ering differences in frames of reference—the world views, priorities, values, and understanding each speaker brings to the encounter—on an individual basis. It requires the use of skills to seek feedback and to verify the conclusions or assumptions we come to as we communicate with another person. Being culturally responsive also means developing skills to ensure that our communication is being received as intended. Learning to develop communication and interpersonal skills to obtain feedback and verify successful communication is critical to working competently with others, and contributes to addressing the problem of health literacy.

Family relations can be a motivating factor in behavior change. The Latino value of familialismo and its influence on health-care interventions and behavioral change in individual Hispanic patients is well documented. Perez-Stable found that the social importance of cigarette smoking was greater for Latinos than for Caucasians. Latinos were also more concerned about the effects of smoking on interpersonal relationships. As a result, they felt more certain that quitting smoking would improve family relationships and provide a better example for their children (Perez-Stable, 1994). Sabogal and colleagues (1987) note that “to motivate a parent to alter a high-fat diet or increase the level of physical activity to prevent a future heart attack, … appeal[s] to his or her sense of duty to the children. The extended family network can similarly be used to persuade patient with or at risk for cardiovascular disease to adhere to prescribed or recommended medication, diet and exercise regimens.”

The contributions of culture and language to health literacy are rich and complex. Potential approaches to issues of culture, language, and health literacy are discussed in the latter section of this chapter.

Finding 4-1 Culture gives meaning to health communication. Health literacy must be understood and addressed in the context of culture and language.

Measures Can Dissociate Culture, Meaning, and Health Literacy

The interface among individuals, cultural processes, layers of cultural experience, families, communities, health systems, and health-care providers is extremely complex. That complexity affects health literacy for people at every level of education and access to care. The challenge is to develop tools for measuring the health literacy effect of that complexity in order to assess and improve health literacy in the United States from both patient and provider perspectives. While strong evidence suggests an association between cultural diversity and health and illness (e.g., IOM, 2003a), the relationships between diversity and health literacy have yet to be fully delineated and investigated. This must begin with meaningful measures of



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