Addressing Cross-Cultural Health
Literacy Challenges in
Clinical Practice
Robert C. Like, MD, MS
Professor and Director
Center for Healthy Families and Cultural Diversity
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
Objectives
• Define the scope and impact of low health
literacy in America
• Discuss selected clinical cases illustrating
health literacy challenges
• Describe practical strategies and resources
that can facilitate caring for patients with
limited health literacy
Institute of Medicine Reports
•
To Err is Human: Building a Safer Health
System (1999)
•
Crossing the Quality Chasm: A New Health
System for the 21st Century (2001)
•
Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care (2002)
•
Health Literacy: A Prescription to End
Confusion (2004)
Who Is Responsible for Improving
Health Literacy?
A health literate America is a society in which
health systems and institutions take responsibility
for providing clear communication and adequate
support to facilitate health-promoting actions based
on understanding.
—Institute of Medicine, 2004
http://www.health.gov/communication/literacy/powerpoint
What Is Health Literacy?
 Health literacy is the degree to which individuals have
the capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions.
 Health literacy is dependent on both individual and
systemic factors:
1.
2.
3.
4.
5.
Communication skills of lay people and professionals
Knowledge of lay people and professionals of health topics
Culture
Demands of the healthcare and public health systems
Demands of the situation/context
http://www.health.gov/communication/literacy/powerpoint
How Big Is the Problem?
More Than 90 Million People in the US Have Difficulty Reading
Approximately 40 to 44 Million
Adults in the US Are
Functionally Illiterate1
Cannot Perform
Basic Reading
Tasks Required to
Function in Society
Approximately 50 Million
Are Marginally Illiterate1
Have Trouble
Reading Maps and
Completing
Standard Forms
Average Reading Skills of
Adults in the US Are Between
the 8th and 9th Grade Levels2
Sources:
1 Kirsch et al., “A First Look at the Results of the National Adult Literacy Survey” Nat’l Center for Education Statistics, 1993
2 Stedman L, Kaestle C. Literacy and Reading Performance in the US From 1880 to Present. In: Kaestle C, Editor.
Literacy in the US: Readers and Reading Since 1880. New Haven (CT): Yale University Press; 1991. P. 75–128
National Assessment of Adult
Literacy Levels - 2003
 Below Basic - no more than the most
simple and concrete literacy skills
 Basic can perform simple everyday literacy
activities
 Intermediate - can perform moderately
challenging literacy activities
 Proficient - can perform complex and
challenging literacy activities
http://nces.ed.gov/naal/
file:///C:/Documents%20and%20Settings/like.CORE/Local%20Settings/Temporary%20Inter
net%20Files/Content.IE5/W3ATUDWR/439,17,Description of literacy levels
Measuring health literacy
Number & Percentage of Adults in
Each Health Literacy Level: 2003
Source: National Center for Education Statistics, Institute for Education Sciences
Percentage of adults in
each literacy level: 2003
36%
77M adults
Source: National Center for Education Statistics, Institute for Education Sciences
Percentage of adults in each
health literacy level, by age: 2003
Who Is at Risk for Low Health Literacy?
 Anyone in the US – regardless of age, race,
education, income or social class – can be at
risk for low health literacy
– Ethnic minority groups are disproportionately
affected by low health literacy
– The majority of people with low literacy skills in
the US are white, native-born Americans
– Older patients, recent immigrants, people with
chronic diseases and those with low
socioeconomic status are especially
vulnerable to low health literacy
Low Health Literacy Impacts a Patient’s Ability
to Fully Engage in the Healthcare System
The Largest Study Conducted to Date
on Health Literacy Found That…
33% Were unable to read basic health care materials
42% Could not comprehend directions for taking
medication on an empty stomach
26% Were unable to understand information on an
appointment slip
86% Did not understand the rights and responsibilities
section of a Medicaid application
60% Did not understand a standard informed consent
Source: Williams MV, Parker RM, Baker DW, et al. Inadequate Functional Health Literacy Among Patients
at Two Public Hospitals. JAMA 1995 Dec 6; 274(21):1,677–82
Implications of Low Health Literacy
 Poor Health Outcomes
 Under-utilization of preventive services
 Over-utilization of health services
 Unnecessary health care expenditures
 Limited effectiveness of treatment
 Needless patient suffering
 Higher patient dissatisfaction
 Higher provider frustration
Video Presentation
Health Literacy: Help Your
Patients Understand
American Medical Association
American Medical Association Foundation
http://www.ama-assn.org/ama/pub/category/8115.html
CASE STUDIES AND
SMALL GROUP DISCUSSION
Weiss BD. Health Literacy and Patient Safety:
Help Patients Understand. Manual for Clinicians, 2nd edition.
