Article from the Boston Globe’s On Call Magazine, November/December 2003

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

Accessing, using, and understanding the United States healthcare system is difficult for almost everyone. But for immigrants new to this country, it can sometimes seem impossible.

Marcia Drew Hohn, EdD, is director of public education and civic outreach at the Immigrant Learning Center in Malden. Hohn says that differences in culture, language, literacy, and familiarity with Western medicine can all be barriers to a new immigrant’s ability to understand the U.S. healthcare system. For example, the healthcare system in America is built on such public health concepts as screening, prevention, and early detection of disease. People from other cultures, on the other hand, may be accustomed to seeing medical providers only when they are seriously ill. Consequently, Hohn explains, new immigrants have no frame of reference to understand why mammograms, pap smears, and blood pressure checks are important.

Another difference that creates obstacles is how health information is communicated. In the United States, health providers are likely to speak quickly, use a lot of medical terms and acronyms, and supplement spoken information with written materials. But new immigrants may have trouble understanding information communicated this way. One reason is that some languages do not have words for certain medical terms. Hohn recalls a Vietnamese interpreter using 16 words to say “cervix.” As the interpreter explained, there is no such word in their language and she needed to use many words to explain what a cervix is, where it is located, and how it functions in the body.

Cultural norms can also make understanding difficult. In America, for example, health providers are accustomed to asking patients and family members if they have any questions. People from other cultures, however, may not feel comfortable speaking up. As Hohn explains, in some cultures people are taught that it is rude to ask questions or admit you do not understand. People also understand the disease process differently. In America, it is commonly accepted that germs and viruses cause disease. But people with other cultural perspectives may be equally certain that diseases are caused by an imbalance of mind and body. With conceptual differences like this, it is no wonder that some new immigrants have difficulty comprehending how medical interventions like surgery and medication can help.

Hohn says these differences are not deficits on anyone’s part. Rather, they occur when people come from parts of the world where healthcare is practiced differently. Hohn offers some suggestions you can use to help make healthcare in the United States more accessible, usable, and understandable for people new to this country.

Create a welcoming atmosphere. While most new immigrants say they want to use the US healthcare system, Hohn says that many also express concern that they will be discriminated against because they don’t speak English or lack health insurance. To counter these concerns, Hohn recommends creating a welcoming environment. One way healthcare facilities can do this is by displaying multicultural artifacts, globes, and worldwide maps. Another way is to have important signs translated into the four or five most common languages in a facility’s patient population. Additionally, healthcare facilities can create a sense of welcome by asking new immigrants if they need an interpreter or would like help filling out health histories and other written forms.

Beyond artifacts, signage, and help with paperwork, Hohn says that new immigrants most value a trusting relationship with their healthcare providers. This includes sensitivity to the fact that new immigrants may feel embarrassed, ashamed, and afraid of being thought of as inadequate when they don’t understand. It also includes an appreciation of emotional issues like stress and depression that are common when immigrants leave behind their culture, language, home, status, material wealth, and family.

Be sensitive to literacy concerns. Health information is most often communicated through words – spoken, written, or both. For new immigrants as well as many others, literacy can be problematic. Hohn says that not everyone has adequate skills – either in English or their native language – to be able to read, understand and use written health information.

Hohn recommends that providers not make assumptions about a person’s literacy skills. Rather than asking patients directly whether they can read and write, Hohn suggests that providers notice signs of difficulty. These signs may include forms that are incomplete, have a lot of obvious mistakes or misspellings, or have signatures in the wrong place. Other indications of literacy difficulties can be a patient holding printed information upside down, making repeated errors following written directions, and consistently bringing a friend or family member to do all the reading tasks.

Find other ways to communicate. Simplified written materials, while helpful, are not the only way to improve understanding. Hohn recommends also using props, pictures, stories, and hands-on practice in patient teaching. For example, instead of just telling a patient how to take a new liquid medication, Hohn recommends using an actual dosing spoon. This way, the provider can demonstrate, and the patient re-demonstrate, how to measure and take this medication.

Hohn cautions, however, about using simple graphics like symbols or icons. Many are “culturally bound,” she says. For example, a picture of a pill bottle alongside a knife and fork may be intended to show that medication should be taken with meals. But for those from countries where food is taken by hand from a common serving bowl, this symbol may have no meaning or relevance.

Make good teaching and learning strategies a part of your regular routine. Frame conversations by making clear what you are going to talk about and why. Focus on key information that patients truly need to know and repeat this information several times and in several ways. Give yourself the leeway to omit less important information and offer a simple instruction sheet instead.

Good teaching also means making sure that people understand. You can do this by offering opportunities to ask questions and raise concerns. You can also do this by asking patients, in non-threatening ways, to tell you highlights about what was just discussed.

Ask people what they need. Hohn says that new immigrants, like most everyone else, “know what they need to know.” She says that health providers needn’t assume all the responsibility for communication. As an adult literacy educator, Hohn knows well the many benefits when new immigrants and healthcare providers collaborate for good communication.

How to Find Out More

Marcia Drew Hohn, EdD is the Director of Public Education and Civic Outreach at the Immigrant Learning Center in Malden, MA. You can reach her by e-mail at mdrewhohn@aol.com and by phone at (781) 322-9777.

In print:

• Doak C, Doak L, and Root J (1996). Teaching Patients with Low Literacy Skills. J.B. Lippincott Company, Philadelphia.
• Fadiman, A (1997). The Spirit Catches You and You Fall Down. Noonday Press, New York.

On the Web:

National Institute for Literacy/LINCS. A large database of adult education and literacy resources in the United States including LINCSearch, MyLINCS, the Health & Literacy Special Collection/Compendium, and NIFL-Health (an online discussion group about health and literacy). www.nifl.gov/lincs.