This is the start of a series of articles we’re posting on how dismantling barriers of patient engagement can lead to better outcomes. We’re starting our series by discussing communication and language elasticity.
In medicine, we're looking at how specificity of language impacts patient behaviors for clinical recommendations.
The purpose of this article is to exhibit how the specificity of language is essential when diagnosing or treating a patient. The seven levels of language and communication1 are critical in reaching the ethnic demographic, particularly underserved minorities, with effective communication to help them better understand their diagnoses and related health conditions.
Immigrants are often limited with poor English proficiency preventing their understanding of their medical conditions.2 Both immigrants and underserved minorities may have lower educational levels and minimal health literacy, which compounds effective communication.3 Further contributing to the problem, providers may not be adequately trained to communicate with populations from differing cultures and educational backgrounds effectively. Cognitive challenges and intergenerational barriers may also influence poor English proficiency and low health literacy. These problems can then lead to a poor understanding of a diagnosis or related health condition and limit the patient’s ability to follow recommendations, resulting in poor health outcomes.4,5 In diagnosing a patient with a disease, the patient must be taught the best practices in treating and managing the condition through communication at their language and health literacy level. To educate the patient, providers must effectively communicate with the patient at a level they can understand. Then, the patient can be more responsive in developing a good understanding of what they need to do going forward to ensure the best outcomes.6
Figure: The seven levels of communication and, by extension—language interpretation. As one can see, the pyramid levels are divided into an informational zone and an influential zone. In healthcare and enhancing the patient-provider relationship, those levels in the influential zone are among the most important. The impact or influence of each communication level increases, moving from handwritten notes to phone calls, events and seminars, and one-on-one meetings. Those one-on-one meetings are among the most important in the patient-provider relationship.
Source: Maher M. The 7 Levels of Communication. Dallas: BenBella Books; 2014.
From the Bottom Up
In exploring the seven levels of language communication, interpretation, and how they influence healthcare outcomes, it is most helpful to address each level, starting at the pyramid’s base in the informational zone and progressing through the influential zone to the top. The informational zone includes advertising, direct mail, and electronic communication. Handwritten notes overlap being informative or even influential. The influential aspects of language and communication include phone calls, events and seminars, and one-on-one meetings.
Advertising is essential in the information flow to potential patients regarding healthcare services in a community. Advertisements on TV, radio, social media, billboards, newspapers, church health fairs, and other community events are often the foundation of getting the word out about helpful healthcare services in a community. Some healthcare systems advertise with pictures or videos of providers, so potential new patients will see that the provider looks like them. In addition, they may also mention in the ad that the provider is proficient in English, Spanish, or other languages if they are attempting to increase their services to a broader community seeking care. Advertising works in getting potential patients connected with available providers. With the diversity of the US population, it is crucial to let potential patients know that providers can relate to them.
Direct mail is another essential avenue to provide information regarding health care services to newcomers in a community or advertise new providers available to serve the community. Direct mail is an effective form of advertising. Some databases are often purchased by potential advertisers of goods and services that detail the contact information of new homebuyers or apartment residents in a community. This is an effective method of sharing information regarding healthcare goods and services to newcomers in a community. Direct mail materials are adapted for a specific population and include language and educational appropriateness. Much of the same information that is shared through advertising is also shared through direct mail.
Today, electronic communication is an effective form of information sharing and transfer. Most people have access to smartphones, e-mail, and social media to keep up with family and friends. E-mail advertising, text messaging, and advertising on social media are newer and very effective methods of information sharing. Many providers have adapted to using this form of communication. Once a potential patient establishes contact with a provider, the providers can send email or text messages directly to the patient to remind them of upcoming appointments or links to other healthcare informational resources.
Handwritten notes are effective in conveying information and influence and are in an overlapping informational/influential zone all by themselves. Fewer and fewer people are handwriting notes to communicate, but it tends to be very effective in many situations. However, the electronic communications boom has enabled healthcare providers or office staff and other industries to communicate efficiently with the masses. One thing worth noting is that often patients may send handwritten notes to the provider and office staff thanking them for taking care of them at a recent visit. These handwritten notes are an important tool that can work for the patient or the provider and are indicative of the overall satisfaction with the visit.
