Helen Osborne: 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 conversations with some really amazing people.

Today, I’m talking with Wilma Alvarado-Little, who focuses on health equity from a linguistic and cultural perspective. Wilma’s experience includes work in public policy, research, health literacy and health literacy disparities prevention.

She also is a healthcare interpreter and has helped develop numerous hospital and clinic-based programs. Wilma is an invited participant on many national and statewide boards that address issues of culture and language in healthcare.

Wilma and I know each other through her work on the National Academy of Science and Medicine’s Health Literacy Round Table. I am delighted to now introduce her to you.

Welcome, Wilma, to Health Literacy Out Loud.

Wilma Alvarado-Little: Hello, Helen. How are you?

Helen Osborne: Great talking with you. You are an expert. You know so much about culture and language in health communication. Let’s start at the beginning and make sure we all have a similar understanding. When you talk about culture as a consideration in health communication, what are you really talking about?

Wilma Alvarado-Little: When we’re talking about culture, there are so many different dimensions of culture that folks immediately sometimes go to race, ethnicity and language.

When we’re talking about the dimensions of that, it could be so much. I call them the usual suspects of age, mental and physical abilities and characteristics, ethnicity, gender, race and sexual orientation.

We might want to think about those as like an inner circle of some of the cultural dynamics. However, there’s so much more to that.

We can think of the dimensions including something like, as an example, socioeconomic status or communication styles. Some of us communicate very easily, just talking about things, whereas others work their magic when they’re writing something.

Sometimes I use the example of crafting an email. Some folks prefer, “Let me just pick up the phone and explain what I’d like to say,” and then others can create that email, first draft, done, easy-peasy, exactly what they want to communicate.

Helen Osborne: Interesting. That’s a part of culture, because as you’re saying that, I’m thinking, “I know certain people are texters, other people are email and other people say, ‘Pick up a phone and call them.’” I have my preference that I don’t want to call people. I’d rather do something else. That’s part of culture?

Wilma Alvarado-Little: Yes. Also, too, there’s the culture of the day shift versus the night shift.

Helen Osborne: You mean for employees?

Wilma Alvarado-Little: Yes. For example, if we’re hospital-based or we’re in an organization that’s running 24/7, there’s how we communicate with individuals who are there during the traditional 9-to-5 or whatever that day shift might be. There might be different mechanisms in place to communicate with individuals during the night shift. Who’s available? Who’s not available? What resources are at the ready?

These are different things to keep in mind when we’re communicating and thinking about various cultures.

Helen Osborne: It sounds like it’s a mosaic. What did you start out with? The basics are ethnicity and race, maybe age or disability, but you’re broadening it so much. How can we possibly fathom all of those variations when we’re talking about communication?

Wilma Alvarado-Little: I think sometimes what we think about is, “Goodness, we have to look at everything all at once.” What might be helpful is looking at what we are trying to accomplish. What’s the starting point? Who are we trying to communicate with, and what’s that mechanism involved in which to communicate with folks?

Sometimes, looking at the macro is good because we’d like to see where we would end up and what that outcome would be.

Helen Osborne: The macro is what?

Wilma Alvarado-Little: The big picture, the huge overview. We start off looking at an overview of all the communities and say, “Goodness, how are we going to be able to do this?” Then look at the smaller piece as to whose needs we need to consider at a more basic level.

Going back to our example of day shift versus night shift, it’s thinking about, “What makes sense to those involved?” and asking the communities, “What makes sense to you? What is helpful to you?” and then moving from there. That seems to have been helpful.

Helen Osborne: I appreciate that. Let’s frame this in terms of health. Say you’re talking about what to eat, the right kind of foods or something like that, and you’re communicating that. You would communicate that differently to someone who works from 7:00 at night to 7:00 in the morning, versus the alternative?

Wilma Alvarado-Little: It could be. For example, during the day, we have the options of running out to a restaurant or making sure that our lunches are available.

Whereas other folks, perhaps their options might be a little bit more limited and they might think, “What should I be eating? What foods do I prepare for my family while I’m away that would be helpful to them for dinner?” for example, if somebody isn’t available during dinner.

There are different ways of thinking about what is accessible and what is healthy.

