Education in the Time of COVID-19 #020 – Warwick
By CEID Blogger, on 20 May 2020
Education, health literacy and COVID-19
By Ian Warwick
There have been a range of country responses to COVID-19, not only with regard to the treatment and care of people living with and affected by the disease, but also in attempts to prevent the transmission of the coronavirus, SARS-CoV-2.
While there has already been some degree of success in interrupting human-to-human transmission of the virus, as well as in treating and caring for those with COVID-19, global responses have been uneven. For example, and notwithstanding the challenges of making country comparisons, it appears that actions in some contexts have shown promise in limiting transmission (for example, in China, Hong Kong and South Korea), while in other contextsthere has been less success (such as the USA and, as looks increasingly likely with regard to excess deaths, Spain and the UK).
Still, the actions taken to limit transmission of the virus, to treat and care for those with COVID-19 and to manage the deaths associated with the disease have come with their own economic, cultural, social and political consequences. In particular, education has been affected for millions of children, young people and adults across the world. Education-related responses have included putting in place and scaling up distance learning opportunities and working with those who have been placed at particular risk of harm.
In this blog post I outline a few of the ways that education, in its broadest sense, might respond to COVID-19 and contribute to wellbeing. In doing so I draw briefly on lessons learned from responding to HIV and AIDS in the 1980s and 1990s. As Hargreaves and colleagues note in making a similar comparison, three areas stand out for them: anticipating and responding to health inequalities, creating supportive environments to enable people to respond as best they can, and interdisciplinary working. Informed by Ottawa Charter for Health Promotion – underpinned as it is by a salutogenic (health enhancing) and social-ecological approach to the promotion of health and wellbeing – I highlight the challenges posed by inequalities, marginalisation and associated discrimination and stigma, note the importance of working on the interface of health and education, and focus on teaching about critical health literacy as one way of enabling people to understand and respond to the challenges presented by COVID-19.
In particular, I suggest that enabling the development of critical health literacy (with its roots in critical education) might be a useful way to understand how the social construction of COVID-19 and responses to it may negatively affect those already marginalised and made vulnerable by structural inequalities. I then focus on how critical health literacy – which must necessarily be accompanied by good education in general – might offer one route towards a post-COVID-19 world.
Learning from crises
Useful lessons can be learned from responses to existing global challenges that have impaired people’s health and wellbeing. HIV and AIDS, for example, (and responses to it) harmed already vulnerable communities. As UNAIDS last year noted,
“Ignorance and fear of HIV has nurtured stigma and discrimination against people living with HIV since the earliest days of the epidemic. Gender inequality, violence against women and girls, and marginalization of the key populations at highest risk of HIV infection (…) pre-date the epidemic by decades, if not centuries. Pushed away by families, friends and entire communities, countless people living with HIV or at high risk of infection have been left stranded and alone, unable to access the services they need.” (p.5)
From the stigma associated with HIV and AIDS, to the use of militaristic metaphors, to the Chirimutas’ argument that racism informed much of science’s output on the disease – COVID-19 raises similar themes. Those most vulnerable in society, often the poorest, will bear the brunt of COVID-19, whether living in high-, middle- or low-income countries. Framing COVID-19 as an invasive and wicked infiltrator sets the tone for spurring paranoia and exacerbating prejudice – such as the fear-driven and xenophobic COVID-19-related reactions to students from East Asia.
In certain countries the health of migrant workers has been neglected, exacerbating their already marginalised status. In others, migrants have been systematically deported back to communities where they have become social pariahs, associated with bringing death and disease. Moreover women, and perhaps young women in particular, have been especially affected by domestic and intimate partner violence exacerbated by reactions to COVID-19.
Compared to their application, lessons are sometimes relatively easy to learn. Promoting health literacy may help turn ideas into practice.
Towards health literacy
Education about COVID-19 needs to adopt a critical stance – identifying how clusters of factors privilege some, disadvantage others and open up possibilities for more equitable ways of being.
Learning from elements of education about HIV and AIDS relevant to COVID-19 suggests that health literacy needs to include, yet go beyond, a basic understanding of prescribed or proscribed behaviours to protect oneself and those close by. Education will best enable people to develop a critical understanding of the clusters of factors that affect their own and others’ lives. Perceiving COVID-19-related health promotion and education in this way, through a social-ecological imagination as it were, suggests a shift away from functional and communicative understandings of health literacy towards critical health literacy.
Low levels of lay health literacy have been associated with clinical health risk. Nutbeam argues that it is not just a question of increasing levels of knowledge but of promoting health literacy as an asset which can enable people to develop a critical understanding of health and wellbeing so they feel they have the capacity to act on issues of value to them (which may include, but not be confined to, clinical outcomes).
