The covid-19 pandemic has generated, fuelled, and amplified a wide range of emotional responses. This is either directly through personal or family related morbidity and mortality, or indirectly through the immense media coverage, political debates, and ongoing impact of our daily lives.

The history of epidemics and pandemics is closely intertwined with our emotional responses to them. The AIDS epidemic generated anxiety, which morphed into panic, paranoia, and discrimination. SARS brought waves of public frenzy and cross-border discrimination. H1N1 felt overwhelming when it started and unimportant after a few months. Ebola created an “ecology of fear.” Zika sparked a continuum of anxiety, inequality, despair, and hope.

Pandemics make headlines, capture the public’s imagination, and ignite their fears in ways that other acute or chronic illnesses do not. In fundraising and aid efforts for humanitarian crises, emotions are understood and accepted as a core part of crisis communications. And there is growing evidence that emotions have an important role to play in driving protective behaviours and the uptake of interventions, especially in times of public health crises. People experience diverse emotions at a time of a crisis and these have the capacity to influence their interpretation of it and guide their behaviour. This principle should be no different in times of a pandemic.

Research on emotions from a behavioural science perspective has shown that initial cognitive processing of a situation gives rise to emotions, which in turn guide the further, more elaborate, cognitive processing which drives our behaviours. This framing helps move the conversation away from a debate of whether reason or emotion is more dominant in the functioning of the human mind. Humans are capable of complex behaviours, and emotions have the capacity to change people’s perceptions, attention, and memory by guiding them to focus on the aspects of their environment that they would consider important.

It is reasonable then to consider emotions as determinants that motivate people to take action (or to follow public health guidelines) or not. A systematic review showed that there are emotional determinants (specific emotions) that predispose people towards behavioural responses to epidemics and pandemics and influence the uptake of interventions. In this review, reporting from 75 studies of over 80,000 subjects across a period of 30 years, there was evidence that the emotions of fear and panic had a negative effect on the uptake of public health interventions during past outbreaks, whereas worry and empathy emerged as the key motivators for action. This will be critical to consider as covid-19 vaccinations are rolled out across the world and nations globally are getting ready to face the next few months of the pandemic.

There is a lot to be learned from studying what worked and what did not in past infectious diseases outbreaks.

When AIDS reached Australia in the mid-1980s, what inspired people who faced the highest risk from HIV to take personal protections was not the fearmongering Grim Reaper campaign, but the co-production and sharing of empathetic messaging with the trustworthy community leaders (be it for LGBT+ community, indigenous, or ethnic minorities).

For SARS in Hong Kong in 2003, a positive dose-response gradient between manageable anxiety levels and uptake of personal protective measures was noted. This was largely down to timely, effective, and realistic communication about risks and precautionary measures. But it was not the case from the start and was possible only after local governing bodies and international organisations collaborated to provide accurate information to the public, managing the initial rampant fear and anxiety.

In the case of the H1N1 pandemic, in several countries, the public went from a flooding of fear to a demand for a vaccine, and from panic and exhaustion to suspicion and indifference. Countries like Greece did not conduct any audience research or co-production to inform the content, design, tone, targeting and emotional appeal of communications provided to the public, due to an “emergency” mindset of government and health officials. This led to “top-down” and “one-size-fits-all” communications of questionable benefit. Greece ended up with one of the lowest vaccination coverage rates and one of the highest annual rates of influenza mortality in Europe in 2009.

Fear and anxiety during the outbreak of Ebola in West Africa in 2014 had important roles on multiple levels, ranging from impacts on preventative behaviours to wider health security concerns for policy makers. Once again, the response to the outbreak started becoming more effective in turning the tide once international efforts became more focused and professionals started co-operating with local communities. Anthropological observations showed that the treatment of Ebola had strongly focused on the biomedical aspects alone and disregarded parameters such as community, society, and culture. Consequently, they started to take emotions—expressed as fears and concerns—and traditional beliefs of the members of local communities seriously. Providing hope and education, and local communities and healthcare practitioners working together were decisive factors in tackling the epidemic, compared to the earlier stages when hopelessness, panic, and desperation were dominant. The failure to adopt community engagement methods and take emotions into account was initially neglected, yet eventually proved effective in winning the trust of rural populations.

Most recently in Brazil, during and after the Zika epidemic of 2016, hope and trust were important to managing uncertainty and risk, given the initial lack of scientific evidence about the neurological consequences of the viral infection. The capacity of healthcare workers and caregivers to trust and to co-create hope allowed relationships to develop that cushioned social impacts, reinforced adherence to therapeutics, and enabled information flow.

Pandemics inevitably cause a wide range of emotions. These emotions are shaped by wider social, environmental, and political influences and have the capacity to impact population responses. Understanding human emotions can bring insights as to why people make certain health decisions, why they respond to health crises in various ways, and what meanings they attribute to health interventions, healthcare providers, or public health strategies and policies.

It is unlikely that any policy for the implementation or distribution of public health interventions addressing covid-19 will be able to succeed until public fears that motivate counterproductive behaviours are addressed, and the interplay between perception, emotion, and behaviour in the public is understood well by governments and public health agencies and professionals.

At a time of immense polarisation, governments and public health agencies around the world have an opportunity to make the recovery from covid-19 effective if they stop using the traditional and unhelpful “top-down” communication approach. The general public is not a vulnerable, passive consumer of state messaging. Public health professionals and governments should resist the view that top down messaging should rule and be accepted without question, even when these messages conflict with the beliefs and emotions of their citizens. Public health messages will be much more effective if they are co-produced in equal partnership between people who use services—or consume information—and professionals, and delivered in a clear and consistent way. Greater involvement of local leaders, who are more representative of their communities, and have a better understanding of what they need,  will be fundamental to overcoming this global crisis.

Antonis A. Kousoulis is a public health specialist, Director for England and Wales at the Mental Health Foundation, and a collaborator of the London School of Hygiene & Tropical Medicine.

Competing interests: none declared.