Communication as Support for Health Literacy in Patients of Different Nationalities in Interaction with the Hospital Environment

Introduction

Communication between nurse and patient is a very important part of nursing care. Effective communication is the foundation of the nurse-patient relationship. Through communication we get to know patients on the ward, try to eliminate fear, build mutual trust and improve patients' health literacy. The healthcare services sector, nursing and medical care are areas where intercultural communication is increasingly applied. This is a consequence of doctors, nurses and other healthcare workers coming into more frequent contact with foreigners — representatives of different national cultures and different languages. Contact occurs whether foreign tourists, students or immigrants come to the hospital for various reasons, or doctors and nurses go to work in other countries as part of international aid to developing countries (Průcha, 2010).

Health Literacy

Hospitalizations of foreigners in 2019 represented 0.3% of total hospitalizations and they were most often treated in inpatient healthcare facilities in the Trenčín region (NCZI, 2019). According to data from the Ministry of Health of the Slovak Republic, healthcare was provided to approximately 30,000 Ukrainians (MZ SR 2023).

Members of an ethnic or cultural group speak the language of their group fluently and may not know the language of the country in which they either live or are currently staying. Communication barriers and lack of information can cause frustration, fear, anxiety, anger, sadness and many other adverse emotional states (Kutnohorská, 2013). "Foreigners must be informed in a language they understand. Pre-printed instructions in a world language may be used" (Vondráček, Vondráček, 2008, p. 19). Kutnohorská (2013) states that finding an appropriate way of communicating in multicultural nursing is difficult. In practice we may encounter several variants. We can communicate not only verbally but also non-verbally through gestures, facial expressions and movement. Advanced communication strategies to overcome language and cultural barriers in patient care include using an interpreter, encouraging questions, using pictograms – communication cards and other tools such as dictionaries, paper and pen, pictures and photographs for communicating about risks, providing instructions in both written and spoken form (Agency for Healthcare Research and Quality, 2022, Center for Health Care Strategies, 2024). It is precisely in such situations that various means of alternative communication can be used, including communication cards (pictograms). PICS pictograms (Pictogram Ideogram Communication Symbols) were created in 1980 in Canada. Their author is speech therapist Subhas C. Maharaj. Pictograms spread primarily in Scandinavia, where they are still very frequently used. They are simple black-and-white symbols, i.e. a white symbol on a black background. They are often used by people with color vision deficiency. Their simplicity and easy recognizability are a great advantage that color picture symbols with many details do not provide (Šarounová et al., 2014). By pictograms we can mean images expressing various activities that may also be supplemented with text. If we try to find an appropriate way to communicate with such patients, we eliminate their fear, frustration, anxiety about the unknown and, above all, we improve patients' health literacy.

Methodology

This brief review study analyzes current professional articles focused on the issue of communication as support for health literacy in patients of different nationalities in interaction with the hospital environment. The keywords used in preparing the paper were: communication, communication cards, foreigner, language barriers, health literacy. The sources used related to the subject matter.

Results

The World Health Organization defines health literacy as cognitive and social skills that determine the motivation and ability of individuals to gain access to information, understand it and use it in ways that promote and maintain good health (Úrad verejného zdravotníctva SR, 2024, online). "It would be desirable if every hospital had various language versions (in English, German) of important documents prepared, for example informed consent or information for hospitalized patients. In some hospitals one may also encounter cards that are supplemented with translations of the meaning into several world languages. These cards facilitate communication with foreigners." (Kapounová, 2007, p. 174). Among the biggest language barriers we count taking a medical history and understanding informed consent. The first question before beginning to take a history should be to ask in which language the patient wishes to communicate (Joint Commission, 2010). Communicating in this way is more time-consuming, but generally provides the necessary information. Each clinical workplace has its own specifics, so when creating communication cards one must first focus on the needs of patients in those particular workplaces. The problem in creating such communication cards is mainly the choice of pictograms, which must be simple enough, descriptive and unambiguous so that people understand them and can identify them. Not all symbols can be easily identified by people without text. Therefore we can recommend that the patient receive appropriate preparation for such a method of alternative communication, whether through family members or an interpreter who can read the description of the pictogram and explain its meaning to the patient. When using communication cards we assume cooperation, because with non-cooperative patients such a method is unusable (Kudlová In Špirudová et al., 2006). "A pictogram (known abroad as PIC – Pictogram Ideogram Communication) is a stylized image, a graphic sign-symbol that denotes something. Pictograms are becoming an international language (well-known pictograms include traffic signs, orienteering maps)." (Uríčková, Boroňová, 2008, p. 82). Patients can use pictograms (Fig. 1) to express their feelings, problems, experiences and needs to those around them. Their use aids decision-making and enables them to engage in conversation so that they are no longer merely passive participants. Using pictograms we can convey various warnings, commands, nursing activities or instructions (Fig. 2).

