Communication in Health Care: Considerations and strategies for successful consumer and team dialogue

Schwartz, Graphical Abstract

Abstract
The ability to communicate information and ideas effectively is increasingly recognized as critical to the success of the healthcare system. Effective communication is required not only for successful interactions between individuals and their health care providers but also between health care providers themselves. As research and best practice initiatives continue to grow, the need for researchers to effectively communicate with these groups is also important. However, there are many challenges inherent to health communication, including low health literacy, cultural diversity, contradicting/confusing health information as well as a lack of training for health care professionals in communicating with consumers. These challenges are further exacerbated by health care professionals who may lack the ability to communicate effectively across professions.

The health care system and science communication overall can be made more accessible to individuals using a range of strategies including critically reflecting on assumptions. In this article, several root causes of difficulty in communication will be discussed, and practical suggestions given to enable more effective communication of ideas between individuals with differing backgrounds in the health care system. For those working in health care and the sciences, an awareness of how best to enable effective communication presents important opportunities for the future.


Introduction
The ability to communicate ideas effectively is increasingly recognized as critical to the success of the healthcare system. Effective communication is required not only for successful interactions between individuals and their health care providers (1) but also between health care providers themselves. Similarly, effective communication of ideas is a critical competency required by the researcher who plans to successfully share information with members of the public and/or to collaborate with researchers from other disciplines. This article will explore some of the unique characteristics of communication both with consumers and between health care professionals.

Many points in the health care system require effective knowledge transfer between health care providers and consumers. Every day, individuals make decisions about health promotion and lifestyle that affect their overall well-being: e.g., what to eat, whether to exercise or smoke, among others. Consumers must also make decisions about different types of preventive care such as vaccinations and visits to the doctor. They must make sense of health and science reports they read in the media (e.g., Bisphenol A causing cancer? Vitamin D preventing multiple sclerosis?) and make decisions about whether to integrate new practices into their own lives. Effective transfer of knowledge also needs to occur between providers themselves in order to enable best outcomes for consumers.

Those who enter the formal health care system as patients must make even more decisions within a complex system that can be difficult for individuals to navigate (2). Within hospitals, they may be challenged to communicate with a large number of health care professionals and have to make difficult treatment decisions. The issue is compounded by shorter lengths of stay and increasing incidence of chronic disease and multiple disorders requiring consumers to manage their own care at home, often with minimal support from health care providers. The need for health care professionals and researchers to effectively communicate with consumers will only grow in its urgency. In Ontario alone, almost 80% of people over the age of 45 have a chronic condition. Of those, approximately 70% suffer from two or more chronic conditions (3). Those managing their own care need effective health information and education to know how to do so (4). For example, managing diet, checking blood pressure and managing insulin may be among health related tasks needing to be performed daily within the home setting. There are many challenges inherent to health communication contributing to the difficulty in communication, including low health literacy, cultural diversity, contradicting/confusing health information, lack of training for health care professionals in communicating with consumers and ineffective communication across professions (e.g. therapists, nurses, doctors, etc.) (5).

Low Health Literacy
More than half of Canadians have difficulty understanding and using health information (6). Sixty percent have low levels of health literacy, defined as the skills required to access and use health information to make vital health care decisions and maintain basic health (6). Canadians with the lowest health-literacy skills were found to be more than 2.5 times likely to be in fair or poor health and to be receiving income support, than those with higher skill levels (6). This is a major concern as those with low health literacy are less likely to understand oral and written information (such as appointment reminder cards), medical terminology (e.g., “hypertension”), follow medication instructions (e.g., “take two pills twice a day until finished”) and accurately report medical histories (7). In the United States, the estimated cost of low health literacy is between $106 and $236 billion USD (8). There is little data on the estimated cost in Canada, but the astronomical cost faced in the US is an indicator of the potential burden that low health literacy can place on the Canadian system.

Health literacy is related to functional literacy, which is also a concern in Canada. Almost half of Canadians have low functional literacy, the reading and writing skills needed to cope with the demands of everyday life. Forty-two percent of adult Canadians aged 16 to 65 scored at the two lowest levels of literacy (9). Those over 65 years performed significantly lower, as did immigrants to Canada. However, even those with average literacy may face difficulties when encountering unfamiliar types of material or texts (2), or information requiring problem-solving or interpretation, such as instructions on missed birth control pills (10). It is therefore important to use best practice communication strategies to address these challenges.

