Health Literacy Among Bhutanese Adult Refugees in the United States: The Sociocultural Approach

Abstract

Drawing on the accounts of literacy as socioculturally situated, this 2-year ethnography explores Bhutanese adult refugees’ health literacy at the intersection of their culture and experiences. This study illustrates the multifaceted relations between health literacy, culture, integration, and empowerment. This study indicates health literacy as sociocultural practice. Health literacy is mediated by Bhutanese adults’ oral tradition, language, education, and experiences over time. This study highlights health literacy as sociocultural participation—it resides in individuals’ community engagement. Rather than simply describing their limited functional health literacy as “a big problem,” this study recognizes Bhutanese adults’ ability to take action to improve personal and community health. This study challenges the deficit view rooted in adult literacy. It advocates integrating health literacy into adult literacy education to raise public awareness that health literacy promotes social justice, human rights, and world citizenship. Implications for a bottom-up approach to health literacy education are provided.

Keywords

health literacy adult literacy adult education Bhutanese refugees language culture

“[When] I’m sick, my children take me to the hospital. I can’t say, read, and express my feelings in English. I pray and take traditional medicine quietly without letting them [children] know,” said Tika, in describing her experience with health literacy. Tika, a 65-year-old ethnic Nepali from Bhutan, who had stayed in the refugee camp in Nepal for 19 years, was eventually resettled in a Northeastern U.S. city in 2008. Refugees like Tika have been resettled annually in the United States since the Displaced Persons Act of 1948, the first refugee legislation in the United States, was enacted (U.S. Citizenship and Immigration Services, 2018). The Bhutanese has been one of the top seven origin groups to resettle during the past decade. Almost half of them were illiterate in their native language and had no or little education (Capps et al., 2015). Their linguistic, cultural, and educational capacity poses challenges for health and literacy providers.

Health literacy has received increasing research attention. Inadequate health literacy contributes to unhappiness, medication errors, and other health problems (Hester, 2009; U.S. Department of health and Human Services, 2010). Most studies are conducted in the fields of medicine and health with a focus on health literacy as a set of oral and written skills (Smith et al., 2009; Wångdahl et al., 2014). However, rarely explored is the influence of culture on health literacy.

To date, the contribution of adult literacy to health literacy literature has been very limited, particularly in the United States. The seminal adult literacy studies, the 1992 National Adult Literacy Survey (Kirsch et al., 1993) and its update in 2003 (Kutner et al., 2005), estimate that almost half of adult Americans lack adequate literacy skills to manage their own health care. Studies in adult literacy indicate that readers’ familiarity with health documents is likely associated with their reading difficulties, particularly, for people with low literacy skills (Cohen & Snowden, 2008; Mosenthal & Kirsch, 1998). Indeed, patients who read below the ninth-grade level have trouble reading written medical information and need simplified written instructions with culturally sensitive pictures (Murphy et al., 1993). Additionally, Feinberg et al. (2018) study on patient–provider oral communication demonstrates that patients with lower literacy levels are asked more closed-ended questions for biomedical and psychological information than those with higher literacy levels. Such studies on the relationship between adult literacy and health are mostly quantitative in nature. Heath literacy research continues to grow and attain increasing attention in and outside the United States in the fields of medicine and health (Bailey et al., 2013). However, little research has been done in the field of adult literacy and adult education, and even less qualitative studies with the 708,354 refugees resettled in the United States between 2007 and 2017 (Zong & Batalova, 2017).

Thus, drawing on a 2-year ethnography in a Bhutanese community in a Northeastern U.S. city, this study aims to explore Bhutanese adult refugees’ health literacy at the intersection of their culture and experience. Two research questions guide this study:

Research Question 1: What are Bhutanese adult refugees’ health literacy practices?

Research Question 2: How are their health literacy practices connected to their culture and before- and after-resettlement experience?

Conceptual Framework

This study draws on the accounts of literacy as socioculturally situated (Barton & Hamilton, 1998; Heath, 1983; Street, 1995). Unlike a skills-based notion of literacy, the sociocultural view of literacy focuses on the contexts of literacy and its linkage to experiences, identities, and power relations in society. The sociocultural view on literacy is also found within Barton’s (2001) concept of text, which means to understand literacy—written or spoken—is to understand the ways that words, things, behaviors are used in social contexts. Inspired by the view of literacy as socioculturally situated, the first author’s own previous studies reveal not only how immigrants’ and refugees’ everyday practices shape and are shaped by literacy but also how their literacy access is fashioned for personal, social, and community development in relation to culture, education, and class (Chao, 2013, 2019; Chao & Kuntz, 2013; Chao & Mantero, 2014; Chao & Ma, 2017).

The sense of sociocultural situatedness in literacy is reflected in the definition of health literacy. In Zarcadoolas et al. (2005, 2006) work, health literacy refers to the ability not only to understand health information but also to navigate the health care environment and take a proactive approach to health care. Nutbeam (2000, 2008) acknowledges health literacy as a public health goal and characterizes it with three levels: functional, interactive, and critical. Functional health literacy is defined as the basic skills to understand health information; interactive health literacy indicates the ability to apply health information to achieve health in everyday practices; and critical health literacy is the advanced ability to critically interpret health information and the impact of social conditions on health, and use these insights to attain greater control and power in life. Nutbeam’s three-level conceptualization of health literacy recognizes health literacy as multifaceted and a tool for individual and community empowerment.

