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Culturally and LinguisticallyDiverse Communities:

Risks and Opportunities

NIFL/LINCS Regional Health Literacy Summit,Center for Literacy Studies

Atlanta, GA March 5, 2008

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Faculty Presenter Disclosure

• No discussion of any drugs or medical devices• No financial arrangement or other relationship with

manufacturers of any commercial products

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Hablamos Juntos

• Practical, affordable solutions that eliminate language barriers and increase quality of care for Latino patients– Increase availability of language

services/interpreters– Useful health-related materials– Easy to use signage

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Presentation Objectives

• Explore risk associated with culture and language differences in patient-provider communication

• Describe promising practices for overcoming language barriers to provide patient-centered care

• Offer thoughts on health system level opportunities

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Why culture and language matter

National Demographic Trends – 9:1 ratio person (1950)– 1.5:1 ratio under age 40 (2000)– Today, nearly 50% of children under age 5 are children

of color– The portion of the U.S. population that speaks a

language other than English increased more than 7 million, in 5 years – bringing the total to 52 million, while the limited English speaking population increased by almost 4 million, to a total of 23 million (2005)

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California the bellwether state

• 1 of 4 Majority-minority states • Nearly 1 in 3 (27.2%) are foreign born• 1 in 5 (20.2%) report speaking English less than

"very well" considered limited English proficient (LEP) (2006 American Community Survey)

7Henry Ford Hospital 1932 – Frida Kahlo

Yes Doctor – lo que diga

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Implications for clinical care

• Comprehension and behavior is influenced by cultural values and beliefs

• Language differences go beyond vocabulary and require more than interpreters

• Health literacy barriers include limited health knowledge and lack of familiarity with human anatomy

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Institute of Medicine Report

Health Literacy: A Prescription to End Confusion (2006)

“Ability to obtain, process, and understand basic health information and services needed to make

appropriate decisions”– Confusion more likely in unfamiliar contexts– A reflection of both the patient and the health care system

(professional skills and processes)

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Communication a cornerstone of patient safety

• Communication problems are the leading root cause of accidental patient deaths and serious injuries among all patients reported by hospitals over the last decade (JCAHO 2005)

• Ineffective communications place patients at greater risk of preventable adverse events

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Communication Challenges

• Beyond language differences, the language we speak in health care is often not plain English

• Studies show the skills required to understand and use health care-related communications exceed the abilities of the average person Health Literacy: A Prescription to End Confusion (2006)

• Disparities in health status/heath outcomes more frequent in populations with language barriers

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Opportunities for patient-centered care with diverse

patient populations

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Multilevel strategies are needed

• Building skills among patients, providers and health workforce in general

• Adapting health care systems and practices to enable personalize health care delivery

• Using incentives and rewards (e.g.; pay for performance)

• Increasing public awareness and common vision about our multilingual, multicultural world

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Process of inquiry

• Culture is a product of lived experiences, it is important to understand the individual in context

• Health care is personal; one reason why every health care encounter is a cross cultural experience

• Seek to discover - Communication approaches and strategies that emphasize the interaction process. Goal is “Cross cultural efficacy” with less emphasis on cultures per se (Ana Nunez 2000)

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Communication-based Approaches

• BATHE Model (psychological & social context)• CRASH Model (foundational values)• ESFT Model (patient’s explanatory model) • ETHNIC Model (patient’s explanatory model) • Kleinman’s Nine Questions• LEARN Model (communication model)

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Communication Techniques• Use plain language• Use “teach back” and “show back” techniques to assess

and ensure patient understanding• Limit information provided to two or three important points

at a time• Use drawings, models or devices to demonstrate points• Encourage patients to ask questions• Employ a “universal precautions” approach to all patient

encounters by using clear communications and plain language, and probing for understanding

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The significant problems we have cannot be solved at the same level of thinking with

which we created them.– Albert Enstein

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Mission, vision and values

• The politics and policies of the U.S. health industry and workplaces with systems, policies and practices great influenced by licensing/accreditation and revenue seeking strategies

• Change requires missions that embrace diverse populations, visions of accommodation and flexibility and values that place the patient first

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Growing multilingual capacity – it’s about time

• US is the only developed country that is not growing multilingual capacity – 3/4th of the world population is multilingual

• English as a Second language is an important investment

• Early language learning and basic health content can be twin goals

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Thank you

For more information...Yolanda Partida, MSW, DPA, Director

Hablamos Juntos, National Program OfficeUCSF Fresno Center for Medical & Education

Research  yolanda@hablamosjuntos.org

www.hablamosjuntos.org or www.wespeaktogether.org