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Feature: CE Connection

Confronting barriers to improve healthcare literacy and cultural competency in disparate populations

Polster, Debra S. DNP, MS, APRN, CCRN, CCNS

Author Information
doi: 10.1097/01.NURSE.0000547717.61986.25


POSITIVE PATIENT outcomes depend on clear communication and understanding. The correlation between limited health literacy and poor health is well known. In 2004, the Agency for Healthcare Research and Quality (AHRQ) and the National Academy of Medicine (NAM; formerly the Institute of Medicine) published reports with complete reviews of the literature on health literacy and health outcomes. Both reports determined that limited health literacy is negatively associated with the use of preventive services (such as seasonal influenza vaccines), management of chronic health disorders (such as diabetes), and self-reported well-being. Researchers also discovered a link between limited health literacy and a surge in avoidable hospital visits and admissions. Additional research has linked limited health literacy to misunderstanding prescription medication directions, medication errors, poor nutrition label understanding, and increased mortality.1

In the US, 88% of adults have health literacy limitations, and 77 million Americans (more than one-third of US adults) are challenged with scheduled self- and family-care tasks such as following discharge instructions, taking prescribed medications, and adhering to childhood immunization schedules.2 Individuals with low health literacy are more prone to poor health.2

Nurses face many challenges in caring for diverse populations when cultural and literacy barriers are present. Patients have the right to health information to assist in making informed decisions. Quality healthcare goals include patient-centered and equitable care for diverse populations.3-5 According to NAM, the goal for improving healthcare is to make care equitable regardless of personal characteristics, including ethnicity, geographic location, gender, or socioeconomic status.3

The healthcare system is experiencing rapid and dramatic transformation, and racial and ethnic healthcare disparities persist despite increased awareness.5 Healthcare disparities are costly and unethical, but these barriers can be reduced with comprehensive strategies to transform organizations.5

The US Department of Health and Human Services' Healthy People 2020 campaign has four central goals:

  • Accomplish health equity, eliminate disparities, and improve the health of all populations.
  • Achieve longer lives free of preventable disease, injury, disability, and premature death.
  • Establish physical and social environments that promote good health.
  • Foster quality of life and healthy behaviors across the lifespan.6

Comprehensive and all-encompassing goals for health promotion, healthcare delivery, and education will enhance quality of life for the population.

Healthcare literacy

Healthcare literacy is the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.7-9 According to the US Department of Education, only 12% of English-speaking adults in the US have proficient health literacy skills.7 Approximately 45% of high school graduates in the US have limited health literacy.7-10 Healthcare decisions can be hindered with health literacy gaps in communication between patients, families, and healthcare team members.

With increasingly diverse and aging populations, health literacy challenges are expanding.5 Nurses, physicians, and healthcare team members must address these challenges to reduce the risk of harm from medication errors, inadequate patient education, failure to follow discharge plans, costly hospital readmissions, and overall poor health outcomes. Evidence-based, culturally competent skills can provide positive patient- and family-centered approaches to reduce health disparities.6

Cultural competency

Nurses' knowledge and skills must continue to evolve to address emerging population needs. Patient and family healthcare beliefs and practices may vary from their own. Nurses' personal values and traditions should be examined to identify cultural differences in providing patient care. Healthcare delivery guidelines that offer structure for bedside clinicians and administrative leaders can positively impact patient outcomes in diverse populations.7

Racial and ethnic differences and low socioeconomic status can contribute to health disparities.7-9 Vulnerable populations must be recognized and supported to reduce health inequities seen in all patient-care areas.

Effective communication strategies are a priority in Healthy People 2020 to improve population health and achieve health equity. The Joint Commission requests additional training and utilization of resources addressing cultural competence and health inequities that undermine patient care and healthcare practice.8

Underlying factors

Health disparities are variances in the prevalence, incidence, mortality, and burden of disease and other challenging health conditions among specific groups. These disparities may be based on race or ethnicity, gender, education, or other criteria. For example, people with cognitive or mental health challenges may have limited access to adequate healthcare.

