Physician Health Literacy Competencies: A Qualitative Study Using Focus Groups

Abstract

Health literacy is crucial for effective physician-patient communication, shared decision-making, and adherence to medical recommendations. This study aims to identify health literacy competencies required for physicians based on insights from physicians, medical interns, and patients. This qualitative study explored physicians’ health literacy competencies through focus group discussions with 21 physicians, medical interns, and patients in Taiwan. Data were analyzed using content analysis to identify key themes and competency domains. Four key physician health literacy competency domains were identified: (1) assessing patients’ health literacy, (2) strengthening physician-patient relationships, (3) facilitating shared decision-making, and (4) Teach-Back and confirmation of patient adherence. These findings highlight essential physician competencies in health literacy, emphasizing the importance of communication, trust, patient-centered decision-making, and structured feedback mechanisms to improve healthcare interactions and outcomes. Strengthening physician’s health literacy competency is essential for improving patient engagement and adherence. Integrating health literacy training into medical education and promoting patient-centered communication can enhance healthcare outcomes.

Highlight.

● This qualitative study identified four essential physician health literacy competencies, including assessing patients’ health literacy, strengthening physician–patient relationships, facilitating shared decision-making, and applying the Teach-Back method. Through focus group interviews with physicians, interns, and patients in Taiwan, the study underscores the importance of communication, trust, and structured feedback in promoting patient engagement and adherence. These findings inform the development of health literacy training in medical education and highlight the need for patient-centered strategies to improve healthcare outcomes.

Introduction

Health literacy primarily focuses on assessing the general population’s ability to understand medical information and navigate healthcare systems.^1,2 Research demonstrates that patients with limited health literacy often struggle with medication adherence, shared decision-making, and informed consent processes.^3,4 While these efforts are essential, they overlook the role of healthcare providers, particularly physicians, in facilitating patient comprehension and engagement. ⁵

Physicians play a central role in mitigating the consequences of health literacy by ensuring that health information is accessible and understandable to patients. To achieve this, physicians must develop a comprehensive understanding of their patients’ health literacy levels and adjust their communication strategies accordingly, ⁶ and provide tailored medical information that supports informed decision-making.^7,8 Physicians who can assess and accommodate patients with low health literacy are better positioned to provide tailored information, promote adherence to medical recommendations, and mitigate misunderstandings that may lead to adverse health outcomes.^9,10

Despite the increasing recognition of health literacy as a key component of effective healthcare, research on physicians’ health literacy competencies remains limited. Existing studies predominantly focus on the development of physicians’ professional knowledge or emphasize communication training without integrating a structured framework that includes an understanding of patient health literacy.^10,11 To fully implement a comprehensive approach to health literacy, it is crucial to consider the healthcare system in which physicians operate.^12,13 In Taiwan, the well-established national health insurance system and accessibility of medical services necessitate consideration of the diverse healthcare-seeking behaviors of the population.

This research gap highlights the need to shift the focus toward understanding the professional competencies required by physicians to effectively support patient health literacy. ¹¹ Health literacy is not only essential for improving patient outcomes but also plays a fundamental role in shaping physicians’ clinical decision-making processes. However, existing research often fails to address the specific challenges physicians face in applying health literacy competencies across diverse cultural and clinical contexts. Given these challenges, it is imperative to investigate how physicians can develop the necessary competencies to navigate health literacy barriers.

This study aims to fill this critical gap by exploring physicians’ professional competencies in health literacy through focus group interviews with physicians, internet, and patients. By employing content analysis, this research seeks to identify key professional competencies that can inform the development of medical education curricula and enhance physician-patient communication in Taiwan.

Methods

Study Design

This qualitative study was designed to examine the professional competencies of physicians in health literacy using a focus group discussion approach. The primary objective was not to achieve consensus but to capture diverse perspectives from various stakeholder groups. Data were collected between August and December 2019 in Taiwan, involving healthcare providers and users, including physicians, interns, and patients. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist, ¹⁴ a comprehensive 32-item framework that ensures methodological rigor, transparency, and completeness in qualitative research reporting. COREQ encompasses 3 domains: research team and reflexivity, study design, and data analysis and reporting, providing a structured approach to documenting critical methodological aspects such as participant selection, data collection procedures, and analytical strategies. Adherence to COREQ strengthens the reliability and validity of the findings by ensuring systematic and replicable qualitative research practices.

