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Department of Veterans Affairs
Medical Center
3001 Green Bay Road, North Chicago, IL 60031
“Analyzing Factors Affecting Functional Literacy in the
Context of Primary Care Patient/Provider Communication”
Dr. Tariq Hassan, M.D., Veterans Affairs Medical Center, North Chicago, IL
Dr. George Lutz, Ph.D, Veterans Affairs Medical Center, North Chicago, IL
Dr. Tom Muscarello, Ph.D, DePaul University, Chicago, IL
David R. Donohue. M.A., Qualitative Technologies Inc., Northwestern University
PURPOSE: Focusing On VA Patient and Provider Communication:
Dr. Tariq Hassan, M.D. Chief­of­Staff, North Chicago Veterans Affairs Medical Center said,
“Good communications builds and maintains quality health care exchange and delivery. It can also,
facilitate and encourage patient participation in their care, reduces anxiety and help patient’s to become
active participants in their treatment/care plans.
As discussed in this article, several factors play a key role in the communication process; however, literacy
and ability to utilize the tools of communication are the basic currency of communication, and unless
literacy issues are identified and properly addressed, it is unlikely that other interventions can be successful
utilized to improve provider–patient communication. (1) (2)
From the administration/organization standpoint, effective communication with the patient can further the
global drivers of health care, namely, access and timeliness of care, quality, patient satisfaction and cost
effectiveness. A well­informed and participatory patient will probably keep appointments, thereby reducing
costly no­shows and unnecessary ER visits. Patients can realize a greater overall satisfaction and level of
care with improved patient/physician interaction. (3)
Increasing patient participation in their care plan and their compliance level will likely increase the
effectiveness of the care itself, improve quality and reduce unnecessary utilization of resources. This can
translate into improving overall cost effectiveness and utilization of human resources within the health care
organization.”
ABSTRACT
PURPOSE: North Chicago VA medical staff instituted a one­page primary care medical appointment
information sheet to help patients navigate through their primary care appointment environment, but
discovered 65% of patients discarded the information sheet. Healthcare providers wanted to know why
the information sheet was not effective.
METHOD: Data gathered in this study used 3 patient and 2 VA doctor/clinician focus groups. Each
group contained 10­15 participants. Focus groups were 60­75 minutes in length. Participants were
asked five to six questions focusing on health care communications.
RESULT: Group discussion is particularly appropriate when the interview(s) have a series of open
ended questions and wish to encourage research participants to explore the issues of importance to
them, in their own vocabulary, generating their own questions and pursuing their own priorities. This
helped our researchers to identify common ground, reveal health communication challenges and areas
of convergence and divergence.
CONCLUSION: Healthcare providers and patients acknowledge significant healthcare literacy
problems exist. We recommend additional research on the impact of low literacy on elderly VA patients
and their medication regimens, a growing VA population most­at­risk. In addition, each primary care
VA patient should be given a health literacy screening test to establish a basic literacy baseline where
new communication interventions can be made available to match that patient’s literacy level.

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In addition, comparatively little attention has been devoted to enabling patients to comprehend their
condition and treatment, to make the best decision for their care and to take the right medications at the
right time in the intended dose. The result is many patients lack the confidence to ask questions concerning
their healthcare. (4)
The modern VA healthcare system began during World War I
with establishment of hospitals to treat and rehabilitate veterans
with service­connected disabilities. A second role was added in
1924 with the addition of hospital care for lower­income
veterans. Although the veteran population is projected to
decline over the next 10 years, the demand for VA health care
services continues to increase due to the aging of veterans
(average age is 62­years) and the comprehensive health care
services offered to veterans, including favorable pharmacy
benefits; the national reputation of VA as a leader in the
delivery of quality healthcare; long­term care services; and
improved access to healthcare with the opening of additional
community­based outpatient clinics. The VA is continuing to
focus on meeting the needs of its core population, especially
those with disabilities that are the result of military service. In
2005 the VA’s appropriation were $30.7 billion and with the
continuing War in the Middle East is proposing to continue
focusing health care on service­connected disabled veterans, as
well as, veterans with lower incomes and those who have special healthcare needs. (4)
A Diverse VA Patient Population—2006
The VA patient population is a vast heterogeneous group—over 5.7 million enrolled veterans, and over 25
million eligible vets. VA Medical Services represents the largest healthcare provider within the United
States today, and will be faced with providing ongoing service to new military veterans, but also to an
aging overall population with special healthcare needs. The VA population spans all races, numerous
cultures, all levels of education, all socioeconomic strata, and both genders, with approximately 85 percent
male. The VA patient population also shows a wide age range of 18 years and up, with two basic spikes 20
to 30 year old veterans with short military stints, and those over 50 years, representing retired military. This
heterogeneity of the population points to the need for greater awareness of differences in attitudes,
perception, and level of technological adeptness. Disabilities in the veteran population (includes blindness,
deafness, multiple chronic disease states, and mental disorders) also present barriers to quality healthcare.
