Journal of Immigrant and Minority Health

, Volume 11, Issue 6, pp 460–467 | Cite as

The Role of Culture in Health Literacy and Chronic Disease Screening and Management

  • Susan J. Shaw
  • Cristina Huebner
  • Julie Armin
  • Katherine Orzech
  • James Vivian
Original Paper


Cultural and language differences and socioeconomic status interact with and contribute to low health literacy, defined as the inability to understand or act on medical/therapeutic instructions. Health literacy is increasingly recognized as an important factor in patient compliance, cancer screening utilization, and chronic disease outcomes. Commendable efforts have been initiated by the American Medical Association and other organizations to address low health literacy among patients. Less work has been done, however, to place health literacy in the broader context of socioeconomic and cultural differences among patients and providers that hinder communication and compliance. This review examines cultural influences on health literacy, cancer screening and chronic disease outcomes. We argue that cultural beliefs around health and illness contribute to an individual’s ability to understand and act on a health care provider’s instructions. This paper proposes key aspects of the intersection between health literacy and culturally varying beliefs about health which merit further exploration.


Culture Health literacy Cancer screening Diabetes Hypertension 



This research was supported in part by grant number 1 R03 HS014086 from the Agency for Healthcare Research and Quality and by grant number R01 CA128455-01 from the National Cancer Institute.


  1. 1.
    Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503–9.CrossRefGoogle Scholar
  2. 2.
    Weiss BD, Hart G, McGee DL, et al. Health status of illiterate adults: relationship between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1994;5(3):257–64.Google Scholar
  3. 3.
    Nelson Jr MD. Socioeconomic status and childhood mortality in North Carolina. Am J Public Health. 1992;82:1131–3.CrossRefPubMedGoogle Scholar
  4. 4.
    Gregg EW, Geiss LS, Saaddine J, Fagot-Campagna A, et al. Use of diabetes preventive care and complications risk in two African-American communities. Am J Prev Med. 2001;21(3):197–202.CrossRefPubMedGoogle Scholar
  5. 5.
    Davis TC, Michielutte R, Askov EN, Williams MV, Weiss BD. Practical assessment of adult literacy in health care. Health Educ Behav. 1998;25(5):613–24.CrossRefPubMedGoogle Scholar
  6. 6.
    Wilson FL. Are patient information materials too difficult to read? Home Healthc Nurse. 2000;18(2):107–15.CrossRefPubMedGoogle Scholar
  7. 7.
    Gausman Benson J, Forman WB. Comprehension of written health care information in an affluent geriatric retirement community: use of the Test of Functional Health Literacy. Gerontology. 2002;48(2):93–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients with low health literacy. J Gen Intern Med. 1999;14(5):315–7.CrossRefGoogle Scholar
  9. 9.
    Jecker N, Carrese J, Pearlman R. Caring for patients in cross-cultural settings. Hastings Cent Rep. 1995;25:6–14.PubMedGoogle Scholar
  10. 10.
    Uppaluri CR, Schumm LP, Lauderdale DS. Self-reports of stress in Asian immigrants: effects of ethnicity and acculturation. Ethn Dis. 2001;11(1):107–14.PubMedGoogle Scholar
  11. 11.
    Schoenberg NE, Drew EM. Articulating silences: experiential and biomedical constructions of hypertension symptomatology. Med Anthropol Q. 2002;16(4):458–75.CrossRefPubMedGoogle Scholar
  12. 12.
    Davidhizar R, Havens R, Bechtel GA. Assessing culturally diverse pediatric clients. Pediatr Nurs. 1999;25(4):371–6.PubMedGoogle Scholar
  13. 13.
    Penchaszadeh VB. Genetic counseling issues in Latinos. Genet Test. 2001;5(3):193–200.CrossRefPubMedGoogle Scholar
  14. 14.
