A Transdisciplinary Approach to Improve Health Literacy and Reduce Disparities

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A Transdisciplinary Approach to Improve Health
Literacy and Reduce Disparities
Linda L. Johnston Lloyd, MEd
Neyal J. Ammary, MPH, CHES
Leonard G. Epstein, MSW
Rae Johnson, RN
Kyu Rhee, MD, MPH
health outcomes. The agenda for addressing this impor-
tant area includes strategies for reducing medical
errors, increasing the appropriate use of effective
health care services, increasing consumer and patient
use of health care quality information, and improving
consumer and patient protections (Health Resources and
Services Administration [HRSA], 2005a).
These strategies will help improve the patient’s
health literacy and self-management skills.
Health literacy, the degree to which individuals have
the capacity to obtain, process, and understand, basic
health information and services needed to make appro-
priate health decisions (U.S. Department of Health and
Human Services, 2001) is an important component of
improving health care quality and eliminating health
disparities. Populations most likely to experience low-
literacy levels are older adults, racial and ethnic minori-
ties, people with low education levels, people with low-
income levels, nonnative speakers of English, and people
with compromised health status (IOM, 2004).
To fully address health literacy, many health care
settings have begun to use a transdisciplinary model of
care. A transdisciplinary model of care includes a treat-
ment team that shares the responsibility for the contin-
ual care of patients and views their roles as overlapping
as they work together to determine the appropriate
treatment for the patient. It is important to form the
team based on the needs of the community and to
include community members as part of the team.
Teams become more effective with training, institu-
tional and systems support, and incentives and rewards
for success (Ruddy & Rhee, 2005).
As the collaborative, cohesive team works together
to share information and to identify those patients with
limited health literacy, it is important to provide appro-
priate resources to improve patients’ ability to prevent
A challenge to public health professionals, health care
providers, and consumers is to come together to improve
the quality of health care and to eliminate disparities.
Improving health literacy skills along with a transdisci-
plinary approach to care contributes to effective patient–
provider communication. This article addresses a team
approach to health care, a community health center
experience, self-management skills, patient education,
and cultural competency training. In addition, the
authors provide concepts that can be incorporated in
health care settings to eliminate health disparities and
improve health literacy.
Keywords: chronic disease; cultural competency; cross-
cultural; health disparities collaborative;
health disparities; health literacy; quality
health care; self-management; transdisci-
plinary model; Unity Health Care
In order to eliminate health disparities, the nation
must look toward improving the quality of health
care. Quality health care means providing patients
with appropriate services in a technically competent
manner, with good communication, shared decision
making and cultural sensitivity (Institute of Medicine
[IOM], 2001).
Improving the quality of health care services includes
the implementation of a variety of strategies to improve
Health Promotion Practice
July 2006 Vol. 7, No. 3, 331-335
DOI: 10.1177/1524839906289378
©2006 Society for Public Health Education
331
the onset of disease and to be able to manage their treat-
ment and their disease.
Priority Areas for National Action: Transforming
Health Care Quality (IOM, 2003a) identified 20 priority
areas for transforming health care quality. One of
these priorities is Self-Management/Health Literacy.
An IOM Committee Consensus (2003a) outlined a crit-
ical need to improve care coordination, support for
self-management, and health literacy for all patients
and their families.
>>UNITY HEALTH CARE:
THE DIABETES COLLABORATIVE
AND TRANSDISCIPLINARY CARE
Since 1985, and then under the name Health Care for
the Homeless, Unity Health Care has served individuals
and families in all eight wards of the District of Columbia
through its network of medical and social services that
reach the homeless and residents. The organization
expanded in 1996 when it became the federal govern-
ment’s emergency grantee for the Community Health
Center Program. In 1997, it adopted the name Unity
Health Care, Inc. In June 2001, Unity Health Care joined
the DC Healthcare Alliance, a collaborative of a variety of
local health care providers that provide wrap-around
services to those most in need in the District of Columbia.
The Health Resources and Services Administration
(HRSA) Health Disparities Collaboratives (HDC) is a
national effort to achieve strategic system change in the
delivery of primary health care. Starting with the chronic
diseases care model, the HDC focused on the condi-
tions of highest importance to the health centers in
terms of cost, volume of patient visits, and/or complex-
ity of care needed. Unity participates in the Diabetes
Collaborative at its Upper Cardozo Clinic. The Diabetes
Collaborative is part of a national effort to reduce the
health disparities and improve treatment outcomes for
different minority and low-income populations who
suffer from chronic diseases. Since 1998, more than
450 HRSA-supported health centers have participated
in Collaboratives focusing on diabetes, cardiovascular
disease, asthma, cancer, and depression. Pilot HDCs
have focused on prevention, diabetes prevention, can-
cer screening, finance and/or redesign, and perinatal
and/or patient safety (HRSA, 2005b).