(5)
Healthcare Literacy North Chicago VA Medical Center
Poor Literacy is a marker for an array of problems within the healthcare system that go far beyond a
persons reading ability or comprehension level. According to a major health literacy study (1), uncovered
major misconceptions involving low literacy skills describing several such widely held misconceptions:
people with low literacy skills are intellectually impaired and slow learners.
In fact, most people with low literacy skills are of average intelligence and function reasonably well by
compensating for their lack of reading skills. In absolute terms, the majorities of those in low literacy
populations are white, native­born Americans and hold a high school diploma. Among patients who did
admit trouble reading, 40% felt shame and more than 50% had never told their spouses or children about
their reading problem. (6)
METHOD:
North Chicago V.A Medical Center One­Page Primary Care Patient Information Sheet
Primary Care Appointment Procedural Policy within the North Chicago V.A. Medical Center used a single­
page patient informational handout to help patient’s understand appointment scheduling, medication
routines, treatment protocols and other pertinent information critical to maximizing the quality of their

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healthcare experience. However, North Chicago V.A. staff discovered in 2004, 65% of the primary care
patient population did not use the information handout. Clearly, answers were needed to why this patient
information sheet was discarded.
Using Focus Groups
Data from this VA study used 3 patient focus groups and 2 VA medical provider staff focus groups, of
between 10 to 15 participants, lasting between 60 to 75 minutes. Gaining access to such a variety of
communication is useful because knowledge and attitudes are not entirely encapsulated in reasoned
responses to direct questions. Everyday forms of communication may tell us as much, if not more, about
what people know or experience, as to gather a wide concourse including developing an array of opinions
and attitudes on issues impacting healthcare literacy, while helping to identify common ground.
Doctor/Clinician Focus Group Discussion Questions
1. Do your patients have problems comprehending and using healthcare information?
2. How do you communicate medical information to patients?
3. How do you know if patients understand information you give them?
4. How confident are you that your patient’s understand the steps they need to take in maintaining
and improving their health?
5. How can you improve communications with your patient’s?
6. Where are the strengths and weaknesses in healthcare communication at the VA?
Patient Focus Group Discussion Questions
1. Do you have problems comprehending and using healthcare information?
2. How does your doctor communicate medical information to you?
3. How do you tell your doctor about medical issues that you need to know more about?
4. How confident are you that you understand the steps you need to take in maintaining and
improving your health?
5. How can communications with your clinician be improved?
6. Where are strengths and weaknesses in healthcare communications at the VA?
Discussion Group Results
Doctor/Clinicians and Patients­Array of Opinions and Attitudes
KEY COMMUNICATION RESEARCH FINDINGS ­ DOCTORS/CLINICIANS SIDE
♦Patient’s hide their literacy level
♦Need to ask patients about their literacy ability
♦Need easy wording in layman terms of diagnostics and medicines
♦Patients have challenges with understanding their multiple medications and treatment routines
♦Write things down, letters, explain things in greater detail
♦Patient’s wants oral communications and simple instructions
KEY COMMUNICATION RESEARCH FINDINGS ­ PATIENT SIDE
♦Patients prefer verbal explanations and simple written instructions
♦Patients need to ask more questions.
♦Patients want additional treatment and medication information
♦Talk in layman terms that I can understand
♦Keep instructions and medical explanations simple
♦Can I bring a friend along to help my healthcare outcome—having support is good.
♦Have additional medical information sources or health library available
♦Asking questions keeps communications open, making it a two way street.
♦They need to tell us in simple language what to do, but it must be useful and condensed.
♦Medical providers should listen more.
PATIENT ISSUES – PERSONAL ISSUES­DOCTOR/CLINICIAN SIDE RESPONSES
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Patients can’t read
Patients hide their literacy level
VA patients getting older, sight, hearing, mental issues
Loss of memory, trouble with memory
Patient worry, patients are nervous during appointments
PATIENT ISSUES­ PERSONAL ISSUES ­PATIENT SIDE RESPONSES
1. Many VA patients have poor memory, can’t remember things
Patients rely on their doctor for the right information, as if it were the Gospel
Patients worry over test results and are stressed.
