Health literacy: the missing link in improving the health of Somali immigrant women in Oslo

Effect of pharmaceutical pictograms on the textual comprehension of Prescription Medication Leaflets: A randomized controlled trial

INTRODUCTION

Clear patient instructions are essential in pharmaceutical care. However, literature reveals a consistent gap between the readability of medication messages and population skills. This study aimed to assess the comprehension of information in three Prescription Medication Leaflets, with and without supplementary US Pharmacopeia (USP) pictograms, among Spanish adolescents completing secondary education.

METHODS

We conducted a multicenter randomized controlled trial. From March to June 2022, 590 students were randomly assigned to read Prescription Medication Leaflets for ibuprofen, amoxicillin/clavulanic acid, and omeprazole, with or without USP pictograms. Comprehension was evaluated via questionnaire, alongside the European Health Literacy Survey short form, and sociodemographic data were collected. Mann-Whitney U and chi-square tests were used for analysis.

RESULTS

Participant comprehension was significantly below the European standard, which requires at least 80 % readability for Prescription Medication Leaflets, even with pictograms. Pictograms, however, significantly enhanced comprehension across all medication package inserts (p < 0.001 for all comparisons), especially among students with higher health literacy. High health literacy was a statistically significant factor in comprehension only within the experimental group (p = 0.005; p = 0.039; p = 0.004).

CONCLUSION

The discouraging results highlight the imperative for innovation in medication labeling design, employing patient-centered approaches. USP pictograms have been shown to significantly enhance the reading comprehension of medication package inserts among the Spanish population.

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.

Understanding the Health Literacy Experiences and Practices of Australian-Resettled Myanmar Refugees: Relevance for Nutrition and Dietetics Practice

Background/Objectives: Refugees typically experience poorer health compared with people from non-refugee backgrounds, and health literacy may play a part in this discrepancy. Using the WHO's revised health literacy definitions as a framework, this qualitative study sought to examine the health literacy experiences and practices of Australian resettled refugees from Myanmar from refugee and service provider perspectives. Methods: Four refugee participant focus groups (n = 27) along with one focus group and four interviews with service providers (n = 7) were conducted in Melbourne, Australia, and analysed using deductive content analysis. Results: Our study found that in addition to individual health literacy, community literacy was practiced by Myanmar refugees, thus highlighting the relevance of social support to health literacy. Furthermore, our study found gaps in healthcare service provision and resourcing related to health literacy development and responsiveness by the healthcare system. Conclusions: Our study confirms the relevance of WHO's revised health literacy definitions to Myanmar refugees while also discussing, in the context of nutrition and dietetics practice, the importance of understanding the different aspects of health literacy and how this relates to working with those who are most marginalised to improve their health and wellbeing.

Eating preferences and behaviors of older immigrants in Oslo: A qualitative study

Norway's population of older, first-generation immigrants is expected to almost triple by the year 2060 due to decreased mortality and continued immigration. Studies indicate that older immigrants in Norway have a higher rate of non-communicable disease than older non-immigrants. Eating a health-supporting diet is important for reducing disease risk and maintaining independence in older adults. The purpose of this study was to increase understanding of the eating preferences and behaviors of older, home-dwelling, first-generation immigrants in Oslo, and to identify influences on their eating preferences and behaviors. This qualitative study took a phenomenological approach to understand older immigrants' shared experience of changing eating behaviors with aging. Fourteen home-dwelling, older immigrants were recruited using a combination of purposeful random sampling and snowball sampling. In-depth interviews were conducted then analyzed according to reflexive thematic analysis. Study findings indicate that older immigrants eat a bi-cultural diet pattern. In addition, they seek out information about nutrition, and incorporate many health-supporting eating habits for disease management and prevention. In this way, older immigrants in Oslo share much in common with older non-immigrants. Hopes and worries for the future motivate older immigrants to eat more healthfully in order to maintain independence and cultural identity as long as possible. These results can be useful for designing culturally tailored programs which support eating habits for health maintenance and disease prevention among older immigrants.

Alignment of Patient Information Leaflets with the Health Literacy Skills of Future End-Users: Are We on the Same Page?

Effective health communication will not be possible if the messages directed to patients do not adapt to their health literacy skills. In this sense, if the Patient Information Leaflets (PILs) are not understood properly, they will not fulfill their purpose. Secondary education aims to develop students' fundamental skills, including reading comprehension, which should align with future patients. This study assesses reading comprehension of commonly used PILs among secondary education students. An observational cross-sectional study involved 590 Spanish secondary school students from March to June 2022. They read 3 original PILs and completed a questionnaire about medication use information. The European health literacy survey questionnaire (short version) and sociodemographic data were collected. The average correct answer rate was only 51%, with just 14.58% understanding when to take ibuprofen, results that fell significantly below the minimum 80% threshold required by the European Union. Age, gender, and cultural background didn't significantly impact comprehension. In conclusion, health literacy skills acquired in secondary education are insufficient for understanding current PILs. Educational reform is necessary to improve students' ability to comprehend medication instructions and enhance PILs for effective communication. At the same time, our work highlights that current PILs need to be redesigned to reduce the cognitive burden imposed on patients.

Cultural factors influencing COVID-19-related perceptions and behavior, seen from immigrants' own perspective - a qualitative study in Norway

BACKGROUND

Cultural factors are often mentioned as a possible explanation for the observed differences between immigrant populations compared to general populations with regards to COVID-19 disease burden and vaccination rates, but usually without any further exploration of what this entails. This paper aims to capture the thoughts of immigrants themselves and explore how they think culture may or may not have affected vaccination rates and health behavior during the pandemic.

METHODS

We performed qualitative interviews with 18 immigrants from Poland, Somalia and Sri Lanka living in Norway. Group interviews and individual interviews were transcribed and analyzed using systematic text condensation.

RESULTS

We identified four main themes the participants thought could influence spread of infection and vaccine hesitancy: cultural factors, transcultural factors, host society factors, and other personal factors. Social habits, religious traditions, attitudes towards and trust in the healthcare system, sense of community and societal duty were understood as cultural factors that influenced health behavior and vaccination hesitancy. However, different cultural factors could have varied impact on immigrants' behavior related to COVID-19 and possibly other health settings for different immigrant groups. In addition, we found examples of other factors related to being 'between cultures', and we found structural and socioeconomic factors not linked to culture.

CONCLUSIONS

Our paper brings awareness to how rules and guidelines may hit harder and interfere more in the way of life in some communities than others. In the continued work towards equity in health promotion and healthcare services, policymakers ought to keep the existence of such cultural differences in mind, to be able to make policies well fitted to ensure good health and quality of life for all.

Comparing healthcare needs by language: interpreted Arabic and Somali telehealth calls in two regions of Sweden, 2014-18

BACKGROUND

Limited language fluency can impede healthcare system navigation. In Sweden, the national telehealth line (Healthcare Guide 1177) offers interpretation in Arabic and Somali. We compared calls by language to identify differences in healthcare use for immigrant populations, focusing on three contact causes: pregnancy; vomiting or nausea in children; and worry/anxiety.

METHODS

We conducted a cross-sectional analysis of 3.9 million (n = 18 351 Arabic, n = 7199 Somali) telehealth calls (2014-18). Using multivariable logistic regression, we investigated associations between language of the call (Arabic, Somali, non-interpreted) and each contact cause. Potential confounders (age, region, year, and additionally for vomiting or nausea, month) and an interaction between age and language were considered.

RESULTS

Compared with non-interpreted calls, interpreted calls were associated with increased odds of being for pregnancy, especially for 19 to 29-year-olds [adjusted odds ratio (aOR) (95% CI) = 4.04 (3.66-4.46) and 4.60 (4.05-5.23), for Arabic and Somali calls, respectively]. Vomiting or nausea showed similar results, with aOR increasing with age: from 0.90 (0.75-1.07) (Arabic, <1 year) to 3.79 (2.86-5.01) (Somali, 5-9 years). In contrast, in unadjusted analyses, Arabic and Somali calls were associated with decreased odds of being for worry/anxiety [OR = 0.47 (0.38-0.58) and 0.34 (0.21-0.50)], respectively, compared with non-interpreted calls.

