- [Jamal] Good morning, good afternoon,
wherever you are in the world. (laughs)
Welcome to the second module in
In It Together: Health Literacy Training.
Thank you for joining us again.
Again, my name is Jamal Refuge.
And I work here at JSI Research & Training Institute,
also known as JSI.
So, thank you for joining us today
to learn how to be a health literacy trainer.
We're In It Together: Improving Health Literacy for All.
Again, my name is Jamal, I'm going to be behind the scenes,
running the webinar and answering questions in the chat.
So you may hear from me from time to time
to let you guys know if someone has a question
or comment that I present that you may not catch.
As a reminder, we have the chat box
that you can type in questions at any time.
And we'll try to answer those as available.
And we will go ahead and get started.
And if you guys let us know, again,
if you have any questions, in the chat box.
And so I'm gonna hand it over to Eddie to get us started.
- [Eddie] Okay.
So let's start by going over what we learned in session one.
To start, health literacy is the degree
to which in individuals have the capacity to obtain,
process and understand basic health information
and services needed to make appropriate health decisions.
Everyone experiences limited health literacy sometimes,
especially when they are ill or under stress.
But some people are more at risk
for limited health literacy than others,
including older adults, people of low socioeconomic status,
people who did not finish high school,
communities of color, and people
who did not speak English during early childhood.
People who have limited health literacy
may not take their medications correctly,
may miss appointments,
or fail to follow through on tests or referrals.
They may not complete their insight forms
or provide a detailed medical history.
Health literacy is dynamic and is influenced
by both an individual's skill
and by the demands placed on them by the health care system.
Therefore it's important that health professionals
and healthcare institutions
provide health literacy services to their clients
to help reduce the risk of miscommunication.
In order to provide medical and support services
to diverse clients in a culturally competent and direct way,
we must understand the social determinants of health
and other contextual factors that can make it more difficult
for clients to optimally engage in care.
That is why the goal for today's module
is that you will increase your understanding
of how the social determinants of health
and other contextual factors can impact
health literacy and how that can affect
clients' engagement in HIV-related services.
We're gonna cover a lot of ground today.
And by the end of today's session,
you'll be able to discuss the cultural,
social, and environmental factors
that can impact health literacy
for diverse clients and describe
three strategies to promote health literacy
through implementation of culturally appropriate strategies.
- [Jamal] Okay, so, the social determinants of health
are conditioned in the environment where people are born,
live, learn, work, play, worship, and grow.
For example, studies have found
that there are differences in HIV transmission
in areas with substantial disadvantages
in education, housing, employment, and income.
These structural factors can impact access to care
in general and health literacy in particular.
So, health equity is the absence
of disparities or avoidable differences
among socioeconomic demographic groups
or geographical areas in health status and health outcomes,
such as disease, disability, or mortality.
In essence, it means that everyone
is on a equal playing field and has the same potential
to achieve positive health outcomes.
So by addressing the social determinants of health,
we promote health equity, so today we'll highlight some
of the notable social determinants of health
that can impact HIV health literacy.
So, I have a question.
So, have any of you guys heard
of the social determinants of health before?
If so, go ahead and chat some in that you may know.
So again, so have you heard of any
of the social determinants of health before?
If you do know what some of those are,
go ahead and chat them in the chat box.
Okay, so, we have socioeconomic status,
poverty,
okay, laws.
So race, social networks, institutions,
environment, housing, okay, so, great job.
So, each of the social determinants
of health encompasses a number of key factors
that affect a person's ability to live a healthy life.
So, for example, economic stability encompasses poverty,
employment, food insecurity, and housing instability.
So we'll talk about some of these
structural factors on the coming slide.
The social determinants of health
are conditioned in the environment
where people are born, live, learn,
work, play, worship, and age.
So, for example, studies have found
that there are differences in HIV transmission
in areas where substantial disadvantages
in education, housing, employment, and income.
So these structural factors can impact access
to care in general and health literacy in particular.
So, the first social determinant of health
is neighborhood and built environment.
This determinant recognizes that fiscal characteristics
of the places that people live affect their health outcomes.
So neighborhood and built environment
look at things like access to food
that support healthy eating, the role crime
and violence can play in a community,
environmental conditions, and quality of housing.
All of these have an effect on clients' ability
to engage successfully in care
and the degree to which people
can prioritize their health or health care.
So chat in an example of how neighborhood
and built environment can affect client ability
to be successful in their HIV care.
Okay, so, someone said crime condition,
poor housing structure, okay.
Food and shelter.
