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Oral literacy demand of health care communication: Challenges and solutions

Debra L. Roter, DrPH*

Department of Health, Behavior and Society, The Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD

a r t i c l e i n f o

Article history: Received 30 August 2010 Revised 9 November 2010 Accepted 13 November 2010

Key words: Health literacy Oral literacy Demand Health care communication Patient-provider communication

* Corresponding author: Dr. Debra L. Roter, School of Public Health, 624 North Broadwa

E-mail address: [email protected] (D.L. R

0029-6554/$ - see front matter � 2011 Elsevi doi:10.1016/j.outlook.2010.11.005

a b s t r a c t

Literacy deficits are widespread; one-quarter of the U.S. population has below basic literacy skills and the health consequences of literacy deficits are well- known and significant. While the need to simplify written health education print material is widely recognized, there has been little attempt to describe or reduce the literacy demand of health care dialogue. Patients with limited literacy complain they are not given information about their problems in ways they can understand, leaving them uninformed, frustrated, and distrustful. The purpose of this article is to review a conceptual approach to describing oral literacy demand in health care dialogue, to review several key studies that support the predictive validity of the conceptual framework in regard to patient satisfaction and recall of information, and to propose several practical ways to diminish literacy demand and facilitate more effective health care exchanges with patients.

Cite this article: Roter, D. L. (2011, APRIL). Oral literacy demand of health care communication: Challenges

and solutions. Nursing Outlook, 59(2), 79-84. 10.1016/j.outlook.2010.11.005.

Literacy deficits are widespread and the health conse- andhumiliation in regard to their literacy deficits8-10 and

quences of restricted literacy are considerable. Restricted literacyhasbeen linkedto lower levelsof self- reported health,1 less use of preventive care and cancer screening,2 less effective diabetes management, more disease-related complications,3 and higher rates of hospitalization4,5 among other health consequences.6

Most health literacy research has focused on skill deficits in reading and numeracy; however, there is evidence that patients with literacy deficits also have difficulty understanding and recalling complex infor- mationdeliveredorally.7 Patientswithpoor literacyskills are especially vulnerable. They report feelings of shame

Department of Health, B y, Hampton House, Room oter).

er Inc. All rights reserved

they experience more communication difficulties and have less satisfying health care visits than patients with adequate literacy skills.11 It is not surprising to find that patientswith low literacy skills are less likely to be active participants in themedical dialogue and in the decision- making process.12,13

The purpose of this article is to review a conceptual approach to describing oral literacy demand in health care dialogue, to review several key studies that support the predictive validity of the conceptual framework in regard to patient satisfaction and recall of information, and to propose several practical ways

ehavior and Society, The Johns Hopkins University, Bloomberg 750, Baltimore, MD 21205.


Nur s Ou t l o o k 5 9 ( 2 0 1 1 ) 7 9e8 480

to diminish literacy demand and facilitate more effective health care exchanges with patients.

Oral Literacy Demand Framework

While some studies have considered particular aspects of medical communication that present challenges to patients with restricted literacy,14 there have been few attempts to consider these challenges in a compre- hensive manner.15 In attempting to contribute to this sparse literature, my colleagues and I have proposed a framework that conceptualizes the oral literacy demand of health care communication by several interaction domains that present special challenges for patients with restricted literacy.16-18 In brief, oral literacy demand is defined by 4 separate language elements: (1) medical jargon; (2) general language complexity; (3) contextualized language; and (4) struc- tural characteristics of dialogue. These are described below, along with selected background literature and, when available, validity studies.

Medical Jargon

Studies dating back to the 1960’s have demonstrated that medical jargon is widely used during routine medical visits and is linked to patient confusion. It is highly likely that a doctor will use at least one unfa- miliar medical term in any given visit, and this has not changed very much over the past 50 years. In their pioneering work in this area, Barbara Korsch and her colleagues19 found that the pediatrician’s use of diffi- cult technical language and medical shorthand was a barrier to communication inmore than half of the 800 pediatric visits that were studied. Mothers were often confused and unsure of terms used by the doctor to describe what was wrong with their children and what the doctor was going to do about it. Although one mother (out of 800) asked the doctor to “repeat what he said in English”, this kind of confrontation was infre- quent. For the most part, mothers did not ask for clarification of unfamiliar terms. Fear of appearing ignorant was the reason most often given by patients for not asking what technical terms meant. The investigators added, however, that some patients may have been flattered by having the physician think that they understood difficult and unfamiliar language, making it even harder for them to admit otherwise.

