Communication barriers represent a significant structural barrier within the healthcare system, driven primarily by two critical factors: patients’ language proficiency and healthcare providers’ communication skills. Effective communication is essential for ensuring that patients possess the necessary health literacy to understand health-relevant information, communicate effectively with healthcare providers, and follow medical instructions. Given its significance in healthcare settings, deficiencies in communication can significantly impair health literacy, leading to negative mental and physical outcomes for patients. During my time as a Mandarin translator at the SHAC clinic in Chapel Hill, I frequently encountered foreign patients visibly stressed by their inability to understand the language. I remember my first patient, a young Chinese girl, who appeared overwhelmed and resorted to nodding at the doctor to mask her confusion. The experience of translation has given me insight into how structural issues contribute to communication barriers and exacerbate the decline in health literacy. These issues include deficiencies in the education and training of healthcare providers, inadequate policies on cultural diversity, and funding constraints in rural healthcare. This essay will explore how health literacy, influenced by communication barriers such as physicians’ inadequate communication skills and patients’ limited language proficiency, affects patients’ access to healthcare and their mental and physical well-being.

Physicians’ Communication Skills

According to the National Assessment of Adult Literacy, ‘36% of adult participants in the U.S. have basic or below-basic health literacy skills’ (Cutilli & Ian, 6). This data suggests varying levels of foundational medical knowledge among patients, emphasizing the significance of proper explanations by physicians. Given this information, healthcare providers’ poor communication skills, including the unintentional use of medical jargon and insensitive and inappropriate expressions, could further deteriorate the already limited healthy literacy.

The use of medical jargon by physicians, without considering patients’ varying levels of health literacy, can lead to negative outcomes. In the Oral History interview, Lisa McKeithan, the Program Director for Positive Life, mentions her observation that “physicians tend to use many jargon that patients cannot follow” (McKeithan, 0:46:05). Using these “big words” confuses patients, leading to misunderstandings and limiting patients’ ability to make shared decisions with physicians (Links, A R et al., 3). Sabra Hammond’s interview suggests a similar situation where she, as a locum tenens physician, needs to “do a lot of talking about patients’ diseases from scratch to try to get their attention,” otherwise, patients may not fully comply with their medication (Hammond, 0:08:43). Sabra not only comments on the impact of medical terminology on the accessibility and quality of healthcare but also on patients’ adverse health behaviors, such as failure to adhere to treatment plans. Additional negative health behaviors encompass skipped primary care visits and inadequate self-management of health. The study conducted by Graham claims that these adverse health behaviors often result in patients returning to a doctor’s office with more severe conditions or, even worse, ending up in the Emergency Room (Graham & Brookey, 2).

In addition to conveying information in ways that patients can clearly understand and follow, healthcare providers also need to express information acceptably and appropriately. Sabra proposes that sometimes translators “are using even simpler language than she is” (Hammond, 0:14:03), such as “this will kill you,” which is too curt and straightforward for patients to accept and process the information. Sabra believes this cruder form of expression influences patients’ active engagement in healthcare, reducing the percentage of patients who are coming back (Hammond, 0:15:27).

The communication skills of healthcare providers are considered a structural barrier, given that the issues are rooted in the medical training systems. Most medical education programs pay attention to the technical and biomedical aspects of healthcare and seldom emphasize the significance of adequate communication, which is essential in “enhancing patient satisfaction, adherence, functional status, and clinical outcomes” (Cegala & Lenzmeier Broz, 1).

In short, the limited communication capabilities of healthcare providers, including the use of jargon and inappropriate forms of expression, will adversely impact patients’ accessibility to healthcare, quality of healthcare, and well-being. In addition to issues of physicians, patients’ poor language proficiency is another factor impairing health literacy.

Patients’ Language Proficiency

Poor language proficiency can be attributed to several factors, but a common theme identified in the Oral History program is the cultural background of immigrants, particularly given that North Carolina has a substantial Hispanic community. Multiple oral history interviews suggest that many patients in North Carolina are Spanish-speaking (McKeithan, 0:22:11). Data collected by the North Carolina Office of State Budget and Management also shows that “between 2010 and 2020, the Hispanic population grew by 40% in NC.” These non-native speakers face significant challenges in clinical settings with their inadequate language proficiency, which can negatively affect health literacy, mental well-being, and accessibility to healthcare.