Participating health centers select a multidiscipli-
nary team of three to five staff members. The Unity
team has been encouraged to explore models such as a
transdisciplinary approach. Elements of this approach
include a team of health professionals that corresponds
with the needs of the community. The Unity collabora-
tive team includes physicians, nurse practitioners, nurses,
medical assistants, administrative staff, a dentist, and
an endocrinologist. The team recently invited the District
of Columbia’s Department of Health to send a repre-
sentative who works closely with the Latino commu-
nity and diabetes. The collaborative team recognizes
the importance of input from consumers as well and
has discussed ways in which we might integrate their
suggestions and feedback. Through bimonthly meetings
during the past few years, this Diabetes Collaborative
has been able to set goals and work together to over-
come obstacles affecting patient care and improve
chronic disease management.
>>UNITY HEALTH CARE: A COMMUNITY
HEALTH CENTER EXPERIENCE
Mr. G shuffled into my office behind his rickety
walker. I was about to count him as a “no show” after
calling for him five different times over the noise in the
bustling waiting room. One of his neighbors had walked
in on my final call and pointed him out to me saying in
Spanish, “You have to look at him directly when you
speak; he doesn’t like to admit that he doesn’t hear very
well.” After I thanked her she smiled and added, “We
have to help each other out in our old age.” Mr. G’s
words of greeting were also in Spanish: “This room full
of people makes me nervous.” His eyes scanned me as
if to assess what I may be able to offer him today and
he declared, “I had to take two buses to get here today.”
332 HEALTH PROMOTION PRACTICE / July 2006
The Authors
Linda L. Johnston Lloyd, MEd, is acting director for the
Center for Quality at the Health Resources and Services
Administration (HRSA) and the HRSA health literacy
coordinator in Rockville, Maryland.
Neyal J. Ammary, MPH, CHES, is assistant director of the
National Eye Health Education Program at the National
Eye Institute at the National Institutes of Health, in Rockville,
Maryland.
Leonard G. Epstein, MSW, is senior advisor on Clinical
Quality and Culture for the Officeof Minority Health and
Health Disparities/Office of the Chief Medical Officer at
the Health Resources and Services Administration, in
Bethesda, Maryland.
Rae Johnson, RN, is a diabetes nurse educator at Unity
Healthcare in Washington, D.C.
Kyu Rhee, MD, MPH, is the president of the Association of
Clinicians for the Underserved and the medical director at the
Upper Cardozo Community Health Center in Washington, D.C.
Even in this brief interaction Mr. G was talking about
his unique needs as a consumer seeking assistance
with his health care.
In my role as a diabetes nurse educator, I have about
30 min to assist patients to determine what will be
most essential in managing their diabetes, equip them
with the knowledge and tools to address these needs,
and formulate a plan best suited to their personal abil-
ities and resources. This is no small task. Patients often
arrive with little comprehension of their disease and yet
need immediate training in specific skills such as insulin
injections or blood glucose monitoring. Fortunately,
our health center encourages patients to return fre-
quently at no cost for needed visits, allowing me to
address their most vital needs up front and schedule
follow-up visits for less pressing and maintenance
issues. Not only does this keep the level of new infor-
mation manageable for patients and their families, but
it also promotes relationship building with their health
care team.
The concept of health literacy augments the need to
assess the unique barriers each patient may have to
receiving and comprehending information. It became
clear to me that Mr. G was faced with several barriers,
most of them common to our general service popula-
tion, not just those seeking diabetes education. As an
82-year-old man, Mr. G’s age alone indicates the poten-
tial need for health literacy assistance. Patients age
60 years and older have a higher prevalence of literacy
problems (Gazmararian et al., 1999). For example, Mr.
G’s hearing impairment had already been revealed, and
his complaint about the glucometer numbers being too
small to read pointed toward low visual acuity. These
factors, along with the anxiety that he expressed from
time spent in the waiting room, were a few of the issues
that would challenge his ability to understand instruc-
tions related to his health care. Language is a common
barrier for many of our patients whose first languages
include Spanish, French, Amharic, Vietnamese, and
Arabic.
The relief in Mr. G’s face when spoken to in his lan-
guage was made clear by the grin on his face. He admit-
ted that he did not always know how to respond to
someone who speaks English to him, even though he
had lived in Washington, D.C., for almost 20 years.
