Equity and Health Literacy during COVID-19 in Saskatchewan: An Interview with Erin Beckwell, Knowledge Translation Specialist

 How to use this resource:

• Explore the equity-oriented health care approach that incorporates the three key dimensions of trauma- and violence-informed care, culturally-safe care and harm reduction and how it relates to COVID-19 responses.
• Discuss best practices for equity-informed communications during crisis or pandemic.
• Support advocacy for equity-informed communications by understanding the risks of lacking consideration, as well as the challenges and benefits.

This article is shortened from the interview’s original length.

Our Community Engagement Specialist at the DSA, Erin Wolfson, sat down with Erin Beckwell, a Knowledge Translation Specialist with the Saskatoon Health Authority (SHA), to discuss the need for consideration of health literacy in our communications about COVID-19, in order to ensure an equitable and effective response to community needs. 

Erin’s work with the SHA focuses on mobilizing knowledge to support the health system to achieve health equity and provide culturally safe care for all. In this interview, Erin explores what health literacy means, how health literacy levels are influenced by stress, the risks of not considering health literacy and highlights the promising practices that have emerged during the COVID-19 response.

So perhaps this is a very big an d broad question. What does a health equity lens look like?

Well, one of my favourite resources is Canadian (called the Key Dimensions of Equity-Oriented Care from Equip Health Care). It’s really an emerging and practise-oriented and also community-based way of framing equity-oriented health care, which is a little different than health equity broadly, but I think it really informs. The resource talks about an equity-oriented response to anything, including COVID, would have to be trauma and violence-informed. We have to understand that people have histories, whether that’s generations ago and systemic stuff like residential schools or 60’s scoop, or whether that’s interpersonal violence that people have experienced in their own lifetime – and often both. Then we also have what is being described as a collective experience of trauma right now with COVID itself, right? And so there’s that piece that has to be acknowledged that this isn’t just an ordinary thing, and it is stirring up historical, older trauma, but it is also new trauma.

Then there is also the harm reduction piece. We often approach services, health messaging, and health education from the perspective of the gold standard or the ideal, even when we know this is unattainable for lots of folks. Typically harm reduction is seen as an intervention around substance use stuff. But I see it much more broadly than that.

When we’re talking about any health experience, we need to meet people where they’re at. We can’t just go at them with ‘this is the gold standard of what the evidence says’, such as ‘the best way to prevent this or manage this or respond to this’, because the reality is that people are not living in the best-case scenario. That’s privilege. So we need to adapt our approach, our messaging and our services to reflect that. 

We need to say, ‘ok, here’s what we know, it is vast, but what’s realistic for you or not needs to be done on a person by person basis’. On a population level, as well as on a more global messaging level is something that impacts often bigger systems and even makes some practitioners really uncomfortable. That is feeling that ‘I don’t want to tell people it’s OK to do something that’s not what the literature said is the best thing to do’. 

The reality is that if our messaging, if our services and if our response doesn’t actually attend to what is realistic, people are going to do what they do anyway, just without sometimes feeling they can be transparent about it with service providers, or even with their family or community. So people end up having shame about that or making decisions without the information they need to make the best decision for them where they’re at right now. So that harm reduction piece is really important if we are going to be equity-informed and be culturally responsive, which hopefully leads to cultural safety in people’s experiences with us as health care providers.

So looking at culture specific to Saskatchewan, it’s important we tend to the lived experience and history of Indigenous peoples. We know that culture can be also experienced much more broadly than that and people often have multiple identities that could be described as cultural. So, how do we actually tailor our responses, whether that’s health messaging or in actual health services to people’s cultural orientation and identities, as well as the broader context that goes with that? 

For example, it is different as a queer person. I can pretty much move through the world in ways that it would be nice if things were adjusted to reflect that, but I also can compensate. I’m not visibly outed necessarily by most, just by showing up. Whereas if I were visibly Indigenous, people might make assumptions – there is profiling and other pieces to that. So we need to also acknowledge that all experiences of culture are not equal and have different implications in our society. 

So those are the three pieces that I see [trauma, harm reduction, cultural safety] and they aren’t typically what’s talked about in terms of equity-informed approaches. We talk about things like health disparities and gaps in health. Those are real things we can see in the data, but in terms of what do we need to do to actually prevent those, adapt for them and hopefully not worsen them? That is really, at the end of the day, the goal – how do we not widen gaps in health? 

