Health Literacy and Delivering Culturally Competent Care

Editor's Note: This text-based course is an edited transcript of the webinar, Health Literacy & Delivering Culturally Competent Care, presented by Kathleen Weissberg, PhD.

Learning Outcomes

After this course, participants will be able to:

• Define health literacy.
• Recognize health literacy concepts including relevant statistics.
• Identify appropriate assessment tools to evaluate health literacy levels.
• Recognize factors that influence health literacy.
• Describe techniques the practitioner can use to facilitate health literacy in his/her practice.

Introduction

Thank you to anyone who is listening today on this important topic, Health Literacy and Culturally Competent Care. I think these really go hand in hand and are critically important for anyone in any level of clinical practice.

Health literacy is the ability to read, compute, understand, and act on health information so that we can make informed decisions. Low health literacy is a serious threat to the wellbeing of persons who are seeking out any sort of medical care. With the increasing diversity of the clients that we are serving in our practice, we may observe that our communication skills are less effective with people from backgrounds that are different from our own.

In this session, we are going to provide an overview of health literacy and talk about techniques for clear and effective communication, both verbal and written. We are going to talk about selecting easy-to-read health materials, assessment tools, and some other things. Throughout all of this talk, we are going to be interweaving some conversation about cultural competence, because of course, these two items go hand in hand.

Definitions

• Literacy
  • Ability to understand and use reading, writing, speaking, and other forms of communication as ways to participate in society and achieve one’s goals and potential
• Health literacy
  • The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

These definitions come directly out of Webster's. Literacy is the ability to understand and use reading, writing, speaking, and other forms of communication as ways to participate in society and to achieve one's goals and potential. Again, we are going to be talking about health literacy more, but this is being able to participate in your daily life, go to the grocery store, go to a place of worship, or whatever it is that you want to do. That is general literacy. Health literacy takes it a step further. It 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. As we will see in just a few minutes, the statistics related to health literacy in this country are really staggering.

We all work in the healthcare industry, and I think every one of us would even agree that sometimes it is even challenging for us to be able to navigate the healthcare system with all of the forms and different things that we need to do.

Health Literacy

• Individual and Systemic Factors
  • Communication skills of laypersons and professionals
  • Lay and professional knowledge of health topics
  • Culture
  • Demands of the healthcare and public health systems
  • Demands of the situation/context

When we look at health literacy, it is dependent on several individual and systemic factors not only within myself but also within the environment where I happen to be. Some of those things are the communication skills of laypersons and professionals. How can I, as a professional, communicate to the person that I am trying to serve so that they can understand me? What are the lay and professional knowledge of health topics? It is not only the communication piece but also knowledge of the topic. As that person is communicating to me, can I understand and incorporate that knowledge? We also need to know about a culture, and we will talk more about this as we go on. There are also demands of the healthcare and the public health system, particularly for situations and content. A demand going to see your general practitioner for a checkup is one thing. A demand going to see your cardiologist because you are having a procedure is something totally different.

• What Does Health Literacy Affect?
  • Affects people's ability to:
    • Navigate the healthcare system, including filling out complex forms and locating providers and services
    • Share personal information, such as health history, with providers
    • Engage in self-care and chronic-disease management
    • Understand mathematical concepts such as probability and risk

Health literacy affects our ability to navigate the healthcare system. I just alluded to this. This includes filling out forms, locating providers, locating services, and choosing your healthcare benefits at open enrollment. It can be very difficult sometimes to navigate through that.

This is also sharing personal information such as health history with providers. How much do I share? What should I not share? How do I share that in a way that is understandable by the healthcare providers so that they can provide care for me?

This is also the ability to engage in self-care and chronic disease management. We are going to talk a lot about this. These are preventative types of things like getting your annual mammogram, routine cancer screenings, or as a diabetic checking your sugar.

It is also important to understand mathematical concepts, such as probability and risk. We may need to understand the dosage of medications or tracking health numbers to determine if is it necessary to call a physician or change medication.

Health Literacy Skills

• Numeracy skills
  • E.g., measuring medications, choosing between health plans, calculating premiums & copays
• Health topics
  • E.g., the body, causes of disease, diet, and exercise

Health literacy includes those numeracy skills. This could be calculating your cholesterol level, blood sugar level, measuring out medications and dosages, or understanding nutrition labels. This is very important, particularly for someone who needs to manage their sugar and fat content. Other topics include choosing between health plans, comparing prescription drug coverage, and calculating premiums, copays, and Medicare deductibles. All of this requires numeracy skills. As an aside, I have two young children at home and my daughter always says to me, "I don't understand why I need all this math?" The answer is that we use math every single day.

In addition to basic literacy skills, health literacy also requires knowledge of health topics. Individuals who have limited health literacy often do not have basic knowledge about health, their body, or the nature and cause of disease. In some cases, they may have misinformation about health. They may be getting their information from an unreliable source like social media. Somebody may have tried to give them the information, but they just could not process it. Without having that basic knowledge, they may not understand the relationship between lifestyle factors like diet and exercise and how that impacts various disease processes and health outcomes.