Cultural Diversity
In a culturally diverse society, challenges to health and functional literacy are only exacerbated. Barriers to accessing information are widely reported among minority groups, often resulting in less participation in health promotion and inefficient utilization of the health care system (11). Not surprisingly, educational resources also often fall short of reaching people from cultural minorities (11); for example, information on diet and nutrition is often reflective of a Western diet and does not include staples from other cultures, such as tortillas. Colors, as another example, can also play a role on how people of different cultures respond to information if it conveys certain meaning to them. For instance, in many western cultures, red is used as a symbol for caution or stopping, as in stop signs and traffic signals. In some Eastern cultures, red is a sign of prosperity and happiness, often worn by brides in weddings. In a health care context, red used as a warning symbol may be overlooked by those who are not accustomed to the Western symbolism of the color.

Language and translation alone play a small part in this problem. Cultural competency includes more than interpreting or translating information or even knowing information about a specific culture; rather, it requires the ability to identify and relate to how culture is reflected in each individual’s understanding of their health, condition and/or required behavioral change (12). Without a shared understanding of health, agreeing on behaviors, such as limiting historically and culturally traditional dietary staples that are proving detrimental to an effective course of care can be particularly challenging.

Contradictory and Confusing Information
Despite these challenges, consumers are avidly seeking out health information. The average Canadian uses 6 different sources of health-related information. Among Canadians, the most popular sources are family physicians (73%) and other health care professionals (69%) (13). While Canadians report that they are able to find relevant information, more than half report finding contradictory information from different sources and one-third report that people don’t have time to answer their questions (14). The use of online information is also growing significantly; 61% of adults now look for health information online (15). Unfortunately, even online information may not be meeting the needs of Canadians with low literacy, as studies have demonstrated that consumer health information is often written at high reading levels and may contain medical jargon (16).

Lack of Communication Training for Health Care Professionals
Despite the important roles health literacy and patient communication play in the effectiveness of health care overall, there are few requirements to teach information on health literacy in professional schools. The topic of patient communication rarely systematically addresses this important area in schools of medicine, public health, nursing, dentistry, or pharmacy (2). In practice, health care professionals may not know how to address the challenges of effectively communicating with consumers. For example, a survey of nearly 700 professionals and policymakers found low levels of awareness of strategies to lower literacy demands and promote health literacy skills (17).

Exploration of the effectiveness of communication between health care professionals themselves (interprofessional communication) offers additional insights into communication challenges and opportunities. Interprofessional communication is critical to enabling the effectiveness of the health care system as the costs associated with ineffective communication between heath care professionals are very high. For example, ineffective communication between providers has been linked to issues of patient safety, medical error (18), low patient satisfaction and complaints by patients and caregivers (5).

Challenges currently faced in interprofessional communication can be related to the development of language specific to each profession. This can pose challenges for communication across professions if providers are unable to understand or lack a shared understanding of key acronyms, jargon and concepts. These challenges are then exacerbated when providers make assumptions about other professionals’ comprehension, meanings they attribute to situations, values, beliefs, behaviors, etc.

Skills that enable communication between health care professionals traditionally are not taught to students (1). Yet there is evidence that this is changing through the growth of interprofessional education efforts and the identification of interprofessional communication as a critical core competency needing to be addressed in health studies curricula (19). Interprofessional education occurs when learners from two or more professions learn about, from and with each other, to enable effective collaboration and improve health outcomes (20). Further, consideration of how to support student learning between health care professionals and potentially biomedical students is starting to be addressed (21).

Steps to Address the Barriers
For those working in health care or the sciences, these challenges present important opportunities for future practice. Increasingly, the need for those working in the sciences to be understood by consumers and other professionals requires the use of effective communication. For example, obtaining informed consent and designing research participant materials, communicating with the media and potential donors and speaking with individuals in other fields are areas where improved communication may be required. The health care system and science communication overall can be made more accessible to individuals using several communication strategies.

Challenge Assumptions
Although some factors (age, income, language) can predict low literacy and health literacy, many individuals with average or high skills are still challenged to interpret health information (22). Several methods can assist with identifying when individuals may need more assistance understanding information and to challenge assumptions made about others (e.g., how well an individual understands health related information).

Effective Teaching
Communication techniques known to improve understanding include engaging consumers in their role in health care and promoting shared decision making, reviewing information with them (especially written materials), and encouraging questions and discussion (23).

