Health literacy of Chinese immigrants living in Australia: measurements, health consequences and opportunities for interventions

Abstract

Background: Immigrants are some of the most vulnerable groups for health disparities, which are in part associated with socio-economic disadvantage among this population. However increasing evidence indicates that low health literacy present among this population may explain many of the health disparities observed. Low health literacy is independently associated with poor healthcare utilisation and health outcomes. Health literacy issues occurring in immigrants are increasingly important to address in the Australian context as one in every five Australians are born overseas. However, understanding of health literacy and related issues in China-born immigrants is lacking. This is an important deficit as China-born Australians currently constitute 2.6% of the total Australian population and are one of the most rapidly expanding groups. Aim: The overall aim of this thesis was to explore health literacy and related issues including disease self-management, healthcare utilisation, health, and health literacy measurement among Chinese immigrants. The potential role of digital solutions for supporting health literacy and self-management in this population was also examined. Methods: The methods utilised in this thesis include scoping review, systematic review, psychometric evaluation, and observational studies. The study participants were recruited from both clinical and community settings in New South Wales, Australia, who were Chinese speakers or Chinese immigrants. Results: The majority of Chinese immigrants included in the studies in this thesis reported inadequate health literacy across all domains and the most affected health literacy domains were those related to accessing health information and healthcare services and interacting with healthcare providers. A high prevalence of emergency department (ED) visits and poor perceived health was demonstrated in Chinese immigrants with 20% of the participants having presented to the ED in the past 12 months; 57% reported fair or poor health status. Inadequate health literacy was independently associated with higher prevalence of ED visits and poorer self-perceived health in these participants. Furthermore, the study participants who were older (≥ 65 years) or had migrated at an older age, had newly migrated, were female, and who lacked university level education or English proficiency were at the highest risk of having inadequate health literacy. Disease self-management in Chinese immigrants was found to be strongly influenced by Chinese core values and beliefs, in the review of the literature. Self-management issues such as having insufficient knowledge of disease and risk factors, and poor health-seeking behaviours, were common among people of Chinese ethnicity living in western countries, and the lower health literacy provides a potential explanation. While measuring health literacy of immigrants is important it is also challenging as health literacy is a broad and complex concept. In addition to the factors that predict health literacy across diverse populations, factors unique to immigrants include age at migration, time living in host country, and language proficiency should be considered when measuring immigrants’ health literacy, adding another layer of complexity to measurement. The systematic literature review of health literacy measurement tools for Chinese speakers shows that although there are a number of tools available to measure health literacy of Chinese speakers, the psychometric properties, measured health literacy components, and underpinning health literacy framework varied between these tools. Due to various adaptation processes and lack of standardisation of these processes, the validity and reliability of tools derived or translated from English language tools could be substantially impacted. Digital solutions such as mHealth, telehealth, and eHealth interventions may offer strong potential for delivering interventions to improve health literacy and self-management, given the wide adoption of digital devices observed in Chinese immigrants in our study. For instance, mobile technology such as smartphones were used by the majority of patients attending a cardiac rehabilitation program, including Mandarin-speaking patients. This technology offers a flexible method of delivering interventions that is not fixed in location or time compared to traditional cardiac rehabilitation. Usage patterns varied between different language speaking groups, indicating a need to involve the targeted consumer groups in the design and development of digital methods. Conclusions: Given the substantial limitations in health literacy experienced by Chinese immigrants, and the implications for their health service use, health and disease selfmanagement, Chinese immigrants urgently need support in accessing health information and services and communicating with healthcare providers. Digital solutions may provide an alternative in delivery care for this ‘hard to reach’ population. Consumer involvement in design, development, and evaluation of tailored interventions is likely to be essential for intervention effectiveness.