❤❤❤ Health Literacy And Cultural Awareness Essay
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What is Health Literacy \u0026 How Is It Measured? (Health Communication)
Time orientation influences situations that can be misinterpreted as numeracy deficiencies; time orientation can impact how strictly a patient adheres to an appointment time or medication instruction. In high context cultures, members have a group orientation, i. There is less need for formal, direct, and written communication, as communication is more about process and relationship than problem solving.
In high context cultures the group has a strong external boundary, so outsiders must work harder to earn trust. Alternately, in low context cultures, such as that of the mainstream U. Basic skills applied in health contexts form the basis of health literacy. To be health literate in the US, one needs to be able to effectively apply a variety of skills to accomplish health-related tasks that are often very demanding.
Skills include reading and writing in English; speaking and listening in English; numerical computing; critical thinking; and decision making. Culture and language affect how patients acquire and apply these skills in health situations. One also needs familiarity with the technical, jargon-rich, biomedical vocabulary used in the English-speaking U. The following sections explore some of the necessary health literacy skills and their interconnection with cultural and linguistic skills needed by culturally diverse patients. Reading and writing are the skills people often first consider when thinking about patient health literacy.
Patients need to be able to read various items, such as discharge instructions, health education materials, insurance statements, medical bills, nutritional information, and consent forms. Writing skills are needed to complete enrollment and intake forms, insurance claims, living wills, and appeal letters. Reading and writing skills vary for the many foreign-born users of the U. Those who speak English as a second language may be non-literate or semiliterate in their primary language. They may also be accustomed to a different alphabet than the one commonly used in the US. These descriptors represent various skill levels, such as no familiarity with written expression or high literacy in a non-Roman-alphabet system.
There is also a subcategory of LEP patients who, while possessing some skills in reading and writing, may have a cultural tradition of folk medicine, for which information is typically conveyed orally. This can create a disadvantage when patients must transition to the reading and writing demands found in the U. Even when an interpreter is used to facilitate understanding Speaking and listening are also health literacy skills that are influenced by culture and language. Even when an interpreter is used to facilitate understanding, or when a patient for whom English is a second language appears to have competent speaking and listening skills in English, cultural issues may still interfere with the effectiveness of communication between the patient and a healthcare provider.
For example, many cultures emphasize showing politeness and deference toward healthcare providers who are perceived as authority figures. High context cultures have a preference for indirect, non-confrontational styles of communication; a cultural preference for conflict avoidance can lead patients to say what they believe the healthcare provider wants them to say, or voice agreement or understanding whether or not they actually agree or understand.
Asking questions and self-advocating in high context cultures might not be acceptable. For example, there may be a preference for listening to a doctor over a nurse, or a male over a female. Differences in vocabulary and measuring systems between cultures can result in serious medication errors. As Andrulis and Brach pointed out, if someone from a culture that does not use spoons is reading a medication label calling for a teaspoon of medication, the person, not realizing spoons come in different sizes, may take too much or too little of the prescribed medication. Additionally, hearing numerical information presented in English, when English is a second language, can be challenging because many numbers sound similar when spoken.
For example, in English, the numbers 14 and 40 can sound very similar. Determining risk is often dependent on a complicated equation including family history, personal medical history, exposures, and health behaviors. These perspectives and perceptions vary across groups. Magico-religious or deterministic health beliefs may keep some patients from comprehending and acting on risk information. Critical-thinking and decision-making health literacy skills are required for patients to make crucial health decisions, such as selecting between treatment options, insurance plans, and care providers; deciding when to seek care and what level of care; weighing risks and benefits of health decisions, and deciding on end-of-life preferences.
These skills draw upon culturally driven value and ethical systems, preferences, norms, and perceptions. A limitation of the IOM definition of health literacy is the use of the word appropriate in the definition. The IOM uses the term appropriate in regard to health decisions, but appropriateness involves culturally bound values. What the U. In the US it is assumed that individuals are responsible for their own health and health-related decisions. In familistic cultures, individuals may look to the nuclear family, extended family, or family head, be that male or female, to make their decisions.
