COVID-19 and the role of health promoters and educators

Abstract

The role of health promoters and educators in the current and future response to COVID-19 is critical, but, to date, under explored. This opinion paper offers a number of important contributions that this professional group may offer both in the immediate and future strategy of global public health. While the importance of a medical model of health cannot be underplayed, the social model of health suggests that some groups in society are being more disproportionately impacted than others. Health promotion has been committed to reducing inequalities and therefore offers “a voice” to those most marginalised. The paper suggests that bottom-up approaches focusing on building individual and community control is essential and, moreover, the concepts of a settings approach in health promotion, the fostering of critical health literacy and “salutogenesis” may be worthy of further debate and discussion.

Citation

Woodall, J. (2023), "COVID-19 and the role of health promoters and educators", Emerald Open Research, Vol. 1 No. 2. https://doi.org/10.1108/EOR-02-2023-0009

Introduction

The global health challenges that have been posed by COVID-19 have been far-reaching, devastating and tragic. The huge cost to society, communities and families will not be rehearsed here, as all readers will be familiar with the implications, both personally and professionally. This short opinion piece, with the hope of stimulating debate and dialogue, suggests that health promoters and educators have a critical role in the current and future response to this pandemic but have so far been slow to respond. This is a starting point in the debate. Indeed the analysis of the situation and its implication will develop further as the pandemic continues and, eventually, dissipates. The focus here is to suggest ideas and concepts for health promoters and educators to use in practice now. We define this professional group broadly, acknowledging long-standing debate on this, as those with a remit to promote and protect individual and community health and well-being.

Health promoters have always aligned themselves with a social model of health. The COVID-19 pandemic has reminded us that this must include access to universal, well-supported and well-funded healthcare systems as well as the other determinants of health in the broad socioeconomic environment (e.g. income. education, social support). Moreover, the importance of public health, sometimes underappreciated in some countries, is now seen as being critical in all aspects of COVID-19.

Public health is a broad term and a useful starting point is to perhaps disentangle health promotion and disease prevention – its two primary constituents. While some conceptual models draw clear distinctions between the two (Green et al., 2019), there is often some ambiguity. Within public health efforts, disease prevention activities are currently being actively employed to protect public health globally. Surveillance measures; policy enforcing self-quarantine; the closure of schools, restaurants and cinemas; the insistence for people to stay at home; and testing and screening measures, are just a few examples. Health promotion, on the other hand, can be seen as focussing primarily on advancing individuals towards the positive end of the disease-health continuum (Breslow, 1999; Brubaker, 1983; King, 1994). Nutbeam (1986, p. 115), for example, draws an important distinction between health promotion and disease prevention. He suggests:

“Disease prevention is essentially an activity in the medical field dealing with individuals or particularly defined groups at risk. It aims to conserve health. It does not represent a positive vision of health that moves ahead, but is concerned with maintaining the status quo. Health promotion on the other hand, starts out with the whole population in the context of their everyday lives, not selected individuals or groups. Its goal is to enhance health.”

What though, can health promoters and educators – focusing on more positive conceptualisations of health – contribute during this pandemic. To date, the response has been slow, but evidence has shown that health promoters play a critical role in pandemics (Laverack and Manoncourt, 2016). The following paragraphs offer some conceptual and practical suggestions both for the immediate and longer-term.

Contribution of health promoters

Glenn Laverack outlined specifically the key contribution that health promotion can make in emergency outbreaks – citing the potential contribution both before, during and after (Laverack, 2017). Health promotion as a practice and discipline is suggested to be well-placed to use ‘bottom-up’, grass-roots approaches to engage individuals and communities in the delivery of the response (Laverack and Manoncourt, 2016). Indeed, we have seen how critical strong and active communities have been – both physically and digitally – in keep people safe and in supporting individual and community well-being. The examples of this in communities across the world have been endless. The active participation of people supporting each other has been a cornerstone of health promotion values for over thirty years (World Health Organization, 1986). Evidence suggests that individuals have a better chance of achieving their health goals if they can share these matters with other people who are faced with similar problems (Woodall et al., 2010) – the rise in people connecting digitally to share experiences and to offer companionship has been so important for many. Through participation, individuals are likely to experience some degree of control as they are better able to define and analyse their concerns, and together they are capable of finding joint solutions to act on their issues (Laverack, 2005). Health promoters are uniquely placed to facilitate and support these efforts, actively contributing to individuals feeling a greater sense of control over their circumstances.

