Gender-Specific Aspects of Health Literacy: Perceptions of Interactions with Migrants among Health Care Providers in Germany

Gender differences in the context of interventions for improving health literacy in migrants: a qualitative evidence synthesis

BACKGROUND

Health literacy can be defined as a person's knowledge, motivation and competence in four steps of health-related information processing - accessing, understanding, appraising and applying health-related information. Individuals with experience of migration may encounter difficulties with or barriers to these steps that may, in turn, lead to poorer health outcomes than those of the general population. Moreover, women and men have different health challenges and needs and may respond differently to interventions aimed at improving health literacy. In this review, we use 'gender' rather than 'sex' to discuss differences between men and women because gender is a broad term referring to roles, identities, behaviours and relationships associated with being male or female.

OBJECTIVES

The overall objective of this qualitative evidence synthesis (QES) was to explore and explain probable gender differences in the health literacy of migrants. The findings of this QES can provide a comprehensive understanding of the role that any gender differences can play in the development, delivery and effectiveness of interventions for improving the health literacy of female and male migrants. This qualitative evidence synthesis had the following specific objectives: - to explore whether there are any gender differences in the health literacy of migrants; - to identify factors that may underlie any gender differences in the four steps of health information processing (access, understand, appraise, and apply); - to explore and explain gender differences found - or not found - in the effectiveness of health literacy interventions assessed in the effectiveness review that is linked to this QES (Baumeister 2023); - to explain - through synthesising findings from Baumeister 2023 and this QES - to what extent gender- and migration-specific factors may play a role in the development and delivery of health literacy interventions.

SEARCH METHODS

We conducted electronic searches in MEDLINE, CINAHL, PsycINFO and Embase until May 2021. We searched trial registries and conference proceedings. We conducted extensive handsearching and contacted study authors to identify all relevant studies. There were no restrictions in our search in terms of gender, ethnicity or geography.

SELECTION CRITERIA

We included qualitative trial-sibling studies directly associated with the interventions identified in the effectiveness review that we undertook in parallel with this QES. The studies involved adults who were first-generation migrants (i.e. had a direct migration experience) and used qualitative methods for both data collection and analysis.

DATA COLLECTION AND ANALYSIS

We extracted data into a form that we developed specifically for this review. We assessed methodological limitations in the studies using the CASP (Critical Appraisal Skills Programme) Qualitative Studies) checklist. The data synthesis approach that we adopted was based on "best fit" framework synthesis. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our level of confidence in each finding. We followed PRISMA-E guidelines to report our findings regarding equity.

MAIN RESULTS

We included 27 qualitative trial-sibling studies directly associated with 24 interventions assessed in a linked effectiveness review (Baumeister 2023), which we undertook in parallel with this QES. Eleven studies included only women, one included only men and 15 included both. Most studies were conducted in the USA or Canada and primarily included people of Latino/Latina and Hispanic origin. The second most common origin was Asian (e.g. Chinese, Korean, Punjabi). Some studies lacked information about participant recruitment and consideration of ethical aspects. Reflexivity was lacking: only one study contained a reflection on the relationship between the researcher and participants and its impact on the research. None of the studies addressed our primary objective. Only three studies provided findings on gender aspects; these studies were conducted with women only. Below, we present findings from these studies, with our level of confidence in the evidence added in brackets. Accessing health information We found that 'migrant women of Korean and Afghan origin preferred access to a female doctor' (moderate confidence) for personal reasons or due to cultural norms. Our second finding was that 'Afghan migrant women considered their husbands to be gatekeepers', as women of an Afghan background stressed that, in their culture, the men were the heads of the household and the decision-makers, including in personal health matters that affected their wives (low confidence). Our third finding was 'Afghan migrant women reported limited English proficiency' (moderate confidence), which impeded their access to health information and services. Understanding health information Female migrants of Afghan background reported limited writing and reading abilities, which we termed 'Afghan migrant women reported low literacy levels' (moderate confidence). Applying health information Women of Afghan and Mexican backgrounds stated that the 'women's role in the community' (moderate confidence) prevented them from maintaining their own health and making themselves a priority; this impeded applying health information. Appraising health information We did not find any evidence related to this step in health information processing. Other findings In the full text of this QES, we report on migration-specific factors in health literacy and additional aspects related to health literacy in general, as well as how participants assessed the effectiveness of health literacy interventions in our linked effectiveness review. Moreover, we synthesised qualitative data with findings of the linked effectiveness review to report on gender- and migration-specific aspects that need to be taken into account in the development, design and delivery of health literacy interventions.

