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PILLAR ONE: KNOWLEDGE & HEALTH LITERACY
DEFINITION:
Health literacy entails people's knowledge and competences to obtain, process, and understand health
information and services to make appropriate health decisions.1 (Institute of Medicine, 2004)
No one is ever fully health literate, and everyone at some point needs help in understanding or acting on
important health information or navigating a complex system, even in economically advanced countries
with strong education systems. Some population categories most likely to experience low health literacy
are older adults, racial, ethnic minorities, low educational level, migrants, and people with compromised
health status.2
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1. The healthcare systems and the way of people life have been questionable globally (Abdel-Latif,
2020):
a. Lack of preparedness of healthcare systems to fight off disease
b. The COVID-19 outbreak has clearly demonstrated the need for reforming the healthcare
systems and health emergency services and the preparedness for the epidemic or pandemic
crises as it has become obvious that these disease outbreaks do not stop beyond certain
boundaries or differentiate between countries, peoples, and systems but affect every
individual and country. Health literacy was reported to be underestimated in the COVID-19
crisis. (Paakari &Okan, 2020) (Abel &McQueen, 2020)
c. The risk of being infected is greatly dependent on other people's behavior and observing the
precautionary procedures and national measures. Health literacy was reported to be
underestimated in the COVID-19 crisis. (Paakari &Okan, 2020) (Abel &McQueen, 2020)
2. The world is witnessing bombardment of complex and contradictory information about COVID-19 in
relation to detection, diagnosis, prevention, and management of the disease. In this pandemic crisis,
most individuals are having problematic issues in accessing trusted information, and social media
pose higher risks than other conventional media because of the wider and faster outreach of the
message and spreading of misinformation.
a. WHO leading this cause to slow the spread of the COVID-19 outbreak, and Zarocostas
(2020) reported that the WHO has launched platforms aiming to combat misinformation
around COVID-19. It is not only the virus that is spreading but falsified information called
‘infodemic’ is also spreading, making the individuals doubtful and confusing to deal with
information and misinformation.
b. One can imagine what will be the picture for other countries that their healthcare systems
are undeveloped and their persons' health literacy is inadequate.
c. Health authorities and organizations have attempted to apply legislative, protective, and
precautionary measures among citizens at different levels by issuing warnings and
recommendations about COVID-19, by setting policies and legal restrictions, and finally by
imposing a complete ‘lockdown’. Decrease access to
The WHO Regional Office for Europe released a publication in 2013 entitled “Health Literacy” as part of
the “Solid Facts” series which states: “Ideally, a health literate individual is able to seek and assess the
health information required: to understand and carry out instructions for self-care, including
administering complex daily medical regimens; to plan and achieve the lifestyle adjustments required
for improving their health; to make informed positive health-decisions; to know how and when to access
health care when necessary; and to share health-promoting activities with others and address health
issues in the community and society”.
A more detailed list of the recommended components of individual’s health literacy would include:
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Understanding that people have an opportunity to protect their own health
Knowing where to look for health information and how to use it
Knowledge of health and its determinants
Knowledge of common diseases and their causes
Knowledge of the major risk factors of cardiovascular diseases, diabetes and of other avoidable
risks to health
Understanding self-care, e.g. the seven pillars
Understanding the value of health screenings at key life points
Knowing how to use self-care products safely and effectively
Understanding medicines and vaccines
Knowing when to seek professional advice
Knowing how to join, help and motivate others such as family members
Understanding the indirect determinants of health, such as understanding food labelling
KEY POINT: Poorer health literacy has been shown to result in less healthy choices, riskier
behaviour, less self-management, poorer overall health and more hospitalisation. Lack of
health literacy at a broader level significantly drains human and financial resources in the
health system.
People are not able realise their health potential unless they can control the factors that
determine their health, and health literacy is one of the strongest predictors of this control. It
is significant that “[health] literacy is a stronger predictor of an individual’s health than
income, employment status, education level and racial or ethnic group” (Weiss, 2007).
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Self-awareness is the personal, practical application of an individual’s health knowledge (Pillar
1) to their own health situation; in other words, health literacy combined with the internalization
of knowledge. This may involve personal or professional assessments, reference to records and
tests. The result is a baseline assessment of their mental and physical state – that is, an
individual’s health capital or health status ‘scorecard’.
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WHO recommendations for self-awareness…
In the 1999 interagency document “Partners in life skills education”, the WHO identified
self-awareness as one of the skills relevant to good health across all cultures.
As a component of health literacy, the WHO states that “awareness of the determinants
of health… encourages individual and collective actions which may lead to a
modification of these determinants.”
