Telephone services for those with low health literacy can be improved in 3 key ways: (1) Avoid automated services and menus with many options, (2) Have real people answer calls who can understand questions and provide clear answers, (3) Speak slowly and clearly when providing information over the phone and have the person repeat back what they heard to confirm understanding.

1. Cultural Competency
&
Cultural Awareness
WNY Rural-AHEC
(Area Health Education Center)
Welcome
1

2. Course Content
 Culture, Cultural Competency, and Cultural Awareness defined.
 Stereotyping/bias and how it affects healthcare.
 Cultural competency and self-awareness tools and why they are
needed.
 Health disparities and factors that affect it.
 Cross-cultural communication and barriers to it.
 Information gathering and communication tools.
 Language Assistance Services and when/how to use them.
 Role of Health Literacy in effective communication, identifying low
health literacy skills, and strategies to help with limited literacy.
Cultural Competency & Awareness
2

3.  A way of life of a group of people.
 Behaviors, beliefs, values, and symbols that they accept without
thinking about it.
 Is learned and passed along from one generation to the next.
Culture
3

4. Cultural Identity
4
Cultural Identity:
• Values
• Language
• Ethnic Identity
• Immigration Status & Experience
• Sexual Orientation
• Family Background
• Gender
• Faith
• Social Class
• Work/Career/Job

5.  The capability of effectively interacting with people from different
cultures.
 The capacity for individuals and organizations to work and
communicate effectively in cross-cultural situations.
What is Cultural Competency?
5

6. Cultural Awareness
 Becoming aware of our cultural values, beliefs and
perceptions.
 Increasing awareness of our communities and
becoming more self-aware.
Cultural Humility
 Not rating one’s own significance or value higher
than that of others.
 Appreciating the skills of others.
Cultural Awareness & Humility
6

7. 7
Cultural Sensitivity
• Being aware that cultures are different, but not giving any value to
that state
• Not good or bad, just different
Cultural Sensitivity

8.  Our concepts of health and healing.
 How illness, disease, and their
causes are perceived.
 The behaviors of patients who are
seeking health care.
 Attitudes toward health care
providers.
How Culture Impact Care
Culture impacts care because it forms:
8

9. How Culture Impacts Care
What factors may affect our ability to provide
culturally sensitive care?
9

10. Ethnocentrism
• A belief that one’s way of life and view
of the world are superior and more
desirable than others.
• Is a form of bias -judge another
culture as 'bad' or 'wrong‘.
Factors That Affect Cultural Competency
10

11. 11
Factors That Affect Cultural Competency
Essentialism
• Defines groups as “essentially” different,
with characteristics “natural” to a group.
• Does not take into account variation
within a culture – stereotypes.

12. 12
Power Differences
• The power imbalance in patient-
provider relationships.
• Some cultural groups may feel
powerless in this situation.
Factors That Affect Cultural Competency

13.  Healthcare professionals – can project their own culturally based
values and expectations onto patients whose beliefs about illness and
health may be different from their own.
 Providers - have been socialized into a "provider culture" that may
conflict with patients who have differing cultural beliefs.
The Importance of Self-Awareness
13

14.  Minority patients - may have experienced
discrimination, lack of quality health care, or
successful treatment with nontraditional medical
approaches that healthcare providers may not
have had.
 Awareness - of one’s own beliefs and attitudes
helps you make sure that you are not providing
different care to patients based on assumptions,
biases, and stereotypes.
The Importance of Self-Awareness
14

15. Involves:
 Finding out what belief system people from
a given culture have about what caused
their illness and what the illness does to
them.
 Asking questions that elicit information
about a patient’s explanation of illness.
The Patient's Explanatory Model
15

16.  Patient-provider communication can be facilitated
by conducting an interview (with patient and
family).
 Key in delivering patient-centered care is asking
questions.
 There are a number of questioning techniques
that can bring about a patient’s health beliefs.
ex. - Kleinman’s Interviewing Questions
Patient Interview
16

17.  Authority
 Physical contact
 Communication
styles
 Gender
 Religion
 Health literacy
 Limited English
proficiency skills
 Sexuality
 Family
Patient-based,
Cross-cultural Approach
Key factors that can create cross-cultural misunderstandings:
17

18. Purnell Model for Cultural Competence
18
 Framework to guide cultural
competency among healthcare team
members.
 Defines situations that affect a
person’s cultural worldview.
 Includes 12 domains that move from
general to specific occurrences.

