How Health Literacy Impacts Health How Health Literacy Impacts Health Disparities in African Americans and Disparities in African Americans and

Other Minorities –Other Minorities –A HRSA PerspectiveA HRSA Perspective

April 26, 2008April 26, 2008Department of Health & Human ServicesDepartment of Health & Human Services

Health Resources and Services AdministrationHealth Resources and Services Administration

Tanya Pagán Raggio-Ashley, Tanya Pagán Raggio-Ashley, M.D. M.P.H. F.A.A.P.M.D. M.P.H. F.A.A.P.Director Office of Minority Health and Health Disparities Director Office of Minority Health and Health Disparities

Chief Medical OfficerChief Medical Officer

Health LiteracyHealth Literacy According to According to Healthy People 2010, an individual is , an individual is

considered to be "health literate" when he or she possesses considered to be "health literate" when he or she possesses the skills to understand information and services and use the skills to understand information and services and use them to make appropriate decisions about healththem to make appropriate decisions about health

Alarmingly, these skills and strategies are absent in Alarmingly, these skills and strategies are absent in more than half of the U.S. populationmore than half of the U.S. population

This fact is more disturbing when one considers that This fact is more disturbing when one considers that these are the very skills and strategies that often lead to these are the very skills and strategies that often lead to longer life, improved quality of life, reduction of both chronic longer life, improved quality of life, reduction of both chronic disease and health disparities, as well as cost savingsdisease and health disparities, as well as cost savings

Source: Clear Communication: an NIH Health Literacy Source: Clear Communication: an NIH Health Literacy Initiativehttp://www.nih.gov/icd/od/ocpl/resources/improvingInitiativehttp://www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htmhealthliteracy.htm

Healthy People 2010 Communication Healthy People 2010 Communication Health LiteracyHealth Literacy

"Objective 11-2. (Developmental) Improve the "Objective 11-2. (Developmental) Improve the health literacy of persons with inadequate or health literacy of persons with inadequate or marginal literacy skills.." marginal literacy skills.."

The issue of health literacy is fundamental to The issue of health literacy is fundamental to efforts to reduce health disparities efforts to reduce health disparities

Two key areas are emphasizedTwo key areas are emphasized

Develop appropriate written materials for Develop appropriate written materials for audiences with limited literacyaudiences with limited literacy

Improve the reading skills of persons with limited Improve the reading skills of persons with limited literacyliteracy

Areas Commonly Associated with Areas Commonly Associated with Health Literacy Health Literacy

Patient-physician communication Patient-physician communication Drug labeling Medical instructions/compliance Drug labeling Medical instructions/compliance Health information publications/other resources Health information publications/other resources Informed consent Informed consent Responding to medical and insurance forms Responding to medical and insurance forms Giving patient history Giving patient history Public health training Public health training Assessments for allied professional programs, such Assessments for allied professional programs, such

as social work and speech-language pathology as social work and speech-language pathology

Health Literacy: A Prescription to End Health Literacy: A Prescription to End Confusion: Institute of Medicine 2004Confusion: Institute of Medicine 2004

Nearly half of all American adults--90 million people--have difficulty Nearly half of all American adults--90 million people--have difficulty understanding and using health information, and there is a higher understanding and using health information, and there is a higher rate of hospitalization and use of emergency services among rate of hospitalization and use of emergency services among patients with limited health literacy…patients with limited health literacy…

Limited health literacy may lead to billions of dollars in avoidable Limited health literacy may lead to billions of dollars in avoidable health care costshealth care costs

More than a measurement of reading skills, health literacy also More than a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual includes writing, listening, speaking, arithmetic, and conceptual knowledgeknowledge

Health Literacy: A Prescription to End Health Literacy: A Prescription to End Confusion: Institute of Medicine 2004Confusion: Institute of Medicine 2004

