March 24, 2009 Feature

Health Literacy at the Intersection of Cultures

Third in a three-part series

Health Literacy: Improving Web and Print Materials for the Public
Health Literacy in Clinical Practice

Every client brings his or her culture to a clinical encounter, as does every practitioner. Clinicians must be aware of the impact of these different cultures on communication with clients, as well as on the potential outcomes of any decisions made as a result of the encounter.

Another aspect of culture that needs to be considered—but that often goes unacknowledged—is the culture of the profession, facility, and setting in which the clinical encounter occurs. When these cultural influences are added to the cultures of the client and provider, one can see the far-reaching impact of culture in clinical practice.

Consider the following broad descriptions of cultures frequently encountered when a person seeks audiology or speech-language pathology services:

  • Culture of special education. The Individuals with Disabilities Education Act of 2004 provides for speech, language, and hearing services to children identified as having special needs. To access these services, parents and caregivers are introduced to terms such as "IEP," "evaluation," "least restrictive environment," and "parental rights and procedures." Not only is there a unique culture to each school, but also a broader culture of special education. It is appropriate to the culture of special education to ask parents and caregivers about the personal details of their family (such as the age of potty training, first words of the child); it would be a common occurrence for a parent to report that a child has a disability that requires special services. Views of disabilities, however, vary across cultures. In some communities, reporting that a child has a disability could bring great shame to a family or imply that they did something wrong in a previous life. The culture of special education can have a profound impact as it intersects with the culture of families.
  • Culture of medical practice in the United States. Medicine in the United States is based upon science and the belief that disease has physical causes that can be identified, measured, and treated. Many alternative treatments that fall outside the realm of "science" often are rejected or viewed with skepticism. Another important cultural aspect of American medical practice is that both male and female doctors treat both male and female patients. These ideas are not accepted by all cultures and may cause some patients to reject medical care or fail to adhere to recommendations.
  • Culture of the insurance industry. Most health care occurs in the context of managed care and insurance coverage. The insurance world has its own unique and complex culture. Driven by the need to provide appropriate health care while controlling costs, this culture is often seen as dictatorial and bureaucratic. Anyone who has tried to navigate the telephone system to find answers about coverage or who has read an explanation of benefits form has experienced the insurance culture—what some might describe as "culture shock." For some clients, decisions made by an insurer—someone they don't know—about their medical care is counter to their cultural beliefs. For many, stepping into the insurance world can be overwhelming.

Health Literacy and Cultural Competence

Speech, language, and hearing professionals must be culturally sensitive in order to provide clinically competent services. Culturally competent providers not only have clinical knowledge of disorders and recommended treatments, but also acknowledge the beliefs and values unique to their clients.

How health literacy is related to cultural competence may be viewed in different ways. As a culturally competent professional, you must understand and respect not only a person's culture, beliefs, wants, and needs, but also his or her ability to understand, process, and use health information to make informed decisions about their care. An individual's use of health information is directly tied to his or her cultural background and beliefs. When developing or selecting educational material or talking with a patient, student, or family, you should consider health literacy as a part of the person's overall needs. In this view, it is cultural competence for which the professional strives, with health literacy as an important component of that competency.

Another view is described in the U.S. Health Resources and Services Administration (HRSA) online training module, "Unified Health Communication: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency". HRSA graphically depicts unified health communication as the seat of a stool with three legs—health literacy, cultural competency, and limited English proficiency—and contends that these three separate, distinct components are equally necessary to ensure good health communication.

Regardless of whether one views health literacy as a component of or distinct from cultural competence, all providers, including audiologists and speech-language pathologists, must become more health-literate and improve the way they communicate important health information.

Health literacy is not just a "problem" for the patient, client, or family. It is not solely the client's responsibility to understand and use health information, but also the professional's responsibility to be sensitive to the client's cultural needs and to provide appropriate and understandable health information.

Where We Go From Here

Clinicians need to be aware that cultures exist all around us as well as within us. Every time you enter a school or health care facility you are experiencing a new culture. Given that discussions about hearing, speech, language, and swallowing involve complex topics and terminology, and may evoke strong emotions, the issue of health literacy within the context of the varied cultures needs to be addressed. Use the resources available to you on ASHA's Web site and from organizations such as HRSA to improve your cultural competency and health literacy.

Whether you view them as related and separate or as one concept, the positive outcomes of being culturally competent and health-literate are significant for both you and your patients.

Amy Hasselkus, MA, CCC-SLP, associate director of health care services in speech-language pathology, can be reached at

Andrea ("Deedee") Moxley, MA, CCC-SLP, associate director of multicultural resources, can be reached at

cite as: Hasselkus, A.  & Moxley, A. (. (2009, March 24). Health Literacy at the Intersection of Cultures. The ASHA Leader.

Resources for Clinicians

The Intersection of Cultures: Case Study


The culture of a medical setting and the use of jargon can have a significant impact on outcomes, as the following story illustrates.

An anesthesiologist and patient possessed similar educational credentials. Both had experience in health care settings and knowledge of medical terminology. Their racial and ethnic backgrounds, however, were different. The anesthesiologist spoke multiple languages and the patient spoke only English.

"Are you having a laminectomy?" the anesthesiologist asked as he flipped through the medical chart.

The patient paused. A laminectomy? She couldn't remember—she was in a hospital gown with a mark on her neck so the surgeon could remember where to cut, and her husband hovered nervously nearby. What was a laminectomy? "I'm sorry, I don't know," she said.

The anesthesiologist shrugged. "Then you probably aren't having one. If you were you would know. It means that we don't have to give you as much medicine."

"I am having the bone chipped away in my neck," she said.

"Well, that's a laminectomy. I guess I shouldn't have used that word. Don't worry, you'll get the right medicine."

Although both parties in this encounter spoke English, they did not understand each other because the medical culture interfered. That culture relies on scientific, medical jargon and often assumes that patients understand and can recall information even under extreme circumstances. It is also a culture that tends to keep things clinical and does not acknowledge a patient's emotions and vulnerabilities.

Providers must strive to understand the culture and communication environment in which they share information with clients and speak to clients in ways they understand—and then confirm with patients that they understand what is being said. 


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