Patients don’t understand medical terms and meds
2.
Oral communications, followed by written communications
5.
Exam and test results need to be explained.
Have a patient appointment exit interview.
Keep information simple. Patients want directions; need test results and what they mean.
HEALTH INFORMATION MATERIAL ISSUES­ DOCTOR/CLINICIAN SIDE
RESPONSES
1. Patient’s need medicine lists and what meds do
Use different forms of health education media.
3. Information is missing
We don’t know if patients understand information given them
5. Font size on medical documents too small
Directions need to be simple
Develop a patient notebook, a profile to carry around
Print patient charts (information) with pictures and symbols
HEALTH INFORMATION MATERIAL ISSUES­ PATIIENT SIDE
RESPONSES
1. Talk in lay terms and tell me what’s going on
Don’t understand the meaning of what doctor is saying.
Keep the information simple. Patients want directions, need information on test results, meanings
Patient wants to know the side­effects of their medications.
2. Preprinted information
Personal medical information written out by doctor
Doctor calls me on phone
3. 5. Patients need to ask more questions in Primary Care appointment time.
Doctors spend too much time on their computer going over patient file information.
Usually I think before I go and make my own little notes on what to ask when I go in.
I use printed pamphlets, brochures, and internet
I use medical books and encyclopedia, journals
Doctors and Nurses tell me information, get opinions.
Main medical information is my doctor.
Patients prefer oral communications and written information.
6. It is probably more so that patients don’t start asking questions that they don’t have the time to answer.
I would be worried that if we could see the screen all the time, we’d try to ask about everything on the
screen. This would take up even more time.
PATIENT/CLINICIAN INTERACTION ISSUES­CLINICIAN SIDE
1. Type patient notes to give to them
Appointment time is limited; spend more time going over things

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We need to use new healthcare educational tools and see what works with particular patients
2. Patients are afraid to ask questions
Have a family member or friend present, an advocate in the appointment
Have MD’s/clinicians read instructions to patient
3. Patients are afraid to ask questions
We don’t have a benchmark to measure patient understanding
5. Ask patient for a small list of problems to discuss
Expand one­to­one contact time with patients
Spend more face time with each patient
Show more compassion, explain things, information
6. Doctor’s don’t explain enough
Show more compassion, explain things, information
Patients are afraid to ask questions
PATIENT/CLINICIAN INTERACTION ISSUES­PATIENT SIDE
1. I need answers to my medications and what they do
Doctors need to explain things more
Healthcare provider needs to ask patient if they understand the instruction they have given, and go over
things. Doctor needs to ask nurse to go over things and explain to patient.
2. Doctor needs to review patient file the day before their appointment.
Need faster medical consultation and my healthcare status.
Give follow up written report after medical appointment, what’s happening to me?
3. Patient’s need to be honest, talk about their conditions openly.
Improvements, as far as patient honesty goes I need to bring things up. You need to be able to get questions
answered.
4. I need answers to my medications and what they do.
The pharmacist needs to explain my meds to me and what they do.
I don’t remember everything about my condition.
5. Where can I go for the right information on my prescriptions?
Try a BEEPER to alert patient on test results
Healthcare provider needs to ask patient if they understand their instructions.
6. Medical test follow­up, results need to be explained. This makes patients more responsible
Patients not informed, they need more information Doctors need to explain things more
Do more health screening, preventative medicine
Doctor’s should not scare patients
TREATMENT/ADMINISTRATIVE ISSUES­PROCEDURE­CLINICIAN SIDE
Document healthcare notes
Make phone procedures simpler (inbound/outbound)
Expand health clerk’s education
Nurses take the lead in patient information­check information for patients
Pharmacy denies medications
Set up exit interviews for each patient
Get patient coming out of the clinics for education, information
TREATMENT/ADMINISTRATIVE ISSUES­PATIENT SIDE
1. We need to update patient information (results) because people are waiting.
I can’t understand him (The Doctor). At Hines and West Side VA you go see 1 doctor for an hour. A
month later you have an appointment at the same clinic and see a different doctor.

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A lot of them are students. You can’t understand them and they don’t understand you.
2. Doctors and Nurses tell me information, get opinions
Main source of information is my doctor.
5. Medical specialist—follow­up—what’s going on and have primary care doctor explain things.
we now get an appointment letter and phone call.
