Covid-19 Health Education and Promotion Strategies for Children: An Integrative Review

Ryan T. Roldan1,2*, Michael Joseph S. Diño3,4, Dominic Hermano2,5

1Occupational Health Services, Saudi Electricity Company, 23211, Jeddah, KSA

2Our Lady of Fatima University, 120 McArthur Highway, 1440 Valenzuela City, Philippines

3Research, Development, and Innovation Center, Our Lady of Fatima University, 120 McArthur Highway, 1440 Valenzuela City, Philippines

4Johns Hopkins University, 3400 N. Charles Street, Baltimore, USA

5Department of Education, School Governance and Operations Division, 1421 Caloocan City, Philippines

*Corresponding Author’s Email: rtroldan@student.fatima.edu.ph

ABSTRACT

Children during the COVID-19 pandemic are considered a vulnerable age group and a primary focus of health education and promotion. Various platforms and approaches were noted in research and non-research studies; however, their applications to children are uncommon. This study explored the COVID-19 health education and promotion (HEP) strategies designed appropriately for children through an integrative review. A totalof sixty-nine (69) articles were identified from PubMed and ScienceDirect are imported to Covidence for screening. Twelve(12) articles were identified that met the criteria for inclusion. Of the 12 articles, five are research articles and seven are non-research articles (theoretical). Six (6) of the articles come from the region of the Americas (AMR), three from the European Region (EUR), and three from the West Pacific Region (WPR). The study shows that social media and website-based information and learning are the most used platforms for disseminating information related to COVID-19, and several approaches to health education and promotion were identified. This integrative review provides valuable insight into the various HEP strategies for Children, which can be redesigned and customized to strengthen the existing COVID-19-related health initiatives and campaigns specifically for children. Moreover, this study can be utilized to develop a direction for future research on epidemic-related health education and promotion for children.

Keywords: Child; COVID-19; Health Education; Health Promotion

INTRODUCTION

As of April 2021, the global COVID-19 pandemic caused by the SARS-COV-2 virus has confirmed more than one hundred forty (140) million cases and three (3) million deaths worldwide (World Health Organization, 2021a). The new variants of SARS-COV-2 are more transmissible than the previously circulating form of the virus (Kirby, 2021) and are linked to partial resistance to the vaccine-induced immunity (Torjesen, 2021). Several studies claimed that COVID-19 cases in children are lower than in adults. According to the global estimates of COVID-19 morbidity and mortality, children account for 0.2% or roughly 3,000 deaths of the total confirmed reported cases (UNICEF, 2021). However, it is proven to be contagious in children of all ages (Dong et al., 2020) and the risk of severe disease manifestations (Kamidani, Rostad, & Anderson, 2021).

The risks brought by the COVID-19 pandemic reversed the remarkable improvements in global child mortality that have been noticed over the past two decades (World Health Organization, 2021b). Many children have mild clinical signs, though certain affected patients have no apparent clinical effects, making it challenging to collect accurate and objective evidence on the incidence of severe COVID-19 (Qi et al., 2021). Therefore, they could be a silent transmitters of the virus, suggesting that the highest susceptibility was in this age group (Gray et al., 2020).

Throughout many aspects, the COVID-19 pandemic has compromised people’s health and quality of life, and this global outbreak affects every sector of society (Aung et al., 2020), which also includes children. As a critical preventive tactic to avert outbreaks, health promotion, and education is vital to reducing the pandemic’s catastrophic effects. According to a study, education and continuous campaign on the importance is a must to increase success rate to end the health crisis. Children must learn about disease infection, health consequences, and the significance of barrier measures among vulnerable people. Parents are responsible for providing the necessary information to their children. Most parents seek information online concerning health or medical issues related to their child, and they mainly use social media regardless of the age category of their children (Bryan et al., 2020).

Also, it is noteworthy that most of the health campaigns that public health experts created are designed primarily for the general population (Gray et al., 2020); this could be a potential issue since children have a different way of learning and understanding concepts compared to an adult. Additionally, children’s public health information campaigns are infrequent (Ghia et al., 2020) and one of the limitations of the existing public health strategies is the lack of a theoretical basis (Grech & Grech, 2021). Therefore, to optimize theeffectiveness of a particular health information campaign, it is imperative to choose the right educational strategies.

Several studies and pieces of literature propose various approaches for effectively delivering facts, information, and awareness about COVID-19 to children. It is essential not to overlook this age group because everyone is at risk of contracting this lethal virus. Hence, this integrative review aims to examine the existing health education and promotion programs during the COVID-19 pandemic designed explicitly for children to identify the most suitable approach.

