Susan C. Dollar, PhD, LCSW
School of Social Work, Missouri State University, 901 S. National Ave., Springfield MO. 65897, United States.
Corresponding Author Details: Susan C. Dollar, School of Social Work, Missouri State University, 901 S. National Ave., Springfield MO. 65897, United States. E-mail: susandollar@missouristate.edu
Received date: 22nd November, 2019
Accepted date: 13th December, 2019
Published date: 16th December, 2019
Citation: Dollar, S.C. (2019). Promoting Health Literacy in Fijian Healthcare and Community Settings. J Pub Health Issue Pract 3: 153.
Copyright: ©2019, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Health literacy (HL) is the key to communicating important medical and health information in “plain language”. Plain language is a term meaning language that can be easily read and understood, generally considered at the 8th grade level.
In this review we will define health literacy in terms of fundamental, cultural, and scientific health literacy. A second objective of the paper is to identify and discuss health conditions among the Fijian population. A focus on chronic disease prevention is selected as this population faces high rates of for diabetes, heart disease, HIV/STDs and other chronic diseases. Third, we will discuss the best forms of communication to adequately address disease prevention and health promotion among this at-risk population. Fourth, we will present effective and culturally appropriate interventions to improve health literacy skills for primary health providers, and their patients.
Key Words: Health Literacy, Population Health, Chronic Disease, Fijian Population, Cultural Competence, Health Education, Health Comunication
Health literacy (HL) is the key to communicating important medical and health information in “plain language”. Plain language is a term meaning language that can easily be read and understood, generally considered at the 8th grade level [1]. Health literacy can be defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” [2]. Improving HL seems likely to improve ability to self-manage health care and perhaps prevent hospitalizations [3].
People with low health literacy are less likely to take medications, adhere to directions, and do not fully understand how to interpret medical labels or health messages [3-6]. A lack of health literacy results in fewer preventative measures, more frequent emergency room visits, higher rates of hospital admissions, and poorer overall health [7]. Lower levels of HL also translate into higher healthcare costs with higher usage of health services [8].
There are different types of health literacy, including fundamental, scientific, and cultural. Each is defined below and each is important to effective public health and patient education [2]. Fundamental health literacy has to do with a person’s basic skills of reading, writing, speaking, and understanding how to gain access to health information and services [2]. Having these skills can greatly affect a patient’s ability to meet their daily needs, by asking questions, understanding instructions, and following medical instructions.
Scientific literacy refers to skills and abilities to understand and use science and technology, as well as understanding the process of science [9]. Understanding medical science includes knowing basic physical and biological principles, and the ability to comprehend common technical terms and numbers, such as those found on a nutrition label or a prescription.
Cultural literacy refers to “the abilities to recognize and use collective beliefs, customs, worldview, and social identity in order to interpret and act on health information.” [9]. This domain places great emphasis on communication in the patient’s primary language, including sign language. Cultural literacy also takes into account nonverbal meanings, attention to cultural norms regarding space and time, and non-traditional medical practices.
Each type of health literacy is important to consider when devising strategies for communication between the medical provider and patient. The next section will describe the patient population.
The Republic of Fiji is a country and archipelago and has the largest population of all the South Pacific island countries [11]. Fiji has an estimated 2018 population of 928, 276 [10] Only one-third of Fiji’s 332 islands are populated, with the majority living on Vanua Levu and Viti Levu, with over half living in urban areas. Suva, the country’s capital is the largest city with a population of 178,000 in 2018 [10].
Fiji became an independent from the United Kingdom in October 1970. The country is governed by a parliamentary republic and the legal system is based upon English model. It is important to note that in the 1980s, Indians outnumbered Melanesian Fijians in government and held the power base until in 1987, when military coups ushered in a new government constitution which favored native Fijians. The coup lead to widespread Indian emigration, changed the power structure, and eventually shifted the population majority to Melanesian Fijians [11]. A revision of the constitution in 1997 resulted in peaceful elections until 2006 when another military coup shook the government. Legislative elections in 2014 and 2018 were deemed “credible” by international observers [10].