CONCLUSION

Our results suggest callers to the interpreted lines may need additional assistance navigating the healthcare system for pregnancy and for vomiting or nausea among children. These findings can inform healthcare services planning for immigrants to Sweden and highlight a novel use of telehealth data as a way to uncover disparities in healthcare use within a multi-linguistic population.

Somali immigrant women's knowledge of and experiences with folic acid supplement use before and during pregnancy: A qualitative study from Norway

INTRODUCTION

Health authorities in many countries recommend that women should take folic acid supplements before and during pregnancy to prevent having babies with neural tube defects. Somali immigrant women in Norway use less folic acid supplements than the recommended amount and subsequently, less than Norwegian-born women.

OBJECTIVES

To explore Somali immigrant women's knowledge of and experiences with using folic acid supplements before and during pregnancy.

METHODS

Data were collected through semi-structured individual interviews with ten Somali immigrant women in Norway. The participants were recruited and interviewed between September and November 2019. Graneheim and Lundmańs qualitative content analysis was used for data analysis.

RESULTS

Two main themes were developed through the process of analysing the data: 1) Attitudes to life and pregnancy affect how health care advice is met; 2) Understanding the benefits of folic acid is crucial.

CONCLUSIONS

The women in this study had varied knowledge about, and experiences with the use of folic acid supplements before and during pregnancy. The findings suggest that the healthcare system needs to adapt the information it provides on folic acid supplementation to target the needs of Somali immigrant women. In line with suggestions from the study participants, information needs to be given in a timely manner, by someone they trust, in their first language, include visual aids, and be offered to all women of childbearing age before their first pregnancy.

Somali women's perceptions and experiences of pain and pain relief during childbirth in Norway: A qualitative study

INTRODUCTION

Research shows that Somali women are less likely to receive epidural analgesia for labor pain compared to non-immigrant women in Norway. It is unclear why. This study aimed to explore the perceptions and experiences of Somali women regarding pain relief during childbirth.

METHODS

In January 2023, semi-structured interviews were conducted with 10 Somali women who had lived in Norway for at least ten years and given birth within the past 12 months. Data were analyzed using thematic content analysis as described by Graneheim and Lundman.

RESULTS

Three themes emerged from the data: a cultural understanding of epidural analgesia, religious and cultural coping strategies, and the midwife's role during labor. The participants expressed that there is a prevalent understanding in the Somali community that epidural analgesia in childbirth subsequently causes physical problems. Participants felt the influence of friends and family, expressed the need for culturally adapted information prior to labor, and concluded that, ultimately, what they decided upon was their own choice. They emphasized the belief that women were designed by God for childbirth. Prayer and placing oneself in God's hands were mentioned as pain management strategies. Nevertheless, the Somali women highlighted the importance of having a culturally competent midwife who is present when needed, creates trust, and provides information and access to different methods of pain relief, including epidural analgesia.

CONCLUSIONS

Understanding Somali women's cultural and religious background while listening to individual needs for information and pain relief is essential to ensure a positive birth experience for women from a Somali background.

Cross-Cultural Contact and Norwegian Language Skills Among Ethnic Minority Women in Norway, and Relationship with Physical Activity in Pregnancy and Postpartum: The STORK-Groruddalen Cohort Study

There are few studies of the migration context factors and physical activity (PA) level among minority ethnic women in Europe. We investigated the association between migration context factors and moderate to vigorous physical activity (MVPA) among minority ethnic women. Objectively recorded MVPA were obtained from 487 minority ethnic women included in the STORK-Groruddalen Cohort Study at three time points in pregnancy/postpartum. We investigated the associations between (a) contact with ethnic Norwegians and (b) Norwegian language skills and. No associations were observed in pregnancy. Postpartum, women who reported contact with ethnic Norwegians accumulated 17 MVPA min/day (95% CI: -.60, 34.54) more than women with no contact. In complete case analyses, this difference was significant (27 MVPA min/day (95% CI: 8.60, 44.54)). In early postpartum women with contact with ethnic Norwegians seems to be more physically active than women without contact. No associations were observed in pregnancy.

Barriers and facilitators to refugees and asylum seekers accessing non hospital based care: A mixed methods systematic review protocol

Context

Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living. People who are socially excluded such as asylum seekers and refugees have complex healthcare needs and tend to present more to the acute hospital setting as emergency presentations. Little is known about barriers and facilitators experienced by this group to accessing nonhospital based care.

Objectives

This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees and asylum seekers to accessing non hospital based care.

Methods

This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews. The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.

Discussion

This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across asylum seekers and refugees, and how they affect accessing non-hospital based care. It will explore conceptual models of access to healthcare and how they influence these factors.

Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women

OBJECTIVE

To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs.

DESIGN

A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis.

SETTING

The study was conducted in Sweden.

PARTICIPANTS

Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth.

FINDINGS

The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information.

KEY CONCLUSIONS

Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns.

IMPLICATIONS FOR PRACTICE

The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

Mental disorder and subsequent marital separation among migrant and non-migrant women

Using national register data between 2006-2014, we investigated the relationship between outpatient mental health service use (a proxy for mental disorder) and subsequent marital separation among women in Norway and whether the strength of the association differed for migrant and non-migrant women. Our sample population included 679,928 married women aged 18-60 years. Service use was strongly associated with marital separation among all women. The relationship was stronger for Filipinas but weaker for Somalis and Russians, compared with non-migrant women. Migration-related factors may influence marital separation among migrant women and barriers to care are likely to exist.

Prevalence of diabetes foot ulcers and associated factors among adult diabetic patients in three referral hospitals in Mogadishu, Somalia

Background

Diabetes mellitus (DM) causes significant morbidity and mortality in sub-Saharan Africa (SSA), including Somalia. Among diabetic patients, diabetic foot ulcers (DFUs) constitute the largest proportion of admissions, amputations, and mortality. The aim of this study is to assess the prevalence of diabetic foot ulcers and subsequently determine factors associated with it among diabetic patients at three major hospitals in Somalia.

Methods

An institutional-based cross-sectional study was conducted among 193 diabetic patients between August and November 2022. All eligible diabetes patients who were attending De Martini Hospital, Madina General Hospital, and Deynile General Hospital during the study period were included in the study. Patients were interviewed using a structured questionnaire. We collected demographic, clinical, and behavioral variables from all participants. A bivariate and multivariable logistic regression model was fitted to identify factors associated with diabetic foot ulcer. An odds ratio with a 95% confidence interval was computed to determine the level of significance.

Result

The mean age of the study's participants was 50.9 ± 13.6 years. The prevalence of diabetic foot ulcer was 15%. Patients who were either overweight or obese (OR 4.63, CI: 2.08-10.30), had a lack of family support in managing diabetes (OR 3.33, CI: 1.74-6.36), and did not check their feet regularly were more likely to develop DFU (OR 1.99, CI:1.08-3.66).

Conclusion

Increased body mass index, lack of family support, and not checking feet regularly were associated with DFUs. The high prevalence of DFUs and the plethora of needs of people with DFUs pose challenges for health care. A coordinated health care system is necessary to meet the needs of diabetic patients and prevent DFUs.

A population-based cohort study on changes in breast, lung and colorectal cancer incidence and mortality among non-Western immigrant women

BACKGROUND

Cancer risk varies geographically, and migrants are influenced by different risk factors before, during and after migration. Increased migration from non-Western countries to the Nordic countries calls for a better understanding of the migrants' cancer risk and the change in risk patterns over time. The aim of this study was to compare the incidence and mortality of breast, colorectal and lung cancer between non-Western immigrant and the native female population in Denmark, Finland, Iceland, and Norway.

MATERIAL AND METHODS

Data from national registries were processed and pre-analysed in each country. Multivariate Poisson regression models were used to model the relative differences in incidence and mortality as rate ratios (RR). The country-specific estimates and summary statistics were pooled together using a random effects model.

