April 26, 2008 Department of Health & Human Services Health Resources and Services Administration

1. 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

2. Health Literacy • 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 • Alarmingly, these skills and strategies are absent in more than half of the U.S. population • 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/improvinghealthliteracy.htm

3. 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

4. Areas Commonly Associated with Health Literacy • 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

5. 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

6. 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

7. Health Resources and Services Administration (HRSA) MissionHRSA provides national leadership, program resources and services needed to improve access to culturally competent, quality health care

8. HRSA GOALS • 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

9. 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

10. 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)

11. 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)

12. HIV/AIDS Bureau 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

13. Bureau of Primary Health Care 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.

14. Maternal and Child Health Bureau Total Title V Program Recipients • 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

15. Factors Impacting Health Disparities Race & Ethnicity Culture Language (LEP)* Social class Health Literacy, Illiteracy Environment

16. 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.

17. 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 basichealth 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

18. 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.

19. Health Literacy in Underserved is Low • Among the elderly (60 years and older) of this sample, 81% of English-speaking patients and 82% of Spanish-speaking 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 high-quality 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

20. 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 low-income 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).

21. 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

22. First Training Program to Integrate Health Literacy, Limited English Proficiency and Cultural Competency Unified Health Communication Web Course

23. Link: www.hrsa.gov/health literacy

24. Unified Health Communication is a 3-Legged Stool

25. 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

26. Selected Resources • HRSA Cultural Competence Web Page • The Portal for HRSA Funded Cross-Cultural Resources www.hrsa.gov/culturalcompetence

27. 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)

28. 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. 

29. 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.

30. 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. 

31. 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

32. 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

33. 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 • traggio@hrsa.gov

34. 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

35. THANK YOU RESPECT