Salutogenesis

In addition to community participation, a further key idea in health promotion is the notion of salutogenesis. There is no doubt that a focus on pathogenesis is absolutely fundamental during COVID-19 and the role of disease prevention central (as noted earlier). During this challenging time, however, it may also be important not to lose sight of the question ‘what makes people healthy?’ or what is the origin of health, as this one of the critical pillars of salutogenisis (Mittelmark and Bauer, 2017). Antonovsky (1996) studied the question of what creates health. His answer was formulated in terms of the sense of coherence (SOC) and generalized resistance resources (GRR). The SOC consists of three dimensions: comprehension, manageability and meaningfulness, reflecting the interaction between the individual and the environment. GRR are factors that can support a person or community to cope effectively – they can include various factors, for instance material resources (e.g., money), genetic (e.g., intelligence), knowledge (e.g., coping strategies), and social (e.g., social network). Both SOC and GRR interplay to support individuals’ health. This brings us to health promotion and education’s fundamental quest for equity and to reduce health inequalities and to consider how COVID-19 may be impacting disproportionately on people’s SOC and GRR. For example, those in manual jobs may be financially impacted during lockdown when it is impossible to work at home; moreover, those living in high-rise buildings may be affected more acutely than those with access to green spaces. Data is continually emphasising that COVID-19 impacts disproportionately on certain groups in our communities. How the health promotion and education community supports these groups now and when the recovery post-COVID commences is fundamental to ensure that these groups are not further marginalised. Health equity must be at the forefront when considering all interventions to support individuals and communities in an equitable way both during and after the pandemic.

Healthy settings approach

The notion of healthy settings is one that has been popular with health promoters and educators and may be a legitimate and practical way to address the inequalities as a result of COVID-19. The key idea of the settings approach, or healthy settings approach, is that investments in health are made in social systems where health is not their primary remit. The settings approach has been criticised for not being joined-up in its approach (Woodall and Freeman, 2020). Any effective activity is ensured when settings ‘join-up’ and work mutually to ensure holistic and integrated activities. This pandemic has perhaps amplified frailties in settings working together – how health messages from schools to homes are communicated for example or how health activities are managed and co-ordinated in environments where people live in close-proximity (prisons, care homes etc.). The idea of holistic working across systems and institutions now seems the only way forward to ensure public health is fully protected. This opens the potential for more cross-cutting, cohesive policy that offers public health gains. This could include, more sustainable travel; increased sustainability in ways of living; and re-thinking the balance between work and social life. While the pandemic has caused huge public health challenges, there will be a potential for health promoters to advocate and re-shape the way individuals and communities are supported to live healthier lives.

Critical health literacy

Finally, at the present time, scholars have noted the importance of health communication during COVID-19 and the importance of critical health literacy (Abel and McQueen, 2020). Indeed, the continuous news, politician briefings and endless commentary on digital platforms creates information-overload and confusion at best and, at worst, panic and anxiety for many (Abel and McQueen, 2020). There are several examples where untrustworthy sources have caught the public imagination and have provided illegitimate concerns, including xenophobia (Shimizu, 2020). In many cases this is perpetuated by social media (through statements such as #ChineseDon'tComeToJapan) that can circulate stories quickly, highlighting the need not only for critical health literacy but also digital health literacy for individuals in responding appropriately. One essential role for health educators is to translate this information into credible sources to promote public understanding and provide accurate and timely information in culturally specific ways. Explanations to children, as one example, is important and health educators could be ideally situated to support parents in their support of their child’s psychological well-being (Wang et al., 2020).

Conclusions

We are in unprecedented times in relation to global health. The immediate threat posed by COVID-19 has seen epidemiologists, scientists and politicians coming together to evaluate how best to manage and control this pandemic. This short piece has suggested that health promotion has been slower to react but that health promoters and educators can make a significant contribution to the current and future issues that emerge from this public health crisis.

Data availability

No data are associated with this article.

Publisher’s note

This article was originally published on the Emerald Open Research platform hosted by F1000, under the Healthier Lives gateway and Coronavirus (COVID-19) collection.

