Patient Perception, Preference and Participation
Patients’ perspectives of the doctor–patient relationship and information giving across a range of literacy levels

https://doi.org/10.1016/j.pec.2008.09.026Get rights and content

Abstract

Objective

This study explored the patient's experience of the doctor–patient relationship and information giving in health care. The views of patients with a range of literacy levels were examined.

Method

321 patients at an in-patient cardiology unit provided the sample. The Health Literacy (HL) of participants was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). All participants (low and adequate HL) were then asked open ended questions about their experiences of communication with healthcare professionals. The qualitative data underwent a thematic analysis.

Results

22% of the patients interviewed were found to have a low level of literacy as indicated by the REALM. Many patients felt that health information should be given in simpler language. Patients frequently stated that they either did not read information leaflets or were confused or worried by them. They described the importance of the doctor–patient relationship and the need to build up trust. These views were expressed by patients with adequate HL as well as patients with low HL.

Conclusion

Many patients irrespective of their HL skills, feel unable to access, understand and utilize health information.

Practice implications

If patients are to be actively engaged in achieving and maintaining good health, healthcare professionals must improve their communication skills and ensure that health information is clear and easy to access.

Introduction

Effective interpersonal communication skills are key to quality health care delivery and shared decision making. Understanding the patient's perception of the problem and its social and emotional impact is an essential part of the doctor–patient interaction. Effective communication can benefit both doctors and patients [1]. Poor communication between doctor and patient can mean the patient's perception of the problems and the resulting social and emotional impacts are inadequately explored [2]. The quality of the doctor–patient relationship can affect diagnosis, treatment and recovery and there is a correlation between effective doctor–patient relationships and improved health outcomes [3], [4], [5]. Despite this, research has shown information given by practitioners to patients is not always tailored to the patients individual needs and consideration is not always given as to whether a patient has understood information concerning treatment implications and options [6].

The ability to read, understand and act on health information has become increasingly important in the current context of healthcare and healthy living. General literacy has been defined as ‘using printed and written information to function in society, to achieve one's goals and to develop one's knowledge and potential’ [7]. General literacy can be conceptualised as a number of ‘domains’, each of which had defined characteristics and a set of ‘skills’ needed by people within society. One such domain is health literacy (HL). There are many definitions of health literacy ranging from a view of HL as a ‘basic skill’, the lack of which can adversely affect health, as seen in the US Institute of Medicine (IOM) definition; ‘the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’ [8]. Other definitions encompass wider skills than simple reading and numeracy, for instance, Kickbusch et al. have defined HL as ‘the ability to make sound health decisions in the context of everyday life, at home, in the community, at the workplace, in the healthcare system, the marketplace and the political arena. It is a critical empowerment strategy to increase people's control over their health, their ability to seek out information and their ability to take responsibility’ [9] thus acknowledging the broad set of skills required to be health literate. In this study we have used the IOM definition, as we wished to examine doctor–patient communication across a range of literacy levels using the REALM, which fits best with this definition of HL. HL has been identified in the US as a major public health problem [10] with significant research and development effort focused on identifying the causes of, and reducing the impacts of, barriers to self-management experienced by people with low HL [11]. There are no data on the prevalence and extent of low HL in the UK however the 1996 International Adult Literacy Survey (IALS) showed UK levels of literacy similar to the US, with a prevalence of low literacy of 22% [12]. We feel that it is likely, therefore that low HL is also of major importance in the UK. In this study we were interested in exploring doctor–patient communication and in the extent to which that might be hindered by low patient HL.

In developed countries, patients are being expected to take a more active role in the management of their health. In recent years the UK government has introduced a range of health reforms, including recommendation for greater patient choice in healthcare options [13] and publications encouraging people to lead healthier lifestyles [14]. The Wanless report [15] called for more focus on effective health promotion and active involvement of patients in their healthcare. An international study [16] of patients in Australia, Canada, New Zealand, US and the UK interviewed over 8000 adults about their experience of primary health care. The study identified the British patients as performing worse than patients from the other countries in the areas of information about medicines, shared decision making, health promotion and self-management of chronic disease.

With increased life expectancy more people are living with chronic diseases which require management and often involve complex treatment options. Studies have shown that people with low literacy have more difficulty following instructions on medication [17]. Low literacy patients with diabetes have been shown to have more poorly controlled blood glucose levels than patients with adequate literacy [18]. The incidence of chronic disease in the UK is 60% of the adult population and 75% of people over 75 years; 45% of those with chronic disease have more than one condition [19]. The elderly are also more likely to have literacy problems [20] and it has been suggested that health literacy skills decline with age [21]. Very little health literacy research has been undertaken in the UK and very few studies have examined the patient perspective. Therefore, this study aimed to explore the patient's experience of the doctor–patient relationship and written and oral information giving in health care. Specifically, participants were asked how they thought health professionals could make it easier for them to get information about their health, and secondly were there any issues about communication with health professionals on which they wished to comment. We explored the views of patients with a range of literacy levels.

Section snippets

Method

The study took place at an in-patient cardiology unit in south west London, as part of a wider study on health literacy in the UK [22]. 321 patients aged over 18 provided the sample and recruitment took place between December 2005 and January 2007. The cardiology consultants gave permission for us to approach their patients and meetings were held with senior management and nursing staff to discuss the practicalities of running the study.

The researcher went to the wards and, in consultation with

Results

563 patients were invited to take part in the study and 321 patients were recruited. The majority of the participants were white (89%) and male (64%). The mean age was 64 years. 22% (71/321) of the patients interviewed were found to have a low level of literacy as indicated by the REALM. The emergent themes of this study concerned the transmission of information, the use of language and terminology, interaction with health professionals and patient self-efficacy amongst people with both low and

Discussion

The results indicate that clear and understandable communication through different modes of transmission is considered as important by many of our participants not only those with low literacy. It has been suggested [29] that doctors’ over estimation of patient literacy may be an important barrier to high quality communication in the consultation, but this study suggests that communication needs to improve for all patients and that the key to empowerment and improved self-care is better initial

Acknowledgements

We would like to thank all the staff of the participating cardiology wards for allowing us to conduct our study. The study was funded by STaRNet London which is funded by the Department of Health.

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