The interconnections between health literacy and equity are explored in a special themed edition of the Health Promotion Journal of Australia, which includes a call to action that “now is the time to decolonise health literacy and let Indigenous experts guide the way to health equity”.
Earlier this week, Croakey’s @WePublicHealth Twitter account did a speed-tweeting session providing an overview of the edition, which is aimed at influencing the National Preventive Health Strategy.
Croakey hopes to cover some of these articles in more depth in coming weeks, but in the meantime below is a summary of the @WePublicHealth Twitter thread.
The introductory article, by Professor James Smith (@jamessmithNT) and Dr Kalinda Griffiths (@Klick22) and colleagues, is titled: ‘Equity and health literacy: Using emerging evidence to inform the development of the National Preventive Health Strategy’.
These authors note that ‘health literacy’ has multiple definitions that encompass individual, population and environmental health literacy – with the underlying tenet being that it is critical for health and health equity, and is a social determinant of health.
The literature on equity and health literacy is relatively diffuse, often lost across multiple sectors and with limited systematic research that provides clear, actionable processes by which health literacy can drive health equity forward, they say.
Hence, emerging evidence is often inaccessible to policymakers and poorly utilised by health practitioners in clinical settings. This special edition aims to address “the knowledge deficit around equity and health literacy”.
This special edition resulted from a partnership between the journal and the Northern Territory Primary Health Network, and five guest editors. It led to an “overwhelming” response and 21 papers accepted for publication.
“To our knowledge, this special issue is the largest collection of articles dedicated to the topic of equity and health literacy, ever published in an Australasian peer‐reviewed academic journal,” the authors say.
“We encourage Minister for Health, Expert Steering Committee, senior bureaucrats and policy staff to actively engage with the content of this special issue and purposively embed key findings into the National Preventive Health Strategy.”
Cultural safety matters
This study, ‘Aboriginal patient and interpreter perspectives on the delivery of culturally safe hospital‐based care’, sought to guage Aboriginal patient experiences of hospitalisation and test a patient experience survey. It draws on interviews with Aboriginal interpreters and sought to identify strategies to improve equity and cultural safety in health care for Aboriginal patients in Northern Australia.
The authors conclude that “systemic issues impede the delivery of culturally safe care”. They say:
Hospitalised Aboriginal people would have a more positive experience of care if they felt more respected.
This could be achieved through better training of health care providers, cultural mentoring of health care providers, a stronger Aboriginal workforce presence on the wards, and through health care providers having more time to achieve effective knowledge transfer with patients and their families, either through increased staffing or restructuring of current systems and processes.
Aboriginal patients and interpreters are well placed to lead discussions about the service redesign steps required. Measurement of Aboriginal patients’ experiences of hospitalisation should address their true priorities through open‐ended questions. Considerable scope exists for hospital staff to improve their knowledge, responses and documentation of Aboriginal patients’ languages and cultural needs.
Rather than creation of additional forms to record patient language and interpreter requirement, we advocate for more staff training in patient‐centred, culturally engaged care, and better systems to support this practice.”
Yolŋu approaches
Another study from northern Australia was titled, ‘Finding a pathway and making it strong: Learning from Yolŋu about meaningful health education in a remote Indigenous Australian context’.
The authors reported “on the process of development and implementation of a Yolŋu approach to community health education to explore the core elements, as well as the strengths and challenges, from the perspectives of both educators and community members”.
They said these included: location of control – a Yolŋu project with Balanda support; developing strong stories through working with experts to integrate Balanda and Yolŋu knowledge; and responding to Yolŋu needs in developing and sharing the stories.
The researchers said:
The greatest challenge experienced by the Yolŋu team was the short‐term funding for the project given the devastating impact of chronic conditions on their lives, their families and their community. This concern was shared by community members.
All of the Yolŋu involved in the project have experienced the trauma of losing close, often young, family members to preventable chronic conditions many times so the ending of the project was a source of great distress.
The Project Team received many requests for ongoing education within and beyond the community that they were unable to meet within their existing resources and the Project time frame, including continued promotion and distribution of video resources.”
The authors say that a key point of difference between this project and other health education work in remote Indigenous contexts relates to the location of control.
“In the context of a colonised minority population that does not share the language and cultural background of the majority, who determine policy, allocate funding and provide services, health communication is intertwined with issues of power,” the researchers wrote.
