Health literacy in selected populations: Individuals, families, and communities from the international and cultural perspective

2.1.The multiple stakeholders in health literacy

There are multiple stakeholders in health literacy, as shown in Fig. 2 [58]. Health literacy thus is influenced by the demands and complexities of health systems, as well as social systems, workplaces, the environment, and the corporate world, particularly food and drink producers and markets.

Fig. 2.

Reproduced from Health literacy. The solid facts. Copenhagen: WHO Regional Office for Europe, 2013 [58].

Health literacy is key to not only health, but to human development at a population level, and to realising human potential. This is exemplified by how health literacy is integral to the Sustainable Development Goals (SDGs), particularly goal number three: “Ensure healthy lives and promote well-being for all at all ages” and goal number four: “Ensure inclusive and equitable quality education and promote life-long learning opportunities for all” [54]. For example, improved health literacy may be achieved through efforts to advance the goal to achieve universal primary education. Similarly, improved health literacy and increased community participation in health and healthcare, in parallel with developments to improve health systems and widening access to Health Care (Universal Coverage or UC) [55], represent a key to achieve a reduction in child mortality, improve maternal health, and combat infectious diseases such as HIV/AIDS, and malaria. For additional discussion of health literacy and the SDGs see Rowlands et al. [50].

This article will examine both elements in the ‘Health Literacy Equation’ shown in Fig. 1.

3.1.Health literacy’s impact on children and adolescents

Efforts to enhance a child’s health literacy, especially functional health literacy (sufficient basic skills in reading and writing to function effectively in everyday health situations) are significantly associated with improvements in basic literacy and numeracy skills [44]. Health literacy initiatives also address (or seek to counter) enduring social determinants of health (SDH); and enable children, teens, and future adults to ‘achieve their goals, to develop their knowledge and potential, and to participate fully in their community and wider society’ [10,32].

The WHO links health literacy initiatives to improved global literacy, which is one of the organization’s international sustainable development goals [54]. The WHO adds language, literacy, and numeracy (LLN), represent a trio of desirable sustainable development goals, which in turn foster self-development [44]. Overall, the development of critical health literacy skills promotes the participation of young persons in external activities, and cultivates their abilities to extract information and derive meaning from different forms of communication, which augments cognitive adaptation [44].

The WHO also hypothesizes that building LLN skills and health literacy in childhood and adolescence effectively provides the tools teens need to make informed decisions about lifestyle and sexual health. The U.S. Centers for Disease Control and Prevention (CDC) recognizes the need to cultivate health literacy based decision making tools, and has a collection of online resources for parents, educators, and child health professionals [10].

An example of an innovative health literacy initiative is the Bigger Picture Campaign, a youth-led diabetes prevention social media campaign co-created by the University of California, San Francisco with participating area adolescents in 2013 (http://thebiggerpicture.org/). Using social media, are adolescents were encouraged to speak to peers regarding how teen lifestyle norms (such as a high ingestion of sugar) is linked to obesity and diabetes. Such health literacy training uses a preferred mode of mass communication among the intervention’s intended audience and involves teen stakeholders appropriately to self-represent the social and environmental factors that impact their health.

While there is a dearth of research about how improved literacy impacts future decision making, a measure for Media Health Literacy has been developed [32]. Also, a recent Canadian study found school children developed a better awareness of ‘hidden’, often health-damaging messages in popular advertising following media-health literacy training [1]. Moreover, the development of health literacy and ensuing literacy and decision-making skills among children and adolescents represent a ripe area for future research, especially regarding the effectiveness and impact of health literacy interventions on teen health and lifestyle decisions. Lifestyle decisions made in adolescence influence both current and future health, and there is evidence that lifestyle choices adopted in adolescence persist into later life [7,53].

