Refugee and Migrant Health Literacy Interventions in High-Income Countries: A Systematic Review

Resettlement needs of refugee women in the United States: An American Academy of Nursing consensus paper

When people must flee their homes due to persecution or conflict, they embark on a journey from loss toward safety that is a global concern and the resettlement country's responsibility. Refugees experience stressors as they secure basic needs such as adequate nutrition, healthcare, transportation, housing, education, and income-generating activities. For refugee women, these stressors are further exacerbated by gender-related roles and experiences. Addressing the unique healthcare needs of refugee women is vital to their well-being as they resettle into life in the United States. Access to care that is provided with cultural humility and fosters trust is critical. Policies are needed that expand health literacy programs and interpreting services, grow, diversify, and train the physical healthcare workforce, grow and diversify the mental healthcare workforce, expand Medicaid coverage in all 50 states, develop and fund peer-to-peer education programs for refugee women, finance access to care and programmatic services, and expand federal funding toward refugee health research.

Parents' or Guardians' Knowledge, Attitudes and Practices in the Prevention and Management of Childhood Myopia

INTRODUCTION

The aim of this study was to assess the knowledge, attitude, and practices (KAP) of parents or guardians regarding the prevention and management of childhood myopia.

METHODS

This cross-sectional study was conducted at the Department of Ophthalmology in the First Affiliated Hospital of Soochow University (Suzhou, China) between August 2023 and November 2023. Parents or guardians who willingly volunteered to take part in the study were surveyed using a self-designed questionnaire.

RESULTS

A total of 571 participants returned valid questionnaires, among whom 288 respondents (50.44%) fell within the 31- to 40-year age group and 474 respondents (83.01%) were identified as myopic. The mean KAP scores for the knowledge, attitude and practices dimensions were 23.34 ± 3.05 (possible range: 0-26), 46.47 ± 4.02 (possible range: 12-60), and 40.52 ± 7.07 (possible range: 11-54), respectively. Structural equation modeling analysis indicated that education had a direct effect on knowledge (estimate = 0.41, P = 0.038), while knowledge directly influenced both attitude (estimate = 0.40, P < 0.001) and practices (estimate = 0.36, P < 0.001). Also, attitude was found to have a direct impact on practices (estimate = 0.45, P < 0.001).

CONCLUSIONS

Parents or guardians had adequate knowledge, a positive attitude, and proactive practices towards the prevention and management of childhood myopia, which might be affected by their educational level. This comprehensive understanding of parental perspectives highlights the potential for targeted interventions in clinical settings to further enhance pediatric eye care.

Global, regional, and national total burden related to hepatitis B in children and adolescents from 1990 to 2021

BACKGROUND

Hepatitis B remains a significant global health concern with widespread communicability. Nevertheless, data on its burden and trends in children and adolescents were limited. We aim to evaluate the global, regional, and national trends of total burden related to hepatitis B in children and adolescents aged 0-19 years from 1990 to 2021.

METHODS

The age-standardized incidence, prevalence, mortality, and disability-adjusted life years (DALYs) were calculated by the Global Burden of Disease (GBD) study from 1990 to 2021. These indicators were stratified by sex, age, socio-demographic index (SDI), and disease stage. We calculated the correlation between them and SDI. The temporal trends were examined using the annual average percentage change (AAPC) and joinpoint regression.

RESULTS

The global age-standardized incidence of hepatitis B in children and adolescents decreased from 1385.20 per 100,000 population in 1990 to 418.68 per 100,000 population in 2021, with an AAPC of -3.76%. Similarly, age-standardized DALYs decreased from 70.78 per 100,000 population to 36.31 per 100,000 population, with an AAPC of -2.13%. The age-standardized prevalence (AAPC - 3.53%) and mortality (AAPC - 2.09%) of hepatitis B also decreased significantly. From 1990 to 2021, the age-standardized incidence and prevalence among males exhibited a higher trend compared to females, although both declined over time. These two indicators also decreased across all age subgroups, with consistently higher rates observed in the 15-19 age group compared to other age groups. The burden of hepatitis B demonstrated a notable reduction in countries with high-middle SDI, while it was highest in countries with low SDI. In 2021, Central sub-Saharan Africa and West sub-Saharan Africa reported the highest age-standardized incidence. For age-standardized DALYs, South Asia was the only region to experience an increase (AAPC 1.09%), while East Asia showed the largest decline (AAPC - 7.58%). Alcohol and drug use remained important risk factors for DALYs among people aged 15-19 years. Furthermore, the impact of drug use on disease burden was increasing, particularly in high-SDI countries.

