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.
Make your office a shame-free environment
Many experts advocate a “universal precautions approach,” in which interventions to address low health literacy are incorporated into routine office practice for all patients. Practice sites should adopt a culture of a “shame-free environment,” in which support staff encourage patients to ask questions and are trained to offer assistance to those having difficulty reading or filling out forms.
On a broader level, medical offices and hospitals can partner with adult-learning specialists to help patients gain skills to navigate the health care system. All signage should be clear and should use plain language as opposed to medical terms. Medical forms and questionnaires should be designed to collect only essential information and should be written at a sixth-grade reading level or below. Patient instructions and educational materials should also be clear and free of jargon.
The ‘teach-back’ technique
The “teach-back” technique is a simple method to confirm patient understanding at the end of the visit. This involves asking patients in a nonthreatening way to explain or demonstrate what they have been told. Examples:
- “I want to make sure I have explained things correctly. Can you tell me how you plan to take your medication when you go home?”
- “I want to make sure I have done a good job explaining things to you. When you go home and tell your spouse about your visit today, what will you say?”
These questions should be asked in a nonthreatening way. Put the burden of explanation on yourself as the first step, and let the patient know you are willing to explain again more thoroughly any instructions that may have not been clearly understood.
Other measures
Pictures and computer-based education may be useful for some patients who have difficulty reading.
Weiss25 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.
Improving health literacy, as it relates to cross-cultural communication of treatment plans, must encompass understanding of health beliefs often based on cultural norms, in order to come to agreement on a mutually acceptable plan of care. Physicians should be aware of preferences for nontraditional or complementary treatments that may reflect specific cultural beliefs.
IF THE PATIENT DOES NOT SPEAK ENGLISH
Verbal communication across language barriers poses another layer of challenge. A trained interpreter should be used whenever possible when treating a patient who speaks a different language than that of the practitioner. When family members are used as interpreters, there are risks that the patient may not fully disclose facts about the history of illness or specific symptoms, and also that family members may place their own “twist” on the story when translating.
The physician should speak directly to the patient in a normal tone of voice. In this setting, also remember that nonverbal communication can be misinterpreted. Gestures should be avoided. Finally, be aware that personal space is viewed differently depending on cultural background, as is eye contact.
It is helpful to have a pre-interview meeting with the interpreter to explain the format of the interview, as well as a post-interview meeting to ensure all parties felt they effectively communicated during the encounter.
TOWARD EQUITABLE CARE
Health care disparities are the result of multiple determinants. In December 2008, a National Institutes of Health summit conference cited not only barriers to access, but also the interaction of biological, behavioral, social, environmental, economic, cultural, and political factors, and noted that the causes and effects of health disparities transcend health care.26
Clearly, an individual physician’s efforts will not be all that is needed to eliminate health disparities. A team-based approach is essential, using skills of nonphysician members of the health care team such as nurses, medical assistants, social workers, and case managers. Continued opportunity for professional training and development in provider-patient communication skills should be offered.
However, the impact of effective cross-cultural communication and managing low health literacy populations on the physician-patient level should not be understated. As practitioners treating patients from diverse backgrounds, improving self-awareness, eliciting the patient’s explanatory model, and assuring understanding of treatment plans for patients with low health literacy or with language barriers, we can do our part in working toward equitable care for all patients.
