” Enhancing health literacy can empower individuals and communities to take control over their health as well as improve safety and quality in healthcare.
However, Indigenous health studies have repeatedly suggested that conceptualisations of health literacy are confined to Western knowledge, paradigms, and practices. The exploratory qualitative research design selected for this study used an inductive content analysis approach and systematic iterative analysis.
Publicly available health literacy-related policy and practice documents originating from Australia, Canada, and New Zealand were analysed to explore the extent to which and the ways in which Indigenous knowledges are recognised, acknowledged, and promoted.
Findings suggest that active promotion of Indigenous-specific health knowledges and approaches is limited and guidance to support recognition of such knowledges in practice is rare.
Given that health services play a pivotal role in enhancing health literacy, policies and guidelines need to ensure that health services appropriately address and increase awareness of the diverse strengths and needs of Indigenous Peoples.
The provision of constructive support, resources, and training opportunities is essential for Indigenous knowledges to be recognised and promoted within health services.
Ensuring that Indigenous communities have the opportunity to autonomously conceptualise health literacy policy and practice is critical to decolonising health care. “
Gordon Robert Boot and Anne Lowell Charles Darwin University, Australia
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Image above from Menzies study : The aim of this study was to understand the interplay between health literacy, gender and cultural identity among young Aboriginal and Torres Strait Islander males living in the Northern Territory.
The health promotion sector is increasingly recognising that developing and improving individual, population, and provider health literacy (HL) is an important and effective strategy to enhance health and wellbeing, as well as to improve safety and quality in healthcare (Australian Commission on Safety and Quality in Health Care [ACSQH], 2014; Centre for Literacy, 2011; Johnson, 2014).
Integral to HL is the capability of individuals and the wider community to take active control and participate in addressing their healthcare needs (ACSQH, 2014, Johnson, 2014, Nutbeam, 2008).
Health outcomes can be improved through HL competencies that enable self-care and self-advocacy, development of mutual trusting relationships with health professionals, more effective access to and navigation of the healthcare system, as well as the ability of service providers to communicate effectively (Paasche-Orlow & Wolf, 2007, Sørensen et al., 2012).
Recent studies have highlighted that inclusion and promotion of Indigenous health knowledges within health promotion practices can enhance overall Indigenous health outcomes through mutual recognition of differing worldviews (Smylie, Kaplan-Myrth, McShane & Métis Nation of Ontario-Ottawa, 2008; Vass, Mitchell, & Dhurrkay, 2011), improved health communication (Lowell et al., 2012), and through strengthening cultural safety within culturally diverse healthcare systems (Rowan et al., 2013; Nielsen, Alice Stuart & Gorman, 2014).
However, representation of Indigenous health knowledges and practices within health literacy-related policy and practice documents does not appear to have been investigated in previous research.
The overall purpose of this paper is to present selected findings of a larger study (Boot, 2016), which has sought to address this knowledge gap by exploring the extent and means by which Indigenous knowledges, paradigms, and practices are recognised, acknowledged, and promoted within HL-related documents across Australia, Canada, and New Zealand.
This article focuses on two themes from the findings that have particular relevance: acknowledging cultural beliefs, practices, and norms, and promotion of Indigenous cultural health knowledges, paradigms, and practices (Boot, 2016).
The next section of this article explores definitions and context encompassing Indigenous health and health literacy. The Methods section describes in detail the exploratory research approach, document selection, and content analysis process.
The Findings section illustrates prominent examples from within the two themes that are represented within this article. The relevance and implications of these findings are further explored in the concluding discussion, and recommendations for future research are presented.
Background
Many countries, including Australia, Canada, and New Zealand, are considered to have world-class healthcare systems (Organisation for Economic Co-operation and Development, 2017).
Extensive efforts are made by governments and the health promotion sector to improve overall health and quality of life outcomes within these populations (Organisation for Economic Co-operation and Development, 2017).
The majority of people living within these countries have reasonably good health and enjoy an average life expectancy of 78 to 82 years of age (Australian Bureau of Statistics [ABS], 2015b; Statistics Canada, 2015; Statistics New Zealand, 2015).
All three countries have a similarly rich history of Indigenous cultures, knowledges, and languages, but life expectancy for many Indigenous people within these countries remains significantly lower, ranging from 69 to 80 years of age, in comparison with the national average (ABS, 2015a; Statistics Canada, 2015; Statistics New Zealand, 2015).
The health inequities Indigenous people experience today are predominantly linked to the effects of colonisation and persistently unfavourable social determinants (Dudgeon, Milroy & Walker, 2014; Griffiths, Coleman, Lee & Madden, 2016; Sherwood, 2013).
Governments and frontline health services aim to overcome these inequities by developing and implementing a variety of policies, strategies, and evidence-based approaches.
Defining Health Literacy
The concept of health literacy originates from the field of education and has in recent years expanded to include a wide range of skills and knowledges. Health literacy is commonly defined as the abilities and skills of an individual or community to access, appraise, and communicate health-related information, to navigate and engage with the healthcare system, and to advocate and maintain personal and community health and wellbeing (Centre for Literacy, 2011; Nutbeam, 2000; Sørensen et al., 2012; World Health Organisation, 2016a).
Governments and scholars advocate that developing and enhancing HL within populations supports the process of empowerment thereby enabling the individual, community, and society to take control over their healthcare needs and engage in collective action to promote health (ACSQH, 2014; Estacio, 2013; Freedman et al., 2009; Johnson, 2014; Kickbusch, 2009; Ministry of Health, 2015; Mitic & Rootman, 2012; Nutbeam, 2008; Sykes, Wills, Rowlands, & Popple, 2013).
