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 Table of Contents  
COMMENTARY
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 13-16

Role of public health literacy during COVID-19 pandemic, its implications and future recommendations- An analysis from India


Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India

Date of Submission17-Nov-2020
Date of Acceptance07-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Sudip Bhattacharya
Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_8_20

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  Abstract 


The term “Health literacy” was coined by Ratzan et al. in 1970s stating for the littlest health education in schools. But still this term is almost new and is in its early phase of development. Though many attempts have been made in the past to define health literacy. WHO construed it as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”. Health Literacy not only focuses on the individual behaviour-oriented communication but also on the various determinants of health like environmental, social, political etc., thus it is ahead of the cramped concept of health education. If health education methods go beyond the bounds of “information diffusion” and bring about interaction, participation and critical analysis, such kind of approach will lead to health literacy, personal aid and social benefit by enabling adequate community action and will contribute to the advancement of social capital. We believe that nowadays, health literacy is limited to the non-communicable diseases, Maternal and Child Health care and health education is provided to the citizens which is more of kind a bureaucratic formality rather than serving its real purpose. However, this COVID-19 pandemic has become an eye opener for us and revealed that health literacy as a part of health education, is equally important for communicable diseases as well and not only system preparedness, but individual preparedness is also the key to deal with the actual life problems during crises situations.

Keywords: COVID-19, Health belief model, health literacy


How to cite this article:
Sharma N, Bhattacharya S. Role of public health literacy during COVID-19 pandemic, its implications and future recommendations- An analysis from India. J Public Health Prim Care 2020;1:13-6

How to cite this URL:
Sharma N, Bhattacharya S. Role of public health literacy during COVID-19 pandemic, its implications and future recommendations- An analysis from India. J Public Health Prim Care [serial online] 2020 [cited 2021 Jan 27];1:13-6. Available from: http://www.jphpc.com/text.asp?2020/1/1/13/305990




  Problem Statement Top


With the emerging of coronavirus infection into a pandemic it has contrived individuals to amass knowledge about the health and adopt good hygiene practices at nimbling rate.[1] Unfortunately to combat this COVID-19, no specific treatment is available to us till date. Prevention of infection and symptomatic treatment are the only available options as per CDC & WHO.[2] It is recommended from the international organizations like WHO, CDC to adopt preventive measures such as social distancing, hand washing, wearing gloves and masks and many more. Besides providing health information to people regarding hand washing and maintaining social distancing, the latest advices and recommendations from authentic health agencies are also being provided.[3] Although, people are trying to adhere to these preventive measures but due to lack of health literacy they are practicing in a wrong manner, as we can see in the following examples:

Example 1: After the coronavirus pandemic people were being advised to follow Social distancing everywhere. Circles, squares, foot markings, lines with at least 3ft apart were drawn in front of grocery shops, pharmacy stores, vendors cart (thela) etc., expecting people to oblige the rule but it was found out that people just dropped their empty bags or slippers in those circles or squares representing its their turn and themselves they were standing at the side without maintain social distancing and chit chatting.

Example 2: The rationale behind the use of mask for breaking the transmission of coronavirus is adequately exercised by the health care personnel's only. There was just a statutory warning of wearing mask, without any training on how to wear a mask properly, when, and how to discard it. Most of the people wear the mask in opposite direction and keep on touching it from the front with the contaminated hands. Beyond 6 hours even when the mask becomes moist, they still use it. For disposal also the masks are thrown hay way without following proper disposal guidelines.

Example 3: Government on every day basis is emphasizing on using the digital modes of payment. This can be relaxed for illiterate and poor people who are not sound with digitalization and does not even have smartphones, but even the literates are exchanging notes without washing or sanitizing their hands before and after touching the money.

Example 4: The proper steps of hand washing have been promoted through media right from the beginning but people are reluctant to wash hands even for 20 seconds forget about following those steps. Reason being most of the people are not aware of those steps, secondly those who are aware don't want to follow it.

Nevertheless, these case scenarios show the deliberate behavior of people neglecting the preventive measures and precautions. Though, there are people who are helping in creating infection-free space, but the free riders who hang out together and do not follow the preventive measures.[4] However, the risk of getting infected depends upon how much the other person is strictly compliant and committed to follow preventive measures.[5] The unwilling people's behavior during this pandemic is not only unjustifiable but is also immoral towards the individuals specially those who work in high risk areas. These are just the few case scenarios among hundreds of cases which evidently proves the weak health system and exposes the level of health literacy that exists during this pandemic time and invokes for the health system rebooting.

