Effective communication management in a public health crisis: lessons learned about COVID-19 pandemic through the lens of health communication executives

Abstract

Purpose

The purpose of the study is to provide insights on the COVID-19 pandemic communication from the lessons learned by health communication executives—how they perceived the COVID-19 pandemic and recommend preparing for communication management of future public health crises.

Design/methodology/approach

A number of top health communication executives in the United States, who worked in the healthcare industry for at least 25 years and held titles like director, president and chief strategist, were interviewed for their unique perspectives on the COVID-19 pandemic. This study used the contingency theory of strategic conflict management for qualitative deductive analysis of the following segmentations of key factors that drove organizational communication management decision making during the pandemic: organization characteristics, relationship characteristics, general external climate, external publics and the issue under question.

Findings

Health communication executives heavily relied on their past health communication experiences, which led to nuanced understandings of the COVID-19 pandemic. Practically, the health communication executives urged future practitioners to constantly assess risks, hire and use diverse and representative decision-makers; set a communication protocol; and keep the communication in perspective. Theoretically, the contingency theory is furthered—there appears to be a theoretical linkage between the construct of general external climate and the construct of the external public.

Originality/value

The unique perspectives of top health communication executives, based in the United States, provided in-depth insights on the COVID-19 pandemic—its nuances, challenges and main influences (e.g. political, racial, etc.). These takeaways and recommendations can be adapted by other organizations and future health communicators in other parts of the world.

Citation

Voges, T.S., Jin, Y., Eaddy, L.L. and Spector, S. (2023), "Effective communication management in a public health crisis: lessons learned about COVID-19 pandemic through the lens of health communication executives", Journal of Communication Management, Vol. 27 No. 1, pp. 64-83. https://doi.org/10.1108/JCOM-12-2021-0137

The COVID-19 pandemic has confronted the healthcare industry and health communication management with a plethora of unprecedented questions (Voges et al., 2021): What exactly is humanity dealing with? How similar is COVID-19 to what has been dealt with before? Are we starting “from scratch” or can we rely on past knowledge to get us through the pandemic? If we can, then by how much? Answers to these challenging questions might be garnered through insights from public health institutions (e.g. Centers for Disease Control and Prevention [CDC], World Health Organization [WHO]) (Nowak and Greenwell, 2021; Offerdal et al., 2021) and healthcare industry in the private sector (e.g. pharmaceutical companies and hospitals) (Hayes et al., 2021; Mazzei et al., 2021), as well as from organizations outside the healthcare arena (Stranzl et al., 2021). In the domain of communication management, scholars have analyzed COVID-19 crisis communication by looking at internal organization emails (Heide and Simonsson, 2021; Yeomans and Bowman, 2021), employee perceptions of COVID-19 internal communication (Ecklebe and Löffler, 2021; Einwiller et al., 2021) and the lived experience of the COVID-19 pandemic on health communication executives' own experiences during the COVID-19 pandemic (Gregory et al., 2021). These instances demonstrate how important it is to understand the effects COVID-19 had on employees, businesses and their internal communication. However, little is known in terms of what and how health communication practitioners, as expert sources (either in-house or outsourced) providing counsel on organizational COVID-19 responses, have learned about the pandemic and what industry-wide insights and lessons they might share with communication management professionals across sectors.

Health communication practitioners are responsible for most of the COVID-19 information management (e.g. Gregory et al., 2021). These individuals specialize in health communication; they use their communication channels to inform clients and stakeholders on how to disseminate information and engage in conversations with stakeholders regarding health issues (Jin et al., 2019). Jin et al. (2019) suggested that health communication practitioners, especially those managing public information on infectious disease threats, face many challenges given that they have to engage in professional public relations activities, like identifying appropriate information sources, spokespeople and media channels.

With regard to managing the communication of COVID-19, one of the most severe infectious disease threats in recent world history, scholars recently researched the impact of COVID-19 on health communication practitioners (Gregory et al., 2021), though studies have mainly used self-reporting and surveys (e.g. Chon et al., 2021; Ecklebe and Löffler, 2021; Einwiller et al., 2021). As a previous study indicated, health organizations and their public health information management decisions are influenced by different external factors (e.g. political pressures, various publics) and compared to past viral outbreaks (Jin et al., 2019), the implications of various factors need to be further investigated. With this in mind and building upon the path of inquiry consistent with Cho and Nowak's (2007) research into the health practitioners' perceived knowledge and power, we conducted the current qualitative study to gain more knowledge through the shared experiences and insights among health communication executives, who have led and heavily engaged in COVID-19 communication decision-making as leaders and area experts and whose organizations are regarded as expert institutions that provide public health information and healthcare communication services.

For this study, given the complexity of COVID-19 as a public crisis and the dynamics in the process of managing communication about COVID-19 (Nowak and Greenwell, 2021), the contingency theory of strategic conflict management, a theory specialized in untangling the complexity in organizational communication management decision making (e.g. Jin et al., 2021a, b) driven by internal and external factors (Cancel et al., 1997), is applied as the primary framework to guide the questions and deductive analysis. In the health context, the contingency theory has been used to examine health communication coverage (Lumpkins et al., 2010) and how stakeholders expected and evaluated how organizations responded to a public health crisis (Kim and Jin, 2020). Most recently, Voges and Binford (2021) applied the contingency theory to examine how US state governments communicated the COVID-19 threat to their constituents.

Based on this line of health communication research grounded in contingency theory, the current study explored how health communication executives perceived the pandemic communication challenges, how organizations have been communicating about it and what lessons health communications can learn from their experiences and observations. Furthermore, a set of internal factors (i.e. organization characteristics and relationship characteristics) and external factors (i.e. general external climate, external public and issue under question) are identified and adapted based on previous studies using the contingency theory in understanding communication leaders' decision making in crisis and conflict situations (e.g. Voges et al., 2022) and in public communication during the COVID-19 pandemic (e.g. Voges and Binford, 2021) due to their relevance to public health crisis contexts.