With poor language proficiency, non-native patients experience mental burdens during doctor-patient conversations. For instance, Jacqui Laukaitis, an interpreter with Open Door Clinic, describes witnessing a pregnant woman who was scared because “she does not speak the language” (Laukaitis, 0:35:03). Meanwhile, Andrea Williams-Morales, an administrative assistant at CommWell, notes that patients may “have a sense of embarrassment” (Morales, 0:38:11). She further claims that patients are afraid to ask questions because they don’t want to be seen as ignorant, which prevents them from engaging in conversation. She believes this creates a form of “regression; there’s more fear […] people are in hiding [and] are not seeking help” (Morales, 0:46:11), leading to the reduced quality and efficiency in healthcare. In addition to the heavy mental burden, the review study conducted by Berkman et al. connects the health literacy of patients with more detrimental physical health outcomes. By screening 111 studies, they concluded that higher all-cause mortality rates, especially among elderly persons, are strongly related to lower health literacy (Berkman et al., 101). Hence, it is suggested that the insufficient language proficiency of patients will disadvantageously impact the quality of healthcare and patients’ mental and physical well-being.

In summary, communication barriers such as physicians’ poor communication skills and patients’ deficient language proficiency significantly deteriorate patients’ health literacy and adversely affect their access to healthcare and overall well-being. Fortunately, many organizations are actively addressing this issue. Claudia Garrett, a health coach, mentions that CommWell Health Clinic “has many staff members who speak [the patients’] language” (Garrett, 0:43:58). Additionally, Jacqui notes that Open Door Clinic offers a service called ‘Language Line,’ where patients can call to have an interpreter provided on demand (Laukaitis, 0:54:01). The engagement of bilingual physicians and trained interpreters could potentially benefit patients and help overcome these communication barriers. It is worth noting, however, that communication barriers involve issues on both the patients’ and healthcare providers’ sides. Therefore, future solutions should make more effort to take both perspectives into account.

References

Berkman, Nancy D., et al. “Low Health Literacy and Health Outcomes: An Updated Systematic Review.” Annals of Internal Medicine, vol. 155, no. 2, July 2011, p. 97. DOI.org (Crossref), https://doi.org/10.7326/0003-4819-155-2-201107190-00005.

Cegala, Donald J., and Stefne Lenzmeier Broz. “Physician Communication Skills Training: A Review of Theoretical Backgrounds, Objectives and Skills: Physician Communication Skills Training: Theoretical Backgrounds, Objectives and Skills.” Medical Education, vol. 36, no. 11, Nov. 2002, pp. 1004–16. DOI.org (Crossref), https://doi.org/10.1046/j.1365-2923.2002.01331.x.

Cline, Michael. “Hispanic Population Is Fastest Growing Population in North Carolina.” NC OSBM, 1 May 2023, www.osbm.nc.gov/blog/2023/05/01/hispanic-population-fastest-growing-population-north-carolina#:~:text=was%20in%201990.-,Since%20the%201990s%2C%20the%20Hispanic%20population%20has%20been%20the%20fastest,%25%20of%20the%20total%20population).

Cutilli, Carolyn Crane, and Ian M Bennett. “Understanding the health literacy of America: results of the National Assessment of Adult Literacy.” Orthopedic nursing vol. 28,1 (2009): 27-32; quiz 33-4. doi:10.1097/01.NOR.0000345852.22122.d6

Graham, Suzanne, and John Brookey. “Do patients understand?.” The Permanente journal vol. 12,3 (2008): 67-9. doi:10.7812/TPP/07-144

Links, A R et al. “Surgeon use of medical jargon with parents in the outpatient setting.” Patient education and counseling vol. 102,6 (2019): 1111-1118. doi:10.1016/j.pec.2019.02.002

Schouten, Barbara C., et al. “Mitigating Language and Cultural Barriers in Healthcare Communication: Toward a Holistic Approach.” Patient Education and Counseling, vol. 103, no. 12, Dec. 2020, pp. 2604–08. DOI.org (Crossref), https://doi.org/10.1016/j.pec.2020.05.001.

Teixeira Da Silva, Jaime A. “Can ChatGPT Rescue or Assist with Language Barriers in Healthcare Communication?” Patient Education and Counseling, vol. 115, Oct. 2023, p. 107940. DOI.org (Crossref), https://doi.org/10.1016/j.pec.2023.107940.