Health Literacy and Health Professionals: Open the Door of Communication for Better Outcomes

Inadequate health literacy is pervasive in all segments of society. Communication improves the mission of health professional and open the door for better health outcomes

Health literacy is a relatively new concept and a complex phenomenon with critical importance in the health field. The term has been used in the health literature for at least five decades [1] responding to society changes and the growing demand for healthcare services.

Its concept is not consensual. Different perspectives have emerged, depending on the context and desired aim, reflecting this way, the complexity of its construct, and stationary and dynamic character. From the 90’s the concept arose from the interest between illiteracy and health conditions derived from clinical care and public health, with a major relevance on the latter, within the range of health promotion and education [2].

Health literacy is closely related to literacy and numeracy, health promotion and education, informational communication, and sociocultural features, being considered among others, one of the health literacy crucial indicators [3-4].

Traditionally it referred to literacy and numeracy skills and knowledge, such as reading, writing, speaking, listening and numeracy, basic skills to be able to function effectively in everyday situations, but necessary competences for the health literacy, to understanding health information, communication and on how to use the health system provide by health care entities [5].

Health literacy involves cognitive, psychological and behavioral components such as people’s knowledge, motivation and skills. These behaviors allow access, processing, understanding and use of health information and navigability in the health system.

These dimensions allow people to be able to make assessments and make decisions in everyday life about health care, disease prevention and health promotion

The goal of health literacy is to maintain or improve quality of life throughout the life cycle [4]. Health literacy integrates other skills such as health knowledge, health-related experience, health beliefs, the ability of motivation and self-motivation, self-efficacy that enables the ability to act and decision-making about health. Health literacy integrates other skills such as health knowledge, health-related experience, health beliefs, the ability of motivation and self-motivation, self-efficacy that enables the ability to act and decision-making about health

Health literacy depends mainly of basic skills literacy and its improvement isn´t only related with an increase in the transmission of information but moreover with the development of competencies that are fundamental for the empowerment of individuals [6].

Also, Sorensen and colleagues [4] advocate that health literacy “is an asset for improving people`s empowerment within the domains of healthcare, disease prevention and health promotion”, and in turn, the health literacy “influence the health behaviour, the use of health service, and thereby will also impact of health outcomes and on the health cost in society [4].

One of the first to describe the concept of empowerment defined it in the easiest way – in its absence – powerlessness and loss of sense of control [7]. This concept defined positively makes it more difficult as it is different for each person and context [7].

Empowerment has become a widely used concept in healthcare but is difficult to define. Findings about the defined attributes of this concept are consistent with the principles of patient centred care, where the healthcare providers adopt a partnership with patients that is respectful and supports informed patient decision-making [8]. Chew, Bradley and Boyko [9] and Parikh and colleagues [10] says that obstacles to routine screening patient health literacy exist, because patients are often ashamed of their low health literacy.

In the field of health education, it is accepted that empowerment is simultaneously an intra and interpersonal process that refers to strengthen individuals’ capacity to control their own health [11]. As an interpersonal process it relies heavily on communication between the provider and patient.

Communication is a process of information exchange, either through writing or speaking. It should be clear, easy to interpret, simple language, organized in order to highlight the main objective of the information and suitable to the person or the target population without neglecting the socio-cultural characteristics. Motivation, problem solving, self-efficacy [12] and knowledge and skills [4] also influence self-care [13] but all these components in the therapeutic relationship are based on communication. Even if the doctor is in silence, he/she stills communicating.

Centred in the consultation, Pendleton [14] suggests that the communication process is a dynamic “care cycle” and an interaction in which patients’ understanding and ability to manage their own health are enhanced at each consultation, influenced by specific factors. For Pendleton [14] the biggest problem that health professionals face is the consistency of the application of physician knowledge” [14].

The communication strategies that health professionals use can lead to improved health literacy if they are used within an empowering approach

Little research has been done around health professionals’ knowledge and understandings of health literacy and strategies to improve it

Studies on health literacy are still recent. There are some reference studies such as the European Health Literacy Questionnaire organized by the Sorensen group and colleagues [4] but given that the subject is also recent in international research (it started with just a brief reference from Simonds in education and research to social policies) and it continues to be very useful to a continuous thinking about this construct, which allows, with some evidence, to change behaviors.

