Eingeschränkte Gesundheitskompetenz in der Physiotherapie bei der Primärversorgung: Setzen Physiotherapeut*innen Techniken zur Verbesserung der Kommunikation ein?

Summary

Background

The paper sheds light on the significance of health literacy (HL) for physiotherapy [1]. In a survey conducted in eight European countries, almost 50 % of participants reported that their HL was insufficient or problematic [2], resulting in diminished self-management of chronic diseases and decreased use of preventive health services, in turn leading to poorer health outcomes and higher health care costs. Low socioeconomic status is closely linked to poor HL, and both are often associated with lower education levels as well as poor reading, spelling and arithmetic skills.

Literature recommends the use of the teach-back technique, short sentences and the avoidance of medical jargon. For physiotherapy, it has not been investigated yet which of these recommendations are relevant.

Objective

The objective of the study by Scheer-Horst et al. was (1) to research which verbal communication techniques are recommended by experts and patients and (2) in how far physiotherapists use these techniques to communicate with persons of low socioeconomic status.

Methods

The authors state that they conducted a two-phase mixed-method study with a qualitative as well as a quantitative approach. In Phase 1, they held semi-structured focus group interviews with patients and experts. The interview guide included questions such as “Imagine a conversation with a patient with limited HL; how did that conversation go?” The first focus group consisted of 5 experts, while the second focus group consisted of 5 participants with limited reading skills as an approximation to diminished HL. The same persons from the research group served as moderators for each of the two focus group interviews.

Phase 2 focused on the use verbal communication during the first physiotherapy consultation of persons with musculoskeletal disorders. Physiotherapists made an audio recording of the first consultation.

For the analysis, interviews and first consultations were transcribed verbatim. The codebook for Phase 1 was developed from literature and new categories were created in consultation by 2 researchers. In the transcripts from Phase 2, clauses were matched to the four relevant communication strategies that had been identified in Phase 1. 2 coders coded the first ten recorded units independently to determine inter-rater agreement. The remaining data from Phase 2 was coded by one person only.

With regard to the frequency of use of certain clauses, logistic regression was used to determine the odds the communicative strategies could be observed in persons with different HL levels.

Results

In Phase 1, two focus group interviews were conducted. One focus group consisted of 2 male and 3 female experts (physiotherapists, doctors, health care providers). The lay group consisted of 3 men and 2 women. Four elements were identified that seem relevant to communication: (a) recognition of poor HL through typical excuses, (b) fear of the poor HL being discovered, (c) a good relationship between health care providers and patients that reduced this fear and (d) recommendations for communication techniques. Both groups recommended the teach-back technique [2), which helps patients to understand information and follow advice. Medical jargon may be used as long as it is being explained. Language should be adapted to the patient’s HL level by using unambiguous wording, short sentences and simple words. The use of metaphors, images and anatomic models was found useful. The experts recommend the “Ask Me 3” method [3].

Use of the teach-back method [2] was only observed once in the group with higher socioeconomic status. Medical jargon was used in both groups in 5 % of the clauses and rarely explained (0.5 % in the group with low educational status, 1.1 % in the group with higher educational status).

Conclusions

The authors highlight the significance of the teach-back technique [2] recommended by experts and patients. However, the results show that there are barriers to using this technique. Previous research has shown that, from the perspective of therapists, these barriers lie with patients as well as therapists. Explanations for communication strategies being used with the same frequency for persons with different HL levels were (a) failure to identify persons with poor HL and (b) a lack of skills for adaptation to communicative needs.

Annotations

The study is examined in terms of reliability and validity as described by Coleman et al. [4].

On reliability

(A) Triangulation: A combination of 2 methods was applied. Similar results from different sources support the consistency of results. (B) Detail and transparency: The questions asked in the focus group interviews are reported in the appendix. However, it remains unclear how the interviews were adapted for persons with poor HL. (C) Coding: When coding the content, 2 researchers analyzed part of the interviews independently. Inter-rater agreement was statistically tested and found to be satisfactory, except regarding the use of medical jargon. There was probably a lack of resources to have the entire data set analyzed by 2 independent coders.

On Validity

(1) Comprehensiveness of the data base: The data base was limited, as there were only two focus groups with a low number of participants. However, it was enriched by patient interviews and audio recordings of consultations. The number of observations in persons with low HL could have been higher. (2) Search for contradictory evidence: No evidence was sought that could potentially refute the present findings; for example, further observations in other settings would have been useful. (3) Validation of results: The results were not presented to the participants for validation, which can be considered a methodological shortcoming. (4) Quasi-statistics: The categories identified were analyzed descriptively. The calculations show nonsignificant results for the hypothesis that patients with different socioeconomic statuses are treated differently. Sample size was mentioned as a critical aspect. The data are interdependent on several levels; it is possible that this was taken into account (LME4 models [5]). Whether the selected parameter (number of matches found for the techniques) is relevant for answering the question “whether they adjust their verbal communication for patients with lower education” must be questioned. Why, for example, should medical jargon be used or explained with varying frequency among different sets of people? The differences should be sought in “how” rather than “how often”. (5) Neutrality: It was not described how the researchers' preconceptions influenced the coding or how this influence was prevented. However, the inter-rater agreement of 2 coders was checked. (6) Triangulation: This also represents an aspect of validity, as various data help to verify the integrity of results.

The positive assessment of the teach-back technique was made not only by experts but also by patients, which is a remarkable result. The relevant observation for teaching and practice is that this technique is not used by physiotherapists. The study’s findings should lead to a rethink in practice.

Publikationsverlauf

Artikel online veröffentlicht:
08. Dezember 2025

• References

• 1 van der Scheer-Horst E, Rutten G, Stortenbeker I. et al. Limited health literacy in primary care physiotherapy: Does a physiotherapist use techniques to improve communication?. Patient Edu Counsel 2023; 109: 107624
• 2 Wittink H, Oosterhaven J. Patient education and health literacy. Musculoskel Science Pract 2018; 38: 120-127
• 3 Institute for Healthcare Improvement, Hrsg. Ask Me 3: Good Questions for Your Good Health. Zugriff am 29. April 2025 unter: www.ihi.org/resources/tools/ask-me-3-good-questions-your-good-health
• 4 Coleman P. Validity and reliability within qualitative research for the caring sciences. Intern J Caring Science 2022; 14: 2041-2045
• 5 Smeets L, van de Schoot R. LME4 Tutorial: Popularity Data. Zugriff am 29. April 2025 unter: www.rensvandeschoot.com/tutorials/lme4/