By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, July 24, 2008

Mr. R works as a day laborer for a landscaping company. He, along with others from a small Mexican village, comes to the U.S. each year for this work. Now Mr. R is at your clinic because of a sprained ankle. You check his vital signs and find he has a significantly elevated blood pressure level of 190/100. Mr. R. is surprised when you tell him this. Other than his ankle injury, he feels just fine.

Since Mr. R speaks only Spanish, you communicate with basic medical phrases you learned in his language. You explain about his blood pressure problem and tell him to take medication each day. Mr. R nods, smiles, and takes the prescription. But when he returns a month later for a follow-up visit, his blood pressure is unchanged. You explain again what he needs to do. Next appointment there still is no improvement – but there should have been.

Frustrated that Mr. R’s condition is not improving, you ask an interpreter to meet with both of you. Through the interpreter you learn that Mr. R didn’t take this medicine because he felt fine and saw no need for it. He said that when he feels sick, he’ll take it.

Situations like this are all too common in the clinic where Jedan Phillips, MD, works. As both a family physician and clinical assistant professor at Stony Brook University School of Medicine in Long Island, Phillips sees many patients from outside the U.S. who speak no English whatsoever. He says that these patients come to the clinic with a sincere desire to get health problems taken care of but literacy or language problems may stand in the way.

Aldustus Jordan, EdD, agrees. He is associate dean at the Stony Brook University School of Medicine and also president of the board for the local literacy program, Literacy Suffolk. Jordan has been making connections between literacy, language, and health for many years. His interest not only is academic but also personal. Both of Jordan’s grandfathers were illiterate and could neither read nor write.

Gini Booth helps make these connections happen. As executive director of Literacy Suffolk, she collaborates with Jordan and Phillips on many projects. The three of them recently discussed what all healthcare professionals can do to bridge literacy and language differences. What follows are their suggestions.

Appreciate your own language limitations

Phillips is realistic about his limited ability to speak Spanish. While he can ask basic medical questions such as “Do you have a headache?” he acknowledges that his fluency is more like that of an international traveler using only a guidebook. He lacks the sophisticated language skills and cultural context needed to fully communicate with Spanish-speaking patients. So when Phillips recognizes a problem, he knows it is time to bring in an interpreter.

Show genuine respect

Jordan says that patients who don’t speak English often think of themselves as outsiders. Sadly, this feeling is reinforced when providers demonstrate an attitude that these people are either dumb or “less than.” Jordan considers this attitude an abuse of professional power and sign of disrespect. It also can impact health outcomes. Jordan talks of patients who do not take prescriptions solely because of the disrespectful ways in which they were treated. “Patients are real people who appreciate what other people do for them,” he says.

Simplify your message

Misunderstandings like the one with Mr. R can be due to differences in language, literacy, or both. To communicate better, Phillips assumes that each patient reads no higher than a 5^th grade level. He simplifies all his messages and only adds complexity when a person shows obvious capacity and interest. Phillips says that patients at all literacy and language levels tell him how much they appreciate this approach, “Thank you so much for making this understandable.”

Limit the number of actionable items

Phillips gives patients only a few “actionable items” (tasks they need to do) at each visit. He has learned from many years of practice that the “batting average” of success increases this way. “If I give patients 6 items to do, they may do none of them. But if I give them only 3, patients may do 2 of them,” says Phillips. He has found that this approach produces very real benefits in terms of patients’ follow-through and health outcomes.

Teach students good communication skills

Regardless of discipline, Jordan believes that all healthcare training programs should address literacy and language in their curriculum. He recommends looking at these issues through both small and large “lenses.” He thinks of the small lens as how providers communicate on a personal level. An example is a doctor who “gets it” and realizes that communication problems are the fault of the provider, not the patient. The big lens is societal context. This looks at how limited language or literacy skills can affect patients’ access to timely and good healthcare.

Create “forgiving environments” in which to learn

Stony Brook University School of Medicine has a very active student-run clinic. Jordan says that this clinic offers an incredibly forgiving learning environment in which students can ask questions or admit they don’t understand. This helps students move beyond their comfort zones and learn to handle situations they first feared. Jordan says this includes learning the “warm fuzzy characteristics” of good communication that are modeled and nurtured.

If you want to change something, get involved

Phillips says we are at a crucial point in healthcare. Literacy and language differences are at the doorstep and healthcare professionals can no longer “push back” about dealing with them. Providers should not wait for someone else to act, says Phillips. “We are privileged as doctors and with that privilege comes responsibility.”

Booth, Jordan, and Phillips all speak with pride of their medical school and literacy program partnership. Booth says this partnership helps “everyone learn from everyone else.” Together, they consider literacy in a holistic way that affects all aspects of communication. Booth acknowledges that health literacy is the “crown jewel” of this partnership. So far, health literacy is the easiest for them to work with. Now their partnership is looking at issues of literacy and the law.

Ways to learn more:

Literacy Suffolk, Inc. is an accredited ProLiteracy affiliate. You can learn more at the Literacy Suffolk Web site.

You can learn more about building community coalitions in Osborne’s recent On Call article, “Communicating Health Information Through Community Coalitions.”

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. She received two “Gold 2008 Plain Language awards from NIH for her work on the NCI booklets “Radiation and You” and “Chemotherapy and You.”Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.