In this study, we interviewed health communication executives, who have worked in the healthcare industry for at least 25 years and held titles like director, president and chief strategist. Our study provides insights and recommendations on the COVID-19 pandemic communication and lessons in preparing for communication management of future public health crises.

Literature review

Public health crisis: an emerging field in communication management

Jin and Vijaykumar (2022) highlighted the role of crisis communication in managing public health emergencies. Scholars advocate the dire need for enhancing the effectiveness of public health crisis communication, as infectious disease outbreak (IDO) triggered health crises at all levels (regional outbreak, epidemic, or pandemic) demand emergency responses due to “their rapidly evolving nature that fuels public anxiety in an environment where multiple crisis narratives compete for media and public attention, disrupting business operations and social functions” (Jin and Vijaykumar, 2022).

According to Jin and Vijaykumar (2022), public health crisis communication represents “communications created, conducted and exchanged in response to a severe and emerging health threat with the goals of informing and protecting affected and at-risk populations from further harm” and “[un]like organizational crisis communication, public health crisis communication, especially during IDOs, often takes place amidst volatile media climate and intense public debates on crisis responsibilities and solutions.” Joining efforts to tackle this challenge, scholars have adapted organizational crisis communication theories (e.g. the situational crisis communication theory [SCCT] to public health contexts), as well as developed new frameworks specifically for understanding public health crisis communication.

Leading crisis communication theories, such as Coombs' SCCT theory (one of the most widely applied crisis theories, see Macnamara, 2021), have been applied by scholars in examining COVID-19 pandemic crisis management. Guided by the SCCT and in the context of Greece, Aspriadis (2021) analyzed the Greek government and public health authorities' crisis management practice (e.g. crisis response strategies) during two waves of the COVID-19 pandemic in 2020 as evidenced in public briefings and public speeches. With a focus on organizational communication, Macnamara (2021) used the SCCT as an analytical framework to examine how an organization, when “faced with major financial losses, staff redundancies and disruption” in COVID-19, responded to stakeholders via communication. Most recently, in the sixth edition of Ongoing crisis communication: Planning, managing and responding (2022), Coombs advanced the discussion on public health crisis and the extension of the SCCT to the public health crisis arena.

Meanwhile, public relations scholars have developed new theoretical frameworks to tackle public health communication challenges. As Liu et al. (2020) argued, it is essential for health organizations and health crisis communication managers to identify and examine unique communicative opportunities to facilitate and enhance public health crisis management, ultimately motivating the public to take preventive actions. Jin and Vijaykumar (2022) also emphasized the need for health organizations and the healthcare industry to “(1) focus on providing information about protective actions individuals can take to keep themselves safe, especially through outlets enabling proactive information seeking; and (2) consider disseminating information to news media and directly to the public, using renewal narratives, focusing on growth, learning, restoration and healing if their credibility is called into question.” The infectious disease threat (IDT) appraisal model (Austin et al., 2021; Jin et al., 2020) represents such a new scholarly effort by mapping out individuals' coping strategy preferences, which can be predicted by their perceived predictability and controllability of different infectious diseases (see Austin et al., 2021). Jin et al. (2020) argued that how individuals appraise an IDT drives their cognitive, affective and conative reactions to a public health crisis caused by the IDT. They further advocated that health organizations and the healthcare industry need to play a more effective crisis leadership role in optimally communicating about IDTs so as to better help the public understand the complexity and uncertainty, often conflicts, associated with a health crisis.

The innate nature of conflict and the emphasis on understanding the dynamics of decision-making in public health crisis communication leads to our theoretical focus of this study, the contingency theory of strategic conflict management, the key elements of which, as directly relevant and essential to pandemic communication, are elaborated below.

The contingency theory and key factors in pandemic communication

The contingency theory of strategic conflict management (hereafter, the contingency theory) was developed by Cancel et al. (1997) as a way to determine how organizations determine the best ways to communicate with their stakeholders. In their development of the theory, the researchers wanted to capture the complexity of public relations practices and allow for the theoretical constructs to reflect this complexity. Commonly referred to as an “it depends” theory, the contingency theory presents a continuum with accommodation on one end and advocacy on the other (Jin and Cameron, 2006). This reflects the dynamism in the communicators' decision-making process. In recent years, the contingency theory has been broadly applied to understanding organizational threats and appraisals (e.g. Kim and Jin, 2020); relationship management paradigms (Cheng and Cameron, 2019; Cheng, 2020); power institutions (e.g. Xie, 2017); and activist organizations (e.g. Kim and Cameron, 2016). These instances demonstrate the fluid nature of the contingency theory and how it guides inquiries of great magnitude and impact. Similarly, we want to utilize the contingency theory to investigate the perceptions of health practitioners on a large-scale issue. Such inquiry is not evident in current contingency theory application.

The contingency theory has been researched and reorganized into various groupings. At the theory's inception, Cancel et al. (1997) organized the variables into internal and external variables—organizational strata that prevail today. They looked to many scholars, such as Dant and Schul (1992), for variables related to communicators' experiences; they proposed variables like issue size and stake. Cancel et al. (1997) included and reorganized these variables—and many more—into internal and external factors. Upon further investigation, researchers reorganized the variables into two other organization strata: predisposing and situational (Cancel et al., 1999). Predisposing variables influence a stance preceding a situation, while situation variables are those that become salient and of varying importance as a result of a certain situation or conflict. Researchers apply the contingency theory to various contextual situations, such as health-related issues and threats. Lumpkins et al. (2010) used the contingency theory to propose a framework for health public relations and how best to advocate health care for various cultural populations. In terms of communicating to the public about health risks and threats, Kim and Jim (2020) urged organizations to communicate early—before the health threat actually begins to affect people. These findings—based on the contingency theory framework—demonstrate how organizations and their communication professionals should treat health threats.