Health literacy is defined as the degree to which Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and individuals have the capacity to obtain, process, and understand basic information and services needed to understand basic information and services needed to make appropriate decisions regarding their healthmake appropriate decisions regarding their health

At some point, most individuals will encounter health At some point, most individuals will encounter health information they cannot understandinformation they cannot understand

Even well educated people with strong reading and Even well educated people with strong reading and writing skills may have trouble comprehending a medical writing skills may have trouble comprehending a medical form or doctor's instructions regarding a drug or form or doctor's instructions regarding a drug or procedureprocedure

Health Resources and Services Health Resources and Services Administration (HRSA)Administration (HRSA)

MissionMission HRSA provides national leadership, HRSA provides national leadership, program resources and services program resources and services needed to improve access to culturally needed to improve access to culturally competent, quality health carecompetent, quality health care

HRSA GOALSHRSA GOALS

Improve Access to Health CareImprove Access to Health Care Improve Health OutcomesImprove Health Outcomes Improve Quality of CareImprove Quality of Care Eliminate Health DisparitiesEliminate Health Disparities Improve the Public Health and Health Care Improve the Public Health and Health Care

SystemsSystems Enhance the Ability of the Health Care System to Enhance the Ability of the Health Care System to

Respond to Public Health EmergenciesRespond to Public Health Emergencies Achieve Excellence in Management PracticeAchieve Excellence in Management Practice

The Health Resources and Services The Health Resources and Services Administration (HRSA) is . . .Administration (HRSA) is . . .

The NationThe Nation’’s Safety Net Provider of Healthcares Safety Net Provider of Healthcare(Over 65% of HRSA(Over 65% of HRSA’’s Patients are Culturally Diverse)s Patients are Culturally Diverse)

– Bureau of Primary Health Care (BPHC) Bureau of Primary Health Care (BPHC) provides health care (physical, mental and oral) for provides health care (physical, mental and oral) for

approximately 15 million persons through 1200 health approximately 15 million persons through 1200 health centers, which are staffed in part by National Health Service centers, which are staffed in part by National Health Service Corps’ (NHSC) 4600 clinicians Corps’ (NHSC) 4600 clinicians

– Bureau of Health Professions (BHPR) Bureau of Health Professions (BHPR) provides education and training for our nations health care provides education and training for our nations health care

professionalsprofessionals with an emphasis on training a culturally and linguistically with an emphasis on training a culturally and linguistically

diverse work forcediverse work force developing the pipelinedeveloping the pipeline

HRSA is the Nation’s Safety Net Provider of HRSA is the Nation’s Safety Net Provider of Health Care cont……Health Care cont……

Maternal and Child Health Bureau (MCHB)Maternal and Child Health Bureau (MCHB) The Children's The Children's Bureau was established in 1912. In 1935, the U.S. Bureau was established in 1912. In 1935, the U.S. Congress enacted Title V of the Social Security Act, which Congress enacted Title V of the Social Security Act, which authorized the Maternal and Child Health Services authorized the Maternal and Child Health Services programs and provided a foundation and structure for programs and provided a foundation and structure for assuring the health of American mothers and children. assuring the health of American mothers and children. (such as state block grants, new born screening, Healthy (such as state block grants, new born screening, Healthy Start, etc.)Start, etc.)  

HIV/AIDS Bureau (HAB)HIV/AIDS Bureau (HAB) Formed in Aug. 1997 to Formed in Aug. 1997 to consolidate all programs funded under the Ryan White consolidate all programs funded under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Comprehensive AIDS Resources Emergency (CARE) Act to improve the quality and availability of care for people to improve the quality and availability of care for people with HIV/AIDS and their families… named after the Indiana with HIV/AIDS and their families… named after the Indiana teenager, Ryan White, who became an active public teenager, Ryan White, who became an active public educator on HIV/AIDS after he contracted the syndrome. educator on HIV/AIDS after he contracted the syndrome. He died the same year the legislation was passed (1990)He died the same year the legislation was passed (1990)

