Institutional crisis communication during the COVID-19 pandemic in Switzerland. A qualitative study of the experiences of representatives of public health organizations

Objectives To identify the main challenges in public communication encountered by representatives in Swiss health institutions during the first two waves of the COVID-19 pandemic. Methods In-depth qualitative interviews were conducted with representatives of key public health institutions (N = 25) across Switzerland. Participants were asked to identify barriers, facilitators, problems, and solutions in their public communication. The interviews were analyzed thematically. Results Swiss institutional communication faced internal challenges (e.g., lack of human resources and training, rigid organizational structure), external challenges related to the public (e.g., low health and scientific literacy, low levels of trust), and environmental challenges related to the broader context (e.g., infodemics). At the same time, institutions developed best practices to foster collaboration, promote transparency, and address misinformation. Conclusion Health organizations need a cultural shift to account for the increasing complexity of crisis communication. Their awareness of the importance of communication should match the implementation of enhanced dedicated infrastructures and processes. Practice implications Institutions need mechanisms allowing innovation and adaptation to prepare for future pandemics. Emphasis should be placed on training communication professionals who can design, develop, deliver, and evaluate texts that meet the information needs of the public, enhance health and scientific literacy, and counter mis/disinformation.


Introduction
The importance of crisis communication has long been recognized. For example, before the COVID-19 pandemic, the World Health Organization (WHO) developed guidelines for public health institutions to deploy risk communication during emergencies [1][2][3][4], and many plans exist to prepare institutions by detailing clear steps that they should take [5][6][7][8][9][10][11]. The pandemic, however, differed from recent public health emergencies and caused institutions worldwide to face unprecedented challenges.
Because of the rapidly evolving situation of the COVID-19 pandemic, combined with the complexities of the virus and the diverse responses to the crisis, it was challenging for institutions to provide a cohesive and unified message [12]. This led to public confusion and mistrust, making it even more challenging to control the spread of the virus [13]. Furthermore, it was the first time in history that crisis communication took place in an "infodemic" context; that is, in an environment with an overabundance of information, including fake news, misinformation, and disinformation [14]. While mis/disinformation has been an ongoing issue in crisis communication (see, e.g., [9]), the pandemic has highlighted the need for clear operational criteria to manage this problem. Managing mis/disinformation is now recognized as a significant challenge that requires the implementation of guidelines and strategies to mitigate its impact [15][16][17][18]. Finally, the emergence of social media as a driver of mis/disinformation has highlighted how previous guidelines have paid little attention to social media, except for seeing it being a potential means of quickly reaching a larger audience. Since the COVID-19 pandemic, social media has become a critical tool for information sharing, and it is essential to develop effective strategies to combat misinformation and disinformation on social media platforms [6][7][8][19][20][21].
The features of the COVID-19 pandemic rendered guidelines and pandemic plans at least partly irrelevant. Indeed, although it had already been argued by 2009 that effective public health communication needs to consider the broader context [22], communication in emergencies has mainly been seen as a "simple" information transfer,

Results
The final sample for the study consisted of 25 individuals representing 23 public health institutions. The average age of the participants was 49.5 years, and most were male (64%). Among the representatives at the cantonal level were seven heads of health departments, six cantonal doctors (i.e., medical professionals serving as chief public health officers for their respective canton), and five communication specialists. The majority of the cantonal institutions included in the study were in the German-speaking part of Switzerland (65%), followed by the Italian-speaking (13%) and French-speaking parts (4%). At the national level, five institutions were represented (21%), and interviewees included communication and media specialists from public health offices, representatives of the COVID-19 task force, and members of the national ethical commission.
The thematic analysis of the interviews highlighted four main themes: challenges at the organizational level, challenges at the public level, challenges at the environmental level, and facilitators and best practices (See Table 1).