19. Cultural and Social Factors
Patient
Religious
Traditions
Language
Socio-
economic
standing
Grasp of
causes of
illness
Food
Intake
Environmental
Impacts
Supernatural
Beliefs
Family
Relationships
19

20. Principles of patient-centered care include:
 Awareness - Be mindful of the role of cultural health beliefs and
practices.
 Dignity - Treat everyone with dignity and respect.
 Unbiased - Share unbiased information with patients and in a
culturally and linguistically sensitive way.
 Control - Build up and support a patients' sense of control and
negotiate treatment options.
 Collaborate - Work in partnership with patients, families, and the
community in deciding what healthcare looks like.
Patient-Centered Care
20

21. It is a balance between a knowledge-centered and skill-
centered approach.
Knowledge-centered - gain specific knowledge about different
cultures including:
 Historical context
 Cultural concepts of illness/disease
 Health-seeking behaviors
 Health-oriented data
 Disease patterns
Patient-Centered Care
21

22. Skill-centered - use
communication skills to
understand the cultural context
of your individual patient’s
experiences.
Patient-Centered Care
22
It’s important to balance cultural knowledge by communicating
with individual patients to learn about their specific health-
related cultural beliefs.

23.  Mnemonic device used for understanding a patient's cultural
experience with illness.
 Involves asking simple questions about BATHE:
B = Background
A = Affect
T = Trouble
H = Handling
E = Empathy
BATHE Model
23

24.  Ask questions to get at a patient's explanation of illness,
treatment, and healers.
 Helps support negotiation of treatment plan.
 Also a mnemonic device:
E = Explanation
T = Treatment
H = Healers
N = Negotiation
I = Intervention
C = Collaboration
ETHNIC Model
24

25. Scenario Review
25
Discussion Activity

26. 26
 Signed into law in 1990 by President George H.W. Bush, it is the first
civil rights law that prohibits discrimination against people with
disabilities.
 Areas that are covered by this law include:
 Jobs
 Schools
 Transportation
 Accommodations
 Telecommunications
 Any places open to public life
Americans with Disabilities Act

27. 27
Americans with Disabilities Act Amendments Act
• The ADA was updated in 2008, and became effective on
January 1, 2009
• Changes were made to the definition of disability and to
requirements
• Updates continue
ADAAA

28. 28
“People with disabilities do not see themselves as problems to be
solved, and ask only for the same human and civil rights enjoyed by
others.”
- www.ncil.org/about/aboutil/
Independent Living

29. 29
Consumer Directed Personal Assistance Program
• A program designed to give the patient more control over the care
they receive, the providers of the care, and the funding for that care
• State-wide Medicaid program
• Used for homecare services
• Usually have to enroll in Managed Long Term Care (MLTC) program
• Your spouse or designated representative cannot be the care
provider
 Also the parent of a child under 21
CDPAP

30. What is Health Literacy?

31. Objectives
 To have an understanding of the impact of literacy and
especially health literacy on health care
 To understand methods of determining if a patient
may have low health literacy
 To learn tools to increase health literacy in the patient
population such as Ask Me 3, Teach Back and
appropriate questioning

32. What is Health Literacy?
Health Literacy is the degree to which individuals
have the capacity to obtain, process, and
understand basic health information and services
needed to make appropriate health decisions.