3.2.The importance of developing health literacy skills in adults

Health literacy skills can also be developed in adults. The UK Skilled for Health Program, which delivered health literacy skills training to individuals and community/workplace groups, showed an increase in health knowledge (diet, exercise, smoking, and alcohol intake, and mental health). Lifestyle behaviors became healthier in the areas of diet, exercise, and mental health. In addition, participants described more confidence in interactive health literacy skills [44], particularly in discussing their health with health professionals, and also skills in navigating the, often complex, UK health system [12]. The program has since been replicated in Canada [16].

In Australia, evaluation of a community education program for adults with low basic skills, developed from the Skilled for Health program, showed improvements in participants’ health literacy skills and confidence, positive student and teacher engagement with course content and self-reported improvements in health knowledge, attitudes, and communication with healthcare professionals [41].

In summary, there is a need for research to assist in identifying which skills and knowledge are needed to more effectively engage with health and healthcare and cope better when health issues arise (e.g. navigation related skills, communication and problem solving skills) – and when and how we develop these capacities in people. In addition, a better understanding is needed as to how to support people when health issues arise, to develop the condition specific skills and knowledge needed to effectively manage their health.

3.3.The impact of developing health literacy skills in families for promoting health

In developed countries, nuclear families are usually the social context within which people live. Families tend to be small (one or two parents with or without children), and often have little social networks and support. Low parental health literacy can result in unhealthy lifestyles and poorer health. In the UK, family health literacy initiatives have shown potential benefit for participants, although evaluations have been small and no large trials have been undertaken.

In both developing and developed settings, health decisions are often not made by individuals – often decisions are made collectively, often by parents or families. Culturally there are significant differences in relation to how decisions are made, but there are equally differences within cultures. Depending on the particular issue, the family and the culture, a decision might be made by an individual (about their own health or that of another family member – for example, a husband making a decision on behalf of his wife) or individuals might come together to discuss and make collective decisions. In some recent research undertaken in Pakistan, male heads of household are usually responsible for making any health related decisions that have financial implications [49].

This complexity brings to light the question of ‘whose health literacy’ is the most important and relevant to actions? In the case of Pakistan, there might be a very health literate wife, but if her husband is the one making the decisions, it is his health literacy that ultimately influences how she engages with health actions and services.

Health literacy programs have been noted to impact not only health decisions, but also family relations. The HEY! (Healthy Eating for Young Children) is an early childhood health improvement program which aims to improve the health literacy of parents who attend. The focus of the health education program is healthy eating within the framework of a healthy lifestyle. The course aims to improve parents’ ability to make more informed and healthier choices for themselves and their toddlers [11]. Anecdotal evidence from participants on the impact of the intervention is striking. One participant describes the health benefits from healthier eating; she also describes improving family cohesion (Box 1).

Box 1.

A Picture from the UK.

Another family health learning initiative from the UK was the Healthy Families, Health Literacy Project. This was developed by an education team with family learning education expertise. It aimed to empower parents living is a socio-economically deprived area of London to improve their functional, interactive and critical health literacy. The learning topics were chosen by the parents and included understanding food labels, dealing with food allergies, and exercising as a family. The course included practical sessions to develop and share food recipes, cook together, and walk together. Participants found the course stimulating and exciting, with a direct and healthy impact on ‘the way they lived their lives’. Participants developed functional and interactive health literacy skills [35].

4.1.Family relationships, communication and health literacy in the cultural context

Cultural norms influence the way in which families communicate with regard to health. Cultures in transition, either due to geographic migration or to societal trends dictating a move from more traditional to Western paradigms, present families with challenges regarding the discourse of health and well-being within the family. Firstly, if in the more traditional model the extended family played a significant role in the individual’s health and well-being, the more Western model emphasizes the dominance of the nuclear family [48]. This transition has not only narrowed the base for support, in many cases it changed the role of family members, particularly with regard to gender. Furthermore, it created challenges regarding the formerly accepted role of the younger and older generations, often creating conflict between generations. An example of this situation is described in the word picture from Malawi (Box 2). Malawi’s story shows the challenges in promoting health literacy in light of societal contexts prohibiting individual empowerment.

