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Health Literacy, Refugee Health, Curriculum, 
Accessibility, English as a New Language (ENL), 
Intervention 

abstract
Newly resettled refugees have poorly managed acute 
and chronic health conditions as a result of their 
migration experience. To add to an already complex 
experience, poor health literacy complicates effective 
utilization of healthcare among these communities 
(Wångdahl et al., 2014). Health literacy has been 
described in the literature as one of the key 
determinants of and potential barriers to optimal health 
(Kickbusch, 2001). Anecdotally, health literacy 
curricula have been implemented in other low-literacy 
communities with success. Yet there are very few known 
structured curricula built into the resettlement 
experience in 
the United States (U.S.), and even fewer have been 
described in the literature. 

In collaboration with Closing the Health Gap and 
Refuge Collaborative, a six-week health literacy 
curriculum was developed and disseminated in 
adult Syrian refugee populations within the Greater 
Cincinnati Area. Using a pre-post intervention design, I 
aimed to assess the baseline health literacy of newly 
resettled adult refugees in the Greater Cincinnati Area 
and evaluate the effectiveness of the health literacy 
curriculum in improving the functional health literacy 

of these communities. This pilot study informed the 
development of a health literacy curriculum aimed at 
high school refugee students enrolled in Cincinnati 
Public Schools. 

 Establishing the effectiveness of such a curriculum 
has the potential to have far-reaching impacts on 
other refugee communities undergoing the resettlement 
experience. Other communities experiencing low health 
literacy, such as African Americans, may also benefit 
from a similar curriculum. Most importantly, improved 
health literacy can indirectly translate into more 
effective health care utilization and lead to overall better 
health outcomes for disadvantaged communities. 

background
There are over 25 million refugees registered 
worldwide, over half are under the age of 18 (UNHCR, 
2019). By the end of 2017, there was approximately 
287,000 refugees living in the U.S. (UNHCR, 2019). 
Ohio is the third most frequent resettlement site in the 
U.S. (Hong et al., 2017). Due to the disruption caused 
by the sociopolitical forces and events that led to 
migration, many refugees suffer from poorly managed 
acute and chronic health conditions, as well as lack of 
access to consistent education and employment that can 
help empower them to be self-sufficient in their new 
communities. As a result, refugees struggle to attain 
optimal health outcomes and effectively access health 
care services even after resettlement. 

Assessing Functional and  
Comprehensive Health Literacy 
in a Syrian Refugee Community

Author
MENTALLA ISMAIL, Founder & Executive Director | Refuge Collaborative, Cincinnati, 
Ohio 

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Assessing this populations’ health needs greatly differs 
depending on their country of origin. Having lived in 
polluted refugee camps for years, migrants present 
with weak immune systems, hepatitis B, tuberculosis, 
and other issues that have compromised their health 
(Wångdahl et al., 2014). Upon resettlement into the 
U.S., public health departments treat these infectious 
diseases during a “domestic health assessment.” 
However, little to no attention is paid to treating chronic 
and mental health issues (Refugee Processing Center, 
2014-2019). While speaking with participants for this 
study, many of them expressed the inhumane conditions 
of the camps they lived in. One participant’s family 
of seven shared a small tent, having to sleep on tarp 
covering the soil terrain. Another shared the stories 
of discrimination she faced due to her hijab, a visible 
symbol of her religious beliefs.  

Poor mental health is cited as a persisting determinant 
in refugee health (Hong et al., 2017). The World 
Health Organization (WHO) and the United Nations 
High Commissioner for Refugees (UNHCR) share 
responsibility for refugee health (Hong et al., 2017). 
However, due to the scarcity of services and inability 
to coordinate national efforts, this population remains 
vulnerable to persistent mental health issues. This can be 
accredited to a combination of the burden of migration, 
socio-economic factors, lived experiences, and the 
uncertainty of resettlement. Prolonged mental health 
issues are also attributed to the duration of the time 
seeking asylum takes (UNHCR, 2019). Throughout the 
duration of the study, one family’s story has persisted as 
a reminder of the devastation caused by a lack of mental 
health services for those seeking asylum. A family of 
four fled from Syria to Turkey to escape the war in 
2011. The only way out of Syria for them was through 
smugglers who promised an escape to Turkey. The 
oldest of the family’s two daughters was paralyzed from 
the waist down since birth and could not endure the 
journey. Choosing between war or survival the family 
decided to split, with the youngest daughter and father 

fleeing while the mother and older daughter stayed 
behind. 