Challenges at the organizational level
The first main theme relates to the organizations' readiness to respond to the unexpected and extraordinary situation caused by the COVID-19 outbreak (Table 2). Although the interviewees reported being well prepared to face the new situation, many agreed that they had faced organizational challenges that prevented them from communicating as effectively as they would have liked.
The first subtheme to emerge was the lack of human resources. To respond to the emergency, many institutions reported reorganizing human resources so that internal staff were tasked with dealing with communications [Q1]. However, this reorganization did not meet the increased needs. There was a lack of human resources to perform the various tasks related to communicating with the public, resulting in an increased workload for everyone involved. This harmed the employees' well-being and the quality of the work [Q2 and Q3].
Many reported that people in communication teams sometimes lacked competence because they had no communication background, especially when they had been transferred from other departments to the communication teams [Q1]. In other cases, the participants had Table 1 Themes and subthemes derived from the interviews.

Main themes Subthemes
Challenges at the organizational level A last subtheme was the rigidity of existing organizational structures, that is, their inability to be changed or adapted. This rigidity was observed when trying to secure additional financial resources or move existing resources, which was often impossible or required great effort [Q7]. Additionally, many stressed how a public office's normal operations and procedures were ill-suited to the flexibility and creativity required in an unknown and evolving situation. Here, rigid protocols were mentioned as a challenge; they prevented a trial-and-error approach that would have provided valuable insights into the most effective communication strategies [Q8] and significantly slowed down communication [Q9].

Challenges at the public level
The second theme related to the public itself (Table 3). Four characteristics of the public seemed to have played a role in making communication from the institutions more complex and less effective.
First, many stakeholders mentioned their constant struggle in daily communication based on scientific evidence. Indeed, they felt that the public lacked the necessary health and scientific literacy to fully grasp its meaning [Q10]. Major efforts were made to provide information in ways that everyone could understand and to constantly evaluate the impact of messages [Q11].
Further, interviewees reported that the high and unrealistic public expectations also challenged communication. People expected certainty, which was unrealistic due to the uncertainty of the virus's lifecycle, development, and spread. These expectations burdened the institutions and may have compromised the quality of communication efforts [Q12].
Communication was also severely hampered by the skepticism and denial of part of the population. While most recognized that only a few held such beliefs, the damage done to the effectiveness of communication was felt to be significant. Not only were those who did not believe in the need for emergency measures less likely to take action but persuading people in a state of denial proved to be much more difficult than simply informing them, placing additional strain on already scarce resources [Q13].
A final subtheme was the perceived low or declining level of public trust in institutions and science, which harmed people's willingness to accept recommendations. Some attributed it to a general trend, independent of Note: The participants' quotes have been translated from the original language to English by the authors for the purpose of publication. For representatives at the federal level only gender and age are provided to preserve anonymity.

Table 3
Challenges at the public level -Participants' quotes.
Q10 "Suddenly scientific processes took place in public, scientific results or results of studies were uploaded on preprint servers and then discussed in publiceven the collegial discussion took place in public, instead of in the academic setting as before, where it was only published when there was agreement. That was something that the public, the Swiss public, couldn't deal with in the beginning. They didn't speak the same language. Science said one thing and the population understood it differently. "For example, people who look after community management or citizens' enquiries are confronted with letters with harsh formulated criticism for one and a half years on various points. And their task is to provide an answer that satisfies the citizen and what they receive as a reply is that it is all nonsense.
[…] One tries to have a satisfactory correspondence with these people but this is not possible.

