Health Literacy: A Review

Miranda R. Andrus, PharmD, Mary T. Roth, PharmD


Pharmacotherapy. 2002;22(3) 

In This Article

Cultural Literacy

Cultural literacy is defined as an understanding of the values and views of those in other social classes and ethnic groups in the mosaic of cultures that exist in the United States[2] Language differences often create huge barriers between patients and providers. In the NALS, African-Americans, Hispanic-Americans, American Indians, Alaskan Natives, and Asian-Pacific Islander adults were more likely than Caucasians to score in the lowest two literacy levels.[1] Even though overall United States mortality rates have declined over the past several decades, the inverse relation between mortality and socioeconomic status remains.[42] The disparity among mortality rates according to income and economic status actually increased between 1960 and 1986.[42] These disparities could be related to many things, including limited functional literacy and lack of information or access to information. Cultural barriers to receiving optimal health care services may exist, but some of these barriers can be overcome or modified to increase quality of care and affect health outcomes.[43,44] Inadequate knowledge about chronic diseases and preventive services, existing language and communication barriers, and inadequate knowledge about how and where to seek care are but a few of the more recognized and potentially modifiable barriers. Those barriers that require attention and are more sensitive to change are core cultural beliefs and values regarding medical care.[2] Nevertheless, it is our responsibility to work with individual patients to identify such barriers and seek ways to address those that may be adversely affecting their health.[43,44]

There are cultural differences apart from language and patient-held beliefs that may affect the delivery of optimal health care. Nonverbal cues vary from culture to culture, such as differ-ences in eye contact, personal space, touching behaviors, and customs.[2] An unintentional disrespect or unwillingness to acknowledge and appreciate such cultural norms may itself be a hindrance to communication beyond that of language.

Hospitals and health care facilities are seeing an increasing number of non-English-speaking patients. Effective communication is often limited, with hand signals and gesturing replacing verbal communication and interaction. The literature suggests that more diagnostic tests are performed than might be necessary because limited communication does not allow for the appropriate verbal dialogue that often is necessary to adequately assess symptoms and medical conditions. Although translation services are available, and in some centers interpreters are present, the provider-patient relationship becomes compromised and it is difficult to establish a trusting relationship between provider and patient.[2]

Written materials are available in several different languages, but illiteracy rates among non-English-speaking Americans remain high. Various estimates indicate that 56% of Hispanic-Americans cannot read and 34% of Native Americans read at the 5th grade level or below.[2] Providing written materials in their native language appears to be of little use for many of these patients. In addition, even patients who are bilingual may not feel comfortable discussing sensitive issues or approaching an emergency situation using the English language. Many of these patients may not have a telephone, so even a toll-free telephone number may not be effective.[2]

Cultural differences also exist among different English-speaking age groups. The prevalence of inadequate health literacy in the elderly population was discussed, but other sectors, such as the teenage population, can present their own challenges. Teenagers are not routinely reached with written information, but with other forms of communication such as television, radio, and their peers.[2] Written information may be ignored, and teenagers may feel threatened or uncomfortable in the health care system, especially if they have an embarrassing medical problem.

Communication also can be difficult with patients who are deaf or hearing impaired.[2] Adequate literacy skills are often essential for these patients to function in the health care environment. Any disability that affects communication can affect health literacy.

Solutions to these problems are not thoroughly discussed in the literature. Many of the solutions described later in this review should be considered and applied, where appropriate, in an effort to overcome cultural literacy barriers that affect health care.