Transcript Dr. Raggio Ashley

How Health Literacy Impacts Health
Disparities in African Americans and
Other Minorities –
A HRSA Perspective
April 26, 2008
Department of Health & Human Services
Health Resources and Services Administration
Tanya Pagán Raggio-Ashley, M.D. M.P.H. F.A.A.P.
Director Office of Minority Health and Health Disparities
Chief Medical Officer
Health Literacy
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According to Healthy People 2010, an individual is
considered to be "health literate" when he or she possesses
the skills to understand information and services and use
them to make appropriate decisions about health
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Alarmingly, these skills and strategies are absent in
more than half of the U.S. population
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This fact is more disturbing when one considers that
these are the very skills and strategies that often lead to
longer life, improved quality of life, reduction of both chronic
disease and health disparities, as well as cost savings
Source: Clear Communication: an NIH Health Literacy
Initiativehttp://www.nih.gov/icd/od/ocpl/resources/improving
healthliteracy.htm
Healthy People 2010 Communication
Health Literacy
 "Objective 11-2. (Developmental) Improve the
health literacy of persons with inadequate or
marginal literacy skills.."
 The issue of health literacy is fundamental to
efforts to reduce health disparities
 Two key areas are emphasized
Develop appropriate written materials for
audiences with limited literacy
Improve the reading skills of persons with limited
literacy
Areas Commonly Associated with
Health Literacy
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Patient-physician communication
Drug labeling Medical instructions/compliance
Health information publications/other resources
Informed consent
Responding to medical and insurance forms
Giving patient history
Public health training
Assessments for allied professional programs,
such as social work and speech-language
pathology
Health Literacy: A Prescription to End
Confusion: Institute of Medicine 2004
 Nearly half of all American adults--90 million
people--have difficulty understanding and using
health information, and there is a higher rate of
hospitalization and use of emergency services
among patients with limited health literacy…
 Limited health literacy may lead to billions of
dollars in avoidable health care costs
 More than a measurement of reading skills, health
literacy also includes writing, listening, speaking,
arithmetic, and conceptual knowledge
Health Literacy: A Prescription to End
Confusion: Institute of Medicine 2004
 Health literacy is defined as the degree to which
individuals have the capacity to obtain, process,
and understand basic information and services
needed to make appropriate decisions regarding
their health
 At some point, most individuals will encounter
health information they cannot understand
 Even well educated people with strong reading
and writing skills may have trouble comprehending
a medical form or doctor's instructions regarding a
drug or procedure
Health Resources and Services
Administration (HRSA)
Mission
HRSA provides national leadership,
program resources and services
needed to improve access to culturally
competent, quality health care
HRSA GOALS
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Improve Access to Health Care
Improve Health Outcomes
Improve Quality of Care
Eliminate Health Disparities
Improve the Public Health and Health Care
Systems
 Enhance the Ability of the Health Care System to
Respond to Public Health Emergencies
 Achieve Excellence in Management Practice
The Health Resources and Services
Administration (HRSA) is . . .
 The Nation’s Safety Net Provider of Healthcare
(Over 65% of HRSA’s Patients are Culturally Diverse)
– Bureau of Primary Health Care (BPHC)
 provides health care (physical, mental and oral) for
approximately 15 million persons through 1200 health
centers, which are staffed in part by National Health Service
Corps’ (NHSC) 4600 clinicians
– Bureau of Health Professions (BHPR)
 provides education and training for our nations health care
professionals
 with an emphasis on training a culturally and linguistically
diverse work force
 developing the pipeline
HRSA is the Nation’s Safety Net Provider of
Health Care cont……
 Maternal and Child Health Bureau (MCHB) The Children's
Bureau was established in 1912. In 1935, the U.S.
Congress enacted Title V of the Social Security Act, which
authorized the Maternal and Child Health Services
programs and provided a foundation and structure for
assuring the health of American mothers and children.
(such as state block grants, new born screening, Healthy
Start, etc.)
 HIV/AIDS Bureau (HAB) Formed in Aug. 1997 to
consolidate all programs funded under the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act
to improve the quality and availability of care for people
with HIV/AIDS and their families… named after the Indiana
teenager, Ryan White, who became an active public
educator on HIV/AIDS after he contracted the syndrome.
