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Open Access Open Badges Research article

Beyond literacy and numeracy in patient provider communication: Focus groups suggest roles for empowerment, provider attitude and language

Doug Brugge1*, Timothy Edgar2, Kelly George3, Janette Heung4 and M Barton Laws5

  • * Corresponding author: Doug Brugge

  • † Equal contributors

Author Affiliations

1 Tufts University School of Medicine, 136 Harrison Ave., Boston, MA, USA

2 Health Communication Program, 120 Boylston Street, Emerson College, Boston, MA, USA

3 School of Communications and Theater, 2020 North 13th Street, Temple University, Philadelphia, PA, USA

4 Harvard School of Public Health, 4/F Landmark Ctr., 401 Park Drive, Boston, MA, USA

5 Tufts Medical Center, 800 Washington St, Boston, MA, USA

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BMC Public Health 2009, 9:354  doi:10.1186/1471-2458-9-354

Published: 21 September 2009



Although the number of people living in the United States with limited English proficiency (LEP) is substantial, the impact of language on patients' experience of provider-patient communication has been little explored.


We conducted a series of 12 exploratory focus groups in English, Spanish and Cantonese to elicit discussion about patient-provider communication, particularly with respect to the concerns of the health literacy framework, i.e. ability to accurately understand, interpret and apply information given by providers. Within each language, 2 groups had high education and 2 had low education participants to partially account for literacy levels, which cannot be assessed consistently across three languages. Eighty-five (85) adults enrolled in the focus groups. The resulting video tapes were transcribed, translated and analyzed via content analysis.


We identified 5 themes: 1) language discordant communication; 2) language concordant communication; 3) empowerment; 4) providers' attitudes; 5) issues with the health care system. Despite efforts by facilitators to elicit responses related to cognitive understanding, issues of interpersonal process were more salient, and respondents did not readily separate issues of accurate understanding from their overall narratives of experience with health care and illness. Thematic codes often appeared to be associated with education level, language and/or culture.


Our most salient finding was that for most of our participants there was no clear demarcation between literacy and numeracy, language interpretation, health communication, interpersonal relations with their provider and the rest of their experience with the health care system.