We found two areas where we mentioned Oslo and Norway respectively. We removed the later as recommended by the reviewer.

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Adrian Moore
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1 Author s response to reviews Title: Health literacy: The missing link in improving the health of Somali immigrant women in Oslo Authors: abdi Gele (abdi@nakmi.no) Kjell Pettersen (kjellsverre.pettersen@hioa.no) Liv Elin Torheim (Liv.Elin.Torheim@hioa.no) Bernadette Kumar (bernadette.kumar@medisin.uio.no) Version: 1 Date: 25 Sep 2016 Author s response to reviews: BMC Mss PUBH-D Reviewer 1 Abstract - Remove all acronyms Done - In Methods, add analysis method Done - Review Results, there is repeated information about study location that should be removed to leave room to more relevant information We found two areas where we mentioned Oslo and Norway respectively. We removed the later as recommended by the reviewer.

2 - Conclusion: Poorly presented. To be refined/expanded The conclusion is expanded as suggested by the reviewer. Page 2 - Use WHO health literacy definition more intensively in the data discussion. The definition addresses social resources.for individuals and communities. Please expand your vision beyond the individual perspective/personal characteristics. - Done. See page 2, introduction, the second paragraph Page 3 - Line 8-12: Although migrants are often initially healthier precipitated by a low health literacy. I suggest authors to review literature on healthy immigrant effect and their financial struggles in the host society that undermines their health status. What did precipitate the deterioration of their health status? Done: look page 3, third paragraph, line Line 41: profound impact refugees engage with health information. Question: Engage with the Norway system of health information? Mass health education system? In Norway, health information is provided through mass media campaigns, through primary health care and through written materials found online in several government institutions websites as well as civil society organizations websites. - Line 41: For maintaining their own health communities, : Question: Any information about how they get information to maintain/improve their families health? Health information can be accessed through different websites in the form of immigrant s native languages. Moreover, it can be found in primary health care centres. However, knowledge of the existence of the material then to actively seek health information itself, is part of health literacy. - Line 44/45: available to them. Question: where? How? As mentioned earlier, the information can be obtained through different channels and it is often available in immigrants native language, but the problem is that these are often direct translations that are not adapted and might not be comprehended and then the next question is whether they use the information? And most importantly, can they act upon the information when they found

3 it? So there are number of related issues and steps to be taken in order to improve health literacy, and we mentioned in the conclusion section as recommendations. - Line 47: but it also involves health care providers competencies.. Question: any cultural resource? Community resource? A multi disciplinary health course addressing health and culture issues is provided for health personnel by the center for minority health Research (NAKMI). Medical students are also provided courses on immigrants health. At the local level sometimes, immigrant organizations are provided funds for delivering health information to immigrants. But to improve health literacy of immigrant population, authorities should address environmental, political and social factors that determine health, including a wide range of skills, and competencies that people develop over their lifetimes to seek out, comprehend, evaluate, and use health information and to make informed decisions, reduce health risks, and improve quality of life Page 4 - Line 59. Question: in which language was the informed consent provided? Were the participants proficient in any of the official language? The information was provided in Somali language which is the native language of all participants and researchers including the first author. - Who did obtain the signed informed consent? A bilingual professional and/or a cultural insider? A trained Somali female (bilingual) who work for Norwegian Center for Minority Health Research as research assistant gave the information to participants and obtained their consent. - Who did conduct the data collection? A bilingual professional and/or a cultural insider? The same female research assistant led the data collection and the first author participated it. Both are bilingual professionals. - Would you document reasons for refusing invitation to participate in the study? The study used respondent driven sampling (RDS) for the recruitment. The RDS method requires payment to participants for their participation, which attract participants and motivate them to participate the study; therefore, there was no refusals at all. Page 5 - Line 19- Convert currency to US $ and add in brackets. Done