Challenges at the environmental level
A further main theme was the role played by the environment (Table 4). This includes the factors that added a layer of complexity to the delivery of critical information and the subsequent adoption of protective measures by the public.
The first subtheme was the disruptive impact of the "infodemic." Many recognized that mis/disinformation on social and mass media significantly hampered institutional communication. In addition to its direct impact on public attitudes and behavior, mis/disinformation forced institutions to devote considerable resources to identifying and, where necessary, countering it. This rendered the investment in communication more complex and demanding, both in terms of time and money [Q16]. Another subtheme was the high level of uncertainty and the fact that scientific knowledge was evolving rapidly. Many reported that this was particularly true during the first pandemic wave, when information was scarce, and new evidence became available daily, sometimes completely changing how the pandemic had to be approached [Q17]. For the interviewees, the inability to give the public a definitive answer, coupled with the lack of scientific literacy, severely hampered communication effectiveness [Q18].
The respondents also frequently mentioned the issue of competing interests between healthcare and the economy, which often resulted in conflicting messages to the public. Specifically, many mentioned that the public found the dichotomy between ensuring public health and the need not to significantly damage the economy particularly confusing [Q19]. Sometimes, the discussion between health authorities and the business sector about what to prioritize left the public wondering where the truth was.
Many cited the epidemiological situation and preventive measures in neighboring countries or other cantons within Switzerland as major sources of confusion and as important communication challenges. In particular, stricter or looser regulations enforced elsewhere were often seen as not doing enough or going too far. This problem was exacerbated by the fact that the Swiss public has historically heavily relied on news from Italy, France, and Germany because of their proximity and the variety of their offering and, especially during the first wave of the pandemic, the epidemiological situation differed greatly between countries and within Switzerland [Q20].
A final subtheme related to the interaction with news media. A large number of respondents recognized the media's positive role in raising awareness and reinforcing institutional communication [Q21], and in some cases, public reaction to news stories had even been useful for institutions in predicting reactions to the introduction of new measures [Q22]. The news media, however, demanded constant updates, partly because the pandemic measures (e.g., general lockdown) left journalists with little else to cover. This put additional pressure on institutions to ensure a constant flow of information to the media, in addition to informing the public [Q23].

Facilitators and best practices
A last main theme from the interviews included strategies and good practices that interviewees had implemented and that helped facilitate communication (Table 5).
Several respondents had ideas about how internal structures and processes could be redefined to facilitate public communication. Many highlighted the importance of incorporating infodemic management into policies. This included having human resources with specific training in this area [Q24]. Here, many stressed how listening (e.g., through social media monitoring) was a helpful tool for gaining basic insights into the mood and needs of the population and had enormous potential to improve the perceived quality of the information provided and increase compliance with recommendations [Q25]. However, a number pointed out that the ability to listen and having skills to use new communication tools effectively were not enough. To communicate successfully, institutions also needed to respond quickly, be creative, and be flexible. All these characteristics, according to many of the interviewees, were not reflected in the standard structures and processes of the public institutions [Q26].
Many reported having learned, often through trial and error, strategies to make their messages more effective. In general, these strategies had two main objectives, seen as fundamental to the messages' persuasiveness, which were increasing trust and ensuring understanding. Regarding trust, the strategies addressed the sender, content, and design "In the Italian-speaking part of the canton, people watch a lot of Italian television. They saw these pictures from Bergamo and of course, they had a completely different effect on the Italian-speaking people than on the German-speaking people in the canton. These people were much more afraid that it will soon be the same in our canton as it was in Bergamo because we were bordering there. And we couldn't absorb that at all at the beginning and deal with it. They were impressed by the pictures they saw from Italy. It took some time until we understood why they were reacting with much tougher demands such as to close the borders immediately and so on. Note: The participants' quotes have been translated from the original language to English by the authors for the purpose of publication. For representatives at the federal level only gender and age are provided to preserve anonymity.
of messages. One that was often discussed was the importance of having a "face of the pandemic"; that is, a person responsible for all communication who would be (or become) familiar to the public [Q27]. Many participants also stressed how showing empathy and targeting messages would make people feel included. Here, many stressed that messages are best received when they are timely and relevant, delivered through different platforms, and using the preferred language of their audience (s) [Q28]. Finally, the participants mentioned the importance of consistency in content and design, citing, for example, how using the same template to communicate preventive measures across the country and through the different phases of the pandemic was particularly well received by the public [Q29]. The participants were also able to name several strategies to ensure understanding. Many agreed that messages should use simple words, focus on only one aspect, and present only as much information as necessary to meet the information needs at a given time so as not to overload the public [Q30]. Further, they mentioned strategies that could be useful to address the effects of the infodemic, in particular those linked to the public's lack of health and scientific literacy, such as breaking down scientific evidence to make it more accessible, addressing uncertainty rather than avoiding it, and using graphical tools to make the messages easier to understand [Q31].
The respondents often emphasized how setting up mechanisms to coordinate the communication activities of the different stakeholders (e.g., cantons, the federal government, professional associations, hospitals) would improve communication by ensuring the delivery of a consistent message and avoiding adding confusion. In practice, this meant working together in communication planning to guarantee that everyone's needs would be taken into account and collaborating in message delivery, when involving a partner would make it more effective [Q32]. Second, some mentioned the importance of increasing synergies between public institutions and academia, since both can provide important insights and facilitate information delivery to the public [Q33]. Finally, many recognized that close cooperation with the media was essential. In particular, many stressed the importance of earning the media's trust so that they could rely on the institutions for their information needs while at the same time providing important insights into the public's possible reactions and giving the institutions time to prepare and adapt their communication [Q34].
A final subtheme was the commitment to evaluation, recognized by many as key to the success of public communication. However, many reported that systematic and regular evaluation of communication was hardly possible because of a lack of resources and time due to the rapidly evolving situation. The decline in COVID-19 infection rates during the summer of 2020 was often seen as an opportunity to look back on the work done during the first pandemic wave and to gain valuable insights. Several participants made significant changes to their communication practices based on evaluation results and reported significant improvements in their communication [Q35].