Building on the previous studies' work, this study uses the contingency theory's framework for qualitative deductive analysis based on the segmentations of the contingency theory. Voges and Binford (2021) took a similar approach to data analysis and applied the contingency theory to the COVID-19 pandemic to analyze how external contingent theoretical constructs were portrayed in gubernatorial communication. They determined that the government's pandemic communication, essentially dismissed the COVID-19 issue—providing the public with oversimplifications, inaccurate advice and overly optimistic predictions about the course of the pandemic. These findings are based on a textual analysis, so there are interpretation limitations. The current study expounds on these ideas by examining perspectives from health communication executives who have many years of experience in the field.

The continuing review of the contingency theory is included to demonstrate how previous scholars have used and segmented the theory's factors, both internal and external, as relative to this study.

Internal factors

Internal factors of interest for this study include organization characteristics and relationship characteristics. These theoretical constructs represent the study's interests in how high-ranking practitioners perceive the pandemic based on their personal experiences and insights.

Organization Characteristics. Organization characteristics is one of five theoretical constructs developed by contingency theorists (Shin et al., 2006). The construct encompasses a set of internal factors, like the organization's culture, the economic stability of the organization and the degree to which the organization is geographically dispersed (Jin et al., 2015). Past studies have found that organization characteristics is one of the most influential situational factors (Shin et al., 2006; Reber and Cameron, 2003), which is noteworthy as organization characteristics may affect the staff's willingness to engage in internal dialogue (Reber and Cameron, 2003). However, there has not been an overwhelming focus on organization characteristics. Thus, the current study furthers our understanding of organization characteristics by investigating health communication practitioners' typical perceptions of health risks and issues. Additionally, the focus on organization characteristics will provide insights into how the unique expertise and tenure of health communication practitioners since their niche area of focus and understanding about health issues are key to broader public health communication.

Relationship Characteristics. When looking to define relationship characteristics, Cancel et al. (1997) looked at how other public relations scholars had defined the primary role of public relations (e.g. Grunig et al., 1992; Cutlip et al., 1985; Ferguson, 1984). Included in this is how much of a factor does the practitioner's relationship with stakeholders play in the resulting communication (Cancel et al., 1997). The core of relationship characteristics defines the connection between an organization and its stakeholders. Specific variables that can affect this relationship include: the level of trust among the parties; the dependency of the parties on one another; and the ideological differences between the parties (Jin et al., 2015). Interestingly, when exploring contingency factors in interviews with practitioners, Cancel et al. (1999) found that some factors are more representative of “potentially negative situations” than others (p. 184). Contemplating relationship characteristics, namely ideological differences, it is important to capture not only how or if health communication practitioners were cognizant of these relational factors but how positively or negatively they perceived these relationships.

Thus, the task was to explore the role of internal factors in the health communication practitioners' managerial decision-making when understanding the COVID-19 pandemic and communicating with stakeholders. We ask:

RQ1.

How do health communication executives make decisions in managing COVID-19 pandemic communication in relation to internal factors suggested by the contingency theory?

External factors

External factors of interest for this study include general external climate, external public and issue under question. These contingency theory constructs guided the current study because the constructs represent the study's primary interests: analyzing how practitioners' perceive the pandemic and its threat to public health.

General External Climate. This factor is adapted from the “general external climate” in the contingency theory. Previous research has found that external culture, including political and social environment (i.e. degree of political/social support of business, see Cameron, 1997; Jin et al., 2021a, b), is the most influential external factor when studying the actions of communicators in a health crisis (Li et al., 2010). Through a survey, Li et al. (2010) were able to understand how Chinese practitioners perceive factors as relative to public relations practice. Culturally, political and social influences were seen as especially important. These findings are viewed as an extension of China's culture—its governmental regulation and the stylistic (political and social) support of Chinese organizations. This begs the question of how such political and social factors influence health practitioners' understanding of the COVID-19 pandemic. Given that the political and social environment is broader and more macro-level than “culture”, especially in the context of a global public health crisis (Jin and Vijaykumar, 2022), we use the term “general external climate” thereafter.

Successfully demonstrating its breadth, the contingency theory subsumes cultural and climate differences as paramount to communication. Cancel et al.’s (1997) factors have been successfully applied to global situations (e.g. Li et al., 2010; Choi and Cameron, 2005) and have demonstrated how important the general external climate is for communication practitioners. Coupled with Li et al. (2010) findings, it can be argued that, as each country dealt with COVID-19, the general climate and how high-ranking health communicators perceived the general climate, are vitally important to understand.

External Public. The external public is a core piece of how an organization's stance is driven (Li et al., 2010; Yarbrough et al., 1998). However, communication professionals perceive external publics differently (Li et al., 2010). Indeed, for Choi and Cameron (2005) “stances in conflicts differ depending on the type of public” (p. 184). This statement is particularly indicative of the nature of the contingency theory. For a health crisis with global impact, it is important to investigate how health communicators contemplate and understand the implications associated with external publics' characteristics. This is especially important considering the qualifications of expert health communication practitioners and the magnitude of the pandemic.

Issue Under Question. Cancel et al. (1997) looked to Dant and Schul (1992) who proposed that the external factors of interest include the issue at hand. Given the contextual focus—COVID-19 pandemic—it is important to fully comprehend the issue, which is the public health crisis. Dozier and Bhiing (1992) suggested that understanding the issue is important because of the need for understanding between the organization and its stakeholders. Essentially, those involved need to reach an understanding of the issue. The type of issue also alters stance choices (Choi and Cameron, 2005). Choi and Cameron (2005) found that, in conjunction with the types of publics and issues under question, fear was a primary driver for communicators in South Korea. This finding is suggestive of how communicators felt and responded to situations and demonstrated how affect can influence a practitioner's approach to communication. For the current study, the researchers want to determine if a similar response is evoked or if other influences, like advanced science and health communication training, override emotions and uncertainty. To further explore the role of external factors in communicators' decision-making in their management of pandemic communication with stakeholders, we ask:

RQ2.