He died the same year the legislation was passed (1990)
AIDS Education and Training
Centers (AETC)
 Supports education and training of health
care providers
 11 regional centers, 4 national resource
centers
 National Minority AETC (NMAETC) builds
capacity for HIV care and training among
minority health care professionals and
health care professionals serving
communities of color (Howard University)
HIV/AIDS Bureau
R ace o f D uplicate C lients Served by C A R E A ct P ro viders, 2005
N =952, 563 duplicated clients ( > 530,000 unduplicated)
A laska
N ative/ N ative
H awaiian, 0.6%
M ulti-racial,
1.5%
White, no t
H ispanic, 28.0%
A sian, 0.7%
B lack, no t
H ispanic, 48.0%
P acific
Islander, 0.2%
H ispanic, 21.0%
HRSA (2006). Ryan White CARE Act Data Report, 2005. HIV/AIDS Bureau, Health Resources
and Services Administration, U.S. Department of Health and Human Services.
Note: Race/ethnicity was unknown or not reported for 36, 431 clients
Bureau of Primary Health Care
Health Center Patients by Race and
Ethnicity
Hispanic/
N= 15,034,123 Patients
Latino
36.10%
White
36.3%
American
Indian/Alaskan
Native
1.1%
Black/African
American
23.0%
Asian/Pacific
Islander
3.5%
28.9% of patients were best served in a language other than English
HRSA(2007) 2006 National Uniform Data System Report, TABLE 3B: Patients by
Race/Ethnicity/Language. Bureau of Primary Health Care, Health Resources
and Services Administration, U.S. Department of Health and Human Services.
Maternal and Child Health Bureau
Total Title V Program Recipients
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Pregnant Women 2,599,338
Infants Less Than 1 Year 3,949,593
Children 1-22 Years 23,626,463
CSHCN 1,418,445
Others 3,046,093
TOTAL 34,639,932
HRSA (2007) Title V Program Data Report, Number of Individuals Served by Title V, by
Class of Individuals. Maternal and Child Health Bureau, Health Resources and Services
Administration, U.S. Department of Health and Human Services.
Note: CSHCN are Children With Special Health Care Needs, and
Others are mostly reproductive-age women
Factors Impacting Health
Disparities
Culture
Race &
Ethnicity
Language
(LEP)*
Social class
Health
Environment Literacy,
Illiteracy
Understanding Health Literacy
 Fourteen percent of adult Americans have
below basic prose literacy and another 29%
have only basic prose literacy in either
English or Spanish.
 Twenty-four percent of adult Blacks, 44% of
adult Hispanics and 14% of Asian/ Pacific
Islanders have below basic prose literacy in
either English or Spanish.
Kutner, M., Greenberg, E., and Baer, J. (2005) A First Look at the Literacy of
America’s Adults in the 21st Century (NCES 2006470). U.S. Department of
Education. Washington, DC: National Center for Education Statistics.
Understanding Health Literacy
 Nearly half of all American adults (90 million
people) have difficulty understanding and
using health information.
Nielsen-Bohlman, L., Panzer, A., and Lindig, D., Editors (2004). Health Literacy:
A Prescription to End Confusion. Washington, DC: Institute of Medicine
 Fourteen percent of adult Americans have
below basic health literacy, and 22 percent
have basic health literacy.
Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of
America’s Adults: Results From the 2003 National Assessment of Adult Literacy
(NCES 2006–483). U.S.Department of Education. Washington, DC: National
Center for Education Statistics
Health Literacy in Underserved is Low
In a study of 1892 English-speaking and 767 Spanish-speaking mostly poor
and minority patients conducted in two urban public hospitals:
 41% were unable to comprehend directions for taking
medication on an empty stomach
 26% were unable to understand information regarding
when a next appointment is scheduled
 59% could not understand a standard informed consent
document
 35% of the English-speaking patients and
61% the Spanish-speaking patients had inadequate or
marginally functional health literacy.
Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &
Nurss, J. (1995) Inadequate functional health literacy among patients
at two public hospitals. JAMA 274(21):1677-1682.
Health Literacy in Underserved is Low
 Among the elderly (60 years and older) of this sample,
81% of English-speaking patients and 82% of Spanishspeaking patients had inadequate or marginal
functional health literacy
 Study conclusions: “Many patients cannot perform the
basic reading tasks required to function in the health
care environment. Inadequate health literacy may be
an important barrier to patients' understanding of their
diagnoses and treatments, and to receiving highquality care.”
