Health Promotion International, 2020;35:181–186

doi: 10.1093/heapro/daaa042
Advance Access Publication Date: 16 April 2020
Editorial

Editorial
Why health promotion matters to the COVID-19 pandemic, and
vice versa

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021

At the time I am writing this editorial, the world is over- one of the core competencies of health educators and
whelmed by the pandmic caused by the SARS-CoV-2 vi- promoters, their advice may help governments to
rus. In a desperate attempt to contain the further spread achieve the required behaviour change. Moreover, and
of the virus and the diffusion of the COVID-19 disease it perhaps more importantly, the rapid and continuous
causes, governments across the world have taken meas- evolution of the COVID-19 problem and the scale of the
ures that are unprecedented. Entire cities, regions and measures that are put in place may, rightly or wrongly,
countries are sealed off, travel is banned, schools and create the perception that the existing health system is
universities are closed, shops are running out of stocks, failing to protect citizens against the spread of the virus.
and all economic, cultural and social activities have This creates a need for people to regain control of their
come to a stop. Never before in modern history has a health, to protect oneself against the disease and to deal
health problem had such an overwhelming impact on so- with its disruptive consequences.
ciety. Health (or rather the threat of ill health) has be- Enabling people to increase control over their health
come the prevailing concern that takes precedence over and its determinants is at the core of health promotion.
all others issues, making health in all policies become a As such, health promotion may paradoxically be more
reality, albeit not in the way it was intended. important in this time of crisis than ever before. As a dis-
At first sight, this pandemic and the world’s response cipline within public health and a field of professional
to it seems far removed from the health promotion per- practice, health promotion can contribute to addressing
spectives we publish and that the International Union the CoV-2 virus threat at different levels (Brownson
for Health Promotion and Education advocates for. et al., 2010): at the downstream level focusing on indi-
When all hands are called on deck to prevent a conta- vidual behaviour change and disease management, at
gious virus from spreading and to reinforce hospital staff the midstream level through interventions affecting
facing a tsunami of patients suffering from a potentially organizations and communities and at the upstream
deadly disease, there seems to be little need for special- level through informing policies affecting the
ists whose expertise lies at the other end of the contin- population.
uum of care spectrum (Springer and Phillips, 2006). The
real war heroes in the battle against the CoV-2 virus are
virologists, epidemiologists, doctors and nurses, and
IMPROVING PREVENTIVE BEHAVIOUR
even if many of the actions taken serve a preventative CHANGE MEASURES
purpose, their focus is on the prevention of disease, not To contain the spread of the CoV-2 virus, health author-
on promoting health. ities have tried to enhance protective behaviour amongst
Yet on the other hand, many of the measures that are citizens, first by issuing warnings and recommendations
now taken to prevent citizens and health workers from about the new virus, and at a later stage by imposing le-
getting infected imply a change of behaviour. Hand gal restrictions, in some cases involving a complete
washing, wearing face masks and protective gloves and ‘lock-down’. These measures have met with varying
‘social distancing’ (which should really be termed ‘spa- degrees of success. Especially in the beginning of the epi-
tial distancing’) are all forms of human behaviour. As demic the public’s response to warnings was often weak
the expertise with regard to health behaviour change is and ineffective, thus wasting opportunities to effectively

C The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
V
182 Editorial

contain the spread of the disease. And even when the ii. create social norms that encourage preventive be-
scale of the problem became pandemic, a significant haviour, through campaigns targeting people’s self-
number of people did (and continue to) not strictly fol- identity and by getting people to give each other
low the recommendations. This lack of adherence is of- feedback;
ten condemned as irresponsible and selfish, but that iii. create the right level and type of emotion by cou-
need not necessarily be the case. Changing people’s be- pling health warnings with concrete advice for pro-
haviour is simply not as easy as just informing them of tective action;
the risks. Years of research in protective health behav- iv. give advice on how risk behaviours can be replaced
iour informed by theoretical models such as the Health by more effective ones, rather than just asking to
Belief Model (Champion and Skinner, 2008) or the stop them; and

