Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, Founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some really remarkable people, hearing what health literacy is, why it matters and ways every one of us can help improve health understanding.

Today, I’m talking by phone with Dr. Michael McKee, who is a family medicine physician and Assistant Professor at the Department of Family Medicine at the University of Michigan.

Dr. McKee’s clinical work and research focuses on healthcare access, health literacy and health communication with disadvantaged populations, including those who are deaf or hard of hearing.

Dr. McKee not only has a professional interest in this topic, but also personal experience, as he himself has a profound hearing loss.

I met Dr. McKee, when he gave a presentation at a Health Literacy Research Conference. I was so impressed with his work that I invited him to be a guest on Health Literacy Out Loud.

Welcome, Dr. McKee.

Michael McKee: Thank you. I appreciate it. It’s definitely an honor to participate.

Helen: I want to focus on communicating health information to everyone, regardless of our abilities, our challenges and every other way. The research I heard was focusing specifically on people who are deaf or hard of hearing. I notice that you seem to have some device behind your ear, too.

Please put this into context. Tell us about hearing loss, from all your many perspectives and how that affects health understanding.

Michael McKee: Absolutely. Coming from a clinical perspective and now getting more into research, one of the things that I’ve certainly found on a daily basis with my clinical work with individuals with hearing loss is that they frequently struggle with health knowledge and also access to healthcare. It really led to the concept of health literacy.

While it’s a concept that’s been relatively well studied in a variety of populations, we really have not extensively studied health literacy in individuals with hearing loss.

This population is actually a very mixed population, whether there are differences in hearing loss, modes of communication and even language.

One of the things that we have noted is that there are extremes. For example, among Deaf American Sign Language users, this is the group that frequently has communication, language and, as now we’re starting to recognize, health literacy challenges. That’s one of the things that I wanted to increase awareness on individuals with hearing losses.

Helen: I want to stop you right here, Mike, because you’ve raised so many important issues I want to get to.

One, you talked about how it’s a very mixed population. I really would welcome just talking about that for a moment.

Explain that spectrum of hearing loss to all of us, please. I think of my friends, where we can’t go to a restaurant anymore because it’s too noisy in the background, all the way to seeing people who are using sign language. Tell us more.

Michael McKee: We have a spectrum of hearing loss. You think of, for example, somebody with a mild hearing loss, and they may have some minor adjustments. They can still have some challenges, even, like you mentioned, in a noisy environment. They may avoid those situations, particularly for individuals with moderate, then going into severe and profound, hearing loss.

These are individuals that frequently struggle with even basic communication, and often will have to look for accommodations to be able to overcome those barriers.

Sometimes technology may be the solution. Sometimes it may be language interpretation and sign language interpreters. Sometimes it’s actually using visual aids. There are a variety of ways we can actually try to assist these individuals.

Helen: Obviously, you’re a fluent speaker. I know some people with hearing loss don’t have as fluent speech as you. Where does that fit in?

Michael McKee: That’s true. We have to be careful with making assumptions on what type of mode of communication. Frequently, we make assumptions that, if somebody has moderate to severe hearing loss, they’re automatically going to be, what we call, oral speaking in an audio language. Some of these individuals may actually prefer to use sign language.

Then it’s the same thing for somebody with a profound hearing loss. Sometimes we expect that they’re going to prefer sign language, but that might not necessarily be true.

It’s important to really assess what their preferred mode of communication or what their preferred language is. We should be doing this with other language groups, as well.

We have a variety of limited English proficiency populations, and we don’t do a very good job in a clinical setting, so it’s important that we address this.

If we don’t have language access, it’s really difficult to try to help with their health literacy challenges.

Helen: That’s interesting. I know your research goes much broader than one group of the hearing loss. You’re talking about language access.

I know you’re a practicing physician, too. You talked about finding out what someone’s preferred mode of communication is and their language. How can you quickly, efficiently and meaningfully do that?

Michael McKee: One of the things that I think should happen is that, when a person actually calls for an appointment, one of the basic questions should be, “We want to assess what your mode of communication is. What is your preferred language?” Document it in your electronic medical record, so sometimes you can actually flag it.

Waiting until the person actually arrives to the clinic will frequently make it too late, especially if you’re not fluent in that language. It’s really critical that we assess the individuals early on, and be able to provide the accommodation they need.

Also make sure that we have communication which has been shown to be effective in improving health outcomes and adherence to medical treatments.

Helen: Mike, many of our listeners are in public health. I know you’re in clinical work. You’re talking about what to do if you know a patient is coming, making an appointment. What would you do in a public health situation? What would you do in an emergency situation?

Michael McKee: In a public health situation, one of the challenges that I see, not only for individuals with hearing loss, but for other language groups, is that information is frequently inaccessible.

One of the things we talk about frequently is the concept of audio format versus visual format. Also, we have to be careful not to assume that they have high literacy, so we have to also assess that.

The other thing that’s important is that these individuals frequently may even lack some health knowledge that we take for granted.

Helen: Tell us more about that. You spoke of that when we met in person at your presentation, and I’m just fascinated. Tell us all more about that fund of health knowledge.

Michael McKee: One of the concepts that we frequently touch on is a concept called “incidental learning.” Individuals with hearing loss, or even Deaf American Sign Language users, one of the things that we have recognized is that these people don’t have equal levels of communication with their peers, family members and even friends.