RESULTS

Non-Western immigrant women had significantly lower breast (RR 0.71, 0.65-0.78), colorectal (RR 0.72, 0.57-0.92) and lung (RR 0.55, 0.42-0.72) cancer incidence rates than native women, and the risk of these cancers among immigrant women increased with duration of residence. Differences were parallel in breast, colorectal and lung cancer mortality (RR 0.64, 0.55-0.74; RR 0.66, 0.48-0.92; RR 0.51, 0.34-0.79). Among immigrant women, higher education increased the risk for breast cancer and decreased it for lung cancer.

CONCLUSION

The results significantly complement and add to the previous findings of cancer burden and cancer burden transition among migrants and provide evidence of a prolonged cancer risk advantage among non-Western immigrant women. However, the findings show an increasing risk of lifestyle-related cancers with increasing duration of residence in the host country. Further studies are needed to discover underlying reasons for this phenomenon.

Improving health literacy responsiveness to reduce ethnic and social disparity in stillbirth and infant health: A cluster randomized controlled effectiveness trial of the MAMAACT intervention

OBJECTIVE

The MAMAACT intervention aims to reduce ethnic and social disparities in stillbirth and infant death by improving communication between pregnant women and midwives regarding warning signs of pregnancy complications. This study evaluates the effect of the intervention on pregnant women's health literacy (two domains from the Health Literacy Questionnaire) and complication management - interpreted as improved health literacy responsiveness among midwives.

DESIGN

Cluster randomized controlled trial, 2018-2019.

SETTING

19 of 20 Danish maternity wards.

PARTICIPANTS

Cross-sectional survey data were collected using telephone interviews (n = 4150 pregnant women including 670 women with a non-Western immigrant background).

INTERVENTION

A six-hour training session for midwives in intercultural communication and cultural competence, two follow-up dialog meetings, and health education materials for pregnant women on warning signs of pregnancy complications - in six languages.

MAIN OUTCOME MEASURES

Differences in mean scores at post-implementation of the domains Active engagement with healthcare providers (Active engagement) and Navigating the healthcare system from the Health Literacy Questionnaire, and differences in the certainty of how to respond to pregnancy complication signs between women in the intervention and control group.

RESULTS

No difference was observed in women's level of Active engagement or Navigating the healthcare system. Women from the intervention group were more certain of how to respond to complication signs: Redness, swelling, and heat in one leg: 69.4 % vs 59.1 %; aOR 1.57 (95 % CI 1.32-1.88), Severe headache: 75.6 % vs 67.3 %; aOR 1.50 (95 % CI 1.24-1.82), and Vaginal bleeding: 97.3 % vs 95.1 %; aOR 1.67 (95 % CI 1.04-2.66).

CONCLUSION

The intervention improved women's certainty of how to respond to complication signs, but was unable to improve pregnant women's health literacy levels of Active engagement and Navigating the healthcare system, likely due to barriers related to the organization of antenatal care. A reorganization of antenatal care and a care model sensitive to diversity within the entire healthcare system might help reduce disparities in perinatal health.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03751774.

Barriers and facilitators to refugees, asylum seekers and people experiencing homelessness accessing non hospital based care: A mixed methods systematic review protocol

Context: Social exclusion is characterised by and represents a form of disadvantage and marginalisation of vulnerable groups of people in society, who cannot fully participate in the normal activities of daily living.  Socially excluded groups consist of, but are not limited to the following groups: people experiencing homelessness, asylum seekers and refugees.  People from socially excluded groups have complex healthcare needs including infectious and non-communicable diseases. People from socially excluded groups tend to present more to the acute hospital setting as emergency presentations.  Little is known about barriers and facilitators experienced by these groups to accessing non hospital based care. Objectives: This mixed methods systematic review, will critically examine the concept of barriers and facilitators for refugees, asylum seekers and people experiencing homelessness, to accessing non hospital based care. Methods:  This methodological review will follow the Joanna Briggs Institute guidance for conducting mixed methods reviews.  The following databases will be searched: Central Medline, PubMed, Embase, CINAHL, and the Cochrane Library. Relevant grey literature will be included. Title and abstract screening, followed by full-text screening will be undertaken independently by two reviewers. The Joanna Briggs Institute extraction tool will be adapted for data extraction.   Discussion: This mixed method review will comprehensively evaluate quantitative and qualitative data, synthesise both barriers and facilitators and follow a systematic approach through establishing use of mixed methods research across a number of marginalised groups, and how they affect accessing non hospital based care.   It will explore conceptual models of access to healthcare and how they influence these factors.

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.

Migration health research in the Nordic countries: Priorities and implications for public health

The past 50 years have witnessed an increase in immigration to the Nordic countries from and beyond neighbouring countries in Europe. Diversity implies variations and differences in health status and health outcomes both within and across populations. Migrant health research has not been prioritized and health policies and practice, especially long-term national plans, often exclude migrants. In this article, we briefly trace the history, the groups, reasons for migration and the road to migrant health research in Norway, Sweden, Finland and Denmark. We discuss the case for data and research including needs, basis for data collection and the methodological challenges. We provide a brief snapshot of migrant health research, identify current gaps and discuss the implications for research. We recommend a regional Nordic strategy to promote intercountry exchange, sharing and learning. Finally, we reflect on the larger picture, implications for policy and practice that could enable societal conditions to reduce avoidable health inequalities.

Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries

BACKGROUND

For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS₁₉-Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region.

METHODS

For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out.

RESULTS

The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS₁₉-Q12 score with social determinants and selected consequences of HL. The HLS₁₉-Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS₁₉-Q47 long form.

CONCLUSIONS

The HLS₁₉-Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument.

Non-European immigrants' self-described strategies for mental health promotion and perceptions of Finnish mental health services: A qualitative descriptive analysis

PURPOSE

This study aims to describe non-European immigrants' perceptions toward mental health care in Finland and the factors that support their mental health.

DESIGN AND METHODS

Participants (N = 17) were interviewed through semistructured interviews, after which interview transcripts were analyzed using a six-phase thematic analysis process.

FINDINGS

The participants reported that developing self-help strategies benefitted their mental health. The participants primarily preferred unprofessional help over professional mental health care. Several structural and cultural barriers to help-seeking were identified.

PRACTICAL IMPLICATION

Health care staff working with immigrants need proper education and knowledge to provide sufficient, holistic care; for this reason, information about the cultural differences among immigrants and cultural sensitivity should be included in basic as well as post-graduate nursing education.

Differences in health literacy domains among migrants and their descendants in Germany

Background

Health literacy (HL) is considered to be an important precondition for health. HL research often identifies migrants as vulnerable for low HL. However, in-depth data on HL among migrants especially in its domains of health care, disease prevention and health promotion and its determinants are still scarce.

Objective

The aim of this study was therefore to analyse the current status of HL among migrants and their descendants from Turkey and from the former Soviet Union (FSU) in Germany and factors associated with it. This has not been studied using large-scale data and bilingual interviews. We differentiate between dimensions of HL, namely the domains of health care, disease prevention and health promotion which goes beyond many previous studies. In addition, we explore new mechanisms by testing the explanatory power of self-efficacy and interethnic contacts for migrants' HL.

Methods

The study includes 825 first- and second-generation adult migrants from two of the largest immigration groups in Germany, from Turkey and FSU, who were interviewed face-to-face in German, Turkish or Russian in late summer 2020. HL was measured using the HLS19-Q47 instrument. Age, gender, educational level, social status and financial deprivation, chronic illness, health-related literacy skills, self-efficacy, interethnic contacts, migration generation, duration of stay and region of origin were considered as possible determinants. Ordinary least square regressions were estimated.

Results

The average general HL score was 65.5. HL in health promotion and disease prevention was lower than in health care. Low financial deprivation, health-related literacy skills, and self-efficacy were positively correlated with each HL domain. Educational level, social status, age, gender, duration of stay and interethnic contacts were positively correlated with HL in some domains. Region of origin was only correlated with the domain of disease prevention until interethnic contact was accounted for.