AUTHORS' CONCLUSIONS

The question of whether gender differences exist in the health literacy of migrants cannot be fully answered in this qualitative evidence synthesis. Gender-specific findings were presented in only three of the 27 included studies. These findings represented only Afghan, Mexican and Korean women's views and were probably culturally-specific. We were unable to explore male migrants' perceived health literacy due to the notable lack of research involving migrant men. Research on male migrants' perceived health literacy and their health-related challenges is needed, as well as more research on potential gender roles and differences in the context of migration. Moreover, there is a need for more research in different countries and healthcare systems to create a more comprehensive picture of health literacy in the context of migration.

Interventions for improving health literacy in migrants

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Using social marketing theory as a framework for understanding barriers and facilitators of human papillomavirus screening in women: A qualitative study

BACKGROUND

Human papillomavirus (HPV) is known as the common sexually transmitted disease and the cause of cervical cancer. The HPV test is being proposed as the primary screening tool for cervical cancer. This study aimed to identify barriers and facilitators of screening based on the social marketing model in designing interventions and planning to increase HPV screening.

MATERIALS AND METHODS

This qualitative directed content analysis was conducted between December 2020 to September 2021 to identify the key concepts of social marketing theory (i.e., the four P's: product, price, place, and promotion) in Mashhad, Iran. Semistructured interviews were fulfilled with 24 individuals (10 women with HPV and 14 key informants) after obtaining participants' consent, who were initially purposively sampled and snowball sampling was then used to facilitate further recruitment. Data analysis was carried out simultaneously with data collection.

RESULTS

Following the code extraction, four main categories (themes) and 10 subcategories extracted. Subcategories included knowledge on screening, screening benefits, and motivational factors for screening (product), individual inhibitors, environmental inhibitors, and facility problems related to price, place of service delivery, and service delivery channels (place) and health promotion and education.

DISCUSSION

Lack of knowledge about HPV and screening, negative attitudes toward sexually transmitted diseases, taboo about sexual issues in society, fear of the reaction of spouse and family members, lack of proper policies and information and communication challenges, high costs of screening, access barriers to facilities such as difficult transportation have been challenges of health systems. It is suggested that HPV screening as a standard method for detection of cervical cancer be considered and the barriers to access are removed.

The Perception of Nurses about Migrants after the COVID-19 Pandemic: Close Contact Improves the Relationship

Nurses have faced during the COVID-19 pandemic a tough professional situation in which they have had to work in a resource-limited context and with a high probability of COVID-19 transmission. In today's multicultural societies, care for immigrant patients is also included. In our study, we have delved into the perception of hospital nurses towards migrant people in the context of the COVID-19 pandemic. We used a qualitative methodology with a phenomenological approach. Semi-structured interviews were conducted with 16 nurses. Seven categories emerged and were distributed in the three blocks of the interviews: (a) perception before the pandemic: prejudices make a mark and communication problems; (b) perception after the pandemic: prejudices weaken and communication worsens; and (c) how to improve care: improve communication, more nurses, and no need for training. The approach in the interpersonal relationship between nurses and patients during the pandemic has improved health care. Proposals arise to overcome the language barrier such as the incorporation of intercultural translators-mediators and professionals of foreign origin. There is a lack of awareness of the need for training in cultural competence on the part of the nurses in the study.

Gender differences of health literacy in persons with a migration background: a systematic review and meta-analysis

OBJECTIVE

To investigate gender differences of health literacy in individuals with a migration background.

DESIGN

Systematic review and meta-analysis. OVID/MEDLINE, PsycINFO and CINAHL were searched in March 2018 and July 2020.

SETTING

Studies had to provide health literacy data for adult women and men with a migration background, collected with a standardised instrument, or report results that demonstrated the collection of such data. Health literacy data were extracted from eligible studies or requested from the respective authors. Using a random-effects model, a meta-analysis was conducted to assess standardised mean differences (SMDs) of health literacy in men and women. Two researchers independently assessed risk of bias for each included study using the Appraisal Tool for Cross-Sectional Studies.

RESULTS

Twenty-four studies were included in this systematic review. Thereof, 22 studies (8012 female and 5380 male participants) were included in the meta-analyses. In six studies, gender-specific health literacy scores were reported. The authors of additional 15 studies provided their data upon request and for one further study data were available online. Women achieved higher health literacy scores than men: SMD=0.08, 95% CI 0.002 to 0.159, p=0.04, I2=65%. Another 27 studies reported data on female participants only and could not be included due to a lack of comparable studies with male participants only. Authors of 56 other eligible studies were asked for data, but without success.

