Education and Literacy

The Expert Panel on Health Literacy, created by the Canadian Public Health Association [82], defined literacy as “the ability to understand and use reading, writing, speaking and other forms of communication as ways to participate in society and achieve one’s goals and potential” (p.3). They defined health literacy as “the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course” 82. People with low literacy levels have been identified by Enarson and Walsh [24] as a high risk population. In the context of pandemic, the ability to understand public health risk communication and act on the recommendation is critical to reducing exposure, monitoring symptoms, and seeking appropriate care. Semenza & Giesecke [25] also identified people with low educational levels as a high risk group that suffers disproportionately from a number of diseases, including respiratory ailments like influenza.

Crighten et al showed that when people develop complications due to influenza, those with lower educational levels are hospitalized more than the rest of the population [57]. Education is a key strategy to connect high risk populations with programs and services offered in preparation for, response to, and recovery from pandemic [83]. The Government of Canada [49] recommends that, at the first sign of an influenza pandemic, educational material should be made available to the public, including; child care workers; teachers; shelter workers; and correctional workers. Some public health interventions have focused on reducing the preparedness divide by distributing educational information door-to-door to high risk populations known to have lower levels of education and lower socioeconomic status [55]. Communication is only useful if it is culturally and linguistically appropriate, targeted at the appropriate literacy level and provided in the medium being accessed by vulnerable groups.

The WHO [3] highlights the type of interventions to be used before, during and after a pandemic. It is recommended that pandemic preparedness interventions targeting individuals and households focus on education about preventive health behaviors (eg. hand hygiene, social distancing, stockpiling supplies and vaccination), how to monitor symptoms, and when to seek treatment. The capacity to access, understand health information, and apply guidelines to take precautionary measures is an important attribute reducing risk of exposure in pandemic. Limited education, literacy skills, and communication can influence people’s knowledge about precautionary measures to reduce exposure, and how to respond (e.g. symptom management and knowing when to seek treatment) [7]. There may also be cultural norms and values around these behaviors and around trust in authority.

In their comparative study of Medicare beneficiaries, Winston et al. [84] found that educational awareness of the vaccine and physician encouragement, were identified as factors that would increase rates of vaccination and reduce the concerns some individuals have concerning side effects. The belief that the vaccine can cause influenza is widespread [77, 84-85], and preventive care education is important in influencing and motivating people to follow vaccination guidelines. Education and income have been found to be positively associated with intention to become vaccinated, due to the increased uptake of health information and recommendations at higher education and income levels [14, 65, 86].

Sub-groups of the Canadian population may have difficulty understanding health information if English/French is not their first language or materials are not provided in an accessible format for people with communication disorders [29]. In a study of migrant farm workers in the US [58], the use of bilingual and bicultural staff called promotora helped to bridge cultural gaps and bring farm working families together for health education sessions. In the same study, it was determined that targeting the children of migrant farm workers in education program about emergency preparations could enhance dissemination of pertinent information to the parents. Usher-Pines et al. [16] also note the importance of making sure pandemic plans are tailored to cultural specifications and that they are translated into multiple languages. Stebbins et al. [87] suggest targeted non-pharmacological interventions for children, to enhance preparedness for pandemic and to reduce exposure. Providing educational information about pandemic in a) a variety of languages, b) different formats, and c) multiple levels of complexity (eg. simplifying information for children) is an important strategy to enhance accessibility of information for high risk populations [29, 88].

Communication of effective health messages is especially important during a pandemic, and providing empirical facts alone is not effective in fostering compliance to public health recommendations [7]. Reasoning and adoption of recommended preventive behaviors are impacted by health beliefs and attitudes, which in turn are influenced by education and culture [87, 89-94]. This finding supports the need to recognize how different cultural and demographic groups interpret messages, and how this may contribute to their attitudes and potential vulnerability during pandemic [65, 89, 94-95].