The ramifications for health literacy are quite significant as exemplified in situations such as reproductive health, where in the traditional paradigm, discourse is forbidden and taboo. While the younger generation in an acculturating family may be embracing the behavioral norms of the more liberal mainstream, with respect to sexual norms, they often still lack access to health information and support from the family. The health outcomes are marked, including the younger generation’s need to cope with sensitive health issues such as unplanned pregnancy and even a high rate of abortions [47]. Difficulties in initiating and maintaining discourse in families related to conditions with high levels of stigma such as mental illness or to communicable diseases such as HIV, are often exacerbated in the context of the stress of culture changes such as acculturation.

Box 2.

A Picture from Malawi.

It should be noted that family acculturation is a dynamic process, with different levels of acculturation. This process supports the previous mentioned definition of health literacy as a complex phenomenon that changes with changing and variable contexts [14].

4.2.Health literacy as a vehicle for promoting social capital in disadvantaged groups

There is evidence showing that, in a diversified society, the more disadvantaged groups tend to use more online sources of health information than the mainstream population, compensating for the lack of social capital that supports more health promoting health information [39]. According to this hypothesis, it would be expected that people from cultures in transition, when families play less of a role as sources of useful health information than in the past, might be using more online tools, particularly in their native languages. If so, this phenomenon may change the assumption about the Digital Divide, however more research is needed to explore this avenue of study.

As critical as interpersonal relations in the family are with regard to health and health literacy, especially in a culturally transitional context, research is still lacking, regarding the role families play, and the most optimal strategies for intervention. Likewise, future research could explore how family role changes that often occur during cultural transitions influence family’s collective health literacy and individual family members capacities and outcomes.

5.1.Challenges to immigrants: The importance of health literacy in inter-culture encounters with the health system

Immigrants encounter many challenges upon their arrival to a new country, one which is communication with health authorities. Some who come from authoritarian regimes or one-party states believe, for example, that health screening is a process of scrutiny to assess suitability for remaining in the country, bringing negative attitudes towards health screening [21]. In cultures where screening for diseases is not usual practice, it may be seen as an unnecessary ‘secondary issue’; immigrants from such cultures often do not believe that they should undergo health screening because they perceived themselves as healthy [21]. Some believe that they have no choice about whether or not to attend health screening; the ‘invitation’ may be interpreted as a ‘requirement’ from the authorities to all the newcomers, for the benefits of society as a whole, rather than individuals themselves [43].

In addition to such misunderstandings, more practical barriers arise, such as not arriving for health appointments due to inability to read the invitation letter, not understanding the reason for invitation, and not knowing when and where the health screening would take place [21]. Such language barriers negatively affect communication between immigrants and health care professionals, reducing the accuracy and willingness of symptoms reporting [3]. Such difficulties cannot always be resolved by the presence of interpreters; often, immigrants’ political or psychosocial reasons hinder the communication [21]. Cultural beliefs about an illness and health care is another determining factor influencing people’s participation in health screening tests. For example, how comfortable one feels to discuss their body with a physician (physical modesty), whether one visits a physician only when there is a presenting symptom, such as pain (crisis intervention approach) or alternatively for regular symptom-free visits, as would be the case for one to seek Eastern medicine. In a study of American Korean men [26], their cultural beliefs about cancer were found to significantly determine their recent uptake of prostate cancer screening tests. The men who used crisis intervention were less likely to seek cancer screening than those who used preventive approach; those who preferred to use Eastern medicine for health care were more likely to seek for prostate cancer screening. The use of Eastern medicine may indicate that these immigrants misunderstand and/or mistrust Westernized health care and medicine, reducing their engagement and participation in treatment [33]. This is evidence that cultural beliefs play a part in health screening decisions.

Culturally influenced preventive behaviors vary across different age groups. The older American Koreans (aged 70 or more) that preferred to use Eastern medicine were more likely to take cancer screening tests; however, the younger American Koreans (aged 50 to 60) were less likely to undergo health screening tests in spite of the fact that they also preferred to use Eastern medicine. Another immigrant group, Chinese Americans, demonstrated similar behavior. This finding suggests that in addition to culture, age also influences health screening and preventive behaviors [26].