Chicago, IL: American Medical Association Foundation, 2007
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Limited Health Literacy:
Clues and Red Flags
Responses to receiving written information
•
“I forgot my glasses. I’ll read this when I get home.”
•
“I forgot my glasses. Can you read this to me?”
•
“Let me bring this home so I can discuss it with my children.”
Responses to questions about medication
regimens
•
Unable to name medications
•
Unable to explain what medications are for.
•
Unable to explain timing of medication administration.
Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians,
2nd edition. Chicago, IL: American Medical Association Foundation, 2007, page 17.
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Limited Health Literacy:
Clues and Red Flags
Behaviors
•
Patient registration forms that are incomplete or inaccurately
completed
•
Frequently missed appointments
•
Noncompliance with medication regimens
•
Lack of follow-through with laboratory tests, imaging tests, or
referrals to consultants
•
Patients say they are taking their medication, but laboratory tests
or physiological parameters do not change in the expected fashion
Weiss BD. Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians,
2nd edition. Chicago, IL: American Medical Association Foundation, 2007, page 17.
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
Brief Health Literacy
Screening Questions
• How often do you have someone (like a family
member, friend, or hospital worker) help you
read hospital materials?
• How often do you have problems learning
about your medical condition because of
difficulty understanding written information?
• How confident are you filling out medical forms
by yourself?
Wallace LS et al. Can screening items identify surgery patients at risk
of limited health literacy? J Surg Res 2007; 140(2):208-213
Health Literacy Screening Tools
 Wide Range Achievement Test (WRAT) reading subtest
 Rapid Estimate of Adult Literacy in Medicine (REALM)
 Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA)
 The Newest Vital Sign
 Short Assessment of Health Literacy for Spanish-speaking Adults
(SAHLSA)

Wide Range Inc. Wide Range Achievement Test (WRAT 3). Wilmington, DE: Wide Range Inc., 1993.

Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument.
Fam Med 1993;25:391-5.

Parker RM, Baker DW, Williams MV, et al. The test of functional health literacy in adults: a new instrument for
measuring patients' literacy skills. J Gen Intern Med 1995;10:537-41.

Weiss BD, Mays MZ, Martz W, et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign
Fam Med 2005; 3:514-522.

Shoou-Yih DL, Bender DE, Ruiz RE, and Cho YI. Development of an easy-to-use Spanish health literacy test. Health
Services Research 2006; 41(4):1392-1412.
Ann
SPEAK: A Mnemonic for Addressing
Health Literacy Issues
S :
Speech - How will the healthcare provider’s speech
be received by the patient and/or caregiver?
P :
Perception - How will the patient and/or caregiver
perceive both the verbal and written content during
the communication with the health care provider?
E:
Education - What is the education level of the
patient and/or caregiver?
A:
Access – How will the patient and/or caregiver
access the health care system?
K:
Knowledge – How will assessment of health
literacy be carried out, and what tools will be used?
Kobylarz FA, Pomidor A, Heath JM. “Speak – A Mnemonic Tool for Addressing Health Literacy
Concerns in Geriatric Clinical Encounters.” Geriatrics 2006; 71(7):20-26.