When we have something like COVID happening, we need to be extra mindful that people who are socially vulnerable are extra vulnerable to contracting COVID, but they also have poor access to care, including testing and also poorer outcomes. Often we can talk about that in terms of their comorbidities or their other health issues – they’ve got risk factors and so on. But, very rarely when those conversations happen are we talking about trauma and harm reduction and cultural safety. We’re talking about, ‘they also have diabetes and are homeless’. Which of course, are important social factors, but equity-oriented approaches don’t just look at those. They can be helping to get a housing situation sorted, which is going to reduce risk of contracting COVID, your ability to follow public health orders or improve your access to care in general, which will hopefully then give you a better shot at a good outcome. We can also look more broadly at these factors that need to be incorporated into everything we do, including our relationships with one another as service providers or community agencies or planners or organizers. Because equity-oriented approaches aren’t just for our clients or our patients, it’s about our communities and our relationships with one another as well. 

From your perspective, how are communities experiencing the COVID crisis right now here in Saskatchewan? 

That’s a good question. I think in Saskatoon in particular, there were a lot of relationships that were quickly mobilized to help folks respond. I think if anyone looks at the media, you can see particularly coming out of urban centres, there’s frustration about fragmented response and lack of communication, particularly between larger systems and community-based service providers and organizations. 

Even then, to really talk about what’s happening in the community, I think there’s a variety of experiences that people are having and in some cases they’re getting what they need when they need it, and there’s lots of situations where people are struggling. I think one of the realities, especially for people whose survival needs aren’t met consistently or typically, is this for many of us COVID-19, especially those of us who work in anything health related, has become the centre of our world for the last month plus right? This is pretty much what we eat, sleep and breathe right now. For people who are just trying to survive and that has been a reality pre-COVID, that continues to be their reality today. So I think that’s an important factor. 

We need to always remember that for us, this may be the drop everything, this is all we talk about now because our work is all COVID work for many of us.  For people living it, that isn’t necessarily reflected. That doesn’t mean people are in denial or that people are somehow not caring about their health or the health of their community or their family. It means their priorities are different because they have unmet physical and social needs, sometimes relational needs, that really do supersede talk about some abstract virus that people don’t really understand or the information changes everyday. 

I think that’s a really critical piece when we’re talking about folks who are seen as “vulnerable” – there’s a wide spectrum and that’s a very big label to slap on folks. This is actually not always helpful because why are people vulnerable? But also then the reality that there’s people who have a home, they have some social supports and community supports, and they’ve been able to maintain or cobble together some system of support to sustain them, at least till now. And then there’s folks on the other end of the spectrum where it’s like, “yeah, COVID, whatever, I just need to know where I’m going to eat in an hour”. They may not necessarily be concerned why everybody’s debating about whether masks or gloves are OK – “I don’t care because that doesn’t help me get food in my belly”. Or they may know really tangible information like services at their local food program have changed how they deliver things, but that’s a tangible reality, not necessarily a whole lot about the ins and outs of why that’s changed. 

Often there’s when we talk about who’s vulnerable there are a lot of assumptions in that, and a lot of risk that we’re going to miss people because vulnerability is socially constructed – it’s structural, but it’s also subjective. People may not feel vulnerable when we deem them so, but we also may think someone isn’t particularly vulnerable and they may feel very vulnerable. So, it’s interesting thinking about what this is like in the community, especially for those of us who are not connected in the community right now. I mean, I’ve been in my house for over a month and feel very disconnected from the community these days. So it’s challenging to even have a sense of what this looks like on the ground. 

So I’m going to switch gears but we can come back to some of those broader questions at the end, in terms of sort of how people can respond. Moving to conversations around Health Literacy – and I use the term Health Literacy, but however you would better describe that, please do. How has the COVID crisis impacted or exasperated this issue? Who is most impacted and how does it impact them? 

Well, I think health literacy is such a critical thing to be thinking about and talking about and integrating into our plans right now. It’s something I’ve not seen consistently done, which is a bit frustrating. I think there’s an assumption when we talk about anything with the word literacy in it, that we’re talking about readability and reading level, which is certainly part of what we’re talking about, but when we talk about health literacy, it’s so much bigger than that. Health Literacy is about how well can individuals and populations access and understand and act upon information to promote health. 

