Popular Health Education and COVID-19: challenges from the perspective of protagonists in national collectives

Abstract

The study analyzes, through the lens of Popular Health Education (PHE), the challenges faced during the COVID-19 pandemic, based on the experiences of Brazilian PHE collectives. Four summary ideas were developed: the exacerbation of structural and social vulnerabilities due to the pandemic context; limitations in access to and proficiency with technology for communication among actors; limited intersectoral and intersubjective communication, resulting in weak coordination and partnerships; and the effects of the pandemic in worsening crises and contradictions within the reality of Primary Health Care. In light of the complexity and structural depth of the challenges discussed, a social response is made possible through dialogue, social control, and collective mobilization.

Keywords
Popular Health Education; coronavirus; Unified Health System; Primary Health Care; social mobilization

Resumo

O estudo analisa, à luz da Educação Popular em Saúde (EPS), os desafios enfrentados durante a pandemia da covid-19, a partir das vivências dos coletivos brasileiros de EPS. Foram construídas quatro ideias-síntese: agravamento das fragilidades estruturais e sociais pelo contexto pandêmico; limites no acesso e na habilidade tecnológica para a comunicação dos atores; pouca comunicação intersetorial e intersubjetiva com limites nas articulações e nas parcerias; efeitos da pandemia no agravamento de crises e contradições na realidade da Atenção Primária à Saúde. Diante da complexidade e da profundidade estrutural dos desafios discutidos, é oportunizada uma reação social que passa pela dialogicidade, controle social e articulação coletiva.

Palavras-chave
educação popular em saúde; coronavírus; Sistema Único de Saúde; Atenção Primária em Saúde; mobilização social

Resumen

El estudio analiza, a la luz de la Educación Popular en Salud (EPS), los desafíos enfrentados durante la pandemia de la COVID-19, a partir de las vivencias de los colectivos brasileños de EPS. Se construyeron cuatro ideas-síntesis: agravamiento de las fragilidades estructurales y sociales debido al contexto pandémico; límites en el acceso y en la habilidad tecnológica para la comunicación entre los actores; escasa comunicación intersectorial e intersubjetiva, con restricciones en las articulaciones y asociaciones; efectos de la pandemia en el agravamiento de crisis y contradicciones en la realidad de la Atención Primaria de Salud. Frente a la complejidad y la profundidad estructural de los desafíos discutidos, se abre la posibilidad de una reacción social basada en la dialogicidad, el control social y la articulación colectiva.

Palabras clave
educación popular en salud; coronavirus; Sistema Único de Salud; Atención Primaria de Salud; movilización social

Introduction

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 (coronavirus disease), caused by the novel coronavirus (SARS-CoV-2), a pandemic, recommending social isolation measures in countries experiencing community transmission (“WHO Says”, 2020). Since then, a sweeping process of change has unfolded in people’s lives around the world, marked by different nuances and intensities in each context, but invariably presenting urgent human challenges in the face of the health emergency, the suffering and anguish brought on by the loss of lives, the scientific and technological race for vaccines, and other measures of care, healing, and rehabilitation in response to the reality imposed by the disease.

In Brazil in particular, the COVID-19 pandemic was managed by the Federal Government in office at the time, which adopted a political agenda characterized by science denialism, the spread of misinformation, and the implementation of policies that both discouraged the population from adopting proper preventive measures and failed to take leadership or coordinate effective and safe efforts toward disease control and rigorous epidemiological monitoring, as discussed by authors such as Ana Paula Morel (2022) and Pedro Hallal (2021, 2022). Furthermore, the pandemic ended up exacerbating a process already underway since the civil-legislative-media coup of 2016 (Fleury, 2018), particularly with the imposition of an ultra-neoliberal economic agenda and an ultra-conservative social platform. This scenario resulted in the neglect of populations in situations of greater social vulnerability, who were left to fend for themselves in the fight against the disease and its far-reaching consequences.

In this pandemic context, while the restructuring of health actions and services was clearly required worldwide — including within Brazil’s Unified Health System (SUS) — there emerged significant political and technical challenges to implementing responses that were firm, scientifically grounded, and humanely sensitive. As a result, social movements and various academic and scientific institutions were compelled to take on key leadership roles in the production of knowledge, social practices, and health work methodologies capable of responding effectively to the challenges of COVID-19 — particularly in addressing the urgent and specific needs of the most vulnerable populations, including Indigenous peoples, Quilombola communities, Roma groups, and residents of urban peripheries in major cities, as discussed by Fleury and Menezes (2022) and Polycarpo and Fleury (2023) in recent studies on the subject.

In this regard, as a field of knowledge and practice aligned with populations in situations of vulnerability — and at the same time committed to amplifying the voices and knowledge of those very populations — the Brazilian Popular Health Education (PHE) movements, expressed through diverse experiences, collectives, networks, and organizations, played a fundamental role during the COVID-19 pandemic, as highlighted by Luanda Lima et al. (2020). The role of PHE was particularly evident in initiatives that denounced the government's neglect at the time, but even more so in the development of concrete actions and proposals aimed at caring for people, promoting health surveillance in communities, and mobilizing collective efforts to combat the pandemic and its consequences. These efforts have been documented and analyzed in works by Albuquerque and Fleuri (2020); David et al. (2020); Fernandes et al. (2022); Méllo et al. (2021); and Pulga et al. (2023).