In some patriarchal cultures, males may make decisions for females. In addition, patients make decisions that are congruent with the health belief system s to which their culture subscribes. If the provider does not subscribe to the same health-belief system regarding disease etiology as does the patient, health directions may not be followed and conflict may arise between the patient and the provider. This article encourages nurses also to consider health literacy, culture, and language when caring for culturally diverse, native-born patients.
Much of the discussion in this article is most applicable to foreign-born patients whose language, culture, and health literacy barriers are easier to identify because of more obvious cultural and linguistic differences. The NAAL findings are a reminder that diverse, native-born patients can also struggle with health literacy. This is particularly true for the African American population. Nurses must tune into the socially transmitted, culturally based health values, beliefs, and preferences of native-born patients that may be missed in the absence of language barriers.
Additionally, culture can influence the spoken and written vernacular language for native-born, English-speaking patients, including vocabulary, grammar, pronunciation, and accents. There are many reasons why culturally diverse, native-born populations exhibit lower health literacy. One reason is because basic literacy and educational opportunities, which are lower in most native-born minority populations than in the majority population, are highly correlated with health literacy Kutner et al. Current healthcare opportunities may be limited by access barriers, such as insurance status. Racher and Annis have encouraged nurses to identify and redress their own cultural biases, which become barriers to seeking healthcare for culturally diverse patients.
Rural-dwelling Americans are another native-born population for whom culture and health literacy interact. Rural populations experience negative health outcomes in a number of different areas, including unintentional injuries, oral health, addiction, mental health, and access to care Gamm, Hutchison, Dabney, and Dorsey, While most rural-dwelling populations are White, non-Hispanic, and English-speaking, as with native-born minority groups, the acquisition and application of health literacy skills are hampered by lower than average educational attainment and basic literacy, as well as limited prior health-related experiences due to access barriers.
Culturally, both Coyne, Demian-Popescu, and Friend and Giger and Davidhizar found familism, high context communication, a connection between health and religious beliefs, use of folk remedies, and distrust of outsiders, including healthcare providers, to impact health and health-related communication in rural Appalachian communities. The following case examples connect the dots of the preceding discussion by illustrating how culture and language can influence patient experiences within three functional domains relevant to health literacy, namely, the health system navigational domain, the clinical domain, and the public health domain Kutner et al. Patient experiences illustrating health literacy challenges in each of these domains are presented below.
NOTE: These case examples are not real patients. Adriana did not understand the time-sensitive responsibility placed on parents to re-enroll children yearly. Adriana was a 25 year old high school graduate who recently moved to Connecticut from Puerto Rico with her husband and two young children to be closer to family. She was bilingual, but more comfortable speaking Spanish. Feeling deterred from seeking healthcare for her children she did not continue her search to find a pediatrician.
When her daughter came down with an ear infection several months later, Adriana took her to the emergency department. Adriana and her children spent the summer in Puerto Rico. Upon returning to Connecticut, a friend put her in touch with a pediatrician who was accepting new patients with Medicaid. In attempting to make an appointment, however, Adriana was surprised to find out her children were no longer covered by Medicaid.
She had not complied with annual renewal procedures while she was gone. Navigating procedures for enrolling in and utilizing public healthcare programs can feel convoluted, paperwork intensive, and bureaucratic to patients. Culturally, in familial, high context fashion, Adriana relied on family and friends to connect her with health information, even though Spanish language materials and outreach had been part of the public program. After an initial unsuccessful attempt to navigate into primary care, including perceived discrimination based on her accent and type of insurance, she decided to seek treatment for a common childhood ear infection in the emergency department, often the default source of care when challenges deter vulnerable patients from more appropriate sources of care.