AIDS Education and Training AIDS Education and Training Centers (AETC)Centers (AETC)

Supports education and training of health Supports education and training of health care providerscare providers

11 regional centers, 4 national resource 11 regional centers, 4 national resource centerscenters

National Minority AETC (NMAETC) builds (NMAETC) builds capacity for HIV care and training among capacity for HIV care and training among minority health care professionals and minority health care professionals and health care professionals serving health care professionals serving communities of color (Howard University) communities of color (Howard University)

HIV/AIDS BureauHIV/AIDS BureauRace of Duplicate C lients Served by CARE Act Providers, 2005

N=952, 563 duplicated clients ( > 530,000 unduplicated)

Asian, 0.7%

Pacific Islander, 0.2%

Alaska Native/Native Hawaiian, 0.6%

Black, not Hispanic, 48.0%

Multi-racial, 1.5%

White, not Hispanic, 28.0%

Hispanic, 21.0%

HRSA (2006). Ryan White CARE Act Data Report, 2005. HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

Note: Race/ethnicity was unknown or not reported for 36, 431 clients

Bureau of Primary Health CareBureau of Primary Health Care

HRSA(2007) 2006 National Uniform Data System Report, TABLE 3B: Patients by Race/Ethnicity/Language. Bureau of Primary Health Care, Health Resourcesand Services Administration, U.S. Department of Health and Human Services.

Health Center Patients by Race and Ethnicity

N= 15,034,123 Patients

Black/African American

23.0%

Asian/Pacific Islander

3.5%

Hispanic/Latino36.10%White

36.3%

American Indian/Alaskan

Native1.1%

28.9% of patients were best served in a language other than English

Maternal and Child Health Bureau Maternal and Child Health Bureau Total Title V Program RecipientsTotal Title V Program Recipients

Pregnant Women 2,599,338 Pregnant Women 2,599,338 Infants Less Than 1 Year 3,949,593 Infants Less Than 1 Year 3,949,593 Children 1-22 Years 23,626,463 Children 1-22 Years 23,626,463 CSHCN 1,418,445 CSHCN 1,418,445 Others 3,046,093 Others 3,046,093 TOTAL 34,639,932TOTAL 34,639,932

HRSA (2007) Title V Program Data Report, Number of Individuals Served by Title V, byHRSA (2007) Title V Program Data Report, Number of Individuals Served by Title V, by

Class of Individuals. Maternal and Child Health Bureau, Health Resources and ServicesClass of Individuals. Maternal and Child Health Bureau, Health Resources and Services

Administration, U.S. Department of Health and Human Services. Administration, U.S. Department of Health and Human Services.

Note: CSHCN are Children With Special Health Care Needs, and Note: CSHCN are Children With Special Health Care Needs, and

Others are mostly reproductive-age womenOthers are mostly reproductive-age women

Factors Impacting Health Factors Impacting Health DisparitiesDisparities

EnvironmentHealth Literacy, Illiteracy

Social class

Culture Race &Ethnicity

Language (LEP)*

Understanding Health LiteracyUnderstanding Health Literacy

Fourteen percent of adult Americans have Fourteen percent of adult Americans have below basic prose literacy and another 29% below basic prose literacy and another 29% have only basic prose literacy in either have only basic prose literacy in either English or Spanish.English or Spanish.

Twenty-four percent of adult Blacks, 44% of Twenty-four percent of adult Blacks, 44% of adult Hispanics and 14% of Asian/ Pacific adult Hispanics and 14% of Asian/ Pacific Islanders have below basic prose literacy in Islanders have below basic prose literacy in either English or Spanish.either English or Spanish.

Kutner, M., Greenberg, E., and Baer, J. (2005) A First Look at the Literacy ofKutner, M., Greenberg, E., and Baer, J. (2005) A First Look at the Literacy ofAmerica’s Adults in the 21st Century (NCES 2006470). U.S. Department ofAmerica’s Adults in the 21st Century (NCES 2006470). U.S. Department of Education. Washington, DC: National Center for Education Statistics.Education. Washington, DC: National Center for Education Statistics.