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021

Protection Motivation Theory (Prentice-Dunn and v. make the behaviour easy, for instance by building it
Rogers, 1986) have shown that people will only act on into existing routines or using nudges.
health warnings if they:
Health promoters can suggest to authorities to follow
i. believe that they are personally susceptible to de- these recommendations when setting up campaigns to
velop the condition against which protection is prevent further transmission of the CoV-2 virus. It will
required; increase the likelihood that people will effectively
ii. perceive the condition as severe; change their behaviour.
iii. perceive the preventive action as effective to reduce
the threat; and
iv. believe they are capable to perform the preventive ACKNOWLEDGING THE ROLE OF HEALTH
action. LITERACY AND INFORMATION BIAS
It is clear that in the case of COVID-19 these condi- In times of crisis people want to be well informed, so
tions are not always fulfilled. People may not consider they know what individual preventive measures they
themselves at risk (e.g. if they have not been in contact must take and how they can deal with the consequences.
with others who have been contaminated), may underes- With respect to COVID-19, there is an abundance of in-
timate the seriousness of the condition (e.g. when they formation available, with official and unofficial websites
are told that most fatalities are older people or people continuously updating recommendations and instruc-
with pre-existing morbidity) or may not see themselves tions, and news media covering the situation around the
as capable to perform the preventive behaviours. clock. The question is, however, whether all this infor-
On the other hand, the wide coverage of the pan- mation is useful. A bombardment of communication, al-
demic by the media and the scope of the preventive though well intended, can create confusion. Therefore,
measures that are taken also create anxiety. While a cer- coordination of key messaging between the health sector
tain level of concern is an important driver for protective and other sectors is necessary in pandemic responses
behaviour, too much anxiety can elicit cognitive avoid- (Smith and Judd, 2020)
ance strategies which minimize the perceived threat Moreover, for information to be helpful it must not
(Croyle et al., 2013). In a similar vein, an individual’s only be available, but also understood, accepted and ap-
social identity needs in interaction with contextual fac- plied. Research on health literacy has shown that more
tors can increase and mitigate the actual rejection of evi- than a third of the population worldwide has difficulties
dence—a phenomenon that is known as knowledge in finding, understanding, evaluating and using informa-
resistance (Klintman, 2019). tion that is necessary to manage their health (Sørensen
Nevertheless, changing people’s transmission-related et al., 2015; Duong et al., 2017). Authorities should
behaviours across society remains important to flatten take that into account when informing the public about
the peak of the epidemic. Drawing on widely accepted COVID-19 and adapt the information to the literacy
behaviour change principles, Michie et al. (2020) make needs of the people they want to reach. That means the
the following recommendations to reduce the transmis- response to the pandemic should be looked at through
sion of COVID-19 in the population: an equity lens (Smith and Judd, 2020), with attention
for those who are the most vulnerable in pandemics,
i. motivate people to adopt preventive behaviour by such as elderly, migrants or people with disabilities.
presenting them with clear rationale, preferably in Okan et al. (2020) give the following recommendations
the form of a mental model of the transmission to take health literacy into account when communicat-
process; ing about the CoV-2:
Editorial 183

i. provide information in an understandable way, rec- persistent ‘myths’ about CoV-2 are the belief that the vi-
ognizing that people and groups with low health lit- rus was made in a laboratory or otherwise engineered,
eracy may need more explanation and different that cold weather or hand dryers can kill it, that young
communication formats such as animations that ex- people cannot get infected, or that antibiotics or vac-
plain the virus, the disease, its transmission and pro- cines against pneumonia protect against the infection.
tective measures; These false beliefs can be reinforced by the false consen-
ii. explain the situation transparently and clarify the sus that is created when information is shared on social
overriding objectives repeatedly, to prepare people media, leading to the ‘echo chamber’ or ‘illusion of
for the fact that interventions and recommendations truth’ effect, basically implying that information that is
might change when new evidence arrives and sce- often repeated tends to be more easily considered as

