsistency across jurisdictions; (2) insufficient clarity, particularly in relation to nuanced matters; and (3) insufficient community engagement to inform communication.
If people are to have confidence in the information they are receiving, it needs to be consistent across common conditions. Confronted with inconsistencies, people are likely to question the message. Participants from all four interview cohorts emphasized the importance of consistency in public health communication, and the need for commonality of core ideas. S4, a public policy scholar from Ontario, emphasized the critical relationship between consistent messaging, public confusion, and trust, highlighting the importance of justifications for interventions, particularly those that limit freedoms:
[I]f we’re doing this again, we have to put way more responsibility on the politicians to articulate why they’re allowing things to happen and how that thing contributes or doesn’t contribute to the end goal. And they’ve got to define what that end goal is. It can’t simply be […] to maintain or to control the virus. [T]hat’s not the reason why a society exists, right? Or the reason why a government is there. The government is there to […] help produce other big goods that we can all benefit from.
The communications examined were strikingly inconsistent and incoherent. While many examples could be cited, an obvious—and surprising—example is the description of public health measures meant to interrupt virus transmission. The terms ‘shutdown’, ‘lockdown’, ‘circuit-breaker’, and ‘stay-at-home order’ were used inconsistently, resulting in ambiguity around meaning and significance. Bol et al. (2020) define a lockdown as a form of nationwide social confinement in which citizens are forced, rather than simply encouraged, to stay at home unless leaving for a ‘valid’ reason. A shutdown refers to a more drastic form of lockdown (Cuoto Zuber, 2021). A circuit breaker is a type of lockdown that has a set end-date rather than one determined by target case counts (Mohan, 2021). Inconsistency in Canadian public health communication—and absence of clarity around inconsistencies—generated feelings of frustration, defeat, and exhaustion, which undermined trust in officials and induced some to create their own rules (Cuoto Zuber, 2021).
Nova Scotia implemented two circuit-breakers and one shutdown in early 2021. On 23 February 2021, a one-month circuit-breaker was announced for Halifax. It was rescinded one week later, with CMOH Strang offering the justification that he would rather “under-promise and over-deliver”. While Premier Rankin contended that safety is a priority, he acknowledged the negative impact of restrictions on businesses (Walton, 2021). After the circuit-breaker was rescinded, active cases spiked. Curiously, the next circuit-breaker was not implemented until after cases declined. That circuit-breaker transitioned to a province-wide shutdown in April 2021. The delay—and discordance between case numbers and implementation of further restrictions—were likely not confidence-inducing for Nova Scotians.
Ontario enacted one province-wide shutdown and two stay-at-home orders from December 2020 to April 2021, without articulating their differences. Public confusion around behavioural guidelines was an ongoing issue, with uncertainty compounded by public officials failing to comply with their own guidelines (Brown, 2021). When informed about public confusion and frustration, Premier Ford insisted that the guidelines “could not be clearer”. After the second stay-at-home order, Premier Ford’s competence was questioned; at one press briefing, he was told he had “blood on his hands”, and that there were “concerns for his moral authority to lead the province,” (CPAC, 2021c) prompting his absence at subsequent COVID-19 briefings.
There were no declared shutdowns or lockdowns in Alberta, although the province employed restrictions similar to those in other jurisdictions. In May 2021, Premier Kenney explained that Alberta “resisted pressure” to implement lockdowns, taking a “balanced approach, following the evidence” because “governments must not impair peoples’ rights, or their livelihoods, unless it is absolutely necessary to save lives” (Government of Alberta, 2021). This reticence to name restrictions as lockdowns or shutdowns contributed to inconsistencies and ambiguity between provinces, and a sense that provinces were doing very different things.