CONCLUSIONS

The global burden and trends of hepatitis B decreased significantly in children and adolescents, exhibiting regional and national variations. Management of alcohol and drug use remains a major challenge for people aged 15-19 years.

Inequalities in health literacy between European population and newly arrived male sub-Saharan migrants in Europe

Increases in migration pressure from sub-Saharan Africa to Europe have increased in recent years. Despite this trend, the health literacy needs of migrants in host communities have not been sufficiently studied. This research aims to explore the health literacy of migrants newly arriving in Europe and compare it with the health literacy levels of the European population, utilizing data obtained from the European health literacy survey. A convenience sampling cross-sectional study was conducted at the Temporary Immigrant Stay Center in Melilla (Spain) in June 2022 using a validated French and Arabic version of the 16-item European health literacy survey questionnaire. A total of 106 sub-Saharan migrants ≥ 18 years of age were surveyed. The general health literacy index of the migrants was 30.02 points (on a scale of 50), placing it in the 'problematic' level. Of the participants, 57.54% had a limited ability to obtain, understand and apply health information and make appropriate health-related decisions. The largest gap compared to European citizens was observed in skills to understand information related to disease prevention. These results reinforce that migrant status is a social determinant of low health literacy and suggest that health professionals should extend their educational role to this vulnerable group.

Medical imaging utilization in migrants compared with nonmigrants in a universal healthcare system: A population-based matched cohort study

BACKGROUND

Medical imaging is an integral part of healthcare. Globalization has resulted in increased mobilization of migrants to new host nations. The association between migration status and utilization of medical imaging is unknown.

METHODS AND FINDINGS

A retrospective population-based matched cohort study was conducted in Ontario, Canada from April 1, 1995 to December 31, 2016. A total of 1,848,222 migrants were matched 1:1 to nonmigrants in the year of migration on age, sex, and geography. Utilization of computed tomography (CT), magnetic resonance imaging (MRI), radiography, and ultrasonography was determined. Rate differences per 1,000 person-years comparing migrants to nonmigrants were calculated. Relative rates were calculated using a recurrent event framework, adjusting for age, sex, and time-varying socioeconomic status, comorbidity score, and access to a primary care provider. Estimates were stratified by migration age: children and adolescents (≤19 years), young adults (20 to 39), adults (40 to 59), and older adults (≥60). Utilization rates of CT, MRI, and radiography were lower for migrants across all age groups compared with Ontario nonmigrants. Increasing age at migration was associated with larger differences in utilization rates. Older adult migrants had the largest gap in imaging utilization. The longer the time since migration, the larger the gap in medical imaging use. In multivariable analysis, the relative rate of imaging was approximately 20% to 30% lower for migrants: ranging from 0.77 to 0.88 for CT and 0.72 to 0.80 for MRI imaging across age groups. Radiography relative rates ranged from 0.84 to 0.90. All migrant age groups, except older adults, had higher rates of ultrasonography. The indication for imaging was not captured, thus it was not possible to determine if the imaging was necessary.

CONCLUSIONS

Migrants utilized less CT, MRI, and radiography but more ultrasonography. Older adult migrants used the least amount of imaging compared with nonmigrants. Future research should evaluate whether lower utilization is due to barriers in healthcare access or health-seeking behaviors within a universal healthcare system.

Acquisition, application, and distribution of health literacy from culturally sensitive type 2 diabetes education among Arabic-Speaking migrants in Denmark: A longitudinal qualitative analysis

BACKGROUND

Effective self-management of type 2 diabetes requires adequate health literacy (HL) and a supportive network. Diabetes self-management education and support programmes play a crucial role in improving these factors. However, limited research exists on how such programmes can support health literacy among migrants and facilitate the dissemination of knowledge within their social networks.

