Can extended health communication improve newly settled refugees’ health literacy? A quasi-experimental study from Sweden

Health Promotion International, 2024, 39, 1–11 https://doi.org/10.1093/heapro/daae015 Article Article Maissa Al-Adhami1,2,*, , Natalie Durbeej1, Achraf Daryani3, Josefin Wångdahl4, Elin C. Larsson,2,5,6, and Raziye Salari1 Child Health and Parenting (CHAP), Department of Public Health and Caring Sciences, Uppsala University, Husargatan 3, 752 37 Uppsala, Sweden 2 Research and Learning for Sustainable Development and Global Health (SWEDESD), Department of Women’s and Children’s Health, Uppsala University, Hammarskjölds väg 14B, 752 37 Uppsala, Sweden 3 Department of Public Health and Caring Sciences, Uppsala University, Husargatan 3, 752 37 Uppsala, Sweden 4 Aging Research Center, Karolinska Institutet and Stockholm University, Tomtebodavägen 18 A, 171 65 Stockholm, Sweden 5 Department of Women’s and Children’s Health, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden 6 Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18 A, 171 65 Stockholm, Sweden 1 Corresponding author: E-mail: * Abstract Structural and contextual factors such as limited work and housing opportunities negatively affect the health and well-being of newly settled refugee migrants in receiving high-income countries. Health promotion initiatives aiming at strengthening health and integration have been tried out within the Swedish Introduction program for refugee migrants. However, longitudinal evaluations of these interventions are rare. The aim of the current study was to compare the effectiveness of a regular and an extended civic orientation course with added health communication and examine whether the latter would improve self-rated health and psychological well-being, health literacy and social capital among newly settled refugee migrants in Sweden. Pre- and post- assessment questionnaires were collected from the intervention group receiving the extended course (n = 143) and a control group receiving the regular course (n = 173). Linear mixed models and chi-square analyses showed a significant increase with a small effect size (0.21) in health literacy in the intervention group. However, there were no significant changes in emotional and practical support, general self-rated health or psychological well-being. The findings indicate that added health communication provided embedded in the civic orientation course can increase health literacy. However, further longitudinal studies are needed to confirm the sustainability of the observed effect and examine whether these short-term improvements in health literacy translate to long-term advances in health and integration. Keywords: evidence-based health promotion, health education, health information, health literacy, intervention, epidemiology BACKGROUND In the past decade, countries in the European Union have seen an increase in the number of refugee migrants from war and conflict-torn countries such as Syria, Iraq, Eritrea and Afghanistan (WHO, 2018b). Even with declining numbers of migrants due to restrictive immigration policies applied in some countries, and the effect of the Covid-19 pandemic, the health of newly settled refugee migrants constitutes a major public health issue in European countries. In ecological terms, the health of migrants is determined by pre-peri and post-migration health status and life conditions (Zimmerman et al., 2011; Miller and Rasmussen, 2017). Refugee migrants are heterogeneous in terms of biology and hereditary factors, educational background © The Author(s) 2024. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/ licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Can extended health communication improve newly settled refugees’ health literacy? A quasi-experimental study from Sweden M. Al-Adhami et al. 2 Contribution to health promotion and other pre-migration conditions and experiences, although they report similar migratory experiences and reasons for seeking refuge (Ben Farhat et al., 2018; Mangrio et al., 2018). Nevertheless, as a group, they often have poorer self-rated general health and mental health compared to the general population (BasSarmiento et al., 2017; Alkaid Albqoor et al., 2020). Moreover, inequities between migrants and majority populations in, e.g., mental health outcomes persist over time in the new countries of residence (Blackmore et al., 2020; Honkaniemi et al., 2020), which highlights the importance of health promotion in the early post-migration phase, i.e. during the first 5 years in the country of resettlement. In the post-migration phase, refugee migrants face structural and context-bound barriers that impact their health and well-being negatively; limited housing and work opportunities, restrictive integration policies, discrimination, isolation and acculturation stress are that examples of known factors adversely affect health in the resettlement phase (Porter and Haslam, 2005; Kastrup, 2016; Li et al., 2016; Juárez et al., 2019; Choy et al., 2021). In addition, migration may negatively affect individuals’ social capital, i.e. sharing, trusting and aiding relationships and networks (Kawachi I. SS, 2008), which are often disrupted by migration and take time to re-establish (Hassan et al., 2016; Sundvall et al., 2021). Similarly, a change of context and setting may lead to lower health literacy, defined as ‘knowledge, motivation and competences to access, understand, appraise and apply health information in order to make • This study compared the effectiveness of a regular and an extended civic orientation course with added health communication for newly settled refugee migrants in Sweden. • Linear mixed models and chi-square analyses showed a significant increase with a small effect size (0.21) in health literacy in the intervention group. No significant changes were observed in emotional and practical support, general self-rated health or psychological well-being. • The findings indicate that added health communication provided within the civic orientation course for refugee migrants can increase health literacy. However, further longitudinal studies are needed to confirm the sustainability of the observed effect over time. judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life’ (Sorensen et al., 2012). Navigating a different health care system and language than one is used to may influence a person’s health literacy capacities, which is reflected in lower health literacy in newly settled migrant populations (Wångdahl et al., 2014, 2018). Social support and health literacy are important resources linked to better health outcomes and empowerment (Kawachi et al., 2008; Nutbeam, 2008) that in turn can buffer against post-m (...truncated)