Conceptually, Popular Education (PE) is understood as a human-centered pedagogy rooted in concrete social reality, ethically and politically guided by the effort to mobilize, organize, and educate the popular classes, fostering critical teaching-learning processes aimed at social transformation (Albuquerque & Fleuri, 2020; Calado, 2020).

Popular Health Education (PHE) has served as a methodological foundation for many grassroots movements and health collectives, focusing on the shared construction of knowledge, practices, and dialogical actions (Vasconcelos, 2009). Pedro Cruz et al. (2020) describe PHE as a framework for critical action in the face of the challenges of the 2020s — particularly for its emphasis on promoting and enhancing popular participation in everyday health practices; for its ethical, political, and epistemological dimensions in health work; and for its role in fostering critical reflection and political resistance to ultraliberalism and ultraconservatism in society and in public spaces. The National Policy of Popular Health Education in the SUS (Política Nacional de Educação Popular em Saúde no SUS; PNEP-SUS) was a landmark achievement of the national PHE movements and collectives, representing a formal demand for the establishment of principles, organizational pillars, and the effective implementation of PHE within the SUS (Bonetti et al., 2014).

Historically significant collectives within the Brazilian Popular Health Education (PHE) movement include: the Thematic Working Group (GT; “Grupo de Trabalho”) on Popular Education of the Brazilian Association of Collective Health (GT/PHE/Abrasco), the Network of Popular Education and Health (Redepop), the National Articulation of Movements and Practices of Popular Health Education (Aneps), and the National Articulation of Popular Extension (Anepop) (Cruz et al., 2018).

Redepop was established in 1998 with the aim of strengthening spaces for communication, experience-sharing, and dialogue among actors (especially health professionals) who had been developing PHE practices within health services and alongside grassroots social movements. The network sought to promote methodologies and alternatives to expand and consolidate PHE in care practices and in the management of health facilities (Rede de Educação Popular e Saúde, 2019).

GT/PHE/Abrasco was created in 2000, bringing together academics and social movement actors interested in incorporating and strengthening the PHE agenda within health education, as well as in developing integrated research projects focused on PHE. The group also worked toward broadening the dissemination and socialization of theoretical-methodological reflections and knowledge production in the field (“GT Educação Popular”, 2016).

Founded in 2003, Aneps emerged as a national organizing initiative aimed at articulating PHE movements and practices throughout Brazil, fostering the participatory formulation and implementation of health policies aligned with the initiatives, proposals, and aspirations of grassroots care practices and struggles for health (Barone, 2006).

Anepop, in turn, was created in 2005, bringing together social actors from across the country involved in university extension activities guided by PHE — particularly led by student extension workers from various projects. Anepop aimed to foster the exchange of experiences among these initiatives, enabling the enhancement of strategies for struggle and progress toward expanding popular extension practices within health-related degree programs at higher education institutions across Brazil (Melo Neto, 2014).

PHE collectively develops ways to address health problems and is, therefore, an activity capable of influencing and reshaping the diverse practices within health services (Vasconcelos, 2015). From this perspective, PHE remains relevant today, as it continues to serve as a guiding framework for initiatives developed collaboratively with socially vulnerable groups (Fernandes et al., 2022).

In their analysis of the potential of PHE as a guiding approach for actions within the scope of Primary Health Care (PHC) during the COVID-19 pandemic in Brazil, Fernandes et al. (2022) found that PHE remains active and productive within PHC. It stands out as a powerful practice in fostering bonds within and with the territory, promoting horizontal dialogue and critical engagement with reality — including the use of Information and Communication Technologies (ICTs) as a means of expanding spaces for activity.

The understanding of a phenomenon aimed at overcoming complex circumstances must be based on critical interpretation; in this regard, PHE's methodology proves to be particularly relevant in assessing the materiality of events based on the practical experience of grassroots groups. The development of Freirean theoretical-practical knowledge is grounded in a meaningful philosophy, especially when analyzing an ultraliberal political context, as it centers the discussion around those most directly affected by the social crisis: vulnerable populations and community-based health workers.

While recent literature features critical-reflective essays by PHE actors focusing on the challenges of the field during the pandemic (Albuquerque & Fleuri, 2020; David et al., 2020; Lima et al., 2020; Morel, 2022), it still lacks contributions that highlight the perspectives of protagonists from these collectives themselves regarding the issue.

Accordingly, this manuscript seeks to systematize and discuss a set of summary ideas that express the challenges perceived and faced during the COVID-19 pandemic within SUS operating spaces, based on the experience of Brazilian collectives historically guided by Popular Health Education (PHE). This endeavor aims to contribute uniquely to the field by highlighting the obstacles encountered by grassroots actors and popular educators in their spheres of action in the face of a complex and historic crisis, which had profound repercussions on social dynamics, access to services, and health care. This remains a timely and necessary discussion to enhance the role of Primary Health Care (PHC) and to strengthen a model of public health committed to universal and comprehensive care.

