During disease outbreaks or pandemics, organizations must convey effective information that will cause members of the general public to cooperate with guidelines and even change their behavior, as in the need for social distancing and isolation during the COVID-19 crisis [1]. Moreover, policy makers must convey information to health care professionals, who must deal with new care conditions and social situations [2]. This information must go beyond factual information such as morbidity and mortality statistics. It must also provide explanations to help the public understand the rationale behind the guidelines as well as information to help population subgroups cope with social conditions such as loneliness and anxiety caused by lifestyle changes.

In communicating this information, health organizations must also address the psychological, sociological, economic, and political factors motivating the behavior of diverse population groups; therefore, conveying information, messages, and guidelines to the public becomes quite complex [3,4]. Moreover, in a media- and communication platform-saturated environment, if policy makers do not convey information that is relevant to people’s needs, the public will lose interest and turn to other resources and channels [5-7].

Health information can be conveyed as statistical evidence or as narrative evidence. Statistical evidence usually entails a dry summary of quantitative information about a sample of cases that can be generalized to an entire population [8]. This information is conveyed in a statistics-based and didactic manner that appeals primarily to cognitive considerations.

In contrast, health information can also be conveyed in the form of narrative, through stories that address both cognitive and emotional aspects. Narrative evidence is constructed in the form of a plot that has a beginning, a middle, and an ending that is often open [9-13]. Stories involve characters who portray incidents, life experiences, problems, conflicts, or questions, and challenges emerging from their daily lives or during crises. These characters transcend their personal stories to represent communal stories that often entail information about goals, plans, actions, and outcomes [9-13].

In examining whether narrative or nonnarrative [9,13-15] means are most effective in conveying health care information and creating health behavior change, research has uncovered apparently contradictory results. For example, one study found that narrative evidence is more effective than statistical evidence [16], whereas a meta-analysis indicated that statistical evidence is more persuasive [8].

In another meta-analysis, Zebregs et al [17] identified the influential factors in the two approaches: statistical evidence versus narrative evidence. Statistical evidence was found to exert a stronger influence on beliefs and attitudes than narrative evidence, whereas narrative evidence had a stronger influence on intention. The authors’ explanation was that statistical evidence, beliefs, and attitudes are mainly related to cognitive responses, whereas both narrative evidence and behavioral intention are more specifically related to affective (emotional) responses. Accordingly, during a pandemic or other crisis, policy makers can employ both means of information transmission: statistical evidence and narrative evidence. As noted by Zebregs et al [17], narratives can help influence people’s intentions to change their behavior, as required by unusual situations.

Hoper and Clippard [18] identified five qualities of narrative messages that make them particularly promising for health interventions. Narrative messages can overcome resistance toward the advocated health behavior. Moreover, they can engage audiences that are less involved, reach audiences that are less knowledgeable, render complex information comprehensible, and ground messages in the culture and experiences of the target audience. In the next section, we describe these five qualities and tie them to the field of emerging infectious disease communication. We also add two qualities that we believe are of particular importance for the use of narrative strategy in health communication. The first is using aesthetic means (nonverbal communication) to convey information based on the edutainment theoretical framework [19,20], as such means are important components of persuasion strategies. The second is conveying a diffused story through social networks based on the diffusion of innovations theory [21,22] and parasocial interactions [23-25], both adapted to the current social media realm.

Resistance can be broadly defined as a reaction against change or an incentive to oppose persuasive appeals. Resistance to persuasive messages may include counterarguing the message’s claims, ignoring the message altogether, or denying the validity of the message due to its source. The greater the public’s resistance, the greater the advantages of the narrative approach in reaching people [26].

Narrative evidence helps people process new or complex information by putting the facts into the context of a specific time and place during an outbreak or pandemic. Moreover, narratives can be used to link the information to the experience of the readers or listeners [27,28].

Policy makers seeking to find the most effective way to lead the public to heed information and guidelines during a crisis need a tool that does not require a high level of literacy or education. Narrative evidence meets that requirement because it can address people at all levels and in all languages [18].

