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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

  • Hospice Care
  • Clergy and Faith Communities
  • Additional Links
    Site Index
    Back to Module 13: Cultural Issues
    Tools for Diagnosing and Mediating Cultural Misunderstandings

    Touch and Gender
    Medical Subculture
    Traditional Medicine
    Body Language
    Bad News
    Literacy Meaning of Illness
    Alternative Medicine
    Imminent Death


    Health professionals deal in the written and electronic word. This goes well beyond just being able to sound out words on a page. We read effortlessly. We write effortlessly. Do not assume that this is true of your patients. This section contains information about:

    Avoiding Assumptions about Illiteracy

    • Adult medical illiteracy is a major barrier to care
    • One study revealed that up to 45% of English-speaking Americans couldn’t read directions on a pill bottle or follow written instructions for care. Literacy was only partly related to years of formal schooling
    • Illiteracy is often a deeply concealed secret. It is never directly volunteered


    Diagnosing Illiteracy

    • Diagnose illiteracy early and non-judgmentally
    • Clues to illiteracy include:
      • The patient does not look at printed material you hand them, or does not automatically turn the page upright if it is handed upside-down

      • The patient always “forgets my glasses” and cannot read large boldface type

      • The patient has forms that “the doctor needs to fill out” that may pertain to a medical condition but do not need to be filled out by a physician


    What to Do if you Suspect Illiteracy

    • Never challenge the patient, “You mean you can’t read that?”
    • If you suspect low vision or low literacy you can offer to read aloud necessary information. You can ask “Is it difficult for you to read this? What would make it easy for you to remember?”
    • Illiterates are not unintelligent. They may come from a part of the world where women in rural areas are not educated (Bosnia). They may be refugees from a country in which the school system was destroyed in war (Cambodia). They may be U.S. born Americans with undiagnosed learning disabilities, which caused them leave school in frustration. In any case, illiterate patients have gotten by for a long time by figuring out ways to compensate. Let them teach you
    • References:
      • The REALM test…citation is a rapid, validated English literacy screening device that tests patients’ ability to understand medical written materials

      • Davis, T. C., Long, S. W., Jackson, R. H., et al. (1993, June). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25(6), pp. 391-395.
    • If you suspect that literacy is making it difficult for your patient to rake medications properly there are a lot of things you can do to make it easier. For Example:
      • With medications, tape the pill or a picture cut out of the PDR on the list next to the instructions

      • Nearly everyone can read numbers and dates

      • Simple line drawings with some orienting details help. Find pictures in health pamphlets


    Evaluation and Adaptation of Written Materials

    Informational brochures and pamphlets are appreciated but may be useless as instruments of patient and family education if the patient or family cannot read them. You may wish to consider:

    Translation of Written Materials into other Languages

    • What about developing some pamphlets?
    • Certainly it is good to have translated materials available in languages you commonly encounter
    • There are cancer-related materials available in Spanish, Polish, and Chinese in most large urban centers. But they may not convey what you want
    • If you wish to develop your own materials...
      • Work with a professional literacy expert to develop the text and with professional translators

      • Select carefully the key ideas you need to convey. Too much information will lose the important message for low literacy readers

      • Never distribute such materials without a pre-market test with several of your own established patients and others in their community
    • If you have low literacy materials, do not assume that simple translation is all that is needed. Again, work closely with communities and professional translators to be sure the message and not the just the words are translated. Immigrant and minority patients may need different information


    Evaluating Written Materials for Readability

    • Most versions of Word for Windows98 6.0 will offer you a literacy score for readability and grade level. The document you are now reading rates 53, low on readability. It should be 70. It rates a grade level of 8.9. It should be around 7.0.
    • Literacy scoring programs are readily available only in Spanish and English
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