Helen Osborne: I’m even thinking as you’re going through this that if you work from 7:00 at night to 7:00 in the morning, your sense of what you eat at what times might change a lot.

If I’m a morning person, I eat breakfast, lunch and dinner. But it could be that you eat your bigger meal another time. I’m starting to see how that can really affect how we communicate about health, and in this case, food.

Wilma Alvarado-Little: Yes. We can broaden the examples to so many other things. For example, being able to exercise during certain times that are helpful to that individual based on what their routine is.

For example, something we think about is keeping appointments, whether they are related to oral health, our mental health, physical health or even our spirituality. What does that look like for those who have, perhaps, nontraditional occupations or schedules, or any other commitments that happen during their life?

Helen Osborne: As you’re talking about that, I’m so appreciating what you’re highlighting there. You’re also talking about the humanity of what makes us special, what makes us different, and how we go through the paces of daily living. I really appreciate that.

Let’s talk about language too. What do we have to consider about language? We have all the facets of culture. What about language?

Wilma Alvarado-Little: Sometimes folks focus on the oral.

Helen Osborne: You mean spoken word?

Wilma Alvarado-Little: Spoken, yes. Thank you. Some folks focus on the spoken. We’ve talked about the written communication as well. I’d also like to put out there for consideration the nonverbal communication as well.

Say, for example, if there’s an individual who is really trying to understand what their provider is sharing with them, what nonverbal cues are being presented and sometimes unaware? For example, perhaps a sigh or frowning. Something like this might give a message that folks aren’t aware of.

Then it’s breaking it down to the language. For example, the US doesn’t have a metric system, and there’s that example of the teaspoon.

Helen Osborne: For medication dosing?

Wilma Alvarado-Little: Yes. There are these pieces that are a part of that, so how effectively is that information being communicated in a way that is going to resonate with the individual who’s the recipient of the message?

Helen Osborne: Just to put this into context, the metric system is used nearly universally except in the US, correct?

Wilma Alvarado-Little: I believe so.

Helen Osborne: When we talk about dosing and all that, I know that there’s a movement to move liquid medication dosing into the milliliter, which is an unfamiliar unit of measurement for those of us in the US.

I can see that’s a problem if you’re communicating with someone from another language or land. They don’t understand if we talk about a teaspoon, or a tablespoon, a drop or whatever we’re talking about.

Wilma Alvarado-Little: There’s a language that we are sometimes not aware of that we use and it’s part of the way we communicate because that’s what we do. If we’re looking at the words being the verbal message, are we having the intent of being as clear as possible?

Helen Osborne: Can you give us other examples? When I think of words, I think of the exact word, and maybe in plain language. We want to find a simpler one. We might say doctor instead of physician, or heart attack instead of myocardial infarction. Those are ones we’ve been dealing with for a while now. What else is involved when we consider words?

Wilma Alvarado-Little: I think exactly what you were saying, Helen. It’s keeping it simple. When we or a loved one are not feeling 100%, we’re a different person and our focus can be elsewhere.

It can be also sometimes overwhelming for individuals to feel that if they’re not understanding or grasping the information, then this is contributing to that overwhelm.

For example, for somebody who might weigh 200 pounds, saying, “You have to lose 10% of your weight,” just say, “It’s advisable to lose 20 pounds.” It’s something like this so they don’t have to do that conversion in their head.

Helen Osborne: It’s our numbers too, not just the words. There’s also something I’m dealing with. As I’m talking with you for this podcast, I’m taking a few notes, and as soon as I write it down, I can let go of what I wanted to ask and concentrate more fully on what you’re saying. Is that a part of communication strategies that work for others?

Wilma Alvarado-Little: Yes.

Helen Osborne: Do we get distracted because we’re thinking of something and we’re not fully listening?

Wilma Alvarado-Little: Yes. Sometimes that happens with folks. There’s a thought about writing things down when you’re meeting with a provider or in any situation. Some folks function really well that way.

I know that I can be a concrete thinker where I have to have a pen in my hand and then write it out so that later I can reflect and absorb the information and then formulate my questions.

Other folks will text themselves or use whatever technology is on a smartphone to be able to keep that information at the ready and be able to reflect later. Other folks need to walk through it.

Helen Osborne: You’re not even talking about people whose first language is not English. I know your background is you’re an interpreter. Interpreter is the correct word, isn’t it, when you help say the spoken word in a person’s preferred language? Is that correct?