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Measuring health status
We know that it is important to measure and monitor health. But how do we do this? A
person with good self-awareness of their health would know, and have recorded, the
general metrics that track levels of health and disease. While a large list, in general this
should include knowledge of:
Your family’s medical history and any genetic predispositions
Which vaccinations you have had
Your resting heart rate and blood pressure
Your weight, height and body mass index (BMI)
Your cholesterol levels
Your HbA1c level (for blood glucose)
Your mental and emotional health
Your stress levels
Your sleep profile
Your oral health situation
In addition, it is important to understand the way in which lifestyle factors contribute to
disease and understand how your lifestyle affects your health, and thus how it could be
improved. To do this, assess:
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Your current level of physical activity
Your diet
Your risk profile of other contributing factors, such as how many tobacco
cigarettes you smoke per week, or the number of alcoholic units consumed per
week
Other useful information that forms part of a strong self-awareness of an individual’s
health includes:
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Knowing which screening tests you should undertake and at what age these
should begin (e.g. colorectal cancer screening recommendations vary based on
age)
An assessment of your day-to-day hygiene practices (e.g. sneezing, coughing,
washing hands after toilet)
An assessment of your ability to use self-care products and services safely, and
whether you access professional help at appropriately and in a timely manner.
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Sedentary behaviour and low levels of physical activity can have negative
effects on the health, well-being and quality of life of individuals. Selfquarantine can also cause additional stress and challenge the mental health
of citizens. Physical activity and relaxation techniques can be valuable tools
to help you remain calm and continue to protect your health during this
time.
WHO recommends 150 minutes of moderate-intensity or 75 minutes of
vigorous-intensity physical activity per week, or a combination of both.
These recommendations can still be achieved even at home, with no special
equipment and with limited space.
Take short active breaks during the day. Short bouts of physical activity add
up to the weekly recommendations. You may use the suggested exercises
below as inspiration to be active every day. Dancing, playing with children,
and performing domestic chores such as cleaning and gardening are other
means to stay active at home.
Follow an online exercise class. Take advantage of the wealth of online
exercise classes. Many of these are free and can be found on YouTube. If you
have no experience performing these exercises, be cautious and aware of
your own limitations.
Walk. Even in small spaces, walking around or walking on the spot, can help
you remain active. If you have a call, stand or walk around your home while
you speak, instead of sitting down. If you decide to go outside to walk or
exercise, be sure to maintain at least a 1-meter distance from other people.
Stand up. Reduce your sedentary time by standing up whenever possible.
Ideally, aim to interrupt sitting and reclining time every 30 minutes. Consider
setting up a standing desk by using a high table or stacking a pile of books or
other materials, to continue working while standing. During sedentary leisure
time prioritize cognitively stimulating activities, such as reading, board
games, and puzzles.
Relax. Meditation and deep breaths can help you remain calm. A few
examples of relaxation techniques are available below for inspiration.
For optimal health, it is also important to remember to eat healthily and stay
hydrated. WHO recommends drinking water instead of sugar-sweetened
beverages. Limit or avoid alcoholic beverages for adults and strictly avoid
these in young people, and pregnant and breastfeeding women, or for other
health reasons. Ensure plenty of fruits and vegetables, and limit the intake of
salt, sugar and fat. Prefer whole grains rather than refined foods. For more
guidance on how to eat healthily during self-quarantine, please see the Food
and nutrition tips during self-quarantine, prepared by WHO/Europe.
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The World Health Organisation’s “Global Recommendations on Physical Activity for
Health” addressed physical inactivity across three age groups: 5 – 17 year olds, 18 – 64
year olds and those 65 years old and above.
