Partnership for Clear Health Communication

1
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
2
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

3
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)

4
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/powe
  rpoint

5
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
• 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

6
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 Approximately 50
Million Are Marginally Illiterate1 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
Natl 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. 75128
7
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/Documents20and20Settings/like.CORE/Lo
  cal20Settings/Temporary20Internet20Files/Conten
  t.IE5/W3ATUDWR/439,17,Description of literacy
  levels

8
Measuring health literacy

• Number Percentage of Adults in
  Each Health Literacy
  Level 2003

Source National Center for Education Statistics,
Institute for Education Sciences
9
Percentage of adults in
each literacy level 2003
36 77M adults
Source National Center for Education Statistics,
Institute for Education Sciences
10
Percentage of adults in each
health literacy level, by age 2003
                                
11
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

12
Low Health Literacy Impacts a Patients 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)1,67782
13
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

14
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
  

15

• 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/3
  67/healthlitclinicians.pdf

16
Limited Health Literacy
Clues and Red Flags

• Responses to receiving written information
• I forgot my glasses. Ill 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/hea
  lthlitclinicians.pdf

17
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/hea
  lthlitclinicians.pdf

18
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

19
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
  199325391-5.
• 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 199510537-41.
• Weiss BD, Mays MZ, Martz W, et al. Quick
  Assessment of Literacy in Primary Care The
  Newest Vital Sign Ann Fam Med 2005
  3514-522.
• 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.

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SPEAK A Mnemonic for Addressing
Health Literacy Issues

• S Speech - How will the healthcare
  providers 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.

21
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

22
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 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 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
23
Example of Health Communication That May Not
Reach a Broad Consumer Audience
70
150
Good Range
TooHigh
TooLow
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
Blood Sugar Is Too Low if It Is Under 70
Blood Sugar Is Too High if It Is Over 240
9th Grade Reading Level
24
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

25
Verbal Communication
Up to 80 of Patients Forget What Their Doctor
Tells Them As Soon As They Leave the Doctors
Office ANDNearly 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 dont understand yet 79 feel
  others dont 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
26
Clear Health Communication in Action
Start by Decreasing the Use of Medical Jargon
Consider Using This One Instead
Instead of Using This Word
Benign Harmless Chronic Happens again and again
does not end Cardiac Heart Edema Swelling build
up of fluid Fatigue Tired Screening Test Intake Wh
at you eat or drink Generic Not a brand
name Adverse events Side effects
27
Ask Me 3 Creates Shared Responsibility for
Clear Health Communication
Patient
Provider
De-stigmatize andReduce Embarrassmentof Low
Health Literacy
RecognizePatient Coping Mechanisms
28
What Is Ask Me 3

• Promotes three simple, but essential, questions
  and answers for every healthcare interaction

29
What Else Can You Do?
People Have Difficulty Making Appointments
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.

• 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.
30
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

31
What Else Can You Do?
People Have Trouble Reading Signs

• 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

32
What Else Can You Do?
People Have Trouble Understanding Maps

• 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

33
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

34
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

35
Becoming a
Culturally Competent
Healthcare Organization
and Service Delivery System
36
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 200731 (Suppl 1)S122-S133.
37

• 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/nc
  cc

38
Joint Commission
Hospitals, Language, and Culture A Snapshot of
the Nation, March 2007 http//www.jointcommission.
org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8
BD3/0/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/rd
onlyres/D5248B2E-E7E6-4121-8874-99C7B4888301/0/imp
roving_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/5
EABBEC8-F5E2-4810-A16F-E2F148AB5170/0/hlc_omh_xwal
k.pdf
39
National Committee for
Quality Assurance (NCQA)

Innovative Practices in Multicultural
Health Care 2006 -2007

http//web.ncqa.org/Portals/0/HEDISQM/CLAS/CLAS_I
nnovativePrac06.pdf Multicultural Health
Care
A Quality Improvement
Guide, 2008
http//www.ncqa.org/tabid/67
6/Default.aspx

Funded by the California
Endowment/Support from CMS
40
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/a
  bstract/7/3/331
• DHHS Office of Disease Prevention and Health
  Promotion
  Health Literacy Improvement
  Website http//www.health.gov/commu
  nication/literacy/powerpoint http//www.health.gov
  /communication/literacy/quickguide
• DHHS Administration on Aging. Communicating with
  Older Adults http//www.aoa.gov/prof/commu
  nicating/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_presentat
  ion.ppt

41
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/healthliter
  acy/training.htm
• AMA/AMA Foundations Health Literacy Toolkits,
  Videos, Partnerships
  Video - Health Literacy Help Your Patients
  Understand
  http//www.ama-assn.org/ama/pub/category/81
  15.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/v
  iewprogram/8603
• American College of Physicians Foundation Health
  Literacy Resources and CD Health Literacy A
  Silent Epidemic. http//foundation.acponline.org/h
  ealthcom/hli/resources.htm
• American Academy of Family Physicians. Play It
  Safe with Medicine! (Toolkit)
  http//www.aafp.org/online/en/home/publications/ne
  ws/news-now/inside-aafp/20061122playitsafe.html

42
Adding wings to caterpillars does not create
butterflies -- it creates awkward and
dysfunctional caterpillars. Butterflies are
created through transformation.
Stephanie Pace Marshall