This clearly shows that people have impoverished knowledge about health, and it is an underestimated problem not only nationally but internationally as well.[6]

The term “Health literacy” was coined by Ratzan et al. in 1970s stating for the littlest health education in schools. But still this term is almost new and is in its early phase of development.[7] Though many attempts have been made in the past to define health literacy WHO construed it as “ the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”. Health Literacy not only focuses on the individual behaviour-oriented communication but also on the various determinants of health like environmental, social, political etc., thus it is ahead of the cramped concept of health education. If health education methods go beyond the bounds of “information diffusion” and bring about interaction, participation and critical analysis, such kind of approach will lead to health literacy, personal aid and social benefit by enabling adequate community action and will contribute to the advancement of social capital.[8]

We believe that nowadays, health literacy is limited to non-communicable diseases, Maternal and Child Health (MCH) care and health education is provided to the citizens which is more of kind a bureaucratic formality rather than serving its real purpose. It is also given in a fragmented approach; the concept of holistic approach is completely missing in the health system. We are focussing on the quantity only not the quality, as an example during an audit, we are more interested in how many immunization training session has been conducted in a particular health facility, how many Accredited Social Health Activist has been trained in MCH care, how many sessions is conducted in health facilities on hand hygiene, training on cough etiquette in a Tuberculosis clinic and calculating the training hours/periods, ignoring the quality of such training sessions.

By this way, we are making two mistakes simultaneously:

Firstly, we are approaching for health literacy in a myopic way, like we are targeting a specific population of health sector for training, which should be a multisectoral approach.

Secondly, we are focussing on behaviour change of adult peoples, which in itself is a difficult and lengthy process, ignoring the “Catch Them Young” concept completely.

However, this COVID-19 pandemic has become an eye opener for us and revealed that health literacy as a part of health education, is equally important for communicable diseases as well and not only system preparedness, but individual preparedness is also the key to deal with the actual life problems during crises situations.[6]

According to WHO “Health education comprises consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health”. Nevertheless, health literacy is beyond reading pamphlets, it is to empower people for accessing health information and use it wisely. It entails in accomplishing personal skills, level of knowledge and confidence to ameliorate not only personal but community health as well through lifestyle changes. Thus, health education is a part of health literacy that enables people to improve their health on their own and it takes time.[9]


  Role of Health Belief Model in Corona Pandemic Times: Is it Tangible? Top


The question here lies is how can we do it? Is the answer to this is through “Health Belief Model” but then what it is? Health Belief Model (HBM) was framed by social scientists at the U.S. Public Health Service in the early 1950s to figure out the reasons for not adopting disease prevention strategies or screening tests by the people that helps is early detection of the disease. This model advocated that probability of adopting any behaviour by an individual depends upon its own belief regarding personal threat due to disease and belief in the recommended health behaviour effectiveness.[10] It is an outstanding public health framework that have been used in areas like vaccination, medication adherence, behaviour modification etc., to study the people's perception.[11],[12]

This model has six constructs and is derived from psychological and behavioral theories.[10] HBM constructs during COVID-19 pandemic are, firstly “Perceived susceptibility” - This deal with person's subjective perception of the risk of acquiring an illness or disease. For example, some people have this myth that if they are consuming hot water, they will never get infected from coronavirus infection as the virus gets killed due to hot water consumption. So, they even go for morning walks, without wearing masks or maintaining social distance. Second is “Perceived severity”, it is also called as “perceived seriousness” this means individual associate a negative consequence with the disease or the illness. For example, some people believe that if they acquire coronavirus infection they will definitely die as there is no medicine or vaccine to cure this deadly disease.

Third is “Perceived benefits” – it refers to individual's perception to accept the suggested health actions and perceive it as beneficial. Like some people are judiciously washing their hands with soap and water for 20 seconds. Fourth is “Perceived barriers” which means individuals feelings on the obstacles in performing any recommended health action. For example, some people do not wear masks because it is expensive, or they feel suffocated while wearing it.

Fifth is “Cues to action” which can be internal or external and refers to the impetus that initiates the decision making for accepting the suggested health action. An example of external cues, some doctors consumed Hydroxychloroquine tablets because their colleagues also took the tablet who were working in triage area of COVID-19 patients. A person though didn't have any history of travelling but developed mild coryza like symptoms and started taking precautions as recommended by the Government. Lastly “Self-efficacy” which refers to the individual's capacity to perform the suggested health action successfully with full confidence. Like some doctors are performing surgeries even without proper PPE kit believing that they will not acquire coronavirus infection.


  What can be Done? -A Multisectoral Approach for Behavior Change Top


It is the time to refrain from the “knee jerk action” and think rationally to act amiably for fruitful results. A “Multisectoral approach” (MSA) can fulfill all the aspects and escalate health literacy. MSA attributes to a meticulous collaboration of stakeholders with other sectors for not only for policy and decision making but also for its implementation. By dovetailing all the expertise of different , the health outcome can be enhanced as all of them work together to achieve a shared goal.[13] MSA also focusses on the social determinants of health as well on people's behaviour aspects which if not taken care of can lead to many health inequalities.[14]

As it is already discussed in the above paragraphs, behavior cannot be changed over nightly, by imposing a short notice to the people (like wearing masks), it is an ongoing long term phenomenon, which should be focused upon on daily basis and audited regularly by the trainer as per the settings.

So, right from childhood the necessary preventive measures and precautions should be inculcated among children so that it becomes their habit. Investing into children for upgrading health is one of the cost-effective and long-lasting measure.

