The Relationship Between Refugee Health Status and Language, Literacy, and Time Spent in the United States

Abstract

Background: There are 3 million refugees living in the United States today whose health and wellbeing may be diminished by not being able to understand and use health information. Little is known about these barriers to health in multiethnic refugee communities. Objective: This present study examined (1) the relationship between English proficiency, health literacy, length of time in the US, and health status; and (2) differences in poor health status caused by limited English proficiency and low health literacy individually and in combination to better understand which barriers might be addressed by improving refugee health. Methods: Refugees ( N = 136) age 18 to 65 years were recruited using health clinics and refugee resettlement agencies. Survey questions included demographics, health status, health literacy, English language proficiency, social determinants of health, and barriers to getting health care. Interpreters were used as necessary. We used a cross-sectional study with purposeful sampling. Key Results: There is a high correlation (Pearson's r = 0.77) between health literacy and English proficiency; they were moderately correlated with health status ( r = 0.40 and 0.37, respectively). Length of time in the US only modestly correlated with health status ( r = 0.16). Health literacy and English proficiency taken individually were strong predictors of health status (health literacy odds ratio [OR] = 4.0; 95% confidence interval [1.6–9.9], English proficiency OR = 3.6, confidence interval [1.5–9.0]) but not significant. Their interaction, however, was significant and accounted for most of the effect (log odds for interaction = 1.67, OR = 5.1, p < .05). Conclusions: English proficiency and health literacy individually and in combination facilitate poor health and present health-related barriers for refugees. Length of time in the US for refugees may not correlate with health status despite studies that suggest a change in health over time for the larger immigrant population. [ HLRP: Health Literacy Research and Practice . 2020;4(4):e230–e236.] Plain Language Summary: The combined effects of limited English proficiency and low health literacy can create significant barriers to good health outcomes in refugee populations. Length of time in the US for refugees may not correlate with health status despite studies that suggest a change in health over time for the larger immigrant population.

Strengthening Culturally Competent Health Communication

“…Residents had low incomes, high unemployment, employment in low-wage jobs, limited or no health insurance coverage, large families living in densely populated housing, and an inability to access systems that provide needed resources. 6,11,12 In our study of healthcare access and social determinants of health in the community, average income ($15,476) was below the poverty level, 41.2% of respondents were employed, 66.9% had been in the United States less than 3 years, 29.4% had health insurance, and 57.4% reported limited English proficiency. 6,11 A lack of English-language proficiency along with poor living conditions further compound social stigma and a mistrust of medical institutions and public health resources.…”

“…6,11,12 In our study of healthcare access and social determinants of health in the community, average income ($15,476) was below the poverty level, 41.2% of respondents were employed, 66.9% had been in the United States less than 3 years, 29.4% had health insurance, and 57.4% reported limited English proficiency. 6,11 A lack of English-language proficiency along with poor living conditions further compound social stigma and a mistrust of medical institutions and public health resources. 13 Having fled situations of oppression, often from their own governments, and facing rumors, misinformation, and information overload upon resettlement, refugee populations tend to be highly suspicious of institutional and governmental messaging.…”

“…4,5 While foundational elements of risk communication require tailoring messages to specific audiences and using plain language, actual implementation of risk communication often fails to meet the needs of vulnerable, marginalized, multicultural communities. [6][7][8] The Most Diverse Square Mile in America Clarkston, Georgia, is a diverse ethnic community on the outskirts of downtown Atlanta where more than 17,000 refugees have initially settled since 2004. It has been referred to as the ''Ellis Island of the South'' and ''the most diverse square mile in the United States.''…”

Consideration of health literacy in implementation science

“…Adding to these challenges, twenty-five million Americans (8.7 percent) have limited English proficiency [10]. There is a strong association between limited English proficiency and low health literacy [11,12]. Taken together, these statistics underscore the relevance of health literacy within implementation science, which requires clear communication to develop shared understanding among increasingly diversifying stakeholders as key players in the design and conduct of the research-patients, caregivers, frontline clinicians, administrators, and researchers.…”

Risk Communication and Institutional Racism: The Protective Health Effect of Refugee-Led Community Organizations

“…A lack of English proficiency and health literacy negatively influences refugee health, even outside of emergency public health events. 13 Resettled refugees also struggle to navigate a fragmented health system and obtain health information. 5,12 RCO leaders regularly assist community members by providing translation during doctors' appointments and emergency visits.…”