COVID-19: health literacy is an underestimated problem
Authors: Leena Paakkari, Orkan Okan
Journal: The Lancet Public Health (2020)

Rapid development of coronavirus disease 2019 (COVID-19) into a pandemic has called for people to acquire and apply health information, and adapt their behaviour at a fast pace.1Zarocostas J How to fight an infodemic.Lancet. 2020; 395: 676Summary Full Text Full Text PDF PubMed Scopus (1225) Google Scholar Health communication intended to educate people about the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and how to avoid getting or spreading the infection has become widely available. Most valuable information is created in an easy-to-understand manner that offers simple and practical solutions, such as washing hands, maintaining physical distance2Prem K Liu Y Russell TW 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; (published online March 25.)https://doi.org/10.1016/S2468-2667(20)30073-6Summary Full Text Full Text PDF PubMed Scopus (1314) Google Scholar, and where to find information about the latest recommendations, and advice. Unfortunately, there is also complex, contradictory, and false information.1Zarocostas J How to fight an infodemic.Lancet. 2020; 395: 676Summary Full Text Full Text PDF PubMed Scopus (1225) Google Scholar Similarly, individuals are considered able to acquire, understand, and use this information in a sound and ethical manner—ie, to be health literate. However, the COVID-19 infodemic1Zarocostas J How to fight an infodemic.Lancet. 2020; 395: 676Summary Full Text Full Text PDF PubMed Scopus (1225) Google Scholar has highlighted that poor health literacy among a population is an underestimated public health problem globally. For instance, in Europe, nearly half of adults reported having problems with health literacy and not having relevant competencies to take care of their health and that of others.3Sørensen K Pelikan JM Röthlin F et al.Health literacy in Europe: comparative results of the European Health Literacy Survey (HLS-EU).Eur J Public Health. 2015; 25: 1053-1058Crossref PubMed Scopus (1130) Google Scholar Health literacy is already seen as a crucial tool for the prevention of non-communicable diseases with investments in education and communication sought to be sustainable, long-term measures starting early in the life course.4Nutbeam D Discussion paper on promoting, measuring and implementing health literacy: implications for policy and practice in non-communicable disease prevention and control. World Health Organization, 2017https://www.who.int/global-coordination-mechanism/working-groups/background.pdf?ua=1Date accessed: April 2, 2020Google Scholar However, when COVID-19 emerged rapidly, two aspects became striking. First, globally, health literacy is as important for the prevention of communicable diseases as it is for non-communicable diseases. Second, along with system preparedness, individual preparedness is key for solving complex real-life problems. In this pandemic, it is difficult, yet possible, to take the time to enhance health literacy because immediate action is required by governments and citizens. For countries to secure health-care services for the most susceptible individuals, many people have adopted policies that restrict physical contact by banning events, sizing limits for group gatherings, and even issuing stay-at-home orders. Governments and health authorities are pleading for individual responsibility in avoiding all unnecessary risks for infection with or spread of SARS-CoV-2. During these times, the discussion around human rights and personal freedom, democracy, social responsibility, and public health action are put to the test. Amid the pandemic, it is difficult to agree with the argument made by Wikler5Wikler D Personal and social responsibility for health.Ethics Int Aff. 2002; 16: 47-55Crossref PubMed Scopus (136) Google Scholar that "if people know they are taking risks but accept them as the price of pursuing goals to which they assign higher priority, then it is not the business of public health to insist that health be valued above all".5Wikler D Personal and social responsibility for health.Ethics Int Aff. 2002; 16: 47-55Crossref PubMed Scopus (136) Google Scholar This argument might be true under different circumstances, but now, irrational behaviour in non-compliance with COVID-19 policies, which might be motivated by misperception of risks6May T Public communication, risk perception, and the viability of preventive vaccination against communicable diseases.Bioethics. 2005; 19: 407-421Crossref PubMed Scopus (65) Google Scholar or other personal priorities, allows a so-called free rider problem.7Buchanan JM The demand and supply of public goods.vol 5. Rand McNally, Chicago1968Google Scholar This issue has been widely discussed in the context of vaccination,8Cullity G Moral free riding.Philos Pub Aff. 1995; 24: 3-34Crossref Scopus (90) Google Scholar but it can also occur during the COVID-19 outbreak by deliberately neglecting precautions and protective behaviour. Most people act in a socially responsible way and with solidarity, thus creating a collective good of infection-free space and decreased infection risk. The so-called free riders enjoy the benefits themselves of others complying with the given policies (ie, decreasing risks)7Buchanan JM The demand and supply of public goods.vol 5. Rand McNally, Chicago1968Google Scholar; however, they travel, hang around in groups, and ignore pleas for protective and preventive behaviour, feeling a false sense of invulnerability.9Gunia A Millennials aren't taking coronavirus seriously, a top WHO official warns.https://time.com/5807073/millennials-coronavirus-who/Date accessed: March 28, 2020Google Scholar Nonetheless, as the risk of becoming infected is dependent on other people's compliance with the guidelines and the risk of others is dependent on commitment to joint efforts, unwillingness to contribute to collective good is unfair on other members of society.8Cullity G Moral free riding.Philos Pub Aff. 1995; 24: 3-34Crossref Scopus (90) Google Scholar, 10van 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: 154-160Crossref Scopus (23) Google Scholar In the COVID-19 pandemic, this behaviour does injustice, especially to high-risk groups, people with diseases, and the health workforce trying to treat these patient groups and save their lives. Health literacy might help people to grasp the reasons behind the recommendations and reflect on outcomes of their various possible actions. However, taking social responsibility, thinking beyond personal interests, and understanding how people make choices—aspects such as ethical viewpoints and behavioural insights—should also be considered within the toolbox of health literacy. Solidarity and social responsibility should not only be accounted for by the general population and decision makers, but also by those individuals who produce and share misleading and false information about SARS-CoV-2. The development of health literacy is even more topical than ever to prepare individuals for situations that require rapid reaction. Above all, health literacy should be seen in relation to social responsibility and solidarity, and is needed from both people in need of information and services and the individuals who provide them and assure their accessibility for the general population. We declare no competing interests.