METHODOLOGY

Searching Strategy

The scientific literature and research presented in this study were obtained in the online databases of PubMed and ScienceDirect between January 2020 and May 2021. The following combination of keywords and Medical Subject headings (MeSH) were used: COVID-19, Child, and Health Education. In addition, the Boolean operators (AND, OR, and NOT) were utilized. The searched results in PubMed and ScienceDirect were saved and uploaded to Covidence, a primary screening and data extraction tool for standard intervention reviews. Considering secondary data were used in this study, no ethics approval was necessary for this integrative review.

Inclusion Criteria

The articles included in this study must contain the following: 1. health promotion and education platforms; 2. Health education and promotion approach; 3. specifically intended to provide information for Covid-19; 4. Must be designed for children ages 4 to 12 years of age.

Study Selection and Data Extraction

The authors independently performed the preliminary evaluation using Covidence, reviewing the title and abstract and deciding which papers were eligible based on the set criteria. The disparity in the author's vote in screening was compared, and various possibilities were discussed to establish a consensus. Once the authors have determined which papers should be included in the review, they proceed to a full-text review to collect the data necessary for the research study. The data gathered was evaluated separately and compared in order to reach a consensus. Data were extracted from all publications that fulfilled the review's eligibility and inclusion criteria. Article title, type of article, first author, date of publication, country, HEP strategy, and critical outputs were all extracted and analyzed.

Quality Appraisal

To assess the quality of the included scientific literature and research, the authors used type- specific appraisal tools. An MMAT (mixed-method appraisal tool) for reviewing research studies and an AACODS (authority, accuracy, coverage, objectivity, date, significance) checklist for reviewing non-research (theoretical) studies were among them. These checklists provided a structured framework for analyzing various sources of data.

Data Synthesis

The datawere synthesized using the constant comparison method, which involves categorizing the concepts based on the commonalities and differences found in the 12 articles. MAXQDA was utilized to aid in the analysis of multiple data sets. The authors convert the extracted data into systematic categories, facilitating the distinction of patterns, themes, and variations, and all data are compared and analyzed.

RESULTS

Articles Description

A total of sixty-nine (69) articles identified from PubMed and ScienceDirect are imported to Covidence for screening. Ten duplicates were automatically removed, and 21 articles were irrelevant. Thirty-eight articles were full text assessed for eligibility, and twenty-six articles were excluded due to the following reasons: 1.) The HEP platform and approach are not specific for COVID-19; and 2.) They are not designed for children 4 to 12 years of age. The authors identified twelve articles that met the criteria for inclusion. Of the twelve articles, five are research articles, and seven are non-research articles (theoretical). Six of the articles come from the region of the Americas (AMR), three from the European Region (EUR), and three from the West Pacific Region (WPR). It is noteworthy that there are no studies developed in the Eastern Mediterranean Region (EMR), South-East Asia Region (SEAR), or African Region (AFR), respectively, relevant to the study.

Figure 1: PRISMA Diagram of The Article Selection Process

Health Education and Promotion Platforms

The use of social media was included in two research studies (Bray et al., 2021; Zenone et al., 2021) and three non-research studies (Cheung et al., 2020; Ghia et al., 2020; Klein et al., 2020) to promote COVID-19 information to children. Facebook, Youtube, WhatsApp, Instagram, TikTok, and Twitter were among the most common social media platforms. The second common platform identified in various articles was website-based information and learning (Bray et al., 2021; Reardon et al., 2020; Zenone et al., 2021), mass media such as TV and radio (Bellizzi et al., 2020; Bray et al., 2021; Gray et al., 2020), and paper-based print media (Bray et al., 2021; Ghia et al., 2020; Younie et al., 2020) in the form of comics, books, leaflets, brochures, newspapers, and magazines. Telemedicine (Kawabe et al., 2020; Klein et al., 2020; Sivaraman, Virues-Ortega, & Roeyers, 2021) has been proposed as an alternative to face-to- face encounters. Despite the children's various cultural backgrounds, one quasi-experimental study on training children with an autism spectrum disorder to wear a mask via a telehealth platform confirms the platform's usefulness (Sivaraman, Virues-Ortega, & Roeyers, 2021). In addition, in one experimental (Younie et al., 2020) and one non-research (Bubadué et al., 2020) study, face-to-face HEP workshops such as playful activity and step-by-step action songs were proposed. This platform may not be applicable, particularly in communities with a high COVID-19 incidence, putting children at risk of infection. However, as most children access COVID-19 information through their parents and caregivers, using this platform at home might be advantageous (Bray et al., 2021).