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021

narios must be adapted; true.
iii. communicate new evidence and information with- To counter these effects, some basic principles can be
out being afraid to correct earlier messages and applied to limit the spread of biased, false or misleading
statements if necessary; and information, such as encouraging people to cross check
iv. avoid blaming, but instead strengthen the well- the accuracy and credibility of information, to check the
informed responsibility of the individual while source of information (where does it come from, who is
showing solidarity with vulnerable population behind the information, what is the intention, why was
groups. it shared, when was it published), to verify the informa-
tion by consulting a second source, to consult family
Authorities also need to acknowledge that taking up
members and trusted health professionals about infor-
health information is an active cognitive process. To in-
mation that is ‘doubtful’, and to think twice before shar-
form themselves about the virus and ways to protect
ing information that has not been fact-checked (Okan
themselves, people actively select information sources
et al., 2020).
and information from within these sources, some of
which may be contradictory. Information processing
theory teaches us that this selection is influenced by con-
text, emotions and selective attention (Estes, 2014), thus EMPOWERING ORGANIZATIONS AND
introducing a potential selection bias whereby more at- COMMUNITIES
tention is paid to some information than to other. The While preventing the further spread of COVID-19 relies
use of cognitive schemes to process this information heavily on informing and encouraging the population to
adds another form of bias, namely confirmation bias adopt protective behaviours, these efforts may be more
(i.e. the tendency to seek information that confirms the successful if the advice from experts is combined with
beliefs already held and to ignore or discard information local community knowledge. Experience with the way
that contradicts these beliefs). Likewise, the activation the Ebola epidemic was responded to in African coun-
of cognitive schemes to filter, classify and assimilate in- tries shows that in an environment of trust, community
formation and make connections with already available partners can help to improve the understanding of dis-
knowledge that takes place when trying to understand ease control protocols and suggest moderate changes
and appraise the information about the virus and to that better reflect the community’s sensitivities without
judge the importance of preventive measures can again compromising safety (Marais et al., 2015). Such an ap-
cause a series of biases. In the context of the COVID-19 proach not only prevents stigmatization and fear-driven
crisis, the most important ones are possibly negative in- responses among affected individuals, families and com-
formation bias (i.e. the tendency to attach more impor- munities that can hamper preventive efforts, but also act
tance to negative than to positive information, resulting as a powerful lever to enhance adherence and mobilize
in « catastrophic thinking »), positive information bias community engagement.
(i.e. the tendency to consider oneself as less at risk for Community engagement can make a substantial dif-
negative consequence, causing « unrealistic optimism »), ference in health outcomes, and strengthen the capacity
and familiarity or recency bias (i.e. things that are famil- to deal with the disruptive effects of the pandemic at or-
iar or recent are more easily retrieved from memory and ganizational and community level. When schools,
therefore more easily considered as « true »). creches, universities, offices, churches, shops, restau-
Since information about COVID-19 is also diffused rants and sports fields are closed, the usual structures
via social media, there is an additional risk that false in- and mechanisms around which people organize their
formation is accessed and taken for truth. Among the daily lives are no longer functioning. Communication
184 Editorial

and interaction can to some extent be replaced by digital the COVID-19 threat and its societal impact. But health
means in the form of online meetings, e-learning platforms promotion can also learn from the crisis.
or distance learning tools, but these tools do not provide One thing that has become clear in the current crisis is
the same depth of interaction as face-to-face meetings and that infectious diseases can pose a major threat to public
require sufficient digital skills and organizational support. health. In its effort to move away from a strongly disease-
Furthermore, they do not allow the same level of ‘infor- oriented approach to public health, health promotion has
mal’ contact that make human interactions meaningful, traditionally focused on non-communicable disease, where
and are difficult to implement at a level that goes beyond it has significantly contributed to the progress made in
the organization and involves the larger community. Yet areas like tobacco and obesity prevention. But with the ex-
while the switch to different modes of operating creates a ception of HIV/AIDS, the application of health promotion