Addressing emotions is one way to make the public feel involved. Emotions have long been acknowledged as an essential ingredient in the recipe for persuasion [29-31]. In the health communication field, persuasive messages that arouse emotions tend to be perceived as more effective than those that do not [32-36]. Even health care workers may be more responsive to messages that address their emotions than to statistical data. Hence, this approach can be used to provide health care workers with tools and vital information to help them communicate with families whose loved ones are hospitalized with COVID-19.

People exposed to other people’s stories in the media undergo a “parasocial relationship” [37] in that they become engaged with the characters despite never having met them. In line with social-cognitive theory [38], such characters may serve as role models for appropriate behavior by demonstrating the costs and benefits of different courses of action. People may be inspired to imitate the actions of positive characters, avoid the problems of negative characters, or follow in the footsteps of characters who undergo a transformation (usually from negative to positive attitudes or behaviors) over the course of the story [39].

In media campaigns, the characters in a narrative can serve as role models for the readers or viewers [40]. For instance, characters representing at-risk population groups can depict different coping situations that the public can learn and imitate [41]. As opposed to merely short text (eg, a Tweet that can contain up to 280 characters), social media platforms such as Facebook, blogs, or COVID-19 forums enable people to create and share their stories. These platforms provide people with opportunities to talk about their fears and concerns as well as their beliefs and risk perceptions in different situations [5,42,43]. Policy makers can study stories on social networks to learn how people understand the epidemic narrative at any given time and use that information to generate appropriate narratives.

Stories can be used for long-term interventions as well as for the short-term needs of a specific context, such as the outbreak of a pandemic. Furthermore, pandemics are not necessarily short. Indeed, the COVID-19 crisis is prolonged and ongoing. For example, policy makers can design stories that model effective behavior for the subgroup of health care workers caring for older people during the COVID-19 crisis.

The newly proposed quality of aesthetic means is of particular importance in health communication. Narratives can use aesthetic means and strategies such as empathy, humor, sarcasm, and irony to convey information using [27]. Edutainment has shown that aesthetic experiences provide viewers with opportunities for meaningful cognitive illumination or change in the context of health or other issues [19,20]. Aesthetic means offer added value that cannot be achieved merely by conveying statistical information.

Conveying a diffused story [21,22] through social media leads to parasocial interactions [23-25] and generates relationships between people that transcend geographic and linguistic borders. These relationships turn strangers into friends and transform passive audiences into active coparticipants [44,45]. People who hear a good story can be expected to share it with others, initiating a pattern of social proliferation, such that messages “go viral” [46,47]. Thus, the boundaries between the personal and the public become blurred. For example, when people identify with a story posted on social networks and share it on their feeds, they actually turn that story into “their” story. Hence, one individual’s story becomes the story of many other individuals, who identify with it and share it with others.

This viewpoint paper combines three intertwining parts to provide a holistic perspective on the use of narrative evidence during a disease outbreak or pandemic. The first part compares the commonly used strategy of apocalyptic narratives to the more desirable strategy of coping narratives, an alternative that has not yet been fully implemented. The second part outlines the conditions necessary to generate an alternative coping narrative and discusses the outcomes of this alternative. Finally, the third part proposes evaluation criteria that can be used in constructing an alternative coping narrative.

The first objective of this viewpoint is to introduce policy makers to the advantages of using narrative evidence [9,13-15] during a disease outbreak or pandemic, such as the COVID-19 pandemic. To date, health organizations have used narratives mainly in the fields of clinical care and education. These narratives usually focus on disease prevention, disease management, patient recovery, and psychological and social resilience [17]. However, using narrative evidence as a tool for changing attitudes and behaviors can be effective not only for long periods of clinical care intervention but also for shorter periods that require the public to change its behavior.

