Pragmatic Skills Used by Older
Adults in Social Communication and
Health Care Contexts: Precursors to
Health Literacy
Marisa I. Wengryn
The Sussex Consortium, Lewes, DE
Eva Jackson Hester
Towson University, Towson, MD
E ffective oral communication skills are essen-
tial for attaining adequate health care (Street,
2003). The recent attention directed to health
literacy and its impact on the health status of Americans
has emphasized the importance of communication skills
in accessing and using health services (Diette & Rand,
2007; Institute of Medicine [IOM], 2004; Ishikawa & Yano,
2008; Tran et al., 2004; Williams, Davis, Parker, & Weiss,
2002). Health literacy is defined in Healthy People 2010
as “the degree to which individuals have the capacity to
obtain, process, and understand basic health information
and services needed to make appropriate health decisions”
(Ratzan & Parker, 2000, p. 147). This definition includes
ABSTRACT: Purpose: Older adults are frequent consumers
of health care services. However, reports have indicated
that breakdowns in communication during provider–patient
interactions may contribute to poor health outcomes in
this population. The purpose of this study was to examine
whether the pragmatic skills used by older adults in social
contexts were related to the communication skills they
used in health care contexts.
Method: Sixty-three older adults ranging from 63 to 93
years of age were administered the Social Communication
subtest of the Functional Assessment of Communication
Skills for Adults (FACS; Frattali, Thompson, Holland, Wohl,
& Ferketic, 1995) along with the Healthcare Communica-
tion Profile (Hester, 2006), which is a self-report measure
CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND
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oral communication as well as reading and comprehending
prescription labels, appointment slips, and other health-
related materials (Hixon, 2004). The consequences of low
health literacy are poor disease management, decreased
health status, and increased medical costs (IOM, 2004).
Hence, health literacy is a link between disease and disabil-
ity prevention, communication with health care providers,
and health promotion (Haber, 2003; Hasselkus & Moxley,
2009).
Although older adults are major consumers of health care
services, they are at particularly high risk for low health
literacy (Hester, 2009; IOM, 2004; Lee, Arozullah, Cho,
Crittenden, & Vicencio, 2009; Williams et al., 2002). As
of communication skills within the health care setting. In
addition, a narrative was collected from each participant.
Correlation and stepwise multiple regression procedures
were completed to determine relationships between the use
of pragmatic skills in the two settings.
Results: Results indicated significant relationships between
pragmatic skills used in social communication settings and
pragmatic skills used in health care settings.
Conclusion: The pragmatic skills used by older adults in
social communication settings are related to the pragmatic
skills they used in health care settings.
KEY WORDS: health literacy, assessment, adults, pragmatics
Wengryn
& Hester:
• Volume 38 • 41–52Pragmatic Skills
• Spring 2011 as Related to Health Literacy
© NSSLHA 41
1092-5171/11/3801-0041
oral language and social communication have been related
to literacy skills in academic settings (Brinton & Fujiki,
2004; Donahue & Foster, 2004; Rowe, 1989), it seems
plausible that the same theoretical concept could be applied
to health literacy in adults, hypothesizing that social com-
munication skills facilitate health literacy via health care
communication skills (Hester, 2009).
Successful health care communication skills involve active
engagement in health management through asking ques-
tions, explaining symptoms, and discussing health concerns
(Cooper & Roter, 2003; Hester & Stevens-Ratchford, 2009;
IOM, 2004; Street, 2003). Patients who are active partici-
pants in their health care have been found to receive a
greater amount of information, adhere to treatment regimens,
achieve positive health outcomes, and be more satisfied with
their health care than patients who are not active participants
(Cooper & Roter, 2003; Mika, Kelly, Price, Franquiz, & Vil-
larreal, 2005; Street, 2003; Tran et al., 2004).
Pragmatic or social communication skills are perhaps
among the most crucial skills for health literacy as indi-
viduals need to engage in effective discourse with provid-
ers. In its broadest sense, pragmatics is defined as “how
language is used in the process of communication” (Müller,
2000, p. 9). Health literacy has been linked to patient em-
powerment during the health care encounter (Tones, 2002).