The U.S. Institute of Medicine (2004) further indicates health literacy as “mediated by education, culture, and language.” As Zarcadoolas et al. (2005, 2006) stress, one domain of health literacy—cultural literacy—which individuals’ health practices are bound with their beliefs, customs, and identities. The existing scholarly literature indicates that refugees’ cultural beliefs shape their health literacy in the United States, especially that of recent arrivals from developing countries where access to biomedicine is much more limited and traditional medicine and spiritual coping are still embraced. For example, Hmong refugees hold medio-spiritual beliefs such as cutting open the body and talking about death directly as taboos (Fadiman, 1997). Vietnamese refugees use herbal medicine as treatment rather than complying with a medication regimen (Ito, 1999). Haiti refugees may listen to a spiritual healer as a preventive tool for mental and physical health rather than seeing a doctor (James, 2011). These studies illustrate how the complexity of culture influences health disparities. As Shaw et al. (2008) indicate that cultural traditions are an integral part of an individual’s ability to understand and act on their health literacy. They emphasize the importance of cultural and literacy brokers in bridging linguistic, cultural, and health divides for both patients and health providers.

Literacy and cultural brokering in refugees’ health literacy has received increased attention worldwide. Perry’s (2009) ethnographic study on literacy brokering among Sudanese refugees in the United States describes literacy brokering as “a complex activity that may involve . . . translation of word meanings, mediation of cultural content, or explanation of genre aspects . . . ” (p. 257). Similarly, in her study on immigrants’ health literacy in England, Papen (2009) finds that immigrants often seek health literacy mediators who can help them with literacy and cultural barriers. These studies indicate that literacy is achieved collectively by individuals’ sociocultural network. There is a need in the current literature to understand how literacy brokers/mediators draw on cultural and linguistic resources for meaning making as they engage in health practices.

Health literacy is also considered as social justice and empowerment for achieving and maintaining well-being among people and community, especially those with low education and poor health (Hill, 2004; Rudd et al., 2004). The multifaceted relations between health literacy, culture, education, and society resonate with the Freirean approach to adult literacy as empowerment and cultural action for freedom (Freire, 1970). The interactions between health literacy and adult literacy and learning provide critical insights in understanding Bhutanese refugees’ literacy sponsors (Brandt & Clinton, 2002) including individuals, families, and communities as well as the relationship of health literacy promotion to their experiences, challenges, and opportunities.

The conceptual framework of this study draws on the sociocultural view of literacy which emphasizes the situated contexts of literacy and supports the significance of health literacy within everyday practices. The socioculturally situated notion of literacy highlights the argument of Green et al. (2007): people construct their health literacy, experience, and knowledge within their own situated context. The situated nature of health literacy helps this study understand how Bhutanese refugees interpret and practically shape their health care experiences in relation to their interconnected beliefs, behaviors, needs, and customs. In what follows, we provide an overview of Bhutanese refugees’ historical and sociocultural situations and the association between culture and refugees’ health literacy.

Overview of Bhutanese Refugees

More than 86,000 Bhutanese refugees have resettled in the United States since late 2007 after living in the camps in Nepal for nearly two decades (Immigration and Nationality Act, 2017). Of the Bhutanese refugee population in the United States, almost 97% are ethnic Nepalis (Center for Applied Linguistics, 2007). Ethnic Nepalis were originally brought to Bhutan as laborers by the Bhutanese government. They highly retain their Hindu culture and Nepali language, while ethnic Bhutanese speak Dzongkha, the national language of Bhutan, and are Buddhists (Giri, 2005; Hutt, 2003).

In the 1980s, the Bhutanese government adopted a series of policies named as Bhutanization, which aimed to impose the Dzongkha majority language and Buddhist culture on the ethnic Nepalis (Hutt, 2003). Some ethnic Nepalis protested against the Bhutanese government to defend their right to maintain their ethnic, cultural, and linguistic identity. The Bhutanese government suppressed the protests. To avoid persecution and arrest, tens of thousands of the ethnic Nepalis fled Bhutan to take refuge in Nepal in the early 1990s (Evans, 2010; Hutt, 2003). There they were mostly confined to camps and not allowed to integrate locally.

Most Bhutanese adult refugees in the United States identify themselves as farmers with little education, knowledge of Western life, and are illiterate in both the Nepali and the English languages (Center for Applied Linguistics, 2007). They practice traditional medicine alongside modern medicine. Bhutanese refugees face great difficulties in English learning in the United States, where everyday practices heavily rely on the ability to read and write in English (Chao, 2019). They also experience literacy and cultural barriers to accessing health care and addressing health issues individually or within families (Chase & Sapkota, 2017). Yet it is still unknown how these barriers construct and are constructed by Bhutanese refugees’ culture and daily health literacy practices. The overview on Bhutanese refugees offers this study a space to explore the influence of culture on their health literacy.

Research on the association between culture and health literacy among refugees is emerging, but very few studies have been done with Bhutanese refugees. This study provides a fuller understanding of cultural diversity and accommodating this diversity in adult health literacy. Given literacy as socioculturally situated, this study design is ethnographic in form (Barton & Hamilton, 1998).

Ethnographic Design

Setting and Participants

This study is drawn from a 2-year (2016-2018) multisited ethnography, with 25 Bhutanese adult refugees who had been resettled to a Northeastern U.S. city. The city has been a major city for refugee resettlement during the past decade, and a significant portion were from Bhutan. This ethnography examines the ways Bhutanese refugees understand their literacy, culture, and integration in the local community.

Three Bhutanese adult refugees were selected as key participants by purposive sampling (Merriam, 2002). They were unemployed and stay-at-home grandparents. The inclusion criteria included (a) being in the middle adulthood (aged 45-65 years), (b) practicing Hinduism, (c) lacking education and literacy proficiency in both Nepali and English languages, (d) living together with family, and (e) having long-term experiences with health care providers after resettlement.

