Building demand for health services: the importance of health literacy
How the EU funded ‘RM Child-Health’ initiative has increased health literacy among refugee and migrant children and their parents.
The ‘RM Child-Health’ initiative has supported work across five European countries to increase health literacy among refugee and migrant children and their parents. As the Initiative, launched in 2020, comes to an end, an independent evaluation has confirmed its positive impact, with refugee and migrant children families empowered to demand health services as their right. As a result, health literacy is now embedded into ongoing activities with refugee and migrant children and parents across all five countries, based firmly on their own views and needs.
Health literacy – the ability to find, understand and use information to promote and maintain good health – is vital for refugee and migrant children and their families. They often face obstacles to accessing health care, such as a lack of information in their own language and that reaches them through the channels and sources they trust.
Health care for refugees and migrants is not only about the ‘supply’ of health care available to them: it is also about their own demand for quality, cost-free health services. For people who have endured long journeys and who face an uncertain future, health care may be low on their list of priorities. Some may be wary of contact with any form of state-provided services, for fear of deportation. And some may not be aware that they have a right to health care in Europe, having come from countries where that right is not always upheld, and where health services are often unaffordable or non-existent.
Through its support for health literacy, the ‘RM Child-Health Initiative’ has helped to increase demand for health services among refugee and migrant children and their families in Bosnia and Herzegovina, Bulgaria, Greece, Italy and Serbia, according to an independent evaluation. The €4.3 million Initiative, launched in 2020 by the European Union Directorate-General for Health and Food Safety, has helped to ensure that they have the right information, in the right format, at the right time to connect them to the health care they need. The initiative has made them more aware of their fundamental right to health care in these countries: a vital aspect of health literacy that helps to build confidence. Put simply, people who know that they have a right to quality health care are more likely to claim that care.
The Initiative has taken a wide view of health literacy that looks beyond immediate access to primary health care to encompass gender-based violence (GBV) and mental health and psychosocial support services (MHPSS). Equipped with new knowledge and confidence, some refugee and migrant women have, for example, identified the impact of GBV on their own lives and on the lives of their children.
A two-pronged approach
The success of the Initiative lies in its two-pronged approach. First, UNICEF and its partners in the five countries consulted young refugees, migrants and their caregivers on their priority health issues, as well as the gaps in health information and in their own knowledge. At every stage, their views, plus the views of UNICEF’s implementing partners on the ground, have informed health literacy packages that were rolled out in all five countries, spanning topics from the importance of immunization and the importance of breastfeeding to GBV, MHPSS and sexual and reproductive health and rights (SRHR).
Second, the materials have been backed by communication plans to make sure their messages landed with their audience, and the materials produced have been culturally appropriate, gender sensitive and, where necessary, child-friendly. Cultural mediators and interpreters have helped to overcome language and cultural barriers, while materials have been made available in many languages, including Arabic, Farsi, Pashto, Tigrinya, Urdu and Wolof, as well as in large print and sign-language versions.
Health literacy activities have been led by professionals who are already trusted by refugees and migrants. Materials have been shared through the channels and in the places they use most often, including asylum offices, temporary reception centres, health centres, Mother and Baby Corners, workshops and discussion sessions, during outreach activities and via social media.
Bosnia and Herzegovina
- Distribution of more than 7000 brochures in six languages on important topics related to public health measures.
- Target for number of refugee and migrant children and parents receiving UNICEF-supported information on health risks, entitlements and services available related to immunization: 2200. Number reached: 3484.
- Creation of a Facebook group by the Council of Refugee Women in Bulgaria, UNICEF’s implementing partner, providing information on COVID-19 and other health issues.
- Target for number of refugee and migrant children and parents receiving UNICEF-supported information on health risks, entitlements and services available related to immunization: 450.
Number reached: 1996.
- A concerted effort to convince women of the importance of exclusive breastfeeding, aiming to reduce dependence on breastmilk substitutes.
- Target for number of refugee and migrant children and parents receiving UNICEF-supported information on GBV prevention and response: 1500.
Number reached: 3600.
