Thematic analysis of the interviews’ data led to the identification of 9 principles of communication: 1) Timeliness, 2) Transparency, 3) Coordination, 4) Accuracy and Consistency, 5) Accountability and Integrity, 6) Independence from politics, 7) Responsiveness, 8) Equity, 9) Trust and Empathy.

In the following sections, after briefly describing the meaning of each principle as explained in the international guiding documents already noted, we cite the challenges to these principles in practice as reflected in specific quotes from the interviewees. For each quote included in the results, we provide the corresponding recommendation, delineated in brackets as [recommendation x], that the research team elaborated from the interviews’ data. The 36 recommendations elaborated by the team are listed in Table 4. For each recommendation, we provide the average rating and standard deviation, describing its level of importance as determined by a group of government officials participating in an in-person meeting.

“Crises are time sensitive…for members of the public, the first source of information often becomes the best source.” CDC CERC [4].

Fourteen interviewees, in citing timeliness as a key communication principle, noted the major tension between timeliness and accuracy during a crisis with regular uncertainty about always evolving scientific evidence complicating the information environment. As a United States interviewee recognized “... even right now [two years after the start of the crisis], we’re still not doing a good job in telling people: this is what we know now, and that it’s going to change again tomorrow”. [recommendation 1a] The same interviewee noted that since the culture surrounding the public health decision- making process typically involved the expectation of bringing multiple stakeholders together in often time-consuming processes, such expectations about consensus building frequently delayed and/or complicated government communication. [recommendation 1b].

An interviewee from Serbia noted the contrast between the lengthy internal clearance process for government release of information to the public versus the rapidity of misinformation spread by social media. This interviewee noted that after inaccuracies are detected, “it takes like a day or two to come up with a very scientific sound response… which subsequently needs to undergo a lengthy clearance”. [recommendation 1c]. An interviewee from Croatia emphasized the importance of having regular meetings among agencies involved in government communication to synchronize efforts internally: “we had a strategy of “holding” regular meetings of the Crisis Unit so that everyone had the same information “at the same time” to deliver to the public”. [recommendation 1d] One interviewee from Brazil also emphasized the importance of synchronicity externally with the public by communicating to the public at a regular predetermined frequency. [recommendation 1d].

Finally, an interviewee from Israel noted that government should be proactive in “leading the narrative “rather than routinely reactive to the misinformation disseminated by various types of media” [recommendation 1e].

“Governments should strive to… comprehensively disclose information, decisions, processes, and data within the limitations of relevant legislation and regulations. Transparency, including about assumptions and uncertainty, can reduce the scope for rumors and falsehoods to take root,” OECD [1].

Twelve interviewees emphasized the importance of transparent communication even in the face of incomplete information and high potential for negative public reactions. An interviewee from Japan underscored that the negative dimensions of public health emergencies and its attendant adverse economic and social impacts complicate people’s ability to process the information received “... if the price is too high, they will not be able to understand it yet”. [recommendation 2a].

All interviewees agreed that the best transparency strategy was to acknowledge what is known and still unknown, and explain the rationale behind the decision-making process related to recommended preventive measures [recommendation 2a and 2b].

An interviewee from Nigeria discussed the importance of being transparent on the mechanisms used for social listening, i.e., gathering data at the population level to understand their informational needs and concerns. This interviewee noted that governments must “…do [social listening] in a way that is governed properly, that is transparent, that is inclusive, that people know what information is collected and what it is being used as identifiers.” [recommendation 2c].

An interviewee from the United States stated the importance of internal transparency within government agencies since if controversial topics are not openly discussed “it looks like we’re trying to avoid the question. We are (only) answering the question that we hope they’d (the public would) ask.” [recommendation 2d].

Interviewees also noted that despite the potential negative consequences of transparent communication at the economic, social, and political levels, the positive impacts outweighed the negative ones over the long term. As one interviewee from Nigeria remarked, “…. no matter how you spin it [the information you are withholding from the public] or you de-emphasize it, or you ignore it, it will all come back to haunt you.” [recommendation 2a].

“Crisis coordination [is] synchronized information sharing between response organizations… Emergency communications and response efforts depend on… careful coordination,” CDC [4].

Fourteen interviewees, in citing coordination as a critical communication principle, emphasized that crisis task forces should routinely include communication experts regarding how best to convey public policy decisions. An interviewee from Italy suggested that such integration should start in the pre-pandemic phase and be made permanent before any crisis begins. [recommendation 3a].

Coordination can occur at multiple levels. To improve coordination between national and local governments during a crisis, interviewees from Italy and Germany recommended creating, during a crisis, a centralized internet presence (i.e., dashboards) for the release of daily situation reports and committing adequate resources to keep web-based information up to date and accurate (i.e., data quality control processes) [recommendation 3b]. Regarding coordination between national and local level agencies, an interviewee from a local agency in Croatia argued that the government agency closest to the population being impacted should be the first to release information to them. This interviewee shared an example whereby COVID-19 results on swab samples, sent by a local agency to a national laboratory that determined them positive for COVID-19, were publicly released by the latter organization instead of the former. As the interviewee noted “... we may have left a feeling of insecurity in the population, that is, that we do not have accurate or do not know the information.” [recommendation 3c]. Further, an interviewee from Brazil highlighted the importance of government-wide cohesion, stressing that all government branches need to be informed about: “who is going to communicate what (i.e., surveillance data, logistical information, overall situation), what role they have (sometimes technical and sometimes political role) and what level of responsibility… A synchronized response.” [recommendation 3d].