I alluded to this earlier. Health information can overwhelm even individuals with advanced literacy skills. We know that medical science progresses quite rapidly. Perhaps what a person learned about health or biology during their school years has changed. As healthcare professionals, we are most likely more up to date. However, the average person may have outdated or incomplete information. Moreover, health information that is provided during a stressful or unfamiliar situation is unlikely to be retained. A stressed brain does not take in that information always accurately, and there can be gaps. And, the stressed brain may fill in those gaps with misinformation.

Low Literacy

• Global crisis affecting many
• Plain language + Clear communication = A solution
  • Without clear communication, we cannot expect people to adopt the healthy behaviors and recommendations that we champion

Low literacy is a global crisis as it affects a lot of people. This is why it is so important to address this issue and confront the facts head-on. Quite simply put, the responsibility is ours as healthcare professionals to communicate in what we call plain language. We will be talking more about that term in just a few minutes. Without clear communication, we cannot expect people to adopt healthy behaviors and the recommendations that we champion. When people receive accurate, easy to use, and easy to read information about a health issue, they are better able to take action to protect themselves and to promote their own health and wellness. 

Plain Language

• Plain language is communication that users can understand the first time they read or hear it
• Elements include:
  • Organizing information so that the most important points come first
  • Breaking complex information into understandable chunks
  • Using simple language and defining technical terms
  • Using the active voice

Plain language is a strategy for making both written and oral information easier to understand. Users can understand plain language the very first time they read and hear it. Oftentimes, it is very conversational in nature. There also may be anecdotes or stories to get a point across. A plain language document is one where the person can get the information that they need and understand it. What is most important for us as healthcare professionals is to act appropriately on that understanding.

Key elements of plain language include the organization of information so that the most important points come first. These are the most important things that you want that person to know or takeaway. It has to be right up front. We also want to break down the complex information into understandable chunks. We do this when we are teaching and training. We want to use very simple language and define the technical terms. This is no place for jargon. Lastly, we want to use an active voice.

What is important to know about plain language is that it may be plain to one set of readers, but it may not be plain to another set. To put this in perspective, I am talking to a big group of professionals here today. You have a college education, and your level of plain language is going to be something very different from a person who may only have a fifth-grade education or their GED. It is critical to know your audience and test your materials before, during, and after they are developed. Make sure that you are meeting your objectives with your target audience.

Speaking plainly is just as important as writing plainly. These plain language techniques also apply to verbal messages. You want to avoid jargon and explain medical and technical terms. You must apply these concepts to both verbal and written information.

Health Literacy Incidence and Statistics

Let's talk a little bit about the incidents and statistics related to health literacy. I shared that some of these are really staggering.

Low Literacy Statistics

• 36 million adults in the US cannot read, write, or do math above a third-grade level
• Low literacy costs the US $225 billion+ per year
• $232 billion in healthcare costs are linked to low literacy
• Each year about 2 million immigrants come to the US, many lacking proficiency in English

More than 36 million adults in the United States cannot read, write, or do basic math above a third-grade level. Low literacy costs the United States about $225 billion or more every year in things like nonproductive work, crime, loss of revenue due to unemployment, and things like that. We spend in the United States about $232 billion every year in healthcare costs that are very specifically linked to low adult literacy skills. We will see more about this on another slide. A lot of that cost is in emergency room visits and other things that may have been mitigated through preventative services but were not. Each year about 2 million immigrants come to the United States. When you look at that group of people, about 58% of them lack a high school education and are not proficient in English.

• 43% did not understand the rights and responsibilities section of a Medicaid application
• 26% were unable to understand information on an appointment slip
• 60% did not understand a standard informed consent
• 33% were unable to read basic health care materials
• 42% could not comprehend directions for taking medication on an empty stomach

(Campinha-Bacote, D., 2005)

A study was done on health literacy by Campinha-Bacote back in 2005. It is a little old, but they found that of the patients surveyed, 43% did not understand the rights and responsibilities section of a Medicaid application. Twenty-six percent were not able to understand the basic information on an appointment slip like when to go back to see the physician or to go to outpatient for services. Sixty percent did not understand a standard informed consent form, and 33% were not able to read basic healthcare materials. Lastly, 42% could not comprehend directions for taking medication on an empty stomach. I have not seen updated statistics for these parameters, but I can only imagine they probably have not changed a lot. You may start to question how much of your teaching and training is really getting through. Although limited health literacy affects almost every adult at some point in time in their lives, there are some disparities in prevalence and severity.

Vulnerable Populations

• Adults over the age of 65
• Recent refugees and immigrants
• People with incomes at or below poverty levels
• Racial and ethnic groups other than white
• People with less than a high school degree or GED
• Non-native speakers of English

(National Center for Education Statistics, 2006)

Certain populations are more likely to experience limited health literacy. This is not saying that they absolutely will. For example, this does not mean that someone with only a high school diploma or GED has low health literacy. This is just saying that they are at a higher risk. Vulnerable populations include adults over the age of 65, recent refugees and immigrants coming to our country, people with incomes at or below poverty levels, racial and ethnic groups (other than Caucasian or white), individuals with less than a high school degree or a GED, and non-native speakers of English. Again, they are a little more vulnerable to the issue than maybe some other individuals.