AIM

This study aimed to investigate the perspectives of Arabic-speaking informants with a migrant background in relation to how their type 2 diabetes-related health literacy was acquired, applied and distributed within social networks through participation in a culturally sensitive diabetes self-management education and support (DSMES) programme.

METHODS

Semi-structured interviews were conducted with 12 informants during the programme and three to 7 months later, from September 2019 to May 2020. Abductive analysis was applied using HL and distributed health literacy (DHL) theory as frameworks.

RESULTS

The analysis generated three themes: (1) sources of health information and the development of health literacy; (2) changes towards active self-management; and (3) distributed health literacy. Prior to programme participation, informants faced challenges in navigating conflicting information from family, friends and social media. After participating in the programme, they reported improvements in HL, particularly in knowledge acquisition. Many became more actively engaged in decision-making and exhibited improved health behaviours, such as dietary choices. Nonetheless, some informants continued to struggle with choosing appropriate prevention and treatment strategies. Notably, certain informants acted as HL mediators, sharing their newly acquired knowledge within their social networks in Denmark and abroad.

CONCLUSION

Culturally sensitive diabetes self-management education programmes have the potential to enhance HL among migrants, leading to the distribution of relevant diabetes knowledge within their social networks. Future studies should explore how members of migrants' social networks perceive their supportive role in type 2 diabetes management. Programmes can benefit from emphasising critical HL and exploring how participant-informants effectively communicate diabetes-related knowledge within their networks to address misinformation and conflicting information.

Antecedents and Consequences of Health Literacy among Refugees and Migrants during the First Two Years of COVID-19: A Scoping Review

Supporting refugee and migrant health has become a critical focus of healthcare policy. Developing and designing health literacy interventions that meet the needs of refugees and migrants is core to achieving this objective. This literature review sought to identify antecedents and consequences of health literacy among refugees and migrants during the first two years of the COVID-19 pandemic. We systematically searched nine electronic databases and numerous grey literature sources to identify studies published between December 2019 and March 2022. The antecedents (societal and environmental determinants, situational determinants, and personal determinants) and consequences of health literacy among refugees and migrants were mapped to a validated integrated health literacy model. Social and environmental determinants (n = 35) were the most reported antecedent influencing health literacy among refugees and migrants during the first two years of COVID-19. Language (n = 26) and culture (n = 16) were these determinants' most frequently reported aspects. Situational determinants (n = 24) and personal determinants (n = 26) were less frequently identified factors influencing health literacy among refugees and migrants. Literacy (n = 11) and socioeconomic status (n = 8) were the most frequently reported aspects of personal determinants. Media use (n = 9) and family and peer influence (n = 7) were the most cited situational determinants reported. Refugees and migrants with higher levels of health literacy were more likely to use healthcare services, resulting in better health outcomes. The findings of this review reveal personal and situational factors that impacted health literacy among refugees and migrants during COVID-19 that require attention. However, the inadequate adaptation of health literacy interventions for linguistic and cultural diversity was a greater problem. Attention to this well-known aspect of public health preparedness and tailoring health literacy interventions to the needs of refugees and migrants during pandemics and other public health emergencies are paramount.

Improving health and scientific literacy in disadvantaged groups: A scoping review of interventions

OBJECTIVE

To explore approaches for developing and implementing interventions aimed at improving health literacy and health-related scientific literacy in disadvantaged groups.

METHODS

A scoping review of literature published in 2012-2022 was conducted, followed by quality appraisal of eligible studies.

RESULTS

Interventions were conducted mainly in community settings, where the most popular venues were adult education facilities. The primary target groups were those with limited income or education, ethnic minorities, or immigrants. Programs were often held in-person using interactive and culturally appropriate methods. They were predominantly focused on functional and interactive health literacy dimensions rather than on critical and scientific ones. Evaluations measured knowledge, health literacy, behavioral and psychological outcomes using various quantitative and qualitative instruments.

CONCLUSIONS

The findings offer a comprehensive overview of the ways to design and evaluate health and scientific literacy interventions tailored to disadvantaged groups.

PRACTICE IMPLICATIONS

Future interventions should prioritize participatory designs, culturally appropriate materials, and shift focus to critical and scientific health literacy, as well as to program scalability in less controlled conditions.