In more recent studies, Castro and colleagues went beyond the previous studies by specifically examining the use of unclarified jargon with patients who have limited literacy skills and by assessing patient understanding of the terms used.20 All 60 patients in the study were diabetic, so it was possible to explore the impact of jargon use on patients’ ability to understand diabetic treatment recommendations. The investigators found that 4 unclarified terms were used per visit

(median¼ 3; range 1-14) andat least oneunclarified term was used in 85% of all visits. Overall, patient compre- hension of the unclarified diabetes-specific terms was low and never reached >40% (range, 13-38%).

My colleagues and I took a somewhat different approach to our validity study of medical jargon during genetic counselingsessions.Wetrackedthe frequencyof 7 key genetics-specific terms used during genetic coun- seling sessions (ie, variation, susceptibility, abnormality, sporadic, hereditary, mutation, chromosome) based on transcript analysis of>150 sessions.18 We found that an average of 3 different key terms (of 7) were used in every session and, when used, a term was repeated often. In fact, key words were typically repeated 20 times in a single session,with some terms repeatedas often as 78 times. We related the frequency of key word use to the subject’s ability to learn genetics-related information fromthesessions.Thiswasdonebyinstructingthestudy volunteers to imagine being the patient in a genetic counseling session they viewed. In this way, the study subjects essentially became “analogue patients,” acting as a proxy for actual patients.

After watching the video, the analogue patients took a knowledge test to assess their learning of genetic- related information conveyed during the session. The knowledge test scores were subsequently related to the subject’s level of literacy and the number of times each key term was used in the viewed session. There were no significant relationships between analogue patient learning and use of medical jargon in the sessions for low literate subjects; it did not appear to significantly aide or hinder the ability of these analogue patients to learn genetic-related information as communicated by the counselor.

Other study analyses, based on ratings by the simulated patients who directly participated in the counseling videos, found a negative effect of medical jargon on their satisfaction with the genetic coun- selors.17 When the counselor’s total use of medical jargon was high, simulated patient’s satisfaction with interpersonal rapport suffered. This suggests it was not the use of specific words, per se, that created a negative impression, but the relative emphasis on these wordsdincluding frequent repetitionsdthat interfered with satisfaction. We also know that in these coun- seling sessions there was a trade-off between attention to technical descriptions of tests and procedures, largely the context within which medical jargon was used, and the address of emotional and psychosocial issues. We suspect that it was the neglect of the latter, rather than the jargon use, per se, that diminished simulated patient satisfaction.

General Language Complexity

The second group of measures in the framework reflects general language complexity, which is directly

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parallel to readability assessment of print material. General language complexity is distinguished from jargon by the structure of the language, rather than its formality, unfamiliarity, or specialized use. The markers of complex oral language can be seen as parallel to those used to assess the literacy demand of print material. In our study of genetic counseling sessions,18 we used Microsoft Word “grammar summary statistics,”21 to generate a variety of language measures including: the total transcript word count, the average number of words per sentence, the percentage of transcript sentences in the passive voice, the Flesch Reading Ease Score, and the Flesch-Kincaid (F-K) Reading Grade Level Score. The percentage of transcript sentences in the passive voice was used as a proxy for conversational formality. Although not directly provided with summary statistics, the average number of syllables per word (ASW) was extrapolated from the Flesch Reading Ease Score.

We found that language complexity was not related to learning among low literate subjects, perhaps because the reading grade level equivalent of the dia- logue transcripts was relatively low.18 However, as was the case for jargon use, the simulated patients rated the genetic counselors who used simpler and less complex language more positively than those who used more complex language.17 More specifically, the simulated patients were significantly more satisfied with the informativeness of sessions that had lower Flesch-Kincaid Reading Levels and less use of the passive voice.

