Cultural competence becomes important to health literacy at the point where language and culture interfere with or support effective communication. While health literacy efforts are not limited to cross-cultural situations, and cultural competence efforts are broader than health literacy, initiatives in both these areas would benefit from coordination with each other. Cultural competency is sometimes approached through recommendations for culturally and socially sensitive communication. These approaches must take into consideration the dynamic and ever-changing nature of culture. As culture is constantly being influenced by lived experiences, so must health literacy approaches that are coordinated with cultural competence be responsive to cultural change. In meeting the health needs of diverse peoples, cultural competency is essential for the development of health literacy.

Language

An ob-gyn resident tells of working with an inner city, Hispanic population. Alone on service late one night, she struggled to communicate with a couple who spoke only Spanish in order to learn the pregnant woman’s due date. Grasping at a word familiar from popular music, she said “navidad, navidad” over and over again to the puzzled couple. Finally, she located another resident who spoke Spanish and helped her ask the couple about the “fecha” (date) the baby was expected. They all had a good laugh over her puzzling repetition of the Spanish word for “Christmas.”

An important component of cultural competence is linguistic competence. Many individuals receiving care from the U.S. health-care system have limited English proficiency (LEP). For individuals whose native language is not English, issues of health literacy are compounded by issues of language and the specialized vocabulary used, both in written and spoken form, to convey health information. The 2000 census indicates that the foreign-born population in the United States is 31 million. More than 300 different languages are spoken in the United States, and 47 million citizens and non-citizens speak a language other than English at home (an increase from 31.8 million in 1990). English is not the primary language spoken in the homes of 41 percent of Hispanics, 34 percent of Koreans, 29 percent of Vietnamese, and 20 percent of Chinese (Collins et al., 2002). Eleven million individuals indicate that they speak English not well or not at all (U.S. Census Bureau, 2000). Some of these individuals live in isolation from English, that is, without personal or social resources to understand English.

The profound effect of primary language on health is widely recog-



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