Understanding Health LiteracyUnderstanding Health Literacy

Nearly half of all American adults (90 million Nearly half of all American adults (90 million people) have difficulty understanding and people) have difficulty understanding and using health information.using health information.

Nielsen-Bohlman, L., Panzer, A., and Lindig, D., Editors (2004). Health Literacy:Nielsen-Bohlman, L., Panzer, A., and Lindig, D., Editors (2004). Health Literacy:

A Prescription to End Confusion. Washington, DC: Institute of MedicineA Prescription to End Confusion. Washington, DC: Institute of Medicine

Fourteen percent of adult Americans have Fourteen percent of adult Americans have below basicbelow basic healthhealth literacy, and 22 percent literacy, and 22 percent have basic have basic healthhealth literacy. literacy.

Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy ofThe Health Literacy of

America’s Adults: Results From the 2003 National Assessment of Adult LiteracyAmerica’s Adults: Results From the 2003 National Assessment of Adult Literacy

(NCES 2006–483). U.S.Department of Education. Washington, DC: National(NCES 2006–483). U.S.Department of Education. Washington, DC: National

Center for Education StatisticsCenter for Education Statistics

Health Literacy in Underserved is LowHealth Literacy in Underserved is Low

In a study of 1892 English-speaking and 767 Spanish-speaking mostly poor In a study of 1892 English-speaking and 767 Spanish-speaking mostly poor and minority patients conducted in two urban public hospitals:and minority patients conducted in two urban public hospitals:

41% were unable to comprehend directions for taking 41% were unable to comprehend directions for taking medication on an empty stomachmedication on an empty stomach

26% were unable to understand information regarding 26% were unable to understand information regarding when a next appointment is scheduledwhen a next appointment is scheduled

59% could not understand a standard informed consent 59% could not understand a standard informed consent documentdocument

35% of the English-speaking patients and 35% of the English-speaking patients and 61% the Spanish-speaking patients had inadequate or 61% the Spanish-speaking patients had inadequate or marginally functional health literacy.marginally functional health literacy.

Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &

Nurss, J. (1995) Inadequate functional health literacy among patientsNurss, J. (1995) Inadequate functional health literacy among patients

at two public hospitals. at two public hospitals. JAMAJAMA 274(21):1677-1682. 274(21):1677-1682.

Health Literacy in Underserved is LowHealth Literacy in Underserved is Low

Among the elderly (60 years and older) of this sample, Among the elderly (60 years and older) of this sample, 81% of English-speaking patients and 82% of Spanish-81% of English-speaking patients and 82% of Spanish-speaking patients had inadequate or marginal speaking patients had inadequate or marginal functional health literacyfunctional health literacy

Study conclusions: “Many patients cannot perform the Study conclusions: “Many patients cannot perform the basic reading tasks required to function in the health basic reading tasks required to function in the health care environment. Inadequate health literacy may be care environment. Inadequate health literacy may be an important barrier to patients' understanding of their an important barrier to patients' understanding of their diagnoses and treatments, and to receiving high-diagnoses and treatments, and to receiving high-quality care.”quality care.”

Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &Nurss, J. (1995) Inadequate functional health literacy among patientsNurss, J. (1995) Inadequate functional health literacy among patientsat two public hospitals. at two public hospitals. JAMAJAMA 274(21):1677-1682 274(21):1677-1682

African Americans & Internet Health African Americans & Internet Health LiteracyLiteracy

African Americans with low incomes and low literacy African Americans with low incomes and low literacy levels disproportionately suffer poor health outcomes levels disproportionately suffer poor health outcomes from many preventable diseases. from many preventable diseases.