Furthermore, although the Brazilian academic and scientific community has made substantial efforts to produce critical and constructive analyses of the COVID-19 pandemic and its impacts on public health and on the SUS, we believe there has been a notable scarcity of studies that explicitly foreground the perspectives of key actors from national collectives and organizations in the field of Popular Health Education regarding the challenges faced — not only in relation to COVID-19, but also in addressing the broader health crisis as it intersected with the political and civilizational crisis experienced in Brazil, particularly between 2020 and 2022. Given that the Brazilian PHE field is structured around four main national-level collectives, networks, and organizations, we were unable to identify any studies that synthesized the perspectives of these entities concerning the phenomenon under investigation.

Methodology

The study was designed as a descriptive, qualitative research project, as grounded in the work of Maria Cecília de Souza Minayo (2014). Primary sources (recorded interviews) and secondary sources — considered historical documents (archives published on websites and blogs) — were collected. These materials, produced by the interviewees and/or their institutions for purposes unrelated to the research itself, were analyzed in a complementary manner.

The study is based on a qualitative approach due to the impossibility of investigating and understanding the research object through statistical data, since the focus lies in interpreting the meanings embedded in human relationships among workers, managers, and service users within the construction of Popular Health Education (Figueiredo, 2008). To this end, individual semi-structured oral interviews were conducted.

To gather accounts that are representative of the research object, the study sought out PHE collectives that have played a prominent role in the national movement over the past decades. The main selection criterion was the collective’s engagement in processes defending the recognition of PHE as a guiding framework for public policy. Examples of such engagement include: the coordination and organization of the most recent National Meeting on Popular Health Education — the sixth edition, held in Parnaíba, in the state of Piauí (Falcão, n.d.); participation in the National Committee on Popular Health Education (CNEPS) (Ordinance No. 1,256, dated June 17, 2009); and contributions to the development of the National Policy of Popular Health Education in the SUS (PNEPS-SUS), as described by José Ivo Pedrosa (2021) in the article “The National Policy of Popular Health Education Under Debate: (Re)cognizing Knowledge and Struggles for the Production of Collective Health” (“A Política Nacional de Educação Popular em Saúde em debate: (re)conhecendo saberes e lutas para a produção da Saúde Coletiva”).

Based on these criteria, four national-level collectives were identified as meeting the requirements: (i) Redepop; (ii) GT/PHE/Abrasco; (iii) Anepop; and (iv) Aneps.

This text will refer to the social groups involved as collectives, as this is the term by which organized groups within the field of Popular Health Education (PHE) at the national level self-identify. Accordingly, in this study, we understand collectives to be political organizations composed of individuals united by a common cause, structured in a horizontal, participatory, and dialogical manner, prioritizing emancipatory educational processes and a political commitment to social transformation (Cruz & Brutscher, 2020). While we conceptually regard them as organizations, we will adopt the term collectives out of respect for the organizational form with which their members identify.

It is also important to highlight the relevance of the selected collectives due to their significant regional distribution and the diverse roles in health care held by their representatives. Redepop is composed primarily of health professionals; GT/PHE/Abrasco is predominantly made up of researchers and university professors; Anepop consists mostly of university students; and Aneps is primarily composed of grassroots social movements. Thus, the study sought to encompass a representative range of experiences and perspectives from different social actors operating across diverse settings and spaces. In doing so, it offers a broad view of the PHE processes related to the COVID-19 pandemic context.

To this end, invitations were sent to the email addresses of the coordinators of each collective. The message included an explanation of the research objectives and relevance, followed by a request for the nomination of one to three members of the organization who were actively involved in the movement to represent the collective in the interview process. Responses were received from three collectives: GT/PHE/Abrasco, Anepop, and Aneps, whose coordinators nominated members to participate in the study.

In total, five participants were interviewed: one representative from Aneps, two from GT/PHE/Abrasco, and two from Anepop. All interviewees identified as female, ranging in age from 27 to 58 years. Two identified as mixed race (parda), one as Black, and two as white. All had professional backgrounds in the health field — specifically, a community health worker, a nurse, a physician, a nutritionist, and an occupational therapist — with experience working in Primary Health Care (PHC) from a Popular Health Education perspective in Brazil’s Northeast and South regions.

The semi-structured interview format is based on adapting the questionnaire to the situational dynamics of the interview, a strategy that supports the description of social phenomena and a holistic understanding (Manzini, 2004).

In July 2020, the interviews were conducted via video call using the Google Meet platform and recorded with its built-in recording tool. Each session included the interviewer, the interviewee, a rapporteur, and an observer — all residents of the state of Paraíba. It is important to note that the presence of three researchers in the interview was necessary to allow each to fully engage in their respective roles: the interviewer focused on attentive and perceptive interaction with the participant’s narrative; the rapporteur aimed to accurately record the dialogue and interactions; and the observer took notes and made observations that later contributed to the systematization of the research report and final results.

