Development of a Communication Intervention for Older Adults With Limited Health Literacy: Photo Stories to Support Doctor–Patient Communication

Figures & data

Fig. 1. Development procedure for the photo story health literacy intervention. NL = The Netherlands; HU = Hungary.

Table 1. Barriers to doctor–patient communication regarding affective communication, information provision and gathering, decision making, and disease- and treatment-related communication

Category and Dimension	Theme	Quote
GP
A	Creating an asymmetrical relationship Being inattentive/not paying enough attention Sticking to a strict schedule	“She sometimes answers your questions really quickly. Then you don’t understand it properly. And she’s already gone before you have a chance to work out what she said.”
I	Being unclear Providing insufficient information Using complicated and difficult language	“He doesn’t explain anything. If I have a complaint, he either asks his assistant or hides behind his computer. He prescribes something, signs it and that’s it.” “Yes, that’s because he doesn’t speak very clearly. And you say ‘I didn’t quite understand. Could you repeat that?’, but you’re not going to ask him to repeat it a third time.” “Then the doctor’s lack of clarity has a greater impact than the illness itself. You suffer twice as much, because you are dealing with something that you know nothing about.”
Patient
A	Distrusting attitude Shame/uncertainty about disclosure Too insecure to confront GP Stress and emotions related to condition	“Sometimes you are nervous.” “Yes, tension and then you feel nervous.” “I don’t enjoy going to the doctor.” “Sometimes you feel ashamed, that it really is something. To say it.” “Yes, something is wrong. Otherwise you wouldn’t be going to the doctor.”
I	Lack of understanding Failure to provide comprehensible information	“Look, as you get older—I have it too—you find it more difficult to understand things.”
T	Being uninformed about medication management	“But I don’t understand it at all. Because this drug is for this and that drug is for that. I’m not usually afraid, but I am when it comes to those drugs.”
Interaction
A	Asymmetrical relationship Being dependent on GP Lack of trust	“No, it’s always at the back of your mind that you have to watch what you say, because at the end of the day it’s your GP and if something’s wrong, you’re dependent on him. So you need to make sure that you don’t irritate him so much that he starts to hate you. That’s what I mean.” “I think it’s because you don’t consider your doctor to be a confidant.” “Once I was told, ‘Yes but I’m the doctor.’ I replied, ‘Yes, but it’s my body!’” “He’s said that to me too: ‘I’m the doctor.’”
Context
A	Patients experiencing fear, stress, and anxiety related to the clinical setting Low availability of GP due to time constraints resulting in GP not paying attention	“I turned out to be allergic to white coats. I check my blood pressure at home and it’s normal, but when I go there it shoots up to 170.” “You notice, or at least I do, that the GP thinks he is pressed for time.”
I	Low availability of GP/care due to time constraints Information about medication difficult to understand	“Well, nothing like enough care is available.” “Do you know what I dislike? The GP’s practice is closed from five on a Friday afternoon until Monday morning. The pharmacist too.”
T	Information about medication difficult to understand	“With some medication I can’t even pronounce what it says on the label.” “Yes, I’m on lots of different medication. But I don’t know what it’s all for.”

Note. GP = general practitioner; A = affective communication; I = information provision and gathering; T = disease- and treatment-related communication.

Table 2. Facilitators of doctor–patient communication regarding affective communication, information provision and gathering, decision making, and disease- and treatment-related communication

Category and Dimension	Theme	Quote
GP
A	Being understanding Respect, trust, sincerity, and security Humane character Paying attention/listening	“We’re really lucky with the GPs here. They’re like normal people.”
I	Clear and adequate information Providing explanation Listening Creating an opportunity to ask questions	“It should be in comprehensible language. If he starts spouting Latin to me, I’m lost.” “That lady took the time to listen to you.”
D	Transparency about and patient involvement in treatment	“She explains things to me … What’s wrong with me. What’s going on. And the best way to deal with it.”
T	Transparency about and patient involvement in treatment Good and appropriate treatment	“If you visit him: ‘What seems to be the problem?’ You expect him to listen, to answer your questions properly or provide the right medication.” “He said, ‘I want you to do the following: Call me if it [injection] helps and call me if it doesn’t!’”
Patient
A	Using appropriate and polite language Being open and honest	“Well, then I just say so, in polite terms of course.” “I just pretend he’s my brother. I tell him, and that’s that.”
I	Asking questions Expressing own ideas/needs to GP Using appropriate and polite language Preparing/writing down questions Appreciating the need for medical care to facilitate disclosure	“Then I interrupt him and ask, ‘What’s that?’” “Well sometimes, when I’m feeling a bit insecure about going to the doctor, I write things down. Then I hand him my notes … with questions.” “Yes and if I don’t understand him, I ask, ‘Could you explain that again?’”
Interaction
A	Mutual respect and trust Symmetrical relationship Mutual openness and honesty	“A good doctor is a partner in these matters. I can ask him questions and he will help me.” “If you have been consulting someone for a while, and you are familiar with each other, it automatically gets easier [to express needs].”
T	Mutual openness and honesty about disease and treatment	“If they don’t know, they should say so rather than give you any old answer.” “You have to tell the doctor. He can’t know just by looking at you.”
Context
A	GP availability: attention, interest, time, patience Social support	“The GP is attentive. He answers questions intelligibly, provided that others let him, as he receives many phone calls. If I sit in the consultation room and he answers the phone too many times, I lose track of what we were saying.” “Yes and we usually go there every 2 months with a list of what we’d like and then that is written down. For us it’s a real bonus that we have a good relationship with the doctor. My father is 81. He usually comes with me and we go in together.”
I	Clear, comprehensible information	“I would go the reception desk and ask the girls there for help.”
T	Availability of care Clear, comprehensible information	“Let them provide a GP’s surgery here [at the care home]. From 10 to 11 or 11.30 in the morning.”

Note. GP = general practitioner; A = affective communication; I = information provision and gathering; D = decision making; T = disease- and treatment-related communication.

Fig. 2. Story 1 about lack of attention from a general practitioner.

Fig. 3. Story 2 about bringing someone for support.

Fig. 4. Story 3 about incomprehensible medical language.

Fig. 5. Screenshot of an interactive video clip on www.oefenen.nl. The question on the right part of the screen asks the user “Have you ever experienced something similar? Were you unable to tell your doctor something?”.