“The approach that evolved through this project resonates with the theory of critical health communication in which power and control are central considerations.”
Another study is titled: ‘“We are sacred”: An intercultural and multilingual approach to understanding reproductive health literacy for Yolŋu girls and women in remote Northern Australia’.
It involved a decolonising participatory action research approach, a senior Yolŋu researcher led interviews, group story sharing sessions, historic site visits and on‐country cultural demonstration sessions with participants on reproductive health topics.
The result: A reproductive health literacy framework that privileges Yolŋu reproductive knowledge, practices and language was successfully co‐designed.
“The framework was embedded in the metaphor of Pandanus mat and uses key cultural domains of Yolŋu identity as a connecting foundation to women’s reproductive knowledges and ceremonial milestones,” the researchers wrote.
The authors discuss decolonising health literacy:
Despite health promotion generally aspiring to the empowerment and participation of Indigenous communities in taking control over their health, it is still framed by colonial values and processes which likely perpetuate health inequities and the subjugation of Indigenous knowledge systems and languages.
It is ironic and destructive from an Indigenous perspective, that these Indigenous knowledge systems and languages, that have actually promoted health and well‐being over at least 60,000 years, are so disregarded by current approaches in the Australian health system.”
The authors conclude that if health literacy is to be transformative and address inequity for Indigenous communities, their research suggests that innovative, decolonising and human rights‐based approaches are required.
“Yet, in many ways, our health workforce is poorly equipped to operationalise health literacy in ways that honours multiple languages, knowledges and literacies; and supports the inherent rights to communicate in Indigenous first languages,” they wrote.
“Now is the time to decolonise health literacy and let Indigenous experts guide the way to health equity.”
Youth in focus
Another study, ‘Using co‐design to develop a culturally responsive reproductive health learning resource for Aboriginal and Torres Strait Islander youth’, examines some of the ethical issues around using Facebook as a “an attractive, time‐efficient and cost‐effective health promotion research tool.”
(However, it doesn’t delve into some of the bigger picture issues of Facebook being such an unethical company.)
Now we come to: ‘HealthLit4Kids: Supporting schools to be health literacy responsive organisations’.
The authors note: “While hospital, health and community settings are familiar with the concept of health literacy and the importance of monitoring their health literacy responsiveness, it is still a relatively new concept for schools.”
The study is part of a wider evaluation of a research program of HealthLit4Kids in five primary schools in Tasmania – a program designed to improve the health literacy of children and their school community.
“Education systems need to acknowledge that health and learning are intertwined. Schools can provide students with the tools to promote their health and develop health literacy as they move through the education system,” the authors write.
“While education is a social determinant, health literacy has been recognised as a social determinant in its own right. Providing children with the asset of health literacy in primary school has lifelong benefits and may redress inequities that exist locally, nationally and globally.”
The study found “that the concept of health literacy is not well known or understood in the school setting”, and the authors proposed these 10 ways forward:
Another study examined ‘Experiences of health service literacy and access amongst Australian young adults from migrant backgrounds’. It involved 25 young adults from migrant backgrounds in greater western Sydney, most of whom said health services were not “youth‐friendly”.
When choosing to access health services, most participants utilised two main sources of information: the Internet via Google and word‐of‐mouth, the researchers reported.
All participants described long waiting times as a barrier to accessing services, particularly for accessing GPs, dentists and specialist services.
“A key finding of this study is the perceived insufficient or ineffective delivery of information about health services and Medicare entitlements in secondary schooling,” the researchers reported.
While studies have explored the delivery of preventative health information, nutrition, sexual health and mental health awareness in secondary education, the researchers said there is a gap in literature that explores the delivery of health service information in educational institutions.
“Participants spoke about the need for more comprehensive health education through school‐based programs, featuring speakers sharing lived experiences or in changes to subject curricula, particularly during senior years of high school.”
Another study investigated ‘Student‐driven partnerships enhancing oral health literacy’. This brief report introduces a pedagogical model for effectual teaching of health promotion in an undergraduate oral health program.
Another study: ‘Healthier Together: Co‐design of a culturally tailored childhood obesity community prevention program for Māori & Pacific Islander children and families’.
Read: ‘A pilot study of adolescent health literacy research in Melbourne: Implementation and reflections’.