Given the imbalance in the number of interviewers relative to the interviewee, care was taken to create a welcoming and comfortable atmosphere. Interviewees were made fully aware of their right to pause, reschedule, or request that the interview be conducted solely with the mediator. Nevertheless, all participants freely agreed to take part under the initial conditions, and the dynamic and fluid course of the interviews serves, in our view, as evidence of that consent.

These sessions were held in the evening and lasted an average of one hour. For the purposes of this study, the main topics addressed in the interviews were the following questions: (i) Considering Popular Health Education and the fight against the COVID-19 pandemic, what do you see as the main challenges within the context of Primary Health Care? (ii) Considering the challenges and possibilities of Popular Health Education in combating the COVID-19 pandemic within Primary Health Care, is there any aspect, consideration, or reflection that, in your opinion, still needs to be addressed before we conclude this dialogue?

The content analysis of the interview data followed the hermeneutic principles outlined by Martins and Bicudo (1989), structured as follows: (i) seeking the “meaning of the whole”, through familiarization with the ideas expressed in the interviewee’s speech; (ii) defining the “units of meaning”, based on the issues outlined by the researcher in the guiding questions; (iii) developing categories of analysis derived from the participants’ statements, organized according to a shared criterion aligned with the study’s objective; and (iv) synthesizing the units of meaning in a way that conveys an understanding of the topic and the overall meaning.

Based on the recordings, full transcriptions were made to facilitate the systematization and analysis of the participants’ narratives. From these transcripts, emerging ideas were identified that pointed toward answers to the objectives of this article. These emerging ideas were then grouped into meaning cores in order to organize similar concepts. Finally, these cores were consolidated into synthesizing ideas (ideias-síntese), highlighting the key dimensions that emerged from the analysis of the full set of narratives.

Thirteen meaning cores were identified. By merging related cores, four summary ideas were formed. In this way, the main perceptions of the interviewees were synthesized regarding the specificities and challenges of PHE in SUS operational settings during the COVID-19 pandemic.

To protect the participants’ identities, they were assigned pseudonyms based on the names of flowers — an exercise in creativity and affection, aligned with the principle of amorosidade (lovingness) that is central to PHE, as set forth in the PNEPS-SUS. It is also worth noting that the study complied with the guidelines established by Resolution No. 466, of December 12, 2012, and was approved by the Research Ethics Committee of the Center for Medical Sciences at the Federal University of Paraíba (CEP/CCM/UFPB), under the following Certificate of Ethical Appreciation Submission number (CAAE): 31236920.6.0000.8069.

Results and Discussion

The results were categorized into four structuring synthesizing ideas, which emerged from the participants’ responses, as presented in Table 1.

Table 1
Synthesizing ideas and corresponding meaning cores

Synthesizing Ideas	Meaning Cores
Exacerbation of structural and social vulnerabilities due to the pandemic context	Intensification of social inequalities as a consequence of the health crisis
	Structural and social challenges within services and communities that hinder compliance with biosafety protocols
Limitations in access to and technological proficiency for communication among actors	Limited access to and use of technological tools for remote communication
	Challenges in verifying the credibility of the vast amount of information circulated during the pandemic due to fake news
Limited intersectoral and intersubjective communication, with constraints on coordination and partnerships	Communication difficulties among health team members
	Weak coordination among grassroots social movements
	Scarcity of PHE initiatives to mediate dialogue within community context
	Resistance to dialogue between community and health units in everyday service delivery
Effects of the pandemic on the intensification of crises and contradictions in the reality of PHS	Work overload among health professionals due to increased demand and reduced staffing
	Difficulty ensuring the safety of SUS users and health professionals in the COVID-19 epidemiological context
	Worsening of PHC underfunding
	Difficulty maintaining continuity of care during the pandemic
	Feelings of fear and uncertainty in response to the severity of the pandemic context

Exacerbation of Structural and Social Vulnerabilities Due to the Pandemic Context

This first summary idea discusses two closely related meaning cores that emerged in connection with the socioeconomic and political landscape exposed by the COVID-19 pandemic:

1. the intensification of social inequalities as a consequence of the health crisis;

2. structural and social challenges within services and communities that hinder compliance with biosafety protocols.

For Meaning Core 1, it is important to note that social inequalities underwent a process of intensification and deepening of an already existing human crisis. The interviewee Lírio (Anepop) states:

In the context of the pandemic, the social issues we face — inequalities, existing vulnerabilities — have worsened significantly... It’s also these socially excluded individuals who often can’t afford to stop working and stay at home to take care of their own health. All of this greatly complicates the matter of physical isolation, of contact, of actually working with Popular Education during this pandemic period.

COVID-19 emerged during a period of intense political instability in Brazil, with economic, cultural, and social implications evidenced by high unemployment rates and the dismantling of the country’s social policies (Werneck & Carvalho, 2020). The current mode of production, along with people’s work and income, are key aspects of the social determinants of the health-disease process in communities (Garbois et al., 2017), directly affecting population health. According to the Continuous National Household Sample Survey (Pnad Contínua), Brazil’s average unemployment rate in 2020 was 13.5% — the highest figure in the historical series that began in 2012 (Brasil, 2021).

