Promoting Health Literacy in Fijian Healthcare and Community Settings
Susan C. Dollar, PhD, LCSW
School of Social Work, Missouri State University, 901 S. National Ave., Springeld MO. 65897, United States.
Journal of Public Health Issues and Practices
Dollar SC, J Pub Health Issue Pract 2019, 3: 153
https://doi.org/10.33790/jphip1100153
Article Details
Article Type: Review Article
Received date: 22
nd
November, 2019
Accepted date: 13
th
December, 2019
Published date: 16
th
December, 2019
*
Corresponding Author: Susan C. Dollar
, School of Social Work, Missouri State University, 901 S. National Ave., Springeld
MO. 65897, United States. E-mail: [email protected]
Citation: Dollar SC (2019) Promoting Health Literacy in Fijian Healthcare and Community Settings. J Pub Health Issue Pract
3: 153. doi: https://doi.org/10.33790/jphip1100153.
Copyright: ©2019
,
This is an open-access article distributed under the terms of the Creative Commons Attribution License
4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
author
and source are
credited.
Abstract
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 dene health literacy in terms of fundamental,
cultural, and scientic 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
Introduction
Dening Health Literacy
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 dened 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,
scientic, and cultural. Each is dened 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.
Scientic 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 Fijian Population
Geopolitical Background: The Republic of Fiji is a country and
archipelago and has the largest population of all the South Pacic
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].
Sociodemographic
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
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Volume 3. 2019. 153 ISSN- 2581-7264
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].
Best Practice Interventions
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-efcacy. 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 Provider Self-Assessment
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 inuences 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 self-
administered 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.
Patient Screening: 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.
Presenting Plain Language Resources and Materials
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].
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British in the 19th century to labor on sugar plantations. The minority
groups are comprised of Europeans, Chinese, and other Pacic
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 Pacic 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 sh 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 ofcial 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.
Health Conditions
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 ofcials
[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 Pacic as well, according to
one UNICEF study. Nearly two out of three children living in the
Pacic are identied 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.
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Based upon the discussion of chronic conditions in Fiji, educational
topics should include: diabetes & insulin therapy, monitoring high-
blood 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].
Work with interpreters and translators
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 difcult 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.
Effective Communication
Communication skills are central to establishing and maintaining
trust and rapport, particularly in Asian American, Native Hawaiian,
and Pacic 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 Pacic Islanders, use “low-context”
communication, which is nonverbal and indirect, particularly
with authority gures, 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 conrm 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].
Work with interpreters and translators
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 difcult 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.
Working with Paraprofessionals
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].
Interagency Collaboration
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.
Specically, 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].
Conclusion
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 inuence
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.
Acknowledgement: This review did not have nancial support
and did not study human participants or animals.
Conict of interest: The author declares no conict of interest.
References
1. U.S. General Services Administration (2017) Write for your
audience.
2. Institute of Medicine (IOM) (2004) Health literacy: a
prescription to end confusion.
3. 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.
4. Doak, CC, Doak LG, Root JH (1995) Teaching patients with
low literacy skills. New York, NY: LWW.
5. Wolf, JL, Gazmararian JA, Baker DW (2005) Health literacy
and functional health status among older adults.
6. Matthews L, Shine A, Curie L, Chan C, Kaufmann, et al. (2012)
A nurse’s eye-view on health literacy in older adults.
7. You ng D, Weinder C, Spring A (2012) Home on the range-
Health literacy, rural elderly, well-being.
8. Schwartzberg JG, VanGeest JB, Wang CC (2005) Understanding
health literacy; implications for medicine and public health.
9. Zarcadoolas C, Pleasant A, Greer DS (2006) Advancing health
literacy: A framework for understanding and action.
Page 4 of 4
J Pub Health Issue Pract JPHIP, an open access journal
Volume 3. 2019. 153 ISSN- 2581-7264
10. Central Intelligence Agency (CIA) (2019) The World Fact
Book: Fiji.
11. Wynn, F (2019) Fiji.
12. Burnet Institute (2019) Fiji Health Challenges.
13. World Health Organization (WHO) (2002) Facing the Facts:
The Impact of Chronic Disease in Fiji.
14. Creaton A, Holt J (2017) Health promotion in Fiji: Is it feasible
in the emergency department?
15. World Health Organization (2008) Primary health care: Fiji’s
broken dream.
16. United Nations Children’s Fund (UNICEF) (2019) Poor diets
damaging children’s health in the Pacic, warns UNICEF.
17. 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.
18. World Health Organization (2019) Chronic disease and health
promotion.
19. World Health Organization (2016) The determinants of health.
20. U.S. Dept. of Health and Human Services (2001) Quick Guide
to Health Literacy.
21. Laverack G (2013) Building capable communities: experiences
in a rural Fijian context. Health Promotional Int 18: 99-106.
22. Goode TD (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.
23. Weiss B, Mays M, Martz W, Castro K, DeWalt D, et al. (2005)
Quick assessment of literacy in primary care: The Newest Vital
Sign.
24. Bass P, Wilson J, Grifth C (2003) A shortened instrument for
literacy screening.
25. Greenburg L (2015) MHPA Center for Best Practices Treatment
Adherence Best Practices Compendium.
26. 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.
27. 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-
Pacic-Islander-Communities.
28. WebMD (2019) Living Healthy.
29. Diamond LC, Luft HS, Chung S, Jacobs EA (2012) “Does this
doctor speak my language?”. Improving the characterization of
physician non-English language skills.
30. Centers for Disease Control and Prevention (CDC) (2019) Tools
for Cross-Cultural Communication and Language Access Can
Help Organizations Address Health Literacy.
31. Osborne, Helen (2019, March) Practical tips: Communicating
with People from Other Cultures and Languages.
32. Singh N, McKay J, Singh A (1998) Culture and Mental Health:
Nonverbal Communication. J Child & Family Stud 7: 403-409.
33. Heneghan C, Ward A, Perera R, Bankhead C, Fuller A, et al.
(2006) Self-monitoring of oral anticoagulation: a systematic
review and meta-analysis.
34. Society for the conuence of festival of India (SCFI) (2019)
Diwali, the festival of lights.
35. Baur C (2016) National action plan to improve health literacy.
36. Wynia MK, Osborn CY (2010) Health literacy and
communication quality in health care organizations.