Food literacy
Another article is: ‘Can addressing food literacy across the life cycle improve the health of vulnerable populations? A case study approach’. This is about Food Bank in Western Australia, which incorporates food literacy programs into its food relief efforts:
Here is a link to Food Bank if you want to find out more about their work: https://foodbank.org.au/WA/food-assistance/?state=wa In the last decade the team delivered 5,047 food literacy sessions to over 62,000 Western Australians.
Their Healthy Food for All team has made addressing health inequity a priority, by enhancing food literacy skills of vulnerable people across the lifespan.
“Food literacy programs aim to improve an individual’s knowledge and skills in the planning, management, selection, preparation and eating of healthy foods.”
Exploring libraries
Read the study here.
The authors write: “As unique trusted community organisations, public libraries are well positioned to contribute to the health literacy movement.” But there’s been limited discussion about their potential in this space.
These five principles are proposed, as a guide for future efforts:
Focus on men and women
A study, ‘Engaging “hard‐to‐reach” men in health promotion using the OPHELIA principles: Participants’ perspectives’, involved men from northern suburbs of Launceston, Tasmania, who experience substantially poorer health outcomes and socioeconomic disadvantage than most Australians. Their issues include isolation, lack of trust in the system, medication non‐adherence, mental illness, and chronic pain.
The work involved co‐design of interventions that were valued by participants. The authors concluded: “Health literacy profiling and genuine community engagement can empower vulnerable, under‐represented communities to co‐design, and engage in, health promotion”
Reporting another study, ‘Health literacy needs in weight management of women with Polycystic Ovary Syndrome[PCOCS]’, the authors reported an “overall sense of women’s frustration and not feeling supported or understood by their health care professionals”.
They wrote:
The issues around delay or uncertainty in the diagnosis of PCOS, lack of sufficient information and poor communication between health care professionals and women with PCOS were a consistent finding in the current and past studies.
This suggests a need for more training and resources for health care professionals in assessing and managing PCOS…also highlights the need for resources to empower women with PCOS to discuss their health issues with their health care professionals.”
Another study, ‘Reducing inequities among adult female migrants at higher risk for drowning in Australia: The value of swimming and water safety programs’, presents findings from a community‐based qualitative evaluation of swimming and water safety programs delivered to 35 women from migrant backgrounds in Sydney.
Another study: ‘Barriers for menopause‐related health literacy among immigrant women from the Horn of Africa nations’.
Communication barriers
Some important messages from this study! ‘Dissonances in communication with sexual health consumers in an inner‐Sydney sexual health clinic in relation to health literacy: A mixed‐methods study’.
This study, with clients of an inner‐Sydney sexual health clinic, suggests “existing models of access for HIV treatment and PrEP in Australia have been developed for high health literacy and may not support consumers who experience communication barriers due to low health literacy”.
The authors note that the Australian Commission on Safety and Quality in Health Care – @ACSQHC – recommends addressing health literacy systemically, including embedding assessment of health literacy into organisational systems and policies.
“We recommend developing tools to assess knowledge levels of consumers accessing sexual health services and incorporating health literacy into clinician training on working with patients from non‐English-speaking backgrounds.”
In short
Read: ‘The relationship of health literacy, wellbeing and religious beliefs in neglected and unequal contexts—Results of a survey study in central Afghanistan’.
Read: ‘Development and evaluation of a health literacy training program for allied health professionals: A pre‐post study assessing impact and implementation outcomes’. The authors conclude: “Staff training is particularly important in highly diverse areas where patients are disproportionately affected by low health literacy”.
Read: ‘Health literacy, digital health literacy and the implementation of digital health technologies in cancer care: the need for a strategic approach’.
Read: ‘Supporting patients to be involved in decisions about their health and care: Development of a best practice health literacy App for Australian adults living with Chronic Kidney Disease’.
Final thoughts
Thank you for following the thread; it was a bit of a whistle stop tour but hopefully gave you an idea of the range of topics covered. What’s missing, I hear you ask?
Wouldn’t it be great to see a study published some day, presenting an evaluation of interventions to improve the health literacy of government ministers as well as their knowledge around health equity etc?
So that when the Prime Minister and Ministers decide to keep people (including children) living in poverty, they understand this is actually an attack on their health and wellbeing, contributing to illness, suffering and premature deaths.
• Croakey welcomes applications from individuals and organisations interested in guest tweeting for @WePublicHealth.