This can be done in schools in urban areas and in rural areas we can seek the opportunity of utilizing our “Anganwadi centers” which prepares the child for their exposure to outside world. The simple hand washing steps on repeat basis can be demonstrated by the Anganwadi worker and made to perform by the children. Children can be trained on cough etiquettes right from the beginning, this should not only be for now but to be continued in future also. Children can be made to accept and adapt these basic measures. These elementary yet important measures can make children a better individual in near future and improve health literacy [Table 1]. Use of subject like “Home science” can be employed for making masks right from the growing days of children. This simple act should be made mandatory to not only make children realize the importance of using the masks but will also help them in the crisis's situation [Figure 1].
Table 1: Proposed options for changing health behavior at different settings

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Figure 1: Multisectoral convergence of different government sectors

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Cough etiquettes can be taught in schools, health centers by teachers/health workers whenever someone encounters a person/child with cough and cold. For this simple behavior change we should not wait for a Chest Specialist in a tertiary care, during a clinical visit [Table 1].

Since time memorial, traditional Indian culture have always laid emphasis on greeting everyone with “namaste”. The added benefit of this nontouch technique is a certain distance can be maintained between individuals and it also helps in preventing disease like influenza.[15] This simple gesture of greeting people with folded hands can be taught to children right from childhood with making them realize its importance too.

Another sector which can be involved in promoting health literacy is our “food industries”. Though there are guidelines for Basics of handling food safely that is “food safety practices” but individuals working in these areas should be trained and retrained frequently to wash their hands and wash the vegetables & fruits properly before using them. The guidelines should not be just there on the papers, but a strict vigilance should be there for bringing these activities into action.


  The Conclusion and Recommendation Top


Government and health authorities are supplicating people to understand their individual responsibility and help in breaking the spread of COVID-19 disease. In such hard times, “human rights and personal freedom, democracy, social responsibility, and public health action” are on stake.[6] Government should perform knee jerk response to mitigate the acute crisis as well as keep a long term vision for health education of the community during this pandemic. This is because, we assume that due to emerging and re-emerging diseases, more outbreak will occur in the future and the truth is, we have to live with this, Eventually, we assume in this way the health literacy can be increased and health system strengthening takes place, in a sustainable way. We also expect that in this way people will adhere to the preventive measures in a best possible way both at individual and community level to health advices for upcoming periods of crisis. Health literacy should be encouraged to benefit the society which can be done by enabling people who require services and need of information and also for the people who can afford and persuade the availability for all.[6] Health literacy will also delve into the latest developments in participatory approaches to arbitrate skills development by the people, enhance knowledge to maintain good health. With the help of other sectors in contributing to health literacy and strategic alliances with the education sector this can be achieved.[8]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zarocostas J. How to fight an infodemic. Lancet 2020;395:676.  Back to cited text no. 1
    
2.
Noorwali AA, Turkistani AM, Asiri SI, Trabulsi FA, Alwafi OM, Alzahrani SH, et al. Descriptive epidemiology and characteristics of confirmed cases of Middle East respiratory syndrome coronavirus infection in the Makkah Region of Saudi Arabia, March to June 2014. Ann Saudi Med 2015;35:203-9.  Back to cited text no. 2
    
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Prem K, Liu Y, Russell TW, Adam JK, Eggo RM, Davies N, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: A modelling study. Lancet Public Health 2020;5:e261-70.  Back to cited text no. 3
    
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Buchanan JM. The Demand and Supply of Public Goods. Vol. 5. Chicago: Rand McNally; 1968.  Back to cited text no. 4
    
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Cullity G. Moral free riding. Philos Pub Aff 1995;24:3-34. van den Hoven M. Why one should do one's bit: Thinking about free riding in the context of public health ethics. Public Health Ethics 2012;5:154-60.  Back to cited text no. 5
    
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COVID-19: Health Literacy is An Underestimated Problem.  Back to cited text no. 6
    
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Simonds SK. Health education as social policy. Health Educ Behav 1974;2 1 Suppl: 1-10.  Back to cited text no. 7
    
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Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80.  Back to cited text no. 8
    
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Integration of Five Health Behaviour Models: Common Strengths and Unique Contributions to Understanding Condom Use [Internet]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175333/. [Last accessed on 2020 May 08].  Back to cited text no. 9
    
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Carpenter CJ. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Commun 2010;25:661-9.  Back to cited text no. 11
    
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Harrison JA, Mullen PD, Green LW. A meta-analysis of studies of the health belief model with adults. Health Educ Res 1992;7:107-16.  Back to cited text no. 12
    
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Rantala R, Bortz M, Armada F. Intersectoral action: local governments promoting health. Health Promot Int. 2014;29 Suppl 1:i92-102. doi: 10.1093/heapro/dau047. PMID: 25217361.  Back to cited text no. 13
    
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Salunke S, Lal DK. Multisectoral approach for promoting public health. Indian J Public Health 2017;61:163-8.  Back to cited text no. 14
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Bhattacharya S, Singh A. Namastey!! Greet the Indian way: Reduce the chance of infections in the hospitals and community. CHRISMED J Health Res 2019;6:77-8.  Back to cited text no. 15
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