Health literacy skills develop across the lifespan, are context specific, and influenced by social, cultural, and political contexts (Centre for Literacy, 2011; Kickbusch, Wait, & Maag 2006; Mitic & Rootman, 2012; Paasche-Orlow & Wolf, 2007; Vass et al., 2011; Zarcadoolas, Pleasant, & Greer, 2005).
Zarcadoolas et al. (2005), for example, asserted that cultural health literacy needs to be inherent within health literacy models. This is defined as having “the ability to recognize and use collective beliefs, customs, world-view and social identity in order to interpret and act on health information” (p. 197).
In addition, Ewen (2011) argued that health professionals need to obtain and effectively utilise cultural literacy skills in order for them to be culturally competent in their service delivery.
Cultural literacy is considered a skill-set that encompasses awareness, respect, and responsiveness to cultural differences and needs (Ewen, 2011). These abilities become critical within culturally diverse healthcare environments where worldviews, values, approaches to communication, and conceptualisations of health and wellbeing differ significantly from those endorsed by the dominant culture.
More recent conceptualisations of HL are increasingly recognising the significance and complexity of the health literacy environment: That is, “the infrastructure, policies, processes, materials, people and relationships that make up the health system and have an impact on the way in which people access, understand, appraise and apply health-related information and services” (ACSQH, 2014, p. 10). The Global Conference on Health Promotion in Shanghai in 2016 also identified HL as a critical social determinant of health that needs to be developed and strengthened within populations (World Health Organisation, 2016b). Enhancing HL skills within Indigenous populations, however, requires sophisticated cultural literacy and a collaborative, comprehensive, and empathetic approach due to the diversity in worldviews, perceptions of health and wellbeing, as well as complex sociocultural factors (Ewen, 2011; Smylie, Williams & Cooper, 2006; Vass et al., 2011).
Indigenous Concepts of Health and Wellbeing
Indigenous populations across and within each of the three countries that are the focus of this article
(Australia, Canada, and New Zealand) are diverse in terms of languages and their physical environment (urban, rural, level of remoteness, and climate), as well as political and social relationships, ancestral heritage, and cultural knowledges and practices (Dudgeon et al., 2014; Greaves, Houkamau & Sibley, 2015; Stephenson, 1995). Although Indigenous Peoples share some common health beliefs, their health knowledges and healing practices are diverse due to the unique social, cultural, political, and environmental circumstances within which they have developed and continue to exist (Dudgeon et al., 2014; Durie, 1994).
Despite this diversity, Indigenous people across all three countries tend to regard health and wellbeing as a holistic, multidimensional, and interconnected concept that cannot be separated from other aspects or fragmented into distinguishable individual units (Durie, 1994; Morgan, Slade & Morgan, 1997; Stephens, Porter, Nettleton & Willis, 2006). Health and wellbeing incorporates physical, psychological, social, ecological, spiritual, and cultural aspects and is sustained by nurturing and attending to all these relational aspects regularly in an appropriate and meaningful manner (Campbell, 2002; Durie, 1994; Morgan et al., 1997; Vukic, Gregory, Martin-Misener & Etowa, 2011; Wilson, 2008). Individual studies within all three countries similarly highlight how positive strengthening and maintaining of those interrelated aspects can provide preventative and long-lasting health benefits (Colles, Maypilama & Brimblecombe, 2014; Dockery, 2010; Hopkirk & Wilson, 2014; Lambert et al., 2014; Lowell, Kildea, Liddle, Cox & Paterson, 2015; Smylie et al., 2008; Wilson, 2008).
Previous research addressing Indigenous health concerns have identified HL-related barriers and challenges including racism, communication and language barriers, poor relationships, and culturally associated misconceptions (Durey & Thompson, 2012; Lambert et al., 2014; Lowell et al., 2015; Vass et al., 2011). Such challenges can significantly obstruct access to and provision of effective primary healthcare services, inevitably influencing health outcomes (Lambert et al., 2014). The need for healthcare systems to adequately acknowledge and incorporate Indigenous health knowledges within health promotion practices has also been identified (Hopkirk & Wilson, 2014; Liaw et al., 2011; Lowell et al., 2015; Nielsen et al., 2014; Priest, MacKean, Davis, Briggs & Waters, 2012; Rowan et al., 2013; Vass et al., 2011).
Incorporating and promoting Indigenous knowledges within an Indigenous healthcare environment has the potential to strengthen culturally safe practices and opportunities for self-determination, enhance health communication, and to foster relationships that are built on trust and mutual respect (Colles et al., 2014; Dockery, 2010, Hopkirk & Wilson, 2014; Lambert et al., 2014, Lowell et al., 2015). However, the majority of current conceptualisations of HL are commonly confined to Western pedagogies and paradigms. As such, they frequently disregard the significance of Indigenous cultures, languages, and knowledges as strengths, with potential health benefits (Akena, 2012; Barwin, 2012; Durey & Thompson, 2012; Lambert et al., 2014; Priest et al., 2012; Sherwood, 2013; Smylie et al., 2006; Vass et al., 2011).
Ingleby (2012) suggested that every person has some form of HL that is intrinsic to their personal and cultural beliefs. Enhancing HL within diverse populations can therefore only be achieved when distinctive personal and cultural beliefs are taken into account and appropriately acted upon (Ingleby, 2012). Indigenous concepts of holistic health and associated knowledges and practices have developed over millennia, ensuring individual and community survival, health, and well-being prior to colonisation and beyond. For example, Indigenous-specific HL includes knowledges and practices related to bush medicines and sourcing traditional food (Ewen, 2011) and the interconnectedness of language, physical, emotional, environmental, and spiritual aspects that as a whole contribute to health and wellbeing among First Nation people (Smylie et al., 2006).