Likewise, pragmatic communication skills have been noted
to empower people (Harris, 1995) through speech acts that
allow a person to negotiate, inform, and question during
discourse. Speech acts are a crucial part of conversation,
narration, and storytelling, though the structure and function
of these acts vary greatly. Speech acts allow the speaker to
maintain power and control within the environment in order
to achieve his or her goals (Bruner, 1983; Harris, 1995).
Speech acts associated with narratives, storytelling, and
monologues take on a different set of rules than those
needed to be successful throughout conversational exchang-
es (Haynes & Shulman, 1998). These rule changes are due
to the extended period of time that the speaker is expected
to talk without the listener interacting and his or her ability
to stay focused on the topic, create sentences that contain
all speech act principals, and use proper language format
for the context (Haynes & Shulman, 1998). A narrative is
the “verbal recapitulation of past experiences or the retell-
ing of ‘what happened’” (Ukrainetz, 2006, p. 196). Narra-
tives are used to report on, evaluate, and organize experi-
ences as well as enable individuals to feel emotionally
involved. Narratives encompass much of an individual’s
daily discourse and components in provider–patient interac-
tions (Street, 2003; Ukrainetz, 2006). According to the IOM
(2004), health care encounters involve a dialogue between
patient and provider in which the patient tells his or her
stories, describes his or her experiences, and provides
explanations to obtain help with his or her health concerns.
Health narratives are stories that describe the patient’s
health. They consist of everyday activities, relationships,
situations, and chronological sequencing of health events
(Street, 2003). Such narratives provide important informa-
tion about the patient’s health behavior, beliefs, and percep-
tions of well-being and are important in attaining adequate
health care services (Street, 2003).
42 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE
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Therefore, the purpose of the present study was to exam-
ine the relationship between communication skills in social
and health care contexts in older adults—a population that
has been identified as having both low health literacy and
inadequate communication skills within the health care set-
ting (Baker et al., 2002; Benson & Forman, 2002; Cooper
& Roter, 2003; Dearborn et al., 2006; IOM, 2004; Kaaki-
nen, Shapiro, & Gayle, 2001; Street, 2003).
PRAGMATIC SKILLS OF OLDER ADULTS
Increased age is one factor that has been associated with
decreased language and communication skills (Duong &
Ska, 2001; Juncos-Rabadan, Pereiro, & Rodriguez, 2005;
Le Dorze & Bedard, 1998; Sorrel, 2006). Studies on aging
have indicated that as adults age, they demonstrate changes
in social communication (pragmatics), word retrieval,
sentence use, memory, comprehension, hearing, and reading
skills (Baker et al., 2002; Benson & Forman, 2002; Bopp
& Verhaeghen, 2005; Cronin & Mandich, 2005; Drummond,
Dancer, & Pierce, 1996; O’Hanlon, Kemper, & Wilcox,
2005). Studies focusing specifically on the pragmatic dis-
course skills of older adults indicate changes in an indi-
vidual’s comprehension and production of communication
over the life span (Drummond et al., 1996; Shadden, 1997;
Ulatoska, Hayashi, Cannito, & Fleming, 1986).
Drummond et al. (1996) conducted a study based on
three narrative discourse tasks and found that the pragmatic
abilities of older study participants (70 to 79 years of age)
were marked by more ellipses and greater referencing er-
rors (i.e., proper nouns, stipulated noun phrases, members
of a class) than those of younger participants (20 to 29
years of age). A related study by Ulatoska et al. (1986)
examined referencing errors of older adults throughout
multiple discourse tasks. Ambiguity of referencing was
noted in the younger elderly (64–75 years of age); how-
ever, it increased in the older elderly population (77 to
92 years of age) with increased complexity of the narra-
tive (Ulatoska et al., 1986). When comparisons were made
between older-old, younger-old, and younger participants,
results indicated that older-old participants provided less
information in discourse, less setting information, and re-
duced relevance of information in complex and open-ended
discourse conditions (Shadden, 1997; Ulatoska et al., 1986).