Bus line, yeah, that definitely affect transportation issue.
Okay, stigma in the community.
Okay, so the clinic may be in a neighborhood
that nobody wants to go to, so you may have
some issues around security and safety.
Okay.
So, these are some great examples.
So if peoples' most basic needs aren't being met,
like those for food, safety, and shelter,
it's almost impossible to prioritize things like health.
- [Eddie] The next social determinant of health
is social and community context.
This determinant recognizes that contextual factors,
such as social networks, discrimination,
and incarceration, have an effect on our health.
Let's take a closer look at some of these factors.
Incarceration and involvement with the court system
have a significant effect on many communities,
and particularly communities of color,
for example, African Americans
are disproportionally incarcerated in the United States,
where almost one in four black men
who have sex with men have been incarcerated.
African American men passing through a correctional facility
are at heightened risk for contracting
infectious diseases, including HIV.
Living with HIV and being incarcerated are very stressful
and contribute to high rates of depression
and mental illness among people who have been incarcerated.
Additionally, many people who are
or have been incarcerated have substance use issues.
Health care providers need to be
on the lookout for and address these issues
among both currently and recently incarcerated clients,
as they can have a substantial impact
on a client's ability to engage in care
and also on the client's ability
to reenter the community successfully after release.
A history of incarceration is a structural factor
that is associated with poor health outcomes
and can lead to social isolation
and disruption of social and sexual network.
Large-scale incarceration can become part
of the fabric of a community and ultimately
impact peoples' prioritization
of health messages and information.
People of all backgrounds, particularly people of color,
immigrants, and LGBTQ people, may experience stress,
discrimination, and rejection that can deter them
from seeking help or assistance
outside their trusted communities.
For example, LGBTQ people may experience
stigma resulting from our heteronormative society.
Heteronormative means that heterosexuality
is perceived by society to be normal
and superior to all other sexualities.
Therefore, anything outside of heterosexuality
is perceived to be less acceptable.
And people who live outside of the bounds
of that normality are often left out of the conversation
or may experience victimization or even hatred
based on their sexual and gender identity.
These lived experiences of homophobia and prejudice
may be deter them from seeking help or assistance
from anyone outside their trusted communities.
Experiences of stigma, discrimination,
or the expectation, or anticipation of these experiences
can be a substantial barrier
to open communication with health care providers.
Therefore, people who work in health care settings,
including the front desk staff and lab technicians,
need to actively demonstrate openness and approachability
in order to ensure that clients feel comfortable
engaging in care at the organization.
Stigma is defined as negative and usually unfair beliefs.
Discrimination is defined as unfairly
treating a person or group of people.
Stigma and discrimination against people of color
and LGBTQ people still exist in the United States
and can negatively affect health and wellbeing.
These negative beliefs and actions
can affect peoples' physical and mental health,
whether they seek and are able to get health care services,
and the quality of the services they may receive.
Such barriers to health are experienced
in all aspects of society,
from health care settings to workplaces,
institutions of faith and worship, and school.
Stigma often stems from fear of the unknown,
ignorance and isolation.
Stigma is also rooted in ethnocentrism,
which is an evaluation of others' cultures
against the values, standards,
and customs of one's own culture.
When someone believes that one person
is superior to another, it is unlikely that he or she
will be open accepting those whose opinions
or lives differ from their own.
Many people are fearful of what they don't know
or understand, sometimes causing them to reject other ways
or a being that are foreign to or are uncomfortable to them.
The lack of exposure to different
kinds of people and ways of being
can cause people to stigmatize people,
circumstances, or unfamiliar ideas.
Stigma is a collection of attitudes
and beliefs against a group of people.
Stigmatized groups are often the object of prejudice,
avoidance, rejection, and discrimination.
There are many opportunities for stigma
to attach itself to marginalized people.
In the case of an HIV positive Hispanic or Latino man,
he may be stigmatized for being HIV positive,
an immigrant, or Hispanic.
When these beliefs spread, the impact of the community
becomes greater and more long-lasting,
affecting every aspect of life, including health care.
Stigma becomes cyclical when it is
internalized by members of the community.
In that way the anticipation of the experience
of stigma or discrimination causes harm.
Stigma also becomes cyclical when it goes unchallenged
and when it is explicitly and implicitly tolerated.
In health care settings, people may also be stigmatized
or expect that they will be stigmatized
for having limited health literacy.
They may worry that their health care providers,
family members, or friends will think less of them
if they find out that they can't easily
understand health information.
This may lead to them wanting to hide
this information from their providers.