This study aimed to explore the health professionals’ perceptions of strategies to increase health literacy on patients

An exploratory study was conducted comprising 5 focus group with key health professionals, with expertise on health literacy (N = 30) composed by medical doctors and nurses, to explore the health professionals’ perception of communication to increase health literacy on patients. Data were analyzed using qualitative methods with content analysis and individual profound interviews

The focus group was based on a semi-structured script, with five areas focusing on the importance of communication skills and the communicational process within the therapeutic relationship. The 5-focus group were transcribed and data was analyzed using content analysis.

Data was collected from March 2017 to July 2018. The discussion was audio recorded. The guide of the discussion had four sections: 1 - Therapeutic relationship; 2 - Contribution of communication skills to the success of the therapeutic relationship and to the increase of health literacy; 3 - The importance of the contribution of communication skills to the success of the therapeutic relationship and for the increase of health literacy; 4 Which communication skills they consider most crucial for the success of the therapeutic relationship and for the increase of health literacy.

The specialists were selected through the database of health professionals who attended post-graduate training in Communication and Health Literacy, and one post graduate course of Health literacy, and for their active intervention in the fields of Health Literacy as consultants. After being identified, they were invited by convenience and by e- mail and telephone, having all answered affirmatively and participated in the focus group.

Professional activities are related to the various health areas, namely: oncology, dental medicine, rehabilitation nursing, pediatric rehabilitation, sterilization. All experts have already had extensive experience in the field and direct contact with patients.

The contribution of communication skills to the success of the therapeutic relationship and to the increase in health literacy was discussed. The results obtained express the perception of these experts they resulted from the cognitive evaluation of these specialists on the subjects in question. The main goal of this study it’s to understand the perception of health professionals about the importance of communication competences in the therapeutic relationship.

Participants were asked to define the therapeutic relationship, and if they would have another suggestion for the classification of the relationship between the health professional and the patient. This question aimed at confirming or re-adjusting the researcher’s definition of the meaning of the therapeutic relationship, since there are multiple definitions, and the concept is somewhat appropriate by psychoanalytic theory [15] which specifies that presence has a vital role in developing a healing environment and a safe and intimate therapeutic relationship [16].

According the opinion of participants on the Focus Group, the therapeutic relationship is approached as a collaborative and interpersonal relationship between professional and patient, in a given space, time and context, aimed at enhancing and empowering the person, to understand and be able to adhere, if possible, autonomously, to health instructions, in order to achieve the best health outcomes

The RNAO - Registered Nurses Association of Ontario [17] devotes a complete guide to the subject of therapeutic adherence, stressing the importance of the communicational aspects of the professional and patient interaction, which professionals must understand and be able to recognize the phase where the therapeutic relationship is found. If information is important in the process of individual therapeutic adherence, “building health literacy is more than providing health information” [18].

The groups of experts unanimous in affirming that effective therapeutic relationships need to be build, in health, daily and in a given context. The guidelines in health communication were considered useful and important in a previous training. Some studies recommend the inclusion of formal communication skills training in curriculum and medical practice [19].

Clinical practice guidelines are procedures, ideas, integrating records, multiple interventions and decisions that are systematically developed to support health care professional and patient decisions appropriate to specific clinical circumstances [20] [21].

In a study organized by Chew and colleagues [9] with 332 patients scheduled for a preoperative visit showed prevalence rates of inadequate and marginal health literacy measured by the STOFHLA.

Even in non-stressful clinical meetings, patients are still reluctant to admit any lack of understanding and feel compelled to follow the recommendations as they see fit, rather than asking for clarification [22]. Studies on communication/interaction and health literacy remain limited [23] and there is no consensus in health professions as to the nature of communication skills [24].

All the groups considered also that therapeutic relationships must be empathic, available, with active listening, which often presupposes the need for silence and other non-verbal aspects, with positive reinforcement of the patient’s action, between the health professional, who possesses technical and communicational skills, and the patient, to his/her state of fragility in varying degrees. Greenfield, Kaplan and Ware [25] and Roter and Hall [26] validated that patients are more active and participative if they are satisfied with their health care, and Street and Millay [27] says that satisfied patients have a greater sense of control over their lives and have a better health experience after consultation.

Effective communication in both directions, dialogical, with a dose of humanization that involves technical skills, but also social and relational skills are also fundamental in the opinion of the group of experts. Stewarts et al. (1979) says that 54% of patient’s complaints and 45% of concerns are not elicited. Heaven, Maguire, & Green, C [28]. says the only one minority of health professionals identify more than 60% of the patient’s major concerns. Medical doctor interrupt frequently and to earlier the patients [29].

The best health outcomes are through access, understanding and interpretation of the patient result is very dependent on the effort created by the health professional, considered the “strong part” of this therapeutic relationship [30]. Also, the success of the satisfaction of the patient it’s based also on the discovery of the “essence” of the medical visit [31].