Although limited health literacy affects most adults at some point in their lives, some groups are more likely than others to have some degree of health illiteracy. Specific populations that have a lower level of health literacy include:

  • those over age 64
  • ethnic and racial non-White groups
  • new refugees and immigrants
  • those with less than a GED or high school diploma
  • those with wages at or below the poverty level
  • non-English-speaking persons.

Despite improving life expectancy and declines in mortality, considerable disparities for minorities persist. For example, native Hawaiians/Pacific Islanders and Hispanic adults are diagnosed with diabetes at rates three times and 1.7 times higher than non-Hispanic White adults, respectively.8 Native American/Alaska Native adults are diagnosed with heart disease at rates twice that of non-Hispanic White adults.10 In association with chronic diseases, 14.4% of non-Hispanic Black adults are disproportionately disabled compared with non-Hispanic White adults (12.4%), Hispanic adults (8.7%), and Asian adults (7.6%).9

The most compelling nonbiological factor influencing the development of health disparities is poverty, which creates some of the behavioral and sociocultural factors that exert profound influence over the entire lifespan. Unhealthy behaviors and poor housing can directly affect health, and can lead to the development of chronic diseases, including cancer, and shortened lifespans. For example, unhealthy behaviors such as smoking directly affect health disparities in general and cancer health disparities specifically. Tobacco use is greater among people in low socioeconomic groups and escalates their risk of death and disability.9,10

With this background, a discussion of health disparities in the setting of cancer prevention raises a broad spectrum of issues, including how cancer health disparities influence the success of cancer prevention efforts and the effectiveness of strategies to overcome barriers to health literacy.9-13

Nursing considerations

A critical role of the nurse is to be the patient's advocate. Attending to patient needs, interests, and values should be the priority of care in disease and illness management.

Nurses have a moral obligation to uphold and protect patient rights.10 Improved health literacy skills can help patients and family members locate community resources and services and make informed decisions about their own healthcare.11-14

Effective strategies for nurses and healthcare professionals to improve patient information, communication, and informed decision-making include:

  • using various types of communication and tools with patients; for example, incorporating pictures, simulations, and performance scorecards to measure achievement and analyze written and verbal communication.
  • using available programs, such as AHRQ's Questions Are the Answer (, to help design communication with patients.
  • using evidence-based methods of verifying patient understanding, such as the teach-back method, to ensure that patients understand information about their medications, treatments, procedures, tests, and medical devices.
  • confirming that pharmacists provide the required counseling in language patients can comprehend for dispensed medications as required by law.
  • using patient-centered technologies such as social media to improve patient access to healthcare.
  • participating in continuous education and skills training in health literacy, plain language, and culturally and linguistically appropriate services.6,15-20

Additional evidence-based innovative strategies to improve healthcare literacy include involving patients in pilot tests of new educational programs and printed educational materials. Testing a small sample of patients to determine preferences in style, design, and content may improve the effectiveness of educational material. Pilot evaluation should include real-time assessment of information learned using the teach-back method. Validating knowledge and skills learned by teach-back will provide a more accurate assessment of printed and verbal education.1-6,17

Use of interpreters

The Patient Protection and Affordable Care Act (ACA) from 2013 denotes requirements that all information must be in plain language that is culturally and linguistically receptive to patients with limited English proficiency. Under the new ACA rule in 2016, a qualified interpreter is one who “via a remote interpreting service or an on-site appearance 1) adheres to generally accepted interpreter ethics principles, including client confidentiality; 2) has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language; and 3) is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such language(s) and English, using any necessary specialized vocabulary and phraseology.”21-23

The interpreter is intended to translate for the patient in the discussion, not take the place of the patient. If using a camera device for remote interpretation, position a camera to face the patient and participants on the call, ensuring face-to-face interaction. Allow extra time to provide the translator with any helpful information to prepare for the session. Be prepared for a few additional moments to establish a connection, for technology setup, and any unexpected nuances. Education should include the process of notifying and collaborating with interpreter services.24

Guidelines for culturally competent nursing care

Nurses and healthcare team members can provide individualized approaches to reduce cultural incompetence. The following guidelines, created by task force members of the American Academy of Nursing Expert Panel on Global Nursing and Health, the American Nurses Association Expert Panel for Cultural Competence, and the Transcultural Nursing Society, provide organizational structure and processes for nurses and healthcare team members.12-18 They provide goals for the highest level of practice and are applicable to nursing around the globe.