4 Page 7 - Table 1 is poorly presented and discussed. What is the interpretation of the closeness among the responses to questions # 5, 11, 12 and 15. We presented table 1 just to show the proportion of people who answered each question. However, as you see in Table 2, questions are combined and analyzed as groups and they were interpreted accordingly. We did not intend to interoperate and discuss each question separately and even if we do it, it will not make sense. What is your interpretation of question #14 results? Question 14 was not interpreted separately but it is combined with other 4 questions which, together formed health promotion indices. We used standard questionnaire that follows standard analysis. - For all questions except #14, participants self-assessment of their abilities to tasks were appraised as easy. How do you interpret those results, when comparing when your baseline argumentation? As I stated earlier, we did not interpret questions individually. We combined questions and divided into categories ranging from inadequate HL to excellent HL. We based our final interpretation with those categories. Page 8 - Line 22: women in Oslo lack the capacity to Question: Any concern about language proficiency (Norwegian or other official language) in host society? Very important! There is a concern about language because Somali community are relatively new to Norway and there are always language issue. Understanding health messages and health information was part of Health literacy questionnaire, which we used for this study. - Line 31: reporting difficulties in communicating effectively Question: Why?. This refers to other studies that reported cultural difference between providers and immigrants from non-western countries regarding the way immigrants present pain, illness and sickness. - Line 37-40: Considering that HL is also a matter of communication, why in this paper you do not address Somalian women s Norwegian language proficiency, Norwegian health care system availability of trained personnel and education material in foreign languages? Thanks for the important question. The issues about access to preventive services and health communication was widely addressed in our previous qualitative paper

5 ( but the current paper was limited to determine HL of immigrants using standard questionnaire. Language is an important issue and we talked about it in page 9, paragraph 2. Page 9 - Criticize in the first paragraph, the existing system of health education to immigrant population. Add information about the use or not use of popular media to health education. Thanks for the important suggestion. We addressed it in page 9, 2nd paragraph, lines 3,4 &5 - Lines 13-18: Therefore, health planners Please expand this sentence by providing concrete action-recommendations. The sentence is expanded. Look the area with red color in page 9, 2nd paragraph, last four lines. - Line Last paragraph. Have job do means an access to additional informal and formal sources of health information and a larger social network. Please review literature about HL in work environment. Suggestion is a publication about the Canadian vision of a health literacy society that could inspire you to expand your discussion : - Thanks for the important contribution. The discussion is expanded accordingly. Look page page 10, second paragraph, line Page 10 - Line 2: as they create channels for immigrants health literacy. Add references here Done. Look page 10, 2nd paragraph, line 14, in red. - Line 2:-6: The results of acculturated. Using lens of knowledge translation please provide some inspiration to policy makers and decision-makers proposing some concrete actions. Moreover, you can review underpinning ideas of health promotion to propose inter-sectorial collaboration to mobilize governments, civil society and Somalian community to jointly work? Done. Look the conclusion section - Line 15-18: However, the questionnaires used received help. This information should be moved to Methods section.

6 We removed the information mentioned by the reviewer - Question: Did you conduct a cross-translation? Did your pilot-tested the translated questionnaire? Provide reasons for your methodological choices and add explanation to Methods. The EU health literacy questionnaire-16 has a Somali version that was developed by Swedish scholars, and previously used among Somali immigrants in Sweden. We also pretested it among Somalis in Norway, and we did not make any modification. - Line 18-21: Please review Table 1 s comments to verify if underestimation or overestimation was documented or not. Individual questions that we presented in Table 1 may not say anything about level of health literacy of the study sample unless they are combined in groups in accordance with EU health literacy consortium model. Nonetheless, 71% of inadequate health literacy is not unexpected among Somali refugee women, while 60% of Canadian population have inadequate health literacy. - Line 21-22: One of the strengths Comment: Please review this sentence about methodological strengths; avoid the pitfall of data novelty. We added methodological strength. Look page 10, final paragraph, line Please explain why in this study there was no data collection about languages proficiency that could indicate an alternative asset to Somalian women to get online health information, for instance. As mentioned earlier, this study was designed to use the standard questionnaire developed by EU health literacy consortium (HLS-EU-Q16). However, understanding health information and health messages is part of the questionnaire. Page 12 - Discuss results question 3 and 4 comparing them with references # 36 and Any special consideration to questions # 8 and 14 results? The aim of the study was not to discuss individual questions but as combined- look the methodology section where we discussed questions and how they were combined and analyzed. It is standard questionnaire that use standard analysis.

7 References - References # 15 and 23 seem to be the same document. Reference #15, the author name is presented in other format. Corrected

International Questionnaire: Migrant Education Policies in Response to Longstanding Diversity

OECD Thematic Review on Migrant Education International Questionnaire: Migrant Education Policies in Response to Longstanding Diversity KOREA August 2009 Background 1. As part of the OECD review on migrant