These problems are compounded for African Americans These problems are compounded for African Americans by cultural insensitivity in health materials. by cultural insensitivity in health materials.

The Internet could become a useful tool for providing The Internet could become a useful tool for providing accessible health information to low-literacy and low-accessible health information to low-literacy and low-income African Americans. Optimal health Web sites income African Americans. Optimal health Web sites should include text written at low reading levels and should include text written at low reading levels and appropriate cultural referencesappropriate cultural references..

Birru, M., and Steinman, R. (2004) Online Health Information and Low-LiteracyBirru, M., and Steinman, R. (2004) Online Health Information and Low-Literacy

African Americans. African Americans. Journal of Medical Internet ResearchJournal of Medical Internet Research, 6(3): e26 (July–, 6(3): e26 (July–

September, 2004).September, 2004).

Basic PrinciplesBasic Principles

Culture, Language and Health Culture, Language and Health Literacy are Health Disparity, Quality Literacy are Health Disparity, Quality and Safety Issuesand Safety Issues

Culture, Language and Health Culture, Language and Health Literacy are Civil Rights Issues – see Literacy are Civil Rights Issues – see Title VI Civil Rights ActTitle VI Civil Rights Act

Health Literacy Health Literacy MustMust be Viewed be Viewed Within a Cultural ContextWithin a Cultural Context

Unified Health Unified Health Communication Web Course Communication Web Course

First Training Program to Integrate First Training Program to Integrate Health Literacy, Limited English Health Literacy, Limited English Proficiency and Cultural Proficiency and Cultural CompetencyCompetency

Link: www.hrsa.gov/health literacyLink: www.hrsa.gov/health literacy

Unified Health Communication Unified Health Communication is a 3-Legged Stoolis a 3-Legged Stool

HRSA’s New Policy on Culture, Language, HRSA’s New Policy on Culture, Language, and Literacyand Literacy

HRSA has put forth new cultural HRSA has put forth new cultural competence standards for program competence standards for program announcements and funding opportunities to announcements and funding opportunities to assure that cultural, language, and health assure that cultural, language, and health literacy factors are integrated wherever literacy factors are integrated wherever possiblepossible

Selected ResourcesSelected Resources

HRSA Cultural Competence Web PageHRSA Cultural Competence Web Page– The Portal for HRSA Funded Cross-Cultural The Portal for HRSA Funded Cross-Cultural

ResourcesResources

www.hrsa.gov/culturalcompetence

Case Examples of Health Case Examples of Health Communication Communication

Within ten miles of Howard University, Within ten miles of Howard University, there are over one hundred and twenty there are over one hundred and twenty different nationalities, ethnic groups different nationalities, ethnic groups and languages spokenand languages spoken

(Source: U.S. Census)(Source: U.S. Census)

Case Examples of Health Case Examples of Health Communication Communication

At a local community pharmacy, a new mother At a local community pharmacy, a new mother (African-American) was given a prescription for (African-American) was given a prescription for infant Tylenol (acetaminophen) suppositories.  infant Tylenol (acetaminophen) suppositories. 

The child had been seen by a physician and was The child had been seen by a physician and was unable to keep food down and was vomiting.unable to keep food down and was vomiting.

The mother complained that the suppositories were The mother complained that the suppositories were not working and the child's fever was still an issue.  not working and the child's fever was still an issue. 

The pharmacist asked how she was administering The pharmacist asked how she was administering the medication only to learn that the mother had the medication only to learn that the mother had not "removed the suppository from the foil packet" not "removed the suppository from the foil packet" and was inserting it intact in the child's rectum as and was inserting it intact in the child's rectum as packaged. packaged. 

Case Examples of Health Case Examples of Health Communication Communication

At a Washington, DC hospital, two patients have the same At a Washington, DC hospital, two patients have the same last name (Pagán) but are unrelated. They happened to last name (Pagán) but are unrelated. They happened to have shared a hospital room. One child was asthmatic have shared a hospital room. One child was asthmatic and the other was epileptic. Both children's parents were and the other was epileptic. Both children's parents were able to stay in the hospital room. The families spoke only able to stay in the hospital room. The families spoke only Spanish.  Spanish. 