So all of us have health literacy, just like all of us have mental health, not just people with mental illness. It’s kind of the same, right? Often we talk about health literacy, and we assume that means people who need things at lower literacy levels. Really, we all benefit when things are written clearly and use simple basic language that is not loaded with jargon and abstract metaphors, but also that’s inclusive of our realities. And so health literacy becomes a really significant challenge for us in this. 

What factors influence someone’s health literacy? 

We know the factors that influence people’s health literacy are reading level and comprehension – all of those things that are attached to literacy typically. Absolutely, that’s part of health literacy, and also language. Are people able to access information in the language that they are most comfortable reading and speaking? Format matters also matter. Is information only put out on social media? What if I’m not on social media? Or is it being put out in long pages of text which are inaccessible to me in some way? 

But then there’s the other piece, which is when people are under stress their health literacy drops. If you have even a graduate degree and you work in the health system, there’s actually some studies that indicate you may be worse off because people assume you should know, but you also overestimate your capacity to understand and access information. So anybody who’s under stress is going to see their health literacy level drop. So they need that accommodation and that adaptation, in terms of the way information is brought together and accessed. 

So where do you get the info? Under stress, people have lower capacity for sleuthing out reliable sources of information so they may be more inclined to take the first info they get. In this situation, there’s also the risk of information overload or fatigue where people are getting so much information that people reach a sort of threshold where there’s a feeling of ‘I’m done anything new, I can’t handle it or I’m not sure what to believe, so I’m not going to believe anything’. So we run into situations where health literacy isn’t named. One of the central parts of the experience is how people get their information and is that information something they can easily understand and act upon as is appropriate in their situation. 

I think so often we’re trying for generic messaging that meets everyone’s needs, but the reality is, there’s no such thing as the general public and we have to be really mindful that people are in different positions. If we’re talking about access and community supports and you live in a rural community, that looks fundamentally different if you live in a very small rural town in Saskatchewan, then if you live in Saskatoon or Regina or even PA. We risk coming across as not very credible or not very informed, and certainly not inclusive because our messaging affirms these positions that everyone can go and talk to a case manager or has a local food bank. Well, what if I don’t have a food bank in my community or what if I’m really worried about confidentiality because my community is so small? Everybody knows everybody, and I don’t feel comfortable going to the local service hub because my neighbour runs that or my family member runs it. So, we really need to think about all of these different factors or else we risk being seen as sort of irrelevant out of touch or at best just not speaking to people directly in ways they can hear us. 

How can we best get information to people?

So one question I’ve had folks ask is, does it make sense to publish stuff in newspapers anymore? Well, if you’re targeting seniors, possibly yeah, that’s a good avenue. But thinking you’re going to reach the general population by printing stuff in a newspaper? There’s probably lots of people who probably can’t remember the last time they actually read something in a newspaper, or who get what their friends share on social media that was perhaps first published in the newspaper. So,we have to have an awareness of how this happens for people, but not just what’s the most effective way to reach the greatest number, but who do we want to reach and what are their needs and how well do we understand that? And are those based on assumptions about what we think we know? Or is it based on what we actually have heard directly from folks? 

Can you speak to the potential outcomes related to the challenges or risks that you see or foresee in terms of not taking that approach? 

Well, the biggest risk is, if our messaging isn’t accessible and relevant and actionable, we may see higher rates, outbreak and poorer outcomes for COVID. I think that’s what all of us are trying to avoid, contain and prevent. Also, if people are exposed to or test positive for COVID, how do we make sure that we’re having the best outcomes – especially for communities where we know there are those vulnerabilities that are real, perceived or otherwise and can increase the likelihood of a poor outcome.

But, there’s also incredible capacity and resiliency in the community, if we’re thinking about it and connected to it and can actually tap into that. Folks in the community, whether the community is rural folks, people who live on reserve, people who are street involved and stay in shelters or access community-based drop in centres and food programs, there are ways they communicate information to one another. We often forget about that sort of informal communication network that has been developed over years and generations of people learning ‘how do I get information’. I mean, none of us live in ideal circumstances and so, who are our trusted community members who translate information and share information for us? Is that an elder? Is that another community leader? Is that the guy I see every day on the street corner? 