In conversation, older adults demonstrated less questioning
and requests for elaboration along with reduced spontane-
ous language and fragmented sentences (Ardila & Rosselli,
1996; Shadden, 1997). These findings suggest a life span
continuum of referential decline within the normal elderly
population (Ulatowska et al., 1986). Conceivably, age-
related changes in pragmatic abilities can impact provider–
patient interactions with older adults.
Provider–Patient Interactions
With Older Adults
For a communication exchange to be successful, pro-
vider–patient interactions must be mutually comprehended.
AND DISORDERS • Volume 38 • 41–52 • Spring 2011
However, reports indicate that providers often use close-
ended questions, speak at a fast rate, and dominate conver-
sations (Street, 2003). This structure leaves little time for
information to be verified and patient concerns to be ad-
dressed (Safeer & Keenan, 2005; Street, 2003). Reports of
health care interactions with older adults have consistently
noted breakdowns in provider–patient communication and
have suggested that more than one-third of older patients
do not initiate necessary medical discussions with provid-
ers, even though they often do not understand technical
terms and the complexity of health-related content and have
inadequate confirmation of their understanding (Institute
for Healthcare Advancement, 2005; Thompson, Robinson &
Beisecker, 2004).
Limited comprehension, topic maintenance problems, and
decreased information-seeking skills have been reported for
older adults (Beers et al., 2003; Georges, Bolton, & Ben-
nett, 2004; Kaakinen et al., 2001; Kreps, 2006; Thompson
et al., 2004). These problems can disrupt the communica-
tion exchange of provider–patient interactions and may be
related to high levels of arousal, including nervousness and
anxiety regarding being perceived as less capable (Thomp-
son et al., 2004; Tran et al., 2004). Older patients may
have decreased organization, more verbal disfluencies, and
greater amounts of pauses that disrupt the topic flow. Taken
together, these communication problems may lead to older
patients avoiding interactions when they are provided with
a choice (Burleson & Planap, 2000; Street, 2003).
Thus, older patients have been reported to be less partici-
patory in both asking questions and informing physicians of
their health concerns (Adelman, Greene & Charon, 1991;
Cooper & Roter, 2003; Nussbaum, Pecchioni & Crowell,
2001; Thompson et al., 2004). Tran et al. (2004) conducted
forums to teach patients how to talk to their doctor and
found that many patients indicated that they were afraid
they would be seen as “stupid” if they asked too many
questions. Furthermore, many older patients do not in-
form their physicians of important medical problems they
experience, resulting in incomplete diagnosis and treatment
(Thompson et al., 2004). Patients who play an active role
in their health care by asking questions and discussing their
health concerns receive more information and are more sat-
isfied with their health care (Cooper & Roter, 2003; Street,
2003). Consequently, these patients have been reported to
feel more in control, and they have better disease manage-
ment than those patients who are passive (Street, 2003).
According to Kaplan, Greenfield, Gandek, Rogers, and
Ware (1996), patients 75 and older reported significantly
less participatory visits than did all of the younger age
groups in their study (as cited in Cooper & Roter, 2003).
Studies of health literacy with older adults have gener-
ally reported low health literacy as assessed by reading and
writing tasks (Davis et al., 1993). Findings have indicated
that older adults have difficulty completing informed
consent documents, determining when appointments should
be scheduled and prescriptions refilled, and reading basic
health-related materials (Baker, Williams, Parker, Gazma-
rarian, & Nurss, 1999; Benson & Forman, 2002; Gordon,
Hampson, Capell, & Madhok, 2002; Williams et al., 1995).
The observation that many patients do not understand
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concepts provided in written materials places a greater
demand on the effectiveness of oral communication (i.e.,
provider–patient interaction) to ensure that an understand-
ing of the information is attained. However, research has
shown that patients with poor health status, older patients,
patients with less than a high school education, and male
patients rate health care visits as less participatory (Cooper
& Roter, 2003). Reports of gender differences note that
older male patients, in particular, play a less active role in
their health care by asking fewer questions and being less
engaged during the medical process (Cooper & Roter, 2003;
Govender & Penn-Kekana, 2008; Thompson et al., 2004).