Enhancing the health knowledge and health literacy of recently resettled refugees through classroom-based instructional methods

Health education can elevate health literacy, which is associated with health knowledge, health-seeking behaviors and overall improved health outcomes. Refugees are particularly vulnerable to the effects of low health knowledge and literacy, which can exacerbate already poor health stemming from their displacement experience. Traditional learning methods including classroom-based instruction are typically how health-related information is presented to refugees. Through a series of interactive classes focused on specific health topics relevant to the resettled refugee population, this study evaluated the effectiveness of a classroom-based health education model in enhancing the health knowledge of recently resettled refugees. We used the Wilcoxon signed-rank test to evaluate differences in pre- and post-class knowledge through test performance. We found a significant improvement in health knowledge in two refugee groups: females and those who were employed. Culturally and socially sensitive considerations including language inclusiveness, class timing, transportation and childcare provisions are important when creating an educational program for individuals with refugee backgrounds. Developing focused approaches to instruction that enhance health knowledge could lead to better health literacy and ultimately improve health-related behaviors and outcomes in the refugee population.

Factors affecting adherence to psychotropics in trauma-affected refugees: data from a randomized controlled trial

Non-adherence to psychotropic drugs may reduce treatment effectiveness and may cause exacerbation of illness. Among migrant populations, studies have identified low adherence to psychotropic drugs. This study aimed to identify factors that were associated with the three basic components of adherence: non-initiation, non-implementation (blood sample), and discontinuation in a clinical sample of trauma-affected refugees diagnosed with posttraumatic stress disorder. The data for this study is derived from a randomized controlled trial (n = 108). Based on existing literature, individual sociodemographic and clinical candidate predictor variables that may affect the initiation, continuation, and implementation to psychotropics were selected as exposure variables. Logistic regression was used to assess the risk relation between non-initiation, non-implementation, discontinuation, and the individual sociodemographic and clinical factors. Three factors - level of education, turn-up rate for medical doctor sessions, and discomfort in relation to the psychotropics - were associated with non-initiation, non-implementation, or discontinuation. The relatively small sample size poses a limitation. Furthermore, factors not examined in the current study may have affected non-initiation, non-implementation, and discontinuation. The study identified level of education, turn-up rate for medical doctor sessions, and discomfort in relation to medicine as important factors in relation to treatment with psychotropics in trauma-affected refugees. Factors contributing to a low turn-up rate, and factors that are consequences of a low turn-up rate, as well as communication and trust in the patient-provider interaction need further research attention. Furthermore, there is a need for research on interventions addressing adherence for refugees with mental illness.

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

Effectiveness of Interventions to Improve Digital Health Literacy in Forced Migrant Populations: Protocol for a Mixed Methods Systematic Review

BACKGROUND

Digital health literacy is considered a health determinant that can influence improved health and well-being, health equity, and the reduction of social health inequalities. Therefore, it serves as an asset for individuals to promote their health. However, low digital health literacy is a major problem among forced migrant populations. They do not always have the capacity and skills to access digital health resources and use them appropriately. To our knowledge, no studies are currently available to examine effective interventions for improving digital health literacy among forced migrant populations.

OBJECTIVE

This paper presents the protocol for a systematic review that aims to assess the effectiveness of digital health literacy interventions among forced migrant populations. With this review, our objectives are as follows: (1) identify interventions designed to improve digital health literacy among forced migrant populations, including interventions aimed at creating enabling conditions or environments that cater to the needs and expectations of forced migrants limited by low levels of digital health literacy, with the goal of facilitating their access to and use of eHealth resources; (2) define the categories and describe the characteristics of these interventions, which are designed to enhance the abilities of forced migrants or adapt digital health services to meet the needs and expectations of forced migrant populations.

METHODS

A mixed methods systematic review will be conducted according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) checklist. The research will be conducted in an iterative process among the different authors. With the help of a medical information specialist, a specific search strategy will be formulated for the 6 most relevant databases (ie, MEDLINE, Embase, CINAHL, Web of Science, Academic Search Premier, PsycINFO, and the Google Scholar search engine). A literature search covering studies published between 2000 and 2022 has already been conducted. Two reviewers then proceeded, individually and independently, to conduct a double selection of titles, abstracts, and then full texts. Data extraction will be conducted by a reviewer and validated by a senior researcher. We will use the narrative synthesis method (ie, structured narrative summaries of key themes) to present a comprehensive picture of effective digital health literacy interventions among forced migrant populations and the success factors of these interventions.