It is the responsibility of all institutions
to adjust biases, prejudices, and discrimination
in order to rebuild trust.
The response to stigma varies from person to person.
However, people will often respond consciously
or unconsciously to experiences of stigma with denial,
feelings of shame, isolation, deceit,
defensiveness, depression, guilt, withdrawal,
fear, self-harm, or loss of self-worth.
So how can a person's responses to stigma
become barriers to health literacy?
Please respond in the chat.
Again, how can a person's responses
to stigma become barriers to health literacy?
They will not seek care,
can result in withdrawal from medical care,
they may not seek clarification about what they don't know,
they won't get the full help they need,
and they'll be less likely to complete a medical history.
That's great, those are some great answers.
- [Jamal] So, a client may be reluctant
to share personal information because they have concerns
about how their personal information will be used or shared.
In order to help mitigate his concerns,
providers should work to build trusting relationships
with clients and help clients understand
doctor-patient confidentiality.
This includes how their data will and will not
be shared and what the data will be used for.
People may be reluctant to share information
about their sexual orientation, gender identity,
or health status with their family,
friends, or health care providers.
There may be many reasons for this reluctance,
including fears about stigma or discrimination,
or feelings of shame, or denial.
For example, many living with HIV
report that they have experienced
or anticipate stigma and discrimination
and may withhold important information
about their life in a way to protect themselves
from experiences of discrimination or rejection.
From this you do see how important it is for providers
to take the time to build open and trusting relationships.
When providers listen to their client,
make sure the client is comfortable asking questions,
they better understand the client's needs
and they can dedicate their time and attention
to ensure their clients understand
how to keep themselves healthy.
Medical mistrust refers to discomfort or unwillingness
to accept, believe or feel confident
about the integrity of health information
offered by medical professionals.
Many people of color, as well as LGBTQ people,
mistrust the medical system for a variety of reasons.
Some people may have experienced trauma
or other negative experiences at the hands
of medical professionals or from governing bodies.
Immigrants may carry the experience of their new country.
Some people born inside the US and outside the US
inherit mistrust, suspicion, and wariness
handed down through the generations.
They believe that the medical system can't or won't
be able to help a family or community member.
Historical medical misconduct or inadequate
or sometimes care completely unethical
were provided to particular communities, have contributed
to medical mistrust among many people of color.
The Tuskegee Syphilis Study, a 40-year study
of the natural progression of untreated syphilis
in black men in rural Alabama,
is perhaps the best known example of racist,
unethical, and gross medical misconduct in the US.
The participants of the study did not know
that they had syphilis and were told that they were
receiving free health care from the government.
So participants were not treated
for their syphilis and were actively prevented
from getting treatment for their syphilis,
even after an effective treatment was made available.
It has led to generations of black Americans
mistrusting the medical and public health system.
And these experiences have led to negative attitudes
about the safety of or intentions
behind prescribed medications and health practices.
Mistrust can also lead to misunderstandings of disease.
For example, some people believe
that HIV is a manmade virus,
developed to eradicate people of color.
Other people believe that HIV is a punishment from God.
We have to be mindful that mistrust
is based on the personal or cultural experience
of the client and make efforts to get past
if I've taken the time to answer questions
and building trusting relationships.
So using clear and simple language
when we talk with our clients can help them
to understand that we want to help and not hurt.
So, question.
Have you ever had a client or friend
who was mistrustful of the medical system?
Okay, so, if you guys have family members or friends
who experience some mistrust of medical assistance,
so, that's definitely not uncommon.
So thanks for that feedback.
- [Eddie] The next social determinant is education.
A person's education across their lifetime,
from early childhood to high school
to higher education, can affect health
in a variety of different ways.
Other related factors, such as language and literacy,
can affect a person across their lifetime.
There is no direct correlation
between the educational level a person attained
and the health literacy level.
People may assume that their lack of education
is the reason that they have difficulty
understanding health information.
Or a person might have a PhD
but not understand what their doctor is saying.
For either reason,
a person might feel embarrassment or shame.
The reality is that all people,
regardless of education level,
are at risk for misunderstanding health information,
especially when it is an emotionally charged
or complex subject like HIV.
Providers should be careful not to lose patience with
or blame a person who have difficulty
understanding health information.
They should also,
a person's capacity to process
health information that may be affected
by their emotions about an HIV diagnosis,
a bad lab result, or a poor prognosis.
They should be aware of the language that they use
to share information by using plain language.
For example, avoid using acronyms
and be sure to explain technical, medical terminology
or use simpler language.
