JNP The Role of Effective
Communication in Reducing
Health Care Disparities
It has been 8 years since the landmark report
“Unequal Treatment” documented the disparities in
health care treatment and outcomes experienced by
African Americans.1 The Centers for Disease Control
and Prevention’s (CDC) “Health Disparities and
Inequalities Report 2011” highlights the fact that
these inequities continue to plague our health care
system, despite ongoing clinical research that docu-
ments and offers suggestions to address them.2
Ethnic minorities in general, and African Americans in
particular, continue to experience higher incidences of
mortality and morbidity, compared to their Caucasian
counterparts.3-5 These disparate outcomes cannot be
adequately explained by genetics, race, environment,
or stage of the presenting disease.4
A recent study reports that when African
American and Caucasian patients present with sim-
ilar complaints to the same physician, there is a dif-
ference in treatment and, consequently, health care
IN MY OPINION
Wayne A. Warner and Gail Washington, DNS
outcomes.6 Research shows that African
Americans tend to have less informative and less
engaged patient-physician communication than
Caucasians, which contributes to this difference in
treatment.7 For instance, providers are less likely to
discuss treatment options and side effects with
African Americans compared to Caucasians
patients. Additionally, fewer diagnostic tests and
treatments are ordered, and an attitude of watchful
waiting can lead to compromised care and gener-
ates a lack of trust in the health care provider.8-10
Moreover, disparate treatment impedes patients’
ability to be active participants in their care and to
make informed decisions.11 Numerous studies
612 The Journal for Nurse Practitioners - JNP
have identified that effective communication is key
to improving health outcomes by decreasing mis-
trust and feelings of powerlessness, increasing
treatment adherence, and increasing patient satis-
faction with their care.5,12
With the advent of health care reform, disparities
in treatment and outcomes may significantly
increase. Previously uninsured patients, including a
considerable number of ethnic minorities, will
access the health care system. This previously
uninsured pool will significantly encumber an
already overburdened system. Advanced practice
nurses, and nurse practitioners (NPs) in particular,
will be in a strategic position to meet these health
care challenges and capitalize on opportunities to
make a difference in health care.
Acknowledging the cultural and informational
needs of these patients is foundational to the
delivery of culturally appropriate quality care. NPs
should be equipped with the psychosocial and
cultural sensitivity necessary to effectively com-
municate with diverse patient populations.
Unfortunately, about one third of Americans are
not health literate, resulting in a diminished
capacity to procure, assimilate, and comprehend
basic health information and services so as to
participate in care and adhere to treatment.13
This perceived powerlessness might impact a
patient’s ability to ask appropriate questions or to
understand health information sufficiently to
make informed health care decisions. Therefore,
it is crucial to use communication that is easily
understood. It is important to explain medical
regimens and treatments based on a patient’s
level of health literacy, while also acknowledging
cultural inputs and language needs that may
improve patient outcomes.14
Anticipating questions that patients might have
and transforming the unasked questions into talk-
ing points can facilitate communication that
Volume 7, Issue 7, July/August 2011
empowers them. Patients who are actively
engaged with their health care provider through
communication will avail themselves of medical
services and have increased personal satisfaction,
better health outcomes, and more trust in the
health care system.12 This care is patient-centered
and is facilitated by good patient-provider communi-
cation in which patients’ needs and wants are
understood and addressed, empowering patients to
actively participate in their own care.12,15 Patient-
centered communication has been shown to
improve patients’ health and outcomes.16,20
The Kalamazoo consensus statement suggests
that the elements of caregiver-patient communication
can be distilled to 7 essentials.17 Effective communi-
cation is facilitated by opening the discussion, gather-
ing and sharing information, understanding the
patient’s perspective, reaching agreement on prob-
lems and plans, and providing closure.17 This
approach, layered within a culturally sensitive frame-
work, will enhance culturally competent care that
leads to improved patient adherence.18
There are many other ways to substantially
improve communication. Plain language, illustra-
tions, and sitting face-to-face with the patient can
lead to improved communication. Asking the
patient more open-ended questions and less bio-
medically-focused questions will also lead to
improved dialogue.5,19 NPs can verify understand-
ing by asking patients to restate the information in
their own words. This will help ensure that the
patient is engaged and understands the plan.21
Additionally, the health care provider should listen
carefully, explain the information, be respectful, and
avoid appearing rushed.
Clear communication contributes to effective,
efficient, and sustained patient involved care.3
Nursing acknowledges patient participation as a
best practice that has a positive impact on patient
care and outcomes.21 Communication also requires
cultural competence. Culturally competent NPs are
more likely to use appropriate adjuvant treatment
and make patient referrals that enhance the quality
of care.12 Culturally competent communication
allows stakeholders to address health concerns
from a patient-centered perspective. This leads to