The Present Study
Although studies have noted problems with pragmatic
communication and provider–patient interactions, no stud-
ies have systematically examined how the pragmatic skills
older adults use in social settings may be related to the
pragmatic skills they use in health care settings. Informa-
tion on the relationship between social communication
and communication skills used in health care contexts is
important for (a) understanding how social communication
skills may facilitate the use of health care communication
skills, (b) providing information on discrepancies noted in
clients’ abilities to use adequate pragmatic skills in social
versus health care contexts, and (c) providing a model for
examining health care communication skills of individuals
with communication disorders.
The present study is a first step in examining social
communication skills within a health literacy context using
a sample of community-dwelling older adults. The study
focused on the relationship between pragmatic functions or
speech acts used by older adults in social communication,
narratives, and health care communication contexts. The
following research questions were posed:
• What is the strength of the relationship between prag-
matic skills used in social communication, narratives,
and health care communication contexts?
• Are there pragmatic skills that are used in social com-
munication that are predictors of pragmatic skills used
in health care communication?
• What is the influence of age, gender, race, education,
and health status on an individual’s health care com-
munication skills?
METHOD
Participants
Sixty-five older adults were recruited voluntarily from
senior centers and churches with the consent of administra-
tors. Volunteers were screened for inclusion in the study
using the Mini-Mental State Examination (MMSE; Folstein,
Folstein, & McHugh, 1975) and an informal reading assess-
ment (Shipley & McAfee, 2004). The MMSE was conduct-
ed as a screening for cognitive and language impairments.
A score of 24 or higher was considered passing, consistent
43
with the test cutoff scores. A brief informal reading screen-
ing was administered that involved silent reading of a
56-word paragraph and answering five oral comprehension
questions to determine functional reading skills (Shipley
& McAfee, 2004). This screening was used to ensure that
nonreaders were not selected as participants as reading was
required to complete the Healthcare Communication Profile
(HCCP; Hester, 2006). Sixty-three of the 65 volunteers met
screening criteria of correctly answering at least four of
the five oral comprehension questions and were selected as
participants in the study. Selected participants ranged in age
from 63 to 93, with a mean age of 75 (Table 1). All par-
ticipants were native speakers of English, and most partici-
pants were retired (n = 50). All of the participants resided
independently in community senior citizen complexes or
individual houses in Maryland and Pennsylvania. Addition-
ally, the self-reported health status of participants ranged
from no significant health conditions (n = 50) to one or
more medical diagnoses (n = 13), which included history of
stroke, heart disease, neurological deficits, depression, and
speech problems.
Assessments
Pragmatics/social communication. The Social Communica-
tion (SC) subtest of the Functional Assessment of Com-
munication Skills for Adults (FACS; Frattali, Thompson,
Holland, Wohl, & Ferketic, 1995) was administered to
assess participants’ functional social communication skills.
Although this subtest was standardized on individuals with
aphasia and traumatic brain injury, it was not used as a
diagnostic tool in the present study but rather as an assess-
ment of participants’ social communication skills. Good
reliability as an assessment of social communication skills
has been reported for the subtest (r = .90). To determine
the reliability of the subtest for the present study, split-half
reliability procedures with Spearman Brown adjustment
were completed on participants’ scores. The results indi-
cated good reliability (r = .76) of the SC subtest for the
purpose of the study.
The SC subtest assesses pragmatic skills involving giving
information, responding, agreeing, disagreeing, initiating,
questioning, requesting, explaining, understanding figurative
language and nonverbal language, and maintaining topic by
engaging individuals in conversation (Frattali et al., 1995).
The SC subtest includes ratings of independence in social
communication contexts and level of effectiveness (i.e., ad-
equacy, appropriateness, promptness, and level of communi-
cation sharing; Frattali et al., 1995). Consisting of 21 items,
the SC subtest provides quantitative data on an individual’s
level of communication independence. Independence levels
are gained by scoring responses based on the individual’s
Table 1. Description of study participants.
Age Gender (n)
Range M Female Male
63–93 75 48 15
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need for assistance and/or prompting on a 7-point scale (1
= does not do with maximum assistance/prompting and 7
= does without assistance/prompting; Frattali et al., 1995).