Make sure language and system services are available
for individuals who have limited English proficiency.
The next social determinant of health is economic stability.
Economic stability can have
a substantial impact on a person's health.
Employment, food insecurity, housing instability,
and poverty are all part of economic stability.
All of these have an impact
on a person's access to health care,
the degree to which they prioritize it, and their ability
to meet the demands of their health condition.
Over the next three slides, we'll take a look
at some examples of economic stability
and their effects on health and health literacy.
Poverty is known to impact access
to health care and poverty is both
a cause and a consequence of poor health.
People with less access to health care
may not be as familiar with the health care system itself,
may not receive the same quality of care
and may have poor health outcomes as a result.
If you remember from my discussion
of Maslow's hierarchy of needs earlier,
people prioritize their most basic needs,
food, water, and shelter,
over other things, such as health.
If a person is living in poverty,
they may devote more time and resources
to meeting those immediate needs
more than their health.
Let's start by talking about housing instability.
Inadequate, substandard, and unstable housing
can have a negative effect on a person's health.
Housing instability can make life difficult in many ways.
To begin, it can affect prioritization of health.
A person's priority will often be shelter,
even if it is at the expense of medical care.
In terms of health access, it can be more difficult
for people to attend medical appointments,
maintain a relationship with the medical care team,
and regularly fill prescriptions.
Inadequate and unstable housing can also impact
how people keep track of things like medication adherence.
People with unstable housing may feel
that their need for shelter is more pressing
than their need to take their HIV meds
or take other steps to care for their health.
People may also struggle to find the privacy they need
to store and take medication regularly.
Poor housing conditions can further compromise health.
The last social determinant of health
that we will discuss is health and health care.
This determinant looks at a person's ability
to access health care when they need it.
It's important to remember that access means more
than just being able to get to a place
where a person could get care like a hospital.
But it also means a person's ability to pay for their care,
the cultural competence of their care,
and their ability to understand
and make informed decisions about their care.
Over the next few slides, we'll talk about
some examples of how access to care
can affect one's health outcomes.
- [Jamal] So bias is a preference for one thing,
person, or group over another.
We all have biases, it's natural.
But biases can become prejudice and can lead
to unfair treatment and discrimination.
There are two types of biases,
conscious or explicit bias and unconscious or implicit bias.
Conscious or explicit bias means
that you're aware of it, you can say what it is.
An example of conscious bias
in the health care field would be when someone says,
"I don't like working with gay people"
or "it takes too long to work with someone
"who needs an interpreter"
or "herbal home remedies can't help at all."
Unconscious or implicit bias
is a type of bias we are not aware of.
We might even deny it.
In the health care field, we might hear people say,
"We know how to work with our clients,
"health disparities don't happen at our organization."
Or providers might prescribe some medications like pain meds
less frequently to people of a certain race or ethnicity.
The problem might be that they are
making individual judgments about the trustworthiness
or irresponsibleness of the patient.
But when we step back, we see
that it's actually a systematic problem.
The biases that are held by individual health care providers
in the leadership of health care organizations
all contribute to the development
of an organizational culture that may or may not
be welcoming to people of color or other groups.
It's important that providers recognize
that though everyone has implicit biases,
there are things that we can do
to reduce them and lessen their impact.
Some research suggests that implicit bias
can be diminished by increased exposure to images
and experiences that are counter to the stereotype,
increased internal motivation better the desire
to change internal biases, increased cognitive empathy,
increased emotional regulation, just trying to be positive
during encounters with diverse patients.
And increased partnership building skills,
which means that the provider and the client are part
of a care team, working for the common goal.
Some organizations encourage or require employees
to participate in implicit bias training
to help become aware of the biases that one holds
and become motivated to change.
- [Eddie] We're going to transition
a little now and talk about culture,
an important social determinant of health.
Let's start with a group discussion.
I wanna hear what culture means to you.
Using the chat window, tell me how you define culture.
So, what does culture mean to you?
A way of life, okay,
religion, makes you spicy. (laughs)
(people laughing)
- [Jamal] I like that one.
- [Eddie] Language, the way we interpret, events, food,
yes, our life, these are great answers, you all.
In the next few slides, we will discuss
some commonly accepted definitions of culture.
Then we'll talk about how culture
can impact a person's health literacy.
Providers need to make sure that they make an effort
to learn about and understand their patient's culture.
This helps to strengthen the partnership
between the client and the provider,
and improves the provider's ability to listen
and communicate with the client.
But what is culture?
As your chats show, culture can be a lot of things.
