Providing Excellent Health Care in a Multicultural World

Health Literacy & Cultural Competency

Objectives

Setting the stage for excellent care Define health literacy and explain the extent of the

problem Highlight the importance of cultural competence Review ways to improve patient understanding

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Who Is Our Customer?

Patient Patient’s family or significant others External customers

Accreditors Regulating agencies

Colleagues

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Service Excellence

On-stage: where patients and other customers see us. Off-stage: with coworkers (without customer contact).

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Off-stage: Can speak and act with

familiar courtesy Discuss problems with

intent of fixing Take breaks Sharing feelings, venting

On-stage: Smile Show professional courtesy Introduce yourself and your

role in patient’s care Undivided attention for

patient and family

Service Excellence

As Bs Cs Anticipate what the patient may need

Body Language makes up 93% of our message

Care

Ask the patient what he/she wants

Behaviors say more than our words

Concern

Answer questions so that patient understands

Bonds are formed when we meet customers

Commitment

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Body Language

Communication is: 93% body language and other

communication cues. Paralinguistic cues: pitch, volume,

tone of speech.

Only 7% of communication is comprised of words themselves.

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James Borg, Body Language: 7 Easy Lessons to Master the Silent Language. Upper Saddle River, NJ: New FT Press, 2009.

Body Language

Which video demonstrates service excellence through body language and speech?

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Insert demonstration video #1 here

Insert demonstration video #2 here

A B

Improve Patient Understanding

Health Literacy

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Cultural Competency

Race

Ethnicity

Language National Origin

Customs

Education

Gender

Sexual Orientation

Disabilities

Religion/Faith

Tastes/ Preferences

Age

Health Literacy

Definition: Capacity of an individual to obtain, process and understand basic health information and services needed to make appropriate health decisions.

Patient may need: Visual literacy Computer literacy Information literacy Numerical or computational literacy

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“Health Literacy,” National Network of Libraries of Medicine, http://nnlm.gov/outreach/consumer/hlthlit.html; IOM, “Health Literacy: A Prescription to End Confusion,” 2004.

Largest Study Conducted to Date on Health Literacy Found

Williams MV, Parker RM, Baker DW, et al. “Inadequate Functional Health Literacy Among Patients at Two Public Hospitals.” JAMA 1995 Dec 6; 274(21):1,677–82.

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

43% Did not understand the rights and responsibilities section of a Medicaid application

60% Did not understand a standard informed consent

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Health Literacy

Approximately 40 to 44 Million Adults in the US Are Functionally

Illiterate

Approximately 50 Million Are Marginally Illiterate

Average Reading Skills of Adults in the US Are Between the 8th and 9th

Grade Levels

More Than 90 Million People in the US Have Difficulty Reading

Cannot Perform Basic Reading Tasks

Required to Function in Society

Have Trouble Reading Maps and

Completing Standard Forms

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Health Literacy

National Assessment of Adult Literacy, 2003, Louisiana statewide estimate, http://nces.ed.gov/naal/estimates/StateEstimates.aspx, accessed 2 December 2013; 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. 75–128.

Louisiana: 16% of adults

lack basic proficiency

Health Literacy 12

Implications of low health literacy: Poor health outcomes Underutilization of preventive services Overutilization of health services Unnecessary expenditures Limited effectiveness of treatment Needless patient suffering Higher patient dissatisfaction Higher provider frustration

Low Health Literacy costs the U.S. at

least $106 billion annually.

Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications for national health policy. Washington, DC: Dept of Health Policy, School of Public Health and Health Services, GW Univ.

Cultural Competence

Definition: Acknowledgement and use of cultural and social factors that surround health, healing, illness, and the delivery of healthcare. Recognition and respect for different traditions. Responsiveness to health beliefs, practices and needs of

diverse patient populations.

Lack of cultural awareness is a reason for health care disparities.

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NIH, “Cultural Competency,” http://www.nih.gov/clearcommunication/culturalcompetency.htm; Betancourt J et al, “Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health

Care,” Pub Health Reports 2003 118:293-302.

Cultural Competence

Changing demographics in Louisiana: 2000-2010: 28% increase in Asian population. 78% increase in Hispanic or Latino population. 58% increase in Native American or Other Pacific native

population. Essentially stable African-American population 0.70% decrease in white, non-Hispanic population.

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Census Viewer, “Population of Louisiana: Census 2000 and 2010 Interactive Map, Demographics, Statistics, Quick Facts,” http://censusviewer.com/state/LA.

Cultural Competence

An Amish woman undergoes a cesarean delivery. After surgery, the woman and her husband are interviewed by a social worker who was called by a nurse to see the couple because they had no health insurance. The social worker immediately begins to tell them how to enroll in Medicaid. They are visibly upset and will no longer talk to the social worker. They refuse to complete any paperwork for Medicaid. They ask to leave the hospital as soon as possible.

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Social worker did not recognize that Amish people generally do not accept what they consider to be welfare.

SW could help the couple contact other Amish community members to provide financial, other needed assistance to the couple.

ACOG, “Cultural Sensitivity and Awareness in the Delivery of Health Care,” May 2011.

Improve Patient Understanding

Consider: What language does patient prefer?

Every patient has the right to a validated medical interpreter.

What does the patient want to know? Can the patient to repeat back what you have said?

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Improve Patient Understanding 17

1. Tailor communication skills to individual. 2. Tailor health information to the intended user. 3. Develop written materials that reinforce the imparted

information.

US Department of Health and Human Services, Quick Guide to Health Literacy, 2006.

Tailor Communication Skills

Use open-ended questions. Use medically-trained interpreters.

Every patient has the right to a certified medical interpreter.

Check for comprehension by asking questions. Train staff and colleagues in patient communication with

cultural competency.

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Joint Commission, “Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals,” 2010; Chen AH et al, “The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond,” J Gen Intern Med 2007; 22(Suppl 2): 362-367.

Tailor Information to Intended Users

Health information should reflect users’ age. Include target users in development (pre-test) and

implementation (post-test) of written materials. Consider cultural factors – race, ethnicity, language,

religion, nationality, age, gender, sexual orientation, income level and occupation.

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US Department of Health and Human Services, Quick Guide to Health Literacy, 2006.

Developing Written Materials

≥12 point font. Limit to one simple message if possible. Focus on the action. Use active voice. Use familiar language. Avoid jargon. Use visual aids whenever possible.

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US Department of Health and Human Services, Quick Guide to Health Literacy, 2006.

Improve Patient Understanding 21

Benign Harmless

Chronic Happens again and again; does not end

Cardiac Heart

Edema Swelling; build up of fluid

Fatigue Tired

Screening Test

Intake What you eat or drink

Generic Not a brand name

Adverse events Side effects

Consider Using This One

Instead of Using This Word

Improve Patient Understanding

Rosa is 55 y.o. Hispanic female with a history of Type 1 DM who goes to clinic with complaint of recurrent fainting spells. Provider draws blood and reviews her meds (insulin, ACE inhibitor, atorvastatin); patient has hyperlipidemia and hypoglycemia. Doctor tells nurse he is frustrated with his non-compliant patient.

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Doctor should ask if Rosa needs a Spanish-language interpreter.

Does the patient understand her medication and diet regimen?

Summary

On-stage or off-stage? Body language communicates a lot. Does patient understand their health and treatment? Have you tailored your message to the individual?

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Acknowledgements

Murtuza Ali, MD Richard DiCarlo, MD Rebecca Frey, PhD Stacey Holman, MD Richard Tejedor, MD Quality, Risk and Safety Department, Interim LSU Hospital. Hospital Training and Development Department, Interim LSU

Hospital.

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