Examples of items on the FACS–SC are “requests informa-
tion from others,” “explains how to do something,” “initi-
ates conversation,” and “expresses agreement and disagree-
ment.” On completion of all 21 items of the SC subtest, a
communication independence mean score can be derived by
adding the rating for each item and dividing the total score
by the number of items.
An oral narrative was also elicited from participants to
assess their organization and elaboration of ideas, topic
maintenance, and thematic development using a picture
from the Peabody Language Development Story Card,
Accident Scene: The Injured Paper Boy (Dunn & Smith,
1967). The picture depicted a paperboy who was hit by a
car while riding his bike. The injured boy was lying in the
middle of the street, surrounded by people and an ambu-
lance.
Health care communication. The HCCP was admin-
istered to assess participants’ health care communica-
tion skills. Speech acts on the HCCP include expressing
opinions, informing, understanding, clarifying, explaining,
questioning, suggesting, disagreeing, and initiating com-
munication. This tool is a 14-item self-report assessment
requiring individuals to rate the frequency with which they
use specific pragmatic speech acts during health care visits
on a 5-point scale (1 = never to 5 = always). Examples of
items on the HCCP are “I ask my doctor questions about
my health condition,” “I understand my doctor’s explana-
tion concerning my health condition,” and “I ask my doctor
to explain terms that I don’t understand.”
Self-report measures have been deemed reliable and
realistic measures for obtaining information about indi-
viduals’ routine behaviors and have been used in health
communication and the field of communication disorders
(Brody, Miller, Lerman, Smith, & Caputo, 1989; Pollard,
Ellis, Finan, & Ramig, 2009; Schorr, Roth, & Fox, 2009).
Preliminary validation of the tool was obtained with 32
older adults ranging from 60 to 82 years of age with good
internal consistency noted (Cronbach alpha = .89). Concur-
rent validity with the Short Test of Functional Health Lit-
eracy (S–TOFHL; Baker et al., 1999) was also determined
to be good, yielding a coefficient of r = .91. Reliability
procedures were completed on participants’ scores for the
present study and yielded an alpha of .81, indicating good
reliability for the purpose of the study.
Procedure
Sessions averaged 1 hr and were administered by one of
the authors individually in a quiet room with consistent
Race (n) Education (years)
Caucasian African American Range M
50 13 6–20 14
DISORDERS • Volume 38 • 41–52 • Spring 2011
order of stimulus presentation for each participant. The
participants were first asked to complete the HCCP. They
were instructed to read each question and rate the frequen-
cy with which they used a given speech act during health
care encounters based on a 5-point scale (1 = never to 5 =
always).
Second, the FACS–SC was administered, in which one of
the investigators engaged the participant in conversation. To
examine participants’ ability to understand facial expres-
sions, three pictures of individuals depicting emotional ex-
pressions of happiness, anger, and sadness were presented.
The pictures were taken from Super Duper Publications
(2000). The participants were asked to label the emotion
depicted in the picture (i.e., happy, sad, or angry). To deter-
mine participants’ understanding of emotional vocal tones,
a prerecorded audiotape was played of a speaker stating the
same sentence using three different vocal tones (i.e., “My
mother went to the store today.”). The participants were
asked to label the emotion portrayed by the speaker by
pointing to the corresponding pictures used previously (i.e.,
happy, sad, and angry). The audiotape was used to maintain
consistency in presentation of the vocal tones.
The final measure assessed participants’ ability to for-
mulate a narrative based on a self-generated story cued by
a picture. Each individual viewed the same picture stimu-
lus of an accident scene in which a boy was hit by a car.
Participants were then instructed to make up a complete
story about the picture beginning with the story starter
“One day….” All narratives were tape recorded and later
transcribed. Each narrative was rated based on a story
grammar analysis using narrative maturity levels. The story
grammar maturity levels progress from Level 1 (isolated
descriptions) to Level 7 (multiple episodes). These narra-
tive maturity levels were developed by Nelson, Bahr, and
Van Meter (2004) based on information in the literature
(see the Appendix for further descriptions of story grammar
maturity levels). This rating scale allowed for a quick and
efficient examination of narrative skills across participants.