How do health communicators make decisions in managing COVID-19 pandemic communication in relation to external factors suggested by the contingency theory?

Method

Previous scholars have conducted studies that investigated COVID-19, but those studies reviewed internal communications and used surveys to gain insights (e.g. Chon et al., 2021; Ecklebe and Löffler, 2021; Einwiller et al., 2021; Heide and Simonsson, 2021; Yeomans and Bowman, 2021). The researchers contend that, for the purpose of the present study, a qualitative and in-depth inquiry into perceptions about the coronavirus pandemic is necessary. Similar exploratory studies have been conducted, such as by Choi and Cameron (2005), that employed a similar method of inquiry into South Korean public relations practices and stance-making.

Researchers identified potential interviewees through specific criteria: high-level experience and influence, seniority or tenure and health communication expertise. These individuals were selected based on the aforementioned criteria coupled with the following rationales: (1) to rely on longstanding experience in the field of health communication, which is necessary to advance our inquiries into both contingency theory and the coronavirus pandemic; (2) to have equal footing in terms of each individual's autonomy and collective experience with health communication.

Among the top health communication agencies identified, roughly forty-eight were contacted for comment and interviews. Potential interviewees were identified based on their professional criteria; they (1) worked in the health communication industry, (2) held a high-ranking position (e.g. executive) and (3) worked in the field for at least ten years. We used professional contacts and networked relationships to reach out to potential interviewees that matched the aforementioned criteria. To explore our research questions, it was essential for us to conduct interviews with those who had the necessary experience and criteria; the interview questions relied on the interviewee's professional experience and tenure.

Participant demographics

The researchers interviewed highly-experienced health communication executives at major public health and healthcare agencies in the United States (n = 7) after reaching data saturation. Previous research suggested that smaller sample sizes—those around ten participants—reach a high majority of data saturation, which is roughly 95% (Weller et al., 2018). This is especially true if the purpose of the interviews is to identify and understand common perceptions between participants (Guest et al., 2006). Among qualitative studies using the contingency theory, Choi and Cameron (2005) interviewed a total of five communicative executives in South Korea, after multiple rounds of efforts in gaining access to, recruiting and retaining highly specialized groups with leadership positions. Given the interviewee qualification requirements criteria, the researchers in this study sought interviewees who worked in health communication agencies and had high levels of experience in health communication. These agencies were for profit communication agencies or consultancies wherein health communication practitioners provided expert counsel to organizations as their clients. There was one interviewee exception where the participant's expertise came from working as a former high-ranking communicator at a US based public health government agency.

Interviewees included four high-level executives, one Chief Health Strategist and consultant and one high-level government health consultant. Each of the interviewees had worked in health communication for an average of 31 years (SD = 6.63)—ranging from just over 22 years–40 years of experience. Of these interviewees, six of them were the top supervisors for their organizations while one interviewee was within two levels of the top supervisor. Lastly, interviewees held the following titles: Managing Director (n = 2); President; Executive Vice President; Chief Health Strategist; former Chief Media Relations of a US federal agency; and Corporate Director of Public Affairs and Media Relations. Of the interviewees, five were female and two were male. The majority of the interviewees were Caucasian (n = 6); one interviewee was African American. All interviewees were over forty years old, with an average of 56 years old (SD = 6.31).

Interview procedure

We received IRB approval from a major research university to conduct the study. In-depth interviews were conducted to gather rich data to illuminate health communicators' experiences. Such interviews provided insight into interviewees' perspectives and life experiences related to the study and guided by the interview questionnaire. The interview questionnaire was semi-structured, which allowed each interviewee to tailor the interview to his or her experiences and areas of expertise. Each interviewee was presented with a digital consent form prior to the start of the interview, including the interview description, transcription process and study purpose and an accompanying survey that captured preliminary demographic data. All interviews were conducted via Zoom, audio-recorded on a separate listening device and transcribed via a transcription service. Each interview lasted roughly an hour. Interviews were conducted between January and August of 2021.

As per typical interview guides, the open-ended questionnaire began with general questions, moved to core and follow-up specific questions and ended with a future-looking wrap-up. The first questions asked for information regarding tenure, responsibilities, educational background and early reflections they had about the COVID-19 pandemic. Core questions focused on the following areas: (a) the COVID-19 situation (e.g. How much of the communication you developed for your organization or clients informed your own understanding of COVID-19?), (b) internal and external influences (e.g. How much outside or external influences (meaning, outside of your organization) influenced or shaped communication?), (c) communication challenges (e.g. What strategies did or do you use to keep up with COVID-19 or critical health information that seems to change overnight?) and (d) similarities/differences as presented by COVID-19 when compared to other health communication challenges (e.g. How does COVID-19 compare to other health uncertainties you've communicated/studied/consulted about throughout your career?). Notably, these questions and categories are reflective of the contingency theory constructs previously mentioned (e.g. general external climate and organization characteristics as internal and external influences).

Analysis of findings

The researchers used deductive reasoning as the basis for data analysis. Regarding the distinction between deductive and inductive—and place—for both types of logic within qualitative research:

As evaluation fieldwork begins, the evaluator may be open to whatever emerges from the data, a discovery or inductive approach. Then, as the enquiry reveals patterns and major dimensions of interest, the evaluator will begin to focus on verifying and elucidating what appears to be emerging, a more deductive approach to data collection and analysis (Patton, 1991, p. 194)

This interpretation of deductive and inductive reasoning essentially makes a case for data analysis. Beyond initial analysis, Patton (1991) suggested that both logical reasonings might be used in a single study—first the inductive and second the deductive. Hyde (2000) cited Yin's (1994) work and the deductive approach taken to case study analysis—focusing on bringing in “statements of proposition” (p. 85). Indeed, there are formal deductive approaches—applied by Hyde (2000)—that researchers can undertake with this type of reasoning, such as pattern-matching based on theory and analysis. This approach was the crux of this study: using the theoretical framework to develop deductive categories based on the contingency theory. The categories include organization characteristics (internal); relationship characteristics (internal); general external climate (external); external public; and issue under question (external). These deductive buckets directly relate to our research questions.

