Overcoming health care disparities via better cross-cultural communication and health literacy
ABSTRACTHealth care disparities have multiple causes; the dynamics of the physician-patient encounter is one of the causes that can be modified. Here, we discuss specific recommendations related to cross-cultural communication and health literacy as practical steps to providing more equitable health care to all patients.
KEY POINTS
- To provide optimal care, physicians and staff need to think about ways to accommodate patients of other cultures and backgrounds, in particular by learning more about the patient’s culture and by examining themselves for possible bias.
- Even people who read and write very well may have limited health literacy. We should not assume that patients understand what we are talking about.
- Weiss (2011) advocates six steps to improve communication with patients in all encounters: slow down; use plain, nonmedical language; show or draw pictures; limit the amount of information provided; use the “teach-back” technique; and create a shame-free environment, encouraging questions.
- The “teach-back” technique is a simple way to confirm a patient’s understanding at the end of the visit. This involves asking the patient in a nonthreatening way to explain or show what he or she has been told.
WHAT DOES THE PATIENT THINK?
A key issue in cross-cultural communication, and one that is often neglected, is to address a patient’s fears about his or her illness. In the study mentioned above, more than half of the patients who reported having anxieties or fears in the hospital stated that their physicians did not discuss their fears.6 But if we fail to do so, patients may be less satisfied with the treatment plan and may not accept our recommendations.
A patient’s understanding of his or her illness may be very different from the biomedical explanation. For example, we once saw an elderly man who was admitted to the hospital with back pain due to metastatic prostate cancer, but who was convinced that his symptoms were caused by a voodoo “hex” placed on him by his ex-wife.
For example, for the man who thought that his ex-wife put a hex on him, asking him “What do you think has caused your problem?” during the initial history-taking would allow him to express his concern about the hex and give the physician an opportunity to learn of this fear and then to offer the biomedical explanation for the problem and for the recommended treatment.
What happens more often in practice is that the specific fear is not addressed at the start of the encounter. Consequently, the patient is less likely to follow through with the treatment plan, as he or she does not feel the prescribed treatment is fixing the real problem. This process of exploring the explanatory model of illness may be viewed on a practical level as a way of managing expectations in the clinical care of culturally diverse populations.
HEALTH LITERACY: MORE THAN THE ABILITY TO READ
The better you know how to read, the healthier you probably are. In fact, a study found that a person’s literacy level correlated more strongly with health than did race or formal education level.9 (Apparently, attending school does not necessarily mean that people know how to read, and not attending school doesn’t mean that they don’t.)
Even more important than literacy may be health literacy, defined by Ratzan and Parker as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”8 It includes basic math and critical-thinking skills that allow patients to use medications properly and participate in treatment decisions. Thus, health literacy is much more than the ability to read.
Even people who read and write very well may have trouble when confronted with the complexities of navigating our health care system, such as appointment scheduling, specialty referrals, and follow-up testing and procedures: their health literacy may be lower than their general literacy. We had a patient, a highly trained professional, who was confused by instructions for preparing for colonoscopy on a patient handout. Another similar patient could not understand the dosing of eye drops after cataract surgery because the instructions on the discharge paperwork were unclear.
However, limited health literacy disproportionately affects minority groups and is linked to poorer health care outcomes. Thus, addressing limited health literacy is important in addressing health care disparities. Effective physician-patient communication about treatment plans is fundamental to providing equitable care to patients from minority groups, some of whom may be at high risk for low health literacy.
Below, we will review some of the data on health literacy and offer suggestions for screening and interventions for those whose health literacy is limited.
36% have basic or below-basic reading skills
Every 10 years, the US Department of Education completes its National Assessment of Adult Literacy. Its 2003 survey—the most recent—included 19,000 adults in the community and in prison, interviewed at their place of residence.10 Each participant completed a set of tasks to measure his or her ability to read, understand, and interpret text and to use and interpret numbers.
Participants were divided into four categories based on the results: proficient (12%), intermediate (53%), basic (22%), and below basic (14%). Additionally, 5% of potential participants could not be tested because they had insufficient skills to participate in the survey.
Low literacy puts patients at risk
Although literacy is not the same as health literacy, functionally, those who have basic or below-basic literacy skills (36% of the US population) are at high risk for encountering problems in the US health care system. For example, they would have difficulty with most patient education handouts and health insurance forms.
Limited health literacy exacts both personal and financial costs. Patients with low health literacy are less likely to understand how to take their medications, what prescription warning labels mean, how to schedule follow-up appointments, and how to fill out health insurance forms.11–14
Medicare managed-care enrollees are more likely to be hospitalized if they have limited health literacy,15 and diabetic Medicaid patients who have limited health literacy are less likely to have good glycemic control.16 One study showed annual health care costs of $10,688 for Medicaid enrollees with limited health literacy compared with $2,891 for all enrollees.17 The total cost of limited health literacy to the US health care system is estimated to be between $50 and $73 billion per year.18
Screening for limited health literacy: You can’t tell just by looking
Given the high costs of low health literacy, identifying patients who have it is of paramount importance.
Groups who are more likely to have limited health literacy include the elderly, the poor, the unemployed, high school dropouts, members of minority groups, recent immigrants, and people for whom English is a second language.
However, these demographic factors are not sufficient as a screen for low health literacy—you can't tell just by looking. Red flags for low health literacy include difficulty filling out forms in the office, missed appointments, nonadherence to medication regimens, failure to follow up with scheduled testing, and difficulty reading written materials, often masked with a statement such as “I forgot my glasses and will read this at home.”
A number of screening tests have been developed, including the Rapid Estimate of Adult Literacy in Medicine (REALM)19 and the Test for Functional Health Literacy in Adults (TOFHLA).20 These tests are long, making them difficult to incorporate into a patient visit in a busy primary care practice, but they are useful for research. A newer screening test asks the patient to review a nutrition label and answer six questions.21
The most useful screening test for clinical use may consist of a single question. Questions that have been validated:
- “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Positive answers are “sometimes,” “often,” or “always.”
- “How confident are you filling out medical forms by yourself?” Positive answers are “somewhat,” “a little bit,” or “not at all.”22–24
These questions can be included either in the initial screening by a nurse or medical assistant or as part of the social history portion of the interview with the physician.
A “brown bag review” can also be helpful. Patients are asked to bring in their medications (often in a brown bag—hence the name). Asking the patient to identify each medication by name and the indication for it can uncover knowledge gaps that indicate low health literacy.
The point to remember is that patients with low health literacy will probably not tell you that they do not understand. However, they would appreciate being asked in a nonthreatening manner.