Wilma Alvarado-Little: Yes. You bring up a very good point. Healthcare is complicated English to English, and then we add the cultural and linguistic component to it and it becomes even more interesting.

For example, the other day I was interpreting for an elder person who was going to be going through a test. They were told that they needed to drink this liquid, and that it was a contrast.

The patient said, “If I drink this, is this going to address my stomach problem?” The patient had been admitted for some gastrointestinal-related concerns.

I interpreted that, and the staff said, “Yes, it’s going to help.” I interpreted that, because as an interpreter, based on my code of ethics, I interpret everything that hits my little ears.

However, the patient was thinking that this was going to help her loose stool and that wasn’t what it was for. It was for imaging.

Helen Osborne: It was a test versus a treatment.

Wilma Alvarado-Little: Exactly. As an interpreter, my sense is, “This provider is responding to the questions. However, it’s not the question that this individual is asking.”

Adding that cultural piece to it and having an awareness of some of the nuances involved, as an interpreter, I stepped into a different role, which was a cultural broker role — to clarify, and asked the provider to please clarify a little bit more regarding the purpose of the contrast.

Helen Osborne: I was just jotting down what you’re talking about. You’re talking about how complicated all this is, and then you add on the extra dimensions of culture and language.

You talk about the nuances and the role of clarification. All key. I so much appreciate your examples of what you mean and what we all should be considering when it comes to language and culture.

We only have a moment or two left. Give us some tips and strategies. What can we do about this? This feels overwhelming, but we all want to do better. What can we do?

Wilma Alvarado-Little: One of the examples I love is when folks say, “Use the language that you would use in your living room or in your kitchen.” Keep it as basic as possible.

It’s being able to explain to an individual without all of what I call textbook and healthcare jargon so that they are able to let you know what they’ve heard.

The teach-back is such a helpful tool for individuals. As a healthcare interpreter, it is really helpful when that opportunity is presented, when that provider says, “I’d like to hear what your understanding is,” or however that is phrased.

Creating that space empowers that individual to say, “This is what I’ve heard,” and that opportunity is for the provider to be able to have that gentle guidance to say, “Yes, this is what we’ve asked,” or, “This is what we’ve said, and in addition to blah, blah, blah.”

There’s that gentle way of correcting and guiding that patient, and also explaining who they can contact in the event they have questions later on.

Sometimes, you walk out away from whatever that situation is and then two or three questions will pop up. You think, “I forgot to ask.” Then who do they ask?

Helen Osborne: I know your world is health literacy. You and I share a commitment to it. All these tips you’re talking about, yet again, reinforce the importance of what we do.

Use those understandable words, be as basic and as clear as possible, allow opportunity for clarification and teaching back, and talk about where to find more information. You’re reinforcing all that we need to do when it comes to understandable communication and health literacy.

Your last point is about where people can learn more. We’ve only started uncovering some of these issues. Where can people learn more about language and culture in health communication?

Wilma Alvarado-Little: The National Center for Cultural Competence, which is part of Georgetown University, has wonderful resources. Think Cultural Health has a wonderful resource. They are the group who worked with the Federal Office of Minority Health and are the architects of the CLAS Standards.

Helen Osborne: That’s wonderful. We’re going to have those links on the Health Literacy Out Loud web page with this podcast.

Wilma Alvarado-Little: Also, I would refer back to your works as well, Helen. I cannot tell you how incredibly helpful your publications have been, and the amount of guidance they have provided is really appreciated, especially when we’re looking at that intersection of cultural competence, language access and health literacy.

Helen Osborne: Thank you. I appreciate that too. We’ll have all the references there.

What I get as the core message is to recognize the humanity in the person we’re talking with and bring out our own humanity. Together, hopefully, we can communicate in ways everyone can understand.

Thank you so much for being a guest on Health Literacy Out Loud, and even more, for doing all you do to help make healthcare more understandable.

Wilma Alvarado-Little: Thank you for inviting me, Helen.

Helen Osborne: As we just heard from Wilma Alvarado-Little, it is so important to consider culture and language in all the ways we communicate health. But it’s not always easy to do so.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

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Until next time, I’m Helen Osborne.

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