# Presentation: 914423

## Culturally and LinguisticallyDiverse Communities: Risks and Opportunities 

- NIFL/LINCS Regional Health Literacy Summit,
- Center for Literacy Studies
- Atlanta, GA
- March 5, 2008

## Faculty Presenter Disclosure

- No discussion of any drugs or medical devices
- No financial arrangement or other relationship with manufacturers of any commercial products

## 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

## 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

## 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)

## 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)

**Notes:**
Majority-minority state is a term used to describe a U.S. state in which a majority of the state's population differs from the national majority population of non-Hispanic whites. This data is usually derived from self-identification questions on United States Census questionnaire and extrapolated data (see race (United States Census).
Four states are majority-minority states: Hawaii (which has long been such a state, and is the only state that has never had a white majority) and more recently, New Mexico, California, and Texas[1] have entered the category, with more ethnic minorities, and in August 2006 the United States Census reported that the percentage of non-Hispanic white residents had fallen below 60 percent in Maryland, Georgia and Nevada.[2] The District of Columbia has long had a majority African-American population. All major United States territories (Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Marianas Islands, and American Samoa) are majority-minority areas.
Throughout most of the 19th century and into the 20th century a number of Southern states had populations that were majority African-American. They were Louisiana (until the 1890s[3]), South Carolina (until the 1920s[4]) and Mississippi (until the 1930s[5]). In the same period, Georgia, Alabama and Florida had African American populations close to but just below the 50% level.[

## Yes Doctor – lo que diga

*Henry Ford Hospital 1932 – Frida Kahlo*

## 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

## 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)

**Notes:**
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002)
“Health care providers should be made aware of racial and ethnic disparities in health care ....all current and future health care providers can benefit from cross-cultural education.”

Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
Health care ...should be safe, effective, patient-centered, timely, efficient and equitable.”

## 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

## 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

## Opportunities for patient-centered care with diverse patient populations

## 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

## 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)

## 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)

## 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

## The significant problems we have cannot be solved at the same level of thinking with which we created them.– Albert Enstein

## 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

## 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

**Notes:**
Social-political-economic forces driving population shifts are accelerating 
California reflects Mexico-Latin American policies, Vietnam, Gulf War, end of the cold war.
Global economics and IRAQ war will continue trends of diversifying cities and states 

## Thank youFor more information...Yolanda Partida, MSW, DPA, DirectorHablamos Juntos, National Program OfficeUCSF Fresno Center for Medical & Education Research  yolanda@hablamosjuntos.org

-  **www.hablamosjuntos.org ****or**** www.wespeaktogether.org**