    Hawthorne K. Effect of culturally appropriate health education on glycaemic control and knowledge of diabetes in British Pakistani women with type 2 diabetes mellitus. Health Educ Res. 2001;16(3):373–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Watson MR, Horowitz AM, Garcia I, Canto MT. A community participatory oral health promotion program in an inner-city Latino community. J Public Health Dent. 2001;61(1):34–41.CrossRefPubMedGoogle Scholar
  16. 16.
    Alcalay R, Alvarado M, Balcazar H, Newman E, Huerta E. Salud para su Corazon: a community-based Latino cardiovascular disease prevention and outreach model. J Community Health. 1999;24(5):359–79.CrossRefPubMedGoogle Scholar
  17. 17.
    Ortega AN, Calderon JG. Pediatric asthma among minority populations. Curr Opin Pediatr. 2000;12(6):579–83.CrossRefPubMedGoogle Scholar
  18. 18.
    Fortier JP, Bishop D. Setting the agenda for research on cultural competence in health care: final report. Brach C, editor. Rockville, MD: U.S. Department of Health and Human Services, Office of Minority Health and Agency for Healthcare Research and Quality; 2004.Google Scholar
  19. 19.
    Anderson LM, Scrimbshaw S, Fullilove M, Fielding JE, Normand J, the Task Force on Community Preventive Services. Culturally competent healthcare systems: a systematic review. Am J Prev Med. 2003;24(3S):68–79.CrossRefPubMedGoogle Scholar
  20. 20.
    Shaffer CF. Factors influencing the access to prenatal care by Hispanic pregnant women. J Am Acad Nurse Pract. 2002;14(2):93–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Davidson B. Questions in cross-linguistic medical encounters: the role of the hospital interpreter. Anthropol Q. 2001;10(2):170–8.CrossRefGoogle Scholar
  22. 22.
    Brach C, Fraserirector I. Can cultural competence reduce racial and ethnic health disparities? Med Care Res Rev. 2000;57(suppl1):1181–217.Google Scholar
  23. 23.
    Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275(10):783–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Elderkin-Thompson V, Silver RC, Waitzkin H. When nurses double as interpreters: A study of Spanish-speaking patients in a U.S. primary care setting. Soc Sci Med. 2001;52(9):1343–58.CrossRefPubMedGoogle Scholar
  25. 25.
    Bonacruz Kazzi G, Cooper C. Barriers to the use of interpreters in emergency room pediatric consultations. J Paediatr Child Health. 2003;39(4):259–63.CrossRefPubMedGoogle Scholar
  26. 26.
    Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14(2):82–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Shaw S. The politics of recognition in culturally appropriate care. Med Anthropol Q. 2005;19(3):290–309.CrossRefPubMedGoogle Scholar
  28. 28.
    Tucker CM, Herman KC, Pedersen TR, Higley B, Montrichard M, Ivery P. Cultural sensitivity in physician-patient relationships: Perspectives of an ethnically diverse sample of low-income patients. Med Care. 2003;41(7):859–70.CrossRefPubMedGoogle Scholar
  29. 29.
    Grossman SA, Piantadosi S, Covahey C. Are informed consent forms that describe clinical oncology research protocols readable by most patients and their families? J Clin Oncol. 1994;12(10):2211–5.PubMedGoogle Scholar
  30. 30.
    Barrett B, Shadick K, Schilling R, Spencer L, et al. Hmong/medicine interactions: Improving cross-cultural health care. Fam Med. 1998;30(3):179–84.PubMedGoogle Scholar
  31. 31.
    Schillinger D, Bindman A, Wang F, et al. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Educ Couns. 2004;52(3):315–23.CrossRefPubMedGoogle Scholar
  32. 32.
    Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.CrossRefPubMedGoogle Scholar
  33. 33.
    Roter DL, Rudd RE, Comings J. Patient literacy: a barrier to quality of care. J Gen Intern Med. 1998;13:850–1.CrossRefPubMedGoogle Scholar
  34. 34.
    Benjamin-Garner R, Oakes JM, Meischke H, Meshack A, et al. Sociodemographic differences in exposure to health information. Ethn Dis. 2002;12(1):124–34.PubMedGoogle Scholar
  35. 35.