The first communications base in the influential zone is that of phone calls. Most people still use the telephone to communicate—scheduling appointments, appointment reminders, and sharing normal results and other important information with patients. It is also important for a patient to communicate with another human on the other end of the phone rather than an automated system. Personal phone calls often mean more to the patient than texts or automated messages. From a business perspective, it may be more efficient to have an automated phone system. However, from the patient’s perspective, speaking to another human conveys an underlying message of care by the providers.
Events and Seminars
Events and seminars are important forms of communication, particularly if it is an event or seminar that targets a particular culture or demographic or health conditions common to them. For example, suppose diabetes or hypertension is prevalent in a community. In that case, health fairs help screen many in the population who may not otherwise have access to the screening. For those with concerning screening results, this also provides an opportunity to connect them to a provider. Providing free seminars to share information about risks of hypertension or diabetes and how to manage them have also been successful—especially if those sponsoring the events or delivering the seminars are of similar demographics and culture.7 One practical example of a seminar that was effective in a southern community was the “Maybe Baby” seminar sponsored by one of the local health care systems. The targeted demographic was all races and demographic groups of reproductive age that were thinking about planning a family or having difficulty getting pregnant. It was a two-evening seminar conducted in the large ballroom of a well-known hotel. The organizers shared all kinds of information (at an 8th grade level) about the reproductive system, financial considerations, and things to expect during the pregnancy, delivery, and post-pregnancy. The seminar was comprehensive. The health system also was able to highlight the diversity of obstetricians and gynecologists as presenters, their desirable health care facilities, and ease of access to and from the facility. It was a hit in the community—with most of the seminar attendees becoming patients of the providers and having their child at their hospital. The same can be done in communities to serve immigrant and low health literacy populations.
One-on-one meetings, patient-provider consultations, or office visits—it does not matter what one calls them. These are the most essential in effectively communicating with a patient, so they can understand and have the opportunity to ask questions. In addition, these one-on-one meetings build trust and long-term relationships. Continuity of care of a patient by the same provider is critical in caring for a patient. As a provider’s fund of knowledge is built over time, the patient is followed longer and usually has better outcomes.
While many provider training programs incorporate patient education modules to enable providers to better communicate and interact with diverse patients, developing appropriate language and communication skills with patients is usually improved over time in practice. All seven levels of language and communication are essential for providers in establishing and building rapport with underserved communities. However, it is the one-on-one patient-provider interaction that is the most essential in communicating effectively with patients so they can understand. One-on-one meetings are very personal, help build trust, and are an integral part of the intimate provider-patient relationship.
- Maher M. The 7 Levels of Communication. Dallas: BenBella Books; 2014.
- Yeo S. Language barriers and access to care. Annual Review of Nursing Research. 2004;22:59-73. Accessed July 28, 2021.
- Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. American Journal of Health Behavior. 2007;31:S96-104. Accessed July 28, 2021. http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105927729&site=ehost-live
- Saha S, Fernandez A, Perez-Stable E. Reducing Language Barriers and Racial/Ethnic Disparities in Health Care: An Investment in Our Future. J Gen Intern Med 22(Suppl 2):371–2 . DOI: 10.1007/s11606-007-0372-4; PMCID: PMC2040485
- Paasche-Orlow M. Health Communication: Not Just Autonomy, Also Justice. American Journal of Bioethics. 2017;17(11):49. doi:10.1080/15265161.2017.1378757
- Anders RL. . Practical tips for effective communication. Nursing Management (Springhouse). 2021; 52 (6): 10-13. doi: 10.1097/01.NUMA.0000752812.54583.d6.
- Jolles EP, Clark AM, Braam B. Getting the message across: opportunities and obstacles in effective communication in hypertension care. Journal of Hypertension. 2012;30(8):1500-1510. doi:10.1097/HJH.0b013e32835476e1