The indigenous Fijians, who make up 51 percent of the population, are from Melanesian Polynesian heritage. Other groups include Asian Indians (44 percent), whose families were brought to the islands by the British in the 19th century to labor on sugar plantations. The minority groups are comprised of Europeans, Chinese, and other Pacific Islanders (5 percent) (11, para 3). The total population is relatively young, with a median age of 29 years of age and only 7% over the age of 60 (2018 estimate) [10].
In the Republic of Fiji, the economy is relatively strong compared with other South Pacific island countries. In 2017, the unemployment rate was at 4.5% (2017 estimate) [10]. It’s reported that most work is in the tourism industry (41%), and in agricultural jobs (44.2%), such as sugar processing, copra, ginger, tropical fruits, vegetables, and meat and fish beef, pork, products, and in clothing or other industries (14.3%) [10]. Despite the low unemployment rate, many are considered “working poor, with 31% living below the poverty line (2009 estimate) [10].
One very positive population feature is the high literacy rate among Fijians. According to the latest statistics, 91.6% of residents can read, perhaps in part because schooling is free and provided by both public and faith-based schools [11]. English and Fijian are the official languages, with Hindustani also spoken among Asian Indians [10]. This high literacy rate among Fijians, and the fact that English is spoken by most, improves access to online instruction and educational websites, to bilingual health materials, and to direct communication in English formats.
Fijians are living longer due to improved health care, with life expectancy standing at 68 years for males and 72 years for females [12]. The median age in Fiji is 29.2 in 2018, which indicates a young population [10]. Nevertheless, there are danger signs for all age groups concerning chronic illness.
Chronic diseases are the major cause of death and disability worldwide, and this statistic is also repeated among the Fijian population. Recent statistics indicate that chronic diseases accounted for 74% of all deaths in Fiji in 2002 (3,900 related to chronic disease compared to total death of 5,300). The major diseases include diabetes, heart disease, high blood pressure, respiratory diseases and cancers [13]. Fiji has the second highest mortality rate in the world from asthma [14]. These chronic diseases have now replaced infectious and parasitic diseases as the principal cause of mortality and morbidity. Sexually Transmitted Infections (HIV, AIDS, and STDS) are increasing, with transmission in their teens [12].
Obesity, or excessive body fat, is a major cause for chronic disease. In Fiji in 2016, the Adult Obesity prevalence rate was at 30.2%, ranked 24th out of 192 countries being recorded by health officials [10]. What’s more, the prevalence of overweight individuals in Fiji is expected to increase in both men and women [15]. Obesity is on the increase among children in the Pacific as well, according to one UNICEF study. Nearly two out of three children living in the Pacific are identified at-risk for poor diets “lacking in nutritious foods and putting them at-risk of poor brain development, weak learning outcomes, low immunity, increased infections and, in many cases, death” [16]. What accounts for this increase in poor health indicators is the consumption of ultra-processed foods and increased fast food and highly sweetened beverages [16]. Consequences of excess weight including “Type II Diabetes, cardiovascular problems, orthopedic and sleep problems, depression, decreased self-esteem, social exclusion, stigmatization and teasing” [17].According to the World Health Organization (WHO), there are 38 million deaths yearly due to heart and lung disease, cancers and diabetes. It is estimated that almost half of these, 16 million, are premature (under the age of 70), and could be mitigated through healthy diet, regular physical activity and avoidance of tobacco products [18]. Health literacy plays a role in addressing risk factors for disease by empowering patients to manage their disease, and through designing plain language and multiple means for communicating health message. The interventions should be holistic in nature, and range from individual, to community and public legislative initiatives to promote systemic change in primary care practices and government public health funding efforts [19].