Conclusion

Our study contributes to the existing knowledge by analyzing different domains of HL and testing its correlations with self-efficacy and interethnic contact among migrants. We reveal that migrants cannot generally be considered as vulnerable for low HL, as oftentimes outlined. There is a need for interventions e.g. to enhance the understanding of health information among subgroups with lower HL.

Psychometrics and measurement invariance: Health Literacy Scale for Vietnamese and Indonesian married immigrants

AIMS

To examine the psychometrics and measurement invariance of the Short-Form Health Literacy 12-item questionnaire (HL-SF12) among Vietnamese and Indonesian married immigrants.

DESIGN

A cross-sectional survey design.

METHODS

In total, 1171 Vietnamese and Indonesian married immigrants were enrolled between September 2019 and December 2019. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to verify the structural validity of the suggested factor structure. The multiple-group CFA (MGCFA) used a series of hierarchical nested-in models as a measurement invariance test which confirmed the adequacy of the model fit at each stage.

RESULTS/FINDINGS

The Kaiser-Meyer-Olkin coefficient was 0.898, and the Bartlett test of sphericity was statistically significant (χ² [66] = 1965.97, p < 0.01). According to a scree plot and Kaiser's criterion for eigenvalues of >1, the EFA explained 61.6% of the total variance and confirmed three theoretically supported factors of health care, disease prevention and health promotion. The 12 items showed factor loadings of >0.4 and four items were in each subscale. The CFA showed adequate structural validity, including a relative chi-squared/degrees of freedom (X² /df) of 2.01, a comparative fit index (CFI) of 0.98 and a root mean square error of approximation (RMSEA) of 0.04 (95% confidence interval [0.03, 0.05]) in married immigrants. For the measurement invariance, a change in the goodness-of-fit measures did not exceed 0.02 for the RMSEA or 0.01 for the CFI. The results indicated Cronbach's α values of 0.87 for the HL-SF12 scale in Vietnamese and Indonesian combined samples (n = 1171). A t-test showed that the HL-SF12 and its three subscales were unable to significantly differentiate between Vietnamese and Indonesian groups (all p > 0.05).

CONCLUSIONS

The HL-SF12 scale showed acceptable theoretically supported structural validity, equivalent measurement invariance and reliable internal consistency among Vietnamese and Indonesian married immigrants. Measurements of immigrants' HL using the HL-SF12 could be integrated into future immigrant health policies.

IMPACT

As the first study of the measurement invariance of the HL-SF12 instrument among immigrants. Related factors of immigrants' HL can be further explored to increase immigrants' health and empowerment.

Immigrants' perspectives on healthy life and healthy lifestyle counseling: a focus group study

BACKGROUND

Immigrants have a higher risk of developing chronic diseases than the general population, but there is a lack of knowledge about appropriate counseling models to promote their health. This study aimed to explore Asian and Russian immigrants' perspectives in Finland on healthy lifestyle and healthy lifestyle counseling to improve the quality of the counseling in primary health care services to prevent type 2 diabetes and other chronic diseases.

METHODS

We conducted a qualitative study using semi-structured questions for eight focus groups. The participants were 46 adult immigrants (21 Asian and 25 Russian) living legally in Finland. Interviews were transcribed verbatim, coded, and analyzed using deductive content analysis.

RESULTS

We identified three themes regarding healthy lifestyle: (1) limited knowledge on different dimensions of healthy lifestyle, (2) understanding the impact of culture and community on healthy living, and (3) changing the lifestyle to live healthier after immigration. Moreover, we found three themes regarding healthy lifestyle counseling: (1) shortcomings in health care for providing healthy lifestyle counseling, such as lack of educational materials and miscommunication, (2) influential individual factors for using healthy lifestyle counseling, such as stress, and (3) positive outcomes of healthy lifestyle counseling.

CONCLUSION

Developing a culturally tailored healthy lifestyle counseling program for the enhancement of immigrants' knowledge regarding healthy lifestyle with consideration of cultural and linguistic aspects is recommended for preventing chronic diseases among immigrants.

Measuring Health Literacy in Romania: Validation of the HLS-EU-Q16 Survey Questionnaire

Objective: Empirical data on health literacy (HL) for Romania is almost inexistent. The present study aimed to validate the HLS-EU-Q16 questionnaire for the Romanian population and explore the predictors of HL in the North-West Region of the country.

Methods: A non-experimental, cross-sectional study was conducted between March and November 2019 on a representative, stratified random sample of 1,622 participants from the North-Western Region of Romania. Exploratory Factor Analysis (EFA), Principal component analysis (PCA), Pearson correlations, and Chronbach’s Alpha were used to validate the scale. Linear regressions were conducted to assess the determinants of health literacy.

Results: Results obtained for the HL scale support its factorial component and reliability, with a Cronbach’s alpha of α = 0.84. Age, gender, education and self-reported health status were identified as determinants of HL.

Conclusion: Study findings indicate that the Romanian version of HLS-EU-Q16 is psychometrically sound and comparable to the original version. These results provide the first validated tool to measure HL in Romanian and the first population level data for Romania.

Health Literacy and Migrant Communities in Primary Health Care

INTRODUCTION

The promotion of health literacy of the population in a situation of migration, in the community, is a fundamental field of intervention in health promotion, for the reduction of inequalities in access to health care services. It is increasingly necessary to make health care services more equitable for migrant populations. The aim of the study was to characterize the level of health literacy of the population in a migrant situation, attending a primary health care unit in the Lisbon region, to identify priority areas for community intervention that will become the focus of intervention and contribute to the increase in the health literacy levels in this population.

METHODS

A cross-sectional study was carried out by applying the Health Literacy Survey (ILS-PT) to a sample of the population in a situation of migration, found by 27 participants.

RESULTS

The general health literacy index of the sample is inadequate (21.23 points). An analysis of the sub-indexes revealed that 75% of the participants had difficulties related to information about health care and 80% had difficulties in the field of health promotion.

CONCLUSIONS

Problematic and inadequate levels of health literacy was significantly frequent among migrant population. So that enhancing health literacy among migrant is essential to reduce health inequalities to achieve better health outcomes and contribute to defense of human rights of this vulnerable population.

Knowledge About How to Manage Warning Signs of Pregnancy Complications Among Immigrants and Their Descendants Compared to Women of Danish Origin

OBJECTIVES

Ethnic differences in perinatal morbidity and mortality are starting points for social inequality in health. Increased incidence and severity of some pregnancy complications are found among immigrant women compared to ethnic majority women in high-income settings. However, little is known about immigrant women's assessment and management of warning signs. We aimed to assess women's knowledge about how to manage warning signs of pregnancy complications among immigrants and their descendants compared to women of Danish origin.

METHODS

A cross-sectional study including phone-based interviews with 1899 women. Women were interviewed during gestational week 30-37 in one of six languages. Maternal ethnicity was categorized as; immigrants, their descendants and ethnic Danes. The outcomes were yes or no to; do you know what to do if you experience 1) sudden swelling, redness, and heat in one leg 2) severe headache and 3) vaginal bleeding.

RESULTS

Immigrant women had lower levels of knowledge about how to manage all three types of warning signs of pregnancy complications compared to women of Danish origin. Adjusted OR for vaginal bleeding for women of European (4.33, 95% CI: 2.24-8.37), Asian (9.26, 95% CI: 5.10-16.83) and African (8.66, 95% CI: 3.26-23.05) origin.

CONCLUSIONS FOR PRACTICE

Immigrant women had lower levels of knowledge about how to manage warning signs of pregnancy complications compared to women of Danish origin. Improved needs-based health education in pregnancy complications and body symptoms during antenatal care is needed to address delays in the management of complications and could potentially improve the health of women and children.

Health literacy levels and correlates among refugees in Mount Lebanon

OBJECTIVES

The study aimed to assess the levels and correlates of health literacy among refugees.

