Health literacy of ethnic minority in remote China: precise intervention is needed

Abstract

At the 9th Global Conference on Health Promotion SHANGHAI 2016, WHO has identified improving health literacy as one of the core mechanisms for achieving the Sustainable Development Goals (SDGs) [[1]Organization WH. Policy brief 4: Health literacy. World Health Organization Geneva; 2016.Google Scholar]. Yet health literacy of ethnic minorities in remote areas of China is far from favorable. Annual national surveys have shown that the proportion of Chinese residents with adequate health literacy has increased from 6.48% in 2008 to 23.15% in 2020 [[2]Wang P Mao Q Tao M Tian X Li Y Qian L Survey on the status of health literacy of Chinese residents in 2008.Chin J Health Educ. 2010; 26: 243-246Google Scholar, [3]China NHCo. National health literacy level rises to 23.15% by 2020 2021 [Available from: http://www.nhc.gov.cn/xcs/s7847/202104/6cede3c9306a41eeb522f076c82b2d94.shtml.Google Scholar]. Despite the improvement, substantial disparities still exist. For example, areas close to economic centers such as the east (29.06%)and central regions (21.01%) tend to have higher health literacy levels than remote areas in the west (16.72%), where a large number of ethnic minorities live [[4]Li Z Tian Y Gong Z Qian L. Health Literacy and Regional Heterogeneities in China: A Population-Based Study.Front Public Health. 2021; 9 (603325)Google Scholar]. Improving health literacy can improve health inequalities among ethnic minorities, and there is little research on this field for ethnic minorities. Health literacy has been defined by two levels, "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others" and "the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others." [[5]Santana S Brach C Harris L Ochiai E Blakey C Bevington F et al.Updating Health Literacy for Healthy People 2030: Defining Its Importance for a New Decade in Public Health.Journal of Public Health Management and Practice. 2000; (Publish Ahead of Print)Google Scholar]. The past several studies have shown that ethnic disparities in health literacy are real. Reasons have been identified as language barriers, limited literacy, unassessed health needs, and poor quality of available health information and services [6Chui CH Arat G Chan K Wong PWC. Growing Old as a Member of an Ethnic Minority in Hong Kong: Implications for an Inclusive Long-Term Care Policy Framework.J Appl Gerontol. 2020; 39: 463-471Crossref PubMed Scopus (5) Google Scholar, 7Liu Y Wang Y Liang F Chen Y Liu L Li Y The Health Literacy Status and Influencing Factors of Older Population in Xinjiang.Iran J Public Health. 2015; 44: 913-919PubMed Google Scholar, 8Vandan N Wong JY-H Fong DY-T. Accessing health care: Experiences of South Asian ethnic minority women in Hong Kong.Nursing & Health Sciences. 2019; 21: 93-101Crossref PubMed Scopus (8) Google Scholar, 9Wang C Li H Li L Xu D Kane RL Meng Q Health literacy and ethnic disparities in health-related quality of life among rural women: results from a Chinese poor minority area.Health Qual Life Outcomes. 2013; 11: 153Crossref PubMed Scopus (35) Google Scholar]. However, one should note that research on health literacy among ethnic minorities in China has remained observational [[6]Chui CH Arat G Chan K Wong PWC. Growing Old as a Member of an Ethnic Minority in Hong Kong: Implications for an Inclusive Long-Term Care Policy Framework.J Appl Gerontol. 2020; 39: 463-471Crossref PubMed Scopus (5) Google Scholar, 9Wang C Li H Li L Xu D Kane RL Meng Q Health literacy and ethnic disparities in health-related quality of life among rural women: results from a Chinese poor minority area.Health Qual Life Outcomes. 2013; 11: 153Crossref PubMed Scopus (35) Google Scholar, 10Cheng L Chen Q Zhang FY Wu W Cui W Hu X. Functional health literacy among left-behind students in senior high schools in an ethnic minority area: A cross-sectional study.Medicine (Baltimore). 2020; 99 (e19167)Crossref Scopus (1) Google Scholar, 11Vandan N Wong JY Fong DY. Accessing health care: Experiences of South Asian ethnic minority women in Hong Kong.Nurs Health Sci. 2019; 21: 93-101Crossref PubMed Scopus (6) Google Scholar, 12Wang A Scherpbier RW Huang X Guo S Yang Y Josephs-Spaulding J et al.The dietary diversity and stunting prevalence in minority children under 3 years old: a cross-sectional study in forty-two counties of Western China.Br J Nutr. 2017; 118: 840-848Crossref PubMed Scopus (24) Google Scholar]. The Chinese government is working on eliminating ethnic disparities in health literacy, primarily through promulgating health information [[13]China NHCo. Health China Action (2019-2030) 2019 [Available from: http://www.nhc.gov.cn/guihuaxxs/s3585u/201907/e9275fb95d5b4295be8308415d4cd1b2.shtml.Google Scholar]. The form and content of propaganda are similar across regions, including pamphlets, display boards, lectures, counseling activities, and individual health education alongside health services. However, ethnic minorities need more than this. Studies on health literacy interventions supported by theoretical models are rarely conducted [[14]Zhang Q Jia W Zhang J Zhan H. Effect of health literacy interventions with the stages of change on Kazakh-Chinese hypertension patients.Chinese journal of behavioral medicine and brain science. 