Qualitative exploration of critical health literacy among Afghan and Congolese refugees resettled in the USA

Data collection

A mixture of availability and snowball sampling methods was used to identify and recruit participants from the local Afghan and Congolese communities. The research team identified two community leaders from each refugee group who were asked to mobilise 10–15 refugees from their own community. A total of 13 Afghan women and 12 Congolese refugees (5 men and 7 women) completed the CHW by attending at least seven out of eight sessions. Two Congolese participants dropped out due to personal circumstances. The CHWs and focus group interviews were offered to each group consecutively (i.e. after the Afghan group was complete, the Congolese group started). A series of open-ended questions for focus group interviews were embedded in each session to explore health literacy skills and capacity over time. The questions included (1) reflection on today’s session, (2) lessons learned from the CHW, (3) unclear or missing lessons, (4) culturally relevant or irrelevant contents of CHW and (5) challenges and future directions. The focus group interviews were conducted by members of the research team who were not involved in the workshops, in order to avoid social desirability bias. The interviews were conducted in English and interpreted by one of the two refugee leaders into Dari and Pashtun for the Afghan group and Kinyarwanda for the Congolese participants. To better trace the process of learning and interaction among the participants and the workshop facilitators, all sessions were audio-recorded upon agreement of all participants and transcribed verbatim into English for data analysis.

Data analysis

This study undertook a hybrid thematic analysis whereby a CHL conceptual framework was applied to emergent themes from the data (Crabtree and Miller, 1999). This method enabled both the capturing of themes from organic interactions in an inductive way (i.e. initial coding) and the organising of these themes in line with existing theoretical constructs (e.g. use of a priori template guided by theory or conceptual definition) (Fereday and Muir-Cochrane, 2006). First, two trained doctoral-level research assistants developed initial codes independently after a thorough review of the transcripts. Through a series of reconciliation meetings between the coders, these initial codes were vetted, modified and/or combined for each refugee group (i.e. Afghan and Congolese separately). In the meantime, the first author independently developed an a priori template that is based on the definition of CHL offered by Nutbeam (2000), such as cognitive skills, social skills, critical analysis of information and use of information to exert greater control over life events and situations. Further conceptual articulation from the work of Chinn (2011) and Sykes et al. (2013) was added to the CHL template, such as critical process of information, self-management, personal skills and confidence, effective interactions with providers and empowerment. Considering the contents of the CHWs, the template excluded themes on direct interactions with medical professionals or in healthcare settings.

Next, the research team organised and categorised the codes in the template by matching the codes with aligned themes (e.g. a code of ‘finding substitute ingredients’ to a theme of ‘critical process of information’). As a non-linear process, this hybrid approach allowed the interactive development of themes between deductive and inductive coding processes. When codes were relevant to CHL but not accurately matched with the existing themes, new themes were created. For example, one existing theme, critical appraisal, was not adequately matched to indicate the reevaluation of cultural practice for health promotion. Therefore, a new theme, ‘critical comparison’, was generated and added to the template. Finally, after the thematic coding of the data from each refugee group, the team finalised the overarching themes across both groups and reconceptualised these themes when necessary. For example, although critical analysis and the critical processing of information were often concurrent, contextualising information by comparative reflection on two cultures was not initially with in the template. As such, we decided to code these themes under ‘critical appraisal’ while keeping three separate subthemes.

To enhance the rigour of this process, the authors used the audit trail and observational notes of the CHW sessions created by a research assistant, which helped ensure the accuracy and completeness of data analysis. Also, the research team’s cultural assumptions and biases were identified by debriefing after each session with the community leaders who interpreted for that session, helping increase trustworthiness of the study.

Critical appraisal: critique, contextualisation and negotiation

Critical appraisal, one of the core skills of CHL, was expressed in three different but interrelated ways: (1) critical appraisal of content, (2) contextualisation of information and (3) negotiation of meaning. Critical appraisal of content emerged as participants were pondering newly gained information about nutrition, healthy eating, stress coping and other health promotion activities. Instead of accepting the given information in an acquiescent and passive manner, participants critically processed the shared health information and discussed challenges to healthy living and implications of the information for daily health practice. When discussing emotional coping skills, for example, Afghan participants delved into the main sources of their stress, rather than limiting the group discussion to coping matters only. They critically related lessons on coping both to the causes of stress and obstacles to coping in order to fully comprehend the provided contents. Discussion extended to the policy gaps in resettlement, healthcare access and insurance, with one woman stating:

For nine persons in a family and only my husband is working, we have to pay for rent, gas, bills, and children. The second problem is that Medicaid does not accept for the teeth or dentist. A lot of us have dental problems and we can’t go to the doctor because it costs too much.