Adriana also did not understand the time-sensitive responsibility placed on parents to re-enroll children yearly. Sola, a 20 year old Cambodian woman who had just come to the US, and her husband Deng, a 40 year old Cambodian refugee who had been living in the US for 15 years and was semi-fluent in English, were expecting their first child. The couple went to several specialists who ultimately told them that the baby had an abnormally large valve in his heart. A cardiology nurse drew a picture of the heart with its chambers and valves to show the couple. Fortunately the problem corrected itself later in the pregnancy, so she did not need to make a decision while concerned about what a beta-blocker might do to her and her baby.
Sola and Deng, who were semiliterate in their primary language and who had been raised in a familistic, high context, deterministic culture, had not learned about human anatomy in Cambodia. They struggled to understand the potentially serious heart problem that their unborn child faced. Their exposure to doctors in their native country had been limited. They did not know that Sola had a right to an interpreter and the responsibility to ask questions of her care providers. They felt lost without extended family around to help with making these important decisions. While they may know how to seek and participate in healthcare in their native culture, many of these people do not have an understanding of what the U.
Nor are these patients necessarily aware of what they can expect from care providers, such as the right to an interpreter or the right to a second opinion. Depending on their culture of origin, LEP patients with low health literacy may avoid printed health materials, not only because they are printed in English, but also because they are presented in a printed rather than an oral manner. Debra was a 38 year old African American woman with a tenth grade education living in Houston. Later, in a temporary shelter, a nurse who was part of the medical response team partnered with Debra to ensure her medication needs were met and to transition her into primary and specialty care.
Preparedness for a public health emergency, especially for patients like Debra with existing medical conditions, calls for the implementation of future-oriented health literacy tasks. Preparedness tasks include generating plans, procuring medical supplies and extra medications, and constructing personal health records. In the face of an impending public health threat, people must think critically and make decisions as they work to decode low-context information and weigh the risks and benefits of acting on health directives.
Communicating risk is challenging for health professionals and accurately interpreting risk is challenging for these patients. From a cultural standpoint, the investigators found that African Americans who did not evacuate tended to be optimistic that they would be okay because of religious faith, did not trust law enforcement to protect their property, and often decided to remain with extended family members who were unable to leave.
Far too often providers rely on uninformed approaches to assess the health literacy of their patients. We offer the following recommendations to help nurses and all healthcare providers enhance the health literacy of our patients whose backgrounds reflect diverse cultures and languages. We would add the ability to recognize health literacy assumptions and biases as part of cultural awareness. To-date, provider self-assessment in the area of health literacy has not been a routine part of nursing practice; there is a need for cultural competence self-assessment tools that incorporate health literacy. Schlichting et al. Gut feelings can be imprecise and influenced by unconscious biases. Nurses can work with other healthcare providers to develop patient assessment tools, as well as strategies that use these tools, to strengthen the healthcare provided.
Broad-based patient assessments will enable nurses to explicitly incorporate health literacy into transcultural nursing practice. New educational settings for patients, nursing students, and practicing nurses that address the interconnections between language, culture, and literacy are needed. This training could involve partnering with a local, adult education center. Adult learners in these centers are eager to practice health literacy skills, such as preparing and asking health-related questions and receiving appropriate health guidance, with nurses in a supported setting.
The learners, in turn, can share their cultures and their experiences of accessing health care with nurses. Nurses can also facilitate partnerships with colleagues in medicine, social work, and public health. All health-related disciplines are struggling to communicate health messages to client populations for whom language, culture, and literacy can be barriers. One approach could involve forming an interdisciplinary learning collaborative on health literacy, culture, and language, in which to share approaches to improving patient care.
Health literacy advocates are needed to motivate healthcare organizations to address patient- communication barriers. Nurses are in an excellent position to serve as such advocates by describing how impaired communication negatively affects patient safety and outcomes, noting how the Joint Commission and federal standards support improvements, and illustrating how decreasing health literacy barriers can bring down legal costs related to communication breakdowns and medical errors Joint Commission, , ; Office of Minority Health, ; Minnesota Health Literacy Partnership, Nurses are encouraged to pursue self-directed learning using the free, web-based resources presented in the Table to develop knowledge and advocacy skills.