This study was reviewed and approved by the Institutional Review Board of the Research Ethics Review Committee of the National Taiwan Normal University (case number 201809HS007). All procedures were conducted in accordance with relevant ethical guidelines and national regulations.

Participants Selection

This study employed a purposive sampling strategy to ensure a diverse representation of medical professionals and patients, capturing perspectives from both healthcare providers and users. Physicians were included if they were formerly practicing in hospitals for 5 years. Interns were defined as medical students or resident physicians. Patients eligible for participation were at least 18 years old and with 5 years of cancer or chronic illness. For a detailed overview of the participant selection criteria, please refer to Figure 1.

Figure 1.

Participant selection and exclusion criteria.

To enhance data reliability, individuals who did not meet the practice experience standard, patients with cognitive impairments hindering participation, and individuals unable to provide informed consent were excluded. Participants were informed of the study objectives via email and invited to participate voluntarily. To acknowledge their time and effort, each participant received a compensation of 60 USD while ensuring voluntary participation and maintaining the integrity of responses. This sampling strategy facilitated a balanced representation of medical expertise and patient backgrounds, enabling a comprehensive examination of physicians’ professional competencies in health literacy.

Data Collection

Three focus group discussions were conducted separately for each participant group—physicians, interns, and patients—ensuring focused and relevant dialog. Each group consisted of 7 participants and sessions lasted approximately 90 min. Discussions were conducted in person in clinical settings and moderated by an experienced qualitative researcher, with a second investigator taking field notes. All sessions were audio- and video-recorded, transcribed verbatim, and continued until data saturation was reached. All data were anonymized to ensure confidentiality.

Interview Guide

The interview guide was developed based on a review of relevant literature and refined through consultation with 5 senior experts in health literacy, qualitative research, and medical education. Content validity was confirmed through expert review. The final guide included the following open-ended questions, aimed at eliciting diverse perspectives on physician health literacy competencies:

1. From your perspective, what signs or cues can indicate an individual’s level of health literacy during medical encounters, and how might physicians assess or recognize them?

2. What communication challenges have you experienced or observed when interacting with individuals with limited health literacy, and what factors contributed to these difficulties?

3. What strategies or approaches do you consider effective in supporting individuals with varying levels of health literacy to understand health information and adhere to medical recommendations?

Content Analysis

This study adopted a structured and iterative content analysis approach grounded in principles of grounded theory. Data analysis was conducted in multiple stages to ensure rigor and thematic saturation. In the initial phase, the research team independently reviewed transcripts, annotated key observations, and generated preliminary codes through open coding. Line-by-line analysis was then conducted to refine emerging codes, with data organized using Microsoft Excel (Office 365) to assist with coding consistency and thematic clustering.

Representative verbatim excerpts were used to illustrate thematic patterns while maintaining participant anonymity. Thematic categories were refined through ongoing team discussions to enhance credibility and analytical depth.

Validity and Reliability

To enhance reliability, 2 independent coders conducted the thematic analysis. Discrepancies were resolved through discussion, with final verification by a third senior researcher. Inter-coder reliability was assessed using Cohen’s kappa (κ = 0.92), indicating strong agreement.

Credibility was further strengthened through member checking, wherein participants reviewed the summarized themes and provided feedback on the accuracy of interpretation. A short questionnaire was used to capture agreement or suggestions for refinement. Data triangulation across participant groups allowed for the comparison of differing perspectives and supported the comprehensiveness of thematic insights. The research team also engaged in regular analytical discussions to enhance interpretative validity.

Results

The study included a total of 21 participants, comprising specialist physicians, medical interns, and patients. The group of specialist physicians consisted of 7 individuals with a mean age of 46.14 years, with 43% currently serving in regional hospitals. The medical intern group also included 7 participants, with a mean age of 24.42 years; among them, 86% were medical interns, while the remaining 14% were postgraduate trainees. The patient group, also composed of 7 individuals, had a mean age of 63.42 years. Notably, 71.42% of the patients had a cancer diagnosis, and all participants in this group had attained a college degree. Table 1 presents the key dimensions and sub-dimensions of physicians’ professional competencies in health literacy identified in this study.

Table 1.

Physician Health Literacy Competencies: Key Dimensions and Sub-Dimensions.