RESULTS

The search strategy and literature search were completed in December 2022. A total of 1232 articles were identified. The first selection was completed in July 2023. The second selection is still in progress. The publication of the systematic review is scheduled for December 2023.

CONCLUSIONS

This mixed methods systematic review will provide comprehensive knowledge on effective interventions for digital literacy among forced migrant populations. The evidence generated will further inform stakeholders and aid decision makers in promoting equitable access to and use of digital health resources for forced migrant populations and the general population in host countries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50798.

"I can't describe how I could get better, but I would like to" - Conception of health and illness of refugee youth in Germany

Introduction and objective

Almost half of all the people displaced worldwide are children and adolescents. Many refugee children, adolescents, and young adults suffer from psychological stress. However, their utilization of (mental) health services is low, probably due to a lack of knowledge about (mental) health and (mental) health care. The current study aimed to explore concepts of (mental) health and illness of refugee youth as well as assess their mental health literacy (MHL) to arrive at conclusions for improving mental health care access and use.

Method

From April 2019 to October 2020, we conducted 24 face-to-face interviews with refugee children and adolescents in an outpatient clinic (n = 8), in youth welfare facilities (n = 10), and at a middle school (n = 6). A semi-structured interview was used to assess knowledge about mental and somatic health and illness as well as corresponding health strategies and care options. The material was evaluated using qualitative content analysis.

Results

Participants (N = 24) were between 11 and 21 years old (M = 17.9, SD = 2.4). The coded material was assigned to four thematic main areas: (1) conception of illness, (2) conception of health, (3) knowledge about health care structures in their country of origin, and (4) perceptions of mental health care structures in Germany. Compared to somatic health, the interviewed refugee children and adolescents knew little about mental health. Furthermore, respondents were more aware of opportunities of somatic health promotion, but almost none knew how to promote their mental health. In our group-comparative analysis we observed that younger children possess little knowledge about mental health-related topics.

Conclusion

Our results show that refugee youth have more knowledge about somatic health and somatic health care than about mental health (care). Accordingly, interventions to promote the MHL of refugee youth are necessary to improve their utilization of mental health services and to provide adequate mental health care.

Application of the optimizing health literacy and access (Ophelia) process in partnership with a refugee community in Australia: Study protocol

Refugees experience health inequities resulting from multiple barriers and difficulties in accessing and engaging with services. A health literacy development approach can be used to understand health literacy strengths, needs, and preferences to build equitable access to services and information. This protocol details an adaptation of the Ophelia (Optimizing Health Literacy and Access) process to ensure authentic engagement of all stakeholders to generate culturally appropriate, needed, wanted and implementable multisectoral solutions among a former refugee community in Melbourne, Australia. The Health Literacy Questionnaire (HLQ), widely applied around the world in different population groups, including refugees, is usually the quantitative needs assessment tool of the Ophelia process. This protocol outlines an approach tailored to the context, literacy, and health literacy needs of former refugees. This project will engage a refugee settlement agency and a former refugee community (Karen people origin from Myanmar also formerly knowns as Burma) in codesign from inception. A needs assessment will identify health literacy strengths, needs, and preferences, basic demographic data and service engagement of the Karen community. This community will be engaged and interviewed using a semi-structured interview based on the Conversational Health Literacy and Assessment Tool (CHAT) will cover supportive professional and personal relationships, health behaviors, access to health information, use of health services, and health promotion barriers and support. Using the needs assessment data, vignettes portraying typical individuals from this community will be developed. Stakeholders will be invited to participate in ideas generation and prioritization workshops for in-depth discussion on what works well and not well for the community. Contextually and culturally appropriate and meaningful action ideas will be co-designed to respond to identified health literacy strengths, needs, and preferences of the community. This protocol will develop and test new and improved methods that are likely to be useful for community-based organizations and health services to systematically understand and improve communication, services and outcomes among disadvantaged groups, particularly migrants and refugees.