Nurses are also well qualified to develop patient forms and educational materials that are appropriate from cultural, linguistic, and literacy standpoints. They are encouraged to develop these materials for the most common patient populations they encounter. Nurses should make appropriate use of trained medical interpreters and cultural brokers. Andrulis and Brach , and Jackson-Carroll, Graham, and Jackson, have stressed that interpreters should be cross-trained in cultural competence and health literacy in addition to medical interpretation training.
Purnell and Paulanka have offered additional tips for effective use of interpreters. The challenges related to this integrative process are daunting considering all the other challenges nurses face in providing daily care to their patients. Likewise, the menu of opportunities for improvement can seem long and under resourced. However, nurses can begin to make a difference by working to integrate cultural, linguistic, and health literacy considerations into daily efforts to effectively communicate with culturally diverse patients.
It is important to recognize, though, that over the coming years, quality care will not be the mere inclusion of health literacy alongside cultural and linguistic competence. Rather it will be an expanded paradigm that involves the substantive integration of all three in ways that are practical for nurses to implement and that make a difference in the patient experience. Letter to the Editor by Epstein. In both of these positions she helps patients from diverse populations who face a variety of health literacy challenges.
Kate previously worked in the adult literacy field as an English as a Second Language ESL instructor, curriculum developer, and teacher trainer. It was while working in ESL that Kate became aware of the health literacy needs of adults with limited English proficiency, as her students shared stories of their attempts to access care and communicate their needs in the United States U. Kate created Pictures Stories for Adult ESL Health Literacy , one of the most popular items on the Center for Applied Linguistics website, to give LEP and low literacy students and teachers a starting point for talking about complex healthcare problems and solutions.
The Picture Stories are used widely across the US and abroad to instruct incoming refugees about the U. Kate also created the Virginia Adult Education Health Literacy Toolkit , to provide adult educators with information and tools for addressing health literacy education. Kate continues to consult, present, and publish literature regarding the health literacy needs of limited-English speakers, bridging the fields of adult education, social work, and healthcare. Elizabeth M. As Senior Program Officer, she manages CT Health's ten year strategic objective to reduce racial and ethnic disparities by improving the patient-provider interaction.
Her responsibilties include developing programmatic initiatives, reviewing proposals, monitoring a multi-million dollar grant portfolio, and providing technical assistance to grantees. Her tenure with CDC included assignments with the National Center for Injury Prevention and Control and the CDC Foundation where she worked on traumatic brain injury, program evaluation, emergency preparedness, and mobile mammography. While at Harvard she studied health literacy with Rima Rudd, her graduate advisor, and went on to initiate successful health literacy programs at the Colorado Department of Public Health and the Connecticut Health Foundation.
Agency for Health Care Research and Quality. National health care disparities report Retrieved on May 4, , from www. Andrews , M. Andrulis , D. Integrating literacy, culture, and language to improve health care quality for diverse populations, American Journal of Health Behavior. Retrieved on May 4, from www. Berkman , N. Literacy and health outcomes. January Burt , M. Campinha-Bacote , J. Many faces: Addressing diversity in health care. Online Journal of Issues in Nursing, 8 1. Patient education: Addressing cultural diversity and health literacy issues. Urologic Nursing, 27 5 , Coyne , C.
Social and cultural factors influencing health in southern West Virginia: A qualitative study. Preventing Chronic Disease, 3 4. Eiser , A. Viewpoint: Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education. Academic Medicine, 82 2 , Elder , K. Flores , M. Ambulatory Pediatrics 5 6 , Gamm , L. Rural healthy people A companion document to healthy people Galanti , G. Caring for patients from other cultures. Philadelphia: University of Pennsylvania Press. Discuss to what extent ethical principles of public health practices are considered. Expand on your insights utilizing the Learning Resources.
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