These specialists of health literacy also considered that, beyond the technical competence of the professional, the communication skills consolidate the trust and confidence and stimulate the individual in the decision making for a better therapeutic adherence and the health instructions.

Nutbeam [6] emphasizes the importance of more personalized and tailor-made forms of communication and education. This greater understanding of the individual promotes their greater literacy in health, through a resilient process and investment in the technical and communicational competencies of the health professional that, through the opportunity of the therapeutic relationship, increases the knowledge and the involvement of the patient with a view to the Better health outcomes.

In a national and European context, which affects more than 50% of the population with inadequate or problematic health literacy [4] people with low literacy have difficulty accessing, using, applying and understanding information and the health system [32]. Patients come in search of authority and often don´t make question to the health professional, to clear reasonable doubts. The group reinforced what the literature has confirmed: people with low health literacy are embarrassed to ask.

Often, they do not even know what to question. They want to be told what to do. The literature on the subject also confirms that the patients ‘judgment about the professionals’ competences, that is, the confidence they have in them, is not usually of a technical nature, but mainly based on the socio-emotional dimension of the relationship, which includes interpersonal communication [33].

In this dialogical relationship there must be interaction, where communication is important and must be understood. The patient must believe what the professional says, in a true empathic process, with a biopsychosocial and also spiritual alignment. Health professional is the stronger part of the relation and has the this “mission” to realize what the patient wants to explain, even without words (nonverbal communication) and to understand this “essence” [31].

Regarding the question of the contribution of communication skills to the success of the therapeutic relationship and to the increase of health literacy, the response of these experts was singular.

Instead of speaking in the verbal and sonorous expression of communication, the experts began by emphasizing the inescapable value of “silence.” And they enunciated the following ideas: The professional must know how to listen. Today we hear little and we talk a lot. We should be concerned about knowing what the patient knows, in a clear and accessible way.

The silence is fundamental for the patient to make a reflection on the information process and for the professional to review their conduct. It is a process of analysis. One of the experts stressed with the agreement of all that “We have to know what to say, to know how to listen, to know what to say and to give voice to silence”. Silence is a process of analysis.

The professional must be present in this relationship, with communication skills and social skills. And what are social skills? It is for example looking at the person, making a smile. Nowadays, electronic questions and the need to write data on the computer does not improve this therapeutic relationship. “We need to Know how to hear” say one of the experts, confirming what Rego [34] refers to the importance of listening as the “touchstone” of communicational efficacy

“You must realize why there is this silence”. Often healthcare professionals try to impose what they feel is right and what is best and ideal. The result of the focus group also emphasizes the phenomenon of real presence, dedicated, motivated to the best results that is based on the effectiveness of the moment, where a mix of skills, communication, technical and social, reinforce the understanding of the receiver inducing it to better perception and therapeutic adherence. Sometimes, the ways of being with the patient go beyond the materialization of physical expression. It’s a matter of education.

Clinical (technical) and care (attention, empathy, humanization, and trust) skills are required by the group, confirming what research has also brought about in this area [35]. The therapeutic relationship becomes an opportunity for optimized contact. “It’s a side-by-side walk.”

A patient with low health literacy is in a specific and delicate situation. There are benefits to health professional to open the “door of communication” because good health communication it’s the key for discover the essence of the consultation and the concerns of the patient [31].

Describing the goal of the health professional in the therapeutic relationship, Bugental [16] talks about illuminating what is “in this room in this now” and called the method “the cultivation of presence who is not didactic or theoretically abstract; it is instead experiential and concrete. According Krug [16] cultivation of presence not only implies the here-and-now, but also describes a therapeutic attitude, that of cultivating as well as a therapeutic intention that of expanded presence.

As stated by Saboga-Nunes, “it is necessary to integrate the citizen in the processes of adherence to therapeutics in a salutogenic view” [36] and look at the person as one system with several levels of inter-influences as peers, family, community, opinion leaders [37].

In these critical times of such low health literacy, with very high rates of inadequate or problematic health literacy [4], the groups agreed that it is important to focus on the qualification of health professionals. The Institute of Medicine itself [38] recommends strengthening communication skills among patients with low health literacy.

For achieving these goals, health professionals must be previous prepared to use this communication guidelines. The ACP Model of health Communication who combines along the consultation the competences of communication as Assertiveness; Clarity of language and Positivity to the desirable behavior of the patient was validated for this health professionals and experts of health literacy [30].