33. Why is it important?
 National Institute for Literacy (NIL)
 More than 90 million US adults are functionally illiterate or
near illiterate
 National Adult Literacy Survey (NALS)
 191 million adults in the US
 32 million can’t read
 50 million read at a 4th or 5th grade reading level
 High school drop out rate is 30% and has been for 30 years

34. Why is it important?
• Only 12% of Americans have
Proficient Health Literacy
• About 1/3 of English
speakers could not read
what is considered basic
health materials
• More than 25% could not
read appointment cards
• 42% did not understand the
labels on their prescription
bottles

35. What does this mean for me?
 Those with low health literacy are more likely to skip preventive
health services
 They are also more likely to utilize the ED and/or have a hospital
admission. These visits are often preventable.
 more likely to wait to seek health care until they are sicker
than those with adequate health literacy

36.  Because they have a harder time
understanding their conditions or the reasons
for preventive care, they are more likely to
have chronic conditions and often less likely
to manage them in an effective way
 They will also use more services for treating
complications of those conditions.
 They are significantly more likely to rate their
health as “poor”.
Individuals with low health literacy

37.  All of this leads to higher healthcare costs per person
 ”According to the report Low Health Literacy: Implications for
National Health Policy ’ low health literacy is a major source of
economic inefficiency in the U.S. health care system.’ The report
estimates that the cost of low health literacy to the U.S. economy is
between $106 billion to $238 billion annually. ”
– National Network of Libraries of Medicine
Economic Inefficiency

38. Are you confused about health information?

39. Stigma
 Often people are embarrassed or feel ashamed because of their
limitations
 Can be a topic that health care providers find difficult to bring up
 Practice! (just like with other difficult topics)
 Be respectful
 Have some literacy resources available

40. Who are the people with low health literacy?
 Elderly
 Low socioeconomic status
 English as a second language
 People that are stressed or worried
 You

41.  It is important not to judge a patient’s health literacy based on
perceived capabilities
 Assume everyone may have difficulty understanding health
information
 Remember to emphasize that the responsibility for making this
information clear is on YOU, not the patient.
Key points

43. National Assessment of Adult Literacy
 2003
 First national assessment of health literacy skills, so the baseline
 Measured both reading and numerical skills as related to health care
information
 Adults only (16 years and up)
 Found that 36% of the population had serious limitations

44. Three Types of Literacy
 Prose Literacy
 Quantitative Literacy
 Documentation Literacy

45. Prose Literacy
 “the knowledge and skills needed to perform prose tasks;
i.e., to search, comprehend and use continuous texts”
 Examples: news stories, instructional materials, health
care brochures
 Levels of Prose Literacy
 Below Basic
 Basic
 Intermediate
 Proficient

46. Quantitative Literacy
 “the knowledge and skills required to perform quantitative tasks, (i.e.,
to identify and perform computations, either alone or sequentially,
using numbers embedded in printed materials).
 Examples:
 Balancing a checkbook
 Determining dosage
 Figuring if a lab report is in a normal range

47. Documentation Literacy
 “the knowledge and skills needed to
perform document tasks,(i.e., to search,
comprehend, and use non-continuous
texts in various formats).”
 Examples:
 Medical forms
 Maps
 Drug or food labels

48. US Consumers’
Understanding of Nutrition
Labels in 2013: The
Importance of Health
Literacy
– A. Persoskie, E. Hennessy, &
W. Nelson

49. Barriers
 Reading and math limitations
 Jargon and medical terms
 Reliance on printed material
 Patient’s knowledge of health topics
 Communication skills of health care professionals
 Culture
 Stress and anxiety of situation/context
 Getting too focused on information and not actions

50. Red Flags
 No shows, or often late for appointments
 Becoming agitated, demanding or angry
 Not asking questions
 Unable to name medications or tell what they are used for
 Not going to specialist appointments or getting testing done
 Not completing registration forms
 Making excuses like ”I forgot my glasses” or “I’ll talk about this with
my family and then get it back to you”