Table 1: Summary of Data Extracted of HEP Strategy on Children

Health Promotion and Education Approach

1. Content Development

   
   

   A total of six articles, two research articles, and four non-research articles in combination suggested that the content of health education and promotion resource materials on COVID-19 for children must be accessible, appealing, legible, and simple to understand (Bray et al., 2021). Contents should be age-appropriate (Zenone et al., 2021) and translated into other languages (Kawabe et al., 2020; Reardon et al., 2020). Additionally, the importance of visual support as a tool is highlighted, such as drawingsand illustrations (Kawabe et al., 2020), theuse of cartoon video-based health education material (Gray et al., 2020), and stories infused in order to convey the desired message (Bellizzi et al., 2020), which is a critical feature in content development relative to COVID-19 prevention for children.

   
   

   1. Information Delivery

      
      

      It was revealed in two research and three non-research articles that the delivery of information must be precise and reliable (Ghia et al., 2020) and should promote interaction among children (Sivaraman, Virues-Ortega, & Roeyers, 2021). Children prefer to learn interactively (through animation, television shows, games, and quizzes) (Bray et al., 2021). On the other hand, parents play a vital role in diluting and filtering the information shared with their children (Bray et al.,2021) to provide an accurate explanation to minimize anxiety among children (Gray et al., 2020). Furthermore, an all-family and all-society approach is recommended when dealing with information on COVID-19 prevention (Bellizzi et al., 2020).

      
      

   2. Behavior Modification

      
      

      Five research studies explored the approach to behavioral modification in children to prevent COVID-19 transmission. Parents and caregivers play a critical role in a child's learning, especially in supervising children in various infection prevention practices (Bray et al., 2021). For instance, one study shows improved hand-washing techniques by integrating newly acquired information and knowledge into children's activities using modeling (Younie et al., 2020). Playful activities such as step-by-step action songs on hand-washing, interactive online games, and glo-gel activities are a few examples that help the child materialize their actions for abstract thought, capable of reproducing acts (Bubadué et al., 2020; Younie et al., 2020). Similarly, Entertainment-education methods such as videos and cartoons, which stimulate children's interests, have proven to reinforce COVID-19 protective behaviors in children as they learn through direct observation, a critical element of behavior (Gray et al., 2020). It is noteworthy that creating a structured and supportive environment can create opportunities for children to practice the desired behaviors (Zenone et al., 2021). In addition, gradual exposure, shaping (Sivaraman, Virues-Ortega, & Roeyers, 2021), and repetition of activity would likely increase learning probability and enable children to modify protective behavior (Younie et al., 2020).

      
      

   3. Information Support Networks

The importance of support networks for children in accessing accurate and reliable information was endorsed in two research studies (Bray et al., 2021; Zenone et al., 2021) and four non- research studies (Cheung et al., 2020; Ghia et al., 2020; Klein et al., 2020; Reardon et al., 2020). One study showed that parents and caregivers are the primary sources of information as self-reported by children aged 7–12 from the UK, Australia, Canada, Brazil, and Spain. In addition, children's knowledge of COVID-19 is influenced by various sources, including individuals, families, communities/schools, and society (Bray et al., 2021). It is crucial to identify key organizations (Ghia et al., 2020) that support health promotion campaigns through evidence-based information delivered in a friendly, developmentally appropriate, and accessible format (Zenone et al., 2021). Likewise, a group of medical students at Harvard Medical School created a website with free online educational modules on COVID-19 applicable to various ages, including elementary and middle school, that have positively impacted the world (Reardon et al., 2020). Coordinated efforts are required to continuously provide appropriate and evidence-based resources (Cheung et al., 2020). Therefore, children must be provided with links, such as websites and online applications, to help them navigate trustworthy resources beneficial to filling knowledge gaps (Klein et al., 2020).

DISCUSSION

This study analyzed the different existing health education and promotion strategies during the COVID-19 pandemic that were explicitly designed and suitable for children. Social media is the most widely used platform to disseminate information on COVID-19 in Children. Among other platforms, it is considered the fastest for sharing information and updates that allow for the integration of multiple media formats to engage audiences by including hyperlinks in social media messages. Further research confirms that most children today have high access to the internet and Wi-Fi, enabling them to utilize social networking sites to find information and assist in learning (Badri et al., 2017). In addition, using social media as a health-related learning platform to bridge knowledge disparities is a valuable learning resource (Goodyear & Armour, 2021). However, though this platform is widely used with many supporters and potential advantages, it lacks conclusive evidence that it improves health outcomes in children (Hamm et al., 2014).

