Functional health literacy and the quality of physician–patient communication among diabetes patients

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Abstract

While patients with poor functional health literacy (FHL) have difficulties reading and comprehending written medical instructions, it is not known whether these patients also experience problems with other modes of communication, such as face-to-face encounters with primary care physicians. We enrolled 408 English- and Spanish-speaking diabetes patients to examine whether patients with inadequate FHL report worse communication than patients with adequate FHL. We assessed patients’ experiences of communication using sub-scales from the Interpersonal Processes of Care in Diverse Populations instrument. In multivariate models, patients with inadequate FHL, compared to patients with adequate FHL, were more likely to report worse communication in the domains of general clarity (adjusted odds ratio [AOR] 6.29, P<0.01), explanation of condition (AOR 4.85, P=0.03), and explanation of processes of care (AOR 2.70, P=0.03). Poor FHL appears to be a marker for oral communication problems, particularly in the technical, explanatory domains of clinician–patient dialogue. Research is needed to identify strategies to improve communication for this group of patients.

Introduction

There is a growing recognition that interpersonal processes of care, in addition to technical processes of care, contribute to the overall quality of health care [1], [2], [3], [4], [5]. Interpersonal processes encompass the social–psychological aspects of the clinical interaction, including patient–provider communication. The quality of interpersonal care processes is associated with patients’ self-care behavior and health outcomes for a number of conditions, including diabetes [6], [7], [8], [9], [10], [11], [12]. Some hypothesize that poor interpersonal care processes contribute to disparities in health between disadvantaged and non-disadvantaged populations [5].

Poor functional health literacy (FHL) is common among patients who have low educational attainment, and among older patients and racial and ethnic minorities [13]. As many as one in three Medicare patients has poor FHL; in public sector settings, poor FHL is the rule rather than the exception [14], [15]. FHL is a measure of a patient’s ability to perform basic reading and numerical tasks required to function in the health care environment [13] and is distinct from education level and language ability. Poor FHL is independently associated with poor self-rated health [16], poor understanding of one’s condition and its management [17], [18], [19], and higher utilization of services [20], [21]. Recently, FHL has been shown to be independently associated with glycemic control and diabetes complications among a cohort of public hospital patients [22]. Although the mechanisms whereby poor FHL impacts health outcomes are not clear, it is likely that ineffective information flow in the health care context plays a role [23].

One natural strategy for circumventing the barriers to written communication associated with poor FHL would be to augment or substitute oral for written clinical communication. However, patients with poor FHL may not only have limitations in reading and numeracy, but also may have difficulties processing oral communication [5], [24], [25], [26]. In the health care context, analysis of focus groups and individual interviews with patients with low literacy revealed pervasive communication problems with health care providers, including problems during face-to-face encounters [27]. For example, patients frequently told of being informed about their medical problems and treatments in ways they could not understand.

We undertook a study of ethnically diverse primary care patients with type 2 diabetes to examine the relationship between FHL and the quality of clinician–patient communication. We selected diabetes because the nature of the disease and its treatment requires intensive, ongoing patient–provider communication around such disparate domains as the elicitation of symptoms, explanations of the condition, self-care, diagnostic testing, and decision-making. Moreover, the quality of patient–physician communication has been shown to be associated with self-care behaviors and clinical outcomes among patients with diabetes [6], [10].

Section snippets

Setting and study participants

We performed this study within the context of a larger study examining the relationship between FHL and diabetes outcomes [22]. The protocol was approved by the Human Subjects Committee of University of California San Francisco (UCSF).

Patients were enrolled in two primary care clinics (a family practice and a general internal medicine clinic) at San Francisco General Hospital (SFGH), the public hospital for the City and County of San Francisco. The clinics serve patient populations that are

Results

Eight hundred and fifty-eight diabetes patients were identified by the San Francisco General Hospital clinical database as potentially eligible for the study. Of these, 142 were ineligible because their primary care physicians informed us that the patients were not in their panel (n=10), did not have type 2 diabetes (n=25), did not speak English or Spanish fluently (n=28), had moved out of the area (n=35), had a psychiatric condition, e.g. dementia, psychosis, or mental retardation (n=23), or

Discussion

To our knowledge, this is the first study to demonstrate an association between FHL and the quality of interpersonal processes of care, i.e. office based, primarily oral patient–physician communication. While patients’ reports of the quality of communication were, in general, quite high, we observed robust bivariate and multivariate relationships between inadequate FHL and reports of worse communication across selected domains involving both the explanatory and participatory components of a

Practice implications

Since type 2 diabetes disproportionately affects ethnic minorities, the elderly, and those of lower socioeconomic status [52], understanding the relationship between FHL and the quality of interpersonal processes of care may provide important insights for clinicians who care for such populations, and may have strategic implications for the reduction of racial, ethnic, and socioeconomic disparities in diabetes care called for in Healthy People 2010 [53]. To date, potential solutions to the

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