II. Communication, Culture, Health, and Mental Health Care

In a diverse society in which many cultures and languages are represented, common knowledge and mental maps about illness, disease, treatment, and wellness may not be shared by patients and providers. This cultural diversity makes information exchange more difficult and miscommunication or misunderstanding more likely.

Disease prevention, diagnosis, and treatment depend heavily on clear communication between patients and providers (DiMatteo, 1995; Frymoyer & Frymoyer, 2002; Levinson, 1999; Neuwirth, 1999; Schneider, Kaplan, Greenfield, Li, & Wilson, 2004).

Language diversity in the United States

The number of languages and cultures represented in U.S. patient populations, especially in large urban areas, presents problems of scale: no health care facility has staff who speak all the languages and dialects occurring among its patients. The U.S. Census Bureau reports that over 300 languages were spoken in the United States (U.S. Census Bureau, 2004).

Census estimates that 47 million people (or 17%) speak a language other than English at home. Although the majority speak English proficiently, a significant number do not. In fact, there are over 11 million children and adults (almost 5%) who are linguistically isolated.

The Census Bureau defines linguistic isolation as living in a household in which no person over the age of 14 years speaks English at least very well (Census Bureau, see http://factfinder.census.gov/servlet/SAFFPeople?_sse=on). Finally, immigration to and migration within the United States are occurring at a high rate, ensuring that significant language and cultural differences will continue to impact health care services for the foreseeable future.

Perspectives on literacy & health literacy

An estimated 90 million adults have lower-than-average reading skills—the latest national data from the National Adult Literacy Survey, 1993, which found that 40 million adults scored at the lowest level of literacy measured, and another 50 million scored at the second lowest level. Both of these levels correspond to difficulties in synthesizing information from complex texts; some individuals scoring at the lowest level were unable to respond to most of the survey.

This study also found that “Black, American Indian/Alaskan Native, Hispanic, and Asian/Pacific Islander adults were more likely than White adults to perform in the lowest two literacy levels” (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993).

It should also be noted that a segment of the population may be neither literate in English nor in their language of origin. Studies show the that persons with low literacy skills are less likely to (1) seek and get preventive care, (2) understand forms for informed consent, (3) understand their children’s diagnosis, (3) understand medication instructions for themselves and their children, and (4) be knowledgeable about the health effects of risks, behaviors, and diseases (AHRQ, 2004).

An emerging body of literature sheds light on the role of health literacy. Although an individual may indeed have excellent literacy skills, that individual may not be literate in the complex terminology used in medical, health care, and mental health care settings. Healthy People 2010 defines health literacy as “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (DHHS, retrieved 2005).

The IOM states that “even people with strong literacy skills may have trouble obtaining, understanding, and using complex health information: a surgeon may have trouble helping a family member with Medicare forms; a science teacher may not understand information sent by a doctor about a brain function test; and an accountant may not know when to get a mammogram.” (Report Brief on Health Literacy: A Prescription to End Confusion, 2004; retrieved February 2, 2005, from http://www.iom.edu/Object.File/Master/19/726/0.pdf)

The IOM clearly states that health literacy does not rest with the individual. A recent article in the American Journal of Preventive Medicine (Gazmararian, Curran, Parker, Bernhardt, & Debuono, 2005) emphasizes the importance of the providers’ communication skills in building health literacy among the public.

The National Center for Cultural Competence (NCCC) includes health literacy in its definition of linguistic competence. In this definition, emphasis is placed on the capacity of an organization and its personnel to convey information in a manner that is easily understood by diverse audiences. Moreover, an organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity. See the Resources section.