Children and adolescents in the 5 – 17 year old age-group, in order to improve
cardiorespiratory and muscular fitness, bone health, and cardiovascular and metabolic
health biomarkers, should:
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Accumulate at least 60 minutes of moderate- to vigorous-intensity physical
activity daily
Gain greater benefit from being active for more than 60 minutes per day
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Generally focus on aerobic physical activity. Vigorous-intensity activities should
be incorporated, including those that strengthen muscle and bone, such games
or sport that include jumping, running and agility, at least 3 times per week
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Adults in the 18 – 64 year old age-group, should:
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Do at least 150 minutes of moderate-intensity aerobic physical activity throughout
the week or do at least 75 minutes of vigorous-intensity aerobic physical activity
throughout the week or an equivalent combination of moderate- and vigorousintensity activity
Perform aerobic activity in bouts of at least 10 minutes duration
For additional health benefits, increase their moderate-intensity aerobic physical
activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity
aerobic physical activity per week
Muscle-strengthening activities should be done involving major muscle groups on
2 or more days a week
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Adults aged 65 years or older should, in order to improve cardiorespiratory and
muscular fitness, bone and functional health, reduce the risk of NCDs, depression and
cognitive decline:
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Do at least 150 minutes of moderate-intensity aerobic physical activity throughout
the week. Or do at least 75 minutes of vigorous-intensity aerobic physical activity
throughout the week or an equivalent combination of moderate- and vigorousintensity activity
 Perform aerobic activity in bouts of at least 10 minutes duration
 For additional health benefits, increase their moderate-intensity aerobic physical
activity to 300 minutes per week, or engage in 150 minutes of vigorous-intensity
aerobic physical activity per week
 Include muscle-strengthening activities, involving major muscle groups, on 2 or
more days a week
 Older adults, with poor mobility, should perform physical activity to enhance
balance and prevent falls on 3 or more days per week
 When older adults cannot do the recommended amounts of physical activity due
to health conditions, they should be as physically active as their abilities and
conditions allow
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 When older adults cannot do the recommended amounts of physical activity due to
health conditions, they should be as physically active as their abilities and conditions
allow
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For a healthy diet, recommendations for individuals include the following:
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Achieve an energy balance and a healthy weight
Increase consumption of fruits and vegetables, and legumes, whole grains and
nuts
Limit energy intake from total fats and shift fat consumption away from saturated
fats to unsaturated fats and towards the elimination of trans-fatty acids
Limit the intake of simple sugars
Limit salt (sodium) consumption from all sources and ensure that the majority of
salt consumed is iodized
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Risk mitigation, in terms of health, refers to the avoidance or reduction of behaviours
that directly increase the risk of disease or death. Broadly, risk mitigation involves
activities such as:
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Making sure you are vaccinated
Not smoking or quitting smoking
Practicing safe sex
Drinking in moderation
Protecting yourself from the sun
Driving carefully and wearing a seat belt
Wearing your helmet when you ride a bicycle
Pillar 5 includes the steps that individuals can take to reduce their own personal risk of
avoidable morbidity and mortality.
The goal of community mitigation in areas with local COVID-19 transmission is to
slow its spread and to protect all individuals, especially those at increased risk for
severe illness, while minimizing the negative impacts of these strategies. These
strategies are used to minimize morbidity and mortality of COVID-19 in societal
sectors such as schools, workplaces, and healthcare organizations.
Implementation is based on:
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Emphasizing individual responsibility for implementing recommended
personal-level actions
Empowering businesses, schools, and other settings to implement
appropriate actions
Prioritizing settings that provide critical infrastructure services
Minimizing disruptions to daily life to the extent possible and ensuring
access to health care and other essential services.
Guiding principles
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Community mitigation efforts aim to reduce the rate at which someone
infected comes in contact with someone not infected, or reduce the
probability of infection if there is contact. The more a person interacts with
different people, and the longer and closer the interaction, the higher the
risk of COVID-19 spread.
Each community is unique. Appropriate mitigation strategies should be
based on the best available data. Decision making will vary based on the
level of community transmission and local circumstances. Refer to Table 1.
The characteristics of the community and its population, health system and
public health capacity, and the local capacity to implement strategies are
important when determining community mitigation strategies. Refer
to Table 2.
As communities adjust mitigation strategies, they should ensure that the
healthcare system capacity will not be exceeded. Precautions should be
taken to protect health care professionals and other critical infrastructure
workers. Communities need to assure healthcare systems have adequate
staffing, a surplus of inpatient and ICU beds, and critical medical
equipment and supplies such as PPE.
As communities adjust mitigation strategies, they should ensure public
health capacity will not be exceeded. Public health system capacity relies
on detecting, testing, contact tracing, and isolating those who are or might
be sick, or have been exposed to known or suspected COVID-19 cases; it
is important to stop broader community transmission and prevent
communities from having to implement or strengthen further community
mitigation efforts.
Attention should be given to people who are at higher risk for severe
illness when determining and adjusting community mitigation strategies.
Certain settings and vulnerable populations in a community are at
particularly high risk for transmission. This includes but is not limited
to congregate settings such as nursing homes and other long-term care
facilities, correctional facilities, and the homeless population.
Mitigation strategies can be scaled up or down, depending on the evolving
local situation, and what is feasible, practical, and legal in a jurisdiction.
Any signs of a cluster of new cases or a reemergence of broader
community transmission should result in a re-evaluation of community
mitigation strategies and a decision on whether and how mitigation might
need to change.