Along the consultation – Opening – gather information – closure the ACP Model can be used in a interdependent and aggregated way. To develop communication skills with precise techniques, health professional must dedicate a part of it’s time to learn the benefits of this important part of care and cure to satisfy the patients needs and accomplish the mission of the consultation. Communication it’s at the core of effective public health [39].

From the result of this qualitative study, agreement was also registered on the effectiveness and importance of previous explanations on health issues, an intervention that allows the reduction of patients’ doubts.

According to Belim and Vaz de Almeida [40], detecting and fulfilling this gap and opportunity, this proposal aims to evaluate the contribution of communication competences, used by healthcare professionals in the clinical relationship with patients”. We consider that it’s possible to increase the understanding of therapeutic adherence and health instructions trough adequate communication competences during all the consultation. To employ assertive conversation and behavior with clarity of language and positivity enriches the health relationship. In a more proactive level and in an attempt to solve the problem of fragile communication, with failures in patient understanding, it is a main goal to construct a model of communication competences that includes the interdependent use of assertiveness, plain language and positivity by the healthcare professional, to which we will designate “ACP model

It’s necessary to guide and encourage the patient and their families to actively participate in their health and outcomes

The groups were unanimous about the importance of health professionals developing communication competences, to enhance patient health literacy levels. The literature confirms the results of all focus group of this health professionals and experts on health literacy

These communication competences include verbal and nonverbal forms, attitude and behaviour able to generate patients´ confidence will allow higher therapeutic adhesion, as well as, the positive consolidation of the therapeutic relationship.

A person with greater literacy will know how to take better care of his health and life. Reinforcing with literature. Tu and Hargraves [41] say that education is the key to explaining the differences in information demand. People with higher levels of education find it easier to do this health research, access, and use of health information and have better health outcomes.

Communication skills should be combined with other clinical skills. It opens the way to relate variables based on health communication domains that can positively influence the therapeutic relationship and therapeutic adherence. Health literacy with better communication it’s a key for better health outcomes.

Set of guiding questions for the implementation of the Focus Group

1. Therapeutic relationship

• How do you define the therapeutic relationship?

• Do you have another suggestion for the classification of the relationship between the health professional and the patient?

2. Contribution of communication skills to the success of the therapeutic relationship and to the increase of health literacy.

3. What importance do you attach to the contribution of communication skills to the success of the therapeutic relationship? And for the increase in health literacy?

4. Which communication skills do you consider most crucial to the success of the therapeutic relationship? Why? And for the increase in health literacy? Why?

None.

No Conflicts of Interest.