Results

Health communication executives' views aligned with contingency theory's key internal factors such as organization and relationship characteristics. Namely, interviewees discussed organizational and personal expertise in relation to managing pandemic communication and how their efforts remained the same during the pandemic as they were before. Health communication executives discussed how organizations had internal dialogue emphasizing the importance of resisting the urge to change company policy with every new development, but instead waiting to receive syntheses of credible information, current data and guidelines from organizations like the CDC. Organizations that lacked internal crisis expertise sought external counsel from communication agencies. External counsel expertise was a bedrock that enhanced client-agency relations and organizations' functional units in novel ways during the pandemic. Similarly, health communication executives did not indicate dissent or conflict regarding scientific information and noted unified flexible and collegial organizational cultures.

Contrarily, health communication executives acknowledged a divisive external climate where the pandemic had been politicized. Some believed that the politicization was also directly related to social unrest; and articulated disdain for the poor treatment of African Americans regarding racist and discriminatory pandemic response. They also discussed how, although the pandemic's impact was pervasive, various publics had different expectations regarding the pandemic. While virtually the entire world was focused on health, interviewees' organizations also realized new opportunities to communicate more specifically with the general public. Health communication executives agreed the heavily politicized climate was their greatest barrier and suggested that in future crises professionals should network with those who are knowledgeable of the situation; conduct ongoing scenario planning; include diverse representation; understand what communication should accomplish; and communicate early and often.

RQ1 sought to understand how health communication executives make decisions in managing COVID-19 pandemic communication in relation to internal factors, while RQ2 inquired about their pandemic communication management related to external factors. RQ1 results indicate that health communication executives viewed the pandemic consistent with the contingency theory's two internal constructs of interest: organization characteristics and relationship characteristics. RQ2 results indicate that health communication executives viewed the COVID-19 pandemic consistent with the contingency theory's three external constructs of interest: general external climate, external public and issue under question.

Organization characteristics

As a reminder, the organization characteristics construct encompasses variables like organization culture and the organization's economic stability and can influence employees' willingness to communicate internally (Reber and Cameron, 2003). Interviewees typically spoke of their organizations' expertise in terms of its in-house experience in science and health communication. This expertise is key to the perspectives offered by the interviewees. They themselves understood how advanced their personal knowledge was regarding issues related to health communication. Essentially, their health expertise was immediately identified by the interviewees as something valuable. Those who worked in health communication did not believe they had to change their efforts during the pandemic; rather, they felt they should continue what they had been doing before the pandemic started. As Interviewee 1 [female, Managing Director] stated,

I think that my team is a team that focuses solely on health care, whether that's in the biopharmaceutical space or whether that's for a hospital or whether that's in the med device space … There's more of an appreciation for the importance of how to communicate science, but I don't think it's changed the way my team thinks about how to communicate science. We've always been very focused on who is hearing this. (Interviewee 1 [female, Managing Director])

Further, some interviewees said business increased as a result of the pandemic: clients who did not have in-house crisis expertise sought the help of agencies which did. As Interviewee 2 [female, President] described,

And then just because we're a health and medical public relations firm. COVID has infused our work with all of our clients and how we advise them. So luckily, we have a lot of expertise in infectious disease. We've actually gotten many new clients as a result of organizations needing to communicate about COVID. We've used … our expertise in infectious disease to get new clients.

This is notable because this type of confidence in one's work was not a standard for most professions; the unemployment level in the United States skyrocketed to thirteen percent of American unemployed, which is around eight million jobs (Smith et al., 2021). In conjunction, interviewees cited how their organizations provided a place to communicate internally about the pandemic—sharing reputable information and sources.

There were several interviews which illustrated the impact of organizational culture on internal communication. Some interviewees spoke about how their organization dealt with the number of pandemic related articles and studies saying, “And I remember even our own organization was weighing in on a lot of debates internally” (Interviewee 5 [male, Executive Vice President]). Interviewee 2 [female, President] said:

We did have an internal conversation saying, listen, there's going to be some one-off studies that are coming out all the time. We should not be making company policy based on them just yet until they're reviewed and synthesized and developed into public health guidance by CDC or others. (Interviewee 2 [female, President])

Furthermore, one interviewee's organization sent out internal surveys to understand how their employees were dealing with the pandemic: “We've been surveying the staff. We've done like two to three surveys … [to] assess their comfort level with going back [to work in person]” (Interviewee 3 [female, Managing Director]).

Relationship characteristics

Factors that comprise the relationship characteristics construct include level of trust between parties, dependency of the parties and ideological barriers of the parties (Jin et al., 2015). When speaking about their current clients, interviewees did not impart any concerns that their clients had or felt throughout the coronavirus pandemic. In fact, when speaking about their clients, the core of their agency—health communication—was invoked. Expertise and experience created a strong foundation between the agencies and their respective clients and the organization's various departments. One interviewee had a unique experience:

It's interesting because in my health team, people were pretty calm through the whole thing because they understand health. But it was so interesting talking with our parent company where they don't have healthy people, they have lots of people freaking out … And so being able to play a role or play the function of calming people down by grounding them in science … It was great to be able to give that service to the company and I think they felt good that they had a part of the company that really was expert in this and that they could turn to, to give them facts, to calm people down. (Interviewee 2 [female, President])

All interviewees reflected on their fairly-ideologically homogeneous organizations with little concern for peers that believed radically different COVID-19 science material; “We did not have anyone who was like a political anti-mask person, for example” (Interviewee 2 [female, President]). This coincides with what the interviewees spoke about regarding organizational culture and how the core of their organizations was both steady and strong in the pressure to both find and distribute appropriate COVID-19 communication.

