Health Literacy

It Takes More Than Just Words: Culturally and Linguistically Appropriate Materials

Article from the Boston Globe’s On Call Magazine, April, 2000

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

We all know how funny and confusing a mistranslation can be. But even when all the words are right and in the right place, your intended audience might still not understand you.

“Everybody needs information to manage health,” says Sandra Smith MPH, CHES. “In this country, anyone who doesn’t read English at a tenth-grade level doesn’t have access to most of that information.” Smith is the health education specialist at the University of Washington Center for Health Education Research and clinical instructor at the university’s School of Public Health. She points out that the ease with which someone can read and understand health information depends on more than sentence length and using the grammatically correct word. “People who don’t speak English may think about things differently, and come from a different experience,” she says. That means even perfectly exact translations may not make sense to people. Their background or culture may give them a different frame of reference than the one you are using, creating imposing barriers to understanding.

To overcome language and cultural barriers, Smith says it’s important to understand and use “culturally and linguistically appropriate materials” — CLAMs. Smith has worked with a research team to develop and pilot test a process for adapting existing English materials to serve the needs of non-English speakers. In her work, she found that CLAMs, the material that makes something clear, must include not only the words people understand, but also the logic they use and a real connection to their experience.

Taking More Than One View

Roberta Rosenberg, MEd, is director of Outreach and Recruitment in the Research and Training Institute at Hebrew Rehabilitation Center for Aged in Boston. She is also chairperson of the Multicultural Coalition on Aging and coordinates a conference that teaches a core health curriculum in eight different cultures and languages. At the conference, workshops are customized and presented by bilingual, bicultural professionals.

A workshop on spirituality at a recent conference illustrates the way CLAMs work in addressing groups with diverse backgrounds. In the Spanish group, people sat in a circle and talked, sang, and shared emotions. In the English-speaking group, an African-American minister opened with gospel singing. For the Chinese, information from a panel of speakers was taped for the senior centers. In the Haitian session, there were no handouts or worksheets since Haitian Creole is traditionally a spoken language.

“If I, as the conference coordinator, had designed the conference myself, it would have been a failure,” says Rosenberg, pointing out that understanding the audience’s culture and experience in order to present appropriate materials often requires a coordinated effort. “I can’t walk in other peoples’ shoes,” she says.

Making Material Speak to Its Audience

There are compelling reasons to make sure that patient materials and programs are made culturally and linguistically appropriate. State and federal civil rights law, as well as accreditation standards, consistently hold health professionals responsible for bridging communication gaps. Language and culture also have an impact on quality-of-care and need to be considered when communicating information about diagnosis, treatment, and informed consent.

Here are four ways to help ensure that the material you present meets the CLAMs standard for health education materials.

Acknowledge culture as well as language. Providing culturally appropriate information is more than a matter of language. It is also requires attention to the context for medical care. For instance, one way to acknowledge culture is by referring to the traditional methods that people practice for self-care. “If we offer solutions that don’t acknowledge what people are already doing,” Rosenberg says, “the message will fall on deaf ears.”

Collaborate with bicultural/bilingual people in your community. Rosenberg suggests using “cultural brokers” to interface with the community. For example, she recently was looking for Asian people to participate in research studies that involved blood draws. The people in the community helped her understand that some Chinese believe that the spirit is released when the skin is punctured. Accordingly, Rosenberg adjusted her recruitment strategies to reflect this understanding.

Test materials with the audience for which they are intended. Rely on the expertise of your intended learners, says Smith. Invite, on a paid basis, at least ten people to test your materials. Check to see if they remember the points you need them to, and find out how information can be better explained. For instance, find out if there are words that are understood by one dialect, but not recognized by others.

Budget for multiple ways to disseminate information. Printed materials are not the only, or necessarily the best, way to communicate healthcare information. Still, your written content is the place to start since it is the basis for other types of materials and interactions. But audio tapes, pictorial materials, and personal interaction may also be needed, especially by people who are not literate in their own language. Budgets should reflect the need for these alternatives and should include the costs of translation, language-appropriate phone lines, and on-site interpreters. Budgets also need to include funds for ongoing testing, an important way to make sure that culturally and linguistically appropriate materials accomplish what was originally intended.

How to Find Out More

Resources in Print

  • Doak C., Doak L., and Root J. (1996). Teaching Patients with Low Literacy Skills. Philadelphia, J. B. Lippincott Company.
  • Fadiman A. (1997). The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors & the Collision of Two Cultures. New York, Noonday Press.
  • Rabbi A. (1988). “Determining Difficulty Levels of Text Written in Languages Other than English.” Chapter in Readability, Its Past, Present and Future. Newark, International Reading Association.

Resources on the Internet


  • (AT&T)
  • “Cultural Competence: 6 Reasons to Incorporate It Into Policy and Practice”
  • “Reviewers Guide and Checklist for Health Information Materials”
  • “Readability Testing Spanish Materials”

Additional resources

Roberta Rosenberg, MEd, is the director of Outreach and Recruitment in the Research and Training Institute at Hebrew Rehabilitation Center for Aged in Boston and chairperson of the Multicultural Coalition on Aging. She can be reached by phone: (617) 363-8557, fax: (617) 363-8936, or email:

Sandra Smith, MPH, CHES is a health education specialist at the University of Washington, Center for Health Education Research.

The Multicultural Coalition on Aging is an ad hoc coalition of agencies, institutions, and individuals providing health care services to older people in the greater Boston area, inclusive of many racial, ethnic, and linguistic groups. Together, Coalition members work to improve the environment in which health care is delivered to older people by increasing the knowledge about, and sensitivity to cultural influences on health practices and health care delivery. The Multicultural Coalition on Aging meets on the first Wednesday of each month from 8:45 to 10 A.M. at Hebrew Rehabilitation Center for Aged, 1200 Centre Street, Roslindale. For more information, call Roberta Rosenberg, MEd at (617) 363-8557.

Article reprinted with permission from On Call magazine and published by a division of Boston Globe Media.