Recent studies attribute refugee mental health issues 
to post-migration conditions. Due to the high influx of 
migrants, addressing the responsibilities of the receiving 
countries to provide health services has resulted in 
anti-migrant and anti-refugee sentiment. Many feel that 
refugees are taking advantage of the welfare services in 
their receiving countries, and do not necessarily believe 
that countries have to accommodate these migrants 
(Nutbeam, 2008). The American public has had a long 
history of not welcoming refugees (Ng et al., 2010) as 
shown by the data in Figure 3. This consensus amongst 
American voters created an opposition in reception of 
responsibility for the well-being of asylum-seekers. 
This opposition breeds a hostile environment, which in 
turn contributes to the mental health distress of these 
individuals. This study was conducted in 2019 when 
Donald Trump was residing in office. Participants did 
not feel safe or welcome within their communities. It 
was extremely difficult to champion mental well-being 
through health literacy with Syrian refugees at a mosque 
when so much anti-Muslim and anti-refugee rhetoric 
was on display constantly. 

Health literacy has been identified in the literature 
as a key determinant and potential barrier to health 
(Nutbeam, 2008). There are two forms of health 
literacy described in the literature (Sorensen et al, 
2012). Functional health literacy (FHL) is defined as 
an individual’s ability to read information about health 
that is necessary to function effectively as a patient in 
that health care system. Comprehensive health literacy 
(CHL) is defined as an individual’s knowledge and 
competency “to access, understand, appraise, and 
apply health information in order to make judgments 
and decisions in everyday life concerning healthcare, 
disease prevention and health promotion to maintain or 
improve quality of life during the life course” (Sorensen 
et al., 2012, para. 17). Refugees and migrants have been 

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shown to have relatively poor health literacy due to a 
combination of factors such as communication/language 
barriers and different cultural perspectives of health 
(Wångdahl et al., 2014).  One study focusing on the 
relationship between health literacy of migrant parents 
and their utilization of pediatric emergency departments 
reports that one in every three parents misuse emergency 
services due to low health literacy (Wångdahl et al., 
2014). Refugees are not the only demographic effected 
by low-literacy rates. In 2003 it was reported that 
36% of adults in the U.S. have limited health literacy. 
With lower literacy rates being higher for minority 
populations as well as individuals living in poverty 
(American Institutes for Research, 2003). The National 
Assessment of Adult literacy observed that 58% of 
African Americans had limited or inadequate health 
literacy in comparison to 28% of whites (American 
Institutes for Research, 2003). 

methods 
Implementation of this intervention occurred at the 
Islamic Center of Greater Cincinnati in the Fall of 2019. 
The participants were a group of 17 Syrian female 
adult refugees enrolled in an English Second Language 
(ESL) course offered through the Islamic Center. The 
participants’ primary language is Arabic. While the 
curriculum was created in English, it was translated in 
Arabic as needed for their understanding and facilitation 
of discussion. The pre- and post-surveys were also 
translated and anticipated to be administered in Arabic. 

The curriculum consisted of six modules which were 
disseminated weekly over a period of six weeks. Each 
session was one hour in length. The modules created 
covered various basic but essential components of 
health literacy, including how to access health services, 
various types of health care, and where to find them, 
health insurance, patient rights, medication and refill 
attainment, and the importance of preventive care (i.e., 
primary care) in maintaining overall health. Module 
descriptions can be found in Table 2. 

Participants were expected to complete pre- and post-
intervention surveys aimed at assessing their functional 
and comprehensive health literacy. The Functional 
Health Literacy Scale (FHLS, Appendix A) is comprised 
of five questions with five semistructured response 
categories: never, seldom, sometimes, often, and always. 
The Comprehensive Health Literacy Scale (CHLS, 
Appendix B) is comprised of five semistructured 
response categories: very easy, easy, difficult, very 
difficult, and don’t know. However, due to the COVID 
pandemic the weekly sessions were halted after week 4 
and a post-intervention survey was not administered. 

Measurement of functional and comprehensive health 
literacy was done using two validated scales, which 
were adopted from a health literacy study in Sweden. 
Dr. Josefin Wångdahl allowed permission of use of 
her validated health literacy scales. Both scales were 
translated in Arabic. 

The Swedish Functional Health literacy scale (S-FHL), 
Appendix A, attributes response categories of “Never” 
or “Seldom” to having sufficient health literacy, while 
responses of “Often” or “Always” lead to inadequate 
health literacy. A participant’s response of “Sometimes” 
to at least one question coupled with no response of 
“Often” or “Always” is attributed to having problematic 
health literacy. The Arabic S-FHL is referenced in 
Appendix C. 