Incidence and Identification

• Nearly nine out of every 10 people in the U.S. have limited health literacy
• Education level is not a good predictor of  health literacy
• AHRQ recommends “universal precautions”
  • Assume that most individuals will struggle to understand health information

(HHS AHRQ, 2015; Kutner, Greenberg, Jin, & Paulsen, 2006; Weiss, 2003; Weiss, 2007; HHS ODPHP, 2010)

Nearly nine out of every 10 people in the United States have limited health literacy and have experienced difficulty using health information to effectively manage their health and their health care. There is often a discrepancy between the health literacy level of the healthcare professional and that of the individual receiving health services. This discrepancy is a huge cause of poor communication in health and healthcare. I sometimes have to step back and think, "Did I say something over their head?" My parents are elderly, and I often have to explain different things to them. You have to give them the information in the language that they understand. 

It is also important to note that somebody's education level is not a good predictor of his or her health literacy. Again, I can use the example of my parents. Both of them have college degrees, but they really struggle with setting up a new glucometer, doing their Medicare forms, et cetera. In fact, since almost 90% of individuals have limited health literacy, these are individuals of all races, ages, incomes, and education levels. For this reason, the Health and Human Services Agency's Healthcare Research and Quality (HHS AHRQ) recommends that we adopt a universal precautions approach. We are very familiar with that as it relates to infection control. But in this case, we are talking about is health and healthcare professionals. We need to assume that most individuals will struggle to understand health information.

Again, literacy skills are a very strong predictor of health status even more so than age, income, employment status, educational level, and racial or ethnic group. We cannot necessarily identify individuals who are going to have limited literacy skills. We are going to talk more about that in just a second, but clients may speak well or appear well-educated. They often do not tell anyone about their difficulties with reading and writing. They become very skilled at masking some of these things. If you adopt that universal precautions approach, you assume that all of your patients can have difficulty somewhere when understanding health information. To reduce the risk of communication issues, it is recommended to simplify all communication and confirm comprehension for all patients. If you do that more often than not, somebody with a higher health literacy is not going to be offended by the fact that you simplified it a little bit. Actually, they will probably be a little bit more appreciative.

Signs of Low Literacy

• Poor compliance with treatments and appointments
• Watching and mimicking others
• Not knowing the names of regularly used medications
• Making excuses for not reading
• Bringing someone who can read to appointments
• Vocalization or sub-vocalization when reading
• Confusion or frustration when reading

There are some signs of low literacy. There can be poor compliance with their treatments and appointments. They may not follow up on their medications. They often watch and mimic others to learn. They may not know the names of their regularly used medications or how often they need to take them. They may make excuses for not reading. "I'll just take this home with me," or "I'll read it later because I forgot my glasses for the appointment." Bringing someone with them to their appointments who can read and give them that information is helpful in these cases. They may also use vocalization or sub-vocalization as they are reading to themselves. They may demonstrate confusion or frustration on their face.

• Behaviors
  • Patient registration forms are incomplete or contain mistakes
  • The patient does not take medication as directed
  • The patient does not follow through with lab tests, imaging tests, or referrals
• 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/spouse."
• Responses to questions about medication
  • The patient is unable to name medications
  • The patient is unable to explain a medication’s purpose
  • The patient is unable to explain the schedule/frequency for taking a medication

(Weiss, 2003)

There are additional signs, and this comes from Weiss in 2003. They may make mistakes or have incomplete forms. The client may not take their medication correctly or not follow through with tests, referrals, or labs. They again use excuses like they forgot their glasses. They may ask if you can read the form to them or want to take it home. They may also say that they cannot make the decision right now or need to discuss it with their family member. They also often do not know the purpose of their medication or the schedule, dose, or frequency. Those are some of our signs that as you are working with individuals you may see.

Relationship Between Health Literacy and Health Outcomes

What is the relationship between health literacy and health outcomes?

Preventative Services

• More likely to skip important preventive measures
• Those with low literacy enter the healthcare system when they are sicker

(Scott, Gazmararian, Williams, & Baker, 2002; Bennet et al., 1998)

I have already alluded to some of these. According to research studies, persons with limited health literacy skills are more likely to skip important preventative measures. These are things like mammograms, Pap smears, flu shots, and routine vaccinations like the pneumonia shot or something like that. When you compare that to those individuals who have adequate health literacy skills, these clients enter the healthcare system sicker as they are skipping a lot of preventative services. 

Knowledge of Conditions and Treatments

• More likely to have chronic conditions
• Less able to manage chronic conditions effectively
• Less knowledge of illnesses and management

(Williams, Baker, & Parker, 1998; Schillinger et al., 2002; Schillinger et al., 2003; Williams, Baker, Honig, Lee, & Nowlan, 1998; Kalichman, Ramachandran, & Catz, 1999; Kalichman & Rompa, 2000; Kalichman, Benotsch, Suarez, Catz, Miller, & Rompa, 2000)

Persons with limited health literacy skills are more likely to have chronic conditions, and they are less able to manage them effectively. Studies have found that patients with things like high blood pressure, diabetes, asthma, or HIV and AIDS often have limited health literacy skills. They have less knowledge about their illness and management. They then enter the healthcare system with more intense symptoms and are sicker than if they had this information.

