Overcoming health care disparities via better cross-cultural communication and health literacy

An english-speaking middle-aged woman from an ethnic minority group presents to her internist for follow-up of her chronic medical problems, which include diabetes, high blood pressure, asthma, and high cholesterol. Although she sees her physician regularly, her medical conditions are not optimally controlled.

At one of the visits, her physician gives her a list of her medications and, while reviewing it, explains—not for the first time—the importance of taking all of them as prescribed. The patient looks at the paper for a while, and then cautiously tells the physician, “But I can’t read.”

This patient presented to our practice several years ago. The scenario may be familiar to many primary physicians, except for the ending— ie, the patient telling her physician that she cannot read.

Her case raises several questions:

• Why did the physician not realize at the first encounter that she could not read the names of her prescribed medications?
• Why did the patient wait to tell her physician that important fact?
• And to what extent did her inability to read contribute to the poor control of her chronic medical problems?

Patients like this one are the human faces behind the statistics about health disparities—the worse outcomes noted in minority populations. Here, we discuss the issues of cross-cultural communication and health literacy as they relate to health care disparities.

DISPARITY IS NOT ONLY DUE TO LACK OF ACCESS

Health care disparity has been an important topic of discussion in medicine in the past decade.

In a 2003 publication,¹ the Institute of Medicine identified lower quality of health care in minority populations as a serious problem. Further, it disputed the long-held belief that the differences in health care between minority and nonminority populations could be explained by lack of access to medical services in minority groups. Instead, it cited factors at the level of the health care system, the level of the patient, and the “care-process level” (ie, the physician-patient encounter) as contributing in distinct ways to the problem.¹

A CALL FOR CULTURAL COMPETENCE

In a policy paper published in 2010, the American College of Physicians² reviewed the progress made in addressing health care disparities. In addition, noting that an individual’s environment, income, level of education, and other factors all affect health, it called for a concerted effort to improve insurance coverage, health literacy, and the health care delivery system; to address stressors both within and outside the health care system; and to recruit more minority health care workers.

None of these things seems like anything a busy practicing clinician could do much about. However, we can try to improve our cultural competence in our interactions with patients on an individual level.

The report recommends that physicians and other health care professionals be sensitive to cultural diversity among patients. It also says we should recognize our preconceived perceptions of minority patients that may affect their treatment and contribute to disparities in health care in minorities. To those ends, it calls for cultural competence training in medical school to improve cultural awareness and sensitivity.²

The Office of Minority Health broadly defines cultural and linguistic competence in health as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.”³ Cultural competence training should focus on being aware of one’s personal bias, as well as on education about culture-specific norms or knowledge of possible causes of mistrust in minority groups.

For example, many African Americans may mistrust the medical system, given the awareness of previous inequities such as the notorious Tuskegee syphilis study (in which informed consent was not used and treatment that was needed was withheld). Further, beliefs about health in minority populations may be discordant with the Western medical model.⁴

RECOGNIZING OUR OWN BIASES

Preconceived perceptions on the part of the physician may be shaped by previous experiences with patients from a specific minority group or by personal bias. Unfortunately, even a well-meaning physician who has tried to learn about cultural norms of specific minority groups can be at risk of stereotyping by assuming that all members of that group hold the same beliefs. From the patient’s viewpoint, they can also be molded by previous experiences of health care inequities or unfavorable interactions with physicians.

For example, in the case we described above, perhaps the physician had assumed that the patient was noncompliant and therefore did not look for reasons for the poor control of her medical problems, or maybe the patient did not trust the physician enough to explain the reason for her difficulty with understanding how to take her medications.

Being aware of our own unconscious stereotyping of minority groups is an important step in effectively communicating with patients from different cultural backgrounds or with low health literacy. We also need to reflect about our own health belief system and try to incorporate the patient’s viewpoint into decision-making.

If, on reflection, we recognize that we do harbor biases, we ought to think about ways to better accommodate patients from different backgrounds and literacy levels, including trying to learn more about their culture or mastering techniques to effectively explain treatment plans to low-literacy patients.

ALL ENCOUNTERS WITH PATIENTS ARE ‘CROSS-CULTURAL’

In health care, “cross-cultural communication” does not refer only to interactions between persons from different ethnic backgrounds or with different beliefs about health. Health care has a culture of its own, creating a cross-cultural encounter the moment a person enters your office or clinic in the role of “patient.”

Carillo et al⁵ categorized issues that may pose difficulties in a cross-cultural encounter as those of authority, physical contact, communication styles, gender, sexuality, and family.

Physician-patient communication is a complicated issue. Many patients will not question a physician if their own cultural norms view it as disrespectful—even if they have very specific fears about the diagnosis or treatment plan. They may also defer any important decision to a family member who has the authority to make decisions for the family.

Frequently, miscommunication is unintentional. In a recent study of hospitalized patients,⁶ 77% of the physicians believed that their patients understood their diagnoses, while only 57% of patients could correctly state this information.