2019; 3: 259-264Google Scholar]. Promoting health literacy requires precise and evidence-based interventions supported by a strong theoretical framework. Evidence from health literacy studies in the United States suggests that model-based health literacy assessment or intervention has led to a better understanding of the needs of community members from racial and ethnic minority groups and meeting those needs [[15]Handley MA Harleman E Gonzalez-Mendez E Stotland NE Althavale P Fisher L Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program.Implement Sci. 2016; 11: 73Crossref PubMed Scopus (49) Google Scholar, [16]Otto AK Ketcher D McCormick R Davis JL McIntyre MR Liao Y Using the health belief model to assess racial/ethnic disparities in cancer-related behaviors in an NCI-designated comprehensive cancer center catchment area.Cancer Causes Control. 2021; Crossref PubMed Scopus (1) Google Scholar]. In domestic, a comprehensive health literacy intervention study based on stage of changes theory (SCT) for Kazakh-Chinese hypertensive patients in pastoral areas is a good start; Zhang et.al. conducted this randomized controlled trial [[14]Zhang Q Jia W Zhang J Zhan H. Effect of health literacy interventions with the stages of change on Kazakh-Chinese hypertension patients.Chinese journal of behavioral medicine and brain science. 2019; 3: 259-264Google Scholar] came to a conclusion that the intervention combined health literacy with SCT is feasible and effective, and the short-term maintenance effects of the intervention is satisfactory. As discussed above, existing observational studies have identified several factors that may influence health literacy among ethnic minorities. Therefore, the next step should be carrying out intervention studies on health literacy among them for granted. In the present study, we would like to provide a process guiding the health literacy intervention of different ethnic groups. There are 55 ethnic minorities in China other than Han. Researchers can analyze the health literacy -related problems based on different backgrounds, nationalities, and scenarios they confront and make corresponding improvements. First, the health status of ethnic minorities differs from that of the Han due to high-intensity labor, residential segregation, ethnic culture, and living habits. For example, Lahu people are accustomed to sleeping in poorly ventilated kitchens and smoking water pipes, leading to a high incidence of respiratory disease. Therefore, being able to identify health-related problems of ethnic minorities and conduct problem-oriented health education is meaningful. Secondly, intervention protocols should be designed based on a sound theoretical model (e.g., theory of Planned Behavior, capacity,opportunity,motivation - behavior model, COM-Betc.). Given that health literacy interventions are population-oriented, the best option is a cluster randomized controlled trial at community level. Thirdly, language barriers and limited literacy are major challenges to health literacy intervention among minorities, making it important to choose the suited language as well as literacy-appropriate content. For instance, Lahu people don't have written language, then an educational picture like a smoker's lung serves better than a text pamphlet as an health literacy intervention. Eventually, make the goal of improving health literacy in ethnic minorities (Figure 1). Health China 2030 has made it a strategic objective to improve people's health literacy across the country. In such context, eliminating ethnic disparities in health literacy, thereby improving health inequalities among ethnic minorities in remote areas, is both a moral duty and a population responsibility. Existing approaches to improving health literacy among the population are universal, but such approaches are sometimes culturally insensitive, unfocused, and rigid. When national approaches for health literacy intervention favor the majority, as a minority, they need precise intervention. We declare no competing interests. The authors would like to acknowledge the work of Prof. Oscar H Franco in providing language-related advice. The work was supported by the Minister of Education of the People's Republic of China (0214513733/20192792) and Huazhong University of Science and Technology (5003513021).