Hospitalization

• Associated with increased preventable hospital visits and admissions
• Higher rate of hospitalization
• Higher frequency of emergency services use

(Baker, Parker, Williams, & Clark, 1997; Baker, Parker, Williams, & Clark, 1998; Baker et al., 2002; Gordon, Hampson, Capell, & Madhok, 2002)

The rates of hospitalization are higher as well. Limited health literacy skills are associated with an increase in preventable hospital visits and admissions. Studies have demonstrated a higher rate, not only of hospitalization but the use of ER services among patients with limited health literacy skills. They are not necessarily seeing routine physicians or using walk-in clinics. Instead, they are going straight to the ER.

Health Status

• More likely to report their health as poor

(National Center for Education Statistics, 2006)

Additional studies show that individuals with limited health literacy skills are significantly more likely to report their health as poor than persons with adequate health literacy skills.

Healthcare Costs

• Greater use of services designed to treat complications of the disease
• Less preventative service use
• Higher hospitalization and ER use associated with higher healthcare costs

(Friedland, 1998; Howard, Gazmararian, & Parker, 2005)

There are healthcare costs. Persons with limited health literacy skills make greater use of services that are designed to treat complications of the disease and less use of services that are designed to prevent complications. In my community, they are trying to change this narrative by offering incentives or contests for people that use more of those preventative services. Whether or not it is working, I have no idea. I have not seen any sort of research or evidence, but I know communities are really trying hard to flip that narrative. In the above studies, a higher rate of hospitalization was noted in those with a lower rate of health literacy. As stated, there is a higher use of ER services by those with limited health literacy. Unfortunately, this translates into higher healthcare costs.

Stigma and Shame

• Negative psychological effects
• Sense of shame about skill level
• Individuals may hide reading or vocabulary difficulties to maintain

(Parikh et al., 1996; Baker et al., 1996)

Low health literacy has negative psychological effects. One study found that those with limited health literacy skills reported a sense of shame. This shame causes them to hide their reading or their vocabulary difficulties to maintain their dignity. As healthcare practitioners, we need to do everything that we can to communicate in a way that does not further exacerbate that stigma and shame. This gives the person a place of comfort where they feel good about communicating and sharing their information.

Practitioner's Role

Practitioner Role

• Ensure health-related information/education matches a person’s literacy abilities; cultural sensitivities; and verbal, cognitive, and social skills
• Provide information and education that promote self-management for optimum health and participation
• Facilitate health literacy by promoting systems of care or environments that adhere to health literacy principles and strategies

(DHHS, 2013)

We can make sure that all health-related information and education that we provide to our patients/families, colleagues, and other people match that person's literacy abilities, cultural sensitivities, and verbal, cognitive, and social skills. The Healthy People 2020 Campaign from the Department of Health and Human Services was published in 2013. It encourages that all clinicians use appropriate communication and education skills to help enable all people to gain access and to understand the services that we are providing. This includes information and education that promotes self-management for optimum health and participation. Besides, I believe we all have a role in facilitating clients' health literacy by promoting systems of care and promoting environments that adhere to health literacy principles and strategies. Within your own environment, you may have already adopted every single one of these principles. But if your environment is not adopting these, you may not be getting that leg up. It really has to be a systemic type of intervention and change.

Link to Literacy

• Stress the importance of:

5.Access to services and equity issues

(Levasseur & Carrier, 2010)

We, as healthcare professionals, are linked to health literacy because we stress the importance of somebody's capacities, capabilities, function, and participation. We want to empower our clients and using a holistic approach. We do not look at our clients in a silo. We want to have a client-centered practice to make sure we are delivering what our clients need. We teach information and use different methods to do that. Lastly, we look at access to service and equity issues within our professions.

Integrating Health Literacy Into Practice

• Be informed about health literacy and recognize it
  • Learn about health literacy and ways to integrate it into practice
  • Do not assume that all clients understand what they are told even if they nod their head or that they can read
  • Recognize the powerlessness, shame, and sense of failure that some people may feel
  • Identify your client’s characteristics

You might be wondering about strategies. How can I improve my client's health literacy? How do I integrate it within my practice? The first thing you need to do is be informed about health literacy and be able to recognize it. This refers to your knowledge, your ability to identify challenging health literacy information, and being able to look at an intake form or a brochure to identify if there is something amiss. What can we do to make this a little bit easier to understand?

You can learn about health literacy and ways to integrate it. Obviously, this is not assuming that all of your clients understand what they are told, even if they nod their head or can read. I think there is a saying out there that it takes you seven times of hearing something before you truly learn it. Seven times may not be the answer, but we cannot assume that they get it on the first try.

We also have to understand the powerlessness, shame, and sense of failure that some people may feel because they cannot understand and carry things through.

We need to identify clients' characteristics. This is their knowledge and teaching preferences. Not everybody is a verbal learner. What are their skills? What are their beliefs? What is their culture? What are their barriers to healthcare? Obviously, culture plays a big piece in that as well. We know that clients with low literacy levels are usually very reluctant to ask questions as they are skillful at hiding their problems.