The European Health Literacy Questionnaire (HLS-
EU-Q16) was used to assess comprehensive health 
literacy. The 16 questions in this survey, seen in 
Appendix B, focus on the following four health literacy 
dimensions: ability to access/obtain health information, 
understand health information, ability to process/
appraise health information and ability to apply/use 
health information. The HLS-EU-Q16 index scale is as 
follows: responses of “Fairly Easy” and “Very Easy” 
result in a score of 1. Responses of “Fairly Difficult” 
and “Very Difficult” result in a score of 0. Responses of 

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“Don’t Know” result in a score of missing. The Arabic 
HLS-EU-Q16 is referenced in Appendix D. 

These participants also served as part of a focus group 
informing the development of a remote adolescent 
refugee health literacy curriculum. Using the Adult 
Refugee Health Literacy curriculum as a framework a 
seven-module curriculum aimed at high school refugee 
students was created. “Lifestyle” and “mental health” 
modules were added in order to better address common 
health topics for this demographic. These modules were 
created to be taught remotely in order to accommodate 
distance learning due to the COVID pandemic. Module 
descriptions can be found in Table 3. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

results 
The pre-intervention survey results concluded that the 
majority of the Syrian adult refugees surveyed had 
inadequate levels of FHL and CHL. Table 1 shows that 
64.7% of participants had inadequate functional health 
literacy while 82.4% had inadequate comprehensive 

health literacy. None of the participants had sufficient 
functional or comprehensive health literacy. 52.9% of 
participants were between the age range of 25-44. 

The adult Syrian refugee curriculum was comprised of 
six modules. Table 2 shows the health topics covered 
and their descriptions. These modules were informed 
by healthcare professionals and refugee medical 
students. This curriculum covers the following health 
topics: introduction to health, health care resources, 
prescriptions, health insurance, preventative care, and 
ethics. 

Based on the discussions and field notes recorded 
during the intervention at the Islamic Center it was 
observed that a majority of female Syrian refugees 
rely on their children to navigate the healthcare 
system for them. This informed the development of an 
adolescent refugee health literacy curriculum. Table 
3 lays out the curriculum for this demographic which 
is comprised of seven modules. These modules cover 
the following health topics: introduction to health, 
lifestyle, prescription, mental health, health insurance, 
preventative care, and ethics.

Figure 1: Students working with their Refuge-UC mentor 
to brainstorm ideas to promote COVID-19 vaccinations 
within their community as part of Refuge Collaborative's 
health promotion initiative

Table 1: Pre-Survey Functional & Comprehensive Health 
Literacy Results



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discussion 
Navigating the American healthcare system is a 
daunting experience for many refugee families. 
Language barriers, cultural differences and limited 
understanding of resources and systems are a few of the 
contributing factors to poor health outcomes. During 
the four sessions with participants, our discussions 
were centered around understanding basic health terms 
and how to access resources without insurance, which 
alluded to a gap in FHL as seen by the pre-survey results 
(in Table 1). Concepts which seemed straightforward, 
such as visiting a primary care physician, proved to be a 
challenge due to a cultural understanding of health.  

It is important to note that the perspective of health 
care amongst Syrian refugees greatly differs from the 
countries they are resettling in. This gap in perspective 
can further exacerbate the health issues this population 
experiences. Western countries view health and health 
care from a scientific perspective that takes medical and 
psychological approaches into account (Wångdahl et 
al., 2014), while the cultural backgrounds of refugees 
have conditioned their perspective to come from a 
blame culture, taking spiritual or political approaches. 

For instance, in Western culture many attribute being ill 
to environmental factors that breed infectious disease. 
Due to the vast cultures and traditional backgrounds 
of refugees that same illness would be attributed to a 
punishment or sign from a higher being. They may also 
view the illness as a government ploy due to the distrust 
in leadership.

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Table 2: Adult Refugee Health Literacy Curriculum

Table 3. Adolescent Refugee Health Literacy Curriculum

It is important to note that 
the perspective of health care 

amongst Syrian refugees greatly dif-
fers from the countries they are resettling 

in. This gap in perspective can further exac-
erbate the health issues this population ex-

periences. Western countries view health and 
health care from a scientific perspective that 

takes medical and psychological approaches 
into account (Wångdahl et al., 2014), while the 
cultural backgrounds of refugees have condi-
tioned their perspective to come from a blame 
culture, taking spiritual or political approaches.



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This intervention was aimed at improving the adult 
refugee’s understanding of the U.S. health care system 
and the participant’s capacity to effectively access 
services to prevent and treat acute and chronic medical 
conditions. However, the process identified the need 
for a robust health literacy curriculum aimed at refugee 
adolescents. 

