Health Literacy Driving Health Engagement in the Pluralist Context of Migrant Health in Australia By Rhonda M. Garad MPH, GDipHSc(HealthProm), GradDipMgt, GCertHE, RN Div. 1 Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Deakin University August 2017 Acknowledgements This thesis was made possible by the generosity, encouragement and support of a large number of people who I would like to acknowledge. Firstly, I am eternally indebted to Mrs Janet Michelmore AO, Executive Director of Jean Hailes whose support was critical to this PhD. In addition, I wish to thank Ms Victoria Kalapac whose encouragement and support have been greatly appreciated. Also, I am deeply grateful to Professor Emeritus John Catford and the Governors of the Windermere Foundation for their generous support of this study. In the process of completing this study it was my great honour to spend time with the 240 members of the Somali, Chinese and Indian communities. I feel very privileged to have been welcomed into their communities and to hear of the struggles and triumphs that have shaped their lives. I am very grateful to these people who gave so altruistically of their time and whose strength of character and generosity of spirit have left an indelible impression on me. I am also grateful to the Multicultural Centre for Women’s Health which provided invaluable support to this study and in particular to the bilingual health educator Yanping Xu for her vital assistance. Also, my thanks to Muna Hassan, Sulaka Ali, SamSam Ali, Wudad Salim and Mariam Issa who were instrumental in accessing the Somali community. I am forever indebted to my three supervisors: Professor Richard Osborne, Dr Sarity Dodson and Associate Professor Liz Hoban. I am profoundly indebted to Professor Richard Osborne for his unswerving support of this PhD. Richard’s pursuit of intellectual excellence and his devotion to advancing the field of health literacy (HL) has had an inspirational effect on me. In addition, I wish to thank Dr Sarity Dodson for her unstinting support, critical insights and intellectual rigour that were essential to this study. And my sincere appreciation to Dr Liz Hoban, who stepped in at a critical time, for her generous support, her intellectual inspiration and insightful supervision and support. I also wish to thank my long-suffering family for their unceasing support. To my partner Ilyas whose migration journey first piqued my interest in the field of migration health. My observations over a period of 25 years of his Somali community have helped me understand the often-relentless hardships a refugee community faces post-migration and the complexities of living on the boundaries of two disparate worlds. It has also been my privilege to witness the extraordinary resilience and adaptability of this community that has served to shine a light on my own privilege. It is that privilege that I have leveraged to produce this study which I hope will make a difference to migrant communities. And, last but not least, to my four beautiful children (Koshan, Mileka, Suraya and Aisha) who have been in lock-step with me in this PhD journey. 4 Dedication In loving memory of Mandy Parish. For Ilyas, Koshan, Mileka, Suraya and Aisha. 5 Glossary of Terms Acculturation is “the process of cultural change and adaptation that occurs when individuals from different cultures come into contact” (Gibson, 2001, p. 19). Body mass index (BMI) is body weight in kilograms, divided by the square of height in meters (AIHW, 2016). Culturally and linguistically diverse (CaLD) is a broad and inclusive descriptor for communities with diverse language, ethnic background, nationality, dress, traditions, food, societal structures, art and religion characteristics (ECCV, 2012). Health literacy (HL) is “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” (Nutbeam, 1999, p. 357). Migrant is any person who is moving or has moved across an international border or within a state away from his/her habitual place of residence, regardless of (1) the person’s legal status; (2) whether the movement is voluntary or involuntary; (3) what the causes for the movement are; or (4) what the length of the stay is (IOM, 2011). Migration health addresses the state of physical, mental and social well-being of migrants and mobile populations (IOM, 2015). Migration is the movement of a person or a group of persons, either across an international border or within a state, and is conceptualised as not a single act but rather a lifelong process that can have a corrosive effect on cultural boundaries and may be marked by inequalities and serious human rights abuses (UNESCO, 2015). Receiving country is a country of destination or a third country. In the case of return or repatriation, also the country of origin. A country that has accepted to receive a certain number of refugees and migrants on a yearly basis by presidential, ministerial or parliamentary decision (IOM, 2011). Refugee is a person who, owing to a well-founded fear of persecution for reasons of race, religion, nationality, political opinions or membership of a particular social group, is outside the country of their nationality and is unable or, owing to such fear, is unwilling to avail themselves of the protection of that country (IOM, 2011). 6 Social determinants of health are factors in the social environment that impact health. Structural determinants and conditions of daily life constitute the social determinants of health and cause much of the health inequity between and within countries (Marmot et al., 2008). 7 Table of Contents Acknowledgements ........................................................................................................................ 4 Dedication ....................................................................................................................................... 5 Glossary of Terms .......................................................................................................................... 6 Table of Contents ........................................................................................................................... 8 List of Figures and Tables ........................................................................................................... 14 Thesis Abstract ............................................................................................................................ 16 Background ................................................................................................................................ 16 Aim ............................................................................................................................................ 16 Methods ..................................................................................................................................... 16 Results ....................................................................................................................................... 16 Discussion .................................................................................................................................. 17 Conclusion ................................................................................................................................. 17 Prologue ........................................................................................................................................ 19 Mariam’s story ........................................................................................................................... 19 About this study ......................................................................................................................... 20 Dissertation introduction ........................................................................................................... 21 Chapter 1: The Rise and Rise of Health Literacy ..................................................................... 22 Introduction................................................................................................................................ 22 What is health literacy? ............................................................................................................. 22 Why does health literacy matter? .............................................................................................. 22 Prevalence .................................................................................................................................. 23 An evolution of health literacy .................................................................................................. 23 HL measurement tools and their limitations .............................................................................. 29 New approaches to health literacy measurement....................................................................... 33 Generating health literacies ....................................................................................................... 35 Conclusion ................................................................................................................................. 36 Chapter 2: Migrant Health ......................................................................................................... 37 Introduction...............................................................................................................................