The same pattern was found in the Congolese group. In the sessions that addressed healthy eating and nutrition, Congolese participants critiqued the US food industry, discussing how chemical usage and unaffordable organic foods prevented them from eating healthily. For example, one Congolese woman stated,

Here we’re eating differently from what we ate back home. The reason is because we can’t find what we used to eat and most of the time we eat things that are frozen, and even if it’s not frozen, it has chemicals in it so it’s not easy to decide if we can change the way we eat because you’re not going to be able to eat the way you used to eat back home. More fresh [foods] and no chemicals in it. So, it’s not easy to change. Even if you decide to change, you’re not going to afford it.

Such critical appraisal of the lesson content was largely derived from reflection and critical comparison between their home country and the USA. Participants navigated and processed new information to make sense of changes in living conditions and to incorporate new information into their cultural customs and traditional practices. Such contextualising of information helped enhance their awareness of both the physical and emotional consequences of migration and resettlement, emphasising the roles and value of daily work and exercise, social life and support systems, and cultural and religious gatherings that traditional culture had provided. One Afghan woman explained what she missed after resettlement:

Because most women they are here, they are jobless, and they are housewives, they are looking for such a khaub [work] that they should have in their houses. For example, you know, if they have some work in their houses, they can do and they can support their children and also they can relieve their economic pain too. Another thing, big thing, is getting fat because some people when they come from Afghanistan, it is a chance to getting fat here. Whatever they are eating, they are getting fat, but maybe they don’t do exercise. In Afghanistan, we used a lot of energy, you know.

Congolese participants also focused on ways to bridge two cultural ways of living by applying information on nutrition and healthy foods to their traditional diet. They discussed the need to understand US ingredients, condiments and overall diet to identify and substitute ingredients for traditional foods from their home country. Similarly, Afghan women raised questions about their traditional foods such as ginger tea, which contains salt, and the health consequences of ingesting salt.

These understandings and navigations of the life transition associated with refugee migration were reported to lead to a redefinition of traditional lifestyles and re-negotiation of the meaning of healthy living in general. Participants reported that the reflective comparison between their two cultures involved grief over the loss of older cultural customs. Afghan participants, for example, missed celebrations of religious holidays and social gatherings known as maymandari (visits) and tafri (picnics), which allowed healthy participation in social events and community building. Despite such interrupted cultural practices, however, participants perceived the ruptured social life in the USA as a trade-off of living in much more safe and stable conditions than in their home country. Both refugee groups reported making efforts to incorporate traditional customs and cultural practices into what they have learned from the CHW, resulting in reflections on their cultural values and reconnections to the traditional ways of living that had been ruptured during the transition to a new life in the USA. Participants reported that this process of new knowledge incorporation and reflection on traditional customs also led to positive self-assurance and empowerment of cultural beliefs and practices.

Self-efficacy and confidence

Although some CHW contents, such as body–mind linkage and role of daily exercise and adequate sleep on body, were not completely new to participants, they reported that contents were still empowering in that they validated and affirmed existing beliefs and practices. The group setting of the CHW, in particular, helped increase participants’ self-efficacy and confidence by encouraging them to share coping strategies and common concerns and to interpret given information in a culturally relevant way. For example, one Afghan woman expressed an increased ability to understand and handle stress by hearing and learning from other group members:

I didn’t know before how to solve my problems. Now, I know that I can solve my problems by talking to my friends or family, go play with my kids, and release my stress. I know I can leave my stress for some time and then can return with a clear head to think about how to deal with my problems.

Another Afghan woman described her confidence in discerning controllable versus uncontrollable stress, stating that she now understood what she could do to control stressful situations in her family. Afghan participants also discussed how they used prayer and religious beliefs, as well as peer support, to cope with stressful situations.