We obtained verbal and written informed consent from participants with translation assistance from their family members. To gain a fuller understanding of their health literacy, we recruited the adult participants’ health literacy brokers as key participants also. They were neighbors or relatives of the adult participants, proficient in both Nepali and English languages, and had a college education. The participants’ profile is presented in Table 1.

Table 1.

Bhutanese Refugee Participants’ Profile.

	Pseudonym	Gender	Age, years	Health status	Education	Years in United States
Adult participants	Tika	Female	65	Poor	No schooling	8
	Mihiri	Female	49	Fair	Second grade	5
	Bhudal	Male	56	Poor	No schooling	6
Broker participants	Dhal	Male	48	Good	Some college	3
	Khar	Male	46	Good	Some college	8
	Simena	Female	42	Good	Some college	6

Researchers’ Positioning

We held the insider-and-outsider positioning (Geertz, 1983) to deepen our understanding and process of this study. The first author was a newly arrived Asian immigrant and a language teacher educator at a local university. She was also an ethnographer and volunteer English as a second language (ESL) teacher in the Bhutanese community. Her personal and professional experience developed her insider’s perspective in understanding refugees’ language and sociocultural adjustment. This insider positioning allowed her to build rapport with participants and “experience-near” (Geertz, 1983, p. 57) perspectives of the study. Though first author’s nonrefugee positioning limited her understanding about refugee life, her increased involvement in the community made her popular and people in the community often called her “Dr. Sunshine.” This signaled that the first author was both an insider to the community as an ESL teacher and an outsider as a researcher.

The second author was a college student majoring in biomedical sciences. She served as a fieldwork research assistant. She was an outsider to refugees’ literacy and community practices. Her outsider positioning allowed her to attentively listen to participants’ experiences and construct “experience-distant” (Geertz, 1983, p. 57) perspectives of the study. Our multiple positionings allowed us to co-construct knowledge in understanding cultural influences on Bhutanese adults’ health literacy.

Data Collection

Fieldwork consisted of observations, fieldnotes, artifacts, and over 80 hours of audio recorded semistructured interviews with participants. We interacted with participants twice a month in various sites that formed their early experiences in the United States, such as refugee households, community-based ESL classrooms, and hospitals. We took observational fieldnotes (Emerson et al., 1995) in the interactions to record the contexts and health literacy activities in which participants engaged. These fieldnotes worked as a tool to elicit further information in the next interviews and observations with participants.

All of our semistructured interviews with adult participants were conducted in the Nepali language with translation from their family members or literacy brokers and then transcribed and translated into English. Interviews with literacy broker participants were conducted in English. The interview questions focused on participants’ culture and experiences regarding health literacy both before and after resettlement. Finally, we collected health literacy artifacts such as health information texts and photographs of medicinal plants from the participants. These artifacts contextualized our interviews with participants to examine how they interpreted and named the artifacts. These multiple data sources provided triangulation for the emergent themes.

Data Analysis

We applied the constant comparative analysis method to identify the nature of health literacy among Bhutanese adults (Corbin & Strauss, 2008). To increase verification of the analysis, this method systematizes the analysis process through constant comparisons until substantive concepts emerge from the data. Our data analysis occurred through four steps. We began with independent data interpretation until categories emerged, with close attention to participants’ use of culturally relevant terms and meaning making regarding health literacy. We wrote analytical memos by relating the data to theories and existing scholarly literature. Then, we shared and discussed our categories and memos, which led us to multiple critical reviews of the data set. Next, we established a confluence of themes, related codes, and diagrams to illustrate the interactions among the triangulated data. Finally, we used member checks (Corbin & Strauss, 2008) to obtain participants’ approval, confirmation, and comments on the themes.

The findings may be of use for health literacy research with immigrants, refugees, and even nonimmigrants. However, the generalizability of the findings is limited by the small sample, the cultural interdependence of health literacy, and the uniqueness to the Bhutanese refugee group.

Findings

The findings are responsive to the research questions regarding Bhutanese adult refugees’ health literacy practices and their connections to Bhutanese culture. They are framed under three elements which constitute Bhutanese refugees’ health literacy in the United States: linguistic, cultural, and social.

Linguistically Conditioned Health Literacy

The participants reported that they experienced language and literacy barriers when they engaged with health practices. These barriers were embedded in both spoken and written practices such as reading prescriptions and patient–provider communications. The participants emphasized that English language and literacy was “the most important thing” for them to access health care. Mihiri explained as follows:

I had a health emergency. I dialed 911. I couldn’t tell [the operator] my home addresses in English. My mind was empty. I was nervous, sweaty. My neighbor called [an] ambulance for me. (June 16, 2017, interview)

When communicating with health service providers, Bhudal also expressed that he felt “weak,” “not useful,” and sometimes like “a disabled person”: “I could only say ‘hello’ to doctors. I could not read and renew health insurance letters. I didn’t know how to pay the bills, talk with pharmacy people . . . ” For others like Tika, they described their children and health literacy broker as their “tongues.” Tika further emphasized the importance of English language and literacy for participation in health practice:

I want to talk with doctors [about] how I feel, where my pain is, and my health history in the camp and here. It is really hard. Language is a big problem. I am silent and see them talking about me to each other. (February 4, 2017, interview)

Tika felt marginalized and “othered” in her hospital visits. In Tika’s words, the adult participants viewed their English language and literacy as “a big problem,” which resulted in difficulty in health communication. Data from this study indicate that the adult participants’ lack of English language and literacy was associated with their limited participation in health care and their loss of a sense of self in communications with health care providers.