This slide shows some elements of culture
and I'm not gonna read them but you can see
that the list encompasses everything from food
to images and symbols to the role of religion
to the role and use of language.
Culture is a shared belief, values, norms,
traditions, folklore, knowledge systems,
forms of expressions, and history of a group.
Culture provides the framework
within which we define ourselves individually
or as members of one or more groups,
including our role, relationship and structures.
It also serves as a lens or filter
through which we interpret information
and make sense of the world,
including how we see our place in it.
And culture guides how we interact with,
respond to, influence, and are influenced by people,
events, circumstances, and conditions,
real or perceived, in our environment.
- [Jamal] So, one useful way of understanding culture
as we consider the role of culture in health literacy
is to compare organizational culture and individual culture.
The culture of an individual impacts
the way one thinks about oneself,
one's family, those around them,
and other personal aspects of life.
The culture of an organization influences
the experience of people who are exposed
to the product or service provided
or those who work in the environment.
- [Eddie] A person's culture affects the way
an individual receives, understands,
values, and applies health information.
People receive health information in many different ways.
Some people may be cautious, fearful, anxious,
relieved, or even joyful just to name a few.
A person's ability and desire to apply health information
depends on how well the information is received,
understood, and valued.
Context matters a lot.
As we discussed earlier, the use of direct
and implied language and nonverbal cues
is connected to one's culture.
The influence of culture on health literacy
is an important consideration because culture
has an impact on health behavior
communication with providers,
adherence to treatment regimens,
health outcome, and even health care cost.
For example, African Americans in the United States
have lower health literacy than their white counterparts,
which makes understanding the impact of culture critical
for maximizing positive health outcomes for this group.
Culture also affects the degrees to which a person values
the health information they get.
The value attached to the information
from a health care provider is related to the degree
that the client trusts that provider.
The value is also related to perceived credibility
of the health messages that are offered.
Recognizing and responding to culture diversity
is an essential aspect of care.
Understanding an individual's background
can help us understand how to communicate better
and identify any unique challenges that they may face.
But as we just discussed, culture is complex.
It shouldn't be surprising then
that while members of different culture groups
may share some characteristics, such as race,
ethnicity, language, gender identity,
sexual orientation, or sexual behavior,
they are not a homogenous group.
We have already talked about most of these
but we're gonna talk about two additional examples
of culture in the coming slide.
As we go through them, it is really important
to remember that all members of a cultural group
do not share the same values, beliefs, experiences,
influences, likes, dislikes, fears, or desires.
Nor are their themes the same within the same group.
The purpose of our discussion today
is to increase awareness and open-mindedness
and not to create stereotypes.
Everyone is different and has a different lived experience.
- [Jamal] Age can have a substantial effect
on a person's ability to understand,
value, and use health information.
Youth and young adults may struggle to understand,
act on, and use health information.
Some youth and adolescents may rely
on their parents and caregivers to help them
navigate the health care system.
Thus their ability to understand, act on,
and use health information successfully
is supported by their parent or caregiver's health literacy.
On the other hand, if the adolescent's caregiver
has limited health literacy, he may not be able
to access or stay in care successfully.
As they begin to access care on their own,
youth and young adults may have concerns
about what information will be shared
with their parents or caregivers.
Youth and young adults living with
or at risk for HIV may be navigating
the health care system alone for the first time
and may have little experience in doing so.
They will need to learn both
about the health care system and their own care.
However, not all youth and young adults
will be engaging with health care system
with their parents or caregivers.
Some LGBTQ youth may access care on their own
to avoid disclosing their personal health information,
sexual or gender identity,
or other information to family or friends.
LGBTQ youth may leave their families of origin,
may become a part of a family of choice,
or they may live on their own.
They are often homeless, couch surfers,
dropped out of school, and at greater risk for HIV,
sexually transmitted infections, depression, and suicide.
This can result in youth engaging
in the health care system on their own
at an earlier age without family support.
This means that they may not have assistance understanding
how to navigate the health care system from their family,
and may be trying to understand their care
and navigate services on their own,
Youth can be often in care without family support
but with the support of case managers
or other service providers.
This may make them feel as if they cannot
advocate for the care that they want.
Additionally, youth, adolescents, and young adults
may be at risk if and when they transition
from pediatrics to adult care.
This transition can be tough
because clients won't necessarily
end the stable, trusting relationship
that they had with their pediatric provider,
will have to attune to a new, different system.
Older adults are particularly affected
by limited health literacy.
According to a recent study, 71% of adults older than age 60
have difficulty using print materials.