The original DOI of the article was 10.35241/emeraldopenres.13608.2

Author roles

Woodall J: Conceptualization

Amendments from Version 1

The reviewers have provided some very helpful comments. The paper has been strengthened to specify the intended audience – i.e. those with a remit to promote and protect individual and community health and well-being. The issue of health equity is emphasised further and some examples to support the claims in the paper are used to provide additional contextual information.

The peer reviews of the article are included below.

Funding statement

The author(s) declared that no grants were involved in supporting this work.

Competing interests

No competing interests were disclosed.

Reviewer response for version 2

Dean Whitehead, University of Tasmania, Hobart, Australia

Flinders University, Adelaide, Australia

Competing interests: No competing interests were disclosed.

This review was published on 08 October 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve

This article revision brings further detail and clarity to the ever-changing and fluid context of Covid-19 and its impact on the health promotion/health education professional's role and function - especially in relation to preventative/public health agendas. It is a context that will change rapidly in the current climate.

Is the topic of the opinion article discussed accurately in the context of the current literature?

Yes

Are arguments sufficiently supported by evidence from the published literature?

Partly

Are all factual statements correct and adequately supported by citations?

Yes

Are the conclusions drawn balanced and justified on the basis of the presented arguments?

Partly

Reviewer Expertise:

Clinical health promotion and health education theory, practice and policy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Reviewer response for version 2

Irving Rootman, School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada

Competing interests: No competing interests were disclosed.

This review was published on 23 September 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve.

Is the topic of the opinion article discussed accurately in the context of the current literature?

Partly

Are arguments sufficiently supported by evidence from the published literature?

Partly

Are all factual statements correct and adequately supported by citations?

Partly

Are the conclusions drawn balanced and justified on the basis of the presented arguments?

Partly

Reviewer Expertise:

Health Promotion, Health Literacy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Reviewer response for version 1

Dean Whitehead, University of Tasmania, Hobart, Australia

Flinders University, Adelaide, Australia

Competing interests: No competing interests were disclosed.

This review was published on 02 July 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve.

Overall, this is a reasonably well articulated 'opinion' piece. The author is well known in this field - and cites a number of eminent authors. I have a few reservations in it's current form.

These being:

1. The topic will be fine if it is aimed at raising awareness with a 'general' redership audience that may not be overly familiar with health promotion and health education processes. However, if the eventual audience were - this would not report much that is not already known and have been established 'issues' within the disciplines pre-Covid as well.

2. In my mind, opinion pieces are best (and safest) with at least two authors.

3. Parts of the text can read as 'notation form' i.e. statement/citation - followed immediately by another statement/citation - especially the health literacy section.

4. I would argue that the two sections on 'settings' and 'health literacy' are too brief. This is easily rectified as there are a number of statements that do not expand on what they are reporting i.e. "There are several examples where untrustworthy sources have caught the public imagination and have provided illegitimate concerns (Shimizu, 2020)." - what examples, why, how? 

I hope that these comments assist.

Is the topic of the opinion article discussed accurately in the context of the current literature?

Yes

Are arguments sufficiently supported by evidence from the published literature?

Partly

Are all factual statements correct and adequately supported by citations?

Yes

Are the conclusions drawn balanced and justified on the basis of the presented arguments?

Partly

Reviewer Expertise:

Clinical health promotion and health education theory, practice and policy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Reviewer response for version 1

Irving Rootman, School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada

Peggy Edwards, The Council on Aging of Ottawa, Ottawa, Canada

University of British Columbia, Vancouver, Canada

Competing interests: No competing interests were disclosed.

This review was published on 08 June 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve-with-reservations.

This is a timely short opinion article on the contribution of health promoters and educators in response to the COVID-19 pandemic, guided by three key concepts in the field of health promotion, namely, salutogenesis, the healthy settings approach and critical health literacy.

In our opinion, this article is an excellent start on developing a framework for defining the role of health promoters and educators in relation to epidemics and is worthy of publication as is.

That being said, here is one revision we would recommend. That is the reference to “the medical model” in the Introduction. The medical model is undefined and appears to be in opposition to the social model of health. In fact, a social model of health includes access to universal quality healthcare (that include a robust public health system). Perhaps the sentence could be modified to say: “Health promoters have always aligned themselves with a social model of health. The Covid 19 pandemic has reminded us that this must include access to universal, well-supported and well-funded healthcare systems (including a robust public health system) as well as the other determinants of health in the broad socioeconomic environment (e.g. income. education, social support).