Their health literacy brokers also experienced communication difficulties with both the adult participants and health care providers. In particular, when they translated “big words” such as muscle cramping into Nepali language, the broker participants usually asked doctors to “elaborate big words slowly in simple words” and “explain or clarify.” They indicated that some “big words” sounded simple but carried significant conceptual information. They needed to understand the meanings of “big words” before applying them in Nepali language.

Also, due to the adult participants’ low education and limited understanding of what these words mean, the broker participants could not use direct translation. To help the adult participants better understand the meanings of “big words,” they had to frame such meanings in a way that made them understandable and familiar to the adult participants’ situated experiences.

At the same time, the broker participants encountered difficulties with Nepali language. Simena indicated,

When doctors use words that I don’t know how to say them in Nepali, I use Google Translate or I just talk around the words and keep saying stuff that are related to the words. When I can’t use Nepali language, I just use English. (August 6, 2017, interview)

This was why the broker participants like Simena preferred face-to-face interpretation. Khar explained, “the expression of face and gestures are the other supporting language for interpretation.” It is important for the broker participants to have visual cues, gestures, and have options to ask for clarification and repetition in health interpretation.

Data from this study illustrate that the adult participants’ low education is associated with their difficulties in health communication. Dhal commented as follows:

Many Bhutanese elders have not been to school. It’s hard for them to understand big words in Nepali also in relation to health. I just use words that they are familiar to explain what doctors say. Many times, they can’t tell where they have pain. They say, “I have pain everywhere.” (January 6, 2016, interview)

Due to lack of education and language and literacy proficiency, the adult participants encountered barriers to explaining their medical situation and participating in health communication. In particular, it was hard for them to understand those “big words.” Khar added,

A lot of elders don’t know about health. They think they have only bones, skin, and blood. They have no idea about what’s wrong with their body, and [find it] hard to identify their medical problems. (August 24, 2017, interview)

The broker participants drew on their Nepali language, visual support, and familiarity with Bhutanese refugees’ backgrounds to facilitate their interpretation.

Health literacy involves not only the ability to read health information but also the cognitive and sociocultural skills to gain access to and use health care information (Nutbeam, 2000, 2008). Hester (2009) argues that U.S. adult native English speakers’ communication is related to their ability to comprehend written health care information. Unlike nonimmigrant adults with limited health literacy, this study demonstrates that the uniqueness to recent refugees and immigrants in a health care encounter is both the oral and literate language barriers. They felt more disempowered by not knowing the English language and the health paradigm with which they interact. Furthermore, they also had difficulties in navigating the U.S. health care system, which is culturally different from that of Bhutan and the camp.

Culturally Bound Health Literacy

Cultural literacy is connected with and guided by values, beliefs, and religions (Barton & Hamilton, 1998; Zarcadoolas, et al., 2005). It is evident from our data that there is a complex interplay of Bhutanese adult refugees’ experiences, beliefs, customs, and religious identity in the U.S. health care system. This interplay influenced the participants to interpret and act on health literacy.

Bhutanese adults’ traditional health culture and treatment was typically conveyed orally. Dhal explained, “Many don’t know anything about health. If someone suggests them to eat something, they eat it. They don’t check the label. Not by reading, but by others’ words and experiences.” Bhutanese adults learned about health from “what they see” and “what people say.” Their cultural literacy is built on oral traditions. Yet the U.S. health care culture is mainly “textually mediated” (Barton, 2001, p. 93), meaning health literacy is not only practiced by spoken language but also by reading and writing. Nonetheless, none of the adult participants were able to read their visit summaries and patient education handouts even in the Nepali language, let alone become health literate from reading them.

The participants described these language and literacy health practices as “a big headache.” They reported that telephone interpretation facilitated their understanding of health communication. However, they felt that their information was “broadcasted.” The adult participants preferred their family members or relatives to serve as their health literacy brokers. It was “really hard” for them to understand American health care culture and documents. Following document familiarity in aiding adult literacy (Cohen & Snowden, 2008; Mosenthal & Kirsch, 1998), the participants’ unfamiliarity with American health care culture and documents increased their barriers to navigating the American health care system.

Data from this study also demonstrate that Bhutanese adults believed in traditional health practices, healing, and nutrition, which they used in Bhutan and the refugee camps. In their words, “we grew up in that way,” as our fieldnotes indicate:

When Bhutanese refugees were in Bhutan, they had to walk an hour or more to reach hospitals. In flooding seasons, there was no way to reach hospitals. They used traditional healers like shaman, people believed to have the supernatural power to remove sickness and the bad spirits from sick people. Traditional healers continued to exist when Bhutanese adults were in the camps. (November 19, 2016, fieldnotes)

Limited access to health care in Bhutan and the camps resulted in the participants’ habit of delaying seeking medical treatment. They viewed medical service such as hospital visits as “privilege” and only for “emergency” or “the worst situation.” Tika sometimes viewed medicine as helpless. She thought that “the bad spirit” caused the sickness. For Bhutanese adults like Tika, using traditional healers is part of their health literacy practice. Our data indicate that health literacy exists in a sociocultural matrix. Health literacy in the United States is perceived as human rights and personal and social empowerment (Rudd et al., 2004). However, there is a meaningful gap between Bhutanese ideas in the camp and Bhutan and American notions of health literacy.