Interrater Reliability and Data Analysis
Interrater agreement was obtained for transcription and cod-
ing of the narratives. Fifty percent of the audiotapes were
transcribed by the second author following initial transcrip-
tion by the first author and a student research assistant.
Interrater agreement for word-to-word transcription was
97%. Coding of narratives was completed by both authors,
yielding 98% agreement. Differences were determined by
consensus of the two authors. Interrater agreement was also
conducted for calculating scores on the FACS–SC and the
HCCP, in which 50% of the assessments were rescored by
the second author, yielding 100% agreement.
To determine relationships between pragmatic skills used
in social communication and health care communication,
Pearson product–moment r correlations were completed
on items from the FACS–SC subtest, the HCCP, and the
narrative scores. Stepwise multiple regression analyses
were used to identify social communication skills that may
be predictors of health care communication skills and to
identify any influence of the independent variables of age,
gender, and health status. The alpha was set at the .05 level
for all statistical procedures.
RESULTS
Descriptive Findings
Table 2 provides information on group means for the as-
sessment procedures. As shown, the various age groups
obtained similar ratings for social communication and
health care communication skills. The results indicate that
all groups demonstrated near maximum performance for so-
cial communication skills (1 minimum – 7 maximum) and
modest performance for health care communication skills (1
minimum – 5 maximum). Thus, the findings reflect that the
participants, in general, were independent in using prag-
matic skills within a social context (mean ratings ranged
from 6.92 to 7.00 = independent or does with minimal
assistance), but sometimes used these skills in a health care
context (mean ratings ranged from 3.32 to 3.90). Narrative
scores ranged from 2.83 to 3.33. Statistical analysis of the
assessment scores indicated no significant group differ-
ences, so the data were collapsed.
Association Between Social Communication
and Health Care Communication
The first research question concerned the relationship
between pragmatic skills used in social communication con-
texts and those used in health care communication contexts.
Pearson product–moment r correlations were completed on
scores from the FACS–SC and the HCCP to examine the
relationship between pragmatic skills used in social

Table 2. Study participants’ group means (and standard deviations) for the assessment measures.

Age group
in years N Mean education Health conditions Males Females FACS-SC HCCP Narrative

63–72 27 13 11 9 18 7.00 (.00) 3.90 (.14) 3.00 (1.5)

73–82 25 14 6 6 22 6.97 (.05) 3.73 (.78) 3.33 (.57)

83–93 9 14 6 0 8 6.92 (.25) 3.32 (.96) 2.83 (1.3)

Note. FACS-SC = Social Communication subtest of the Functional Assessment of Communication Skills (Frattali et al., 1995), HCCP =
Healthcare Communication Profile (Hester, 2006).

Wengryn & Hester: Pragmatic Skills as Related to Health Literacy 45

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contexts (SC) and those used in health care contexts
(HCCP). Results indicated several significant correlations,
suggesting up to moderate relationships between variables.
These findings were interpreted according to guidelines
offered by Cohen (1988), which indicate the following:
0–.29 = small correlation, .30–.49 = medium, and .50–1.00
= large correlation. Table 3 summarizes the findings. As
shown, findings indicate a small but significant correlation
between scores on the FACS–SC and the HCCP (r = .27,
p < .05). In addition, significant correlations emerged for
the HCCP items of inform, initiate, and question and the
FACS-SC items of explain, vocal tone, facial expression,
and understanding television. Significant correlations also
emerged for the FACS–SC total mean and the HCCP items
of disagree, giving opinions, and informing.