Notwithstanding the many definitions of health literacy (26 at least), Nutbeam has provided a useful three-part classification of an asset-based approach to health literacy as: functional, interactive or critical. In brief, functional health literacy aims to increase an individual’s knowledge about a specific disease so that they can comply with prescribed actions and participate in health programmes (such as screening and immunization). Interactive health literacy is linked to increased self-confidence and an ability to act with a degree of independence on health-related knowledge. Being critically literate in health is associated with improved resilience to social and economic adversity and an enhanced capacity to act on the social and economic determinants of health.
While not devaluing the necessity of at least basic health literacy, there are at least four key reasons why it might be important to aim for critical health literacy in the context of COVID -19. These include helping people engage with multiple sources of information – including medical uncertainty – responding to lay health theories, redressing inequalities, as well as enabling new alliances and promoting advocacy.
First, and with regard to multiple sources of information, concerns about inaccurate COVID-19 related information – misinformation, disinformation and malinformation – has led to a description of the disease not only as a pandemic, but also an infodemic. About which Abel and McQueen respond:
“… critical health literacy has never been more needed than in these days when an infectious disease crisis arrives at a time of information excess and high expectations of controlling health. Public health personnel have generally assumed that knowing about the risk factors of infectious diseases has always been key to controlling and preventing an epidemic infectious disease’s devastating consequences. What is different with COVID-19 is that we live in an age when expectations about mastering health—and here that means specifically, controlling risks of a deadly infectious disease—are higher than ever. These advanced expectations meet with another unique condition: never in human history has there been such an abundance of health information available from numerous more or less trustworthy sources.” (p.20)
To counter this information overload– and to improve at least functional health literacy – the publication of research-informed information is essential, with many resources on COVID-19 already published. These include, advice for the public from the World Health Organisation, and sets of fact sheets from the Covid-19 Health Literacy Project, welcomingly available in a range of languages. Moreover, there are public health uncertainties, as can be seen with debates as to whether members of the public should wear masks routinely or only when caring for someone with COVID-19.
Second and perhaps relatedly, people hold their own lay health theories about health and disease. From AIDS, cancer and COVID-19 to vaccination, treatment and care, lay health theories may or may not be aligned with biomedical understandings. Misalignment may be harmful at times, such as disregarding the value of vaccination or prophylaxis. At others this may be a trigger to promote advocacy to question the limitations of biomedical responses which undermine the health of communities – the early days of AIDS activism come to mind here. Whether aligned or otherwise, lay theories around health and disease in general and COVID-19 in particular are important to understand and respond to as they will likely shape people’s reactions to COVID-19 related illness, irrespective of their contribution to reducing its harms.
Third, with regard to inequalities and not unrelated to generalised “do’s and don’ts” in posters and leaflets, many people are unable to engage with exhortations to take one or another course of action due to the particular contexts in which they find themselves. Not uncommonly, for example, mass and small media urge people to wash their hands with clean water or, if that is not possible, to use a hand sanitiser. Yet globally, it is reported that 785 million people do not have access to clean water close to home, let alone an alcohol-based hand sanitiser of sufficient strength.
Advice to stay at home presents further challenges when living in a violent household. As van Gelder et al note with regard to intimate partner violence (IPV):
“Many of the strategies employed in abusive relations overlap with the social measures imposed during quarantine. Next to physical and geographical isolation, IPV survivors describe social isolation (i.e., from family and friends), functional isolation (e.g., when peers or support systems appear to exist but are unreliable or have alliances with the perpetrator), surveillance, and control of daily activities. During quarantine, measures intentionally imposed in an abusive partnership, may be enforced on a massive scale in the attempt to save lives. Isolation paired with greater exposure, psychological and economic stressors, as well as potential increases in negative coping mechanisms (i.e., excessive alcohol consumption) can trigger an unprecedented wave of IPV.” (p.1)
Fourth, inequalities mark social life in general, influence health and wellbeing in general, as well as shape who and how people are affected by COVID-19. Consequently we need, as Marmot highlights, not only to build an understanding as to why things have happened in the way they have but also to take action to promote equity. He notes:
“The aim should not be simply to find a way to restore growth of GDP, but to create better societies, characterised by better health and narrower health inequities. The findings of Marmot 2020 show what the building blocks of those better societies should be: reductions of child poverty, and funding of services to improve outcomes for children; proper funding for education; improvement of working conditions; ensuring that everyone has at least the minimum income to lead a healthy life; creating healthy and sustainable environments in which to live and work; and creating the conditions for people to pursue healthy behaviours.” (p.1414).