Cross-cutting community mitigation strategies can be organized into the
following categories: promoting behaviors that prevent spread; maintaining
healthy environments; maintaining healthy operations; and preparing for
when someone gets sick. Presuming a community is not sheltering-in-
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place, cross-cutting strategies under each rubric are outlined below and
should be implemented to the extent possible, and in accordance with the
amount of ongoing community transmission. Refer to Table 3.
Community mitigation strategies should be layered upon one another and
used at the same time—with several layers of safeguards to reduce the
spread of disease and lower the risk of another spike in cases and deaths.
No one strategy is sufficient.
There are range of implementation choices when setting or adjusting
community mitigation plans. These choices offer different levels of
protection from the risk of community transmission.
Communities need to decide the level of risk that is acceptable and make
informed choices about implementing mitigation plans accordingly.
Individuals make choices about following the behavioral practices that are
recommended. Compliance to community mitigation decisions will also
impact the spread of COVID-19.
CDC offers setting-specific strategies for a variety of sectors that
include businesses, schools, institutes of higher education, parks and
recreational facilities, and other places.
Travel patterns within and between jurisdictions will impact efforts to
reduce community transmission. Coordination across state and local
jurisdictions is critical – especially between jurisdictions with different levels
of community transmission.
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When you are well
Everyone – even when well – can help slow the spread of COVID-19.
This means:
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wash your hands often with soap and water. This includes before and after eating and
after going to the toilet
use alcohol-based hand sanitisers when you can’t use soap and water
avoid touching your eyes, nose and mouth
clean and disinfect surfaces you use often such as benchtops, desks and doorknobs
clean and disinfect objects you use often such as mobile phones, keys, wallets and work
passes
increase the amount of fresh air by opening windows or changing air conditioning
POINT 4:
How to make your environment safer
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Avoid the 3Cs: spaces that are closed, crowded or involve close contact.
o Outbreaks have been reported in restaurants, choir practices, fitness
classes, nightclubs, offices and places of worship where people have
gathered, often in crowded indoor settings where they talk loudly, shout,
breathe heavily or sing.
o The risks of getting COVID-19 are higher in crowded and inadequately
ventilated spaces where infected people spend long periods of time
together in close proximity. These environments are where the virus
appears to spread by respiratory droplets or aerosols more efficiently, so
taking precautions is even more important.
Meet people outside. Outdoor gatherings are safer than indoor ones,
particularly if indoor spaces are small and without outdoor air coming in.
o For more information on how to hold events like family gatherings,
children’s football games and family occasions, read our Q&A on small
public gatherings.
Avoid crowded or indoor settings but if you can’t, then take precautions:
o Open a window. Increase the amount of ‘natural ventilation’ when
indoors.
o WHO has published Q&As on ventilation and air conditioning for both
the general public and people who manage public spaces and buildings.
o Wear a mask (see above for more details).
POINT 6
how to wear a mask:
Clean your hands before you put your mask on, as well as before and after you
take it off, and after you touch it at any time.
Make sure it covers both your nose, mouth and chin.
When you take off a mask, store it in a clean plastic bag, and every day either
wash it if it’s a fabric mask, or dispose of a medical mask in a trash bin.
What to do if you feel unwell
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Know the full range of symptoms of COVID-19. The most common symptoms
of COVID-19 are fever, dry cough, and tiredness. Other symptoms that are less
common and may affect some patients include loss of taste or smell, aches and
pains, headache, sore throat, nasal congestion, red eyes, diarrhoea, or a skin
rash.
Stay home and self-isolate even if you have minor symptoms such as
cough, headache, mild fever, until you recover. Call your health care provider
or hotline for advice. Have someone bring you supplies. If you need to leave your
house or have someone near you, wear a medical mask to avoid infecting others.
If you have a fever, cough and difficulty breathing, seek medical attention
immediately. Call by telephone first, if you can and follow the directions of
your local health authority.
Keep up to date on the latest information from trusted sources, such as
WHO or your local and national health authorities. Local and national
authorities and public health units are best placed to advise on what people in
your area should be doing to protect themselves.
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The rational and responsible use of health products and services as part of self-care
involves individuals safely and effectively managing their health (and any everyday
ailments or minor conditions), where appropriate with medicines, products or services.
Self-care products and services are the ‘tools’ of self‐care, supporting health awareness
and healthy practices, and may include the use of:
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Prescription medicines (in conjunction with a doctor)
Nonprescription medicines
Preventative health products, e.g. dental care, mosquito netting, sleep aids
Natural health products, traditional medicines and vitamins, minerals and
supplements
Devices and diagnostics, e.g. home blood pressure monitors
Substance control products, e.g. nicotine gum for tobacco cessation
Wellness services, e.g. nutrition planning, gym memberships
Health services, e.g. acupuncture, chiropracty, smoking cessation programmed