The World Health Organization [19], explains that education can lead to positive attitudes about health, access to preventive services, involvement in peer groups, further leading to higher self-esteem and self-efficacy. Coincidentally, comprehensive chronic disease management programs have been shown to improve care for patients with illness [19]. These programs emphasize plain language principles, identifying HL gaps through patient screening, and educating patients in multiple ways to improve understanding and compliance with medical instructions [19]. Several of these methods are discussed in the next section.
Health providers should practice cultural and linguistic competencies when working with those from different cultures from their own. It is well-established that recognizing the cultural beliefs, values, attitudes, traditions, and language preferences will lead to positive health outcomes [20]. The influences of cultural traditions and beliefs affect patients’ perception of illness, willingness or level of participation in treatment, perceptions of time, and communication styles with health care professionals [21].
One tool for gauging the provider’s cultural readiness and understanding is the Self-Assessment Checklist for Personnel Providing Primary Health Care Services [22]. This is a selfadministered 37 item checklist uses a 3-point Likert Scale to rate the respondent’s awareness and knowledge along three dimensions: Physical Environment, Materials, and Services; Communication Style, and Values and Attitudes.
It is important that medical materials and resources be at an appropriate reading level and in a language, patients understand [4]. There are numerous standardized screening tests for use by providers to assess reading level and comprehension. Two culturally appropriate tools are the Newest Vital Sign (NVS) and the Rapid Estimate of Adult Literacy in Medicine (REALM). NVS a nutrition label used to test a patient’s understanding of information [23]. The REALM test is a short and effective screening test for a person’s reading level of basic medical information [24]. Both are effective ways for determining the types of instruction and reading levels of information to provide patients.
When speaking directly to an individual or family, it is important to speak slowly, using everyday language and avoiding medical jargon and acronyms. Using graphics, drawings, telling stories, or providing a “hands on” demonstration are effective means for communicating medical instructions. When possible, pamphlets and newsletter should generally be presented at the eighth-grade reading level. When presenting information to a broader audience, it is important that native speakers be involved in scripting information in the production [25]. Videos, local talk shows and radio productions can be useful in community settings, such as a clinic while the patient is waiting for care.
The Internet, via mobile phones and tablets, can be a reliable source of information for those with moderate literacy levels, particularly younger audiences [26]. With nearly half the Fijian population (46.5% or 425,680 residents) connected to the Internet [10], it is critical to utilize the Internet for web-based telehealth, screenings, and patient education [27]. Additionally, there are numerous online sites that offer multilingual translations, such as WebMD, which translate information to Hindu, English, and Indonesian languages, among others. This site offers information about medical symptoms, explains certain types of medications, and provides resources for care [28].
Based upon the discussion of chronic conditions in Fiji, educational topics should include: diabetes & insulin therapy, monitoring highblood pressure, cholesterol management, diet and exercise, HIV/ AIDS/STD prevention, medication management, substance abuse and addiction, and mental health conditions, such as depression or anxiety [13].
Studies have shown that “language concordance between patients and providers results in better health care quality and outcomes” [29]. Speaking the native language would not only improve patient literacy but also improve trust in the patient-provider relationship. When this is not possible, professionally trained medical interpreters and translators, should be used to relate health and medical information. Keep in mind that not all languages have words for something that exists in other language or culture, and some ideas are difficult to translate or explain in another language [30]. Asking bilingual family, friends or volunteers to interpret is not advised, as this can result in misinformation and traumatizing those who may be affected by the medical news.
Communication skills are central to establishing and maintaining trust and rapport, particularly in Asian American, Native Hawaiian, and Pacific Islander communities (AANHOI) [27]. Respect should be paid to “communication rules” since “as part of a cultural group, people learn communication rules, as who communicates with whom, when and where something may be communicated, and what to communicate about” [30]. In particular, providers should be mindful of family rules, by asking who makes the decisions in the family, and include the primary decision-maker in health decisions [31].