• Important to recognize individual and societal barriers to the promotion of health literacy
  • Functional declines associated with aging
  • Lack of reading and writing proficiency
  • Low levels of formal education or lack of health knowledge and skills
  • Different mother tongue or cultural beliefs
  • Living with disabilities and social stigma
  • Experiences in early childhood

Although there are diverging opinions about whether or not we can truly evaluate health literacy, it is important to recognize that there are both individual and societal barriers to the promotion of health literacy. There are functional declines associated with aging. There can be a lack of reading and writing proficiency. There are low levels of formal education or lack of health knowledge and skills. A client can have a different mother tongue. There can be a different native language or cultural belief from where this person is accessing their services. They can have disabilities and incur social stigma. Then, of course, they may have experiences from early childhood. This is outside of the scope of this session, but there is a lot of research on trauma-informed care in the literature. Experiences in early childhood have a significant impact on how someone accesses and utilizes health services and their overall health behaviors later in life. It is all interwoven.

• Standardize practice to health literacy
  • Develop professional standards and position statements for health communications and interactions
  • Include health literacy criteria into quality and accreditation standards of health care organizations

We can also standardize practice to health literacy. What does that mean? This focuses on your ability to take into account a client's level of health literacy during your intervention. In addition to being informed, we all can go back to our national professional associations or our regulatory and licensing bodies. Those different organizations can contribute to developing professional standards, position papers, and position statements that really help to standardize the integration of health literacy into our practice. I think all of our boards have certainly done that. In fact, all employees may value health literacy, and it may be included in every health and medical care facility's policies and goal. 

• Consider health literacy by making information accessible
  • Adapt the information to individual needs, circumstances, and abilities to show how it is relevant
  • Communicate in a comprehensive way using more than one way of exchanging information
  • Combine oral instructions with written information
  • Use a structured educational approach
  • Use demonstration, experimentation, and repetition when teaching

We also need to consider health literacy by making the information accessible. This refers to the ability of us to improve how we use the information to educate our clients. We are adapting the information to individual needs, circumstances, and abilities. Are we showing them how it is relevant to their particular situation? Are we communicating in a comprehensive way and in more than one way of exchanging information? This can be verbal, gestures, and written information. This is combining oral along with the written information in a clear simple language for future reference. You can also use demonstration, audio, visual aids, videos, or equipment. This is using a structured educational approach. We also need to use demonstration, experimentation, and repetition to increase the effectiveness of that teaching.

• Design written information
  • Active voice
  • Clear simple language
  • Pictures or drawings to illustrate procedures
  • Interactive and with recaps
  • Most important information placed first
  • Personalized

We need to do this in the active voice. These are common words, short words, and short sentences with 10 words or less. This is not using technical terms, value judgment words, jargon, abbreviations, or acronyms. We should use examples to explain difficult words or maybe a story to explain them. You can use the same words throughout the entire material or use pictures or drawings to illustrate. This can be for an exercise or a breathing activity. You can also use photos to do that. You want it to be interactive with recaps along the way. The most important information should be first and it should be personalized. If the information is not personal to them, they are probably not going to retain it.

• Communicate effectively and simply
  • Announce the subject
  • Convey the message
  • Ask clients to say in their own words what they remember of the information or methods taught

There are other ways to communicate. It is important to communicate effectively and simply in an atmosphere that is conducive to that communication. Announce the subject and convey the subject. We will talk about teach-back in a little bit. You want to ask the person about the information and have them say it back in their own words. "What do you remember about this information?" "What do you remember about what we just taught you?" I think we intuitively do this in our treatment. It allows us to identify any misunderstandings and correct them.

• Use the Ask Me 3

1.What is your main problem today?

2.What do I need to do for you concerning this problem?

3.Why is it important to you?

Use the Ask Me 3 method. "What is your main problem today? What do I need to do for you?" Or, "What are you seeking from me concerning this problem?" And, "Why is it important to you?" You can start every single session with that so that you know you are doing what is most important to that client.

• Help clients make optimal use of health services
• Increase the quality of professional communication
• Use anecdotal information as appropriate 
• Do not overburden clients with information or recommendations

We can help our clients to make optimal use of health services and increasing the quality of our own communication. We have talked about that in our own professional competencies as it relates to health literacy. We can use anecdotal information. I already shared that. Personal stories sometimes hit home more than anything. Obviously, this is not overburdening our clients with information or recommendations. I see this so many times when we deliver home programs or home instruction. We just bombard them with everything under the sun. We do not need to do that. Let's just keep it simple on what they really need to focus on.

• Strengthen interactions
  • Encourage clients to ask questions
  • Take an understanding attitude
  • Shame-free environment
  • Increase the time spent on giving information
  • Observe and listen actively

This goes back to creating an environment where they are comfortable. You want to encourage them to ask questions and have an understanding attitude rather than a blaming attitude. You wat a shame-free environment. We want to increase the time that we spend on giving information. Speak slowly, repeat, observe, and listen actively. One of the best things we can do is just be quiet. Give clients the time to organize their thoughts to identify what their issues are, their constraints, and to formulate their questions.