2. Lack of Clarity
Complacency, convenience, and confidence influence vaccine acceptance (MacDonald et al., 2021). Confidence is influenced by information and communication. Though misinformation and disinformation are known to encourage vaccine hesitancy (MacDonald et al., 2021), it is generally accepted that communication is most persuasive when it is accurate, evidence-based, clear about risk, and avoids blame and stigma-generation (Bardosh et al., 2022). Unfortunately, it was not uncommon for official communicators across Canada to shame those who were not vaccinated, a common refrain being that “this is a pandemic of the unvaccinated.” S4 identified the potential harm of such shaming:
We’re really not giving people who have not been vaccinated a chance to feel good about getting vaccinated. We’ve already moved, like, fully into the shame mode, right? And that’s going to be hard for some people to walk back if they’ve got any kind of pride, right? So, you can try to force them with vaccine passports. But you know, they’re going to be resistant, right? So, we haven’t gotten that piece right.
Shaming aside, accurate information must be conveyed clearly, and in ways that are understood. FL8, a healthcare worker in Alberta, warned that focusing on purely scientific data without considering factors such as health literacy can harm public understanding:
[D]octors and public health professionals are up here all the time, talking about efficacy. I had a client talk to me at one of the vaccine clinics, and she said, “I’m so glad to hear the vaccine has an 80% efficacy rate. It’s just such a shame that 20% of the people will die.” Like, that was the way that the information was being read and received […]. Efficacy [is] a tough mathematical idea to understand.
Clarity around what we expect from vaccines is also critical, and was not often achieved, a point made by FL3, a physician from Ontario, who noted the disconnect between common beliefs about what vaccines are meant to protect against, and what they actually can do. Neither flu nor COVID-19 vaccines, FL3 observed, are meant to protect one from getting infected, but rather from dying from the infection, and governments have long failed to convey this reality. A further example of unclear communication contributing to confusion and hesitancy is related to the viral vector vaccines. The government recommended different vaccines with different efficacy and safety profiles that were dependent on recipient health conditions, but government communicators spoke of vaccine adverse events without articulating this or identifying specific at-risk groups, which negatively influenced public perceptions. FL5, an infectious disease physician in Ontario, acknowledged the challenges posed by this situation, and the utility of federal guidance in conveying difficult messages:
You need to control the release of information. You need a structured pathway through which information flows. The provinces should buy into that. It avoids mixed messages [and] confusion when decisions are made. For example, I think the communication relating to the AstraZeneca vaccine and clots associated with that could have been handled differently. And that’s one example of decisions that are made regarding communication at a federal level versus at provincial levels.
FL6, a primary care physician in Alberta, stated:
[T]hey were like, “You should take it!” And then they were like, “No, you shouldn’t!” And they were like, “Well, if there’s enough COVID in your area, you should. And if you’re under this age, you should.” […] They were saying, “Yeah, there’s a risk of this happening with AstraZeneca. But for those of you—in Calgary at that point it was a total disaster—yeah, get AstraZeneca because your risks if you get COVID are far higher.” But that’s a confusing concept, I think, for a lot of people. And it felt very tied to emotions and […] so maybe a little bit less flip-flopping would have been helpful.
Ultimately, the handling of specific vaccine-related concerns lacked accuracy and clarity, causing confusion. R4 suggested that a better approach would have been to underline the impact of vaccines on death rates, to be much clearer about the need for future boosters, and to emphasize that getting vaccinated is one step people can take for individual and collective protection.
CMOH Strang (NS) announced that the benefits of COVID-19 vaccines “far outweigh” the potential risk of myocarditis or pericarditis. He emphasized that Nova Scotians need to make informed decisions, although he did not identify where trustworthy information could be found. CMOH Williams (ON) urged those who were hesitant to speak to trusted healthcare providers, a point emphasized by S4:
[O]ur Chief Medical Officers of Health, God bless them, they’ve been doing a really hard job, [but] people would rather talk to their doctor. They’d rather talk to the pharmacist about a vaccine to understand it. So, it really doesn’t help for someone on the TV to say, “AstraZeneca has side effects, but only for this narrow slice of the population.” Right? It helps ... to say, “This is a very good vaccine. It might not be the best vaccine for you. But talk to your doctor, and they’ll tell you which vaccine is the best one for you. One of the three or four—is going to be the best one for you.” I think that’s a much better way of communicating it. […] [L]eave the conversation on particulars of the particular vaccines […] to people who are trusted.