The participants’ sociohistorical and sociocultural experiences translated into their health literacy practices after resettlement. They usually tried traditional medicine first when they were sick. If the sickness got worse, they went to see doctors. They expressed that they often relied on traditional medicine including medicinal plants and materials such as turmeric, aloe, tulsi, lemon, spinach, and salt. Figure 1 illustrates traditional medicinal plants in Bhudal’s home.

Figure 1.

Medicinal plants in Bhudal’s home.

Simena commented, “50% of Bhutanese people’s mind is covered by traditional treatment. They are culturally different in understanding food and exercise.” Mihiri said, “Dal bhat is our traditional food but doctors here say eating rice twice a day is not good.”

When asked about their ways of exercise, Mihiri continued, “Working in the field before. Now, we have no field, no exercise.” “Working in the field” was the main exercise for the participants before resettlement. Khar commented, many adults viewed jogging or running as “kids’ work” and “crazy.” Cultural differences in health care present a challenge for Bhutanese adults to engage in American health practice.

Religion was also associated with Bhutanese adults’ health literacy. Tika expressed, “my religion teaches me to keep home hygiene.” Our observation data demonstrate that the adult participants’ homes were clean and tidy. When they or their children were sick, they prayed for help from Hindu gods. Simena and Mihiri, respectively, used religion as “an indirect effect” and “a resource” to describe the role of religion in guiding their health practices. Dhal acknowledged the intersection between Bhutanese adults’ culture and health literacy: “Culturally, Bhutanese people have knowledge and ideas about health.” Khar indicated Bhutanese adults expected “culturally responsive doctors,” who could “understand what problems we faced in the camp” and treated them as human beings rather than “broken machines” in primary care interactions. Yet our data indicate it was a challenge for them to reach culturally responsive doctors.

Bhutanese adults had their own ways of knowing, understanding, and acting on health literacy. Their oral culture and tradition created a challenge when they transitioned to the reading and writing demands of the U.S. health care system.

Socially Constructed Health Literacy

Data from our study indicate that Bhutanese adults’ health literacy is shaped by their situated social context. The participants felt challenged to manage health after resettlement. Tika noted,

I was busy and happy in Bhutan and the camp. I had friends chatting, singing, talking about holy books. But nothing like that here. I have many [health] problems here. I am really confused why. I have doctors and everything here is better. Maybe because we live separately and I am alone a lot. (June 20, 2017, interview)

Bhudal also echoed Tika’s loss of socialization and exercise after resettlement: “I used to work in the field in Bhutan and the camp. Now, I sit home like a rock everyday.” The adult participants felt it difficult to adjust to the U.S. lifestyle. They felt lonely and had no sense of worth.

Bhutanese adults expected community-based social activities. Tika said, “I like to have easy nearby yoga classes, old-age clubs. We get together and talk about health over there. I go to the yoga class by the Bhutanese community, but it’s only once a week.” Likewise, Mihiri noted, “I like to have volunteers explain about diet, nutrition, and get people together to talk about health, so I can go around and not have to remain within the apartment alone.” The adult participants desired to participate in community-based health literacy practices to “mingle with people” and “learn about health.”

The participants expected television could be a resource for learning health literacy in their social practices. Our data illustrate that watching TV was the adult participants’ main health literacy practice. They mostly watched entertainment programming such as Nepali singing or dancing for “fun” or watched cartoons with their grandchildren. They expected to watch types of programming connected with healthy lifestyles. As Bhudal noted, “There is no program about health. I get curious to watch if it’s about health, like yoga even in simple English language.” In the notion of Nutbeam’s (2000) interactive health literacy, the adult participants viewed watching health TV programs and socializing into community as part of health literacy practice. Doing so could allow Bhutanese adults to “mingle with people” and extract new health information.

Bhutanese adults also intentionally collect health literacy artifacts like the food pyramid to guide their daily health practices. This is well exemplified in the healthy diet flyer which Khar received from his children’s school as shown in Figure 2.

Figure 2.

Health literacy flyer in Khar’s home.

Khar noted, “The flyer teaches my family to balance diet. Such materials are helpful.” Data from our study challenge the deficit view rooted in adult literacy that negates adults’ resources and motivation to learn (Belzer & Pickard, 2015),

The participants experienced health literacy from the high collective and oral culture-mediated society of Bhutan and the refugee camp to the high individual and “textually mediated social world” (Barton, 2001, p. 93) of the United States. They encountered linguistic, cultural, and social barriers not only to medical settings but also to everyday settings. These barriers did not allow them to engage meaningfully in the U.S. health care system and daily practice of health literacy.

Discussion

Drawing on the accounts of sociocultural situatedness in literacy, this study explores Bhutanese adult refugees’ health literacy at the intersection of their culture and experiences. It highlights language, culture, and beliefs as an integral part of health literacy (Shaw et al., 2008). We argue health literacy as sociocultural practice. It is a connecting concept. At the individual level, health literacy is intrinsically intertwined with Bhutanese adults’ linguistic, cultural, and social elements. At the collective level, health literacy is bound to both individuals and their situated contexts. Indeed, health literacy is constructed, shared, practiced, and learned mainly through oral culture among Bhutanese refugees.

Our study finds that Bhutanese adults’ health literacy is mediated by language, culture, education, and experience over time. In their words, “we grew up in that way.” Following cultural literacy (Zarcadoolas et al., 2005, 2006), health literacy is socioculturally specific and dependent. Bhutanese adults’ cultural literacy incorporates various types of health practices in their situated contexts. Bhutanese adults acquire health literacy via authentic daily conversations with families, friends, and neighbors while “working in the field” and “mingling together.” In their words, Bhutanese adults’ health literacy acquisition is mainly shaped “not by reading, but by others’ words and experiences.” They hold together to construct health literacy explicitly in and through oral culture.