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021

lot of insecurity and stress, many communities react by principles and methods to tackle infectious diseases has
showing high levels of solidarity and mutual support. been largely neglected. As a result, public health professio-
These expressions of a positive mindset, which are not un- nals who deal with communicable diseases are often un-
common in times of crisis, show the communities’ resil- aware of the approaches used by health promoters
ience, and provide a strong basis to build on to help (ECDC, 2014), although there is a good reason to assume
organizations and communities cope with the unfamiliar that these can be usefully adapted and applied to prevent-
situation, re-organize and regain control. ing infectious diseases as well. That would require, how-
Health promotion has a long tradition of helping ever, that health promotion researchers and practitioners
organizations and communities to increase control over develop a keen interest in infectious diseases. McQueen
the factors that define health. The Ottawa Charter (2015) argues that to further the cause of health promo-
emphasizes the importance of community action, in the tion applied to both infectious and non-communicable dis-
sense of needs assessments, setting priorities, joint plan- ease, health promotion needs to focus more on
ning, capacity building, strengthening local partnerships, intervention research and understand the processes in-
intersectoral working and enhancing public participation volved in implementation, rather than on outcomes and
and social support (Nutbeam, 1998). All of these activi- causality. As interventions are dynamic and subject to
ties aim to create empowered communities, where indi- change during implementation, participatory methods
viduals and organizations apply their skills and resources should be further developed, recognized and documented
in collective efforts to address health priorities and meet in the scientific literature and in research protocols.
their respective health needs. Importantly, community A second lesson to be learnt from the COVID-19 cri-
action builds on the existing strengths and capacities sis is that human health is not an isolated issue. There is
within a community, to further strengthen its resilience. a general consensus that the SARS-CoV-2 virus is of ani-
The models, strategies and case examples of success- mal origin, jumped species boundaries to infect humans
ful community action and empowerment documented by either before or after it evolved to its current pathogenic
health promotion researchers and practitioners over the state (Andersen et al., 2020), and could then very rap-
years can provide guidance to communities facing the idly spread in a globalized economic system character-
challenge of the COVID-19 pandemic. In a similar way, ized by high levels of interconnectedness and mobility.
the expertise of health promotors with creating healthy Health promotion has never paid much attention to zoo-
settings, or places where people actively use and shape notic causes of human health, but the current crisis sug-
the (organizational) environment so as to create or solve gests that maybe it should. A good starting point would
problems relating to health, can be a source of inspira- be to embrace the concept of ‘One Health’, which recog-
tion and support for schools, universities and workplaces nizes the interconnection between people, animals,
that have to deal with the longer-term disruptive effects plants and their shared environment, with the goal to
of the pandemic. Such actions can take different forms, achieve optimal health outcomes (Atlas et al., 2010;
but will usually involve some form of organizational de- Calistri et al., 2013). After all, the collaborative, multi-
velopment, including changes to the physical environ- sectoral and transdisciplinary nature of the One Health
ment, the organizational structure, the administration approach is very much akin to health promotion’s prin-
and even the management (Nutbeam, 1998). ciples and strategies. It also links very well with the
growing interest of health promotion researchers and
practitioners for sustainable development, as exempli-
LEARNING FROM THE CRISIS fied by recent projects (e.g. INHERIT; https://www.in
The above paragraphs illustrate that health promotion herit.eu) and by the choice of ‘planetary health and sus-
can contribute in several ways to tackle the challenge of tainable development’ as the theme for the latest IUHPE
Editorial 185

World Conference on Health Promotion (Ratima, Atlas, R., Rubin, C., Maloy, S., Daszak, P., Colwell, R. and
2019). Hyde, B. (2010) One health—attaining optimal health for
A third lesson to be drawn from the COVID-19 pan- people, animals, and the environment. Microbe, 5,
383–389.
demic is that health promotion should not wait until a
Brownson, R. C., Seiler, R. and Eyler, A. A. (2010) Measuring
crisis happens, but prepare itself to respond swiftly. To
the impact of public health policies. Preventing Chronic
deal with an epidemic effectively, we must not only un-
Disease, 7, 1–7.
derstand viruses and how they spread, but also the ways Calistri, P., Iannetti, S., L. Danzetta, M., Narcisi, V., Cito, F., Di
in which people make decisions, organizations operate Sabatino, D., et al. (2013) The components of ‘One
and communities relate in reaction to them (Kickbusch World–One Health’ approach. Transboundary and
and Sakellarides, 2006). Health promotion researchers Emerging Diseases, 60, 4–13.