Bringing about such change – and doing so while not reinforcing mis-, dis- or malinformation – is likely to require “(…) sustained interactions between power holders and representatives of constituencies lacking formal representation to achieve changes in the distribution or exercise of power.” (p414). In short, public health advocacy.
This suggests a need, as the International Union for Health Promotion and Education highlight, to build and take part in alliances internationally, regionally, nationally and locally to advocate for change. That is, multi-levelled strategies across a range of action areas with the redistribution of power at its heart – as Carroll and Hills note, the very basis of health promotion.
Education and the promotion of health and wellbeing
It is one thing to learn new lessons about health issues – for example, how factors cluster together to enhance or diminish people’s wellbeing and/or their ability to be prepared for and respond to health crises – and quite another to apply these lessons.
To assist with that, there are two features of education to consider here. The first relates to the protective role of a ‘good’ education on people’s wellbeing. In short, as UNESCO has highlighted, education (particularly for girls and young women) improves lives:
“Education is one of the most powerful ways of improving people’s health. It saves the lives of millions of mothers and children, helps prevent and contain disease, and is an essential element of efforts to reduce malnutrition. Educated people are better informed about diseases, take preventative measures, recognize signs of illness early and tend to use health care services more often. Despite its benefits, education is often neglected as a vital health intervention in itself and as a means of making other health interventions more effective.” (p.24)
COVID-19 has emphasised the need for education in general and schools in particular to prioritise wellbeing.
Second, is to develop education about COVID-19 in a way that enables people to be critically literate about health so as to understand, prepare for and respond to the pandemic with regard to wider economic and political systems. Such teaching would be as much about advocating for the wellbeing of others as it is about a person’s own wellbeing – the former often missed out in discussions of critical health literacy.
How best to teach about COVID-19 within a critical health framing poses an important contemporary challenge. As Aggleton and others have noted, there have been limits to what teachers have been able to teach about with regard to HIV and AIDS. Some of this is related to content (issues related to sex and relationships, recreational drug use, women’s empowerment) as well as to matters of pedagogy (such as the importance of participatory teaching activities) – which are known to enhance critical health literacy.
While teaching about COVID-19 may not highlight topics related to issues such as sex and drug use so directly (although in some contexts this may be so), as noted, issues related to socio-economic status, class, gender, marginalisation are all present. Moreover, many teachers may be ill-equipped to incorporate pedagogical innovations in the classroom, such as participatory learning approaches.
For example, engagement with what some see as challenging topics through the use of interactive and dialogic styles of teaching have shown promise in Sykes and Wills’ review of 12 projects to build critical health literacy among marginalised communities. Project participants included socially disadvantaged adults and Aboriginal community members in Australia, African- American and Latina women community workers in the USA and Indigenous community members in the Philippines.
The work highlighted some limitations in approaches typically adopted by schools in which health literacy was conceptualised as little more than improved cognitive skills as teachers struggled to facilitate critical discussions about health and wellbeing beyond individual responsibility. Education through community settings, showed more promise – with action-oriented, arts-, participatory-, and change-based methods enabling participants to better understand social and other determinants of health and to see themselves as both consumers and producers of knowledge. While the findings may raise disappointment in that schools are difficult places through which advocacy might take place, they nonetheless highlight the value of complementarity across school-based and community/out-of-school programmes to promote the wellbeing of children and young people.
While in global responses to HIV and AIDS not everyone had to become an activist, civil society mobilisation became a necessary part of the politics of AIDS. In South Africa – as in many other countries – the creativity, anger, sadness, humour and determination among activists to build new forms of association for advocacy – education accompanying activism one might say – was an important counter to political inaction and biomedical inadequacy, of which both were underpinned by systemic inequalities and disease-related stigma.
In this blog post I have sought to outline some commonalities between earlier responses to HIV and AIDS, while noting the particularities that COVID-19 presents. Education has a role to play in our ongoing response to global crises, just one of which at present is COVID-19. While it may be an ambition too far to believe we can leave behind the sort of normality that has brought us to where we are now, we can aim at least to bring the best of education with us.
Acknowledgements: My thanks to Dr Elaine Chase for her insights on an earlier version of this post. Thanks too, to Rosie Peppin-Vaughan who provided helpful editorial comments.
Ian Warwick is an Associate Professor at the UCL Institute of Education.
Opinions expressed on the CEID Blog are only those of the author, not the Centre for Education and International Development or the UCL Institute of Education.
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