The second objective of this viewpoint is to propose an alternative coping narrative based on health and risk communication approaches and models. Throughout human history, authorities have tended to employ apocalyptic narratives that include threats, intimidation [48], and the use of “good” and “bad” protagonists. However, alternatives are available to this apocalyptic narrative.

The third objective of this viewpoint is to propose five conditions for constructing and using alternative narrative evidence to launch a communication campaign on social media.

The fourth objective of this viewpoint is to propose criteria for evaluating a narrative’s effectiveness and potential to generate change: narrative mechanisms, rhetorical concerns, and empirical questions.

Based on the aforesaid, policy makers can use narrative evidence not only for long-term interventions but also during disease outbreaks and pandemics when members of the public are called upon to follow guidelines and change their behavior. In the next section, we propose an alternative coping narrative model instead of the apocalyptic narrative model commonly used during disease outbreaks and pandemics.

The literature underscores the importance of segmenting [91,92] and mapping [93,94] each subgroup in the population to tailor [95,96] the information and media campaign to the barriers, risks, concerns, and unique needs of each group. During every disease outbreak or pandemic, some groups are at higher risk than others. The narrative put forward by the authorities must communicate and distinguish between actions taken for the benefit of the public at large and those targeting specific at-risk groups. For example, during the COVID-19 pandemic, young people between the ages of 18 and 30 years without any underlying conditions are at lower risk of serious illness. Therefore, the authorities must tailor risk messages to particular at-risk groups without resorting to intimidation.

The strategy of barrier reduction entails reducing existing difficulties and barriers to the adoption of desirable behavior [97,98] and offering incentives and solutions to the population. This strategy can be useful during a disease outbreak or pandemic. One of the barriers to adoption of desirable behavior during the COVID-19 pandemic is the difficulty of maintaining social distancing. By means of narratives that illustrate this barrier while providing ways of coping with it, the public can be given solutions for complying with social distancing without the use of intimidation.

Research has shown that role models, identification, and social support can be used effectively in interventions to change health behavior [38,99]. According to Bandura’s sociocognitive theory, individuals can learn a behavior by observing a model. Moreover, they will be more likely to perform this behavior if they see positive and appealing reinforcement for the behavior. The use of role models boosts self-efficacy in that the characters demonstrating a particular health behavior provide viewers with tools and skills.

The use of role models to teach social behavior through narratives can be implemented during disease outbreaks or pandemics as well. During the COVID-19 pandemic, for instance, narratives using positive role models can demonstrate the advantages of following the guidelines, thus strengthening people’s self-efficacy. Likewise, patients who survived COVID-19 can share their experiences and give tips to the public. Leaders dealing with the crisis can also serve as role models through their behavior. For example, during the COVID-19 crisis, New Zealand’s Prime Minister Jacinda Ardern announced a 20% salary cut for herself and the members of her cabinet [100].

Beyond strengthening individual self-efficacy, narratives can strengthen collective efficacy by illustrating the community’s ability to provide social support for its members. A community’s collective efficacy can be reinforced through stories that emphasize solidarity and mutual support for weaker community members during a health crisis or pandemic. For example, during the COVID-19 pandemic, civic organizations and individuals can support older people under lockdown by helping them obtain food and medicine.

During a health crisis, authorities sometimes worry that at-risk population groups will reject relevant information for fear of being stigmatized by the media and society. The literature points to the possibility of self-stigmatization or social stigmatization if media outlets use sensational means to communicate a risk [101]. For example, during the COVID-19 pandemic, the Asian American community expressed strong fears of being blamed for the spread of SARS-CoV-2. Therefore, policy makers should stress stigma reduction and create narratives that underscore social solidarity.

Scholars investigating the topic of risk found that dealing with uncertainty is a major challenge in risk assessment and management. According to Frewer et al [102], public health experts tend to believe that the public is incapable of coping with the uncertainties associated with risk management. Contrary to this opinion, studies in the risk communication literature indicate that in risky situations [70,71,103,104], especially those that involve uncertainty [105], the public wants full information transparency. Transparent communication does not provoke negative reactions among the public; rather, it helps reduce negative feelings and increases the public's respect for the risk-assessing agency [79].