• Strengthen interactions
  • Increase cultural competency
  • Follow up on interventions to see if recommendations have been followed and if clients have questions
  • Involve not only the client but also families

Increase your own cultural competency. Be a professional who really respects those differences. You want to be open to learning and willing to admit that there is more than one way to look at the world. Follow up on those interventions to see if the recommendations have been followed and if they have any questions. We want to involve the client and their families. The families are often cultural brokers for our clients.

• Intervene to increase client’s health literacy
  • Optimize reading/writing skills including use of the Internet
  • Increase knowledge of health
  • Encourage clients to read every day
  • Foster empowerment by using a client-centered approach

We want to increase the client's health literacy. These are interventions focusing on the client's health literacy level. You can use the internet to optimize their reading and writing skills. You want to increase their knowledge of health and health determinants. We have that opportunity to teach and train. You want to encourage them to read every day and take a local health literacy program. This is outside of our scope, but it is a nice thing to do. If you know there are programs in the community, turn these folks on to them. We want to foster empowerment, using a client-centered approach. Give them confidence in their ability to take more control of their life. Empowerment includes making them responsible for taking care of their health, making decisions about their health, and truly being engaged. They are responsible for their health and not just along for the ride and doing what the physician says. They are responsible, and we can help them to find ways to do that.

• Collaborate to increase clients’ health literacy
  • Participate in intersectoral activities
  • Provide education to other health care professionals about health literacy topics

We have an important advocacy role in influencing the goals of the health facility where we work regarding health literacy. We may want to participate in public health initiatives or research. We can raise awareness among other players in the clinical setting within our own organization, other stakeholders, support staff, managers, and community partners to lead the charge and work on education.

Effective Communication with Diverse Populations

There can be communication challenges as we start to care for an increasingly diverse patient population. We need to effectively gather information from patients to foster individual care and to demonstrate a cultural understanding. When we look at effective health communication, it is influenced by cultural values, attitudes, and beliefs. It involves providing healthcare-related information to an individual in a way that is understandable and increases their knowledge. Again, our end goal here is to positively influence their health behaviors and interventions. 

Communication

• Verbal
  • Sharing information in a one-on-one interaction, usually orally, to achieve a shared meaning
• Nonverbal
  • Conveying meaning without words, including using gestures, facial expressions, eye contact, body language, and clothing
• Written
  • Using written symbols, such as letters and numbers, as well as pictures and graphics

(Adeyanju, 2008; Wanless & Cameron, 2010; Norton, 1983; Poyatos, 1983)

There are three different ways that we communicate. We have verbal, non-verbal, and written. We use all of these when we communicate, but the linguistic characteristics can also include dialects, regional variants, literacy levels, and more. Even though you are using these types of communication, there are variations within them.

Communication and having a trusting relationship between the patient and the healthcare provider are critically important. Research shows that individuals with communication needs often have poor health outcomes, they have trouble following medical advice, and they are less satisfied with their healthcare interactions overall than individuals who do not have any sort of communication barriers. Recognize that every patient enters the healthcare system with their own unique illness experience. You can learn a lot about a person by adopting skills and communication techniques that are nonjudgmental to allow that person to share what is most important to them.

• Compared to patients who are simply told what to do, patients who are encouraged to discuss their perceptions of illness and expectations for treatment:
  • Experience a greater sense of control and feel more involved in their care
  • Suffer less from anxiety
  • Are more likely to accept hospital routines and treatment schedules

(Muñoz & Luckmann, 2005)

Clients that are encouraged to be partners and discuss their perceptions and expectations have a greater sense of control. They feel more involved, have less anxiety, and most importantly are more likely to accept routines and treatment schedules. When a person cannot describe an experience of illness, you cannot communicate effectively about disease or treatment. You lack that basic connection that you need to provide appropriate care.

This is where we get into some assessments and guides and additional information to help us. These are additional resources available to you. There are a lot of different models out there that can help you to provide or facilitate patient-centered care. They promote effective communication and cross-cultural encounters. I will present these, but you need to take some time to feel comfortable using them in your daily practice. As you do, you can gain a better understanding of that patient's perspective about their illness in light of social, cultural, historical, and other factors that contribute to that experience.

Transcultural Assessment Guide

• Bio-cultural Variations and Cultural Aspects of the Incidence of Disease
• Communication
• Cultural Affiliations
• Cultural Sanctions and Restrictions
• Developmental Considerations Restrictions
• Educational Background
• Health-Related Beliefs and Practices
• Kinship and Social Networks and Practices
• Values Orientation
• Nutrition
• Religious Affiliation

(Boyle, 2003)

The first tool that we are going to talk about is Andrews' and Boyle's Transcultural Nursing Assessment Guide. It was initially designed for nurses, but there is a lot of applicability to other groups. The authors of this particular model found that a comprehensive cultural assessment is a foundation for culturally and linguistically competent nursing or healthcare. Looking at, what is my communication? What are my values as it relates to my culture? How do I approach nutrition? What is important to me as it relates to nutrition, religion, et cetera? And again, how do those guide my healthcare interactions? There is a lot more information about this and additional handouts.