By focussing on just three useful concepts in health promotion (perhaps due to the need to be brief) the piece points to the need to address some additional issues. One critical issue is who should be considered to be a “health promoter” or “health educator”?  Is a health promoter someone that does something that results in improvement of somebody’s health or the health of an organization or a community. Similarly, is a “health educator” someone who teaches individuals or groups how to improve their health or the health of an organization or community?  Or is a “health promoter” someone  that has studied “health promotion” and received a diploma or degree in “health promotion” or “health ‘education”? Clearly, this is a matter for debate that has not yet been totally resolved. At minimum, it seems as if the author is suggesting that it might be someone who understands the concepts of salutogenesis, the healthy settings approach and  critical health literacy, and knows how to apply them in practice.

If this is the case, we would like to suggest that there are other concepts in health promotion and health education that are particularly   relevant to promoting health in a pandemic and its aftermath.

For example, we suggest that not only is critical health literacy relevant to addressing the current pandemic and future epidemics, but so are other kinds of health literacies. As we have learned from the increased use of digital technologies to connect during the current pandemic, “digital health literacy” defined by Norman and Skinner (2006b)¹ as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” has become an essential skill.

The same is likely true for functional health literacy (sufficient basic skills in reading) given that people that can read are more likely to be able to understand or solve problems on their own. Similarly, people who have “interactive health literacy” skills (more advanced cognitive and literacy skills and social skills) that allows them to understand information and derive meaning from different forms of communication, and to apply new information to changing circumstances” (Nutbeam, 2000)² certainly will fare better in a pandemic.

Another health promotion concept that is used frequently by academics and practitioners in health promotion work is “action areas”. The following such areas or strategies are enshrined in the Ottawa Charter for Health Promotion: Build Healthy Public Policy; Create Supportive Environments; Strengthen Community Action; Develop Personal Skills; and Reorient Health Services. The opinion article mentions actions related to creating supporting environments, strengthening community action, and developing personal skills to which health promotion and education has, or could contribute. We think that COVID-19 has also stimulated the need for action on building healthy public policy and reorienting health services. Health promoters and educators, however defined, could also make a significant contribution in these two action areas An example of a proposal for such a policy stimulated by COVID-19 can be found in a recent article in the Journal of Medical Internet Research (Katapally, T.R., 2020)³.

Finally, two other concepts that are fundamental to health promotion and other health and non-health fields of practice that have been particularly important in assessing the implications of COVID-19 are “equity “and “determinants of health”. For example. a recent British study found that “greater proportions of residents from ethnic minority backgrounds had statistically significantly higher COVID 19 mortality rates, as did local authorities with a greater proportion of residents experiencing deprivation relating to low income” (Rose, et al., 2020⁴) While the author mentions the health promotion goal of recusing inequalities in the section on salutogenesis, it could be made clearer that equity needs to be a fundamental value in responding to pandemics. The author also makes reference in this section to the “need for material and social resources.” This could be more strongly and clearly discussed under the importance of the concept “determinants of health” which is well known and central to health promotion) when responding to pandemics.

In the end, it falls to proponents of health promotion to better address the above issues; if they wish to position health-promotion strategies as viable tools for addressing pandemics. Health promotion can complement and strengthen public and population health efforts. It has a rich history of enacting a comprehensive range of strategies that are well placed to deal with complex challenges like COVID-19.

Is the topic of the opinion article discussed accurately in the context of the current literature?

Partly

Are arguments sufficiently supported by evidence from the published literature?

Partly

Are all factual statements correct and adequately supported by citations?

Partly

Are the conclusions drawn balanced and justified on the basis of the presented arguments?

Partly

Reviewer Expertise:

Health Promotion, Health Literacy

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

References

1. Norman CD, Skinner HA: eHealth Literacy: Essential Skills for Consumer Health in a Networked World. J Med Internet Res. 2006; 8 (2): e9

2. Nutbeam D: Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000; 15 (3): 259-267

3. Katapally T: A Global Digital Citizen Science Policy to Tackle Pandemics Like COVID-19. Journal of Medical Internet Research. 2020; 22 (5).

4. Rose T, Mason K, Pennington A, McHale P, et al.: Inequalities in COVID19 mortality related to ethnicity and socioeconomic deprivation. medRxiv. 2020.