Predictors of Health Care
Communication Skills
The second research question probed whether pragmatic
skills used in social communication were predictors of
pragmatic skills used in health care communication, as
reported on the HCCP. To examine this issue, a series of
stepwise multiple regression analyses were completed with
mean scores and specific items on the SC subtest, HCCP,
and narratives. Although no predictors of health care com-
munication skills emerged from the SC subtest, results of
the analysis indicated that the narrative was a predictor of
the HCCP item of inform, R2 = .138, β = .371, F(1, 29) =
4.637, p = < .05. The results indicate that the participants’
production of more complex narratives was associated with
their self-reports of higher frequency of informing physi-
cians of health concerns. The narrative accounted for 13%
of the variance for informing. According to interpretations
in the literature, moderate variance begins at the 9% level,
whereas large variance is ≥ 25% (Cohen, 1988; Cohen,
Cohen, West, & Aiken, 2003).
Influence of Background Variables
To further examine the influence of the independent
variables on an individual’s health care communication
skills (the third research question), individual items from
Table 3. Selected correlations between the FACS–SC and the
HCCP.
FACS–SC HCCP
FACS–SC mean HCCP mean
FACS–SC mean Disagree
FACS–SC mean Opinion
FACS–SC mean Inform
Explain Inform
Vocal tone Initiate
Facial expression Initiate
Vocal tone Inform
Facial expression Inform
Understand TV Question
*p < .05, **p < .01.
46 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE
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the HCCP were entered into a series of stepwise multiple
regression analyses with each of the four independent vari-
ables of age, gender, education, and health status. Health
status emerged as a significant predictor of health care
communication skills in two areas. First, a positive relation-
ship was found between health status and health care com-
munication skills in general, R2 = .148, β = .372, F(1, 49)
= 8.514, p < .00. These findings showed that health status
accounted for 14% of the variance for HCCP total score.
Second, a negative relationship was found between health
status and the specific health care communication skill of
questioning, R2 = .136, F(1, 51) = 7.943, p < = .05, β =
–.369. Another significant finding was that age was a pre-
dictor of the understanding health information item on the
HCCP, R2 = .159, F(1, 51) = 8.764, p < .05, β = .399. No
predictive value emerged for gender, education, or race.
DISCUSSION
The present study was designed to examine the relationship
between communication skills and health literacy in older
adults through comparison of pragmatic skills used in social
communication and health care contexts. The motivation
for analyzing these relationships originated from a grow-
ing emphasis on the importance of communication skills in
the attainment of adequate health care (IOM, 2004; Kreps,
2006). This study was a first step in examining how social
communication skills may provide a foundation for health
literacy with regard to communication within the health
care context. Thus, the preliminary findings from the study
add information to the existing literature in several ways.
Pragmatic Skills and
Health Care Communication
A major finding from this study is that there is a moderate
relationship between pragmatic skills used in social com-
munication contexts and those used in health care com-
munication contexts. This finding suggests that the social
communication skills used by older adults may be related to
their ability to communicate with their health care provider.
One example is that relationships were found between the
FACS–SC score and the HCCP verbal items of disagree,
express opinion, and inform. This finding is consistent with
previous findings discussed, suggesting that the overall prag-
matic skills used in social communication contexts may play
r an important role in one’s pragmatic skills used in the health
care encounter. When an older adult presents with strong so-
.279*
cial communication skills, he or she may be more inclined to
.242*
.353** disagree, as well as provide information and opinions, than
.521** older adults with weaker social communication skills. Thus,
.300* older adults with stronger social communication skills may
.516** gain greater benefit from their health care encounter than
.516**
.369** those with weaker skills. This interpretation is consistent
.307* with previous reports of the benefits of patients’ participa-
.281* tion in their health care. Reports indicate that the patient’s
communicative behavior influences the physician’s responses
(Cooper & Roter, 2003; Tran et al., 2004). Patients who
AND DISORDERS • Volume 38 • 41–52 • Spring 2011
actively engage in their health care by questioning, providing
information on health concerns, and expressing their opinions
feel more in control and have better disease management
than patients who are passive (Cooper & Roter, 2003; Mika
et al., 2005; Street, 2003; Tran et al., 2004).