Coordination is also critical between countries, especially of neighboring nations. An interviewee from Armenia noted, “...if we worked better with our neighbors…it would have helped because we would have been able to share information together.” [recommendation 3d]. An interviewee from Norway noted the importance of both formal and informal information-sharing mechanisms based on long-term pre-existing trusted relationships: “You need to know their face, and you need to trust. And then you can alarm each other when you know you are short on time, you can’t wait for a paper or go through the system – you just have to tell them.” [recommendation 3d].

“... the use of consistent messaging via different information sources in an emergency increases the likelihood that messages will be believed and acted upon… absent or contradictory and inconsistent information from the authorities leads to uncertainty.” WHO [5].

Of the nine interviewees that cited the importance of consistent communications, one from Malta noted that communication inconsistencies are “quickly picked up and amplified by the media”, confuse the public and damage the credibility of government spokespersons. While interviewees overall noted that messaging inconsistency almost inevitably regularly arise due to the natural evolution of the scientific process, different interpretations of scientific findings, and the need for policies to be adapted to the local needs, they cited instances where inconsistencies could have been easily prevented. For example, an interviewee from Italy stated that government agencies were very efficient in rapidly creating web pages to post answers to COVID-19 frequently asked questions (FAQs), but then lacked processes to generate regular information. An interviewee working at the international level noted: “...if we don’t take down outdated information, that fuels misinformation because people that really want to misuse information that’s on the internet can literally say that the health authority is inconsistent in communicating.” [recommendation 4a]. The same interviewee pointed to the lack of customization of FAQs to meet people’s informational needs, noting: “... a conspiracy theorist and a medical doctor looking for factual information are both expected to get an answer from the same FAQ”. [recommendation 4b].

An interviewee from Japan also noted that inconsistency can arise when politicians not well briefed a priori by their scientific experts incorrectly translate and then communicate technical scientific content into plain language. [recommendation 4c].

Finally, an interviewee from Croatia emphasized the importance of consistency between words and personal behaviors, arguing that government officials should show consistency between what they recommend professionally and do personally (i.e., referring to COVID-19 the interviewer talked about wearing a mask and refraining from social gatherings in their personal life). [recommendation 4d].

“More continuous and committed efforts to listen to and understand public sentiment… can contribute to greater accountability and responsiveness.” OECD [1].

Seven interviewees emphasized that a crisis demands accountability practices beyond those determined by law. The interviewees highlighted the need to provide the public with explanations about the decision-making process behind newly released policies especially when they are based on limited or contradictory scientific evidence. [recommendation 5a].

The need for apologies and corrections when mistakes occur was acknowledged by interviewees from San Marino and North Macedonia. [recommendation 5b] An interviewee from Serbia reported that accepting invitations to be interviewed by journalists with politically opposing views is an opportunity to address criticism and practice social accountability. [recommendation 5c].

Agencies regularly face challenges when discussing issues that are outside of their mission and area of technical knowledge. An interviewee from the United States emphasized the need to discern what falls outside the purview of one’s public health institution and determine ahead of time “... what is within your wheelhouse, what is your role as an institution (government institution) versus the role of another institution”. [recommendation 5d].

An interviewee working at the international level spoke about the importance of implementing evidence-based communication practices to ensure government accountability. [recommendation 5e] On this matter, a government official from the United Kingdom highlighted the usefulness of establishing rapid evaluation mechanisms to hold governments accountable for the information they decide to release and funds they invest in related public outreach campaigns. [recommendation 5e].

Finally, an interviewee from the United States spoke about the need for government agencies to assume accountability not only in response to current emergencies but also “... thinking ahead of events” for the future, with a special obligation to reduce social inequities that may impact future crises. [recommendation 5f].

“Public communication should strive to be independent from politicization in implementing interventions to counteract mis- and dis-information. Public communication should be separate and distinct from partisan and electoral communications,” OECD [1].

Of thirteen interviewees that cited such independence as a key principle, one from the United States remarked that when a health decision becomes politicized, the health authority quickly loses control over the information being conveyed, saying, “.... at that point, you just have limited influence.” Therefore, creating a non-partisan context is critical. For example, during COVID-19, specific segments of the population refused vaccination in part because politicians with political views opposed to theirs advocated for it, as remarked by an interviewee in the UK.. A government official from Italy spoke of the need of separating the scientific spokespersons from the political appointee during public speech. Having political appointees and administrators explaining the operational aspects of specific policies (i.e., what services are open and closed during a lockdown), leaving all related scientific explanations around such policies to the public health technical experts. [recommendation 6a].

An interviewee from the United Kingdom argued that vaccination mandates challenged communication when enforcement was viewed as unachievable. Similarly, an interviewee from Germany reported that the contrast between the broad scope of a policy recommendation and the government’s limited ability to execute it frequently fueled attention to politics, not health. [recommendation 6b].