Analyzing the social indicators associated with employment during the pandemic reveals that the worst inequality indicators were concentrated among the most vulnerable groups, such as women and Black individuals. The year 2020 was marked by a significant shift toward unemployment or labor market inactivity, especially among private-sector informal workers, those with low levels of education and income, and individuals working in accommodation services and domestic labor (Costa et al., 2021). In this context, the financial vulnerabilities brought on by unemployment have deepened social inequalities in the country, giving rise to extreme conditions such as hunger and poverty.

From this perspective, we arrive at the second meaning core: “Structural and social challenges within services and communities that hinder compliance with biosafety protocols”. In this regard, health workers — particularly those in Primary Health Care (PHC) — face the difficulty of engaging with communities in the field, as their work involves educational actions to promote health and prevent illness. This was identified as another key challenge by the interviewee Daisy (Aneps), who stated:

I think the main challenge is re-education because, for example, we have a lot of difficulty talking to people about health, about hygiene issues, and the main challenge we’re facing right now is going out into the streets, forming groups that respect all the criteria for physical distancing.

With the new social interaction rules imposed by the pandemic, work processes and some activities at Basic Health Units (UBSs) had to be reconfigured. Among them were educational activities carried out through group meetings and community gatherings (Barbosa & Silva, 2020), which undermined methodologies rooted in Popular Health Education (PHE) within Primary Health Care (PHC) — a situation noted by the interviewee Sunflower (GT/PHE/Abrasco):

Nowadays we don’t have groups, we avoid gatherings, we are encouraging people not to meet. So, there’s that too. Even though we are people of the encounter, we are asking people not to come together. And that’s already a contradiction in itself, isn’t it?

In light of this reality, certain barriers imposed by the pandemic context become evident, hindering the full development of activities and initiatives guided by the methodological philosophy of Popular Health Education (PHE). During this crisis, PHE practices encountered vulnerabilities both in terms of enabling people’s participation and regarding structural conditions and available resources. At the same time, they may open up possibilities for fostering connections between grassroots resistance movements active in local territories and the initiatives undertaken by health services (Vasconcelos, 2015).

Limitations in Access to and Technological Proficiency for Communication Among Actors

This synthesizing idea here encompasses two meaning cores: (i) limitations in access to and operation of technological tools for remote communication; (ii) challenges related to verifying the credibility of the vast amount of information circulated during the pandemic, especially in light of the spread of fake news.

The growing use of Information and Communication Technologies (ICTs) has been accompanied by a phenomenon in which social inequalities are mirrored in virtual environments through digital exclusion (Rossi & Valentim, 2020). This exclusion is not shaped solely by economic factors, but also by the availability of social support, modes of use, and levels of proficiency in handling digital tools (Ragnedda & Ruiu, 2016).

Thus, although it is reasonable to recognize the potential of technology as a means of overcoming the public health guidelines based on social distancing, the use of ICTs proves to be a solution that does not reach the entire population. The testimony of Tulip (Anepop) reinforces this perception:

This is a time when the internet is important — but also a major challenge. Not everyone has internet access. That’s another challenge… these [community leaders] don’t have internet, don’t have access to information, don’t have a computer, don’t have a cell phone — or sometimes they do, but it’s full and can’t take any more apps, which makes communication difficult — or they don’t know it, don’t know how to use it..

Given this context, it becomes clear that engaging community leaders in discussions about the pandemic is a challenge, as there is no equity in access to technology, internet connectivity, or the instruction necessary to use these tools. While it is true that those who assume social leadership roles should not bear — and are not expected to bear — the sole responsibility or centrality in driving necessary actions in each territory, it is nonetheless important to recognize the empowering potential of granting them more qualified access to technology and media resources. Such access would enhance their capacity for mobilization and constructive engagement within their local contexts.

This development would not only facilitate stronger communication and closer ties between PHE collectives and community leaders, but would also foster the leaders’ autonomy in seeking out, critically analyzing, and appropriating information — assessing its relevance and potential impact within their territorial realities. It is worth emphasizing here that PHE promotes the protagonism of individuals within their own territories and does not place the sole responsibility for action on community leaders. At the same time, however, PHE recognizes and values the accumulated experience of certain actors in the territory as key to energizing initiatives, mobilizing people, and bringing together local social groups for participatory and educational health activities. It is also important to highlight that, within this process of limited access to virtual spaces, older populations were particularly affected, as noted by the interviewee Sunflower (GT/PHE/Abrasco):

So, I think there’s a lot of complexity here, you know? For example, we have a Local Health Council, and since there are many elderly people in our health unit, there are a lot of seniors who take part in the council. So we started holding council meetings on Zoom [videoconferencing platform]. Well, some of them couldn’t join because they had absolutely no idea how to operate their cell phones to get there.