Sandman and Lanard [106] emphasize the need to “proclaim uncertainty,” advising authorities to disseminate tentative information if it is the only type of information they have. A number of studies conducted during pandemics, such as the Ebola outbreak in the United States [107] and the polio outbreak in Israel [108], reinforced Sandman and Lenard’s hypothesis by showing that the public wants organizations to communicate uncertainty. Furthermore, the public becomes impatient and uncooperative when authorities only give them partial or selective information [109].

Table 1 summarizes the strategies and components of a pandemic coping narrative based on health and risk communication approaches. For each apocalyptic pandemic narrative, an alternative pandemic narrative that offers coping strategies is presented to help health organizations transform one narrative to the other. Figure 1 depicts an apocalyptic pandemic narrative, in which COVID-19 is depicted as an apocalyptic explosion of an atomic bomb causing severe harm to humans. Figure 2 depicts an alternative pandemic narrative that offers coping strategies, using additional tools provided to people to cope with the COVID-19 pandemic.

In this section, we explained how an apocalyptic narrative can be transformed into a coping narrative. In the next section, we propose several conditions necessary for constructing and using a coping narrative to launch a communication campaign on social media.

Despite the theoretical understanding that national health authorities should build segmented profiles of their publics [111], this understanding has not yet been fully implemented. During the midst of the H1N1 pandemic, countries were called on to adapt their communication strategies to specific cultural needs [112], pointing to a general lack of such cultural and social adaptation [111]. Although government agencies have long recognized the ineffectiveness of one-size-fits-all messaging [113], studies have indicated that segmentation is still far from adequate implementation [114-118].

Studies show that when health organizations want to communicate facts to the public, they often distinguish between myth and fact [121-123]. This distinction is not neutral and has been found to be ineffective for two reasons. First, when information provided on a website is identified as a myth, people still remember the information, even though it is totally or partially untrue. Second, the public refuses to accept a judgmental approach without scientific evidence. In two studies on public attitudes toward the measles-mumps-rubella vaccine and the seasonal influenza vaccine [124,125], pro-vaccine information from the US Centers for Disease Control website had a “backfire effect.” After being given information intended to refute the supposed connection between vaccinations and autism, vaccine skeptics formed even stronger negative opinions about vaccinations.

Health organizations must provide separate and distinct treatment for any kind of information unit or theory that arises on social networks. For example, social media platforms are filled with rumors pertaining to COVID-19 [126,127]. Health organizations have generally used a single approach to handle information they consider unfounded, without sufficient differentiation. Thus, they countered the claim that the virus originated in a laboratory in Wuhan in the same way they countered the proposal to eat garlic as a cure or the notion that the virus can be killed through exposure to sunlight. These units of information differ, and each deserves to be engaged and addressed on its own merits.

According to Singhal [128], “the Positive Deviance (PD) approach is based on the premise that in every community there are certain individuals or groups whose uncommon behaviors and strategies enable them to find better solutions to problems than their peers, while facing worse challenges and having access to the same resources. However, these people are ordinarily invisible to others in the community.” The PD approach seeks to identify and streamline existing resources deriving from within a community rather than to import external “best practices.” Such practices are distributed and implemented over time via social networks [129,130].

Health organizations should seek out positive deviants [131-133] who propose creative (“outside the box”) solutions for stressful situations emerging from the COVID-19 crisis that other members of the community did not find.

Storytelling relies upon realism, identification, and transportation to help people understand different points of view and change their attitudes and health behavior [134]. According to Lee et al [134], “narrative communication is context-dependent because it derives meaning from the surrounding situation and provides situation-based stories that are a pathway to processing story content.”

According to Larson [135], “educational materials and resources are important, but limited; health officials and educational campaigns often fall short because they craft messages based on what they want to promote, without addressing existing perceptions. Dialogue matters. Strategies must include listening and engagement. We have to get better at this…”