We must ensure that people of refugee background have the confidence, support and resources to manage their health
Health literacy is defined as the degree to which an individual can obtain, communicate, process and understand basic health information and health services to make appropriate decisions about their health.1 Low health literacy is inextricably linked to poor health outcomes. Individuals with limited health literacy have higher rates of illness and more hospitalisations.2 Acquiring good health is a process that requires access to health care and health knowledge to inform positive health behaviour coupled with ongoing access to necessary resources.
The refugee experience is often characterised by displacement with limited access to services and basic necessities. For resettled refugees, low health literacy can be expected as they navigate a new country, language and culture. The stressors of cultural and language differences, and securing housing and employment may exacerbate trauma, leading people to feel isolated and helpless, with attendant symptoms of sleeplessness, poor concentration and emotional issues. The psychological effects of trauma may be long term and experienced intergenerationally.3 Many may have had disrupted education owing to protracted time in precarious living situations, so it cannot be assumed that they have reading ability in their own language. Further, due to displacement and changes in family composition, traditional ways of sharing health information may be fragmented.
Such experiences have a profound impact on the way people engage with health information, health care services and preventive health activities.4 Being clear about the role of health services and health care providers, and explaining the purpose of appointments, benefits of preventive activities and recommended treatment regimens may assist. The situation is complex — a standard knowledge base cannot be assumed, precaution is necessary and the provision of information needs to be modified.5 Clinicians could mindfully adapt their skills to care for this population; however, we recognise that the provision of information is not necessarily straightforward. Our research found little consistency in the approach that maternity care providers take to providing health information.6 Afghan families reported that they mostly received brief verbal information, a few received written information in their own language, and some had seen pictorial information. Many sought information and advice from family members overseas, and several obtained information from the internet.
Providing the best possible standards of professional interpreting requires systems to facilitate access, training and practice.7 Enabling people to communicate freely in their own language supports the development of trust, respect, rapport, cultural safety and relationship-centred care.8 The role of interpreters is to provide a language service with strict parameters with no ongoing relationship. Bicultural workers, however, may assist people to navigate health services, get to appointments and negotiate expectations. They also act as an aid for clinicians to understand differing health beliefs and social circumstances that may affect decision making. Bicultural workers provide a bridge to reduce the social distance that often exists between health professionals and clients.
The health care setting offers a dynamic learning environment in which clinicians are in a key position to improve health literacy.9 A tool that encourages two-way participation is teach-back. Teach-back is an evidence-based communication strategy that requires health professionals to ask the individual to repeat back what they have explained but in their own words. It is not a test of the individual’s memory.10
Some health literacy advocates suggest that assessing health literacy is an important step in addressing health disparities.2 However, this has the potential to create shame and stigma. Many measurement tools do not inquire about the full scope of health literacy and are narrowly focused on reading, writing and numeracy deficits. If applied, assessments need to be completed in the context of relationship-centred care.8
The health system needs to support clinicians to adopt novel ways of responding to low health literacy.11 A health-literate organisation is defined as one that makes it easier for people to navigate, understand and use information and services to take care of their health.12 A health-literate organisation would recognise that refugees may have concerns that are perceived as more immediate than their personal health status.13 People of refugee background are often worried about finances, learning English and family members who remain in dangerous situations. To support clinicians working with diverse communities, health services need to develop stronger local service partnerships that broaden access to existing community and local resources.
We believe that improving health literacy in this population involves much more than access to information — it is about people having the confidence, support and resources to manage their health. Health literacy in refugee populations could be tackled by multifaceted, multidisciplinary interventions and policies that are responsive to these unique circumstances.14
Provenance: Not commissioned; externally peer reviewed.
- 1. Berkman ND, Davis TC, McCormack L. Health literacy: What is it? J Health Commun 2010; 15 Suppl 2: 9-19.
- 2. Paasche-Orlow MK, Wolf MS. Promoting health literacy research to reduce health disparities. J Health Commun 2010; 15 Suppl 2: 34-41.
- 3. Hudson CC, Adams S, Lauderdale J. Cultural expressions of intergenerational trauma and mental health nursing implications for US health care delivery following refugee resettlement: an integrative review of the literature. J Transcult Nurs 2015; May 25 [Epub ahead of print]. doi: 10.1177/1043659615587591.
- 4. Volandes AE, Paasche-Orlow MK. Health literacy, health inequality and a just healthcare system. Am J Bioethics 2007; 7: 5-10.
- 5. DeWalt DA, Broucksou KA, Hawk V, et al. Developing and testing the health literacy universal precautions toolkit. Nurs Outlook 2011; 59: 85-94.
- 6. Yelland J, Riggs E, Wahidi S, et al. How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families? BMC Pregnancy Childbirth 2014; 14: 348.
- 7. Yelland J, Riggs E, Szwarc J, et al. Compromised communication: a qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care. BMJ Qual Saf 2015. doi:10.1136/bmjqs-2014-003837.
- 8. Cooper LA, Beach MC, Johnson RL, Inui TS. Delving below the surface. Understanding how race and ethnicity influence relationships in health care. J Gen Intern Med 2006; 21 Suppl 1: S21-27.
- 9. Wolf MS, Wilson EA, Rapp DN, et al. Literacy and learning in health care. Pediatrics 2009; 124 Suppl 3: S275-281.
- 10. Koh HK, Rudd RE. The arc of health literacyJAMA 2015; 314: 1225-1226.
- 11. Koh HK, Brach C, Harris LM, Parchman ML. A proposed ‘health literate care model’ would constitute a systems approach to improving patients’ engagement in care. Health Affairs 2013; 32: 357-367.
- 12. Brach C, Dreyer BP, Schillinger D. Physicians’ roles in creating health literate organizations: a call to action. J Gen Intern Med 2014; 29: 273-275.
- 13. Wong W, LaVeist T, Sharfstein J. Achieving health equity by design. JAMA 2015; 313: 1417-1418.
- 14. Baur C. New directions in research on public health and health literacy. J Health Commun 2010; 15 Suppl 2: 42-50.
We thank our collaborators Josef Szwarc and Sue Casey for their valuable contributions to this article. Jane Yelland is supported by a National Health and Medical Research Council Career Development Fellowship and Stephanie Brown is supported by an Australian Research Council Future Fellowship (2012–2015). We acknowledge the support of the Victorian Government Operational Infrastructure Support Program.
No relevant disclosures.