Other Communication Models

• LEARN Model (Berlin & Fowkes, 1983)
• BATHE Model (Stuart & Lieberman, 1993)
• ETHNIC Model(Levine, Like, & Gottlieb, 2000)

Three others are out there, and these all use mnemonics. The LEARN Model suggests this framework for listening, explaining, acknowledging, recommending, and negotiating. The "N" or negotiating is what we put forth as a healthcare practitioner. We have to sometimes negotiate what the course of treatment is going to be and what kind of health outcomes we are looking for as it relates to what we are trying to achieve in this setting.

The next one is something called the BATHE Model. This helps us to understand the psychosocial context of the patient's experience with illness. We ask them very simple questions about background, affect, trouble, handling, and then expressing empathy. What is the background? "Tell me a little bit about this illness and what you're experiencing." "How has this caused you trouble in your daily life?" "How have you been handling it?" "Have you been seeking medical attention from a physician?" "Have you been seeking medical attention from an herbalist or using over the counter remedies? Then, you start to get an understanding of what is their primary health concern, and how are they addressing that. Once you know that, the next question is, "How can we help?" Remember, what their primary health concern is and what my primary health concern is for them may be totally separate things. You have to step back and this leads to negotiation. I see this all the time in long term care. People will come in and develop these grandiose care plans for them like they are going to lose weight, but that is not what the patient wants. If the goal is not something the client wants, they are never going to adhere to it.

The final one is ETHNIC. This is a framework to use for culturally competent clinical practice. Many of the questions are open-ended questions to garner their explanation (E) of their illness. The next is treatment. What treatment (T) have you tried or what advice have you have sought from healers (H)? Negotiation is the "N" and is about mutually acceptable outcomes. Lastly, there is intervention (I) and then collaboration (C). Obviously, you can see a theme with all of these models. One appeal of this particular model is that it does not frame the patient's beliefs as exotic or different. If they are seeing an herbalist or a cultural or spiritual type of healer, it is seen as okay as it is part of their culture. It looks at how that fits with what they are engaging in right now in the healthcare continuum. Your most successful care plans are the ones where you marry those two together. 

Language Assistance Services

Overview

• Interpretation of verbal communication
• Translation of written documents
• Using interpreter services and translated documents ensure better understanding by providing a common language.
• Language assistance services help you provide quality care to all of your patients by facilitating effective communication

(Shi, Lebrun, and Tsai (2009)

When we look at language assistance services, these include the interpretation of verbal communication and the translation of written documents. Using interpreter services and translated documents ensures better understanding by providing a common language. Hopefully, these are things that are available to you in your setting. Many settings have said that the provider must offer these types of services. You might need to just ask around what is available to you. Communicating in different languages during a healthcare encounter can lead to a lot of confusion. It affects the quality of care, treatment decisions, and understanding. The bottom line is that it affects compliance with healthcare recommendations and treatment plans. Therefore, effective clinical encounters depend on mutual understanding between the healthcare provider and the patient. The language assistance services can help you to provide quality care to all of your patients by facilitating effective communication with individuals with any sort of communication needs, including limited English proficiency. You will see this acronym, LEP, or limited English proficiency, in some of the other slides.

Again, when we are talking about translation and interpretation, this may not just be somebody who maybe speaks a different language. It could be someone who has hearing difficulty. It could be somebody who maybe has a speech and language communication type of issue. We know that language assistance will help you do your job better when you and your patients can understand each other. You are more likely to deliver quality care and services because you are more aware of your patient's needs.

With Language Assistance

• Interpretation and translation
• Trained interpreters, who can communicate fluently with both the patient and health care provider
• Translated written materials such as intake forms and patient education
• Graphics and signage

(National Council on Interpreting in Health Care, 2008; Torres, 2001)

With language assistance, your patients are more likely to understand their health conditions, to understand their treatment plans, to follow the recommendations that you are giving to them, and to rate their care satisfactorily. This might be outside of your scope, but this is very important for all of our providers is to have really good satisfaction surveys at the end of care. We want to make sure that we are giving people information in a way that they can understand.

Language Assistance Services

• Interpretation and translation
• Trained interpreters, who can communicate fluently with both the patient and health care provider
• Translated written materials such as intake forms and patient education
• Graphics and signage

(National Council on Interpreting in Health Care, 2008; Torres, 2001)

Again, interpretation is verbal, and the translation is written. We are going to talk about both of those as we go along. These terms are very different and are not used interchangeably as they require two totally different skillsets. Interpretation requires strong listening and speaking skills. Translation involves reading and writing skills.

When we talk about language assistance services, we are going to talk a lot about trained interpreters and trained translators. Trained interpreters are those who can communicate fluently with both the patient and the healthcare provider. These are people who can provide valuable assistance during encounters with patients with limited English proficiency and other issues to improve the quality of care.

Also, we need to really look at our written materials. These are intake forms, consent forms, assessment tools, and patient education materials. I will only speak from my own experience. Within my organization, we started quite some time ago converting materials that we were giving out to our therapists, patients, and providers. We translated these into multiple languages because we realized that we just were not hitting the mark. Thus, we need to look at what we are doing so that we can develop and translate forms into a patient's language, into a provider's language, or a colleague's language.