1. Simonds SK (1974) Health education as social policy. Health Education Monograph 2: 1-25.
2. Berkman ND, Terry CD, McCormack L (2010). Health Literacy: what is it? J Health Commun 15(S2): 9-19.
3. Kickbusch I, Maag D (2008) Health Literacy. In: Kris Heggenhougen and Stella Quah, eds International Encyclopedia of Public Health, (3). San Diego: Academic Press, pp. 204-211.
4. Sorensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J et al. (2012) Health Literacy and public health: A systematic review and integration of definitions and models. BMC Public health, 12:
5. Nutbeam D (1998) Health promotion glossary. Health Promotion International 13: 349-364.
6. Nutbeam D (2000) Health literacy as public goal: a challenge for contemporary health education and communication strategies into de 21^st Health Promotion International 15(3): 259-267.
7. Rappaport J (1984) Studies in empowerment: introduction to the issue.
8. Bravo P, Edwards E, Barr PJ, School I, Elwyn G, et al. (2015) Conceptualising patient empowerment: a mixed methods study. BMC Health Services Research 15: 252- 266.
9. Chew LD, Bradley KA, Boyko EJ (2004) Brief Questions to Identify Patients with Inadequate Health Literacy. Family Medicine 3: 588 -594.
10. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV (1996) Shame and health literacy: the unspoken connection. Patient Educ Counseling 27: 33-39.
11. Gibson CH (1991) A concept analysis of empowerment. Journal of Advanced Nursing 16: 354-361.
12. Bandura A (1986) Social foundations of thought and action: A social cognitive theory. Englewood Cliffs: Prentice-Hall.
13. Paasche-Orlow MK, Wolf MS (2007) The causal pathway linking health literacy to health outcomes. American Journal of Health Behaviour 31(1): S19-26.
14. Pendleton D, Schofield T, Tate P, Havelock P (2003) The New Consultation. Developing doctor-patient communication. Oxford: Oxford University Press.
15. Vilardaga R, Hayes SC (2009) Acceptance and commitment therapy and the therapeutic relationship stance. European Pshychotherapy 9(1): 1-23.
16. Krug OT (2009) James Bugental & Irvin Yalom Two Masters of Existential Therapy Cultivate Presence in the Therapeutic Encounter. Journal of Humanistic Psychology Existential-Humanistic Institute.
17. Registred Nurses Association of Ontario (2006) Nursing best practices guideline. Shaping the future of nursing in RNAO. (2006). Ontario.
18. Kickbusch I, Maag D (2008) Health Literacy in K Heggenhougen & Stella Quah (Eds.) International Encyclopedia of Public Healt, (3). San Diego: Academic Press, pp. 204-211.
19. Ranjan P, Kumari A, Chakrawarty A (2015) How can doctors improve their communication skills? Journal of Clinical and Diagnostic Research 9(3): JE01-04.
20. Field, MJ, Lohr, KN (Eds) (1990) Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine (US) Committee to Advise the Public Health Service on Clinical Practice Guidelines. Washington (DC): National Academies Press (US), pp. 1990.
21. Graham ID, Harrison MB, Brouwers M, Davies BL, Dunn S (2002) Facilitating the use of evidence in practice: evaluating and adapting clinical practice guidelines for local use by health care organizations. Journal of Obstetric Gynecologic & Neonatal Nursing 31(5): 599-611.
22. Dickens C, Lambert BL, Cromwell T, Piano MR (2013) Nurse overestimation of patients’ health literacy. Journal of Health Communication 18(Supply 1): 62-69.
23. Ishikawa H, Kiuchi T (2010) Health literacy and health communication. Biopsychosoc Med 4: 18.
24. Spitzberg BH (2013) (Re)Introducing communication competence to the health professions. Journal of Public Health Research 2(3): e23.
25. Greenfield S, Kaplan S, Ware JE Jr (1985) Expanding patient involvement in care effects on patient outcomes. Ann Intern Med 102(4): 520-528.
26. Roter DL, Hall JA (1989) Studies of doctor-patient interaction. Annual Review Public Health 10: 163-180.
27. Street RL Jr, O’Malley KJ, Cooper, LA, Haidet P (2008) Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Ann Fam Medicine 6(3): 198-205.
28. Heaven C, Maguire P, Green C (2003) A patient-centred approach to defining and assessing interviewing competency. Epidemiol Psichiatr Soc 12(2): 86-91. 
29. Marvel MK, Epstein RM, Flowers K, Beckman HB (1999) Soliciting the patient’s agenda. have we improved? JAMA 281(3): 283-287. 
30. Almeida CV (2018) literacia em saúde: capacitação dos profissionais de saú O lado mais forte da balança In Literacia em Saúde: Modelos, estratégias e intervenção. Lisboa: Edições ISPA 33-42.
31. Egener B, Cole Kelly K (2004) Satisfying the Patient, But Failing the Test. Academic medicine 79(6): 508-510.
32. Kickbusch I, Maag D (2008) Health Literacy. In K Heggenhougen & Stella Quah (Eds), International Encyclopedia of Public Health, (3). San Diego: Academic Press, 204-211.
33. Dimatteo MR, Prince LM, Taranta A (1979) Patients' Perceptions of Physicians' Behavior: Determinants of Patient Commitment To The Therapeutic Relationship. Journal of Community Health 4(4): 280-90.
34. Rego A (2016) Comunicação pessoal e organizacional, (4ª Ed), Lisboa; Silabo.
35. Greenhalgh T, Heath I (2010) Measuring quality in the therapeutic relationship. An Inquiry into the quality of general practice in England. The King’s Fund.
36. Saboga-Nunes L (2014) Literacia para a saúde e a conscientização da cidadania positiva. Revista Referência (III): 94-99.
37. McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15(4): 351-377.
38. Institute of Medicine (2004) Health Literacy: A Prescription to End Confusion. Washington DC: National Academies.
39. Bernhardt JM (2004) Communication at the core of effective public health. Ann J Public Health 94(12): 2051-2053.
40. Belim C, Vaz de Almeida C (2017) Healthy thanks to communication: A model of communication competences to optimize health literacy: Assertiveness, clear language, and positivity. In VE Papalois & M Theodospoulous (Eds), Optimizing health literacy for improved clinical practices(pp. 124-152). Hershey, PA: IGI Global.
41. Tu HT, Hargraves JL (2003) Seeking health care information: Most consumers still on the sidelines. Issue Brief Cent Stud Health Syst Chang, 61: 1-4.