As noted, officials occupy a competitive informational space. This demands acknowledging and (carefully) countering the informational quagmire. On the misinformation/disinformation issue, CMOH Strang (NS) remarked, “No matter how many YouTube videos or conspiracy theories from so-called experts that you send to me, we will not agree ... Please, please, get vaccinated” (CPAC, 2021b). CMOH Williams (ON), responding to concerns about vaccines on fertility, drew on evidence from consultations with the Society of Obstetricians & Gynecologists of Canada. FL8 suggested that knowing the audience and tending to emotional aspects can be effective:
[…] [T]hey need to have a better understanding of where misinformation comes from and why people believe it. I think that’s been a really specific and really unique challenge to this vaccination campaign […] To use a pre-COVID example, if you say to a family, “Vaccines don’t cause autism. We have studies.” That’s true. But why do they think that? And what other beliefs have led them to this place? You can’t just say, “That’s not true.” Because that’s not emotionally compelling. It’s not persuasive. […] [I]n terms of public health messaging, I think there have been some emotionally compelling things about “We’re all going to get back to doing things we love.” […] And I think in some cases, that’s been effective. […]
Ultimately, to achieve clarity, communication should be accurate, evidence-based, but also tailored to the audience and sensitive to emotional drivers. Public health communicators, FL8 suggested, have operated too much from their own perspective, without meaningfully empathizing with communicatees.
3. Engaged Communication Practice
Complex, multicultural liberal democracies like Canada are shaped by many and often competing values, some of which may even be pitted against each other in specific contexts or discourses (Wu et al., 2021). For example, individualism—emphasizing autonomy, rights, and perceived risks/benefits to individuals—and communitarianism—emphasizing solidarity, responsibilities, and risks/benefits to the community—may both be important, but they are often unequally expressed. Though specific values were rarely identified in the communication examined, and almost never reconciled where values were in competition, value-preferencing and expression can be seen. CMOH Strang (NS) did this overtly throughout September 2021, calling upon individuals to be kind, and to think about the community:
Only you can prevent [spiking cases] from happening here. Please continue to be vigilant and follow public health measures to protect yourself, your loved ones, and your community (Government of Nova Scotia, 2021).
At another briefing, emphasizing individual responsibility instead of individual entitlements, he added:
Personal choice cannot be all you think about when it comes to COVID vaccines. I would ask you to focus on others and that you focus on the ‘we’ and not the ‘me.’ The choice to be vaccinated or not has implications for everyone around you (CPAC, 2021a).
In Ontario in April 2020, CMOH Williams highlighted the importance of wearing masks, not in fear of others but to protect them. CMOH Hinshaw took a slightly different angle in Alberta. In an effort to encourage Albertans to follow government recommendations, she emphasized individual agency and personal empowerment. In March 2020, she said, “We are all responsible for each other’s health at this time,” and “We all have a responsibility to prevent the spread of this virus” (Government of Alberta, 2020a). In April 2020, she reiterated, “I want to stress overall that the future of this pandemic is in all of our hands. We have a say in how COVID-19 will impact our province” (Government of Alberta, 2020b). Premier Kenny further underlined this notion by stating that the course of the pandemic will be decided by the choices individuals make.
S2, an immunization expert from Quebec, highlighted the utility of emphasizing responsibility within the context of infectious disease, saying that the consequences to family and others of not being immunized needs to be explained, but that it wasn’t explained consistently or well. If one is being offered a vaccine for which they don’t have any medical contraindication, the right to refuse is properly circumscribed by the right of others not to be infected as a result of this.