After resettlement, Bhutanese adults encounter difficulties in understanding the textually centered and implicit American health care culture. They rarely participate in “textually mediated communities of practice” (Barton, 2001, p. 100). Like Tika, Bhutanese adults rely heavily on their “tongues”: children and literacy brokers. For them, their limited language and literacy proficiency is “a big problem,” and their social life is like “sit[ting] home like a rock everyday.” Their low functional health literacy and isolated social life translate into their “othered,” “useless,” and “disabled” social identities.

Consistent with previous research (Belzer & Pickard, 2015; Hill, 2004), our study challenges the deficit view rooted in adult literacy that ignores cultural differences and negates individuals’ resources, knowledge, and motivation to learn. Bhutanese adults conceptualize religion as “an indirect effect” and “a resource” of health literacy. Their religious practices such as praying not only serve as a macro-level force that signifies empowering them to deal with sickness but also as a micro-level tool embedded in their daily practices such as “keep[ing] home hygiene.” This study yields a fuller insight into health literacy as everyday practice across the life course.

Rather than simply describing their limited functional health literacy as “a big problem,” this study recognizes Bhutanese adults’ ability to take action to improve personal and community health. These actions include building own literacy sponsors (Brandt & Clinton, 2002) such as literacy brokers and ethnic community-based yoga classes, collecting school-based health literacy artifacts, making and taking their traditional medicine, and hoping to “mingle with people” and “learn about health.” Following Nutbeam’s (2000) notion of critical health literacy, Bhutanese adults draw on their autonomy and culturally grounded traditional knowledge to take individual and social action to empower their individual and community capacity to adapt to the U.S. health environment.

Bhutanese adults have their own ways of knowing, doing, and valuing to understand and enact health literacy. Findings from this study indicate health literacy as sociocultural participation. Health literacy evolves when Bhutanese adults engage in community practices. Thus, health literacy resides in refugees’ sociocultural integration—it is “shared knowledge and expertise” (Papen, 2009, p. 27).

Consistent with studies in adult literacy (Cohen & Snowden, 2008; Mosenthal & Kirsch, 1998; Murphy et al., 1993), this study indicates that Bhutanese adults’ limited education, illiteracy in both Nepali and English languages, and unfamiliarity with American health documents and culture are associated with their health communication difficulties. Bhutanese adults need simplified and culturally responsive explanation and instructions. Understanding “big words” is complex for Bhutanese adults. Their health literacy brokers mainly draw on things familiar to Bhutanese adults to recontextualize the meanings of “big words,” facilitating their understanding from the familiar to the unfamiliar.

As suggested by the opening quote from Tika, refugees arrive in the United States with language and literacy barriers, traditions, and experiences with health literacy. This study illustrates the multifaceted relations between health literacy, culture, integration, and empowerment. While this study examines Bhutanese refugees’ health literacy practices, problems, and challenges, these factors may be shared by immigrants and nonimmigrant U.S. residents. Optimizing health literacy has potential not only for improving individuals’ well-being but also for empowering them in social integration. This study implicates a shared interest, effort, and opportunity for local forces to work together to improve health literacy and adult health education.

Implications

The contributions of this study are both theoretical and practical. On the theoretical level, from Bhutanese adult refugees’ health literacy practices before and after resettlement, we build on the multifaceted and multilevel conceptualization of health literacy (Nutbeam, 2008). In particular, we present a sociocultural approach to health literacy which highlights the complex nature of health literacy; that is, health literacy is not only a linguistic construct but also a socioculturally defined construct. It intersects with individuals’ sociocultural identities and practices. The findings of our study also offer theoretical insights for the Freirean pedagogy of adult literacy and adult education, aiming toward critical perception through authentic dialogues grounded in learners’ histories and experiences (Auerbach, 2000; Chao, 2019; Chao & Kuntz, 2013; Chao & Mantero, 2014; Freire, 1970; Freire & Macedo, 1987; Graman, 1988). In such dialogues, both learners and teachers critically reflect on contexts and beliefs and create a shared opportunity to read the “word-world” (Freire, 1983, p. 8).

On the practical level, our research suggests a bottom-up approach to adult literacy, particularly in the promotion of educational opportunities for refugees. In adult literacy classrooms, health literacy instruction can be delivered from Freirean theory to empower individuals and communities. It can be integrated into refugees’ everyday practices by linking their cultures and experiences. Doing so enables refugees to read both the word and the world and understand health literacy as social justice, human rights, and world citizenship. Developing critical health literacy can empower refugees not only in the medical and adult education classroom settings but also in their everyday practices.

Outside adult literacy classrooms, as well, health care providers, adult literacy programs, schools, faith-based organizations, and public libraries can become health literacy sponsors to integrate language, culture, and community to improve refugees’ health literacy. To shorten sociocultural distance between patient–provider communications, health literacy sponsors may provide refugees field trips such as health clinic visits. Doing so can help refugees become familiar with medical environments and know that health services are accessible to them. Also, health literacy sponsors can invite health literacy brokers as guest speakers to bridge refugees’ cultures and experiences with health literacy and that of the U.S. health care system. Moreover, health literacy sponsors can apply health literacy media in instruction such as health TV programs in simple English to help refugees seek health care information.

The bottom-up approach to adult literacy education we presented here encourages greater participatory learning communities (Auerbach, 2000) in which practitioners need to see the “bigger picture” of learners and understand how their sociocultural experiences shape their ways of learning, doing, and being. Such understandings help practitioners involve different ways of learning and valuing in practice rather than simply rote learning and imparting linguistic skills.