A significant consideration in content development related to COVID-19 prevention for children is interactive, cartoon/animation, and video-based health education material associated with stories to communicate the intended message. Content should be age- appropriate, translated into different languages, available, appealing, and simple to grasp. Education-entertainment is a practical solution for children to improve social and emotional learning capabilities (Hubley et al., 2020), especially during a pandemic. Interactive learning resources significantly influence their learning abilities and adaptability (Islam et al., 2014), consistent with another study where computer animation enables children to visualize content or ideas difficult to visualize in the actual world and explain difficult-to-understand concepts (Rohana Mansor et al., 2020). Additionally, illustrations can depict abstract concepts and generally unseen things and phenomena through visible metaphors. However, it requires a strong narrative and an appealing, easy-to-read illustration of complex messages in a non- threatening and accessible way to ensure the message is delivered effectively (Ghia et al., 2020).

Information delivery can be challenging for parents and caregivers as it may impact children's mental health, and providing assistance is essential for easing children's anxiety. This study supports the concept that an effective HPE strategy should involve parents as partners in delivering COVID-19 information to children. Supplementarily, conveying the key message on COVID-19 prevention through shows, games, and quizzes and using animation and television is recommended because children prefer interactive learning. Mainly, children rely on their parents or guardians for guidance on how to respond during a crisis (Phelps & Sperry, 2020). With the guidance of clear, accessible, guilt-free, and trustworthy sources of information, children can better comprehend their position in a continuously changing environment (Ghia et al., 2020), which can help them develop resilience and motivate them to actively participate in the COVID-19 pandemic battle (Stark et al., 2020).

Behavior modification requires a collective strategy of structured activities designed for children, starting with generating a conducive learning environment where they can directly observe and are allowed to participate in and perform hygiene practices that will protect them from COVID-19. Stimulating their interest through playful activities and technology like interactive online games will enable them to produce protective behaviors against COVID-19 (Goldschmidt, 2020). For children, changes in their usual daily routine caused by the COVID- 19 pandemic and its complex disease information could pose general mood and behavioral issues as they could perceive it differently (Carroll et al., 2020; Singh et al., 2020). Early and deliberate planning is critical in behavior modification, for this will influence the child's ability to develop resilience to drastic changes brought about by the pandemic (Stark et al., 2020).

Developing a support network requires extensive key stakeholders' collaboration (Varda & Talmi, 2018) to continuously provide appropriate and evidence-based information (Cheung et al., 2020). The exponential proliferation of health information daily presents a concern in assessing the quality of information. Parents and caregivers, as primary sources of information, must identify accurate and reliable sources to avoid false and misleading health information since most children rely on them for details about COVID-19 (Bray et al., 2021). However, the sustainability of information support networks and securing and maintaining engagement by all key stakeholders could be challenging.

The lack of theoretical basis for existing public health strategies (Grech & Grech, 2021) can be addressed through the HEP strategies identified, and at the same time, the usual health campaigns designed for the general population (Gray et al., 2020) can now be redesigned and customized for children. Furthermore, since various health programs and services on COVID- 19 have no strong emphasis on the child's health (A. Singh & Vellakkal, 2021), health educators and practitioners can use these strategies to strengthen existing epidemic-related health initiatives and campaigns specifically for children.

Limitation

Although this integrative review gave us valuable insight into the various HEP strategies for Children in the COVID-19 pandemic, several limitations should not be overlooked in this work. For instance, some relevant studies were not considered because they had been published in languages other than English (e.g., Chinese and Spanish). Another thing to consider is that the literature in this systematic review is limited to PubMed and ScienceDirect; other databases such as CINAHL and PsychINFO could have expanded and produced a different result. Third, even though the authors have adopted a comprehensive search strategy and meticulously screened and reviewed the articles in the literature selection, there is a possibility that some other articles on this theme skipped the author’s attention and analysis. Lastly, the studies identified for this integrative review originated from the regions of the Americas (AMR), European Region (EUR), and West Pacific Region (WPR).

CONCLUSION

This integrative review highlights the vital role of individuals, families, communities, schools, and society in influencing children's knowledge and health behaviors. Overall, this study suggests a positive recommendation for using social media and website-based information and learning platforms combined with the identified HEP approaches: (a) Content development,(b) Information delivery, (c) Behavior modification, and (d) Information support networks in providing critical information on the disease and promoting health and positive behavior for children in the COVID-19 pandemic. Future studies may explore various HEP strategies to validate their implications. The findings of this study can be utilized to develop a direction for future research on epidemic-related health education and promotion for children.

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ACKNOWLEDGEMENT

The authors are thankful to the institutional authority for completion of the work.

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