STUDY DESIGN

This is a cross-sectional study design.

METHODS

Health literacy was assessed through face-to-face interviews in eight primary healthcare centers (PHCs) in Mount Lebanon. The questionnaire consisted of the Arabic Functional Health literacy scale, the short version of the European Health Literacy Survey (HLS-EU-Q16), socio-economic questions (sex, age, nationality, marital status, educational level, and ability to pay for medical fees at PHCs), and health-related questions (self-perceived health, long-term illness, recent visit to health care, and freedom to make health decisions). Statistical analyses were performed to evaluate the association between functional health literacy (FHL), comprehensive health literacy (CHL), and potential explanatory variables.

RESULTS

Of 263 participants (61.6% females), mean age 38.49 ± 12.80 years, 52.1% had inadequate FHL and 35.7% had inadequate CHL. The likelihood of having inadequate CHL was higher in refugees who were ever married (odds ratio [OR] = 2.794; 95% confidence interval [CI]: 1.187-6.576) or had average ability to pay for medical expenses at PHC (OR = 4.562; 95% CI: 1.554-13.393). The odds of having inadequate FHL was lower in refugees with some level of education (OR = 0.211; 95% CI: 0.077-0.580). Furthermore, their perceived lack of freedom to make personal health decisions was associated with inadequate levels of CHL (OR = 5.195; 95% CI: 2.693-10.022) and FHL (OR = 4.676; 95% CI: 2.610-8.376).

CONCLUSIONS

Health messages and delivery should be tailored to refugee health literacy levels. Initiatives should seek to improve refugee interaction with the health system, promote uptake of available health services and facilitate health-related decision-making in daily life.

Health literacy as a determinant of healthy eating and active living in Canadian immigrant youth

The purpose of the study was to explore health literacy and community engagement in relation to active living with newcomer young people and their families. We employed a case study design and a participatory approach. The data collected included photovoice and photo-assisted focus group interviews, which included an initial stage when youth participated in workshops creating collages on healthy living. A follow-up focus group centred on discussion of the collages with subsequent training on the photovoice method and the use of the cameras, and a second focus group, which incorporated photos taken by participants during the programming and their leisure time. Different themes were developed from the data: active living, balance, body talk, challenges, environment and health, culture and health, family, health and food, health and safety, knowledge, source of knowledge, peers and friends, personal hygiene, recreational activities, socio-emotional health, social isolation and spiritual health. Excerpts were taken from the different themes to demonstrate the immigrant/refugee youths' understanding of levels of health literacy and its contribution to healthy eating and active living. The qualitative findings are presented under the different tenets of health literacy. Health literacy extends beyond the individual level and effects the whole family and communities; intervention need to extend to include community connections and involvement activities. Future research needs to focus on the long-term effects of critical health literacy among immigrant communities.

Adapting a Parental Support App to Promote Healthy Diet and Physical Activity Behaviors (MINISTOP) for a Multi-Ethnic Setting: A Qualitative Study on the Needs and Preferences of Parents and Nurses within Swedish Child Health Care

Early efforts for prevention of childhood overweight and obesity are needed. In order to adapt an app promoting healthy diet and physical activity behaviors in children (MINISTOP 1.0) for multi-ethnic communities, we explored: (1) needs and concerns among Somali-, Arabic-, and Swedish-speaking parents in terms of supporting healthy diet and activity behaviors in their children; (2) nurses’ perceptions of parental needs and concerns in relation to diet and physical activity behaviors; and (3) how the features and content of the MINISTOP 1.0 app could be refined to better support health behaviors in children, among both parents and nurses. Focus groups with Somali-, Arabic-, and Swedish-speaking parents (n = 15), and individual interviews with nurses (n = 15) were conducted. Parents expressed several challenges in supporting children’s health behaviors, the need for a tailored app, and alternative ways of accessing the content (audio/video). Nurses emphasized the need of supporting parents early, and the value of a shared platform in different languages, to facilitate communication. This study contributes valuable insights about parental needs and relevant adaptations to a parental support app, such as addition of audio/video files for increased accessibility. This adapted app version—MINISTOP 2.0, can be useful for childhood obesity prevention in multi-ethnic communities.

Vaccine completion and infectious diseases screening in a cohort of adult refugees following resettlement in the U.S.: 2013-2015

BACKGROUND

Refugees are frequently not immune to vaccine-preventable infections. Adherence to consensus guidelines on vaccination and infectious diseases screening among refugees resettling in the U.S. is unknown. We sought to determine rates of vaccine completion and infectious diseases screening in refugees following resettlement.

METHODS

We conducted a retrospective cohort study of refugees resettling in a region in the U.S. using medical data from June 2013-April 2015. We determined the proportion of vaccine-eligible refugees vaccinated with measles-mumps-rubella (MMR), hepatitis A/B, tetanus, diphtheria, and acellular pertussis (Tdap), and human papillomavirus (HPV) following resettlement. We also determined the proportion of refugees who completed HIV and hepatitis C (HCV) screening.

RESULTS

One hundred and eleven subjects were included, primarily from Iraq (53%), Afghanistan (19%), and Eritrea (11%). Of the 84 subjects who were vaccine-eligible, 78 (93%) initiated and 42 (50%) completed vaccinations within one year of resettlement. Odds of completing vaccination were higher for men (OR: 2.38; 95%CI:1.02-5.71) and for subjects with English proficiency (OR: 3.70; 95%CI:1.04-17.49). Of the 78 subjects (70%) completing HIV screening, two (3%) were diagnosed with HIV. Nearly all subjects completed screening for HCV, and one had active infection.

CONCLUSION

While most refugees initiate vaccinations, only 50% completed vaccinations and 70% completed HIV screening within 1 year of resettlement. There is a need to emphasize vaccine completion and HIV screening in refugee patients following resettlement.

Fish consumption and awareness of fish advisories among Burmese refugees: A respondent-driven sampling study in Milwaukee, Wisconsin

BACKGROUND

Since 2000, more than 6000 Burmese refugees were resettled in Wisconsin. The Burmese diet is traditionally rich in fish and fish products, and studies show that Burmese refugees continue to rely on local waterbodies for food. Given that Wisconsin has five Areas of Concern (AOC) that are severely affected by pollution, long-term exposure to contaminants in sport-caught fish is a health concern. To better understand fish consumption among Burmese refugees, we conducted a biomonitoring study in Milwaukee. The present study examined Burmese refugees' fish consumption habits and awareness of fish advisories.

METHODS

We used respondent-driven sampling (RDS) methodology to recruit Burmese refugees in Milwaukee. RDS Analysis Tool 7.1 was used to obtain adjusted population estimates for demographic characteristics, fish consumption habits, and awareness of fish advisories. Homophily and equilibrium were investigated to evaluate the effectiveness of RDS in recruitment.

RESULTS

Initiated by five active seeds, we recruited 103 respondents to participate in the study. Respondents had a strong preference to recruit those with the same ethnicity (Homophily-score: 0.614 to 0.699) and a relatively weak preference to recruit those with the same sex (Homophily-score: 0.188 to 0.222) to participate in our study. The majority (72.5%) of respondents were women of childbearing age (WCBA). Most (68.5%) had 8th grade or less education. Regarding sportfish consumption per month in the last year, 30.6% reported eating 1-3 meals and 21.2% reported eating more than 3 meals. When asked about purchased fish consumption per month, 26.3% reported eating 1-3 meals. The overwhelming majority were not aware of safe-eating sportfish guidelines for Wisconsin (88.3%) or Milwaukee waterbodies (96.6%).

CONCLUSIONS

RDS is an effective methodology to recruit hard-to-reach populations, such as the Burmese surveyed in this study. High percentages of WCBA eating potentially contaminated sportfish meals, low awareness of consumption advisories, and limited economic resources make the Burmese population more likely to be exposed to contaminants. Health education efforts should be focused in this vulnerable population, particularly among Burmese WCBA.