Footnotes

Acknowledgements

Thanks to research participants as well as anonymous reviewers for their insightful and constructive comments on the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by the Paluse Faculty Research Grant and the Faculty Development Fund from Duquesne University.

ORCID iD

Xia Chao

Author Biographies

Dr. Xia Chao is a faculty of language and literacy education at Duquesne University. Her research focuses on the language and literacy practices of culturally and linguistically diverse populations and on the professional development and preparation of teachers to work with English language learners. Dr. Chao’s work has been funded by the National Geographic Society and honored by the 2015 J. Michael Parker Award of the Literacy Research Association and the 2016 Outstanding Early Career Scholar Award of the American Educational Research Association’s Adult Literacy and Adult Education Special Interest Group.

Boping Kang currently works as an outpatient scribe at the Children’s Hospital of Pittsburgh and will attend medical school in fall 2020. Prior to this, she pursued one year of pre-heath post-baccalaureate studies at Duquesne University and graduated from the University of California, Berkeley with a major in molecule and cellular biology and a minor in Scandinavian Studies. Ms. Kang’s research interest focuses on the influence of culture on health literacy.

References

Auerbach

E. R.

(2000). Creating participatory learning communities: Paradoxes and possibilities. In Hall

J. K.

Eggington

W. G.

(Eds.), The sociopolitics of English language teaching (pp. 143-164). Multilingual Matters.

Bailey

S. C.

McCormack

L. A.

Rush

S. R.

Paasche-Orlow

M. K.

(2013). The progress and promise of health literacy research. Journal of Health Communication, 18(1), 5-8. https://doi.org/10.1080/10810730.2013.830042

Barton

(2001). Directions for literacy research: Analysing language and social practices in a textually mediated world. Language and Education, 15(2-3), 92-104. https://doi.org/10.1080/09500780108666803

Barton

Hamilton

(1998). Local literacies. Routledge.

Belzer

Pickard

(2015). From heroic victims to competent comrades: Views of adult literacy learners in the research literature. Adult Education Quarterly, 65(3), 250-266. https://doi.org/10.1177/0741713615580015

Brandt

Clinton

(2002). Limits of the local: Expanding perspectives on literacy as a social practice. Journal of Literacy Research, 34(3), 337-356. https://doi.org/10.1207/s15548430jlr3403_4

Capps

Newland

Fratzke

Groves

Auclair

Fix

McHugh

(2015). The integration outcomes of U.S. refugees: Successes and challenges. Migration Policy Institute.

Center for Applied Linguistics. (2007). Bhutanese refugees in Nepal. http://www.culturalorientation.net/learning/populations/bhutanese

Chao

(2013). Class habits: Middle-class Chinese immigrant parents’ investment in their newcomer adolescents’ L2 acquisition and social integration. Anthropology and Education Quarterly, 44(1), 58-74. doi:10.1111/j.1548-1492.2012.01179.x

10.

Chao

(2019). “What defines me is what I’ve been through.”: Bhutanese refugee youth identity in the U.S. British Journal of Sociology of Education. 40(6), 809-825. https://doi.org/10.1080/01425692.2019.1604210

11.

Chao

Kuntz

(2013). Church-based ESL program as a figured world: Immigrant adult learners, identity and power. Linguistics and Education, 24(4), 466-478. https://doi.org/10.1016/j.linged.2013.06.001

12.

Chao

(2017). Transnational habitus: Educational, bilingual, and biliteracy practices of Chinese sojourner families in the U.S. Journal of Early Childhood Literacy, 19(3), 399-423. https://doi.org/10.1177/1468798417729551

13.

Chao

Mantero

(2014). Church-based ESL programs: Social mediators for empowering “family literacy ecology of communities.” Journal of Literacy Research, 46(1), 90-114. https://doi.org/10.1177/1086296X14524588

14.

Chase

Sapkota

R. P.

(2017). “In our community, a friend is a psychologist”: An ethnographic study of informal care in two Bhutanese refugee communities. Transcultural Psychiatry, 54(3), 400-422. https://doi.org/10.1177/1363461517703023

15.

Cohen

D. J.

Snowden

J. L.

(2008). The relations between document familiarity, frequency, and prevalence and document literacy performance among adult readers. Reading Research Quarterly, 43(1), 9-26. https://doi.org/10.1598/RRQ.43.1.2

16.

Corbin

Strauss

(2008). Basics of qualitative research (3rd ed.). Sage.

17.

Emerson

R. M.

Fretz

R. I.

Shaw

L. L.

(1995). Writing ethnographic fieldnotes. University of Chicago Press.

18.

Evans

(2010). The perils of being a borderland people: On the Lhotshampas of Bhutan. Contemporary South Asia, 18(1), 25-42. https://doi.org/10.1080/09584930903561598

19.

Fadiman

(1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. Farrara, Straus, and Giroux.

20.

Feinberg

Tighe

E. L.

Greenberg

Mavreles

(2018). Health literacy and adults with low basic skills. Adult Education Quarterly, 68(4), 297-315. https://doi.org/10.1177/0741713618783487

21.

Freire

(1970). The adult literacy process as cultural action for freedom. Harvard Educational Review, 40(2), 205-225. https://doi.org/10.17763/haer.40.2.q7n227021n148p26

22.

Freire

(1983). The importance of the act of reading. Journal of Education, 165(1), 5-11. https://doi.org/10.1177/002205748316500103

23.

Freire

Macedo

(1987). Literacy: Reading the word and the world. Bergin & Garvey.

24.

Geertz

(1983). Local knowledge: Further essays in interpretive anthropology. Basic Books.