51. Activity

52. Continuum of Confusion

53. Davis, T.C., et al Study
 Chose 5 common prescriptions and asked people to read them
 46.3% could not read 1 or more labels correctly
 22% misread teaspoon for tablespoon (prescription was for 3 times
daily, so actually would have taken 9 teaspoons instead of 3, or 45
ml instead of 15)
 84.3% could state “Take 2 tablets by mouth twice daily”, but only one
third correctly showed that they would take 4 tablets per day
 Most patients did not pay attention to the warning labels
 The more prescriptions a patient was taking, the less likely that they
would understand the label instructions

55. What can I do?

56. Strategies
Ask:
• How do you learn best?
• What would help you best to learn about your health and/or illness?
• What help do you need as you take this medication?
• Where do you usually get your health information?

57.  Keep the number of messages to 3 or 4, less if the patient seems
very stressed or emotional
 Add pictures or the use of models
 Use medically trained interpreter
 Check for understanding
 Teach-back method
 Ask open-ended questions
 Not yes or no
Strategies

58. Activity

59. When giving information
 Is this appropriate for the users?
 What is the patient (or family) perspective?
 Is this information easy to use?
 Am I being culturally sensitive?
 Am I speaking clearly?
 Am I listening carefully?
 Am I being respectful?

60.  Approximately 1 in 6 people in the
US has a communication disorder
or difference. All of these present
unique challenges to them, and to
us as health care professionals.
Communication disorders or differences

61. Plain language
 “…is a strategy for making written and oral information easier to
understand. It is one important tool for improving health literacy.”
- US Department of Health and Human Services
 Using plain language allows someone hearing an explanation to
understand the first time they hear it.

62. Activity

63. Remember…
 What is “plain” to you may not be to everyone else!
 For people with difficulty reading, conversation
with someone working in your facility may be the
most important and effective method of sharing
information
 Test with your target audience throughout the
process
 Before, during and after development and use
of information

64. Ask me three
 What is my main problem?
 What do I need to do?
 Why is it important for me to do this?

65. Teach Back
 Also called the “show me” method
 Used by physicians and other health care workers to ensure that
patients understand the information that they have been given. It can
also be used to make sure that patients understand which pieces of
information are the most important to remember.

66. Activity

68. Written documents
 Use consistent, easy to read font, size 12 or larger
 Avoid ALL CAPITAL LETTERS
 It is best to use dark lettering on a light background (black on white)
 Use justification on the left margin only
 Leave large margins
 Use active voice

69. Active Voice
 This is a simple but effective difference in writing style. It indicates
that the patient was active in their own care.
 Passive voice: Dr. Rodriguez was contacted by Michael.
 Active voice: Michael contacted Dr. Rodriguez.

70. Telephone Services
Many of us have automated telephone services. These can be
very frustrating for patients. We can improve their experience by:
• Having an option to speak to a “real” person
• Having an option to repeat what was just stated
• Clear and simple language
• Using a slow pace and speaking as if in a conversation
• Having directions to the facility available; these should include
multiple forms of transportation if that is applicable

71. Signage and Maps
 Make sure entry signs are visible from the street and in
the parking area
 Use large wall maps that have a star or other symbol and
“You are Here”
 Be consistent with colors and symbols
 Include a key
 Post at several locations
 Color coded lines on the walls at eye level can be helpful
 Have all materials written in multiple languages
 Interpreters should be available to help patients from the
front desk throughout the process
 Don’t forget – plain language!

72. Websites
 Make things easy to find
 Use the same rules as for written documents
 Keep in mind that people may have very slow computers
at home, so avoid items that might slow down the site

73. Key things to keep in mind
 Talk or write about your most important points first
 Break up the information into blocks or “chunks” that are
understandable
 Use simple, or plain, language
 Define technical terms or those that people may not recognize
 Use active voice (the person the sentence is about is the one
performing the action discussed)

74. Questions?