Congolese participants shared that the CHW taught them that their community can help alleviate stress by providing support and helping to solve problems. Increased confidence was reported to lead to a positive emotional state. One woman stated,

I thought if I have a problem I can only be in my room by myself. I found out that I can talk about it with others and help the stress to come down. Usually, when I have problems and I keep it to myself, it’s only going to hurt nobody else but me. I’m just going to be with it and nobody’s going to help if I don’t get it out. I learned that meeting with other people and talk about it, it’s good. What we’re doing [workshop] here, it’s part of it too. We’re sharing everything. You [facilitators] are asking us for things without you thinking that we’re going to say everything that we have. Like her [one of the participants], you didn’t know her problem. But then getting it out and speaking it here, it helps.

A male Congolese participant expressed, ‘It is good not to keep things to ourselves and hold things in. It is good to talk to other people. Not talking about things makes little sense when it can be solved with other people’. The group experiences of sharing and seeking led the community members to advocate for their common needs while further empowering the participants, both individually and as a group.

Advocacy and empowerment

Participants reported that the CHW encouraged them to strengthen and renew cultural practices while helping accommodate their practice to a different cultural context. Afghan participants shared this sense of empowerment by accepting and valuing new family duties and roles gained after resettlement, such as beginning to drive and shop in grocery stores by themselves, which were traditionally considered men’s jobs in their home countries.

Such changes in lifestyles and roles were discussed as the group encouraged Afghan women to advocate both within and across the community. One Afghan woman explained how transport is important in order to access healthcare and other basic needs, advocating for driver’s licence manuals to be translated into her native language:

You know, driving lessons in here it is all in English, but this is in Farsi. A few months ago, I went to the DMV. Our language is Dari, but the language that they have translated in DMV and Virginia, it is all in Irani Farsi. But that is not in our own language. Some words, some things, they are totally different. People could not understand it here, but maybe we can suggest that if it is possible it should be in Dari. That will be good, because all the people that we have it in Dari and also in Pashtun if it is possible in the future.

Additionally, participants reported that the CHW was empowering and encouraged them to spread information throughout their community. One Afghan woman explained that she had acquired new skills through the CHW and planned to use what she had learned to help other community members:

It is a good thing that they learned how they can release and escape from stress by exercising and stretching. We got a lot of new lessons from these classes and affected a lot for them. For example, for this programme, around 10 or 20 or 16 women got this information and they can spread this information to one another. I think we should have a programme like this in the future. It would be nice and good.

By sharing information with other community members and by seeking materials to assist others, participants advocated for the further empowerment of refugee peers. Additionally, participants appreciated the opportunities to share their cultural experiences and religious values with people outside of their community, which reinforced cultural beliefs and practices and encouraged participants’ self-advocacy for more culturally responsive service provision in the community.

Problem-solving and collective action

Another theme prevalent in both groups was problem solving and collective action, which were often seen as concurrent and inseparable. When discussing stress management and emotional coping skills, participants redirected discussion to the source of stress and searched for solutions not only for the individual but for the group and the community, rather than focusing on how to deal with emotional distress. Congolese participants, for example, emphasised how the causes of stress, such as lack of transportation and childcare, obstructed access to English classes and induced stress. The Congolese female co-facilitator stated, ‘It’s hard to take care of that stress if she does not take care of that problem. I’m telling her, you know that problem, you’re going to take care of it first’. A focus on problem-solving was also common among Afghan participants, whose concerns related mostly to childcare and their children’s wellbeing. One woman explained how she was worried about her children’s future because they behaved differently once they came home from school. In response, an Afghan woman suggested a solution, stating,

About children’s education, they [children] can get together one hour a day and whatever religious [lessons] you can teach your children, be with your children and speak with your children. The child will get better and better every day. It is up to you. You can improve your children’s education this way.