Contextualizing Language

Decontextualized language conveys abstract ideas or novel use of language or metaphors to describe an event or an internal state to another person. Individ- uals with restricted literacy tend to have difficulty with these sorts of explanations and are more likely to use and understand language that is concrete and groun- ded in what is directly seen and experienced.22,23 In this regard, personalized information may be recog- nized as more relevant and useful than information given in general terms. An example of personalized information about risks in the genetic counseling context is: “Based on what you told me about yourself and your family, you have a 1 in 400 risk of having a baby with Down’s Syndrome.” The more general reference was: “Nobody has a risk of zerodwomen over 35 have about a 1 in 400 risk of having a baby with Down’s Syndrome.”

Some 35% of all information given by counselors in sessionswas coded as being personally contextualized, and findings relating knowledge scores to personally contextualized language were striking.18 Analogue patients with restricted literacy skills learned signifi- cantly more from the counselors in sessions in which

information wasmade less abstract andmore concrete by personal contextualization.

Dialogue Structure

Threeaspectsofdialoguestructureareconsidered in the literacy demand framework: (1) speech speed, (2) turn density, defined as the number of thoughts communi- cated in one speaking turn, and (3) interactivity, the conversational up and back of the dialogue defined as the rate per minute at which speakers exchange the floor.

There is some evidence that faster-than-normal speech speed adversely affects comprehension,24 and patients in focus groups complain about the fast pace in which information is communicated to them.9

While a patient can explicitly request that the physi- cian slow down or repeat information, patients with low literacy skills are less likely to make requests of this kind than other patients.9 Although speech speed was included in the oral literacy demand framework, it was not found to be related to analogue patient recall in the genetic counseling study.18 A second simulation study, this one conducted in primary care, also explored the relationship between speech speed and simulated patient ratings.25 In this study, simu- lated patients rated physician demeanor, interper- sonal satisfaction, and decision-making partnership more positively when the clinician spoke at a faster rate.

Turn density is the amount of uninterrupted speech delivered by a speaker at a single speaking turn. We know that when information in print material is pre- sented in manageable chunks, only a few items at a time, readers are more likely to remember the information given26 and, in medical visits, there also appears to be an inverse relationship between the amount of information given and the proportion of information a patient can recall.27,28 A corollary in oral exchange is the informational block delivered during a speaking turn. Thus, the longer a clinician speaks, the denser the informational chunk, and the greater the oral literacy demand.

Doak and colleagues suggest that readers cannot comfortably process more than 5 pieces of informa- tion at a time.26 In the genetic counseling study described earlier, the average turn density for coun- selors was 6.8 statements, suggesting that the infor- mation load each time a counselor spoke would be challenging for anyone, but especially so for patients with restricted literacy.16 In fact, analogue patients with restricted literacy skills learned significantly less in sessions with long, dense counselor speaking turns.18

The last dialogue dimension is interactivity, defined as the rate of speaker change per minute of interaction

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throughout the session. Greater interactivity results in amore conversational exchange that provides speaking opportunities for patients, as well as a natural break between informational monologues. Once again, there is a parallel to dialogue interactivity in print assess- ment. To more effectively engage print readers, inter- active strategies such as question/answer formats, quizzes, brainstorming exercises, and risk self- assessment has been suggested.26 While the mode of interactivity is obviously different inprint anddialogue, the rate of speaker exchange similarly demands active attention and engagement of speakers in a reciprocal process of informational evaluation and response.

There is evidence that analogue clients with restricted literacy skills learned significantly more when viewing genetic counseling sessions with greater interactivity18 and that simulated patients rate highly interactive sessions more positively in regard to provider demeanor, interpersonal satisfaction, and decision-making partnership in both the genetic counseling context and in primary care.16,25

Implications for Nursing Practice

Based on the framework presented and research reviewed, 3 straightforward strategies can be proposed to reduce oral literacy burden in face-to-face commu- nication with patients. While none of the studies cited in the review were specifically conducted with nurses, the principles are fully applicable to the nursing setting. The strategies can be summed up as: “strip it down”, “bring it home” and “mix it up.”