There was an unspoken undertone of internal, organizational dependence on employees and peers to demonstrate flexibility and patience. Values like empathy and compassion were invoked when speaking about this togetherness and the impact that COVID-19 had on organizational togetherness:

Our team is really reaching out to individuals regularly to make sure people are OK. Every time we hear that someone has COVID … we make sure like we're on top of it, we're not we haven't come back to any of our offices yet. (Interviewee 3 [female, Managing Director])

General external climate

Given the reach of the COVID-19 pandemic, each interviewee referenced the overarching external climate that they—and everyone—operated in. Nearly every interviewee referenced the political atmosphere that coincided with the pandemic. Interviewee 6 [male, Former Chief of Media Relations for a US federal agency] reflected on how, prior to the pandemic, “that was often the assumption and it was generally the case that political differences didn't interfere with trying to respond to the pandemic.” This type of statement, referencing the political atmosphere, was common among the interviewees, “the government doesn't want you to know that, like it's just amazing how political the whole management of the health crisis became” (Interviewee 5 [male, Executive Vice President]); “everything from the political and like knowing like what's the right information out without offending anyone” (Interviewee 3 [female, Managing Director]).

Some interviewees believed the politicization led to the US’s social unrest in the United States and the issues with race and minority groups: “And the systemic racism thing honestly has been more significant for many clients in terms of how they communicate about themselves and how they change their own practices” (Interviewee 2 [female, President]). Interviewee 4 [female, Chief Health Strategist] considered it “a perfect storm, a coming together, a confluence of a lot of really bad things that we hadn't been taking care of.” Interviewee 1 [female, Managing Director] suggested that the external climate is going to be in disarray until consensus can be achieved on a larger scale, “until the world can politically align behind global goals.” The merged perspectives–on race, politics and health–demonstrate the intricate nature of these topics.

External public

The interviewees explained how, even though the pandemic affected everyone, that different publics held different expectations. All interviewees referenced the absolute breadth of reach that the pandemic's reach has on peoples and publics: “… because the pandemic is in some ways the quintessence ….demonstrating that health is everything and that every one of us is a consumer of health, an influencer of health …”(Interviewee 4 [female, Chief Health Strategist]); the “magnitude on everybody's life lately, there's rarely been a health issue that we've seen in a very, very, very long time that has touched everybody” (Interviewee 5 [male, Executive Vice President]).

However, the practitioners concurred that the pandemic offered chances for them to communicate more specifically with stakeholders because “we as an organization have so much to say that's relevant to the general public now, which never happened pre pandemic” (Interviewee 3 [female, Managing Director]). Pitted against this ease, though, was something the majority of the interviewees reflected on: race and discrimination. Most interviewees raised the concept of race and railed against the lack of sensitivity and treatment of African Americans. One interviewee said, “We have racism. We had inequity in our country. We have inequity, now we have health inequities” (Interviewee 4 [female, Chief Health Strategist]).

One interviewee addressed the political and partisan expectations that exacted influence on how health communicators interacted with external publics. This is notable because the response illustrates how the external political culture introduces a very influential external public, which are government employees:

When it comes to government agencies, whether it's local, state or federal; politics will come into play because it turns out that, you know, there are people who work for local governments, state governments, federal governments, but they have to intersect with elected officials and the people that they appoint. And so that comes into play and that happens everywhere and it happens with democrats and republicans. (Interviewee 6 [male, Former Chief of Media Relations for a US federal agency])

Furthermore, Interviewee 7 [female, Corporate Director, Public Affairs and Media Relations] explained how their communication efforts were dependent on the organization's relationship with political figures. This external public placed pressure on what communication was allowable or permissible for the organization.

Issue under question

The interviewees provided thoughts on the COVID-19 pandemic in respect to how it relates to (1) people and (2) other uncertainties. One interviewee said, “… the first time that people were scared by the fact that we had an illness that was quickly circulating that we didn't really have proven treatments for. We didn't really know how to heal” (Interviewee 5 [male, Executive Vice President]). Regardless of this uncertainty, a strong and common theme for all interviewees was prevention, “actually, this is the only preventable pandemic we've ever had” (Interviewee 4 [female, Chief Health Strategist]). Many interviewees identified politics as the biggest barrier related to coronavirus and its prevention.

The interviewees agreed that science was working hard and fast to find solutions to the virus, but scientists and communicators were not starting at level zero. Interviewees recalled past infectious disease outbreaks, such as H1N1 and Ebola. The interviewees recalled these viruses as they reflected on the COVID-19 pandemic. Interviewee 4 [female, Chief Health Strategist] referred to various outbreaks, “there is Ebola, there was SARS, the first SARS, not this SARS and MERS and Zika. All that happened in those years. And I had something I was involved in all of them in terms of communication”. Interviewee 5 [male, Executive Vice President] described the vaccine process for H1N1 and compared the magnitude of H1N1's magnitude to COVID-19's:

But, you know, we had had a lot of pandemic plans in place like for H1N1 pandemic issues in the past and companies were prepared. In fact, I've done some work with Sanofi Pasteur. That was one of the primary vaccine makers for this H1N1 vaccine. And I remember that they had a request that when I was at another agency that was working with them, that we had to have a pandemic plan of work sustainability. So in the event there's a pandemic, can we ensure that the people in the business, the organization that all the [computer] servers, everything else, for us to be able to service them as a client, to get the messages out as a communication partner, that we could still do it despite the pandemic. And so there it felt like through a lot of plans that we had in the past … And again, until I tell you, I don't think and it's pretty clear since 1918, we haven't had to deal with anything like this since the Spanish flu of this magnitude. (Interviewee 5 [male, Executive Vice President])

For the interviewees, the threat of a viral outbreak—or a pandemic—was very real. Interviewee 7 [female, Corporate Director, Public Affairs and Media Relations] emphasized the importance of a pandemic plan—one that was (1) created by researching previous pandemics and (2) put into place for the COVID-19 pandemic. The breadth was considered differently and for many interviewees was a challenge, but many elements—preparedness, pandemic plans and vaccines—were commonplace for health communicators.

