“I can’t read and don’t understand”: Health literacy and health messaging about folic acid for neural tube defect prevention in a migrant population on the Myanmar-Thailand border

Abstract

Health literacy is increasingly recognized as an important determinant of health outcomes, but definition, measurement tools, and interventions are lacking. Conceptual frameworks must include both individual and health-systems domains which, in combination, determine an individual’s health literacy. Validated tools lack applicability in marginalized populations with very low educational levels, such as migrant worker communities on the Myanmar-Thailand border. We undertake a comprehensive health literacy assessment following a case study of a recent public health campaign promoting preconceptual folic acid uptake in this community. A mixed-methods design utilized quantitative analysis of the prevalence and predictors of low Health literacy, and focus group discussions to gather qualitative data from women about proposed and actual posters used in the campaign. Health literacy was measured with a locally developed tool that has been used in surveys of the population since 1995. Health literacy was low, with 194/525 (37.0%) of tested women demonstrating adequate health literacy, despite 63.1% (331/525) self-reporting being literate. Only one third of women had completed 4th grade or above and reported grade level attained in school was more predictive of health literacy than self-reported literacy. Focus group discussions revealed that low literacy, preconceived associations, and traditional health beliefs (individual domain) interacted with complex images, subtle concepts, and taboo images on posters (health-systems domain) to cause widespread misunderstandings of the visuals used in the campaign. The final poster still required explanation for clarity. Low health literacy is prevalent among pregnant women from this migrant community and barriers to communication are significant and complex. Public health posters need piloting prior to implementation as unanticipated misperceptions are common and difficult to overcome. Verbal communication remains a key method of messaging with individuals of low health literacy and educational system strengthening and audiovisual messaging are critical for improvement of health outcomes.

Barriers to Receiving the Recommended Standard Care During Pregnancy by Illiterate Women in Rural, Northern Tanzania

“…In both India (14,15) and SSA (16)(17)(18), researchers identi ed illiteracy (de ned as not knowing how to read or write) as an important risk factor for failure to attend ANC and higher maternal mortality. This is consistent with general linkages between low literacy and worse health outcomes (19) and lower utilization of health services by illiterate women (20). Some studies have identi ed lower care-seeking due to the stigma associated with illiteracy: some illiterate individuals were hesitant to disclose their illiteracy to healthcare workers, compromising provider support for such individuals (21)(22)(23).…”

Choosing where to give birth: Factors influencing migrant women’s decision making in two regions of Thailand

“…In designing the study we opted to utilize focus groups as this method helps to facilitate conversations between participants, is culturally appropriate and has been successfully utilized by other studies in this setting [10][11][12]. We held focus group discussions [13] with 72 non-Thai pregnant migrant women at three non-government clinics in a rural border area and at two hospitals in Chiang Mai, the largest city in Northern Thailand in May and June of 2018.…”

“…Prior to the fieldwork, we developed a series of images with examples of possible reasons why women would seek to deliver birth at a specific location. We decided to use photos and drawings produced by the research team to engage participants, many of whom had low literacy levels, as these methods have been used to engage participants in prior studies [10,11]. These images were based on themes identified in the literature and previous informal discussions with migrant health care providers.…”

“…However, we perceive that undocumented women may feel uncomfortable presenting at the district office to request a birth certificate due to their own precarious status and an associated fear of authorities. Inability to speak Thai (or read in Karen or Burmese) may be another barrier for parents who do not have support from someone who can interpret during the registration process [10]. Women, especially first-time mothers, may also not be knowledgeable of pathways to birth registration.…”

Prevention of mother-to-child transmission of hepatitis B virus: protocol for a one-arm, open-label intervention study to estimate the optimal timing of tenofovir in pregnancy

“…Secondary objectives include: estimation of the proportion of women with HBV DNA <2 log10 IU/mL (or <100 IU/mL) at delivery; the concentration of TDF in maternal and cord blood at birth in women who have detectable HBV DNA and a subset of women with undetectable HBV DNA; to monitor the safety of TDF on the Myanmar–Thailand border in pregnant women with low health literacy rates 30 and address potential barriers to implementing TDF in early pregnancy to prevent MTCT of HBV; to determine the rate of hepatic flares post partum after cessation of TDF; to estimate the proportion of cases of vertical transmission in infants of 2 months of age; to assess fetal growth by monthly ultrasound, and infant growth at 1, 2, 4 and 6 months and neurodevelopment at 6 months.…”