Review
Health literacy in the “oral exchange”: An important element of patient–provider communication

https://doi.org/10.1016/j.pec.2014.12.002Get rights and content

Highlights

  • The review examines the intersection between health literacy and the oral exchange.

  • Three tools have been developed to measure patient or provider oral/aural literacy.

  • High literacy demand is associated with reduced patient learning.

  • Low patient oral and aural literacy are associated with poor health outcomes.

  • Use of plain language and teach-back, as well as future research, are recommended.

Abstract

Objective

Oral communication between health care providers and patients—the “oral exchange”—greatly impacts patient health outcomes; however, only recently have health literacy inquiries been incorporated into this field. This review examines the intersection between oral and aural literacy and the oral exchange.

Methods

A systematic literature search was carried out. Papers published in English since 2003 that specifically examine oral/aural literacy and oral patient–provider communication were included.

Results

The search yielded 999 articles, 12 of which were included in this review. Three tools have been developed to measure either patient or provider oral/aural literacy. There is a discrepancy between patient and provider oral/aural literacy levels, and high literacy demand is associated with reduced patient learning. Low patient oral/aural literacy is associated with poor health outcomes. Two interventions have been developed to reduce literacy demand.

Conclusion

This review demonstrates the critical role of oral and aural literacy in the oral exchange, the importance of reducing literacy demand, and the need for future research in this field.

Practice implications

Recommendations include the use of plain language and teach-back by providers, as well as incorporation of awareness of oral and aural literacy into community programs and health care provider education and training.

Introduction

Research in health communication, specifically in doctor–patient communication, has greatly contributed to physician practice and training [1], [2], [3]. However, only recently have findings from health literacy inquiries contributed to this body of work. Oral communication between physicians and patients has been shown to impact patients’ knowledge, motivation, decision-making, engagement and empowerment, and even health [4], [5], [6]. Furthermore, oral communication is critical for appropriate diagnosis, treatment, and management of disease. Given that an average medical visit lasts between 10 and 16 min, effective and constructive oral communication is highly significant in ensuring positive health outcomes [1], [7].

Health literacy inquiry began with a focus on the links between literacy skills of patients and health outcomes. Research findings indicate that poor reading skills are associated with an increased use of emergency care, hospitalizations, and all-cause mortality, a decreased use of preventive services, and poor health maintenance [8], [9], [10], [11]. However, over the past decade, researchers have moved beyond a focus on patients’ reading skills alone to include a broader range of literacy skills: writing, speaking and listening, and math. In addition, health literacy researchers are currently examining other components of the health context, such as the complexity of health materials, the demands and assumptions of health institutions, and the communication skills of health professionals [11], [12], [13], [14].

Adult literacy research findings indicate that half of American adults lack needed skills to consistently and accurately use print material for commonplace tasks [15], [16], [17], [18]. At the same time, there is a scarcity of literature focused on literacy skills and its impact on oral communication in health and health care settings [5]. This paper provides an overview of the existing literature to examine the intersection between health literacy—specifically, speaking and listening skills—and the “oral exchange,” or the oral communication between healthcare providers (doctors, nurses, allied health professionals, pharmacists) and patients.

The 2004 Institute of Medicine report on health literacy called for attention to the intersection between people's skills and health systems’ demands and expectations [19]. Furthermore, this early assessment of developments in the emerging research area of health literacy called on researchers to include a broad array of literacy skills including numeracy, speaking, and listening, in analyses. Consequently, current research has shifted to focus more on the role of health systems and health professionals in both creating and ensuring access to usable health information and allowing for systemic changes to consider health literacy [11], [12].

Similarly, research in patient–provider communication has undergone recent changes. With increasing evidence of the relationship between the characteristics of the patient–provider exchange and health outcomes, health inequities, chronic disease management, and quality of care—all in the setting of a fragmented care delivery system—increasing attention has been devoted to a patient–centered approach to communication [20], [21]. This approach has been shown to have positive effects on clarification of patients’ concerns and beliefs, communication about treatment options, levels of empathy, and patient perception of provider attentiveness [22]. In addition, innovations in health information technologies have enabled researchers in patient–provider communication to expand beyond face-to-face interaction to include communication by phone and online between encounters [20].

These movements toward a broader definition of health literacy and an increasing emphasis on patient–centered communication have resulted in the examination of the interaction of the two. In doing so, several studies have found an association between high health literacy and better patient–physician communication [23], [24], [25], [26], [27]. Additionally, several intervention studies have aimed to improve health outcomes by developing computer programs or telephone follow-up systems aimed at patients with low health literacy [28], [29], [30]. However, in these studies, despite examining face-to-face interactions and verbal communication, health literacy is measured as reading or writing skills, and in some cases measured by level of education as a proxy. Nevertheless, a limited amount of research has emerged in recent years looking specifically at the intersection between speaking and listening skills and patient–provider communication—this topic is the focus of this review.

Section snippets

Definition of terms and review questions

For the purposes of this review, “oral exchange” refers to the spoken communication between providers and patients. Speaking and listening skills refer to oral and aural literacy, respectively. Research questions include: (1) how oral and aural literacy relate to other literacy skills (reading, writing, and numeracy), (2) how the literacy demand placed by providers (speaking skills of providers) can be measured, how it affects patient outcomes, and how it can be reduced, (3) how the speaking

Search results

The systematic search in Pubmed yielded a total of 999 articles. Of those, 125 had abstracts that noted oral and/or aural literacy, speaking and/or listening skills, health literacy, outcomes, and/or patient–provider communication, and were therefore saved. After thorough examination of these articles and application of the inclusion and exclusion criteria described in Search Methodology, 8 articles were included in the final review (see Appendix A and Fig. 1). Four additional articles were

Discussion

This review illustrates the critical role of oral and aural literacy in the oral exchange by presenting existing evidence on oral literacy demand placed by providers, the oral and aural literacy skills of patients, and the relationship between oral/aural literacy and other types of literacy. Examination of the literacy demand placed by providers on patients reveals not only the existence of a significant discrepancy between patient and provider oral literacy skills, but also the detriment to

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