Holistic cultures, such as Pacific Islanders, use “low-context” communication, which is nonverbal and indirect, particularly with authority figures, such as health providers [32]. As a rule, verbalization may be less important than the nonverbal cues provided. For example, a shrug, which is a common nonverbal cue in the Fijian and Maori cultures, means “I don’t know” (not to be confused with “I don’t care”). Eye contact while talking with others may seem confrontation to holistic cultures. Fijians, Tongans, Samoans, show respect by physically lowering themselves to the “superior”, so they will sit down as quickly as possible, or squat or bend down as a sign of respect. This is not the Western norm, since we usually rise when someone of importance enters the room [32]. Silence has meaning as either a show of interest in the message or as agreement. Agreement should never be assumed by health providers, and may just mean they wish to talk it over with others before deciding what to do. It’s always important to seek understanding from native colleagues regarding cultural norms. Provider’s should confirm understanding using the “teach back” method, to help ensure the message is understood, rather than rely on a nod or smile to indicate understanding. The “teach back” method is simply conveying the information, the asking the patient to explain what was said. If the person does not understand, then other approaches should be made to communicate the message [31].
Studies have shown that “language concordance between patients and providers results in better health care quality and outcomes” [29]. Speaking the native language would not only improve patient literacy but also improve trust in the patient provider relationship. When this is not possible, professionally trained medical interpreters and translators, should be used to relate health and medical information. Keep in mind that not all languages have words for something that exists in other language or culture, and some ideas are difficult to translate or explain in another language [30]. Asking bilingual family, friends or volunteers to interpret is not advised, as this can result in misinformation and traumatizing those who may be affected by the medical news.
Another method to increase trust and effective communication is to hire bicultural, multilingual staff who are familiar in the community [27]. Trained paraprofessional health workers and peer support volunteers can serve to expand services outside of standard working hours and assist in basic self-care screenings, such as taking blood pressure, diabetes care, nutritional guidance, home safety inspections, and wellness checks [27]. Training patients to self-manage their chronic disease has proven to as improve health outcomes and place fewer demands on the health care system [33].
Partnering with local organizations to integrate health information into community events has long been an effective health outreach method [27]. It is important to establish an advisory group who is familiar with the local community, the languages, and cultures in order to identify the places people go for important information [30]. The physical location for educational outreach will affect the meaning and importance of the message. Ideally, health education should be done early in the lifespan by teaching youth in the school system. Another effective venue for nutrition and lifestyle education would be the Hindu public holiday of Diwali, a traditionally Indian festival of lights. The Diwali activities are now celebrated by those who speak English, Hindu and Fijian languages, and is multiracial, multilinguistic and multicultural holiday [34].
Interagency cooperation should go beyond community planning to one which serves to improve plain language in the workplace. Specifically, the advisory group should advocate for adoption of plain language in patient administrative forms, medical instructions, medication labels, as well as other media that is used for employee and patient educational purposes [35].
Health literacy methods and plain language are central to health care communication [36]. Improving fundamental health literacy can improve patient’s understanding of the disease process, and influence compliance with medical instructions, and other health decisions and behaviors. Making available plain language resources in a format that is both culturally and practically accessible will further advance health education, appropriate referral to specialist care, and serve to reduce preventable health behaviors that lead to chronic illness.
This review did not have financial support and did not study human participants or animals.
The author declares no conflict of interest
U.S. General Services Administration (2017) Write for your audience.