80% had difficulty using documents, such as forms or charts,
and 68% had difficulty with interpreting
numbers and doing calculations.
The limited health literacy experienced
by older adults is particularly dangerous
because older adults have greater health needs
and may need to manage multiple
chronic conditions in addition to their HIV.
Older adults with limited health literacy
often take their medications incorrectly,
have poor chronic disease management,
low use of preventative health services,
and increased risk of mortality.
Additionally, older adults may struggle
with online health information
or other health information technology
due to the unfamiliarity with the technology.
Organizations that use health information technology
or online health information should be certain
to use health literacy practices.
We will discuss this in greater detail in later modules.
Older adults may not ask many questions
of their health care providers.
Older adults often feel that their health care provider
is in a position of authority over them
and that asking questions is inappropriate.
Cognitive decline.
Even absence of dementia
or HIV-associated cognitive disorder
can start as early as mid-adulthood.
Older adults often struggle with fluid cognitive abilities,
such as verbal fluency, reading comprehension, reasoning,
working memory, numeracy, and reasoning.
However, generalized knowledge
of vocabulary often stays stable over time.
So it's not that people forget the things that they know,
but that their ability to use or apply the information
to make health decisions decreases.
It's important to know that older adults may have caregivers
that are responsible for ensuring their wellbeing.
This can include family members, friends,
or paid medical staff, such as assisted living
or nursing care staff or a home health aid.
It's important to ensure that these caregivers
understand health information as well.
So, gender is a complex concept
that includes an individual's sex, sexuality,
identities, and social relations.
Gender is socially constructed,
and refers to how society and culture conceptualize
the differences between the sexes.
A person's gender identity is their internal sense
of their gender as male, female,
a combination of male and female,
another gender, or no gender at all.
It can be the same as or different
from the sex assigned at birth.
Sex refers to the biological and physiological differences
that define human beings as male and female.
Sex is biological, sex is generally constant unless changed
through a surgical and/or hormonal intervention.
Transgender is a broad term that describes anyone
whose gender identity, gender expression, and/or behavior
do not match their assigned sex at birth.
It is not an indicator of sexual orientation.
It's also used more narrowly to reflect
a binary gender that is opposite or across
from the sex you were assigned at birth.
Throughout this training, we use the acronym LGBTQ
as an umbrella term that refers
to the entire community of lesbians, gay, bisexual,
transgender, queer, or questioning people.
But we do want to know that this acronym
is inclusive of both sexual orientation
and gender identity, which are not the same.
Gender identity and gender expression
are separate from sexual orientation.
Sexual orientation is how a person describes
their emotional and sexual attractions to others.
People may describe their sexual orientation
using terms such as straight, lesbian, gay,
bisexual, or same-gender-loving, or another term.
Sexual orientation is a continuum
and is fluid for some people.
A person's sexual behavior may not align
with their sexual orientation.
- [Eddie] LGBTQ people experience many health disparities
that require them to seek health care
more often than heterosexual people.
Moreover, the health literacy of LGBTQ people
may be temporarily compromised by the stress
of coming out to the health care providers,
and communicating with potentially hostile
or uninformed health care providers and organizations.
LGBTQ people often expect to experience discrimination
and prejudice from their health care professionals
and may delay or not access necessary services.
For example, lesbian and bisexual women
are less likely than heterosexual women
to get cervical pap tests and mammograms
or to conduct self-breast exam.
Also, studies show that gay and bisexual men
may fragment their care into sexual health
and other medicine and not communicate
with their primary care provider about their sexual health.
Therefore, it's really important
that health care providers demonstrate
their openness to their clients' sexual identities
and their willingness to work with patients
to help them achieve positive health outcomes.
It also demonstrates the need for health professionals
to clearly communicate the importance
of appropriate preventative care
and screening to the LGBTQ patient.
For example, anyone with a cervix,
which can include transgender men,
lesbian women, and heterosexual women,
of age 65 should receive a regular cervical pap test.
- [Jamal] So, just to emphasize this point,
recognizing and responding to cultural diversity
is an essential aspect of care.
There are people from a variety of countries of origin,
each with a distinct culture, living in the US.
Communities in our country represent
a rich and diverse ethnic heritage.
Even within a group, members may not speak
the same language, use the same dialect,
or share the same ideas and experiences.
For example, people who are Hispanic or Latino
may have roots in any number of countries,
including South America, Central America,
North America, the Caribbean, or Europe.
Using an individual background can help us understand
how to communicate better and identify
some of the unique challenges that they may face.