Exploring Health Literacy and the Correlates of Pap Testing Among African Immigrant Women: Findings from the AfroPap Study

African immigrant (AI) women have low rates of Pap testing. Health literacy plays a pivotal role in health behaviors. Sources and types of health information could shape health literacy and inform the Pap testing behaviors of AI women. However, the influences of health literacy, sources, and types of health information along with cultural and psychosocial correlates on the Pap testing behaviors of AI women are poorly understood. To examine how sources and types of health information impact health literacy, and in turn, how health literacy and cultural and psychosocial factors influence the Pap testing behaviors of AI women. An adapted Health Literacy Skills Framework guided the selection of variables for this cross-sectional study. Convenience sampling was used to recruit 167 AI women, 21-65 years. Multivariate logistic regression was used to assess correlates of Pap testing after adjusting for covariates (age, education, English proficiency, employment, income, health insurance, access to primary care, marital status, and healthcare provider recommendation). Most participants (71%) had received a Pap test in the past and used multiple (two or more) sources (65%) and types (57%) of health information. Using multiple sources of health information (aOR 0.11, p < 0.01) but not types of health information was associated with Pap testing. Having negative cultural beliefs (aOR 0.17, p = 0.01) and having high self-efficacy (aOR 9.38, p < 0.01) were significantly associated with Pap testing after adjusting for covariates. High health literacy (OR 3.23, p < 0.05) and high decisional balance (OR 5.28, p < 0.001) were associated with Pap testing in bivariate models but did not remain significant after controlling for covariates. Cultural beliefs was a significant correlate of AI women's Pap testing behaviors regardless of other known social determinants of health (education, English proficiency, age, access to primary care). Disseminating health information through various sources has the potential to promote Pap testing among AI women. Larger studies which utilize a robust sampling strategy and include a diverse group of AI women are needed in order to optimize health interventions aimed at improving Pap test screening behaviors among AI women.

The Sociodemographic Determinants of Health Literacy in the Ethnic Hungarian Mothers of Young Children in Eastern Europe

Parental health literacy is a decisive factor for child health and quality of life. Children of parents with limited health literacy are at increased risk of illness and longer recovery periods. The research at the Quality of Life Research Centre is aimed at studying the health literacy of ethnic Hungarian mothers in Eastern Europe (Hungary, Slovakia, Romania) as well as at assessing its socioeconomic and demographic antecedents. The sample size is 894 mothers. Our standardized online questionnaire includes the HLS-EU-16 and the BHLS questions, with the latter intended to screen for inadequate health literacy. Predictors of health literacy in mothers are socioeconomic status, age and partnership status. A key finding is the improvement of health literacy with age. Assessing the association of partnership status and health literacy is a novelty in this region. Our analysis reinforces the role of socioeconomic capital, widely recognized to be associated with health literacy in general and with parental health literacy in particular. Results indicate the necessity of improving caregiver health literacy with a range of health promotional activities in Eastern Europe, especially among mothers with low socioeconomic status. The hardships of young mothers and single mothers should also be considered in this respect.

Association Between Mass Media Use and Maternal Healthcare Service Utilisation in Malawi

Introduction

Using data from Malawi Demographic and Health Survey (2015–16), in the present study, we aimed to assess the role of exposure to family planning information through various mass media on the utilization of maternal healthcare services.

Methods

The sample population included 13,217 women aged 15–49 years with a history of at least one childbirth. Outcome measures included essential maternal healthcare services such as early and adequate use of antenatal care, skilled delivery service. Multivariate logistic regression models were used to find the association between maternal healthcare services and exposure to family planning messages by controlling for sociodemographic characteristics.

Results

Women who reported receiving family planning message through internet [odds ratio=1.48, 95% CI=1.15, 1.91], radio [odds ratio=1.15, 95% CI=1.05, 1.26], TV [odds ratio=1.53, 95% CI=1.32, 1.76] and mobile phone [odds ratio=1.23, 95% CI=1.02, 1.48] had higher odds of having timely ANC care. For using adequate number of ANC, the associations were significant for TV [odds ratio=1.41, 1.23, 1.62] and mobile phone [odds ratio=1.20, 95% CI=1.01, 1.43] only. For the use of facility delivery, a strong association was observed for poster [odds ratio=1.43, 95% CI=1.12, 1.82] and TV [odds ratio=2.99, 95% CI=1.78, 5.03]. The odds of using all three services varied noticeably between urban and rural areas, eg, receiving family planning messages through internet increased the odds of antenatal care and facility delivery services in the urban areas only, whereas that from poster was associated only for facility delivery and only in the rural areas.

Conclusion

The findings indicate a positive association on media communication regarding family planning on the uptake of maternal healthcare services.

Distributive health literacy and medication management: A longitudinal qualitative study with Bhutanese former refugees in Tasmania

ISSUE ADDRESSED

Tasmania, Australia is home to a population of Bhutanese former refugees who have resettled since 2007. Their refugee journey and disrupted education opportunities have resulted in gaps in literacy in their primary language (Nepali), and many suffer one or more chronic conditions (ongoing communicable or noncommunicable diseases (NCDs)). This research explored how this community perceives chronic conditions and managed their medication using the concept of distributed health literacy.

METHODS

A longitudinal qualitative method was used whereby 15 former refugees and their carers were interviewed 3-4 times over 9 months. Data were thematically analysed using a hybrid approach of inductive and deductive coding and theme development.

RESULTS

Four themes related to distributed health literacy were identified. These were "barriers to medication literacy and adherence," "support people as health literacy mediators," "understandings of chronic disease" and "strengthening distributed health literacy." Participants described managing relatively low levels of knowledge about their chronic conditions and medications by appointing support people who acted as health literacy mediators. This resulted in interactions with health professionals, information gathering and medication use being enacted collectively between family members. Carers felt responsible for supporting others who were new to the Australian health system to learn new skills in addition to assisting with tasks such as informal interpreting. SO WHAT?: Interventions to improve the health literacy of former refugees should focus on collective critical health literacy action rather than just the functional health literacy of individuals. Health literacy mediators are a vital form of support for former refugees managing chronic conditions, so must be included in education and support programs.

Measles vaccine coverage among children born to Somali immigrants in Norway

Background

Despite overall good vaccination coverage in many countries, vaccine hesitancy has hindered full coverage and exposed groups to the risk of outbreaks. Somali immigrant groups have been known to have low measles vaccination coverage, leading to outbreaks in their communities. Current research indicates a general lack of trust in the healthcare system, the use of alternative information sources and inadequate health literacy can be contributing factors. We explore measles vaccine coverage in children born to Somali parents in Norway, whether it has changed over time and factors that may influence coverage.

Methods

Data was extracted from the National Population Register on all children born in Norway from 2000 to 2016, where both parents originated from Somalia. Date of birth, gender, residential area at birth and date of immigration and emigration for both parents was linked to information on measles vaccination from the National Immunisation Register.

Results

We found that children born to Somali immigrants in Norway had suboptimal measles vaccine coverage at 2 years; for children born in 2016 the coverage was 85%. Coverage declined between 2000 and 2016, and at a greater rate for boys than girls. Children born to mothers residing in Norway for 6 years or more had lower coverage compared to those with mothers residing less than 2 years prior to their birth. Children born in the capital and surrounding county had significantly lower coverage than children born elsewhere in Norway.

Discussion

New targeted interventions are needed to improve measles vaccine coverage among Somali immigrants in Norway. Some possible strategies include using Somali social media platforms, improving communication with Somali parents and tighter cooperation between various countries’ vaccination programmes.

A qualitative study on the experiences of southern European immigrant parents navigating the Norwegian healthcare system

BACKGROUND

Patients' experiences with health providers and their diagnostic and treatment expectations are shaped by cultural health beliefs and previous experiences with healthcare services in home country. This study explores how Southern European immigrant parents navigate the Norwegian healthcare system, through its focus on how this group manage their expectations on diagnosis and treatment practices when these are unmet.