Institute of Medicine (IOM) (2004) Health literacy: a prescription to end confusion.View
Kutner, M., Greenburg, E., Jin, Y., & Paulson, C. (2006). The health literacy of American’s adults: Results from the 2003 national assessment of adult literacy.View
Doak, C.C,, Doak, L.G., & Root, J.H. (1995). Teaching patients with low literacy skills. New York, NY: LWW.View
Wolf, JL, Gazmararian, J.A., & Baker, D.W. (2005). Health literacy and functional health status among older adults.View
Matthews, L., Shine, A., Curie, L., Chan, C., Kaufmann, et al. (2012). A nurse’s eye-view on health literacy in older adults.View
Young, D., Weinder, C., & Spring, A. (2012). Home on the range- Health literacy, rural elderly, well-being.View
Schwartzberg, J.G., VanGeest, J.B., & Wang, C.C. (2005). Understanding health literacy; implications for medicine and public health.View
Zarcadoolas, C., Pleasant, A., & Greer, D.S. (2006). Advancing health literacy: A framework for understanding and action.View
Central Intelligence Agency (CIA) (2019) The World Fact Book: Fiji.View
Wynn, F (2019) Fiji.
Burnet Institute. (2019). Fiji Health Challenges.
World Health Organization (WHO) (2002) Facing the Facts: The Impact of Chronic Disease in Fiji.View
Creaton, A., & Holt, J. (2017). Health promotion in Fiji: Is it feasible in the emergency department?View
World Health Organization (2008) Primary health care: Fiji’s broken dream.View
United Nations Children’s Fund (UNICEF) (2019) Poor diets damaging children’s health in the Pacific, warns UNICEF.View
Peterson, S., Moodie, M., Mavoa, H., Waqa, G., Groundar, R., et al. (2014). Relationship between overweight and health related quality-of-life in secondary school children in Fiji: results from a cross-sectional population-based study.View
World Health Organization (2019) Chronic disease and health promotion.
World Health Organization (2016) The determinants of health.View
U.S. Dept. of Health and Human Services (2001) Quick Guide to Health Literacy.View
Laverac., G. (2013). Building capable communities: experiences in a rural Fijian context. Health Promotional Int 18: 99-106.View
Goode, T.D. (2009), Promoting Cultural Competence and Cultural Diversity for Personnel Providing Services and Supports to Children with Special Health Care Needs and their Families, June 1989.
Weiss, B., Mays, M., Martz, W., Castro, K., DeWalt, D., et al. (2005). Quick assessment of literacy in primary care: The Newest Vital Sign.View
Bass, P., Wilson, J., & Griffith, C. (2003). A shortened instrument for literacy screening.View
Greenburg, L. (2015). MHPA Center for Best Practices Treatment Adherence Best Practices Compendium.View
Sheridan, S., Halpern, D., Viera, A., Berkman, N., Donahue, K., et al. (2011). Interventions for individuals with Low Health Literacy: A Systematic Review, Journal of Health Communication.View
Substance abuse Services and Mental Health Services Organizations (SAMSHA) (2014) Strategies-for-Behavioral- Health-Organizations-to-Promote-New-Health-Insurance- Opportunities-in-Asian-American-Native-Hawaiian-and- Pacific-Islander-Communities.View
WebMD (2019) Living Healthy.
Diamond, L.C., Luft, H.S., Chung, S., & Jacobs, E.A. (2012). “Does this doctor speak my language?”. Improving the characterization of physician non-English language skills.View
Centers for Disease Control and Prevention (CDC) (2019). Tools for Cross-Cultural Communication and Language Access Can Help Organizations Address Health Literacy.
Osborne, Helen. (2019, March). Practical tips: Communicating with People from Other Cultures and Languages.
Singh, N., McKay, J., & Singh, A. (1998). Culture and Mental Health: Nonverbal Communication. J Child & Family Stud 7: 403-409.
Heneghan, C., Ward, A., Perera, R., Bankhead, C., Fuller, A., et al. (2006). Self-monitoring of oral anticoagulation: a systematic review and meta-analysis.View
Society for the confluence of festival of India (SCFI) (2019) Diwali, the festival of lights.View
Baur, C. (2016). National action plan to improve health literacy.View
Wynia, M.K., & Osborn, C.Y. (2010). Health literacy and communication quality in health care organizations.View