5.2.Health literacy as a protective factor for acculturation challenges

Migration in later life can be a stressful event; for example for older Chinese Australian immigrants, migration is associated with depression and anxiety due to language difficulty, knowledge and literacy, and the change of role and status within the family and society [15]. Loss of job, loss of physical health and loss of friends in the original country, and the changed roles in families, can produce feelings of hopeless and can lead to depression. Because mental health has stigma in many societies, some immigrants refuse to admit the clinical manifestations of anxiety or depression, and have limited knowledge about mental health symptoms and services (poor mental health literacy) [36]. As an example, acculturative stress – the stresses experienced due to migration to a country or a place in which people encounter practices that are significantly different from their own cultural practices or practices in their home countries – and depression was experienced by Filipino migrants when they migrated to Australia [36]. Acculturative stress negatively affected health-seeking behavior, with depression as a major modifying factor [15]. Health literacy and social support could be the protective factors to acculturative stress, as depicted in Fig. 3. For those migrants with higher health literacy or higher level of social support, they were more likely to have less acculturative stress [36]. In Maneze and team’s study, reverse relationships (i.e. from acculturative stress to health literacy or to social support) were not tested. More effective and culturally appropriate health system responses could help migrants overcome the stress of migration and perhaps prevent resulting health challenges.

Figure 3.

Reproduced from Maneze et al., 2016 [36].

Further research is needed to understand the complex inter-relationships between culture, language, social support and networks, use of health services, and mental and physical health. This can then lead to the development of effective interventions, culturally appropriate and based in communities, to better promote health and effective use of health services in immigrant populations. Because of the wide variety of different cultures, such interventions should be tailored to, and developed in partnership with, the communities they are designed to support. In addition, future research on the global level is needed to explore the possibility of universal stressors and challenges related to migration, that services should be mindful and responsive to, what are the culture influences, and what might be anticipated as different challenges experienced on the individual level.

6.1.Traditional vs. western cultures: Dissimilarities in health decision making

Cultural values and practices affect health behaviors and health decisions. Many cultures are hierarchical in nature, with health practitioners having elevated, respected positions. For example, Chinese people will often refrain from asking health practitioners questions, believing that asking questions is impolite as it is perceived as “challenging doctors and nurses” or “putting burden on these professionals” [29]. A similar phenomenon was observed in many Chinese societies including Hong Kong, Taiwan and Chinese communities in Los Angeles, USA [29]. Cultural preferences and lack of understanding of Western medicine can lead to delays in the diagnosis of important health conditions. Estacion found that South Asian men with diabetes in UK preferred to seek the help of a religious leader/community leader, or ignore symptoms for an extended duration before referring to formal Western health services in UK [56]. Future research can help to better understand what drives these observed practices and preferences and how interventions might be developed to support health decision making in the contexts of cultures in transition. More research should be carried out to explore the impact of culture on health decision making and health behaviors. The American Diabetes Association advocates actions to be taken to address health disparities and develop structured interventions that are tailored to ethnic populations’ culture, language, religion and literacy skills [8].

6.2.Cultural change between generations: coping with cultural changes in society

Immigration results in generational effects, with different levels of acculturalization in different generations. First-generation immigrants are less likely to report disability, as compared to the third generation [45]. Yet no significant difference in disability reporting was found between the second- and the third-plus generations. Among the first-generation immigrants in Canada, those who had not immigrated from Europe or the US were less likely to report disability than their counterparts. This is likely to be partly related to the use of language. Health literacy was found to be significantly negatively associated with disability reporting only of the first-generation immigrants. This may be due to the low functional health literacy among first-generation immigrants, while better education, employment and higher income in the new country, providing paths for the second- and third-plus generations to develop better health literacy competencies for accessing and navigating the health system [45]. Some programs have even targeted young immigrants, as a means to improve access to care for entire migrant families. Picture Boxes 3 and 4 offer real-life examples of how these concerns surface in the daily lives of immigrants, presenting challenges for improving health, even when individuals have awareness of the need for adopting health promoting behavior.