METHODS

The study had a qualitative research design. Fourteen in-depth interviews and two focus group discussions with 20 Southern European immigrant parents were conducted in 2017 in three Norwegian municipalities. With the help of NVivo software, data were transcribed verbatim and coded. Following a thematic analysis approach to identify patterns in immigrants' experiences with the Norwegian healthcare services, the codes were organized into two themes.

RESULTS

The first theme includes immigrants' expectations on diagnostic tests and medical treatment. Southern European immigrants expected more diagnostic tests and pharmacological treatment than what was deemed necessary by Norwegian health providers. Experiences with unmet expectations influenced how immigrants addressed their and their children's healthcare needs. The second theme comprises immigrants' experiences of seeking healthcare in Norway (attending medical consultations in the private sector, seeking immigrant healthcare providers, and navigating the healthcare through their Norwegian social networks). This category includes also the alternative solutions immigrants undertook when they were dissatisfied with the diagnosis and treatment practices they were offered in Norway (self-medication and seeking healthcare in home countries).

CONCLUSIONS

Cultural health beliefs and previous experiences with healthcare services from home country shaped immigrants' expectations on diagnosis and treatment practices. This had great implications for their navigation through the healthcare system and interactions with health providers in the host country. The study suggests that successful inclusion of immigrants into the Norwegian healthcare system requires an acknowledgement of the cultural factors that influence access and use of healthcare services. Exploring immigrants' perspectives and experiences offers important information to understand the challenges of cross-cultural healthcare and to improve communication and equitable access.

Is health literacy of family carers associated with carer burden, quality of life, and time spent on informal care for older persons living with dementia?

INTRODUCTION

Family carers are cornerstones in the care of older people living with dementia. Family carers report extensive carer burden, reduced health-related quality of life (HRQoL), and extensive time spent on informal care (Time). Health literacy (HL) is a concept associated with people's ability to access health services, and navigate the healthcare system. This study's aim was to investigate HL among family carers, and investigate the associations between HL and carer burden, HRQoL, and Time spent on informal care.

METHOD

We designed a self-administered survey comprising validated instruments, including the Health Literacy Scale (HLS-N-Q12) to measure HL, Relative Stress Scale (RSS) to measure carer burden, the EQ-5D-5L instrument to measure HRQoL, and some modified questions from the Resource Utilization in Dementia (RUD) questionnaire to measure time spent on informal care (Time). Descriptive analysis in addition to bivariate and multiple linear regressions were undertaken. In multiple linear regression analysis, we used HL as the independent variable to predict the outcomes (carer burden, HRQoL, Time). Analyses were adjusted for the effects of explanatory independent variables: age, gender, education levels, urban residency, having worked as health personnel, caring for someone with severe/mild dementia, and being born abroad.

FINDINGS

In a non-probability sample of 188 family carers from across Norway, most of them female and over the age of 60, we found high levels of HL. In the bivariate analysis, carer burden and HRQoL (EQvalue) showed significant associations with HL. In the multiple regression analyses, HL was statistically significantly associated with carer burden (B = -0.18 CI:-0.33,-0.02 p = 0.02), HRQoL (EQvalue: B = 0.003 with 95% CI: 0.001, 0.006 p = 0.04), and Time (B = -0.03 with 95% CI: -0.06, 0.000, p = 0.046), after adjusting for the effect of independent variables.

CONCLUSION

This is one of the first studies to investigate the associations between HL and different outcomes for family carers of older people living with dementia. Additional research into the associations identified here is needed to further develop our understanding of how to support family carers in their roles. Targeted support that increases family carers' HL may have potential to enhance their ability to provide sustainable care over time.

Psychometric Assessment of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) for Arabic/French-Speaking Migrants in Southern Europe

Improving health literacy (HL) is critical for addressing health inequalities. Low literacy rates are believed to be more prevalent in ethnic minorities, which may have an impact on people's health. For measures to be implemented in this regard, HL must be evaluated to obtain specific indicators. Our aim, therefore, was to develop a version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16), which is recommended to be used with vulnerable populations, suited to Arabic/French-speaking migrants who reside in south-eastern Spain, and to explore its psychometric properties for assessing health literacy in this population. A cross-sectional survey was carried out in a convenient sample of 205 migrants. The structural validity was calculated by a confirmatory factorial analysis (CFA), which suggested appropriate adjustment indicators, and which indicated that the three-dimensional model is adequately adjusted to the data obtained in the study. The coefficient omega showed high internal consistency in the three HL dimensions (health care, disease prevention, and health promotion). Concurrent validity presented a significant correlation with the Newest Vital Sign test (r = 0.390; p < 0.001). The multigroup CFA showed that the heterogeneity of the sample used was not a problem for establishing the structural validity of the scale. The Arabic/French version showed good construct validity.

A system analysis of the mental health services in Norway and its availability to women with female genital mutilation

BACKGROUND

This article explores mental health services in Norway and their availability for women subjected to female genital mutilation/cutting (FGM/C). The article focus on the system of communication and referrals from the perspective of health workers, and aims to identify bottlenecks in the system, what and where they are to be found, and analyze how different mental health services deal with Sub Saharan African (SSA) women in general, but in particular with respect to FGM/C.

METHOD

The study was conducted in Oslo, Norway, using a qualitative fieldwork research design, with the use of purposeful sampling, and a semi-structural guideline. One hundred interviews were done with general practitioners (GPs), gynecologists, psychologists, psychiatrists, midwives and nurses.

ANALYSIS

A system analysis is applied using socio-cybernetics as a tool to identify the flow of communication and referrals of patients.

FINDINGS

The study shows that borders of subsystems, silencing mechanisms, regulations and "attitudes" of the system can lead to women with SSA background having difficulty getting access to the specialist services. High standards for referral letters, waiting lists, out pushing to the lower levels, insecurities around treatment and deference rules silencing mental health issues during consultancies, have a negative impact on the accessibility of services. Consequences are that mental health problems due to FGM/C are under-investigated, under-referred, and under-treated and a silenced problem within the mental health services for women.

CONCLUSION

A better integration of subsystems at the specialist level with the GP scheme is necessary, as well as providing competence on FGM/C to the different levels. It is also important to strengthen and integrating the services at the Municipal level and provide information to SSA women about the low threshold services.

Simple contents and good readability: Improving health literacy for LEP populations

Accessing and receiving quality healthcare in an unfamiliar health system is a significant challenge for many new immigrants and refugees. This study aims to provide a three-phase model to develop a web-based health information website that helps populations with limited English proficiency (LEP) increase health literacy and improve healthcare service access.

METHOD

First, we conducted a needs assessment from community leaders and service providers. Second, we developed contents from credible sources and tested each item using multiple readability tests. Last, we revised each item to lower the readability and retest its readability.

RESULTS

The average reading level for the original 99 topics was assessed at 10.84 (SD= 3.26). After revisions, we were able to lower the readability to 8.56 (SD= 2.96), which was around two grade levels lower, on average.

CONCLUSION

the main purpose for building an English based health information website was to assist the population with LEP. By using simple English with lower readability, it will ease the translation process. This study demonstrates a process to develop suitable contents for populations in need. In the future, incorporating visual aid and other multimedia will be beneficial in user engagement and knowledge retention.

Experiences and needs concerning health related information for newly arrived refugees in Sweden

BACKGROUND

Owing to communication challenges and a lack of knowledge about the health care system, refugees may be at risk of having limited health literacy, meaning that they will have problems in achieving, understanding, appraising and using health information or navigating in the health care system. The aim of this study was to explore experiences and needs concerning health related information for newly arrived refugees in Sweden.

METHODS

A qualitative design with a focus group methodology was used. The qualitative content analysis was based on seven focus group discussions, including 28 Arabic and Somali speaking refugees.

RESULTS

Four categories emerged. 'Concrete instructions and explanations' includes appreciation of knowledge about how to act when facing health problems. 'Contextual knowledge' comprises experienced needs of information about the health care system, about specific health risks and about rights in health issues. 'A variation of sources' describes suggestions as to where and how information should be given. 'Enabling communication' includes the wish for more awareness among professionals from a language and cultural point of view.