Often patients will attempt to use English in the clinic
as they are comfortable with casual conversations and
give the false appearance of English comprehension. It
is very different to apply conversational English to nav-
igate the health care system. Many patients are embar-
rassed to admit that they don’t always understand
everything that is communicated to them in English. It
is also important to note that spoken Spanish—like
other languages—is unique to each country of origin,
often causing confusion even between native Spanish
speakers from different countries. Fortunately, Unity
has addressed this language barrier by providing access
to a Translator Phone Service whenever needed. I did
not need to use the service with Mr. G that day but have
successfully used it with other patients and families.
Even though Mr. G had lived with the diagnosis of
diabetes for more than a decade, he did not hesitate to
express that he would like to understand more about
this disease that had taken the lives of a number of his
family members. Because his level of understanding
had not yet become evident to me, my communication
with him included many pictures and diagrams designed
for patients with limited health literacy. Many people
are ashamed to admit they experience literacy prob-
lems; however, I have discovered that asking the ques-
tion “Do you like to read?” often solicits an honest
answer. He expressed that he had never learned to read
well and that he would appreciate any materials in
Spanish to take home and share with his son.
Mr. G made many references to his home country of
El Salvador throughout our visit. It was clear that his
daily actions and thoughts were guided by his culture.
I am aware that his unique culture gives him a frame of
reference different than the one that many who work in
our clinic are using, thus creating barriers to under-
standing health information and services.
As we discussed his logbook of home blood glucose
monitoring, I noticed that he had extremely varying
numbers marked by many high readings. Something
didn’t seem to fit when he said that he was injecting his
insulin “as scheduled” according to these readings.
Through continued conversation he reluctantly admit-
ted that he had not been injecting the insulin as his
doctor had prescribed it, but rather that he was chang-
ing the dosage depending on how he felt. This infor-
mation became clear to me only after I invited him to
share with me the story that insulin had played in his
life. He explained a commonly accepted belief among
Salvadorans that insulin causes blindness. He said that
people in his culture only took medicine when they
began to feel bad. The concept of a chronic disease had
not yet become a part of his understanding or self-
assessment. As I formulated a care plan with him, my
top priority was to next share this new information
with his primary care provider and other team members.
The team meetings that are held in the health center
have provided a forum to discuss how we can work
together to help our patients. This has helped us meet the
needs of Mr. G. Mr. G’s provider, who is part of the team,
was grateful to be informed of this new information
regarding the sporadic insulin usage. He requested the
Johnston Lloyd et al. / TRANSDISCIPLINARY APPROACH 333
first available referral to our endocrinologist. The medical
assistant working with the endocrinologist is a Latina
woman and part of the collaborative team as well. She not
only made space for a brief visit with the endocrinologist
that day but also provided the language translation and
acted as cultural broker for Mr. G’s first encounter with the
specialist. She interpreted the information about Mr. G’s
beliefs and usage of insulin in a manner that respected his
culture yet clearly reflected the discrepancies. The strate-
gies used to address Mr. G’s health care improved his abil-
ity to obtain health information and better manage his
disease, thus improving his literacy skills.
>>HEALTH LITERACY AND DISEASE
SELF-MANAGEMENT
Disease self-management is an area where health liter-
acy plays a crucial role. As rates of chronic disease con-
tinue to rise, the health care system is increasingly
recognizing the importance for patients and their families
to manage their own diseases and make healthy deci-
sions. Many self-management and self-care models view
the individual patient as playing a central role in these
tasks. To prevent further complications and manage their
disease, individuals must be able to make informed
health decisions and understand how to access care
when it’s needed. Health literacy is more than reading
and writing skills and includes the ability to comprehend
and assess health information in order to make informed
decisions about health behaviors, self-care, and disease
management (U.S. Department of Health and Human
Services, 2004; Zarcadoolas, Pleasant, & Greer, 2003).
Limited health literacy can be identified as a key
contributor to disparities in health outcomes and has
shown to be associated with poor self-care in diseases
such as hypertension (Williams, Baker, Parker, & Nurss,
1998), diabetes (Kim, Love, Quistberg, & Shea, 2004),
HIV/AIDS (Kalichman & Rompa, 2000), and asthma
(Williams, Baker, Honig, Lee, & Nowlan, 1998). Healthcare professionals addressing health literacy can improve
the self-management skills of individuals and signifi-
cantly help them face challenges of managing their dis-
eases and navigating the health care system. In a recent
study, individuals with limited health literacy were
shown to have less health knowledge, poor self-
management skills, lower use of preventive services, and
higher hospitalization rates (Wolf, Gazmararian, & Baker,
2005) than those with adequate health literacy skills.