What do we understand, especially those of us who are health communicators, about those informal networks that aren’t going to be Facebook or the newspaper or the radio. How do we know, for example, the radio is huge in the north. It’s a huge way that people get their information and stay connected to the community. Partly because people are geographically spread out and it’s an effective, accessible means of accessing information. So in other parts of the province, that may not be the case. I mean, many people now don’t listen to local radio anymore. So that’s an example of understanding sort of that the community has created a way of sharing information. There’s a sense that it is accessible to people of different ages and people with different language groups. 

So, we must be able to think about what the community already knows and what they do well. I think sometimes the risk we run is assuming the community knows nothing. Therefore, we come in and we inform the community, but the reality is a really good response needs to be informed by the community. Community knows what they need to know. They may not know all the nuances of COVID-19 and I think the biggest thing that the community often doesn’t know is how things are getting decided and planned and all the things happening in the big systems. That’s the information the community often doesn’t get – they don’t have access to it. Community knows what they need and the question is, then, how can those of us in health communications create space for that knowledge to actually be heard and then integrated into that plan and response? How do we create avenues for that information to flow both ways? It’s not a one way street. 

In times like these when it’s challenging and stressful and there’s a sense of urgency, there is sometimes a reticence to create space because we don’t have time and we don’t have capacity. Everybody’s scrambling. We’re starting to go off script sometimes with this stuff because we haven’t been in this position before. We didn’t plan for this, so we don’t really know, and sometimes people’s way of coping with that or a system’s way of coping with that is to hunker down and get a little protective and cautious. We don’t want to go too far. We don’t want to push too hard. We don’t want to jump the gun and say something and then realise we’re wrong. 

Whereas in community, things may happen differently. My challenge is always, how do you get better alignment between these things? What sometimes can be a different way of approaching things from a bigger system, to the way the community tends to be, like ‘we’ll do something and if it’s not working, we’ll change it’. It tends to work often, not just in COVID times, just in a different way that’s very relational. For example, I’m going to pick up the phone and call somebody about that information rather than there’s gonna be a big formal process of calling a meeting and having an agenda and writing notes about it. I think finding the balance between what the big system brings to the table in terms of lots of capacity, but how do we do that in a way that honours the resiliency and capacity in community and that inherent knowledge? 

I think the other piece of that is that there is knowledge that isn’t valued often or may even be dismissed or critiqued. So, thinking about how we also acknowledge traditional knowledge or collectively held knowledge isn’t always what the official health communication is about. Those are messy conversations, always, about how do we balance out what’s often seen as the legit science with the traditional knowledges. I think that’s another piece, though – if we just say we’re not going to acknowledge that, well people are still having these conversations. People are still engaging in traditional practices and medicines and ceremonies. So, if we don’t step into the conversation in a way that’s humble and open and actually creating space for people to truly say, ‘this is what my teachings are on this’ or ‘this is what my question is about’, people will still talk about it, but just not with us right? So there will be that sense that we [health care workers] are not safe to even ask that question to or express that belief to or share that practise with. But, people are still doing it. 

So, we really are potentially widening a gap in health, sometimes inadvertently, because we just don’t go there – when we think, ‘oh, no, we don’t know enough to say anything about that, so we’re not going to even acknowledge that’s a question or a consideration’. I think that in a context where our history in Saskatchewan and Canada has been about erasing, dismissing, critiquing, and trying to essentially assimilate – we need to. This is an opportunity to really say ‘how could we do this differently and how can we be better at this’? One of the questions I get asked a lot in my work, pre-COVID, is ‘what does cultural humility really look like?’. It’s saying ‘tell me about your understanding of this or how your traditional teachings might be useful to us in understanding what’s happening right now’?, because, quite frankly, we’re all just figuring it out as we go along. 

Do you have any specific examples of ‘promising practices’, whether locally, nationally, globally, demonstrating how to do this work well? 

Yeah, I love ‘promising practises’ and I also love ‘wise practices’ as language. I think looking at what Morningstar Lodge has been doing and really just coming up with stuff off the cuff, as needs arise or as people have ideas. So they’ve done some really great resource sheets and videos. 