This situation results in the weakening of efforts to coordinate and discuss issues that are essential to well-being within local territories. This brings us to the second meaning core: “Challenges related to verifying the credibility of the vast amount of information circulated during the pandemic, due to the spread of fake news”.

As a recent discursive phenomenon, fake news has no widely agreed-upon definition in the literature, but two main interpretations can be identified: false information that is not intended to deceive, because the author genuinely believes it to be true; and false information that consists of intentional lies, deliberately crafted to mislead the public (Wardle & Derakhshan, 2020).

During the pandemic, an alarming volume of fake news has spread, to the point that the WHO described the situation as an “infodemic” — an overabundance of both information and misinformation that impairs the population’s understanding of the public health reality, distorting perceptions of the risks posed by the SARS-CoV-2 virus (Van der Linden et al., 2020).

Regarding the challenges posed by the infodemic, Tulip (Anepop) and Sunflower (GT/PHE/Abrasco) voiced concerns in their interviews:

Sometimes the quickest information came through social media, but how do we filter that information? How can we tell what’s fake news and what isn’t? How is that information reaching the population, and how are they responding to it?

(Tulip).

… he amount of information and counter-information is so large that it confuses people… I think one of our biggest challenges is starting from what people are actually understanding in order to reframe that understanding. Or realizing that they aren’t understanding anything at all, right?

(Sunflower).

In the context of this “infodemic”, the ability to filter reliable information is influenced by each individual’s capacity to understand and make decisions regarding their own health (Moscadelli et al., 2020). When this understanding of health is lacking or insufficient, the likelihood increases that a given group may be coerced or misled by misinformation.

It can thus be inferred that social distancing weakened dialogical contact. As a result, Popular Health Education (PHE) faces significant obstacles in maintaining a presence in the population’s discussion spaces and in collaboratively developing strategies to assess the credibility of information circulating within virtual social environments.

Limited Intersectoral and Intersubjective Communication, with Constraints on Coordination and Partnerships

This synthesizing idea comprises the following meaning cores:

1. weak coordination among grassroots social movements;

2. lack of Popular Education initiatives to mediate dialogue within community contexts;

3. resistance to dialogue between the community and the basic health unit in the day-to-day operations of health services.

It is worth noting that perceptions of fragile coordination among grassroots social movements were primarily reported by members of Anepop. It is also important to highlight that social movements, as collective actions aimed at questioning prevailing conditions, emerge from sociocultural realities in which their participants create spaces of solidarity, exercise citizenship, promote learning, and seek to transform both the realities they live in and the conditions for social development (Batista, 2020).

Among the actors involved in these social movements, there is a clear understanding that confronting a public health crisis requires effective dialogical coordination. Health, after all, is not shaped solely from an organic perspective; it also involves psychological, spiritual, cultural, and social dimensions (Anderson & Rodrigue, 2019).

With the onset of the public health crisis, social isolation measures further weakened Anepop’s already fragile activities. According to the group’s members, as expressed in interviews for this study, during the COVID-19 pandemic, Anepop functioned more as a space for publicizing actions than as an active promoter of Popular Education initiatives with direct impact in the communities, as highlighted by the interviewee Lírio (Anepop):

… honestly, we haven’t been holding meetings within Anepop lately to have those discussions. I’ll be very frank with you. We’ve mostly been functioning as a space for sharing information. There’s always a lot of people posting activities in the group..

This situation can be understood as one of the indirect factors leading to another issue identified by the interviewees: the scarcity of PHE initiatives to mediate dialogue within community settings during the pandemic.

Historically, PHE has played an essential role in the development and refinement of many innovative practices in collective health (Vasconcelos et al., 2017), with dialogue serving as a structural core of its pedagogical approach (Cananéa & Melo Neto, 2017). In light of the current challenges, communication stands out as a key element for effectively addressing public health issues. However, certain conditions necessary for communication — such as building rapport and maintaining close contact — have been weakened or even obstructed by the necessary social distancing guidelines. These circumstances have led to a reduced presence of PHE in care environments, which have been adapted to minimize gatherings. This reduction in PHE presence is noted by the interviewee Lavender (Aneps): “What we notice is that we are missed, the language of popular education is missed in those spaces — really missed... I can see how much it matters to speak the language of the person who’s listening to us, you know?”

In addition to this, we find the discussion of the meaning core “Resistance to dialogue between the community and the Basic Health Unit in the day-to-day of services”. The scarcity of PHE practices contributes to the worsening of communication difficulties between the community and health service spaces.

There has also been a reduction in home visits and territorial outreach practices. This has a negative impact on care, as the physical presence of health professionals in the territory already constitutes a form of health communication and helps structure a sense of community-based care (Rozemberg, 2009). The public health imperative to provide care while avoiding gatherings requires a restructuring of health education and guidance processes. As previously noted, alternative measures have tended to rely on digital communication — yet this is not accessible to all, thereby perpetuating the challenge of dialogue and guidance). This perspective is evident in the account of Tulip (Anepop):

How people were going to organize themselves was a challenge too. And even once organized, how were they going to share that information with the community, since they couldn’t get close to people? But at the same time, how would that information reach them? That was another challenge..