“Strip it down” refers to limiting unnecessary use of medical jargon and complex general language. This has a common sense appeal that is supported by a variety of studies. It is, however, important to note that some judicious use of key medical terms may be important to orient a patient to language that is likely to be encountered in the course of medical care and treatment.When a technical term is required, theword or concept should be defined and used in the context of patient care, but it should not become the primary focus of the dialogue. Patients want to be informed, but they also want to know how and why the terms that define their medical condition and treatment fit into the broader fabric of their lives. It is here that caremust be taken to convey meaning and relevance and not simply a dictionary entry.

While there is far more attention in the literature to medical jargon than general language complexity, exploration in this regard may well be worth the effort. There has been broad support for a Plain Language initiative by the government for the past 10 years. As noted by Vice President Al Gore announcing the Exec- utiveMemorandumdirecting the heads of all executive

departments and agencies to begin writing in plain language to the American people, “Plain Language is NOT. to enhance the level and facility of reading comprehension attained by the government’s inter- locutors according to objectively considered contem- porary standards and measures. That was the old point; the new point. is to make sure you can understand us.”29 The take home instruction is to engage patients in conversation that is stripped down to more effectively facilitate understanding, establish rapport, and diminish social distance.

“Bring it home” refers to communicating informa- tion in a personally relevant context. It also goes further than this, and establishes a challenge to make information concrete by grounding it in the experience of learners. This strategy not only has intuitive appeal but resonates with the adult education literature that characterizes adult learners as drawing on life experi- ence to make sense of new information.26 By refer- encing prior experiences, the utility of the information to address immediate needs is increased. This includes not only personalizing amessage in the way illustrated above, but building a connection with patients by beginning an educational session by asking patients what they know and using that as a starting point for building interest and assuring that communicated information is relevant.

The last instruction, “mix it up”, suggests trans- forming the all-too-often series of mini-lectures and monologues that characterize significant segments of the healthcare encounter to a dynamic up and forth of a true conversation. The study findings suggest, specifically related to interviewing, to talk less and listenmore. It may bemore important for physicians to guard against their own tendency toward long mono- logues even if they are careful to offer the patient a chance to speak when they are finished. For example, when presenting treatment options it is not uncommon to overview several options and leave questions to the end. This is likely to result in far less meaningful patient engagement in the dialogue than chunking information and checking frequently for patient understanding and asking for questions as they arise. By consciously increasing the interactivity of the exchange, more opportunities are created for the patient to engage in the back and forth of normal conversation and, consequently, greater opportunity for the expression of patient voice.16


Oral literacy burden goes beyond the specific words that are used, examples that are given, or dialogue chunking and interactivity. It goes to a fundamental commitment to assisting patients in becoming full participants in their own health care. Although these

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issues have received little more than minimal atten- tion in traditional medical and nursing curriculum, there is some evidence that small changes in the way health care communication is delivered can pay off in terms of patient understanding, satisfaction, and motivation for self-care.

The studies presented in this review have come from outside of the nursing literature and several have relied upon simulated and analogue patients. Never- theless, the findings are worth consideration and worthy of raising a challenge to the nursing field to explore these questions directly within the context of nurse-patient communication. The results may look different for nursing than other health care profes- sionals, and that would be an important contribution to the growing evidence base through which the negative consequences of restricted health literacy on valued patient outcomes may be diminished.

Finally, as noted by the Surgeon General’s Healthy People 2010, closing the gap in health literacy “is an issue of fundamental fairness and equity and is essential to reduce health disparities.”30

r e f e r e n c e s

1. Gazmararian JA, Baker DW, Williams MV, Parker RM, Scott TL, Green DC, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA 1999;281:545-51.

2. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care 2002;40:395-404.

3. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, et al. Association of health literacy with diabetes outcomes. JAMA 2002;288: 475-82.

4. Baker DW, Gazmararian JA, Williams MV, Scott T, Parker RM, Green D, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. AJPH 2002;92:1278-83.

5. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. JGIM 1998; 13:791-8.

6. DeWalt DA, Pignone M. Health literacy and health outcomes: Overview of the literature. In: Schwartzberg J, Van Geest C, Wang J, Gazmararian JA, Parker R, Roter D, et al., editors. Understanding Health Literacy. Chicago, IL: AMA Press; 2005. p. 205-27.

7. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med 1998;158:166-72.

8. Baker DW, Parker RM, Williams MV, Pitkin K, Parikh NS, Coates W, et al. The health care experience of patients with low literacy. Arch Fam Med 1996;5: 329-34.