Dimensions	Sub-dimensions	Explanation
1. Assessing Patients’ Health Literacy	1.1 Observational Strategies for Health Literacy Assessment	Physicians used observational strategies to assess patients’ health literacy by evaluating factors such as occupation, hygiene, and lifestyle.
	1.2 Communication-Based Strategies for Health Literacy Assessment	Physicians assess health literacy through patients’ verbal and nonverbal responses, particularly noting that those with lower health literacy often feel confused by medical terminology.
2. Strengthening Physician-Patient Relationships	2.1 Effective Communication Strategies for Patient Engagement	Physicians enhance patient engagement by simplifying medical language, using relatable analogies, and maintaining eye contact.
	2.2 Patient Trust and the Impact of Communication Barriers	Physicians must balance technical explanations with interactive dialog to maintain patient trust.
3. Facilitating shared decision-making	3.1 Structured Approaches to Shared Decision-Making	Physicians use structured tools like SDM platforms and educational materials to enhance patient involvement in decision-making.
	3.2 Respecting Patient Autonomy in Decision-Making	Physicians must balance professional guidance with patient autonomy to ensure informed and empowered choices.
4. Teach-Back and Confirmation of Patient Adherence	4.1 Reinforcing Understanding Through Teach-Back	Physicians use the Teach-Back method to reinforce patient understanding and adherence by having them restate key information.
	4.2 Strengthening Adherence Through Follow-Up	Proactive follow-ups, such as reminder calls and appointment tracking, reinforce medical instructions and offer patients a sense of accountability and support.

Assessing Patients’ Health Literacy

Physician health literacy competencies are essential for effectively assessing patients’ ability to understand health information. These competencies involve using both observational strategies and communication-based strategies to tailor interactions and ensure clear, comprehensible communication, thereby improving patient engagement and adherence.

Observational Strategies for Health Literacy Assessment

Physicians and interns emphasized the importance of assessing patients’ health literacy levels to ensure the use of appropriate communication strategies. Interns frequently relied on observational assessments to gauge patients’ familiarity with health-related information, considering factors such as occupation, attire, hygiene, and lifestyle behaviors. These contextual cues guided discussions regarding medical history and treatment adherence:

You can assess a patient’s health literacy by considering their occupation, clothing, hygiene habits, or lifestyle behaviors such as betel nut chewing and alcohol consumption when taking their medical history. (P11, Intern)

Communication-Based Strategies for Health Literacy Assessment

In contrast, physicians focused more on verbal and nonverbal responses to adjust their communication strategies. Some interpreted patients’ use of medical terminology as an indication of familiarity with medical concepts, prompting them to provide more direct explanations. However, not all patients perceived these assessments as accurate. Some reported difficulty in understanding medical terminology and expressed frustration with overly technical explanations, which made them feel excluded from their own healthcare decisions:

If a patient uses medical terminology when speaking with me, I will engage with them directly. Even if their understanding is partial, I will adjust my communication using both verbal and nonverbal cues to ensure clarity. (P9, Physician)

Doctors are really busy, and they throw out all these medical terms like GOP, GPT. . . honestly, I don’t understand any of it! My health condition is already complicated enough—how am I supposed to know all these medical terms? It just makes my head spin (P3, Patient)

Strengthening Physician-Patient Relationships

Effective communication is essential for building trust and engagement in the physician-patient relationship. However, barriers such as technical jargon or insufficient interaction can lead to patient disengagement. This highlights the significance of physician health literacy competency, which enables healthcare professionals to tailor their communication to the diverse health literacy levels of patients.

Effective Communication Strategies for Patient Engagement

Health literacy is a key determinant in effective physician-patient interactions, influencing patients’ ability to understand medical information and make informed decisions. Clear, concise, and engaging communication serves to bridge gaps in understanding, thereby enhancing trust and encouraging active participation in care. Physicians identified several strategies, including simplifying medical terminology, employing relatable analogies, and maintaining consistent eye contact, all of which enhance patient engagement. Additionally, nonverbal communication, such as handshakes and light physical contact, was considered a significant factor in building rapport with patients:

I usually use gestures like handshakes or a pat on the back to help patients feel cared for and reassured.(P10, Physician)

Patients emphasized the importance of attentive listening and minimizing distractions, asserting that physicians who avoided excessive jargon and adopted clear, accessible language were perceived as more trustworthy and easier to engage with:

And like I mentioned earlier, for a first consultation, eye contact is important. Also, doctors shouldn’t use too much medical jargon—they should keep it simple, clear, and easy to understand in everyday language！ (P6, Patient)

Patient Trust and the Impact of Communication Barriers

Despite these efforts, when physicians rely excessively on technical explanations without promoting interactive dialog, some patients experience disengagement and seek additional consultations for reassurance. This issue emphasizes the importance of not only simplifying medical language but also fostering a supportive and interactive communication environment:

Patient trust in doctors is really important. I’ve seen cases where patients consult a doctor and then go to(my) Hospital for a second opinion, just to make sure. (P13, Intern)

Facilitating Shared Decision-Making

While structured tools support decision-making, effective SDM also depends on how physicians communicate and respect patient preferences. Beyond providing information, physicians must balance guidance with autonomy, ensuring that patients feel both supported and in control of their healthcare decisions.

Structured Approaches to Shared Decision-Making

Health literacy plays a crucial role in shared decision-making (SDM), shaping patients’ ability to comprehend medical options and participate in treatment decisions. Physicians recognize that patients’ preferences vary, with some favoring a directive approach while others seeking greater involvement. However, the complexity of medical information often poses a challenge, limiting meaningful patient engagement. To address this, physicians utilize SDM platforms, educational brochures, checklists, and mobile applications to support decision-making, emphasizing the necessity of tailoring these tools to align with patients’ knowledge levels and attitudes toward healthcare.

These approaches need to be tailored to each patient, as their knowledge and attitudes toward healthcare can vary significantly. (P8, Physician)

Interns described their role in explaining diagnostic results, treatment options, associated risks, and costs, ensuring that patients comprehended key aspects of their care:

The doctor interprets imaging results to provide treatment options, such as prescribing painkillers or recommending surgery, while also explaining the associated risks and costs. (P7, Intern)

Respecting Patient Autonomy in Decision-Making

From the patient’s perspective, clear and direct communication fosters confidence in making treatment decisions. Patients valued physicians who reduced uncertainty by presenting options in a structured and decisive manner while still respecting their autonomy:

This doctor speaks with confidence and gets straight to the point, leaving no room for hesitation. They clearly explain the options, making sure I understand that the final decision is mine to make (P19, Patient)

Effective SDM requires balancing professional guidance with patient autonomy, ensuring that individuals feel informed, supported, and empowered in their healthcare decisions.

Teach-Back and Confirmation of Patient Adherence

Building on shared decision-making, ensuring that patients fully understand and adhere to health recommendations is essential for effective care. The Teach-Back method facilitates comprehension verification, while follow-up strategies reinforce adherence. These approaches contribute to improved patient engagement, adherence, and health outcomes.

Reinforcing Understanding Through Teach-Back

Health literacy is essential for ensuring that patients fully comprehend and adhere to medical recommendations. Physicians frequently employ verbal reinforcement techniques, such as repeating key instructions and utilizing the Teach-Back method, in which patients restate information in their own words. This approach allows healthcare providers to assess patient comprehension and address misunderstandings before they impact adherence. However, some patients perceive Teach-Back as a test of their knowledge rather than a supportive strategy, leading to discomfort and disengagement.

To mitigate these concerns, some physicians and case managers integrate verbal instructions with hands-on demonstrations, ensuring that patients correctly follow treatment procedures:

The doctor or case manager demonstrates the procedure first, then asks me to do it myself to make sure I’ve got it right. (P5, Physician)

Interns also emphasize the importance of confirming patient comprehension through verbalization, reinforcing key messages and allowing patients to clarify uncertainties:

I think we can confirm their understanding by asking them to repeat the information back (P4, Intern)

Ensuring patient engagement in this process requires a balance between verification and support, allowing patients to actively participate without feeling pressured.

Strengthening Adherence Through Follow-Up

Despite these efforts, unclear instructions remain a challenge for some patients, leading to medication errors and non-adherence. Factors such as complex medical terminology, insufficient explanation, and lack of reinforcement contribute to misunderstanding, underscoring the need for alternative strategies to enhance patient adherence.

