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

• 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

Objectives

• 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)

Institute of Medicine Reports

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. Communication skills of lay people and professionals2. Knowledge of lay people and professionals of health topics 3. Culture4. Demands of the healthcare and public health systems5. Demands of the situation/context

http://www.health.gov/communication/literacy/powerpoint

How Big Is the Problem?

Approximately 40 to 44 Million Adults in the US Are

Functionally Illiterate1

Approximately 50 Million Are Marginally Illiterate1

Average Reading Skills of Adults in the US Are Between the 8th and 9th Grade Levels2

More Than 90 Million People in the US Have Difficulty Reading

Sources:1 Kirsch et al., “A First Look at the Results of the National Adult Literacy Survey” Nat’l Center for Education Statistics, 19932 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

Cannot Perform Basic Reading

Tasks Required to Function in Society

Have Trouble Reading Maps and

Completing Standard Forms

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%20Internet%20Files/Content.IE5/W3ATUDWR/439,17,Description of literacy levels

Measuring health literacyNumber & 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

Source: National Center for Education Statistics, Institute for Education Sciences

36%

77M adults

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…

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

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

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

Ann 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.

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

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

Introducing the Partnership for Clear Health Communication

Written Communication

87% report reading Rx information Yet only 34% believe others read this same information

What Do We Do?

Develop Written Materials at 6th Grade or Below, Where 160MM Can Understand and Act

Written

Making Health Information Understandable

Source: Health Literacy & The Prescription Drug Experience: The Front Line Perspective From Patients, Physicians and Pharmacists, Roper ASW, May 2002

50% of adults read at below 8th grade reading levels

20% of adults read at below 5th grade reading levels

40% of seniors read at below 5th grade reading levels

Consumer healthcare materials written at 10th grade or above, where only 50MM can understand and act

What You Need to Know About Low Blood Sugar

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, sugar-sweetened 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 Health Communication That May Not Reach a Broad Consumer Audience

70 150

Blood Sugar Is Too Low if It Is Under 70

Blood Sugar Is Too High if It Is Over 240

Good Range

TooHigh

TooLow

9th Grade Reading Level

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

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

Create an Environment of TRUST

What Can We Do?

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

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

Benign Harmless

Chronic Happens again and again; does not end

Cardiac Heart

Edema Swelling; build up of fluid

Fatigue Tired

Screening Test

Intake What you eat or drink

Generic Not a brand name

Adverse events Side effects

Consider Using This One Instead

Instead of Using This Word

Start by Decreasing the Use of Medical Jargon

Ask Me 3 – Creates Shared Responsibility for Clear Health Communication

Patient Provider

De-stigmatize andReduce Embarrassmentof Low Health Literacy

RecognizePatient Coping 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:

Why Is It Important for Me

to Do This?

Context

What Do I Need to Do?

Treatment

What Is My Main Problem?

Diagnosis

What Else Can You Do?

When making an appointment, provide people with simple options and clear facts

Appointment InstructionsAlso 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.

Your Name

Your Appointment DateTimePlace

Our Telephone Number:Do not eat or drink for 6 hours before the day and time on this card.

People Have Difficulty Making Appointments

What Else Can You Do?

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

People Have Trouble Understanding Phone Recordings

What Else Can You Do?

Ambulatory Entrance

Hospital XYZ

Some people become confused about whether this entry was intended for ambulances or for patients

Ambulatory Entrance

The use of visuals clarify the message

Contrast in color makes it easy to read

Try to be consistent when hanging signs

People Have Trouble Reading Signs

What Else Can You Do?

To make maps easier to follow: Match the color in the map with the

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

Maps are usually hard to follow: Too complicated Codes are hard to understand Names and directions not always match Small fonts

People Have Trouble Understanding Maps

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

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.

Health Literacy, Cultural Competence, and Linguistic Competence

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 2007http://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 2008http://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-E7E6-4121-8874-99C7B4888301/0/improving_health_literacy.pdf

Crosswalk Between OMH CLAS Standards and Joint Commission 2007 Standards for Hospitals, Ambulatory, Behavioral Health, Long Term Care and Home Carehttp://www.jointcommission.org/NR/rdonlyres/5EABBEC8-F5E2-4810-A16F-E2F148AB5170/0/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/inside-aafp/20061122playitsafe.html

“Adding wings to caterpillars does not create butterflies -- it creates awkward and dysfunctional caterpillars. Butterflies are created

through transformation.”

Stephanie Pace Marshall