    Watson J, Obersteller EA, Rennie L, Whitbread C. Diabetic foot care: developing culturally appropriate educational tools for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Australia. Aust J Rural Health. 2001;9(3):121–6.CrossRefPubMedGoogle Scholar
  36. 36.
    Griffin JA, Gilliland SS, Perez G, Helitzer D, Carter JS. Participant satisfaction with a culturally appropriate diabetes education program: The Native American Diabetes Project. Diabetes Educ. 1999;25(3):351–63.CrossRefPubMedGoogle Scholar
  37. 37.
    Ikeda JP, Pham L, Nguyen KP, Mitchell RA. Culturally relevant nutrition education improves dietary quality among WIC-eligible Vietnamese immigrants. J Nutr Educ Behav. 2002;34(3):151–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Hoang G, Erickson R. Cultural barriers to effective medical care among Indochinese patients. Ann Rev Med. 1985;36:229–39.CrossRefPubMedGoogle Scholar
  39. 39.
    Lannin DR et al. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. JAMA. 1998;279(2):1801–7.CrossRefPubMedGoogle Scholar
  40. 40.
    McDonald JT, Kennedy S. Cervical cancer screening by immigrant and minority women in Canada. J Immigr Minor Health. 2007;9:323–34.CrossRefPubMedGoogle Scholar
  41. 41.
    Pobutsky AM, Pordell P, Yamashita B, et al. Community based participatory approaches to address health disparities in Hawai’i: Recent applications in cancer prevention, detection and treatment programs. Pac Health Dialog. 2004;11(2):183–90.PubMedGoogle Scholar
  42. 42.
    Davis T, Arnold C, Berkel H, et al. Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer. 1996;78:1912–20.CrossRefPubMedGoogle Scholar
  43. 43.
    Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20):1585–92.CrossRefPubMedGoogle Scholar
  44. 44.
    Meiser B, Eisenbruch M, Barlow-Stewart K, et al. Cultural aspects of cancer genetics: setting a research agenda. J Med Genet. 2001;38(7):425–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Boyer LE, Williams M, Callister LC, Marshall ES. Hispanic women’s perceptions regarding cervical cancer screening. J Obstet Gynecol Neonatal Nurs. 2001;30(2):240–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Davis TC, Dolan NC, Ferreira MR, et al. The role of inadequate health literacy skills in colorectal cancer screening. Cancer Invest. 2001;19(2):193–200.CrossRefPubMedGoogle Scholar
  47. 47.
    Chavez LR, et al. Structure and meaning in models of breast and cervical cancer risk factors: a comparison of perceptions among Latinas, Anglo women, and physicians. Med Anthropol Q. 1995;9(1):40–74.CrossRefPubMedGoogle Scholar
  48. 48.
    Chavez LR, McMullin JM, Mishra SI, Hubbell FA. Beliefs matter: cultural beliefs and the use of cervical cancer-screening tests. Am Anthropol. 2001;103(4):1114–29.CrossRefGoogle Scholar
  49. 49.
    Paisley JA, et al. An examination of cancer risk beliefs among adults from Toronto’s Somali, Chinese, Russian and Spanish-speaking communities. Rev Can Sante Publique. 2002;93(2):138–41.Google Scholar
  50. 50.
    Juon HS, Choi Y, Kim MT. Cancer screening behaviors among Korean-American women. Cancer Detect Prev. 2000;24(6):589–601.PubMedGoogle Scholar
  51. 51.
    Collins KF. International students’ perceptions of health care. J Sch Nurs. 2001;17(3):140–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Fadiman A. The spirit catches you and you fall down: a Hmong girl, her American doctors and the collision of two cultures. New York: Farrar Straus and Giroux; 1997.Google Scholar
  53. 53.
    Gomez-Beloz A, Chavez N. The botanica as a culturally appropriate health care option for Latinos. J Altern Complement Med. 2001;7(5):537–46.CrossRefPubMedGoogle Scholar
  54. 54.