The medications for the children were mixed up.  The The medications for the children were mixed up.  The asthmatic received the epileptic's medication and the asthmatic received the epileptic's medication and the epileptic received the asthmatic's medication.  epileptic received the asthmatic's medication. 

The medical staff did not speak fluent Spanish (just enough The medical staff did not speak fluent Spanish (just enough to "get by"). They did not see progress in the health to "get by"). They did not see progress in the health outcome for the two patients, so they proceeded to outcome for the two patients, so they proceeded to increase the medication doses.increase the medication doses.

Case Examples of Health Case Examples of Health CommunicationCommunication

The Pharmacist reviewing the therapeutic ranges of The Pharmacist reviewing the therapeutic ranges of medications went on rounds and discovered that medications went on rounds and discovered that "Emilio" was receiving "Julio's" medication."Emilio" was receiving "Julio's" medication.

The parents were unaware of their children's The parents were unaware of their children's medications and could not read English. The medications and could not read English. The nursing staff thought that they were correct and nursing staff thought that they were correct and that the two patients were related. The medical that the two patients were related. The medical staff had increased the medication dosing without staff had increased the medication dosing without carefully identifying the correct patient.  carefully identifying the correct patient. 

Effective Communication Between Effective Communication Between Patients and Health Care ProvidersPatients and Health Care Providers

What do these statements mean to you?What do these statements mean to you?

Do you have some of those nature pills?Do you have some of those nature pills?

Yes I am eating my “greens”Yes I am eating my “greens”

Take x medication once a dayTake x medication once a day

Effective Communication Between Effective Communication Between Patients and Health Care ProvidersPatients and Health Care Providers

““Nature” Pills –Patients with may never mention Nature” Pills –Patients with may never mention they have hypertension, diabetes mellitus, they have hypertension, diabetes mellitus, depression, sickle cell and/or substance abuse, depression, sickle cell and/or substance abuse, combination of different medicinescombination of different medicines

Eating your greens – Can mean salads, spinach Eating your greens – Can mean salads, spinach etc. or cooking collard greens with fatback, lots of etc. or cooking collard greens with fatback, lots of salt although this could be a teaching opportunity salt although this could be a teaching opportunity to cook greens in a healthy manner with turkey to cook greens in a healthy manner with turkey and no saltand no salt

For Spanish patients once also means elevenFor Spanish patients once also means eleven

HRSA CONTACTSHRSA CONTACTS

Director Office of Minority Health and Health Director Office of Minority Health and Health DisparitiesDisparitiesTanya Pagán Raggio-Ashley, Tanya Pagán Raggio-Ashley, M.D., M.P.H., F.A.A.PM.D., M.P.H., F.A.A.P..

– (301) 443-8305(301) 443-8305– traggio@hrsa.gov

Final TipsFinal Tips Have patients repeat back their understanding of Have patients repeat back their understanding of

medication use/instructions before they leave the officemedication use/instructions before they leave the office Have patients/parents demonstrate how to use medications Have patients/parents demonstrate how to use medications

such as inhalers etc. such as inhalers etc. Take a team approach with staff members who may have Take a team approach with staff members who may have

better linguistic/cultural concordance with patients assisting better linguistic/cultural concordance with patients assisting you to assure accurate communicationyou to assure accurate communication

Use pictures, audio/tele/photo novelas or storiesUse pictures, audio/tele/photo novelas or stories Write information like consent forms at a sixth grade level Write information like consent forms at a sixth grade level

or less and review them verbally with patientsor less and review them verbally with patients Share with patients that prescriptions can be labeled in the Share with patients that prescriptions can be labeled in the

language they are most comfortable withlanguage they are most comfortable with