Moreover, understanding a person's culture
and multiple culture identities
can help us understand resilience factors,
affirmative health beliefs and practices,
familial and community support systems.
When we are talking to the clients
or creating materials for diverse clients,
we need to consider the different ways
the information will be interpreted and used.
We also need to consider what our client's experiences
and history with the medical system are.
Some people, particularly people
who have immigrated from another country,
may not understand the US health care system,
and may need extra assistance understanding
why it is important to get and stay engaged with care.
Interpretation and translation services alone
may not be enough for people
whose first language is not English.
Some words and concepts do not
translate easily from one language to another.
Translating materials need to be written clearly
and take cultural context into consideration.
For example, the US health care system is complicated,
and may be unfamiliar to people from another country.
For instance, a person born in the US
who has limited health literacy
and is living with HIV might be able
to communicate with health care providers,
navigate the health care system, and manage the HIV
more effectively than a recent immigrant
who also has low literacy and is also living with HIV.
So it's important that we take the time to make sure
that our verbal communication is clear to all clients,
including those with limited English proficiency.
Additionally, it's important that all written material,
including legal documents, consent forms,
and insurance information, be tested
with the intended audience to ensure
the messages resonate appropriately.
We'll talk more about this in a later module.
Many cultures have traditional forms
of healing or medication.
So some clients may be reluctant to engage
with the US health care system and therapies.
Or they may want to supplement
their provider prescribed therapies
with traditional remedies.
It's important that providers take the time
to understand the client's beliefs
around medication and treatment.
When appropriate, and as long as these traditional remedies
and behaviors are not medically contraindicated or harmful,
providers should give clients tailored health information
that compliments their existing beliefs
while also conveying information
about the importance of the provider recommended treatment.
This can include using familiar and accepted language,
images, and examples to reinforce key points.
- [Eddie] Language has a direct impact
on the way that people are able to navigate
and interact with our health care system.
People with limited English proficiency
are less able to access health care services
and are at risk for adverse outcomes,
such as drug complications.
It's important to remember that just because a person
does not speak fluent English, it does not mean
that they have limited health literacy.
They may have proficient health literacy
in their native language and may only require
interpretation or translation services
in order to successfully engage with care.
For example, a person who is deaf or hard of hearing
may need an assistive device or sign language interpreter.
When needed, it is important that providers
use trained medical translators and interpreters.
Professional interpreters, if an in-person interpreter
is not available, via telephone,
increases patient satisfaction,
improves adherence and outcome,
and improves outcome.
Untrained interpreters, such as family members,
friends, or untrained bilingual staff,
are more likely to make errors, violate confidentiality,
and increase the risk of poor health outcome.
Untrained or non-professional interpreters
may be uncomfortable with sensitive topics,
use euphemisms, give unsolicited advice,
or not have the language necessary
to get the information across accurately.
Children should never be used as interpreters,
except in emergencies.
It is also important that providers understand
that not all people who speak the same language
speak the same dialect.
Merely having translation into the base language
may not be sufficient for a patient to understand.
For example, Spanish language speakers
come from many parts of the world,
and there are many different dialects.
Health care organizations should make an effort
to understand the language and communication needs
of the communities that they serve.
- [Jamal] Different geographic regions
also have distinct cultures.
Where someone lives affects
how they view and access health care.
And also how they engage with their health care providers.
For example, rural and urban settings
affect health literacy.
Rural communities have fewer health care providers
and people often have to travel
long distances to access appropriate care.
Transportation options may be limited
and the distance can be a substantial barrier to care,
resulting in people attending fewer medical appointments
than people in urban areas.
Because they have few opportunities
to interact with the health care system,
they may be less familiar with it.
They may not understand what services they need,
where they get them, how to access them,
and why they are important.
Even if services are available
and acceptable to people in rural communities,
people living with HIV in rural areas
report experiencing a lot of stigma around the condition,
which can affect their willingness
to disclose their illness or receive care.
Many people who live in small or rural communities
have significant concerns about confidentiality.
They worry that if they get tested
or receive treatment for HIV, the community,
other people will learn their status.
This can mean that people travel outside the community,
perhaps to the nearest city, for care.
However, because of the time and resource commitment
this kinda travel entails, people may not be willing
or able to meet regularly with their providers.
There are also geographic disparities in health literacy.
In general, people in the southeastern United States
have poorer health literacy
than people in the rest of the country.
Providers in these communities
should take particular care to explain health information
to the clients that they serve.
People can be classified to many groups
based on social constructs, like race, gender,
sexual orientation, and socioeconomic status.