9. Bennett IM, Switzer J, Barg F, Aguirre A, Evans K. “Breaking it down”: Patient-clinician communication

and prenatal care among African American women of low and higher literacy. Ann Fam Med 2006;4:334-40.

10. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: The unspoken connection. Patient Educ Couns 1996;27: 33-9.

11. Schillinger D, Bindman AB, Wang F, Stewart A, Piette J. Functional health literacy and the quality of physician-patient communication among diabetes patients. Patient Educ Couns 2004;52: 315-23.

12. Roter D. Health Literacy and the Patient Provider Relationship. In: Schwartzberg J, Van Geest J, Wang C, Gazmararian J, Parker R, Roter D, et al., editors. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, IL: AMA Press; 2004. p. 101-18.

13. Cooper LA, Beach MC, Clever SL. Participatory decision-making in the medical encounter and its relationship to patient literacy. In: Schwartzberg J, Van Geest J, Wang C, Gazmararian J, Parker R, Roter D, et al., editors. Understanding Health Literacy: Implications for Medicine and Public Health. Chicago, IL: AMA Press; 2004. p. 101-18.

14. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, et al. Closing the loop: Physician communication with diabetic patients who have low health literacy. Arch Intern Med 2003;163:83-90.

15. Nielsen-Bohlman L, Panzer AM, Kindig DA. Institute of Medicine Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004.

16. Roter DL, Erby LH, Larson S. Assessing oral literacy demand in genetic counseling dialogue: A preliminary test of a conceptual framework. Social Science Med 2007;65:1442-57.

17. Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): Models of practice. Am J Med Genet C Semin Med Genet 2006; 142:209-20.

18. Roter DL, Erby LH, Larson S, Ellington L. Oral literacy demand of prenatal genetic counseling dialogue: Predictors of learning. Patient Educ Couns 2009;75: 392-7.

19. Korsch BM, Gozzi EK, Francis V. Gaps in doctor- patient communication: I. Doctor-patient interaction and patient satisfaction. Pediatrics 1968;42:855-71.

20. Castro CM, Wilson C, Wang F, Schillinger D. Babel Babble: Physicians’ use of unclarified medical jargon with patients. Am J Health Behav 2007;31:S85-95.

21. Microsoft Systems. Readability scores. http://office. microsoft.com/en-us/word-help/readability-scores- HP005186318.aspx. Microsoft Office, 2003.

22. Dexter ER, LeVine SE, Velasco PM. Maternal schooling and health-related language and literacy skills in rural Mexico. Comp Educ Rev 1998;42:139-62.

23. Farmer SA, Roter DL, Higgenson IJ. Chest pain: Communication of symptoms and history in a London emergency department. Patient Educ Couns 2006;63: 138-44.

24. Schmitt JF, Carroll MR. Older listeners’ ability to comprehend speaker-generated rate alteration of passages. J Speech Hear Res 1985;28:309-12.

25. Roter DL, Larson SM, Beach MC, Cooper LA. Interactive and evaluative correlates of dialogue sequence: A simulation study applying the RIAS to turn taking structures. Patient Educ Couns 2008;71: 26-33.

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26. Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills. 2nd ed. Philadelphia, PA: JB Lippincott Company; 1996.

27. Ley P. Patients’ understanding and recall in clinical communication failure. In: Pendleton D, Hasler J, editors. Doctor-Patient Communication. London, England: Academic Press; 1982. p. 89- 108.

28. Roter DL, Hall JA, Katz NR. Relations between physicians’ behaviors and analogue patients’

satisfaction, recall, and impressions. Med Care 1987; 25:437-51.

29. Gore, Al, National Small Business Week Awards/Plain Language Announcement, 1998, http://www. plainlanguage.gov/examples/award_winning/ nogobbledygookanncounce.cfm.

30. HHS. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington, DC: U.S. Department of Health and Human Services; 2000.

  • Oral literacy demand of health care communication: Challenges and solutions
    • Oral Literacy Demand Framework
      • Medical Jargon
      • General Language Complexity
      • Contextualizing Language
      • Dialogue Structure
    • Implications for Nursing Practice
    • Conclusion
    • References