Interviewees were asked to provide advice for future health communication executives. Four interviewees noted the importance of scenario planning while Interviewee 6 [male, Former Chief of Media Relations for a US federal agency] and Interviewee 7 [female, Corporate Director, Public Affairs and Media Relations] emphasized how important it is to “practice the plan” (Interviewee 7 [female, Corporate Director, Public Affairs and Media Relations]).

Aside from scenario planning, the interviewees urged health communicators to network with people who understand the situation and can give perspective before a situation becomes a health issue (Interviewee 3 [female, Managing Director]; Interviewee 7 [female, Corporate Director, Public Affairs and Media Relations]); communicate early and often (Interviewee 3 [female, Managing Director]; Interviewee 5 [male, Executive Vice President]); represent and include diverse decision-makers (Interviewee 2 [female, President]; Interviewee 3 [female, Managing Director]); and know what the communication should accomplish (Interviewee 6 [male, Former Chief of Media Relations for a US federal agency]).

Discussion

Highly-experienced health and risk communication practitioners provided unique and important insights into the COVID-19 pandemic. Insights demonstrate how the interviewees' experiences provided them the ability to act with confidence and understand the nuances of the COVID-19 pandemic despite the intense political and social challenges. Further, the interviewees' insights provide practical applications for future health communication practitioners and how they should prepare for future viral outbreaks. The contingency theory is advanced by applying the theoretical constructs as deductive guidelines for health-related studies. Moreover, the theory is advanced by demonstrating how internal influences, such as organization and relationship characteristics, should be understood against and in tandem with external influences, such as the general external climate, external publics and the issue in question.

In general, it can be said that both practitioners and scholars agree: more crisis communication is needed to help the public manage public health emergencies. As stated by our interviewees, echoing arguments made by Jin and Vijaykumar (2022), there is a need for health communication practitioners to both consider and examine the effectiveness of public health communication. Scholars identify a growing need for theoretical scholarship to address this (Jin and Vijaykumar, 2022) while practitioners find themselves identifying communication failures within the broader field of public health communication, such as with how different external publics are communicated with unequally. Further, both the interviewees in the current and previous studies (see Austin et al., 2021; Jin et al., 2020) argued for the inclusion and reliance on those with such niche expertise—such as health communication practitioners.

Interviewees described the unusual number of the external public in the case of the coronavirus pandemic. The expert health communication practitioners contended that communication, regardless of the breadth of the pandemic, needs to be tailored to specific audiences and groups. In this discussion, the topic of race and discrimination—coupled with politics—redirected to what communication should reflect, which the public the health communicators serve is. This is consistent with Lumpkins et al. (2010) approach to analyzing newspapers to determine how well African American communities are being served in accordance with health concerns. Essentially, the interviewees identified a weakness: communicating to diverse groups amidst a pandemic or infectious disease outbreak that affects everyone. This is demonstrative of how the contingency theory's two external theoretical constructs conflated to influence practitioner perspectives. The external public—viewed through the general external climate—led interviewees to better identify disenfranchised groups, which is a true and practical communication challenge. Ultimately, the COVID-19 pandemic, to the interviewees, uncovered an unfortunate and disparate reality—that wide-reaching health risks can lead to inconsistent treatment of public. Practically speaking, interviewees emphasized the importance of monitoring the general culture, in terms of race and urged communicators to include representative decision-makers in the communication process. The general external climate—speaking to the political and social context—resulted in an in-depth understanding of external publics and it is argued that the interviewees' perspectives of pandemic communication are influenced by their processing of the general US culture. Essentially, public health communication and the general, external climate are inexplicably intertwined and should not be understood as separate concepts. Rather, the future of public health communication needs to understand the relationship between a country's political and social happenings in order to fully (1) understand the public health situation and (2) identify potential communication issues, as seen with the insights the interviewees had about US racial issues.

When asked about their own organizations and internal guidance, interviewees quickly praised their operational practices as paramount to understanding the pandemic. For the practitioners, the foundation of the health-based agency communication practices facilitated their understanding of the coronavirus. They acknowledged easy adaptations, ready sources and supportive organization cultures. Practically, this demonstrates how daily operations—such as the practitioner's career—can influence a person's understanding of global events. Other communicators—those who do not practice health communication—should look to health communicators for insights into how to address different publics—both within their organization and their publics. This practice would emulate an actual interviewee's experience—where the health communication department was able to provide counsel to those in other departments of the parent organization.

Practically, organizations should identify the strengths of health-focused internal departments and/or external consultancies and create communication and business plans that include expertise allowances—wherein a specific department should be relied on during a potential or current issue. Organization culture and internal communication should benefit from such a plan, as seen through some of our interviewees' experiences. Indeed, scholars define the contingency theory's theoretical construct, organization characteristics, as organization culture and organizational stability (Jin et al., 2015). Further, the relationship characteristics include trust, ideological barriers and dependency (Jin et al., 2015). These aspects are not only present for the interviewees, but they are arguably the most important. These aspects provided a strong core for the health practitioners—an opportunity to add knowledge about the coronavirus to their strong subject foundation of health concerns. In a time when many people faced uncertainty in a capacity not felt for some time, a foundation based on logic, facts, information, trust, togetherness and compassion was paramount. Collectively, organization culture and a logic-driven understanding of science resulted in open communication (e.g. surveying employees) and the chance for health communication organizations to grow their businesses.

The general external climate, especially politics, was of grave concern for the interviewees. Voges and Binford (2021) contended that each state's gubernatorial offices were woefully unprepared to communicate about the coronavirus pandemic. The interviewees in this study similarly viewed the political sphere as an unfortunate interference to both distributing and understanding COVID-19 information. Part of the interference, the experts argued, created a discriminatory divide within the public. Indeed, when speaking about the political edge in the coronavirus pandemic, it was virtually impossible for the interviewees to not bring up the public. The experts' comments regarding politicization, social unrest, classism and racial discrimination suggest the topics are inextricably linked and therefore interwoven into the fabric of health communication surrounding the pandemic. Moreover, the experts specifically derided the treatment of African Americans. Therefore, when applying the contingency theory, there seems to be a theoretical linkage between the general external climate and the external public. The question that requires further investigation, is the relationship between these two theoretical constructs. It is apparent in the current study that the interviewees viewed the external public through the lens of the external climate. Whether that is true for other health-related situations remains to be seen.