Reaching a Solution
Introducing the Partnership for Clear Health Communication
 The Partnership for Clear Health Communication
is a coalition of national organizations that are
working together to promote awareness and solutions
around the issue of low health literacy and its effect on
health outcomes
Written Communication
Making Health Information Understandable
Written
 87% report reading Rx information
 Yet only 34% believe others
read this same information
 50% of adults read at below
 Consumer healthcare
8th grade reading levels
materials written at
10th grade or above,
where only 50MM can
understand and act
 20% of adults read at below
5th grade reading levels
 40% of seniors read at below
5th grade reading levels
What Do We Do?
Develop Written Materials at 6th Grade or Below,
Where 160MM Can Understand and Act
Source: Health Literacy & The Prescription Drug Experience: The Front Line
Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002
Example of Health Communication That
May Not Reach a Broad Consumer Audience
70
150
Good
Range
Too
Low
Too
High
What You Need to Know About Low Blood Sugar
Blood Sugar
Is Too Low if
It Is Under 70
Blood Sugar
Is Too High if
It Is Over 240
9th Grade
Reading Level
Treat low blood sugar quickly. If you have signs of
low blood sugar, eat or drink something that has sugar
in it. Some things you can eat are hard candy, sugarsweetened soda, orange juice, or a glass of milk.
Special tablets or gel made of glucose (a form of
sugar) can be used to treat low blood sugar. You can
buy these in a drug store. Always have some of these
items handy at home or with you when you go out in
case your blood sugar drops too low. After treating a
low blood sugar reaction, eat a small snack like half
a sandwich, a glass of milk, or some crackers if your
next meal is more than 30 minutes away.
Source: The National Institute of Diabetes and
Digestive and Kidney Diseases
Example of Clear Health Communication –
That Reaches a Broad Consumer Audience
 Common visual used
to explain concept
 Uses action captions
that clarify the point
of the visual
 Creates interaction
with the reader
Verbal Communication
Up to 80% of Patients Forget What Their Doctor Tells Them As
Soon As They Leave the Doctor’s Office – AND
Nearly 50% of What They Do Remember is Recalled Incorrectly
Patients experience shame around the issue
 Only 14% of patients say they feel awkward admitting they don’t
understand; yet 79% feel others don’t understand
Providers experience time challenges
 Providers interrupt patients 30 seconds after they start speaking;
if not interrupted, patients will speak less than two minutes
What Can We Do?
Create an Environment of TRUST
Source: Health Literacy & The Prescription Drug Experience: The Front Line
Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002
Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Instead of
Using This Word
Consider Using
This One Instead
Benign
Chronic
Cardiac
Harmless
Happens again and again; does not end
Heart
Edema
Fatigue
Screening
Intake
Generic
Swelling; build up of fluid
Tired
Test
What you eat or drink
Not a brand name
Adverse events
Side effects
Ask Me 3 – Creates Shared Responsibility
for Clear Health Communication
Patient
Provider
De-stigmatize and
Recognize
Reduce Embarrassment Patient Coping
of Low Health Literacy
Mechanisms
 Provides a consistent approach to patient-provider dialogue
 Allows patients to get information they need to manage their health
 Time-efficient for providers to reinforce healthcare instructions
What Is Ask Me 3
 Promotes three simple, but essential, questions
and answers for every healthcare interaction:
What Is My
Main Problem?
What Do I
Need to Do?
Diagnosis
Treatment
Why Is It
Important for Me
to Do This?
Context
What Else Can You Do?
People Have Difficulty Making Appointments
Appointment Instructions
Also see: Urgent Care (if you are too sick to wait for an appointment)
Making a medical appointment for the first time, it is straightforward: You call
555-2222 and make a appointment at XYZ Health Services just like you would
at any doctor's office.
You can request a specific clinician if you have someone in mind, or you can
explain your need or problem to the appointment counselor, and he or she will
schedule you with an appropriate clinician at the earliest possible date. At your
first appointment you will receive a medical record card -- often referred to as
your "gold card" -- which you will keep and use as your XYZ Health Services
identification.
