Language: A Powerful Tool in Promoting Healthy Behaviors

Abstract

Words have the capacity to empower or devastate someone. Although a “rose by any other name” may “still be a rose,” if language is not precise and thoughtful in taking into consideration perceptions, values, biases, and culture of people, it may influence the patient, thereby potentially leading to negative patient outcomes. Health promotion interventions include teaching and empowering people to embrace the components of lifestyle medicine utilizing a variety of approaches. An essential part of the intervention is how the message is delivered, specifically the language used to deliver the message. In this article, the implications of language on patient outcomes and suggestions on how to rephrase language with potential negative connotations are described.

‘Studies have shown correlations between effective communication and improved patient health outcomes.’

“Sticks and stones may break our bones, but words can never hurt you . . . unless you believe them. Then, they can destroy you.”¹ This quote begins familiarly, but ends very differently from the original saying. Effective communication skills, both verbal and written, are fundamental in health care.² Studies have shown correlations between effective communication and improved patient health outcomes.³ One such study describes how teaching patient-centered communication skills led to improved outcomes during the patient encounter; an increase in patient knowledge, self-efficacy, and informed decision making soon after the encounter; and improved long-term health outcomes (well-being, quality of life, and mortality).⁴ Although communication skills are taught within health professions’ curricula, they are not too often included in postgraduate and continuing education training. However, practices that have utilized programs to teach and reinforce communication skills have shown an increase in physicians’ self-confidence and improvements in patient satisfaction.⁴ Although there may be a lack of on-the-job continuing training, there are research studies, consensus statements, and institutes dedicated to improving health care communication⁵ (https://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/).

Effective Health Care Communication

Health care communication is also interchangeably used to describe different situations, including communication among health care professionals and communication with patients. This article is going to focus on the latter; however, principles of effective communication such as tone and nonjudgmental language even among health care professionals will allow shared information to remain unbiased and factual. Holistically, communication is verbal and nonverbal. A study found that people were more likely to disclose information during a patient interview if the physician utilized effective eye contact, posture, tone of voice, head nods, and gestures.⁶ Active listening, expressing empathy, using open-ended questions, and word choice are all components of verbal skills. Word choice influences actions of both health care providers and the public because words can affect perceived severity and susceptibility, which in turn may influence decision making, at all levels of health care, from the patient, to health care provider, to funding agencies.⁷

Effective communication comprises several components, each with evidence to support its purpose. Health literacy refers to the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”⁸ One strategy to improve health literacy is using plain language, which allows one to find, understand, and use information that they need. Another strategy is to ensure cultural and linguistic competency, which means health organizations and practitioners recognizing that diverse populations have unique cultural beliefs, values, attitudes, traditions, language preferences, and health practices.⁹

The role of stigma is another consideration in effective communication. Link and Phelan¹⁰ describe stigma as the result of 5 components: (1) people identify and label human differences; (2) linking labeled person to undesirable characteristic (stereotyping); (3) us versus them; (4) person who is stigmatized experiences discrimination and loss of status; and (5) power. Stigma is especially dangerous when it is associated with medical conditions because it is linked with a worsened clinical course and outcomes. Reasons for this include people wanting to avoid seeking treatment or wanting to distance themselves from the label.¹⁰ Labels that are often used, even if they are not intended to cause harm, include using the disease or action to define the person (ie, diabetic, noncompliant, obese, difficult, unmotivated, uncontrolled). While promoting positive health behaviors, ensuring language is free from stigma is key and can be accomplished by focusing on individuals and not labeling them based on their medical condition or their adherence/willingness/abilities to engage in lifestyle modifications.

Language Recommendations

Although the literature on specific word choices is not abundant, the evidence shows a correlation between language, perceptions, attitudes, and outcomes. Lilienfeld et al¹¹ published an article describing 50 psychological and psychiatric terms to avoid for a variety of reasons, which they explain in detail. For example, they report that the term hardwired is typically used to suggest that human psychological capacities such as cognitive biases are innate rather than modifiable by environmental experience. If health care providers believe that certain people are hardwired to not want to make health behavior changes, then the interventions may not be as meaningful or successful.

A task force comprising experts from the American Association of Diabetes Educators and the American Diabetes Association published a consensus report titled, “The Use of Language in Diabetes Care and Education,” that has recommendations for written and verbal language to be used by health care professionals.¹² A diabetes working group also published an evidence-based position statement for England, with practical examples of language that promotes positive outcomes.¹³ There are several components to their guiding principles for communication and recommendations for language that can be universally applied while providing lifestyle medicine interventions:

• stress, shame, and judgment may be a result of stigma;

• the most effective approach is respectful, inclusive, and person centered and based on facts, actions, or physiology;

• health care professionals should use strengths-based language that emphasizes what a patient knows and can do, and encourages the patient to see positive possibilities (ie, “Sally has started eating more vegetables 2 to 3 days a week with dinner” rather than “Sally is nonadherent to the dietary changes discussed”);

• health care professionals should use person-first language that emphasizes the person rather than their disability, disease, or action/inaction (“Sally has diabetes” versus “Sally is a diabetic”);

• health care professionals should avoid language that implies rules and replace that language with phrases that empower the patient to make plans and embrace their freedom of choice (such as “May I tell you about some sleep strategies?” or “Would you consider walking for ten minutes once a day this week?”); and

• health care professionals should not use descriptions such as the person is in denial, unmotivated, unwilling, or suffering because these types of descriptions make inherent assumptions about people and do not allow the telling of the whole story.

Implications

The power of language is well described in the literature and the potential for positive outcomes, both during the actual patient encounters and long term, is substantial. One cannot effectively promote lifestyle changes by just using a different word if the health care professional’s attitude does not match the language used. Person-centered care and empathy will need to be at a health care professional’s foundation in order for language and word choice recommendations to be effective.¹⁴ The scoping review published in this journal describes a comprehensive approach to a health promotion intervention program. The addition of incorporating concepts behind the power of language may allow an even more positive outcome.