Both groups extended this action-oriented focus to ways in which the CHW could help solve resettlement challenges within their communities. Afghan participants requested future workshops about knitting, sewing and gardening, including how to find a place to sell the goods produced through gardening and handwork. They explained that these solutions could help not only to reduce financial stress but also to improve a sense of empowerment and socialisation. Similarly, Congolese participants explained that they could alleviate stress if they were provided with financial literacy classes and access to farming space to produce healthy food. One male participant stated,

Another good thing to change the way we eat is if we find places for us to grow our own stuff. Is there a way for you [facilitators] to help us find a space where we can – he [one participant] says there are other communities – they have a space where they grow food and fruits there. He [another participant] is asking if there is a way we can have a space for us too where we can grow stuffs for a community, for us. That way we can have our own fresh stuff that we grew.

Reportedly encouraged by CHWs and group discussions, Congolese participants proposed forming a community organisation for regular meetings, having reflected on a traditional practice of sitting and talking under a tree to relieve stress and solve problems collectively.

Limitations

This study has several limitations. Convenience sampling of Afghan and Congolese refugees may limit the generalisation of findings to other refugee groups in different contexts. CHL domains may vary across refugee groups, depending on variations in education, literacy levels, gender, social status and geographical region of origin (Shaw et al., 2009). Additionally, the group of Afghan refugees consisted only of women, which likely affects the results of the study since gender influences levels and forms of health literacy (Cotton et al., 2006; Lee et al., 2015). Furthermore, the themes found in this study may not be comprehensive but were dependent on the intervention topics, such as nutrition, stress coping, and help seeking. While important in the understanding of health literacy, these themes do not involve medical treatment or patient–provider interactions, which are crucial to health outcomes and disparities (Suri et al., 2016). In addition, structural obstacles critical to health promotion, such as social discrimination, isolation or segregation, policy gaps and anti-immigrant sentiment and Islamophobia, were not explicitly discussed in the CHW curriculum nor in the focus group interviews. This led to the omission of capacity for political action and structural change that might have shed light on broader issues of health disparity in refugee populations. Different curricular frameworks (e.g. human rights–based health education, a structural competency framework or healthcare consumers as social change agents; Metzl et al., 2017; Mogford et al., 2010) with different refugee groups may expand and diversify our understanding of refugee CHL in future research.

Furthermore, social desirability and cultural biases need to be considered in interpreting the findings of this qualitative and cross-cultural research. Power relations between and among participants and researchers influence not only data collection and interpretation but also other aspects of the interaction (Ritchie et al., 2009). Our multicultural research team, several of whose members had immigrant backgrounds, cultivated fruitful exchanges between participants and facilitators and helped reinforce an egalitarian group process. Sharing important roles with respected community volunteers helped the transparency of the process. Despite such efforts, subtle meaning of power differences and cultural dynamics may not be fully captured in the study.

Refugee participants often perceived the CHWs as a lecture or a class due to limited experience with a highly engaging intervention programme or an empowerment approach which included participatory activities. Our team reassured participants when introducing this different educational format, suggesting health education may need to involve an orientation to new a learning style or learning-about-learning in some communities. CHWs as well as focus group interview meetings emulating a social circle (e.g. a traditional and informal group for social gathering) helped understanding and acceptance of group participation.

Implications

This study has implications for future research on CHL in refugee communities. Given the existing lack of culturally relevant health literacy measures grounded in refugee experiences (Wångdahl et al., 2014), future research may benefit from utilising the CHL domains identified in this study, which reflect refugees’ intercultural experiences during resettlement. In particular, researchers and practitioners may wish consider the unique strengths of refugees derived from their experiences of two or more cultures, such as cross-cultural comparison to integrate new and old health knowledge, and reappraisal and negotiation of the meaning of cultural practices. In addition, future interventions with refugee populations may find it important to pay attention to certain aspects of CHL that have been weakened during and after migration, such as community support systems and collective problem-solving, which are critical to individual and community health promotion. The CHL domains of this study suggest the need for health educational interventions based on the complex and multidimensional aspects of CHL rather than more general forms of health literacy. Since forms of CHL, such as empowerment and contextualising information and re-negotiating meanings, are as much a process as an outcome, a combined process and outcome evaluation and a mixed-methods design involving the triangulation of data may therefore be the best process to adopt in future research. Further elaboration of methodologies to investigate and consolidate CHL will help advance health promotion and the healthy adjustment of refugee populations who are in need of culturally adequate interventions and services.