tified 69,961,280 people from 19 other ethnic and cultural groups living in America (U.S. Census Bureau, 2000). Many of these diverse American populations have differing systems of belief about health and illness. Cultural health beliefs affect how people think and feel about their health and health problems, when and from whom they seek health care, and how they respond to recommendations for lifestyle change, health-care interventions, and treatment adherence.

Cultures also differ in their styles of communication, in the meaning of words and gestures, and even in what can be discussed regarding the body, health, and illness. Health literacy requires communication and mutual understanding between patients and their families and health-care providers and staff. Culture and health literacy both influence the content and outcomes of health-care encounters.

A definition of health literacy that does not recognize the potential effect of cultural differences on the communication and understanding of health information would miss much of the deeper meaning and purpose of literacy for people (Nutbeam, 2000). Culture provides a context through which meaning is gained from information, and provides the purpose by which people come to understand their health status and comprehend options for diagnoses and treatments. A conceptual understanding of the interconnections between culture and literacy through the idea of cultural literacy can provide insights into the deeper meanings of how diverse populations in the United States come to know, comprehend, and make informed decisions based on valid data regarding their health.

This intersection between culture and literacy is recognized in the U.S. Department of Health and Human Services (HHS) National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. The standard states that “health care organizations must make available easily understood patient-related materials … in the languages of commonly encountered groups …” (HHS, 2001:11). The standard goes on to state explicitly that in addition to being culturally responsive, these materials need also be responsive to the literacy levels of patients and consumers. Issues of culture, language, and learning are interrelated, and to be effective, health education must be conducted in both culturally and linguistically appropriate formats to address the increasingly diverse multicultural and multilingual population (AMA Ad Hoc Committee on Health Literacy, 1999).

Cultural, social, and family influences shape attitudes and beliefs and therefore influence health literacy. Social determinants of health are well documented regarding the conditions over which the individual has little or no control but that affect his or her ability to participate fully in a health-literate society. Native language, socioeconomic status, gender, race, and ethnicity along with mass culture as represented by news publishing, adver-



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