Fig. 1 Pictograms (communication cards) – examples of patient health problems (including foreign language versions)

Fig. 2 Pictograms (communication cards) – examples of nursing activities (including foreign language versions)

According to Allen-Meares, Lowry, Estrella, Mansuri (2020) written and oral communication must be available in different languages according to the target population. The entire healthcare system rests on the assumption that patients understand complex written and spoken information. Many patients have difficulty understanding medical terms, navigating healthcare facilities, or even following medical prescriptions. A visual representation (Fig. 3) will contribute to better understanding of pharmacological treatment indications in individuals with low health literacy, in patients of different ethnicity, etc.

Fig. 3. Prescription – taking medication

Health literacy is influenced by individual factors such as level of education or cultural background, as well as the healthcare environment. According to Maia, Marques, Goes, Gama, Osborne, Dias (2024) limited language proficiency can indeed hinder understanding of health information and access to services. Low health literacy is associated with worse health outcomes, higher mortality rates, lower participation rates in check-ups, preventive healthcare including influenza vaccination, mammography, cervical and colorectal cancer screening, and higher treatment costs (Collins, et al. 2012).

Patients with low health literacy:

• have a higher risk of adverse health events,
• have less knowledge about their own health, have lower medication adherence,
• have less knowledge about the importance of preventive healthcare,
• are less able to participate in self-management of chronic diseases,
• have higher rates of depression,
• communicate less with healthcare workers, ask fewer questions,
• spend more on healthcare and medications (Agency for Healthcare Research and Quality, 2015).

Research (Maia, Marques, Goes, Gama, Osborne, Dias, 2024) conducted in Portugal with 506 hospitalized migrants found that half of the respondents feel there are significant gaps in their knowledge and that they do not have the information they need to manage their health problems, and that despite maximum effort they do not understand most health information and are confused by conflicting information. To ensure successful participation/orientation of patients with low health literacy in a healthcare facility, we pay attention to the following measures:

• the facility name is clearly displayed and entrance signs are visible,
• signs use ordinary, everyday words in addition to the term "outpatient care", such as "enter",
• maps are available for navigating the premises,
• signs/navigation used have large letters and are in the languages of the population majority,
• color codes or symbols are consistently used on walls and floors,
• all staff wear some form of identification, such as a uniform, name badge (Center for Health Care Strategies, Inc., 2013).

Healthcare facilities are often large, confusing and constantly changing. Departments move, services expand and renovations take place, making it even more difficult to determine the hospital layout. Hospitals and healthcare facilities as such must consider indoor mapping and indoor navigation tools that can better assist patients and visitors and ultimately provide quality care. Upon arrival at the hospital campus, patients are often highly stressed and need help to immediately find their destination. Unfortunately, distinguishing features are often lacking. Static maps and signs are often confusing and ineffective in guiding visitors to their destination. Digital indoor mapping and navigation provides a solution because it enables easier and less time-consuming wayfinding. Several ways this technology can be implemented in hospitals:

• Websites,
• Mobile application,
• Kiosks and directories,
• Printed materials,
• QR codes (Mappedin Inc, 2024)

"Easy access to healthcare services and navigation of them is an important aspect of using healthcare services. Therefore, a healthcare facility must use language, symbols and signage that is simple and easily understandable even for users with low levels of health literacy" (International Working Group Health Promoting Hospitals and Health Literate Healthcare Organizations, 2019, p. 31).

The Department of Health Services of the Ministry of Health of the Czech Republic prepared bilingual patient communication cards to ensure easier communication between Czech healthcare workers and their foreign patients. The cards are available in nine language versions and are thematically divided into five areas. Each card contains a set of questions in Czech, their translation into the foreign language and also a phonetic transcription of pronunciation in that language. Within nursing, the following thematic areas are covered – information upon patient admission to hospitalization, elimination, sleep, nutrition, self-care and hygiene, sensory perception, pain, breathing, physiological functions, invasive access, medication use, skin, biological specimen collection (Fig. 4, 5). (Source: Ministry of Health of the Czech Republic, 2020).

Fig. 4 Communication card: Nutrition

Fig. 5 Communication card: Medication use

Training of healthcare workers in health literacy has been shown to improve staff communication skills and achieve desirable outcomes, namely patient satisfaction, building trust, and correct diagnosis of disease (Nesari, M et al. 2019).

Conclusion

"Successful communication requires knowledge of the cultural specificity of communication." (Kutnohorská, 2013, p. 67). For patient health and safety it is necessary to bridge the gap between the literacy of healthcare workers and their patients in order to achieve effective communication and understanding. "The nurse, every healthcare worker who provides care to clients from different cultures should be equipped with at least minimal knowledge of multicultural communication, sensitivity and understanding, and should be equipped with a high level of communication culture, because communication with the sick is of fundamental importance; it can greatly help, but also greatly harm." (Kutnohorská, 2013, p. 68).

Authors: PhDr. Marcela Ižová, PhD. PhDr. Mgr. Mariana Magerčiaková, PhD., MPH, MBA Faculty of Health, Catholic University in Ružomberok

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