Williams, M., Parker, R., Baker, D., Parikh, N., Pitkin, K., Coates, W. &
Nurss, J. (1995) Inadequate functional health literacy among patients
at two public hospitals. JAMA 274(21):1677-1682
African Americans & Internet Health
Literacy
 African Americans with low incomes and low literacy
levels disproportionately suffer poor health outcomes
from many preventable diseases.
 These problems are compounded for African Americans
by cultural insensitivity in health materials.
 The Internet could become a useful tool for providing
accessible health information to low-literacy and lowincome African Americans. Optimal health Web sites
should include text written at low reading levels and
appropriate cultural references.
Birru, M., and Steinman, R. (2004) Online Health Information and Low-Literacy
African Americans. Journal of Medical Internet Research, 6(3): e26 (July–
September, 2004).
Basic Principles
 Culture, Language and Health
Literacy are Health Disparity, Quality
and Safety Issues
 Culture, Language and Health
Literacy are Civil Rights Issues – see
Title VI Civil Rights Act
 Health Literacy Must be Viewed
Within a Cultural Context
Unified Health
Communication Web Course
First Training Program to Integrate
Health Literacy, Limited English
Proficiency and Cultural
Competency
Link: www.hrsa.gov/health literacy
Unified Health Communication
is a 3-Legged Stool
HRSA’s New Policy on Culture, Language,
and Literacy
 HRSA has put forth new cultural
competence standards for program
announcements and funding opportunities to
assure that cultural, language, and health
literacy factors are integrated wherever
possible
Selected Resources
 HRSA Cultural Competence Web Page
– The Portal for HRSA Funded Cross-Cultural
Resources
www.hrsa.gov/culturalcompetence
Case Examples of Health
Communication
Within ten miles of Howard University,
there are over one hundred and twenty
different nationalities, ethnic groups
and languages spoken
(Source: U.S. Census)
Case Examples of Health
Communication
At a local community pharmacy, a new mother
(African-American) was given a prescription for
infant Tylenol (acetaminophen) suppositories.
The child had been seen by a physician and was
unable to keep food down and was vomiting.
The mother complained that the suppositories were
not working and the child's fever was still an
issue.
The pharmacist asked how she was administering
the medication only to learn that the mother had
not "removed the suppository from the foil packet"
and was inserting it intact in the child's rectum as
packaged.
Case Examples of Health
Communication
At a Washington, DC hospital, two patients have the same
last name (Pagán) but are unrelated. They happened to
have shared a hospital room. One child was asthmatic
and the other was epileptic. Both children's parents were
able to stay in the hospital room. The families spoke only
Spanish.
The medications for the children were mixed up. The
asthmatic received the epileptic's medication and the
epileptic received the asthmatic's medication.
The medical staff did not speak fluent Spanish (just enough
to "get by"). They did not see progress in the health
outcome for the two patients, so they proceeded to
increase the medication doses.
Case Examples of Health
Communication
The Pharmacist reviewing the therapeutic ranges of
medications went on rounds and discovered that
"Emilio" was receiving "Julio's" medication.
The parents were unaware of their children's
medications and could not read English. The
nursing staff thought that they were correct and
that the two patients were related. The medical
staff had increased the medication dosing without
carefully identifying the correct patient.
Effective Communication Between
Patients and Health Care Providers
What do these statements mean to you?
 Do you have some of those nature pills?
 Yes I am eating my “greens”
 Take x medication once a day
Effective Communication Between
Patients and Health Care Providers
 “Nature” Pills –Patients with may never mention
they have hypertension, diabetes mellitus,
depression, sickle cell and/or substance abuse,
combination of different medicines
 Eating your greens – Can mean salads, spinach
etc. or cooking collard greens with fatback, lots of
salt although this could be a teaching opportunity
to cook greens in a healthy manner with turkey
and no salt
 For Spanish patients once also means eleven
HRSA CONTACTS
 Director Office of Minority Health and Health
Disparities
Tanya Pagán Raggio-Ashley, M.D., M.P.H., F.A.A.P.
– (301) 443-8305
– [email protected]
Final Tips
 Have patients repeat back their understanding of
medication use/instructions before they leave the office
 Have patients/parents demonstrate how to use
medications such as inhalers etc.
 Take a team approach with staff members who may have
better linguistic/cultural concordance with patients assisting
you to assure accurate communication
 Use pictures, audio/tele/photo novelas or stories
 Write information like consent forms at a sixth grade level
or less and review them verbally with patients
 Share with patients that prescriptions can be labeled in the
language they are most comfortable with