To address this, patients emphasize the importance of simplified language, written materials, and visual aids, which improve comprehension and confidence in following medical recommendations. Additionally, proactive follow-up interventions by healthcare providers, such as reminder calls and appointment tracking, play a critical role in ensuring adherence:

If I miss my appointment, and the nurse notices that I was supposed to pick up my medication, they will call to check and confirm with me. (P14, Patient)

These follow-up measures not only reinforce medical instructions but also provide patients with a sense of accountability and support, ultimately improving long-term treatment outcomes.

Discussion

This study underscores the significance of physicians’ health literacy competencies in facilitating effective communication, shared decision-making, and patient adherence to medical recommendations. In light of the increasing complexity of healthcare, the integration of structured communication strategies and patient-centered approaches is essential for optimizing healthcare delivery and improving patient outcomes. As Karuranga et al emphasized, ¹⁵ health literacy competencies for healthcare personnel are crucial in ensuring that professionals can bridge the communication gap with patients, enabling better patient engagement and understanding. Karuranga et al’s study highlights the need for health professionals to be well-versed in health literacy practices to provide effective care, which is essential in European healthcare settings and is similarly relevant in Taiwan.

Accurately assessing patients’ health literacy is critical for effective healthcare delivery. However, reliance on verbal and observational assessments may be misleading, as individuals with limited health literacy often struggle to articulate comprehension difficulties.^16,17 This can result in miscommunication and reduced adherence to medical guidance.^{18 -20} In Taiwan, the limited duration of medical consultations further complicates comprehensive health literacy assessments,^21,22 necessitating efficient yet flexible strategies. Approaches such as open-ended questioning and simplified explanations are essential to facilitate patient understanding without inducing cognitive overload.

Trust in physician-patient relationships is predicated on effective, patient-centered communication. Excessive medical jargon, technical explanations, and limited dialog have been shown to undermine trust, whereas active listening, minimizing distractions, and utilizing nonverbal cues foster rapport. ⁵ An authoritative communication style may further disengage patients, reducing their participation in medical discussions. ²³ Given the increasing complexity of healthcare, physicians must employ empathetic and adaptive communication strategies to ensure patients feel heard, respected, and empowered.^24,25 Integrating structured verbal techniques with written materials enhances comprehension, while the chunk-and-check method, which segments information and iteratively confirms understanding, has been shown to improve patient recall and engagement. ²⁶

While some patients prefer a directive approach from physicians, others seek greater involvement in medical decision-making; however, the complexity of healthcare information can hinder meaningful participation. Structured shared decision-making models, such as the choice-option-decision framework, enhance patient confidence and reduce uncertainty by systematically guiding them through available choices and preference-based decisions. ²⁷ Nonetheless, physicians often struggle to balance comprehensive explanations with patient comprehension, particularly among individuals with limited health literacy. ⁹ Integrating decision aids, tailored discussions, and simplified explanations can support shared decision-making while preventing cognitive overload, ensuring that patients feel informed and confident in their healthcare choices.^16,17

Patients’ comprehension and adherence to medical recommendations are critical determinants of treatment effectiveness and health outcomes. While repetition and simplified explanations are commonly employed, structured communication strategies such as the teach-back method are still underutilized in clinical practice, with limited evidence of systematic implementation. ²⁸ Furthermore, interdisciplinary collaboration in Taiwan’s teaching hospitals has been introduced to enhance patient education and facilitate the accurate comprehension and adherence.^29,30

While these findings offer valuable insights, several limitations should be noted. The results may be influenced by Taiwan’s healthcare context, limiting generalizability. Moreover, factors such as cultural influences and institutional constraints were not extensively explored. Future research should address these aspects to further inform the development of health literacy competencies.

Conclusion

This study highlights the critical role of physicians’ health literacy competencies in fostering effective communication, shared decision-making, and patient adherence to medical recommendations. As healthcare systems become increasingly complex, the ability of physicians to assess and address patients’ health literacy levels is essential for improving patient engagement and treatment adherence. Integrating structured communication strategies, such as the teach-back method, along with patient-centered approaches, can enhance comprehension and trust in physician-patient interactions.

To improve healthcare delivery, medical education should incorporate targeted training in health literacy assessment and communication techniques. Additionally, healthcare institutions should implement interdisciplinary collaboration models that facilitate comprehensive patient education and support. Future research should explore the effectiveness of specific interventions designed to enhance physician-patient communication, particularly among populations with low health literacy.