Graphics and signage are other areas. We will be talking a little bit more about that in just a few minutes. These help to make sure that individuals with limited English proficiency can understand healthcare instructions and navigate through the healthcare system. Even if the material is not verbal, you can oftentimes get there through photos, gestures, demonstration, and signage with pictographs.

Issues with Language Barriers

• Impact access to health services
• Jeopardize comprehension of diagnosis, treatment, and follow-up care
• Diminish quality of care
• Increase health care costs

(Perkins, 2003; Grantmakers in Health, 2003)

When language assistance services are minimal or non-existent, the resulting language barriers present a lot of different challenges within the healthcare system. As an example, language barriers have been shown to impact access to health services at a lot of different entry points. It is not just when you are providing treatment, but it can affect whether a client has health insurance or receives basic preventative and specialty care. It may also jeopardize a patient's comprehension of their diagnosis, treatment, treatment options, and follow-up care. It can diminish the quality of care, and ultimately, lead to adverse clinical outcomes because the person did not follow through with recommendations. It can increase healthcare costs due to inefficiencies. Research suggests that language barriers can impede access to health services as much as the lack of health insurance can.

Interpreter Services

• “The process of understanding and analyzing a spoken or signed message and re-expressing that message faithfully, accurately, and objectively in another language, taking the cultural and social context into account “
• Provided for low English proficiency status
  • Limited ability to read, speak, write, or understand English

(HHS OCR, 2003; (National Health Law Program, 2010)

Interpreter services facilitate communication between two or more individuals who do not speak the same language. This is a basic definition from the National Health Law Program. It is also defined as the process of understanding and analyzing a spoken or assigned message and then re-expressing that message faithfully, accurately, objectively in another language, taking the cultural and the social context into account.

Interpreter services can be provided to those with limited English proficiency or low English proficiency, hearing loss, or any other circumstance that would make it difficult for that person to hear or understand a conversation. It can also be instructions, advice, or any oral communication. Limited English proficiency status includes a limited ability to read, speak, write, or understand basic English. The vast majority of our healthcare system is in English. We need to understand this to navigate.

Interpreter Service Skill Set

• Proficiency in both the language of the patient and the provider (typically English)
• Cultural competency
• The ability to work in stressful situations
• Avoid the use of untrained interpreters and/or minors including family, friends, and ad hoc clinical staff interpreters

Interpreters have different skills including proficiency in both the language of the patient and the provider, typically English. It is also not just the language. I find this so interesting because I am engaged in doing a lot of translation services. It is not just language, but it is also dialect. You may have someone who speaks Mandarin, Spanish, or Cajun French. There are also different dialects for very specific words and phrases. You really have to know where is that coming from and make sure that the interpreter is trained in that dialect, not just the language.

The person should also have cultural competency and an understanding of what culture brings to the table. Culture impacts every aspect of communication. They also have to have the ability to work in stressful situations. When people use this service, it is because someone is accessing the healthcare continuum and need your services. They need respiratory services and are accessing your service. This is a stressful situation, and you do not want your interpreter to cause any more stress or grief for your patient than they are already going through.

We know that interpreters sometimes can be really tough to find, but you can recruit them from bilingual staff members. Again, I will take a page out of my own book as this is what we have done within our own organization. We have found individuals who speak various languages, and they assist with those types of services. You can also use a dedicated staff interpreter that you have hired or use a contract agency. There are specific agencies out there and also community volunteers. I remember working in a community where the primary language was Russian. It was really interesting. We brought in individuals from that community at large to assist us with those types of activities. It does not matter who you use, but you do have to make sure that their language skills have been assessed and they are appropriately trained to provide these interpretation services.

Do not use untrained interpreters, minors, family, or friends. Minors and family members do not always give the whole message as they are too close to the situation. Untrained interpreters have been associated with poor quality of care. There is a conflict of interest and mixed agenda. They have their own agenda. And, higher rates of interpreter errors can really lead to severe clinical consequences.

Providing Written Materials

• Written materials are appropriate for patients with communication needs
• Translated written materials may include:
  • Signage
  • Applications
  • Consent forms
  • Medical/treatment/exercise instructions
• Clearly identify the audience for the materials, including literacy level, culture, and language

We have talked a lot about providing written materials already. Written materials improve communication. We want to make sure that written materials are available in other languages through the translation of existing written materials. Now, keep in mind that the translated written materials should never substitute for oral interpretation if an oral interpretation is more appropriate. If you want to do a verbal education, that would be the way to go.

Again, when we think about translated materials, it is signage in our office and community, applications, consent forms, instructions, pamphlets, marketing materials, et cetera. Everything that you touch within your organization might need to be translated.

There are web-based applications. My smartphone just updated, and there is a translation app on it now that I never had before. Those are great in a pinch, but those are not necessarily the types of translation materials that you want to create. If I use this app to translate something to another language and send it to a person that is fluent in that language, often they will say that the phase is not the way they would have said it. Thus, I would strongly caution you from overusing this option.

As we start to look at the written materials that we might need to develop, we should identify the audience for the material and their literacy level? What is their culture? What is their language? What is