Discussion
We explored the views of people responsible for institutional public communication in Switzerland during the first two waves of the COVID-19 pandemic. To our knowledge, this is the first study to give a broad account of the lived experiences of those in charge of crisis communication with the public during this period. We identified important challenges in public institutional communication that can advance knowledge of crisis communication.
First, we observed organizational challenges. Although the lack of resources to adequately deal with the extraordinary situation was an issue, the main obstacle to public communication seems to have been related to the lack of specific skills needed to make the institutions' voices heard in the information landscape of the time. We also showed how organizational rigidity impeded the flexibility and creativity needed to face new situations. Therefore, investment is needed to train professionals to manage communication in an infodemic context. The WHO framework for infodemic management [17] has already been Table 5 Facilitators and best practices -Participants' quotes. Q24 "For us, it was clearly human resources first because when you have peaks of 4000 comments or 3000 comments in one day, you just need a human to be able to deal with them. "The strategy had to be adapted a bit because you can't talk in the same manner when you have 300 or even 3000 followers, whereas now we have half a million.
[…] Very quickly, we had to put things in place to be able to respond to the community appropriately and also in writing. Indeed, they need not only to hear, but also to see, to read and a lot of visual content, which is important on social networks. Thus, we had to bring a lot of visual elements." [Male, 53, Federal level] Q27 "And that was also based on the analysis of our media managers, who then said, somehow, I am well received by the people, I am credible. The recognition effect is there, and I was now Miss Corona in our canton." [Female, 50, Cantonal doctor] Q28 "Social media is certainly more important. But you can still see that the older population goes to the website or informs itself via the newspaper or the free newspaper. Depending on the demographic and age group to some extent, we used different channels." [Female, 53, Head of cantonal health department] Q29 "For the population, we always had the goal that the "This is how we protect ourselves" campaign should be this anchor for the population as a recognition, in the sense of 'Okay, it is information that comes with the Swiss cross below, it's from the federal government'. We know from other evaluations, impact measurements, and surveys that this Swiss cross generates a lot of trust in the population." [Male, n/a, Federal level] Q30 "But we must always make a selection because the great risk is to focus on correcting the details and then lose what the basic messages are, so a few but repeated messages, and not to run after all the fake news. "We have established different instruments relatively early on to see if it will have the impact we would like it to have. We have had our own fake news media review for a few months now where we also look at what information there is that we might have to react to. We also had a summary of all the media coverage from an external source several times a week, who then gave his input, so that we also have an external view of the whole thing. We also commissioned a resonance and reputation analysis from the University of Zurich. We look at exactly where we stand, where the problems are. We see how we have to adjust our communication so that we achieve what we want as far as possible." [Female,57,Federal level] translated into training to empower professionals [31]. The challenge is to ensure that these professionals become an integral part of the staff across public health institutions. Moreover, institutions need to critically reflect on their internal decision-making processes to ensure that those in charge of public communication have enough room and flexibility to be creative and to try out new things that have been shown to work elsewhere. Alternative governance models implemented in the private sector may inspire change toward more flexible public health organizations [32]. Second, we identified issues related to the public, particularly their low levels of trust in institutions and their limited health and scientific literacy, sometimes leading to unrealistic expectations and reduced compliance with recommendations. Trust, health literacy, and scientific literacy have been studied extensively in health communication, and their centrality in explaining the impact of messages is established [33,34]. However, the fact that they are still among the main challenges, as a large body of evidence published since the COVID-19 outbreak shows [35][36][37], suggests that something is still missing. This could be because we still rely on conceptualizations of trust, health literacy, and scientific literacy that do not fully consider the complexity of the current information landscape, which is dominated by social media and user-generated content with a high risk of mis/disinformation [38]. To overcome this barrier, it will not be enough for countries to invest in developing interventions to build public trust and empower health and scientific literacy; scientists must also join forces to advance their understanding of these concepts and identify effective ways to target them in collaboration with the institutions themselves.
Third, we observed challenges related to the environment, some of which were beyond anyone's control. For example, that information from other cantons and countries created confusion among the public could barely be avoided in a world where people are increasingly interconnected. In other cases, however, something can be done. For instance, the media landscape can be improved. Although there is evidence that the media coverage of the pandemic in Switzerland was relatively accurate during the first two waves, suggesting that there had been good cooperation [39], institutions must develop mechanisms to ensure constant feedback to and from the media. It is important not to turn media from a useful ally into an obstacle to effective communication, as occurred in some countries [40]. Existing literature on media advocacy [41] can provide useful insights on how to do this successfully.
We also identified ways to overcome challenges. Institutions know that public communication is important, but this needs to translate into a cultural shift. In practice, this does not mean simply ensuring that communication specialists are routinely hired as an integral part of the workforce; rather, it requires everyone involved in communication planning within a public health organization to have a comprehensive understanding of the central role of communication in improving population health and of the steps needed to ensure its effectiveness. Only with this sensitivity can it be expected that institutions devote sufficient resources to communication, that policies are enforced to allow the necessary degree of flexibility, that investments are made to build trust and improve public health and scientific literacy, and that actions are then taken to establish strong collaborations, ultimately laying the foundations for better communication with the public. To achieve this goal, the scientific community needs to develop evidence-based training specifically tailored to the needs and circumstances of those in charge of communicating with the public. While efforts are needed to advocate for its adoption, we believe that the current post-pandemic phase, with the experience still fresh in people's minds, is a perfect window of opportunity to build in this direction.