To address these disparate health outcomes, a variety
of methods can be used to improve the patient’s health
literacy. Examples of strategies that have been effective
for communicating with limited health literacy patients
with diabetes include focusing on select critical behaviors,
reducing the complexity of information, using clear, con-
crete examples, concentrating on single topics at a time,
avoiding medical jargon, and using teach-back methods
(Rothman et al., 2004). These strategies can be used for
teaching self-care skills for a variety of diseases and con-
ditions in which individuals play a central role. In health
promotion, self-care is seen as empowering. When indi-
viduals are able to acquire self-care skills, they are better
able to participate in decisions affecting their own health
and in influencing conditions that manage their health
(Kickbush, 1989).
Health care providers need to promote informed
decision making and facilitate actions designed to
increase patient self-efficacy, particularly when self-
management is vital to maintaining or improving health.
By using the concept of health literacy to guide the
development of self-management skills, a solution to
the challenges faced by health systems in achieving
good health outcomes can be found (Levin-Zamir &
Peterburg, 2001). Thus, health literacy plays an optimal
role for aiding the improvement of health outcomes
and in addressing health disparities.
Health Disparities
Disparities are defined in Unequal Treatment: Con-
fronting Racial and Ethnic Disparities in Health Care as
differences that remain after taking into account patient
needs and preferences and the availability of health care
(IOM, 2003b). This landmark IOM report suggests several
approaches that the United States could take to eliminate
disparities. One approach is to increase awareness of
racial and ethnic disparities in health care among the gen-
eral public and key stakeholders, and implement patient
education programs to increase patients’ knowledge of
how to best access care and participate in treatment deci-
sions. Patient education programs in this approach should
be developed to include tools that make it easy for the
patient to understand the information.
Two other approaches that, if implemented, would
contribute to improving health literacy are the use of
interpretation services where community need exists
and the use of community health workers.
In addition to empowering patients, programs must
include tools to improve patient–provider communica-
tion. The IOM report recommends the development
and use of training programs that would increase
health care professionals’ awareness of disparities,
enhance patient–provider communication and trust,
and integrate cross-cultural education into the training
of all current and future health professionals.
A recent study identified key domains of cultural
competence from the perspective of ethnically and
334 HEALTH PROMOTION PRACTICE / July 2006
linguistically diverse patients. Using focus group research
methods, participants in 19 groups were asked the mean-
ing of culture, and what cultural factors influenced the
quality of their medical encounters. Patient-identified def-
initions of culture included value systems, customs, self-
identified ethnicity, nationality, and stereotypes. Factors
influencing the quality of medical encounters common to
all ethnic groups included sensitivity to complementary
and/or alternative medicine, health insurance–based
discrimination, social class–based, discrimination, ethnic
concordance of physician and patient, and age-based dis-
crimination. Physicians’ acceptance of the role of spiritu-
ality and of family, and ethnicity-based discrimination
were cultural factors specific to non-Whites. Language
issues and immigration status were Latino-specific fac-
tors (Napoles-Springer, Santoyo, Houston, Perez-Stable,
& Stewart, 2005).
Some health plans have begun to move toward sys-
tematically examining the quality of care for important
subgroups of their enrollees with chronic illnesses.
Furthermore, recognizing that measurement alone will
be insufficient to produce results, they are designing
and testing a variety of interventions to address the dis-
parities they have found. Although it is too soon to
know how successful these efforts will be, the studied
plans, which collectively cover 90 million people, are
consciously changing their systems of care.
>>CONCLUSION
It is important that key stakeholders are aware of
racial and ethnic disparities in health care and that
they recognize the role of patient–provider communi-
cation, self-management skills, and transdisciplinary
care in improving health literacy and in eliminating
disparities. In addition, the link between the cultural
competency skills of providers and health literacy has
been cited as a strategy for improving the knowledge,
attitudes and skills of health professionals. Policy
implications suggest the need for (a) reimbursement for
time spent to improve health literacy and patient edu-
cation, (b) support for training for transdisciplinary
teams, and (c) funding for demonstration programs that
promote self-management, development of health liter-
acy skills, and formation of transdisciplinary models.
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Johnston Lloyd et al. / TRANSDISCIPLINARY APPROACH 335
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 /PTB <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>
 /DAN <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>/NLD <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>
 /ESP <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>
 /SUO <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>
 /ITA <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>
 /NOR <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>
 /SVE <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>
 /ENU <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>
 >>
>> setdistillerparams
<<
 /HWResolution [2400 2400]
 /PageSize [612.000 792.000]
>> setpagedevice