an increased awareness of concerns and unmet
expectations that may affect patient outcomes.22
www.npjournal.org
Cultural competence establishes congruent
behaviors and attitudes that enable and support
effective cross-cultural connectedness.23 A sense
of connectedness is crucial if African Americans are
expected to respond favorably and effectively par-
ticipate in self-care management.24 Using a holistic
nursing approach, NPs can be instrumental in
reducing health disparities and restoring trust in the
health care system.
In conclusion, it is paramount that NPs recog-
nize that communication is a critical component
in providing effective, efficient, and quality care.
Such communication is essential as it will
empower African American and other minority
patients to understand their care and treatment
options as they navigate the health care sys-
tem.25 A wide-angle perspective allows the NP
to better address patient concerns, garner trust,
and ensure adherence to the treatment regimen.
Ultimately, cultural competence translates into
effective communication and can be useful in
bridging the gap in African American health care
disparities and improving patient outcomes.7,8
Clearly, NPs can play a pivotal role in positively
impacting patient care by engaging patients in
effective communication that leads to improved
health care outcomes.
References
1. Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care. Washington, DC:
National Academies Press; 2003.
2. Centers for Disease Control and Prevention. Health Disparities and
Inequalities Report United States, 2011. Available at: http://www.cdc.
gov/mmwr/pdf/other/su6001.pdf. Accessed March 17, 2011.
3. Kagawa-Singer M, Dadia A, Yu M, et al. Cancer, culture and health
disparities time to chart a new course? CA Cancer J Clin.
2010;60(1):12-39.
4. American College of Physicians. Racial and ethnic disparities in
health care [policy paper]. Available at: http://www.acponline.org/
advocacy/where_we_stand/access/racial_disparities.pdf. Accessed
March 17, 2011.
5. Rao L, Anderson L, Inui T, et al. Communication interventions make a
difference in conversations between physicians and patients a
systematic review of the evidence medical care. Med Care.
2007;45(4):340-349.
6. Ford M, Havstad S, Davis S. A randomized trial of recruitment
methods for older African American men in the prostate, lung,
colorectal and ovarian cancer screening trial. Clin Trials. 2004;1:343-351.
7. Institute of Medicine. National Health Care Disparities Report.
Available at: http://www.hablamosjuntos.org/resources/pdf/
nhdr03.pdf. Accessed March 17, 2011.
8. McNeill JA, Reynolds J, Ney ML. Unequal quality of cancer pain
management: disparity in perceived control and proposed solutions.
Oncol Nurs Forum. 2007;34(6):1121-1128.
9. Johnson RL, Roter D, Powe NR, et al. Patient race/ethnicity and
quality of patient-physician communication during medical visits.
Am J Public Health. 2004;94:2084-2090.
10. Gordon HS, Street RL Jr, Kelly PA, et al. Physician-patient
communication following invasive procedures: An analysis of post-
angiogram consultations. Soc Sci Med. 2005;61:1015-1025.
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11. Zeliadt SB, Ramsey SD, Penson DF, et al. Why do men choose one
treatment over another? A review of patient decision making for
localized prostate cancer. Cancer. 2006;106(9):1865-1874.
12. Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor
communication. Cancer Prev Control. 1999;3:25-30.
13. Gazmararian J, Williams MV, Peel J, et al. Health literacy and
knowledge of chronic disease. Patient Educ Couns. 2003;51(3):267-275.
14. Gordon HS, Street RL Jr, Kelly PA, et al. Physician-patient
communication following invasive procedures: an analysis of post-
angiogram consultations. Soc Sci Med. 2005;61(5):1015-1025.
15. Stewart M, Brown JB, Donner A, et al. The impact of patient
centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
16. Anderson EB. Patient centeredness: a new approach. Nephrol News
Issues. 2002;16(12):80-82.
17. Makoul G. Essential elements of communication in medical
encounters: the Kalamazoo consensus statement. Acad Med.
2001;76:390-393.
18. Barksdale D. Provider factors affecting adherence: Cultural
competency and sensitivity. Ethn Dis. 2009;19(4 Suppl 5):S5-3-7.
19. Barrier P, Li J, Jensen N. Two words to improve physician-patient
communication: What else? Mayo Clin Proc. 2003;78:211-214.
20. Department of Health and Human Services Office of Disease
Prevention and Health Promotion. Health Literacy Strategies:
Improve the Usability of Health Information. Available at:
http://www.health.gov/communication/literacy/quickguide/healthinfo.
htm#three. Accessed March 17, 2011.
21. Cahill J. Patient participation: a concept analysis. J Adv Nurs.
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22. Betancour J. Cross-cultural medical education: conceptual
approaches and frameworks for evaluation. Acad Med.
2003;78(6):560-569.
23. Beacom A, Newman S. Communicating health Information to
disadvantaged populations. Fam Community Health. 2010;33(2):152-162.
24. Department of Health and Human Services Office of Minority Health.
What is cultural competency? Available at: http://minorityhealth.hhs.gov/
templates/browse.aspx?lvl⫽2&lvlID⫽11. Accessed March 17, 2011.
25. Fennell M. Racial disparities in care: looking beyond the clinical
encounter. Health Serv Res. 2005;40(6 Pt 1):1713-1721.

Wayne A. Warner is a Research Initiative for Scientific

Enhancement (RISE) Fellow at California State University in Los
Angeles. He is supported by an NIH NIGMS grant. He can be
reached at waynewarner1@yahoo.com. Gail Washington, DNS,
RN, is an associate professor in the Nursing department at the
university.

1555-4155/11/$ see front matter

© 2011 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2011.05.021

614 The Journal for Nurse Practitioners - JNP Volume 7, Issue 7, July/August 2011