    Ries A, Picchi M, Nguyen L, et al. Asthma in a Vietnamese refugee population. Am J Respir Crit Care Med. 1997;155:1895–901.PubMedGoogle Scholar
  55. 55.
    Pachter L, Cloutier M, Berstein B. Ethnomedical (folk) remedies for childhood asthma in a mainland Puerto Rican community. Arch Pediatr Adolesc Med. 1995;149:982–8.PubMedGoogle Scholar
  56. 56.
    Guarnaccia P, Pelto P, Schensul S. Family health culture, ethnicity, and asthma: coping with illness. Med Anthropol. 1985;9(3):203–24.PubMedCrossRefGoogle Scholar
  57. 57.
    Ito K. Health culture and the clinical encounter: Vietnamese refugees’ responses to preventive drug treatment of inactive tuberculosis. Med Anthropol Q. 1999;13(3):338–64.CrossRefPubMedGoogle Scholar
  58. 58.
    Tedeschi A, Barcella M, Bo GA, Miadonna A. Onset of allergy and asthma symptoms in extra-European immigrants to Milan, Italy: possible role of environmental factors. Clin Exp Allergy. 2003;33(4):449–54.CrossRefPubMedGoogle Scholar
  59. 59.
    Arcia E, Skinner M, Bailey D, Correa V. Models of acculturation and health behaviors among Latino immigrants in the U.S. Soc Sci Med. 2001;53(1):41–53.CrossRefPubMedGoogle Scholar
  60. 60.
    Coonrod DV, Bay RC, Balcazar H. Ethnicity, acculturation and obstetric outcomes: Different risk factor profiles in low- and high-acculturation Hispanics and in white non-Hispanics. J Reprod Med. 2004;49(1):17–22.PubMedGoogle Scholar
  61. 61.
    Mendoza FS. Health risk profiles and race, culture, and socioeconomic status. In: Pachter LM, editor. Child health in the multicultural environment. Columbus, OH: Ross Products Division, Abbott Laboratories; 2000. p. 5–18.Google Scholar
  62. 62.
    Zambrana RE, Scrimshaw S, Collins N. Prenatal health behaviors and psychosocial risk factors in pregnant women of Mexican origin: the role of acculturation. Am J Public Health. 1997;87:1022–6.CrossRefPubMedGoogle Scholar
  63. 63.
    Kleinman A. Concepts and a model for the comparison of medical systems as cultural systems. Soc Sci Med. 1978;12:85–93.PubMedGoogle Scholar
  64. 64.
    Kendall C, Foote D, Martorell R. Ethnomedicine and oral rehydration therapy: a case study of ethnomedical investigation and program planning. In: Brown P, editor. Understanding and applying medical anthropology. Mountain View, CA: Mayfield Publishing Co.; 1998. p. 415–22.Google Scholar
  65. 65.
    Pearce TO. Lay medical knowledge in an African context. In: Lindenbaum S, Lock M, editors. Knowledge, power and practice: the anthropology of medicine and everyday life. Berkeley: University of California Press; 1993. p. 150–65.Google Scholar
  66. 66.
    Pachter LM, Weller SC, Baer RD, et al. Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans. J Asthma. 2002;39(2):119–34.CrossRefPubMedGoogle Scholar
  67. 67.
    Becker G, Beyene Y, Newsom E, Rodgers D. Knowledge and care of chronic illness in three ethnic minority groups. Fam Med. 1998;30(3):173–8.PubMedGoogle Scholar
  68. 68.
    Heurtin-Roberts S, Becker G. Anthropological perspectives on chronic illness: Introduction. Soc Sci Med. 1993;37:281–3.CrossRefPubMedGoogle Scholar
  69. 69.
    Lambert H, Sevak L. Is ‘cultural difference’ a useful concept? In: Kelleher D, Hiller S, editors. Researching cultural differences in health. London: Routledge; 1996. p. 124–59.Google Scholar
  70. 70.