Conclusion
This paper offers unique insights into the challenges that Swiss health institutions encountered in public communication during the COVID-19 pandemic. As the pandemic unfolded, different regions of Switzerland faced diverse epidemiological situations and implemented various preventive measures. Therefore, our findings may have implications beyond Switzerland and provide a useful indication of the communication challenges that health institutions in other countries encountered during the pandemic. Overall, our findings suggest that the established structures and practices for managing communication in emergencies, developed over more than 30 years of research, were insufficient to deal with the particularities of this pandemic. The high level of uncertainty, the public's heavy reliance on social media, and the infodemic environment demonstrated the need to develop and implement risk communication management processes to ensure the effectiveness of public communication. Overall, our findings point to the need for a cultural shift in which institutions recognize the importance of communication and restructure their offices and resources around it. Hypothetical future public health emergencies will certainly share the characteristics of the COVID-19 pandemic. This means that now is the time for healthcare organizations to synthesize the lessons learned and grow in how they plan, implement, and evaluate risk communication.

Practice implications
The study offers a novel perspective on the internal, external, and environmental obstacles that health organizations now face in crisis communication and proposes a cultural shift in these institutions to account for its new complexity. Five main recommendations for health institutions to strengthen their public risk communication can be derived from this work. The first, through organizational change, is establishing communication offices with sufficient resources to manage the complex communication landscape during public health emergencies. The second is to train staff in communication, taking into account not only evidence from health communication, social marketing, and health campaigns but also infodemic management as a field in its own right. The third is to develop a framework for managing risk communication that not only considers traditional theories and models in the field but also recognizes social media's role in spreading mis/disinformation. The fourth is to implement a structure for designing, creating, delivering, and testing messages to respond to the information needs of individuals and communities. The fifth is to include a strong component of health and scientific literacy and how to strengthen them in individuals and populations.

Funding
This work was supported by a research grant awarded to SR and ND by the Swiss National Science Foundation [Special call on Coronaviruses, grant number 31CA30_196736].

Declaration of Competing Interest
None.