If you are unsure about whether you should make an appointment, you may call
the Advice Nurse at 666-7777. Also, in advance of your first appointment, be
sure to read "How to Make the Most of Your XYZ Visit."
Please call 643-7177 to make an appointment in the Specialty Clinics, including
Allergy & Travel. Specialty appointments require a referral.
You may also drop by the Appointment Office to make a medical appointment.
The Appointment Office is located on the first floor in Room 1111. You may
also make an appointment in the Specialty Clinics by going to the Specialty
Clinic reception desk, located behind the elevators on the first floor.
If you need to cancel an appointment, please call our 24-hour cancellation line
at 643-7033. Please note that you will be billed for a broken appointment fee if
you do not show up for your appointment and have not called to cancel it.
 When making an
appointment, provide
people with simple options
and clear facts
Your Name
Your Appointment Date
Time
Place
Our Telephone Number:
Do not eat or drink for 6 hours
before the day and time on this card.
What Else Can You Do?
People Have Trouble Understanding Phone Recordings
 Phone answered by a tape
recording. Speaking quickly,
the caller is offered numerous
options and alternatives
 Speak slowly and clearly
 Provide an easy way to
connect with a live person
 Provide options in
other languages
What Else Can You Do?
People Have Trouble Reading Signs
Ambulatory
Entrance
Ambulatory
Entrance
Hospital XYZ
 Some people become
confused about whether
this entry was intended for
ambulances or for patients
 The use of visuals clarify
the message
 Contrast in color makes
it easy to read
 Try to be consistent when
hanging signs
What Else Can You Do?
People Have Trouble Understanding Maps
Maps are usually hard to follow:
To make maps easier to follow:




 Match the color in the map with the
Too complicated
Codes are hard to understand
Names and directions not always match
Small fonts
paint color on walls or floors
 Match the names in the map to the
names on the signs
 Use 14 point font size or larger
What Should We Do?
 Raise professional and public awareness about health
literacy
 Need for activated, informed, and empowered
patients/consumers, families, and caregivers
 Implement a “universal precautions” approach in
screening for low health literacy
 Create “shame-free” and “blame-free” environments
What Should We Do?
 Develop health education programs and materials
that are appropriately targeted and tailored for diverse
populations
 Provide culturally and linguistically appropriate services
(OMH CLAS Standards - www.omhrc.gov/CLAS)
 Monitor for disparities in access to care, service
utilization, quality, safety, and health outcomes
 Address ethical issues and concerns in health literacy
improvement efforts
Becoming a
Culturally Competent
Healthcare Organization
and Service Delivery System
Health Literacy, Cultural Competence,
and Linguistic Competence
The Need for Integrative Approaches
•
Patient Assessment Strategies
•
Workforce Strategies
•
Education and Training
•
Other Main Strategies
Andrulis DP, Brach C: Integrating Literacy, Culture, and Language to Improve Health Care Quality
for Diverse Populations, American Journal of Health Behavior 2007:31 (Suppl 1):S122-S133.