Frequently, these individuals being in a mainstream society may not access mainstream level information.

We frequently talk about the concept of “water cooler talk,” where you get your water or coffee and you hear miscellaneous conversations taking place. These people miss it.

The same thing happens when you talk about family get-togethers. Somebody may actually talk about another family member having a health problem, high cholesterol or heart disease, and these are things that can be missed or misinterpreted.

They frequently will come back to the clinical setting and may not have that information, which is really critical health information, in my opinion.

Helen: I know when you talked about that, it’s all of those things we pick up when we think we’re not paying attention or communicating.

Everyone listening to this podcast cares about communicating health information more clearly. What can we do about that fact that incidental learning, that water cooler talk, just didn’t happen?

Michael McKee: It’s really important that, whether it’s in a public health setting, research or even in healthcare, we have to frequently try to reach out and get a better sense of where they’re coming from.

It’s learning about their backgrounds, their modes of communication and their health knowledge, but doing it in a way that it’s not dumbing down or making them feel inferior.

It’s making sure that you have standard information. Also, the use of pictographs, visual aids and all of that is actually pretty readily accepted by anybody.

There frequently can be modes or technology that we think are more compatible with hearing loss population, but, in reality, we frequently like it for other groups as well.

Helen: Can you paint a picture for us of what this is like in your practices? Share a story about what this really is like as you implement this where you’re not dumbing down. You’re being very respectful and considerate, but you also are finding out where they’re coming from and what they know before your encounter.

Michael McKee: Frequently, what I would do is talk about the information in a healthcare setting. If there’s a certain condition or disease, I frequently like to draw pictures. I also frequently bring up Google Images or other tools, or even use my academic library to bring up pictures. That helps to describe it.

Frequently, with practice, we can make some better judgment of where they’re coming from, but we have to be careful sometimes. We’re not good in that.

Frequently, what I would also do is ask them, “Can you repeat the information back to me?” to allow them the concept of teach-back. Sometimes you can avoid where they’re afraid to say that they don’t understand. It allows us to have a better dialog back and forth.

Sometimes I actually have people who really are lacking more of a basic health knowledge, and that will require additional visits.

It’s also really critical that health information is not just given in a healthcare appointment. Frequently, what I try to do is set up community talks because that will allow people to learn and share with their peers.

Helen: Community talks, please tell us more about those.

Michael McKee: What we frequently do is a concept community health talk. We call it Deaf Health Talks. We have provided that in Rochester, New York, and also now here in Ann Arbor and Southeast Michigan.

It’s really available for people to come together. We allow the community to decide what topics are missing. Sometimes gatekeepers will relay that information.

What we do is we provide a one-hour or sometimes an hour and a half or more in-depth information. What we do is share resources for them. What that will do is help to elevate some of the community knowledge in there.

One of the things that I notice is that they frequently will share with some of their friends or family because they’re also desperate for information.

Helen: Do you think that this message is easier to give because you also have a hearing loss?

Michael McKee: Yes, with my personal hearing loss, and also my knowledge of American Sign Language, it really helps me to relate and be able to connect to these populations.

In a way, having a similar background helps to make them feel a little more comfortable, just like what you would see with other racial, ethnic minorities. Frequently, we like to have similar backgrounds.

There does appear to have kind of a gain in terms of trust to be able to follow the information. There’s also that concept of cultural brokering that takes place. All of this is really critical and key for improving health literacy or addressing some of the gaps that we see.

Helen: Thank you. I really like how you’re framing this in the larger context of cultural brokering.

Often, we will be in situations where we do not share as much in common with the other person we’re speaking with. What are some of those ways you’ve just found to bridge that cultural gap?

Michael McKee: We’re actually now at a period where, in our research, we’re trying to figure out what the more effective interventions are, and that’s still ongoing.

Frequently, what we’re seeing in the literature, and from my expert opinion, I really feel that, first of all, it’s finding out what their preferred language and preferred mode of communication are. Get a sense of what technology is useful.

It’s just taking a minute before you go further into the appointment and making sure to ask, “Is this comfortable for you? Can you see me clearly?”

It’s just looking at the environment, and making sure that the environment is conducive for individuals with hearing loss. Can they hear you effectively? Just take a moment and assess the situation.

Also, really talk to them. They’re the expert on knowing what is going to be effective and how to communicate with you. Sometimes we think we’re the experts, but we’re not. Really talking to them is going to be helpful.

Sometimes, we have to take a step back and maybe be a little more humble and say, “What works for you? Let me see if I can try to meet those needs.”

Helen: I love the way you are framing that. They’re the expert, take that step back, take that moment and add a dose of humility to our work.

I want to thank you so much for all you are doing and for teaching us about how to bridge these gaps and communicate with everybody regardless of language, language access, hearing abilities and all the myriad of other ways that we are different, as well as the same.

Thanks for being a guest on Health Literacy Out Loud.

Michael McKee: Thank you so much. I appreciate you allowing me to participate.

Helen: As we just heard from Dr. Michael McKee, there is so much to think about and do when it comes to communicating to everyone—regardless of our abilities, our challenges or our differences. There’s a lot of work ahead and a lot of opportunities in health literacy.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com.

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You can find resources, including ones from Dr. McKee, written transcripts and much more information at the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and tell your friends. Together, let’s let the whole world know why health literacy matters.

Until next time, I’m Helen Osborne.