Knowledge of cultures. Nurses will obtain knowledge and awareness of the perspectives, values, traditions, practices, and family systems of culturally diverse individuals, families, communities, and populations they serve. Nurses must have knowledge of the complex variables that affect their patients' health and well-being.

Education and training in culturally competent care. Nurses will obtain the knowledge and skills to ensure nursing care is culturally compatible and will be included in global healthcare programs that require formal education and clinical instruction. Continuing education should be the standard for all nurses.

Critical reflection. Nurses will critically reflect on their own beliefs, values, and cultural traditions for an awareness of how these values and issues can affect culturally compatible patient care.

Cross-cultural communication. Nurses will use culturally competent nonverbal and verbal communication skills to determine a patient's values, beliefs, practices, perceptions, and individual healthcare needs.

Culturally competent practice. Nurses will apply cross-cultural knowledge and sensitive skills in employing culturally competent patient care.

Cultural competence in healthcare systems and organizations. Healthcare organizations will offer the structure and resources to analyze and accomodate cultural and language needs of diverse patients.

Patient advocacy and empowerment. Nurses will identify the effect of healthcare policies, resources, and delivery systems for their patient populations. They will empower and support their patients as needed. Nurses will advocate for the inclusion of cultural practices and beliefs for all areas of healthcare.

Multicultural workforce. Nurses will incorporate efforts to support a multicultural staff in healthcare with recruitment and retention measures in hospitals and all healthcare settings.

Cross-cultural leadership. Nurses will influence people and systems to address outcomes of culturally skilled care for diverse populations. Nurses will be knowledgeable and skilled in working with public and private organizations. Policies and guidelines will be established for widespread implementation and evaluation of culturally competent patient care.

Evidence-based practice and research. Nurses will apply interventions that have been scientifically tested and noted to be most effective for culturally diverse populations. Nurse researchers will explore and test new effective interventions to reduce health outcomes disparities.11-17

In addition, the AHRQ's Health Literacy Universal Precautions Toolkit ( can assist nurses and team members in building similar essential skills for overcoming barriers in communication.6,10-14

Communities are becoming more diverse across the country, and healthcare teams now recognize the importance of cultural and linguistically appropriate services in their specific discipline and context. It is important for caregivers to pursue cultural competency training and related nurse development activities. Educational and skill-building exercises that improve understanding of diverse cultures can be included in organizational orientation programs. Annual competency assessements may also provide focussed education on predominant cultures in the hospital community and population.

Skill-building exercises, using simulation, can increase comfort and ability to communicate and establish rapport with patients and families across many forms of diversity. Patient caregivers can benefit from inclusion in educational activities that reduce disparate challenges.15

Strategies to improve communication

Patient- and family-centered care demands clear and effective communication strategies. Giving explanations in plain language enhances patient and family understanding. Key messages should be emphasized with repetition and rephrasing.

Return demonstration can validate skills learned from the nurse. The teach-back method simply confirms what the patient and family heard from the nurse; it is not a test of the patient's ability to perform skills taught by the nurse. When the patient and family members correctly verbalize what they heard, it validates how well the nurse educated the patient.

Additional strategies include the following evidence-based recommendations:

  • Instructions should be articulated slowly and in plain language that can be easily understood.
  • Questions should be simple and focused on validating essential self-care points.
  • Printed educational materials should provide visually appealing tools that emphasize essential home care needs.
  • Educational sessions should be uninterrupted and conducted in a calm environment without distractions.
  • When appropriate, patient caregivers and family members should be included for additional support.

Communication is essential

Understanding healthcare literacy, cultural competency, and health disparities/inequalities is essential for providing empathetic care to patients and their family members. Guidelines to provide culturally competent care may enhance the patient experience and improve healthcare provider communication.


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      cultural competency; disparate populations; evidence-based practice; healthcare literacy; nursing guidelines

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