National Center for Cultural Competence
Georgetown University
•
A Guide to Planning and Implementing Cultural
Competence Organizational Self-Assessment
•
Cultural Competence Health Practitioner Policy
Assessment
•
Planning for Cultural and Linguistic Competence in
Systems of Care
•
Process of Inquiry: Communicating in a Multicultural
Environment
•
Bridging the Cultural Divide in Health Care Settings:
The Essential Role of Cultural Broker Programs
•
Self-Assessment Checklist for Personnel Providing
Primary Health Care Services
http://www11.georgetown.edu/research/gucchd/nccc
Joint Commission
Hospitals, Language, and Culture: A Snapshot of the
Nation, March 2007
http://www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf
One Size Does Not Fit All: Meeting the Health Care
Needs of Diverse Populations, April 2008
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_04_21_08.htm
“What Did the Doctor Say?:” Improving Health Literacy
to Protect Patient Safety, February 2007
http://www.jointcommission.org/NR/rdonlyres/D5248B2E-E7E6-4121-887499C7B4888301/0/improving_health_literacy.pdf
Crosswalk Between OMH CLAS Standards and Joint
Commission 2007 Standards for Hospitals, Ambulatory,
Behavioral Health, Long Term Care and Home Care
http://www.jointcommission.org/NR/rdonlyres/5EABBEC8-F5E2-4810-A16FE2F148AB5170/0/hlc_omh_xwalk.pdf
National Committee for
Quality Assurance (NCQA)
Innovative Practices in Multicultural
Health Care 2006 -2007
http://web.ncqa.org/Portals/0/HEDISQM/CLAS/CLAS_InnovativePrac06.pdf
Multicultural Health Care:
A Quality Improvement Guide, 2008
http://www.ncqa.org/tabid/676/Default.aspx
Funded by the California Endowment/Support from CMS
Selected Health Literacy Resources
 Nielsen-Bohlman L, Panzer AM, Kindig, DA, eds. Committee on Health
Literacy. Health Literacy - A Prescription to End Confusion. Institute of
Medicine, Washington, DC: National Academies Press, 2004.
http://www.nap.edu/catalog/10883.html
 Andrulis DB, Brach C. “Integrating Literacy, Culture, and Language to Improve
Health Care Quality for Diverse Populations. American Journal of Health
Behavior 2007; 31 (Suppl 1):S122-S133.
 Johnston Lloyd LL, Ammar NJ, Epstein LG, Johnson R, Rhee K. A
Transdisciplinary Approach to Improve Health Literacy and Reduce Disparities.
Health Promotion Practice 2006; 7(3):331-335.
http://hpp.sagepub.com/cgi/content/abstract/7/3/331
 DHHS Office of Disease Prevention and Health Promotion
Health Literacy Improvement Website
http://www.health.gov/communication/literacy/powerpoint
http://www.health.gov/communication/literacy/quickguide
 DHHS Administration on Aging. Communicating with Older Adults
http://www.aoa.gov/prof/communicating/communicating.asp
 AHRQ Health Literacy and Cultural Competency Website
http://www.ahrq.gov/browse/hlitix.htm
 Partnership for Clear Health Communication/Ask Me 3 “Advancing Clear
Health Communication to Positively Impact Health Outcomes” Presentation
http://www.askme3.org/PFCHC/professional_presentation.ppt
Selected Health Literacy Resources
 Health Resources and Services Administration. Unified Health Communication
101: Addressing Health Literacy, Cultural Competency, and Limited English
Proficiency
http://www.hrsa.gov/healthliteracy/training.htm
 AMA/AMA Foundation’s Health Literacy Toolkits, Videos, Partnerships
Video - Health Literacy: Help Your Patients Understand
http://www.ama-assn.org/ama/pub/category/8115.html
 Weiss BD. Health Literacy and Patient Safety: Help Patients Understand.
Manual for Clinicians, 2nd edition. Chicago, IL: American Medical Association
Foundation, 2007
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
 Allen CE, Kindig, DA, Parker RM, Roter DL. Assuring Quality Care for People
With Limited Health Literacy CME/CE Medscape Family Medicine, January 25,
2008.
http://www.medscape.com/viewprogram/8603
 American College of Physicians Foundation Health Literacy Resources and CD
Health Literacy: A Silent Epidemic.
http://foundation.acponline.org/healthcom/hli/resources.htm
 American Academy of Family Physicians. Play It Safe with Medicine! (Toolkit)
http://www.aafp.org/online/en/home/publications/news/news-now/insideaafp/20061122playitsafe.html
“Adding wings to caterpillars
does not create butterflies -- it
creates awkward and dysfunctional
caterpillars. Butterflies are created
through transformation.”
Stephanie Pace Marshall