Beyond physical limitations, there has also been motivational resistance to gathering for dialogue and participating in collective actions. The pandemic was mentally exhausting for many people, especially health professionals (Saragih et al., 2021; Vindegaard & Benros, 2020), and this was exacerbated by an overwhelming workload. As a result, some individuals feel no impulse to engage in health-related social mobilization efforts, thereby weakening the role and dialogical capacity of Popular Health Education (PHE). This situation is described by Tulip (Anepop):

Participation is also a challenge because everyone is tired. People don’t want to engage at this point; sometimes they just want to be quiet and withdrawn, they want to rest, they don’t want to think about COVID right now. So, what would make me want to join a space to talk about COVID? And it really depends on the moment, on the person… it’s also a challenge to get people involved in this discussion and to tell them that they are co-responsible in this process too — we all are, whether we’re health professionals or not.

The weakening of communication expressed through reduced contact, weakened bonds, and less dialogue in PHE activities also diminishes the cohesion between community members and health professionals. This is especially significant, as PHE practices encourage empathy and collective engagement. Physical distancing has created intense demands for creativity and reinvention in order to “keep the ball in the air” with regard to communication among the protagonists of PHE experiences. Communication involves sharing and dialogue — in other words, making an experience common to all — and for that reason, it can be understood as central to promoting dialogical and integrative care in pursuit of better quality of life (Rozemberg, 2009). Communication is also understood and embraced by health services as a key strategy for disease prevention and the promotion of health-related actions (Rojas-Rajs & Soto, 2013). Moreover, it plays an essential role in fostering users’ autonomy.

Effects of the Pandemic on the Intensification of Crises and Contradictions in the Reality of Primary Health Care (PHC)

The synthesizing idea discussed below encompasses five meaning cores:(i) work overload among health professionals due to increased demand for care and a reduced number of available staff; (ii) difficulty in ensuring the safety of SUS users and health professionals in the epidemiological context of COVID-19; (iii) worsening of the chronic underfunding of PHC; (iv) challenges in maintaining continuity of care in the face of the pandemic reality; (v) feelings of fear and uncertainty given the severity of the pandemic context..

Primary Health Care (PHC) within the SUS has consistently reaffirmed the importance of organizational and structural principles grounded in community orientation, ensuring universal access, equity, and comprehensive health care (Nedel, 2020). According to the National Primary Care Policy (Política Nacional de Atenção Básica – PNAB) (Ordinance No. 2,436, of September 21, 2017), Primary Care:

… considers the individual in their uniqueness and sociocultural context, seeking to provide comprehensive care, incorporate health surveillance actions — which constitute a continuous and systematic process of collecting, consolidating, analyzing, and disseminating data on health-related events — and aims to plan and implement public actions for the protection of population health, the prevention and control of risks, harm, and disease, as well as the promotion of health.

Accordingly, it is worth emphasizing that the PHC setting in Brazil has historically asserted itself as a key locus for numerous successful PHE experiences, grounded in dialogical and democratic processes. In this sense, PHE helps reorient and reorganize the activities carried out within health services, becoming a pathway for social participation and collective construction (Vasconcelos, 2015).

With regard to the first meaning core, the increased demand for care and the emergence of new needs brought on by the pandemic — such as the creation of alternative work shifts at night and on weekends — resulted in an overload for health workers. Moreover, since part of the Family Health Strategy (eSF; “Estratégia de Saúde da Família”) teams included professionals who belonged to high-risk groups, many had to be removed from service, causing an imbalance within the teams that could not be immediately corrected. This situation was highlighted in the account of Tulip (Anepop):

… because health professionals are becoming exhausted — they’re working morning, afternoon, and night. Since information now has to be delivered much faster, whether to users or to health managers, people are ending up extremely tired and overworked because they don’t have any leisure time or time to rest, you know? They’re not having the time to engage in Popular Health Education spaces.

O The second meaning core concerns the inadequate provision of personal protective equipment (PPE) for Family Health Strategy (eSF) teams and the new safety protocols introduced into work processes. In addition, given the new demands brought about by the pandemic, implementing updated biosafety standards within Basic Health Units (UBSs) proved to be a significant challenge. As previously discussed in Meaning Core 1, overworked and unprotected professionals were unlikely to find the conditions necessary to sustain PHE actions during the pandemic. This is made explicit in the account of Sunflower (GT/PHE/Abrasco):

You couldn’t allow gatherings — so, for instance, I work at a health unit that usually saw about 100 to 120 people per day, sometimes more. With the structure of a small waiting room, and considering the need for social distancing, there was no way that could continue, right? That really influenced the whole process of care. If you can’t keep the same organizational model, then what model are you going to adopt?