CONCLUSION

Men with a migration background-while being much less frequently examined-may have lower health literacy than women. As heterogeneity between studies was high and the difference became statistically insignificant when excluding studies with a high risk of bias, this result must be interpreted with caution. There is a paucity of research on the social and relational aspects of gender in relation to health literacy among people with a migration background, especially for men.

PROSPERO REGISTRATION NUMBER

CRD42018085555.

"The system has to be health literate, too" - perspectives among healthcare professionals on health literacy in transcultural treatment settings

BACKGROUND

Effective communication is a central aspect of organizational health literacy. Healthcare professionals are expected to ensure an effective and satisfactory flow of information and to support their patients in accessing, understanding, appraising, and applying health information. This qualitative study aimed to examine the health literacy-related challenges, needs, and applied solutions of healthcare professionals when engaging with persons with a migrant background. Based on the integrated model of health literacy (Sørensen et al., BMC Public Health 12:80, 2012), we focused on environmental, personal, and situational factors that shape health literacy in transcultural treatment settings.

METHODS

We conducted five focus group discussions with healthcare professionals (N = 31) who are in regular contact with persons with a migrant background. Discussions were transcribed verbatim and analyzed using qualitative content analysis by applying a deductive-inductive categorization procedure. Deductive categories were derived from the integrated model of health literacy.

RESULTS

Challenges included a mismatch in the provision and use of health services. Participants regarded easily accessible services and outreach counselling as helpful solutions. Further challenges were the migrant patients' distrust in healthcare professionals and the German healthcare system, the participants' uncertainty in dealing with patients' expectations and needs, and the patients' non-compliance with appointments. Environmental factors included systemic lack of time and economic pressure. Both were reported as impeding the flow of information in all treatment settings. Participants with a migrant background themselves (n = 16) regarded this personal factor as an opportunity that increased patients' trust in them. They also reported challenges such as high levels of responsibility felt when ad hoc interpreting for colleagues.

CONCLUSIONS

Known issues observed in the delivery of healthcare for the majority population (i.e., systemic lack of time, economic pressure) appear to be intensified in the context of migration. An increasingly diverse patient clientele indicates a growing need for culture-sensitive, health-literate healthcare organizations. A corresponding diversity of the health workforce is desirable and should be strengthened by national finance and educational programs. Healthcare professionals who interpret for colleagues should be given the necessary time. Further studies are needed to develop appropriate interventions for improving health literacy at individual and organizational levels. Funding for interpreting services should be expanded.

Social Literacy: Nurses' Contribution Toward the Co-Production of Self-Management

We share findings from a larger ethnographic study of two urban complex care management programs in the Western United States. The data presented stem from in-depth interviews conducted with 17 complex care management RNs and participant observations of home visits. We advance the concept of social literacy as a nursing attribute that comprises an RN's recognition and responses to the varied types of hinderances to self-management with which patients must contend in their lived environment. It is through social literacy that complex care management RNs reconceptualize and understand health literacy to be a product born out of the social circumstances in which patients live and the stratified nature of the health care systems that provide them care. Social literacy provides a broader framework for health literacy-one that is situated within the patient's social context through which complex care management RNs must navigate for self-management goals to be achieved.

Interdisciplinary Perspectives on Health Literacy Research Around the World: More Important Than Ever in a Time of COVID-19

As we write our editorial for a health literacy special issue in the midst of the international COVID-19 crisis, we take this opportunity to highlight the importance of individual, community, and population health literacy. We are not only in a "pandemic" but also an "infodemic". Health literacy is more important than ever in the face of these global health threats, which have impacted outcomes across the levels of the socio-ecological model (SEM), including individual health behaviors, family relationships, organizational behavior, state policy-making, national mortality statistics, and the international economy in the span of weeks. Our special issue sought to pull together interdisciplinary threads guided by two principles. The first was defining health literacy as essential skills and situational resources needed for people to find, understand, evaluate, communicate, and use information and services in a variety of forms across various settings throughout their life course to promote health and wellbeing. The second was the idea that enhancing health literacy in populations and systems is critical to achieving health equity. In this time of public health need across traditional borders, the inter-sectoral and international perspectives of special issue articles are more urgent than ever. A greater understanding, appreciation, and application of health literacy can support policy action on multiple levels to address major public health challenges. Health literacy should be built deliberately as a population-level resource and community asset. We have summarized the set of articles in this special issue across the levels of the SEM, hoping their thoughtful considerations and interesting findings will help to support global health and wellness and inspire future research, policy, and practice in this global public health emergency and beyond.