25.

Giri

(2005). Mourning the 15th anniversary of crisis: The plight of Bhutanese refugee women and children. Journal of Asian and African Studies, 40(5), 345-369. https://doi.org/10.1177/0021909605057742

26.

Graman

(1988). Education for humanization: Applying Paul Freire’s pedagogy to learning a second language. Harvard Educational Review, 58(4), 433-448. https://doi.org/10.17763/haer.58.4.0126051676j2000k

27.

Green

Lo Bianco

Wyn

(2007). Discourses in interaction: The intersection of literacy and health research internationally. Literacy & Numeracy Studies, 15(2), 19-35. https://doi.org/10.5130/lns.v15i2.2205

28.

Heath

S. B.

(1983). Ways with words: Language, life, and work in communities and classrooms. Cambridge University Press.

29.

Hester

E. J.

(2009). An investigation of the relationship between health literacy and social communication skills in older adults. Communication Disorder Quarterly, 30(2), 112-119.

30.

Hill

H. H.

(2004). Health literacy is a social justice issue that affects us all. Adult Learning, 15(1), 4-6.

31.

Hutt

(2003). Unbecoming citizens: Culture, nationhood, and the flight of refugees from Bhutan. Oxford University Press.

32.

Immigration and Nationality Act. (2017). Proposed refugee admissions for fiscal year 2017: Report to the Congress. U.S. Department of State, U.S. Department of Homeland Security, U.S. Department of Health and Human Services.

33.

Institute of Medicine. (2004). Health literacy: A prescription to end confusion. National Academies Press.

34.

Ito

(1999). Health culture and the clinical encounter: Vietnamese refugees’ responses to preventive drug treatment of inactive tuberculosis. Medical Anthropology Quarterly, 13(3), 338-364. https://doi.org/10.1525/maq.1999.13.3.338

35.

James

E. C.

(2011). Haiti, insecurity, and the politics of asylum. Medical Anthropology Quarterly, 25(3), 357-376. https://doi.org/10.1111/j.1548-1387.2011.01165.x

36.

Kirsch

I. S.

Jungeblut

Jenkins

Kolstad

(1993). Adult literacy in America: A first look at the results of the national adult literacy survey. U.S. Department of Education, National Center for Education Statistics.

37.

Kutner

Greenberg

Baer

(2005). National assessment of adult literacy (NAAL): A first look at the literacy of America’s adults in the 21st century (Report No. NCES 2006-470). U.S. Department of Education, National Center for Educational Statistics.

38.

Merriam

S. B.

(2002). Qualitative research in practice: Examples for discussion and analysis. Jossey-Bass.

39.

Mosenthal

P. B.

Kirsch

I. S.

(1998). A new measure for assessing document complexity: The PMOSE/IKIRSCH document readability formula. Journal of Adolescent & Adult Literacy, 41(8), 638-657.

40.

Murphy

P. M.

Davis

T. C.

Long

S. W.

Jackson

R. H.

Decker

B. C.

(1993). Reading estimate of adult literacy in medicine (REALM): A quick reading test for patients. Journal of Reading, 37(2), 124-130.

41.

Nutbeam

(2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259-267. https://doi.org/10.1093/heapro/15.3.259

42.

Nutbeam

(2008). The evolving concept of health literacy. Social Science & Medicine, 67(12), 2072-2078. https://doi.org/10.1016/j.socscimed.2008.09.050

43.

Papen

(2009). Literacy, learning and health: A social practices view of health literacy. Literacy & Numeracy Studies, 16(2), 19-34. https://doi.org/10.5130/lns.v0i0.1275

44.

Perry

K. H.

(2009). Genres, contexts, and literacy practices: Literacy brokering among Sudanese refugee families. Reading Research Quarterly, 44(3), 256-276. https://doi.org/10.1598/RRQ.44.3.2

45.

Rudd

Kirsch

Yamamoto

(2004). Literacy and health in America (Policy Information Report). https://www.ets.org/Media/Research/pdf/PICHEATH.pdf

46.

Shaw

S. J.

Huebner

Armin

Orzech

Vivian

(2008). The role of culture in health literacy and chronic disease screening and management. Journal of Immigrant and Minority Health, 11(6), 460-467. https://doi.org/10.1007/s10903-008-9135-5

47.

Smith

S. K.

Dixon

Trevena

Nutbeam

McCaffery

K. J.

(2009). Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Social Science & Medicine, 69(12), 1805-1812. https://doi.org/10.1016/j.socscimed.2009.09.056

48.

Street

(1995). Social literacies: Critical approaches to literacy in development, ethnography, and education. Longman.

49.

U.S. Citizenship and Immigration Services. (2018). Refugee timeline. https://www.uscis.gov/history-and-genealogy/our-history/refugee-timeline

50.

U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy. https://health.gov/communication/initiatives/health-literacy-action-plan.asp

51.

Wångdahl

Lytsy

Mårtensson

Westerling

(2014). Health literacy among refugees in Sweden: A cross-sectional study. BMC Public Health, 14, 1030-1041. https://doi.org/10.1186/1471-2458-14-1030

52.

Zarcadoolas

Pleasant

A. F.

Greer

D. S.

(2005). Understanding health literacy: An expanded model. Health Promotion International, 20(2), 195-203. https://doi.org/10.1093/heapro/dah609

53.

Zarcadoolas

Pleasant

A. F.

Greer

D. S.

(2006). Advancing health literacy: A framework for understanding and action. Jossey-Bass.

54.

Zong

Batalova

(2017). Refugees and asylees in the United States. Migration Policy Institute.