These constructs are not intrinsically negative,
they are what makes each person unique.
However, communities of color, LGBTQ people,
and other vulnerable populations
may experience discrimination or oppression
directly related to any or all of these qualities.
The effect of discrimination or oppression
for any one cultural identity can be substantial.
And when we think about a person's experience
with oppression, we usually think about each of these
and peoples' reactions to them separately.
But actually, these qualities are not
completely independent of each other.
Discrimination, oppression, and the result in strife
and other negative effects can be compounded
when a person experiences multiple forms
of discrimination at the same time.
This is referred to as intersectionality.
Often, these intersectional identities,
like being a black transgender woman,
can feel at odds with one another,
forcing the person experiencing it
to have to choose an identity with which to respond
at the expense of the experience of the other identity,
or they may not feel truly accepted by either one of those.
A person can experience marginalization
by all their different identities
and by people outside of these communities.
In the example of the black trans woman living with HIV,
she may experience discrimination
or marginalization at the hands
of the black community or other cis and trans women
and by people outside of these communities.
Understanding these subtleties of experience
can help us as health care professionals
become better listeners and avoid stereotyping.
So, can anyone provide an example
of how this might play out?
Please answer in the chat.
So, in the example of the black trans woman living with HIV,
she may experience discrimination
or marginalization at the hands
of the black community, other cis and trans women,
and by people outside these communities.
So, can anyone provide an example
of how this might play out in a health care setting?
Okay, so, they may refer to using their government, yeah,
the clinic doesn't have any trans representative,
okay.
- [Eddie] Organizational culture is a set
of shared assumptions
that guide what happens in organizations
by defining appropriate behavior for various situations.
People within organizations generally share assumptions
that influence how they understand different cultures.
Organizational culture stems from the practices
of members of their organization.
Leaders play an important role
in the development of organizational culture.
Over time the characteristics and behaviors
of the leaders then form the organizational culture,
which is eventually passed on two new employees.
Thus it is important that leadership
reflects the type of organization that it wants to be.
Can anyone think of an example
of a time that a leader affected
the culture of an organization?
Please type your responses into the chat.
So think of an example of a time that a leader
affected the culture of an organization.
Okay, revise policies and procedures,
Great, some other examples, the leader
took the first initiative with a pay cut.
Revising, and more using, agreements, new programs,
great, these are great answer.
It is important that all health professionals
be attentive and responsive to the unique needs
of each patient and are respectful
to the patient's individual experiences and perspective.
Patients' needs, experiences, and perspective
are shaped and influenced by their culture.
Health literacy and cultural competency
are intimately interwoven.
Because health literacy is an essential component
of providing culturally competent care to our client,
it's vital that we take socio-cultural context,
like socioeconomic status and other factors,
such as the ones we discussed today,
into consideration when we communicate with our client.
But how do we do this?
What does it look like for communities of color,
LGBTQ people, and other vulnerable populations?
Let's start with an overview
of cultural competency and cultural humility.
These terms are often used interchangeably
but they aren't really the same thing.
One implies an attitude and the other implies an ability.
Both are needed to assist and respond
to challenges with health literacy.
Cultural humility the willingness
to accurately assess yourself and your limitations,
the ability to acknowledge gaps in your knowledge,
and an openness to new ideas.
Cultural competence is the ability to understand,
appreciate, and interact with persons from cultures
and/or belief systems other than one's own.
These two concepts are interwoven
because a person needs cultural humility
as they journey towards cultural competency.
And working toward cultural competency
is an ongoing journey.
It's important not to assume that you fully understand
a person's life just because you acquired
a basic understanding of their cultural background.
It's also important to remember
that it may not be possible to ever fully
be culturally competent, even if you share
a similar cultural background.
- [Jamal] Alright, so, let's wrap it up.
So, today we learned cultural, social,
and environmental factors that impact health literacy,
and how to promote health literacy
through culturally appropriate strategies.
So, in Module 3, you will learn strategies
that health professionals can use
to improve verbal communication with their clients.
So be on the lookout for that.
If you have any questions, prior to our next session,
please feel free to email them to the health literacy inbox,
you can find our contact information on the screen,
we're happy to help you in any way that we can.
This concludes today's session,
so thank you guys so much for joining us
and we look forward to seeing you all
again tomorrow for Module 3.
As a reminder, there are two sessions
but you only need to participate in one of them.
So, thank you guys again so much for joining us,
we look forward to seeing you tomorrow,
take care and enjoy the rest of your day.
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