Tips and Tactics to Overcome Literacy and Cultural Barriers Friday, August 9 3:45 – 4:15 PM George R. Brown Convention Center Houston, TX

Sandra Arévalo MPH, RDN, CDE, CLC, FADA Director of Nutrition and Outreach sarevalo@montefiore.org Montefiore South Bronx Health Center Bronx, NY

Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: No COI/Financial Relationship to disclose Non-Endorsement of Products: No endorsements to disclose Off-Label Use: Nothing to disclose

Objectives At the completion of this presentation, the participant will be able to: Explain the influx of literacy and culture in health choices and outcomes Identify practices of patients with low literacy and cultural barriers to diabetes self-care Practice innovative methods that help to break literacy and cultural barriers to enhance adherence to recommendations

What is literacy?

What is literate?

43% of people in the US have limited reading ability Are we literate? 43% of people in the US have limited reading ability

“Functional” Literacy “ An individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.” National Literacy Act of 1991

What is culture? Culture is not only about race or country of origin, but about the experiences that shape our personality and the way we live our lives.

One Size Doesn’t Fit All Individuals from the same territory might be united by broad cultural similarities, but each segment might have its own habits and traditions Again, very important point! I am thinking this would be a nice slide to have before talking about food differences, slide 9. Do you like chile, pique or whatever it is called ? Or eat tortillas at most meals like I do? We could play off of each other’s differences with this one to show the audience that we are very different although we share a common language.Like it… I agree – we can compare our own experience throughout the presentation as well as those of our family members and friends.

Immigrant Cultures in The US Origin Dominant Emphasize traditional health choices U.S. Dominant Emphasize American health choices Bi-cultural Emphasize positive behaviors of both cultures 12 12

Latinos are all different Different culinary habits and traditions Many variations in the language Again, very important point! I am thinking this would be a nice slide to have before talking about food differences, slide 9. Do you like chile, pique or whatever it is called ? Or eat tortillas at most meals like I do? We could play off of each other’s differences with this one to show the audience that we are very different although we share a common language.Like it… I agree – we can compare our own experience throughout the presentation as well as those of our family members and friends.

One Language Many Variables USA Mexico Central America Caribbean South America Beans Frijoles Habichuelas/ Judias Fríjoles/Habas Squash Calabaza Calabaza/ Ahuyama Ahuyama/ Zapallo Corn on the cob Elote Maiz asado Mazorca Peanuts Cacahuates Maní Rice stuck to the pot Pegado de arroz Concón Pega/concolón Comida – Food – Implication for insulin administration or medication Vegetables or Verduras? Pictorials are important

Health Literacy and Acculturation Level of acculturation can further compound to our challenges

Illness, Poverty & Literacy Low literacy costs $73 million or more per year in terms of direct health care costs 43% of adults at level 1 literacy skills live in poverty vs 4% of those at level 5 90% of welfare recipients are high school dropouts https://www.begintoread.com/research/literacystatistics.html 05/31/2019

Illness, Poverty & Literacy

Low health literacy is associated with: Less knowledge of disease and self-care Worse self-management skills Lower medication compliance rates Higher hospitalization rates Worse health outcomes Higher rates of depression

Am I doing a good job?

Let’s put ourselves in their shoes…

Exercise #1 Hint: The first word is “CLEANING.” GNINAELC = ot erussa high ecnanrofrep, yllacidoirep naelc eht epat sdaeh dna nalspac revenehw uoy eciton na noitaiurnicca fo tsud dna nworb-red edixo selcitrap. Esu a notton baws denelsiom htiw iyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa ti sdnet: ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad thole ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio. Read the entire passage below out loud to yourself. You have 1 minute to read. Hint: The words are written backwards and the first word is “CLEANING.”

Exercise #2 Select a partner and after reading the information below, use the “teach back” technique to demonstrate understanding of the information. “Mrs. B., your doctor would like you to take two tablets, twice a day, on an empty stomach. He wants you to make an appointment to see him again in two weeks and then he will give you a referral to the Gastroenterologist”.

Exercise #3 Global Financial Group Inc. (GFG-TSX Venture) announces that the non-brokered private placement previously announced December 16, 2003 has been over subscribed. The Company has increased the non-brokered private placement, subject to the approval of the TSX Venture Exchange, up to 703,800 units of the Company at a price of $0.25 per unit. Each unit will consist of one common share and one non-transferable share purchase warrant entitling the holder to purchase one additional common share of the Company for a period of one year at a price of $0.30 per share. The proceeds of the private placement will be used for the development of the e-globe x-change and general working capital.

Tips and Tactics to Overcome Literacy and Cultural Barriers

1. Identify patients with low literacy High risk group: - did not complete high school, minority, elderly. Does not know names of medicines Frequent missed appointments “I forgot my glasses” Always comes with someone else: “surrogate reader”

2. Identify literacy levels Use “social history” to ask about education, literacy, etc. “How far did you go in school?” Do you enjoy reading? What do you like to read? “A lot of people have trouble reading things they get from the doctor because of all the medical words. Is it hard for you to read the things you get here?”

3. Assess Acculturation Ask about: country of origin length of permanency in the US roots, family values, holidays, celebrations home remedies and health believes activities patient loved to do at original country markets, cultural foods, ingredients, and recipes Discuss advice for medical professional Vs Advice for patient/caregiver Key questions: How long they’ve been living in the US Where are they from Suggest Lorena’s book For both providers and patients: get personal – work as a team, know each other

4. Help patients improve comprehension Ask patient to read and explain Prescription labels. “If you were going to eat lunch at noon, what time should you take the medicine before lunch?”

Ask patient to read and explain Appointment slips “When is your next Appointment? Where?” Endocrinology

Ask patient to read and explain Glycemia readings “Is your blood sugar normal today?”

Ask patient to read and explain Handouts “Which of these symptoms do you feel when your sugars are low?”

Ask patient to read and explain Food labels “How much sugar is in this bottle?”

5. Use Friendly-Educational Materials Simple wording Short sentences Picture based Focus on key points Use cultural appropriate examples

6. Inspect your community Attend ethnic events Enjoy ethnic festivals Visit ethnic stores Join cultural groups Read books about other countries Join list-serves Share with people from other countries

7. Use Other Tips & Tactics Define new words and concepts Slow down the pace of your speech Do not raise the tone of your voice Use analogies Use lots of visuals Focus on key messages and repeat often Use demonstrations followed by “teach back” Use good translations Both providers and patients can learn from each other and need to follow this tips to enhance communication

Am I doing a good job? Yes, we are! It just isn’t easy!