Box 3.

A Picture from the US health, even when individuals have awareness of the need for adopting health promoting behavior.

Box 4.

A Picture from China.

7.1.The needs for enhancing effective interpersonal and inter-cultural communication for health literacy

A myriad of research has been conducted exploring a vast scope of needs and vantage points with regard to ways in which health literacy is influenced by, and influences the relationship between the individual and the health care provider. The continuing trends of massive migration and globalization have most recently amplified the need for this exploration more than ever.

The needs are particularly rooted in the fact that so many health care professionals have different ethnic/cultural backgrounds than their patients, many of them migrants and immigrants. Not only do communication barriers exist [2], many of the communities in cultural transition are, on the one hand, coping with life in a new and strange culture, while encountering new and unfamiliar health problems, some due to migration. Research suggests that immigrants coming from a more traditional, low-technology lifestyle adjusting to a Western culture, suffer from higher rates of chronic conditions and morbidity than previously experienced, and more prevalent even than the non-immigrant populations. Diabetes and depression are examples of the latter conditions [38]. This situation can be a source of misunderstanding between well-intentioned physicians and patients, fueling distrust, and resulting in mutual disappointment and eventually health disparities.

Migration, particularly migration to a country or region with different cultural beliefs and societal structures, is highly stressful, often leading to migrant health decline [24]. Generally migrants arrive in host countries in better health usually, than those from the host country. Trajectory decline in self-rated health was observed in the initial four years upon arrival, and it was particularly obvious in women and minority ethnic groups. Language partially contributes to this decline, but does not solely address the aforementioned deeper issues; merely providing oral and written translation services will not solve problems that immigrants face in a new society. Often, immigrants will have deeply-held beliefs about different systems of medicine, such as acupuncture or Ayurvedic medicine, which are based on totally different philosophical beliefs about the body, mind, health and illness. Health literacy has the potential to add significantly to our understanding of this, and to help bridge the gap between the contrasting understanding of health systems.

7.2.The inter-cultural context between provider and health service consumer

Many traditional cultures view health problems in the context of whole life experience, as opposed to isolated health problems, as is often the approach adopted by Western health systems. Moreover, the holistic perception of health may not differentiate between physical, emotional and mental well-being, as is often perceived among Western health providers. The opportunity to promote health literacy through interpersonal communication, is often impeded, even when there is a common language, due to the differentiated perception of what needs to be explained and expressed by the person seeking health services. Warfa et al. [57] determined that immigrant patients often attributed one reason to an illness, while healthcare providers often provided a different explanation for the same illness.

The health service professional often has never had specific training nor has been provided with tools to tackle the abovementioned issues, that are as basic as understanding health data with regard to ethnicity [22,38]. In particular, very few academic curricula include training future providers about migrant health decline. More research needs to be conducted regarding the role that the healthcare provider can play in slowing or preventing the inevitability of health decline due to the stress, the adjustment, and the lack of concordance of existing services and systems between culture beliefs, norm and language.

7.3.Interpersonal, community and cultural influences and health literacy skills – supportive action

Cultural competency is the set of skills which enables the health care provider to function effectively within the cultural context of the people that he/she serves, whether on the individual, family or community levels. In this way, health literacy can either be promoted and improved or alternatively communication can be adapted to the individual according to his/her to health literacy needs [49]. For example, it is important to learn of the cultural perception of chronic disease in order to best communicate on chronic disease prevention, early detection or self-care. In many traditional societies the concept of a chronic/asymptomatic health problem does not exist. Rather, the individual may expect the healthcare provider to solve the cause of the problem and thus to remove it at its root. This gap in expectation can be bridged through promotion of cultural competence among the health professionals to learn of ways in which their patients understand and conceptualize health, and thus to adapt the communication [47]. Likewise, culturally sensitive interventions can be carried out that helps immigrants understand the context within which the health system can be accessed including appointment making, receiving treatment and other points of contact with the health care system.