Another important method is the ‘teach-back’ or ‘show-back’ technique, in which the provider asks the consumer to teach back the information from the health care encounter in different words. This allows the provider to assess and ensure consumer comprehension in a more thorough manner than asking ‘Do you understand?’ This can be especially important in encounters where informed consent is sought and it is imperative the consumer has a clear understanding of the risks and benefits. Those communicating between different professions can also benefit from using these strategies.

Literacy Screening
There are several standardized tests that can be used to evaluate literacy and health such as the TOFHLA (Test of Functional Health Literacy in Adults) and the Rapid Assessment of Adult Literacy in Medicine (24). However, these tests take between 3-12 minutes on average to administer, which can be cumbersome. In addition, they can contribute to the feelings of shame and embarrassment associated with low literacy and health literacy.

Several single item literacy screening questions appear effective in identifying literacy and health literacy skills (25). One question, ’How confident are you filling out medical forms by yourself?’ was more accurate at identifying low health literacy than other questions tested, more so even than questions based on demographic characteristics. Based on the comfort level identified, marginal health literacy and functional literacy can be predicted. A question that focuses on comfort level with medical forms also removes the focus from the patient’s literacy level. Thus, using a single question screening may be a time-efficient way to determine which patients need additional probing or information.

Cultural Competency
The inability to provide culturally sensitive health information to minority populations has most certainly contributed to disparities in health care (12). It is imperative that health care providers understand the meaning consumers place on health and wellness, rather than assuming that the dominant Western medical model is shared. Taking the time to ask open-ended questions can reveal the underlying beliefs and assumptions that a consumer holds, which will allow the communicator to target information and education accordingly.

The Kleinman questions (26) provide eight questions that can be used in practice to identify personal meaning for health and wellness (12). They include:

  1. What do you think caused the problem?
  2. Why do you think it happened when it did?
  3. What do you think your sickness does to you? How does it work?
  4. How severe is your sickness? Will it have a short course?
  5. What kind of treatment do you think you should receive?
  6. What are the most important results you hope to receive from this treatment?
  7. What are the chief problems your sick ness has caused for you?
  8. What do you fear most about your sickness?

Incorporating these questions into general discussion, history taking or other opportunities in a health exchange can provide a wealth of information for all recipients of health information.

Similarly, professionals also need to reflect critically on assumptions they hold about others; McKee (27) suggests professionals may benefit from asking questions such as:

  • What assumptions am I making about this profession? What can I learn from them?
  • What values orient me in my profession? In other professions?
  • How might someone in another profession understand this?
  • How is my professional role both enabling and limiting my understanding?

Be Aware of Jargon and Language
The use of terminology particular to a discipline/profession can significantly impede understanding between professions and between a provider and consumer. Jargon and complex language can also have the effect of making consumers feel ashamed or inadequate (23). Awareness of one’s own language enables one to recognize that others may not share the same understanding of a key concept or word. For example, the term ‘transfer’ can have different meanings in health care. For some professions, it may mean moving from the bed to the wheelchair; however for others it may refer to the process of referral from one hospital to another. Recognizing one’s own use of jargon, requesting clarification from colleagues when unclear terminology is used and using jargon-free language where possible are important first steps in enabling effective communication.

Make it Meaningful
Careful consideration of how to communicate most effectively to audiences with varying needs underpins the translation of research findings into practice (28). It is important to consider what will be most meaningful to the recipient in terms of both how the information is shared (e.g., does this audience respond best to online dissemination?) and the content itself. Instead of solely asking, ‘what key messages do I want to share?’ consider ‘what information would be most meaningful to this audience?’ or ‘what real life examples might help this audience relate well to this information?’

Summary: Opportunities for More Effective Communication
The ability to successfully communicate ideas to individuals with differing roles, abilities and priorities is recognized as an enabler to the effectiveness of healthcare overall. Currently, health care practice and education fall short of equipping providers and consumers with the abilities to effectively communicate with each other. Health care professionals and researchers have an opportunity to improve practice by improving communication efforts with consumers and with each other. However, many continue to practice under the assumption these trends do not apply to their consumer groups, or that they are effective communicators despite the absence of specific training, effort and feedback.

Fortunately, there are strategies to promote more effective communication that everyone can use including: awareness of jargon, consideration of how to make information most meaningful and challenging one’s own assumptions. As with the development and refinement of other skills, building one’s awareness, searching for opportunities to put strategies into practice and asking for feedback are key first steps to building on competence in the area.

References

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