In any event, these justificatory nuances speak to a value variance across different communities, and to the concomitant need for much more robust and refined ways to enhance communication through processes that involve and mobilize communities, and in the end speak more powerfully to communities. Ultimately, public health interventions must find support in communities with different experiences, practices, and aspirations, and so potentially different values and worldviews. If interventions are to be widely understood and taken up, communication must be informed by and reflect those communities. Indeed, communication must be approached as a collaborative practice that is grounded in communities, and that permits the local (i.e., community values, knowledge, experience, and needs) to inform not only the nature of messaging, but also the interventions expressed.
Again, such local-to-central communicative engagements must lead to practices and interventions that reflect, or do not profoundly undermine, values held within communities. This is a particularly pressing and demanding requirement in Canada, which is so diverse in populations and their experience of government. Note should be taken of the legacy of dispossession, marginalization, and genocide experienced by Indigenous Peoples in Canada, their troubled history with Canadian institutions, and the Indigenous-specific racism that persists in healthcare, all of which have left many Indigenous Canadians suspicious of healthcare workers and hesitant to accept vaccines (Mosby & Swidrovich, 2021). In addition to deliberative engagements to craft messages (and interventions) that resonate, attention must be paid to the messenger. PH11, a federal public health official, commented on the importance of the communicator and their ability to effectively speak to equity-seeking groups:
[T]here’s been colonization for Indigenous people. And there’s been experimentation […] without consent. So, there’s a lot of skepticism and distrust. [They wonder], “Hmm, is this another experimentation?” Only, you know, when […] one involves the leaders of the community—the Elders in the Indigenous community context, or Indigenous doctors, nurses and other champions—they explain, “No, this is not that. COVID is a real danger. This is, you know, not—not someone trying to put microchips into our arms.” […] But that […] message would be much better received, if it’s coming [...] from the same community, leaders in the community. And that goes for other racialized marginalized groups as well.
FL5 confirmed the importance of the communicator:
I think it’s important to have individual people who are making decisions with respect to the vaccine rolling out, and making decisions with respect to communication, really look like the Canadian population. It speaks to diversity. And that includes ensuring that there’s adequate representation of certain groups like the Indigenous population, Black communities, other communities. It requires ensuring that there’s diversity in the people making decisions and in people who are doing the communication.
These quotes highlight the importance of engagement and deliberation with people with diverse perspectives, and of facilitating solutions and communicators from those communities.
Government communicators during the pandemic were often less than exemplary at achieving compassionate communication that avoided stigma. For example, some communicators location-named the virus, which was both inaccurate and harmful, generating region- or culture-specific blame, which in turn encourages individual and community discrimination (Lou et al., 2022). In Ontario, Premier Ford referred to the “UK variant” of the virus (CPAC, 2021d), and when COVID-19 cases were rising in a predominantly racialized region of Ontario, he stated, “I understand that a lot of cultures have massive weddings, bringing people from all over the world. You just can’t do it.” In fact, many of these citizens were essential workers living in multigenerational homes, reliant on public transit, and without the luxury of working safely from home; indeed income, occupation, education, housing, and ethnicity contributed to higher infection rates in racialized or lower-income areas across Canada (Nasser, 2020). By contrast, in Alberta, CMOH Hinshaw stated that communities experiencing rising case numbers were not to blame, and that additional actions were warranted to control the spread of COVID in those areas. Such statements place responsibility on governing bodies to assist and increase resources and help dispel the notion that vulnerable communities are responsible for insecure conditions.
Ultimately, politicians and public health officials took insufficient notice of the diverse communities and lives that shaped experiences of (and risks from) the pandemic, and failed to appreciate that a one-size communication approach does a disservice to communities and the interventions that are meant to protect them. Values, knowledge, perspectives, and experiences must inform solutions and communication strategies, or they risk being perceived as harsh, ill-conceived, and misunderstood. Of course, as noted above, that communication must still be informed by good science; communication needs to be science-driven, but messaging has to resonate with our communities. This is not an easy balance, and, as should be clear from the above, it demands ongoing, authentic community engagement and infrastructure.