CONCLUSION

Concrete instructions and explanations are experienced as valuable and applicable. Additional information about health issues and the health care system is needed. Information concerning health should be spread by a variety of sources. Health literate health organizations are needed to meet the health challenges of refugees, including professionals that emphasize health literacy.

Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department

In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.

Associations of socio-demographic factors with adiposity among immigrants in Norway: a secondary data analysis

BACKGROUND

Obesity is becoming an important public health challenge, especially among immigrants coming from low and middle income to high-income countries. In this study we examined the relationship between overweight/obesity and various socio-demographic indicators among different immigrant groups in Norway.

METHODS

We used data from the Living Conditions Survey among Immigrants 2016, conducted by Statistics Norway. Our study sample included 4194 immigrants from 12 different countries. Participants were asked about a number of topics including health, weight, height, demographic factors, length of residence and employment. We ran logistic regression analysis to determine the odds ratio (OR) of the associations between socio-demographic factors with adiposity among immigrants.

RESULTS

Approximately 53% of the sample was overweight/obese. There was a significant difference in overweight/obesity by gender, age, country of origin and marital status. Overall immigrant men were almost 52% more likely to be overweight/obese than women. Women from Somalia had the highest odds (13.1; CI: 7.4-23.1) of being overweight/obese, followed by Iraq (8.6; CI: 4.9-14.9), Pakistan (7.5; CI: 4.2-13.4), Kosovo (7.0; CI: 4.1-12.1), and Turkey (6.8; CI: 4.0-11.6) as compared to the women from Vietnam (reference). Whereas men from Turkey had the highest odds (5.2; CI: (3.2-8.3)) of being overweight/obese, followed by Poland (4.2; CI: 2.7-6.1), Bosnia (4.1; CI: (2.6-6.5) and Kosovo (3.9; CI: 2.5-6.1). The odds for obesity increased with age and odds were highest in the eldest group 45-66 years (4.3; CI: 3.2-5.8) as compared to reference group16-24 years. The odds of being overweight/obese was higher among married (1.6; CI: 1.3-1.9) and divorced/separated/widowed (1.5; CI: 1.1-2.0) as compared to singles. Education, employment status, physical activity and length of residence were not associated with the odds of being overweight/obese.

CONCLUSION

The findings of this study call attention to the importance of a greater understanding of the processes leading to obesity among certain immigrant groups in Norway. Moreover, there is a need for culturally adapted prevention strategies targeting immigrant men and women with high rates of overweight/obesity.

ehealth literacy and health literacy among immigrants and their descendants compared with women of Danish origin: a cross-sectional study using a multidimensional approach among pregnant women

OBJECTIVE

To explore ehealth literacy, ability to actively engage with healthcare providers and health system navigation among pregnant immigrant women and their descendants compared with women of Danish origin.

DESIGN AND SETTING

A cross-sectional survey at antenatal clinics in 2016, Denmark.

PARTICIPANTS

Pregnant women attending antenatal care (n=405).

OUTCOME MEASURES

The eHealth Literacy Questionnaire (eHLQ) and two domains from the Health Literacy Questionnaire (HLQ): ability to actively engage with healthcare providers and health system navigation. Range of response options for eHLQ (1-4) and HLQ (1-5). With mixed-effect linear regressions, eHLQ and HLQ among immigrants and their descendants compared with women of Danish origin were assessed.

RESULTS

The response rate was 75%. The overall trend was lower ehealth literacy and HLQ domains among immigrants and their descendants compared with women of Danish origin. For ehealth literacy, the results suggest that challenges related more to digital abilities than motivation, trust and access to technology. The mean ability to engage with digital services was 3.20 (SD 0.44) for women of Danish origin. Non-Western descendants (-0.14, 95% CI -0.31 to 0.02), non-Western (-0.20, 95% CI -0.34 to -0.06) and Western (-0.22, 95% CI -0.39 to -0.06) immigrants had lower adjusted means of this outcome. No differences in motivation to engage with digital services were found for descendants (-0.00, 95% CI -0.17 to 0.17), non-Western (0.03, 95% CI -0.11 to 0.18) or Western (-0.06, 95% CI -0.23 to 0.10) immigrants compared with the mean of the reference (2.85, SD 0.45). Lower ability to engage with healthcare providers was found for non-Western born immigrants (-0.15, CI 95% -0.30 to -0.01) compared with the mean of women with Danish origin (4.15, SD 0.47).

CONCLUSION

Generally, descendant and immigrant women had lower levels of ehealth literacy and health literacy than women of Danish origin. These differences are potentially antecedents of adverse birth outcomes and could inform structural efforts to mitigate health inequalities.

Association of Immigrant and Refugee Status With Risk Factors for Exposure to Violent Assault Among Youths and Young Adults in Canada

IMPORTANCE

Immigrant populations continue to grow across Western countries. Such populations may face vulnerabilities that contribute to the risk of experiencing violent injury. Youths are at disproportionate risk compared with other age groups, and such violence may be preventable with appropriately targeted injury prevention strategies.

OBJECTIVE

To examine the association of immigrant or refugee status and immigration-related factors with the experience of assault.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health and administrative databases in Ontario, Canada, where health services are funded through a universal, single-payer health insurance plan. All youths and young adults aged 10 to 24 years (hereafter referred to as youths) residing in Ontario from January 1, 2008, to December 31, 2016, were eligible to participate. Data were analyzed from April 13, 2017, to January 6, 2020.

EXPOSURES

The main exposure was immigrant status. Secondary exposures were immigration-related factors, including visa class, time since immigration, and region and country of origin.

MAIN OUTCOMES AND MEASURES

The main outcome consisted of violent injuries requiring acute care (emergency department visit or hospitalization) or causing death. Poisson regression models were used to estimate rate ratios for injuries.

RESULTS

A total of 22 969 443 person-years were included in the analysis (51.3% male and 48.7% female participants). Compared with nonimmigrants, a greater proportion of immigrants lived in the lowest neighborhood income quintile (30.5% vs 18.2%) and urban areas (98.9% vs 87.7%). Among immigrants, 17.9% were refugees. Rates of violent injuries experienced were 549.0 (95% CI, 545.7-552.2) per 100 000 person-years in nonimmigrant youth, 225.0 (95% CI, 219.4-230.7) per 100 000 person-years in nonrefugee immigrant youth, and 525.4 (95% CI, 507.2-544.1) per 100 000 person-years in refugee immigrant youth. The rates of violent injury among nonrefugee and refugee immigrants were lower than among nonimmigrants (nonrefugee adjusted rate ratio [aRR], 0.41 [95% CI, 0.38-0.43]; refugee aRR, 0.82 [95% CI, 0.76-0.89]). Older age (oldest vs youngest aRR, 6.90 [95% CI, 6.53-7.29]), male sex (aRR, 2.60 [95% CI, 2.52-2.68]), and low neighborhood income (aRR, 2.42 [95% CI, 2.32-2.53]) were associated with violent injury risk. Rates of experiencing assault were lowest among South Asian (aRR, 0.33 [95% CI, 0.30-0.37]) and East Asian (aRR, 0.23 [95% CI, 0.19-0.26]) immigrants. Only Somali immigrants experienced higher assault rates (712.0 [95% CI, 639.3-805.3] per 100 000 person-years) compared with nonimmigrants. Most injuries (79.9%) were from being struck, followed by being cut (5.9%).

CONCLUSIONS AND RELEVANCE

The low rates of assault experienced by immigrants, including refugees, compared with nonimmigrants suggests that Canadian immigrant settlement supports and cultural factors may be protective against the risk of experiencing assault.

Somali women's experiences of antenatal care: A qualitative interview study

OBJECTIVE

To explore Somali women's experiences of antenatal care in Norway.

DESIGN

A qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone.

SETTING

Norway.

PARTICIPANTS

Eight Somali-born women living in Norway.

KEY FINDINGS

Four themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women.