This leads to the importance of understanding the issue at hand—in this case, the COVID-19 pandemic. Where previous studies identified fear as a motivator (Choi and Cameron, 2005), interviewees in the current study expressed confidence in their ability to understand and communicate public health information, but there was a level of frustration at the general external political and social climates. Although this frustration is disheartening, it is unsurprising considering Voges and Binford (2021) found political figureheads to be poor public health communicators. This, again, demonstrates the interwoven nature of the political and social experiences as related to the pandemic, specifically, the issue at hand. Public health practitioners should expect political figureheads to communicate and discuss the issue and find ways to communicate more specifically with external publics—about the issue—using tailored messages and previously identified community leaders. As expressed by almost every interviewee, these relationships are paramount to good communication and should be established prior to an issue.

There are several important points as demonstrated through this study. First, the expertise granted to the health communication practitioners through the very nature of their jobs granted them an edge. Interviewees knew where to look for scientific information, had contacts with scientists already forged and had previously dealt with similar infectious disease challenges (e.g. H1N1, Ebola). This demonstrates how internal factors, such as organization culture and stability, set a strong and important foundation for communicators; each interviewee spoke with confidence in their knowledge-base. Second, this study demonstrates an intertwined nature between the general external climate and the external public. The interviewees saw the public through the lens of the general culture, mainly the political and social lenses and saw discrimination and unequal communication. They considered the guidance for different groups—what to think and how to act in the pandemic—as failed efforts, which reinforced the need for diversity and audience-specific communication. Third, the health communication practitioners lamented the overall communication throughout the pandemic—with some going as far as to say that much of what happened in the pandemic was preventable, if not the pandemic itself. It is easy to inflate the differences seen, which the interviewees agree is the absolute breadth of reach the coronavirus has, but the similarities to other viral outbreaks is important to acknowledge.

Health public relations and health crisis communication have increasingly joined hands in advancing the knowledge and practice in managing public health crisis communication (Coombs, 2016; Liu et al., 2020; Nowak and Greenwell, 2021). Our study focuses on gaining insights from healthcare communication experts, who counsel health authoritative sources in crisis responses (Avery et al., 2021; Siegrist and Zingg, 2014) and issuing recommendations on not only what to do but also how to psychologically cope with public crises and emergencies (Coombs, 2019; Ma and Zhan, 2016). Recently Kim et al. (2022) advocated for improving the relationships between health authorities and their publics, as publics' perceived relational and communicative qualities experienced with health organizations hold the key to public confidence in the effectiveness of public health crisis management. Through the empirical lens of our study, we clearly see that public relations and crisis communication theories have jointly enriched the investigation of our overarching research question, grounded in the contingency theory and shed new light to the next frontier charted by the emerging IDT appraisal model (Austin et al., 2021; Jin et al., 2020) and the greater call for public health crisis communication research.

Limitations and future directions

This study has limitations that should be addressed in future studies. First, our interviews were conducted with a very specific group of health communication practitioners at top executive levels. In addition, our sample, primarily composed by executives from communication agencies providing expert counsel to client organizations, was unequal in terms of being heavily female and white. Though our insights are unique and quite compelling, the small sample size, due to the challenges of gaining access to, recruiting and retaining top executive interviewees in discussing conflict management topics (see Choi and Cameron, 2005), does provide some limitations. Second, the interviews were conducted between late January and August of 2021; there were ongoing developments throughout these months the time the interviews were conducted and more development throughout the remainder of the year. Future studies should ask health communication practitioners to reflect on the COVID-19 pandemic in stages, such as initial lockdown, vaccine development and vaccine distribution. Third, this study was conducted in the US, where the deep dive into healthcare communication professionals' insights was lacking at the time and critically needed for US.-based practitioners. To further bridge the geographical and cultural gaps to enhance diversity and inclusiveness in theory and practice (see Diers-Lawson and Meißner, 2021a, b; Jin et al., 2021a, b), future studies, guided by the contingency theory and using in-depth interviews with communication executives in non-US countries beyond agencies/consultancies, will need to be conducted.

The present study demonstrates the contingency theory's general external culture (examined as general external climate in this study to reflect the more general and macro-level cultural, political and social environment during a global pandemic) and external publics (e.g. politics, class, race) in the health communication context. Future research should investigate whether the linkage appeared in the current study is typical for health crisis communication and if the theoretical linkage appears for communication industry contexts beyond health. Future studies should also investigate internal protocols as relative to other internal variables as suggested by the contingency theory.

Conclusion

As Jin and Vijaykumar (2022) advocated, “[i]n managing a public health crisis, it is pivotal for government agencies, health organizations, communities and other vital entities in the public health ecosystem to collaborate so as to communicate more effectively to crisis-threatened publics, which include victims/patients, potential victims and at-risk individuals, family members, communities, caretakers, medical professionals and other first responders.” The unique challenges and opportunities include “disseminating accurate crisis information, motivating protective action taking and ultimately strengthening resilience and safeguarding public health” (Jin and Vijaykumar, 2022) and providing health crisis managers and health information officers valid and reliable system and tools to evaluate their performance and assessing health communication management effectiveness in and other pandemics (Jong, 2020).

Our study demonstrates the promising integration of the contingency theory and the IDT appraisal model when it comes to understanding how external climate interacts with external publics' characteristics and how the latter assess their relational and communicative qualities with health organizations throughout the process of public health crisis management. In the spirit of learning from history, the health communication practitioners urged future practitioners to constantly risk assess, hire and use representative decision-makers; set a communication protocol; and keep the communication in perspective.