The medical tests don’t tell you a reading on your test and don’t explain things.
Doctors and Nurse seem to spend more time with patient explaining things, and see the patient understands.
Changes patient want to see on clinic procedures
1. Provider interaction
2. New procedures overall to help patients
3. More patient education, to explain things
PATIENT PSYCHO­SOCIAL ISSUES­CLINICIAN SIDE
Motivational issues
Control issues
Patients don’t want their medications
Passive VA patient’s (not actively involved)
PSYCHO­SOCIAL ISSUES­PATIENT SIDE
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N. Chicago VA Healthcare staff, friendly, professional and concerned about patients.
Don’t talk over my head
I’m confused by the high level medical talk
LITERACY ISSUES­PATIENT SIDE
Prefer verbal explanations and simple written instructions
Where can I go to get answers to my treatment or medications?
Talk in layman terms that I can understand
Keep things simple, instructions and medical explanations
Literacy levels change in patients due to diet, fatigue, lack of sleep and other factors
Use a 3” X 5” card to write questions down to ask doctors in appointments
Patient’s want to become more active in their treatment
CONCLUSION:
KEY RECOMMENDATIONS
1. Healthcare providers and patients acknowledged a healthcare literacy problem exists. Our
recommendation is to institute a patient healthcare literacy screening test at the Primary Care
Medical Appointment, as a benchmark to evaluating individual literacy level.
2. Additional research is needed to discover what healthcare educational media would be the most
effective and useful to a particular patient’s literacy level.
3. We recommend research focusing on older VA patient population, a group most­at­risk. The VA
needs to design new communication interventions helping patients with low literacy to manage
their medication regimens to reduce errors, and noncompliance level, resulting in increased
patient safety and quality of care of all stakeholders.
Establishing good communication practices between patient/clinicians help also to build strategies for
improving patient compliance including giving clear, concise, and logical instructions in familiar language,
adapting drug regimens to daily routines, eliciting patient participation through self­monitoring, and
providing useful and understandable educational materials that promote overall good health in connection
with medical treatment. (7) (8) (9)
Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient:
the physician knew best and the patient accepted the recommendation without question. This era is
ending, being replaced with involving the patient directly in health care outcomes and the movement

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toward shared decision­making. Patients are advising each other to "educate themselves and ask questions".
Patient satisfaction with their care rests heavily on how successfully this transition is accomplished. Ready
access to quality information and thoughtful patient­doctor discussions is at the fulcrum of this growing
healthcare communication revolution. (10) (11)
Reference:
(1) Nielsen­Bohlman LT, Panzer AM, Hamlin B, Kindig DA. , editors. Institute of Medicine.
Health Literacy: A Prescription to End Confusion.
(2) Davis TC, Wolf, MS. Health Literacy Implications for Family Medicine, Farm Med 2004
Sept; 36: 595­8.
(3) Shea JA, Guerra CE. Health Literacy Weakly but Consistently Predicts Primary Care Patient
Dissatisfaction. Int. J Qual. Health Care, 2006 Dec 18 th
(4) Smith JL, Haggerty J. Literacy in Primary Care Population: Is It A Problem?” Can J Public
Health, 2003 Nov­Dec; 94 (6): 408­12.
(5) Kelly PA, Haidet P. Physicians Overestimation of Patient Literacy: A Potential Source of
Health Care Disparities. Patient Educ Couns, 2006 Nov 29
(6) Wallace L. Health Literacy Skills: The Missing Demographic
Variable in Primary Care Research. Ann Farm Med. 2006 Jan­Feb; 4 (1): 85­6.
(7) Persell SD, Heiman HL. Understanding of Drug Indication by Ambulatory Care Patients. Am
J Health Syst Pharm, 2004 Dec 1; (23) : 2503.
(8) Davis TC, Wolf MS. Low Literacy Impairs Comprehension of Prescription Drug Warning
Labels. J Gen Intern Med. 2006 Aug; 21 (8): 847­51.
(9) Weiss BD, Mays MZ. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign.
Ann Farm Med. 2005 Nov – Dec; 3 (6): 514­22.
(10)Carty B, Kenney K. Consumer Informatics in Primary Care. Stud Health Technol Inform,
2006; 122: 36­37.
(11)Bailey P., Jones L. Family Physician/Nurse Practitioner: Stories of Collaboration. J Adv Nurs.
2006 Feb; 53 (4): 381­91.
Editor­ David R. Donohue, M.A.
QTinc@alumni.northwestern.edu
Cell (847) 651­3891