Furthermore, an interviewee from Germany expressed concerns that some political decisions were announced during TV talk shows, creating a media effect further politicizing health matter “leadership has become more of a performance artist that has undercut the trust in government institutions …. so, it’s very difficult for anyone who represents a government to overcome that sort of bias.” [recommendation 6c].

“Effective risk communication allows… authorities and experts to listen to and address people’s concerns and needs so that the advice they provide is relevant, trusted and acceptable.” WHO [5].

Of the 20 interviewees who highlighted responsiveness, one from the United States suggested that “you have to engage with the community, discern what their concern is and then bring them into the picture to work on the problem that they see.” [recommendation 7a]. Another interviewee from Nigeria noted that listening can enable government officials to understand that focusing on a single issue (i.e., vaccination) may not be reflective of community priorities, saying “...when the government emphasizes a singular issue, it can inadvertently undermine itself” [recommendation 7a] and that “... that is how those who derail people actually get this misinformation out because they do that (listening) perhaps even better than those of us who are trying to do the right thing.”

When discussing listening tools, interviewees from France, Italy, Serbia, and Qatar described helplines as useful for monitoring the population’s informational needs. An interviewee from Croatia also cited the usefulness of national polls to identify public concerns, behaviors, and misinformation endorsement. [recommendation 7a].

Interviewees also discussed the importance of building networks of community leaders and professional figures (i.e., religious, business leaders, academic institutions) who can share with government officials the concerns of the community and support efforts to the disseminate messages to specific audiences. An interviewee from Serbia noted: “... people will simply not believe me, but they will believe our religious leader, they will believe our local politician or some other authority, maybe at the neighborhood level”. [recommendation 7b]. An interviewee from Nigeria emphasized that training of healthcare workers in communication helps reach diverse audiences “People are … listening to the health worker that goes to their neighborhood and brings the vaccine. And if that health worker is not well prepared to answer their questions, that may be where they make that decision (of not getting vaccinated).” [recommendation 7b] Furthermore, an interviewee from the U.S. discussed the need for public-private partnerships, referring to social media companies that have the tools to disseminate the information, monitor informational needs, and identify misleading informational narratives. [recommendation 7c].

“The benefit of specific, culturally, and contextually appropriate actions that people can take themselves during an emergency was emphasized… Equity– providing realistic actions to vulnerable groups– was an important element…” WHO [5].

Of the 9 interviewees that cited equity as a key communication principle, one at the international level noted, “Access to health information is a human right.” Developing an equitable messaging strategy must account for variations in the linguistic background, health and digital literacy, internet access, and culture of the population. As an interviewee from Malta said, “There were always the foreigners with the language problems, you know, who don’t hear our news, who don’t see the television, the radio, or read the newspapers and I used to try to use NGOs to help me”. [recommendation 8a and 8b]. An interviewee from Indonesia noted how such a grassroots approach aided digital literacy educational campaigns to recognize misinformation and reduce its spread. [recommendation 8c].

Efforts to increase access to information must start prior to an emergency. One interviewee working at the international level argued, “It has to be a huge systemic effort through all health programs during peacetime to make sure that they get the services they need, and they get connected to the health system better. So, when the emergency hits, you have a shot.” [recommendation 8d].

“One of the most important factors in effective communication is how much your audience trusts you and your organization. Establish trust through empathy and openness.” CDC CERC [4].

Of the twelve interviewees citing trust as a critical communication principle, one from Croatia noted that the multiyear length of the pandemic, and related negative economic and social impacts, challenged the government’s ability to maintain public trust. Interviewees emphasized that trust needs to be built over time but trust, during this long pandemic was inevitably eroded. As an interviewee from Sweden described, “I think it’s really important for a system as a whole to gain trust beforehand, because during the crisis you have to start paying... It’s like a bank account. And the minute the crisis hits, it’s like the central banks, they are now distributing money…” [recommendation 9a].

Interviewees referred to multiple sites for trust---e.g., in government, in fellow citizens, in pharmaceutical products (i.e., vaccine), in the healthcare system, in politics, in scientists, and in science—as well as between national and sub-national government agencies, government, and media, and between the public and the private sector. An interviewee from the United States affirmed that trust building accompanies relationship building. He said that during a crisis, government officials should travel to the affected areas to talk in person to those leading the response and to the citizens affected: “without the (in-person) relationship, it’s really hard to have that trust”. [recommendation 9b] An interviewee from Sweden also noted the importance of building trust between fellow citizens “We were constantly telling people that you have to behave a certain way, but we [the government] had to make them trust that we would do our share”, and continued by saying “... you have to start building trust in institutions before you come to the stage where you actually can avoid restrictions … I would argue that restrictions in themselves are actually diminishing the trust in institutions and between people. Because what society says using restrictions is that we cannot trust you”. [recommendation 9b] Another interviewee from the United States highlighted the importance of validating people’s feelings, stating, “... if you’re able to absorb some of their anger, validate some of it, then you can begin to talk about developing a trusted relationship so that your messaging gets through.” [recommendation 9c].