I think that they are examples from all over the world. That’s one of the things I’ve done myself to kind of cope personally and professionally with all this is combing the Internet and social media and the news for what people are doing that’s really breaking the mould, maybe challenging us to do this a little differently. There’s some exciting stuff out there, like groups that are developing COVID-19 basic information targeted to people with cognitive disabilities or who are neuroatypical, because so often the way we talk about these things doesn’t resonate well and doesn’t translate well for people who see the world differently and whose communication approach is different. 

There’s some good work happening and I think that’s the exciting thing for me – we don’t have to start from scratch. There are people all over the world who are taking their own shot at doing this, often inspired by or leaping off of other people’s work. I think that’s really how we’re going to get through this in terms of developing really good resources for our own communities and with our own communities. What are other people doing and how do we adapt that for use here? I think that’s exactly what Morningstar Lodge is doing. That’s what other groups are doing. It’s just like, OK, what’s the need? Let’s figure out how we take that person or that group’s approach and make it fit for our group. A lot of these are living documents that get updated frequently, which can be less than ideal sometimes for people accessing information, but I think it’s just part of the reality of COVID. Things are changing quickly and we need to be on top of it. 

Do you see any impacts or learnings that might affect your professional community and folks like yourself who support transfer of knowledge?

My hope is that we will come out of this even more deeply committed to equity oriented work in general. We couldn’t have scripted this better in terms of a way to illustrate what equity oriented health service should look like. Because I had my fear that we’re going to get to the end of this part of COVID – I think this is going to be a long journey for us in a lot of ways – and that the lessons will be what we could have done better. Hopefully it will inform us moving forward and not just specific to COVID and not just specific to public health, but more broadly to what we talk about with health and well-being. We have all seen inequities and structural gaps in our society and inequities in terms of who has access to stable housing and good social supports and all health care. This is going to be the really tangible, concrete case study of that. Lots of people have been living real life examples of that forever, but it’s not been on a scale that people can actually see it and understand ‘oh, that’s what that is’. 

I also hope this is an opportunity for all of us to reflect on and maybe scrutinize the way we communicate, the emphasis we put on official communications, processes and timelines and all those things. I hope that we look at how we can better support people with lived experience. I think so often there is that sense that we need to educate people about things they already know because they live it and that we don’t do a really good job of really supporting and expecting that mutual reciprocal process. I don’t think we’re doing particularly well right now. I think we have little shining examples. My hope is that we will come out of this with a deeper commitment to forging those relationships and being able to do the work in a way that looks more community-oriented than system-oriented. Maybe I’m a little bit delusional for thinking that’s possible, but that’s the hope. 

What would you say is the priority call to action? And who is the call to action for? 

I would say the biggest request is geared towards the folks who are generating that official communication stream. You know, those who have access to communications professionals and support. Typically the capacity for that in community-based organizations is more limited or looks different. I mean they don’t have communications departments typically. In the larger systems where we have these communications departments, that’s where there’s a need to embed these ideas and shake things up a bit. 

I know there’s often a sense that especially in a crisis like this, we’re all stretched and just scrambling to keep up. I always say I don’t see equity-informed, equity-oriented approaches as adding anything – it’s doing different with what we’ve got. It’s not, ‘let’s add some in addition to all the generic messages we already have’. We will have targeted messages, but we can also integrate different images, different language, different formats into our existing messages that makes them more accessible and more actionable for folks. 

I think that’s really especially right now with COVID, where there’s a real need, and I see this in all sorts of larger systems in terms of what they’re putting out, is they’re they’re just trying to get messaging out. The ability to sort of tap the brakes a bit and say, who is this for? How are they accessing it? What do they already know? How do I know what they know? All of those questions that we ask from a health literacy perspective – I think there’s individuals asking those questions, but collectively as a strategy that isn’t necessarily embedded yet. My hope is we get there and I think that’s a real call to action because that community is much more able to be nimble and responsive, but also is doing that on a shoestring with somebody typically who’s also doing a million other things. So the interesting thing is what we see coming in a community tends to reflect those principles better, partly because there’s more room and less process. That sense of how we work in community is we see a need and we try to meet it, and then if we realise we said something we shouldn’t have, we change it later. And there is isn’t always, I think, the same sense of caution and such. Right now I think really what we need. we don’t have to be cavalier about it or, you know, rush. But we also, I think, need to be intentional always in terms of integrating those considerations. 

Learn more about Equip Health Care’s Key Dimensions of Equity-Oriented Care from Equip Health Care HERE.