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021

should learn from crisis situations, analyse the reactions Champion, V. L. and Skinner, C. S. (2008) The health belief
and document the learnings. A good example is the way model. In Glanz, K., Rimer, B. K. and Viswanath, K. (eds),
the Singaporean government dealt with the SARS out- Health Behavior and Health Education: Theory, Research,
break in 2003, where it was shown that, rather than the and Practice. Jossey-Bass, San Francisco, CA, pp. 45–65.
Croyle, R. T., Sun, Y. C. and Hart, M. (2013) Processing risk
actual knowledge about the virus, the high confidence
factor information: defensive biases in health-related judg-
and trust in the government’s ability to cope with SARS
ments and memory. In Petrie, K. J. & Weinman, J. A. (eds),
was a key factor in controlling the crisis (Deurenberg- Perceptions of Health & Illnes. Psychology Press, New
Yap et al., 2005). This confirms findings from other stud- York, pp. 283–306.
ies highlighting the importance of trust in dealing with Deurenberg-Yap, M., Foo, L. L., Low, Y. Y., Chan, S. P.,
crisis situations (Siegrist and Zingg, 2014). In a similar Vijaya, K., & Lee, M. (2005). The Singaporean response to
vein, a comparison between the response to Hurricane the SARS outbreak: knowledge sufficiency versus public
Katarina in New Orleans and to SARS in Toronto put trust. Health Promotion International, 20, 320–326.
the success of the Toronto response down to social cohe- Duong, T. V., Aringazina, A., Baisunova, G., Pham, T. V.,
sion (Matthews, 2006, cited by Kickbusch and Pham, K. M., Truong, T. Q., et al. (2017) Measuring
health literacy in Asia: validation of the HLS-EU-Q47 sur-
Sakellarides, 2006). These and other findings call for fur-
vey tool in six Asian countries. Journal of Epidemiology,
ther research on the ways trust in public institutions can
27, 80–86.
be enhanced and social capital can be mobilized in order
ECDC. (2014). Transferability of Health Promotion and Health
to make populations more resilient against crises. Education Approaches between Non-communicable and
Just like the banking and terrorism crises before it, Communicable Diseases. European Centre for Disease
the COVID-19 pandemic teaches us that the faith in the Prevention and Control, Stockholm.
predictability and control of events that has dominated Estes, W. K. (2014) Handbook of Learning and Cognitive
our thinking since the Enlightment may be too optimis- Processes (Vol. 5): Human Information Processing.
tic. We have to accept uncertainty and learn to live with Psychology Press, New York.
it. The only certainty we have is that the world will be Kickbusch, I. and Sakellarides, C. (2006) Flu City—Smart City:
different after COVID-19. As a consequence, this crisis applying health promotion principles to a pandemic threat.
Health Promotion International, 21, 85–87.
can also be a turning point for health promotion.
Klintman, M. (2019) Knowledge Resistance: How We avoid
Confucius, in all his wisdom, believed that it is the study
Insight from Others. Manchester University Press,
of the past that helps to define the future. But in the cur- Manchester, UK.
rent situation, it may well be the present that gives us Marais, F., Minkler, M., Gibson, N., Mwau, B., Mehtar, S.,
directions in which to look forward. Ogunsola, F., et al. (2015). A community-engaged infection
prevention and control approach to Ebola. Health
Stephan Van den Broucke Promotion International, 31, 440–449.
McQueen, D. V. (2015) Health promotion applied to infectious
Psychological Sciences Research Institute Place Cardinal
diseases. Global Health Promotion, 22, 3.
Mercier 10, 1348 Louvain-la-Neuve, Belgium
Michie, S., West, R., Amlôt, R. and Rubin, J. (2020). Slowing
E-mail: [email protected] dow the covid-19 epidemic: changing behaviour by under-
standing it. BMJ Opinion, March 11, 2020 (last accessed 17
March 2020).
References
Nutbeam, D. (1998) Health promotion glossary. Health
Andersen, K. G., Rambaut, A., Lipkin, W. I., Holmes, E. C. and Promotion International, 13, 349–364.
Garry, R. F. (2020) The proximal origin of SARS-CoV-2. Okan, O., Sørensen, K. and Messer, M. (2020) COVID-19: a
Nature Medicine, 1–3. https://www.nature.com/articles/ guide to good practice on keeping people well informed. The
s41591-020-0820-9.pdf (last accessed 17 March 2020). Conversation, March 19, 2020
186 Editorial

Prentice-Dunn, S. and Rogers, R. W. (1986). Protection motiva- Smith, J. A. and Judd, J. (2020) COVID-19: vulnerability and
tion theory and preventive health: beyond the health belief the power of privilege in a pandemic. Health Promotion
model. Health Education Research, 1, 153–161. Journal of Australia, 33, 1–3.
Ratima, M. (2019) Leadership for planetary health and sustain- Sørensen, K., Pelikan, J. M., Röthlin, F., Ganahl, K., Slonska, Z.,
able development: health promotion community capacities Doyle, G., et al. (2015). Health literacy in Europe: compara-
for working with Indigenous peoples in the application of tive results of the European health literacy survey (HLS-EU).
Indigenous knowledge. Global Health Promotion, 26, 3. European Journal of Public Health, 25, 1053–1058.
Siegrist, M. and Zingg, A. (2014) The role of public trust during Springer, F. and Phillips, J. L. (2006). The IOM model: a tool for
pandemics: implications for crisis communication. prevention planning and implementation. Prevention
European Psychologist, 19, 23–32. Tactics, 8, 1–7.

Downloaded from https://academic.oup.com/heapro/article/35/2/181/5820891 by guest on 26 March 2021