Greece: Building trust to address gender-based violence (GBV)
In Greece, UNICEF’s implementing partner Melissa delivered mental health and psychosocial services (MHPSS) through group therapy, which built trust, was more culturally acceptable, and helped to replace a disrupted social network. This approach proved vital during the COVID-19 pandemic because it could be transferred smoothly to online delivery to maintain women’s engagement. A separate grant made it possible to provide women with tablets, which they often called ‘Melissa’s eye in their house’, saying that this made them feel safer. Melissa also developed a code word women could use to ask for help. This worked because Melissa had already gained women’s trust through in-person sessions. Women felt secure enough to share their experiences in the knowledge that they would get the right support, resulting in a high rate of self-disclosure. One key factor was that women were referred quickly without having to complete extensive questionnaires. Instead, a team of highly skilled psychologists and therapists identified GBV survivors and provided follow up.
- Dissemination of brochures on immunization, GBV and mental health and psychosocial services (MHPSS) during the COVID-19 pandemic, as well as short videos on all these topics, which are available through U-Report on the Move.
- Target for number of refugee and migrant children and parents receiving UNICEF-supported information on health risks, entitlements, and services available related to MHPSS: 3000
Number reached: 115,000.
Italy: culturally appropriate information on sensitive topics
In Italy, the ‘RM Child-Health’ Initiative has supported the development of materials in diverse languages that are now available for linguistic and cultural mediators, health workers, social workers and others. These include Q&As on subjects that are often sensitive and difficult for young refugees and migrants – and even frontline workers themselves – to discuss, such as gender-based violence (GBV) and, in partnership with the United Nations Population Fund, sexual and reproductive health (including the meaning of consent). Most recently, the Initiative has supported the development, production and dissemination of clear information on menstrual hygiene. All of the materials have provided clear, concise, user-friendly information to dispel the many myths and misconceptions around these issues.
- Health literacy materials in six languages distributed to children and caregivers in 18 reception and asylum centres on: access to health services, MHPSS, GBV, breastfeeding and infant and young child feeding, and substance abuse and risky behaviours.
- Target for number of refugee and migrant children and parents who receive UNICEF-supported information on health risks, entitlements, and services available related to MHPSS: 500
Number reached: 3547.
Building trust in Serbia
With support from the ‘RM Child-health’ initiative, UNICEF’s partner Info Park organizes workshops at its safe space for women and girls at the Reception Centre in Vranje, Serbia. Milica and Aleksandra from Info Park provide support and referrals for their physical health but psychosocial support is often the priority. “They’re often withdrawn, they don’t communicate much with others,” says Milica. “We’re trying to reach them through conversation.”
Aleksandra stresses the need to build trust. "Women at the Centre often complain about gender inequality in their intimate relationships. We are establishing trust with them so that, if they are at risk of violence, they can come to us for help, and we then refer them.”
Equipped with their new knowledge, women support each other. Together, they encouraged a woman who was suffering GBV to report the perpetrator. As a result, she was moved to a safe house.
“We tell them that they have to know their rights,” says Milica. “They have to know that they don't have to be afraid.”
Stakeholders report a range of impacts, including greater awareness of child nutrition and the importance of breastfeeding (in one camp in Greece, requests for baby formula milk ceased completely). More refugee and migrant children are now fully immunized (before the Initiative, some parents were reluctant to immunize their children). More women and girls are demanding access to support for their physical and mental health. The impact seems to have been most profound for women and girls who took part in many workshops over several months, with local staff seeing changes in their views on parenting, GBV, gender and sex, and child marriage.
UNICEF’s partners reported positive feedback from refugees and migrants, with parents now asking for specific health topics to be included in future sessions. Above all, the support offered by the ‘RM Child-Health Initiative’ has helped to build trust – a key factor in raising demand for health services in general, and for GBV services in particular.
This story is part of the Project ‘Strengthening Refugee and Migrant Children’s Health Status in Southern and South Eastern Europe’, Co-funded by the Health Programme of the European Union (the ‘RM Child-Health’ initiative). It represents the views of the author only and is her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the European Health and Digital Executive Agency (HaDEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.
 UNICEF (2021). Interim Report, p.26
 U-Report is a digital platform that lets young migrants and refugees in Italy speak out on issues that matter to them and be heard by decision makers: U-Report On The Move | Linktree
 UNICEF (2021). Interim Report, p.12