Areas that should be addressed in health literacy and cultural competence training include involving community stakeholders for training, to help reflect upon the needs of the individuals and families that they treat [34]. Evaluation of the impact of such training could include patient satisfaction with encounters with health professionals. Since health literacy can be viewed as the balance between the capacities of patients and the demands and complexities of the health system [46] (see Fig. 1), such an intervention should result in improved health literacy.

Box 5.

A Picture from Israel.

Shim [52] has expanded the concept of cultural competence to “cultural health capital” defined as the “repertoire of cultural skills, verbal and nonverbal competencies, attitudes and behaviors, and interactional styles, cultivated by patients and clinicians alike, that, when deployed, may result in more optimal health care relationships”. The concept is framed within the discourse of unequitable care, due to health disparities. Such cultural health capital thus moves from physician understanding of cultural issues to two-way patient: physician partnerships. It can be hypothesized that the benefits to be expected from such interventions would be even more effective than the simpler cultural competence interventions at improving patient satisfaction, improving health literacy, and improving patient outcomes. Involving patients and families in service planning, implementation and evaluation, and adjusting the services to meet the needs of the individual, should increase critical health literacy skills i.e. ‘more advanced cognitive skills which, together with social skills, can be applied to critically analyze information and to use this information to exert greater control over life events and situations’ [44].

The use of cultural liaisons in primary care has proven successful [31] and as exemplified in Box 5. Rather than perpetuating a system of disconnect stemming from cultural gaps, bringing a cultural liaison (a member the cultural community being served) into the health care team helps communicate with the provider, on behalf of the person receiving care. In addition, the liaisons help narrow the gap between patients/families and health providers by communicating and instructing the individual with regard to the treatment recommended, using culturally appropriate tools. Incorporating cultural liaisons in the community health care team helps to promote interactive health literacy, and to develop and reinforce skills that support the individual’s independence in expressing his or her need to the health care providers, and thus to develop a trusting relationship. The research conducted on this shows that the program positively influenced the ability of new immigrants to navigate the health system, without increasing public or individual expenditure on services. The evidence showed that in clinics where the program was not implemented, a large number of unnecessary medical tests and referrals were performed. However, in spite of the evidence, many decision makers still place the burden on immigrants to adapt themselves, after so many years living in the country, preventing the program to be expanded to all clinics serving the Ethiopian community. Policy is being established in coordination with the Israel Ministry of Health which will place this special initiative under regulation requiring all clinics serving populations in need, to employ health liaisons through cultural mediation. Box 5 offers an example of inter-cultural perceptions of health service navigation, and offers an example of how this can be identified and addressed in the primary care system.

Future research should aim to study health literacy in the cultural context. Acknowledging that health literacy is a complex phenomenon, improving health literacy, is the responsibility to be shared between society and individuals/groups. Thus, interventions aimed at improving health literacy need to be directed to the individual, families, the general population, health care professionals and policy makers to increase awareness of health literacy. This can increase their awareness of the phenomenon to change attitudes, such awareness may inspire to stakeholders to develop action items that guarantee the access to relevant, health-related information, presented in ways that promote the health of individuals and groups with various life situations and with different ethnic, educational or social background. Health care professionals should be more aware of their important role as agents for improving health literacy. Through more appropriate professional training we can shed more light on health literacy in its different facets promoting a person and family centered approach in accordance with deep-rooted cultural values.

9.1.The contribution of health literacy to digital health services and systems

New strategies are emerging in light of the tremendous challenges mentioned for individual, families and communities rooted in cultures in transition vis-à-vis accessing empowering health information and even navigating the health system. New frontiers are being forged through eHealth, mHealth, and other health technologies. The broad range of applications include not only online information websites, but also interactive electronic records in various languages, health decision support programs, mobile health, and online communities that the individuals can access. An increasing body of knowledge is based in the dynamic research, showing how online sources of health information have and can be adapted to cultures, language and to groups with a particular status in society [25]. While there is concern regarding the “digital divide” great potential exists for promoting functional health literacy [44], interactive, and even critical health literacy. The vast potential for use of mobile phones to promote health literacy is beginning to unfold and must be seriously considered and utilized where appropriate for promoting health among individuals and in communities [50].