Through discussions surrounding the varying health 
topics within the six-week curriculum it was evident 
that most of the Syrian refugee families relied on their 
children to navigate the healthcare system on their 
behalf. Whether it was translating medical documents, 
ordering medical prescriptions, or accompanying their 
parents to the physician’s office – teenage refugees were 
at the forefront of navigating the American healthcare 
system. 

Keeping this information in mind, I then created a 
seven-week health literacy curriculum targeted to high 
school refugee students. Working with experts including 
family and adolescent medicine physicians, the pediatric 
refugee health collaborative, and the Center for 
Closing the Health Gap, we’ve created a health literacy 
curriculum to address this need. 

As a Tillery Fellow through the Center for Closing 
the Health Gap, I’ve been able to further understand 
how health literacy influences disparities. My focus 
throughout this intervention has been to serve a 
community whose health is disproportionately affected 
due to their linguistic and cultural barriers. Lower 
literacy levels greatly impact African American 
populations in the United States. This disproportionately 
low health literacy rate can be attributed to a multi-
faceted system of barriers of which being historically 
unjust power structures (Muvuka et al., 2020). 
 
Working with the Center for Closing the Health Gap as 
a Tillery Fellow has been essential in my understanding 
of how health literacy influences disparities. My 

focus throughout this intervention has been to serve a 
community whose health is disproportionately affected 
due to their citizenship status, native language, and 
culture.  

While the implementation of this particular intervention 
was incomplete, it uncovered the dire need for health 
literacy in underserved populations. Effective use of 
health care services can, by extension, directly and 
indirectly lead to improved health outcomes. Knowledge 
of appropriate use of health care services and 
improvement in health status also directly and indirectly 
promote effective assimilation into a new community.

 

conclusion 
The focus of public health is on the social and 
environmental determinants of health of a specified 
population. Yet, there has been a significant gap in 
addressing the well-being of the refugee population. 
Throughout the development of both curriculums 
and the implementation of the adult health literacy 
intervention I’ve been able to apply the various program 
and concentration core competencies. 

Promoting health equity in populations and communities 
has been the foundation of this work. The design, 
implementation, and evaluation of the Adult Refugee 
Health Literacy curriculum ensures that a group of non-
English speakers are able to access health information. 
Further, analyzing the global issues that impact gender 
inequities aided me in delivering this health service to 
a group of female refugee participants. Developing the 
Adolescent Refugee Health Literacy curriculum will 
lead to delivery of a sustainable intervention which 
addresses health conditions of a marginalized group. The 
approaches and methodology used in implementation of 
this initiative were founded on the basis of inclusivity 
to address a diverse population. Working with refugees 
requires ongoing advocacy in order to effectively 
address the inequities shaped by social and racial 
determinants of health. 



 
 
 
 
 
Further research is needed in order to properly address 
refugee barriers to care. However, there does not 
seem to be one method that would adequately address 
the various health disparities this population faces. 
Each case is unique to its own cultural background. 
Additional data is needed in support of the claim that 
access to healthcare for refugees in their host countries 
is restricted despite their urgent need for medical 
attention.

With short-term transition systems in place, refugees 
transition into a system that is not designed to sustain 
them. The systems in place at a national level do not 
take the cultural traumas these individuals have survived 
into account, nor do they present an arrangement for 
prolonged treatment. Implementation of health literacy 
programs could prove significant in promoting the 
understanding and practice of preventative care amongst 
the refugee population. 

 
 
 
 
 
We offer these people no real source of stabilization. 
Refugees contribute to the richness in diversity, races,  
and ethnicities. It is vital to understand the priorities of 
the countries they migrate from in order to understand 
how their health behaviors are influenced. Once they 
have survived a few years in detention centers awaiting 
resettlement, they are met with more obstacles while 
they come to terms with rebuilding their lives. Refugees 
are a resilient people reminding us of the universality of 
the human experience. 

Figure 2: Students from the first Adolescent Refugee Health Literacy cohort with Refuge  
Collaborative Director, Mentalla Ismail 

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Citation: Wångdahl, J. M., & Mårtensson, L. I. (2015). Measuring health 
literacy—the Swedish functional health literacy scale. Scandinavian 
Journal of Caring Sciences, 29(1), 165–172. https://doi.org/10.1111/
scs.12125

Modified version of the HLS-EU-Q16

Developed by J.Wångdahl and L. Mårtensson based on the original 
version, HLS-EU Consortium (2012)



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