Even the most jaded endocrinologists in the audience were stunned to hear the story at the National Hispanic Medical Association conference.
At their latest visit, Mrs. Muñoz explains how she administers her husband’s insulin injections, exactly the way she interpreted the materials she was given at their previous visit. The bilingual brochure showed how to use an orange to practice giving insulin injections. It did not explicitly say that once proficient with oranges, the caregiver should then directly inject the patient.
So what is the logical next step in the mind of this well-meaning caregiver? Mrs. Muñoz feeds the insulin-laden orange segments to her husband. Thus, his A1C levels were higher than at the previous visit, 2 months after starting on insulin.
This example of poor compliance is becoming more common as more health organizations produce materials in Spanish. Hispanic patients’ and caregivers’ frequent inability to comprehend even the most basic health information is becoming more apparent, as we create more and more content for them to try to digest.
Health literacy is a growing concern for all of us who produce content, especially marketers seeking to drive patients to treatment, improve adherence, change behavior, and manage disease.
The initial hurdle – nearly half of Americans are functionally illiterate.
According to a study conducted in April 2015 by the U.S. Department of Education and the National Institute of Literacy, 32 million adults in the U.S. can’t read.
44 million are now functionally illiterate, unable to read a bedtime story to their children.
The second hurdle – health literacy.
Health literacy is not the same as overall literacy, although the latter obviously exacerbates the former.
Health literacy is defined 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. It includes knowing how and when to take medications, being able to have useful discussions with medical providers and knowing which of the numerous decisions we make throughout the day impact our health.
People with low health literacy use more health care services, have a greater risk for hospitalization, and have higher utilization of expensive services, such as emergency care and inpatient admissions. They are less likely to:
- Know how their bodies work
- Know how to read a thermometer or take medication correctly
- Interpret numbers or the comparative risks of a health care decision
- Maintain control of their disease
The reality is that approximately 50% of Americans read so poorly that they are unable to perform simple tasks such as reading prescription drug labels. And today, the average patient information document is written at an 11th grade level.
Health literacy among Latinos.
According to a study by the National Center for Education Statistics, 41% of Hispanic adults lack basic health literacy. Only 1 in 25 Latinos, a scant 4 percent, have the proficient health literacy necessary to make appropriate health decisions.
All of the above is made worse when the Hispanic patient or caregiver we target has limited literacy in both Spanish and English, especially if the content is translated vs. transcreated.
The numerous ways our health system contributes to poor health information for Latinos include:
- The constant use of technical and medical terminology vs. plain language
- Inclusion of confusing or unnecessary statistics
- Over-reliance on written communication, vs. tools Hispanic patients prefer
- A focus on awareness and information rather than specific actions, behaviors and risks.
Additionally, we, as healthcare marketers, tend not to capture data on the performance of specific marketing content, nor integrate lessons learned into subsequent strategies. As healthcare marketers, we need to operate under the assumption that our core problem is overall literacy levels for all target communities.
However, all is not lost. There are ways to market to Latinos, overcome literacy and health literacy barriers and contribute to better outcomes for Hispanic patients.
RULE #1: Invest in creating a diverse infrastructure of staff, internal and external partners.
Your awesome internal marketing and communications team can move mountains with miniscule budgets. But it’s challenging to develop successful healthcare marketing programs, within budget and time constraints, for patients with whom they don’t necessarily share experiences or context. Invest in a diverse web of support for them.
Invest in cultural competency of your team. There are few better investments than equipping your team with the framework and knowledge they’ll need to create relevant, effective communications, especially when they form part of specific health interventions.
- Develop everyone’s cultural competency. I’ll be posting more about this topic, but for now, check out the list of excellent, free resources throughout the rest of this article, starting with the invaluable information available from the Office of Minority Health of HHS.
- Improve their knowledge of language- and culture-based regulatory frameworks, such as the National CLAS Standards (Culturally and Linguistically Appropriate Services in health and healthcare), and The Joint Commission standards for patient-centered communications.
Create an external advisory board for participatory design and testing of communication strategies and products. Involve members of the target population, patients, caregivers, home healthcare attendants, promotoras and other community health workers.
Augment the team with the external resources to complement the skills and knowledge of the internal staff team, including agencies with specific experience in developing healthcare content in plain language in both English and Spanish. Link your medical translation service and your agency and content developers to build a common glossary, utilizing plain language standards in both languages.
Assess the health literacy levels of your staff and advisory board members in both languages, utilizing a resource such as the Agency for Healthcare Research and Quality’s Health Literacy Measurement Tool. And that includes you.
RULE #2: Adopt a philosophy of Patient-Centered Design.
Once your team infrastructure is in place, the focus should move to patient centricity in all planning, developing, implementing, disseminating, and evaluating health and safety information.
- Issue plain language guidelines for the development of all information. Start by accessing these Plain English Guidelines.
- Establish formal mechanisms to review and address the literacy level, quality of translation, and cultural appropriateness of all written information for patients.
- Don’t assume that the target patient has access to what you are creating. Make sure they do. Whenever possible, ensure the target consumer has access to the Internet and/or devices that can deliver health information you’re intending to disseminate.
RULE #3: Assume all patients and caregivers have low health literacy
Studies show that even the most literate patients will have difficulty understanding health information. Structure the communication of information as if everyone has limited health literacy.
- Mandate clear communication in plain language to everyone, regardless of his or her perceived health literacy skills. As we’ve discussed here, HIGHER LITERACY ? HEALTH LITERACY.
- Constantly test efficacy of communications. Take advantage of the advisory board you’ve created to ascertain whether or not the communication strategies being planned are on the right track.
RULE #4: Find all the metrics you can, or invent new ones.
This is not as complicated as it sounds, given that there are now many existing resources.
- Integrate health literacy audit tools, standards and scorecards into all quality process and performance improvement activities and metrics. One of the most valuable resources for Hispanic healthcare marketers is the “Think Cultural Health” portal of the Office of Minority Health of the US Department of Health and Human Services.
- Create feedback loop on utilization, comprehension, effectiveness, and any positive or adverse events. Evaluate the contribution of poor communication and information to patient safety incidents and poor health outcomes.
- As your organization becomes more sophisticated in Hispanic healthcare marketing, create mechanisms to measure self-management of interventions of target patients and caregivers. Once they’ve used the materials/content survey patients and caregivers to ask about ease of understanding and usefulness of them. If possible, monitor them for improved medication dosing and adherence.
And for extra credit, RULE #6: Build community partnerships.
Beyond the advisory board described in Rule #1, it pays to establish multiple partnerships, clearly delineating the added value to both parties of improving health literacy among Latinos you serve.
- Build networks with community and faith-based organizations, social service agencies, and literacy service providers — to secure ongoing input on what messaging is getting through to your target Hispanic patients and caregivers.
- Support, participate in or establish community literacy projects for patient navigators, health coaches and community health workers to help patients access recommended services and information
- Negotiate with third-party payers on reimbursements for patient education and interpreter services. You never know what resources they may have already created which you can co-brand.
The story of Mrs. Muñoz and her oranges reminds us that building exceptional Hispanic healthcare marketing strategies can help, hinder, or hurt. Every word, image and technique we use – in Spanish or English – will have a direct effect on the health outcomes and lives of Hispanic patients, their families and the overall quality of healthcare.