“The worsening of PHC underfunding” was identified as the third emerging meaning core within this synthesized idea. Two aggravating factors were observed: (i) the invisibilization of Primary Health Care (PHC) in contrast to the overvaluation of tertiary care, which, due to the worsening of COVID-19 cases, led to hospital-centered demands. This shift was driven by the fact that recovery in severe cases was closely tied to the availability of health resources such as intensive care unit (ICU) beds, mechanical ventilators, and sufficient numbers of health professionals (Emanuel et al., 2020); and (ii) the dismantling of health teams caused by defunding of community health workers (CHWs), who play a key role not only in the functioning of PHC but also in the practice of Popular Health Education. CHWs are responsible for following up with families in the community, disseminating information, and intervening in educational processes. This situation is described by Sunflower (GT/PHE/Abrasco):

… In terms of care, we gradually saw that the focus on primary care was disappearing. That included funding too. There was heavy investment in the hospital sector because the logic — both among the population and within the government — is hospital-centered, isn’t it?

In this context, the difficulty in maintaining continuity of care — the fourth meaning core — was observed through statements that pointed to the challenge of attending to patients with chronic conditions. This was due to the suspension of home visits and even a decrease in demand for chronic care at the UBS, which in turn made it harder to continue and implement PHE-related activities.

The fifth and final meaning core that makes up this synthesized theme identified that among community populations and popular health educators, feelings of fear and uncertainty acted as barriers to anything perceived as potentially violating biosafety protocols — including the very manner in which Popular Education could be practiced and conveyed. This is reflected in the account of Daisy (Aneps):

… People used to come to us asking for help, but now demand is much lower. With the guidance to stay home, people are afraid to go to the health unit. Demand has gone down, and it’s also hard for popular health educators, who are afraid too.

Thus, given the uncertainty surrounding the disease and the recommendations for physical distancing, it no longer seemed appropriate to leave home or receive visitors unless absolutely necessary. As a result, there were simultaneous challenges: on the one hand, maintaining the participation of professionals in PHE initiatives became difficult; on the other, the population itself withdrew due to fear of infection.

Final Considerations

The challenging context brought about by the COVID-19 pandemic has exposed diverse and complex obstacles to advancing Popular Health Education (PHE) experiences. The unprecedented nature of the health crisis served as a powerful catalyst for adverse circumstances that directly impacted the practice of PHE within SUS operational spheres. These include environments marked by fear, mistrust of information, structural limitations in access to remote communication technologies, the intensification of social inequalities and vulnerabilities, the lack of coherent discourse across levels of government, and the evident lack of preparation and reliable information among health professionals.

It must therefore be reaffirmed that the pandemic has not only triggered public health consequences but also disrupted social dynamics, which — within this context — were profoundly affected by political instability, leading to economic effects such as unemployment. Moreover, the pandemic weakened processes of health education and community dialogue, restricted access to technology, intensified the phenomenon of infodemia, and exposed difficulties in the articulation between grassroots social movements. In PHC settings, health professionals were overburdened, PPE was scarce, and the system continued to suffer from chronic underfunding — all of which contributed to growing fear and uncertainty among frontline workers.

From a PHE perspective, these challenges present an opportunity for response — one that must be built collectively, in keeping with the foundational principles of the field. As such, the difficulties discussed in this article should serve as stimuli for identifying pathways to overcome these obstacles, whose potential solutions may be explored in future research. Most importantly, however, these responses must also emerge from within the very collectives cited here — and from many others across the diverse movements and practices that give life to PHE — so that this social and educational perspective on health may not only continue to be strengthened, but may also contribute to the expansion, consolidation, and deepening of meaningful practices in the fight against COVID-19 and other relevant public health and epidemiological challenges.

PHE can play a crucial role in shaping new social actions and research initiatives in which its pedagogical framework guides powerful, participatory, and socially committed alternatives aimed at generating new horizons, experiences, and spaces for the comprehensive promotion of health — and for the pursuit of buen vivir in communities and health services, particularly within the policies and practices of the SUS.

• Research ethics:
  The research was submitted and approved by the Research Ethics Committee of Plataforma Brasil, according to Process no. 31236920.6.0000.8069.
• Copy Editing services:
  Portuguese version - Copy editing and standardization of citations and bibliographical references (7th. Edition APA): Tikinet Academic Eireli [e-mail]
  English Version: Francisco Lopez Toledo Correa [e-mail]
• Support and Funding:
  Grant from the Pro-rectorate of Extension (Proex) Extension Program, Federal University of Paraíba (UFPB), (Grant/Award Number: ‘Edital Proex 02/2020’).

Research data availability:

Research data will be available on demand to authors.

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• Werneck, G. L., & Carvalho, M. S. (2020). A pandemia de covid-19 no Brasil: crônica de uma crise sanitária anunciada. Cadernos de Saúde Pública, 36(5), e00068820. https://doi.org/10.1590/0102-311x00068820
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Edited by

• Responsible editors:
  Associate Editor: Edivaldo Góis Junior https://orcid.org/0000-0002-0521-1937>
  Editor-in-Chief: Nome Chantal Medaets https://orcid.org/0000-0002-7834-3834>

Publication Dates

• Publication in this collection
  20 Oct 2025
• Date of issue
  2025

History

• Received
  16 July 2024
• Reviewed
  13 Nov 2024
• Accepted
  30 Apr 2025