In spite of the assumption that digital tools are utilized mainly by younger populations, older adults are not exempt from reaping the potential benefits of digital development. Health literacy training that addresses the unique characteristics of older adults should be encouraged, as this age group can be the most disadvantaged group. For example: older adults in Hong Kong with no or minimal education have poor health outcomes, and frequently visit public health services. Initiatives were launched in Hong Kong in 2006 to develop community-dwelling older adults’ skills and capacity to get reliable health information from the web [28]. Interestingly, participants of this study clearly indicated that having online searching skills did not replace the importance and preference of having face-to-face communication with health professionals and receiving health information through reading books or watching television [28]. This reinforces the notion that multiple channels would be needed to develop and support older adults’ health literacy. It was worth noting that only one-third of older adults or soon-to-be adults preferred to seek health information from the Internet [30].

MHealth provides new opportunities for offering essential health information and support to the general public, however the criteria for increasing individuals’ capacity to understand and interpret e-health information (e-health literacy) need to be met. Mobile apps have been developed to support patients in the various aspects of their involvement in promoting, maintaining and improving health, such as disease prevention, medication adherence, illness management, lifestyle modification and in navigating the health care system including making appointments in health services [4,9,18,19,40,51]. The most common disease-specific apps aim to provide education on diabetes, hypertension and hepatitis [19]. Most apps are provided on both iOS and Android platform free of charge [19].

An increasing number of studies investigating the effects of digital health interventions have suggested innovative digital tools are useful. A Cochrane review, comprised of four randomized controlled trials with 182 participants, analyzed the impact of mHealth (using mobile phone messaging) on self-management of long-term illnesses (including diabetes, hypertension, and asthma) [6]. Moderate evidence suggests some benefits mobile phone messaging interventions can: increase diabetic patients’ self-management capacity including self-efficacy improve hypertensive patients’ rate of medication compliance; and impact the peak expiratory flow variability for asthma patients [6]. There evidence was less pronounced regarding the impact of eHealth on health service utilization, and no evidence suggested long-term effects on health outcomes and cost-effectiveness form mobile phone messaging interventions [6]. The small number of studies and the limited number of participants in this review support the need for continued research and review of the evidence on health outcomes and service utilization.

While digital tools for promoting health are readily available as mentioned above, their appropriateness, particularly for people with low health literacy should be of concern. On the one hand, there is an increasing body of knowledge that suggests online sources of health information have and can be adapted to cultures, language and to groups with a particular status in society [25]. Additionally, a recent systematic review of 74 studies, suggests five relevant areas of future inquiry include: online health related content; features of eHealth services; interventions to improve eHealth literacy; health literacy measurement tools; and online health information seeking behavior [23]. The review suggests most online health content is not well-matched to user readability levels and therefore inaccessible. The review also suggests text-to-speech apps may help people with low health literacy access important online health information, that touch screen computers are helpful when surveying health literacy levels [23]. The review added even adults with high levels of health literacy sometimes evidenced low levels of self-efficacy, which deters finding reliable online information to inform health behaviors [23]. The review included was based on studies published in English [23]. Although cultural appropriateness was not investigated, the conclusions of the review have obvious implications regarding the extent to which digital tools can currently be considered a panacea for solving health literacy challenges across cultures. The importance of continued research and reviews cannot be overstated due to the significant investment in innovative tools and their sweeping uptake by health systems.

10.1.Future areas for applied research and exploration

The answers to the following questions are essential for appropriate action and can be investigated through collaborative research:

These are all key questions that the health literacy research, practice and policy community can help to answer; the results of such research can then lead to informed and improved practice to promote health and reduce and manage illness in immigrant populations.