    Michaud P, Blum R, Slap G. Cross-cultural surveys of adolescent health and behavior: progress and problems. Soc Sci Med. 2001;53(9):1237–46.CrossRefPubMedGoogle Scholar
  71. 71.
    Weinick RM, Jacobs EA, Stone LC, et al. Hispanic healthcare disparities: Challenging the myth of a monolithic Hispanic population. Med Care. 2004;42(4):313–20.CrossRefPubMedGoogle Scholar
  72. 72.
    Goodman A. Bred in the bone? Sciences. 1998;37:20–25.Google Scholar
  73. 73.
    Krieger N. Does racism harm health? Did child abuse exist before 1982? On explicit questions, critical science and current controversies: an ecosocial perspective. Am J Public Health. 2003;93(2):194–99.CrossRefPubMedGoogle Scholar
  74. 74.
    Schillinger D, Chen AH. Literacy and language: disentangling measures of access, utilization and quality. J Gen Intern Med. 2004;19:288–300.CrossRefPubMedGoogle Scholar
  75. 75.
    Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475–82.CrossRefPubMedGoogle Scholar
  76. 76.
    Miller LG, Liu H, Hays RD, Golin CE, Ye Z, Beck CK, et al. Knowledge of antiretroviral regimen dosing and adherence: a longitudinal study. Clin Infect Dis. 2003;36(4):513–8.CrossRefGoogle Scholar
  77. 77.
    Heurtin-Roberts S, Reisin E. The relation of culturally influenced lay models of hypertension to compliance with treatment. Am J Hypertens. 1992;5(11):787–92.PubMedGoogle Scholar
  78. 78.
    Roubideaux YD, Moore K, Avery C, et al. Diabetes education materials: recommendations of tribal leaders, Indian health professionals, and American Indian community members. Diabetes Educ. 2000;26(2):290–4.CrossRefPubMedGoogle Scholar
  79. 79.
    Mull DS, Nguyen N, Mull JD. Vietnamese diabetic patients and their physicians: What ethnography can teach us. West J Med. 2001;175(5):307–11.CrossRefPubMedGoogle Scholar
  80. 80.
    Rosal MC, Goins KV, Carbone ET, Cortes DE. Views and preferences of low-literate Hispanics regarding diabetes education: results of formative research. Health Educ Behav. 2004;31(3):388–405.CrossRefPubMedGoogle Scholar
  81. 81.
    Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267–75.CrossRefPubMedGoogle Scholar
  82. 82.
    Lutfey KE, Wishner WJ. Beyond ‘compliance’ is ‘adherence’: improving the prospect of diabetes care. Diabetes Care. 1999;22(4):635–9.CrossRefPubMedGoogle Scholar
  83. 83.
    Samuel-Hodge CD, Headen SW, Skelly AH, et al. Influences on day-to-day self-management of type 2 diabetes among African-American women: Spirituality, the multi-caregiver role, and other social context factors. Diabetes Care. 2000;23(7):928–33.CrossRefPubMedGoogle Scholar
  84. 84.
    von Goeler DS, Rosal MC, Ockene JK, et al. Self-management of type 2 diabetes: a survey of low-income urban Puerto Ricans. Diabetes Educ. 2003;29(4):663–72.CrossRefGoogle Scholar
  85. 85.
    Becker G. Effects of being uninsured on ethnic minorities’ management of chronic illness. West J Med. 2001;185:19–23.CrossRefGoogle Scholar
  86. 86.
    Plescia M, Groblewski M. A community-oriented primary care demonstration project: refining interventions for cardiovascular disease and diabetes. Ann Fam Med. 2004;2(2):103–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Susan J. Shaw
    • 1
  • Cristina Huebner
    • 2
  • Julie Armin
    • 1
  • Katherine Orzech
    • 1
  • James Vivian
    • 3
  1. 1.Department of AnthropologyUniversity of ArizonaTucsonUSA
  2. 2.Research DepartmentCaring Health CenterSpringfieldUSA
  3. 3.Department of PsychologyUniversity of HartfordHartfordUSA

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