Second, findings indicate a positive relationship between
understanding vocal tones and facial expressions and initiat-
ing communication in the health care setting. Approximate-
ly 60% of the meaning in social interactions is communi-
cated nonverbally, and most communication acts carry a set
of nonverbal components (i.e., facial expression, gestures,
eye contact, vocal behaviors; Burgoon, Buller, & Woodall,
1994). Moreover, nonverbal cues are typically believed
when there is a conflict with verbal messages (Burgoon
& Bacue, 2003). An individual’s use of facial expressions
can aid in the meaning of a message being conveyed,
and changing characteristics of vocal tone such as intona-
tion, loudness, or stress can modify the social meaning of
a sentence (Nelson et al., 2004). All of these nonverbal
components play an especially important role in the initial
encounter of individuals by influencing the length, tone,
and quality of an interaction (Rigglio, 1992).
The ability to encode and decode nonverbal communica-
tion exchanges successfully may have an effect on
provider–patient interactions during the health care en-
counter. For instance, if a patient perceives the nonverbal
messages (vocal tone and facial expression) of the provider
as positive, this may create a climate where the patient is
more willing to initiate communication regarding his or
her health care. When a patient has a negative perception
regarding the provider’s nonverbal behaviors, the outcome
may be the opposite reaction. These perceptions may result
in the decreased likelihood that the patient will share infor-
mation with the provider and take an active role in his or
her health care planning.
Previous studies regarding provider–patient interactions
have indicated that patients often worry that they may be
considered to be “ignorant” or “stupid” by their physician
when asking questions or providing their opinion regarding
their health care (Tran et al., 2004). In addition, Greene
and Adelman (2001) found that the interactional processes
and the global tone of the physician in the first visit are
strong predictors of the physician–patient interactions in
subsequent visits. Therefore, if an individual perceives
the provider’s vocal tone and facial expressions as nega-
tive, such as condescending or uninterested, combined with
existing fears of being viewed as unintelligent, increased
hesitancy to initiate communication regarding health con-
cerns may result. Likewise, studies have indicated that the
patient’s affect impacts physician–patient interactions and
the length of patient visits (Cooper & Roter, 2003).
Third, the narrative production task was a significant
predictor of informing on the HCCP. This result indicates
that skills needed to comprise a narrative are imperative
to success in both daily life and health care encounters.
In daily encounters, narratives take on a dynamic interac-
tion between a sender and a receiver wherein an individual
must organize knowledge and experience to convey a
message pertaining to a present circumstance (Ukrainetz,
2006). Health narratives are important components in a
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patient’s care because they provide information regarding
the patient’s health status as it impacts his or her activities
of daily living, as well as a chronological account of health
events (IOM, 2004; Street, 2003). The present findings
suggest that older adults who exhibit strong narrative skills
in social communication contexts would be more likely to
provide information regarding their health during health
care encounters. These older adults may not only be more
proficient at formulating a narrative, but may also demon-
strate a greater ability to coordinate their responses with
the provider to create a smooth exchange of information
(Street, 2003). Hence, the present findings support existing
reports regarding the importance of narrative skills during
communication in the health care setting.
Health Care Communication Skills
as Related to Age and Health Status
Health status emerged as a significant predictor of health
care communication skills, although findings indicate
both positive and negative relationships. These conflicting
findings were not anticipated, but they are both consis-
tent and inconsistent with previous studies (Beers et al.,
2003; Cooper & Roter, 2003; Dearborn et al., 2006; Kreps,
2006; Tran et al., 2004). Several reports have suggested
that patients with good health status tend to have higher
health literacy levels, are more participatory in health care
visits, and are more satisfied with their health care (Cooper
& Roter, 2003; Rudd, Kirsch, & Yamamoto, 2004; Wolf,
Gazmararian & Baker, 2005). Contrary to these findings,
the present results found health care communication ratings
to increase with an increase in reported health conditions.
These results are consistent with a study by Cooper and
Roter (2003) that found that patients with health condi-
tions or sicker patients tended to provide more biomedi-
cal information during physician–patient interactions but
were less engaged in social conversation than patients
with good health status. Sicker patients also reported less
satisfaction with their health care (Cooper & Roter, 2003;
Thompson et al., 2004). Similarly, in the present study,
increased health conditions were related to higher overall
health care communication ratings. Recall that 79% of the
participants reported having no significant health condition,
and 20% reported having a history of one or more of the
following health conditions: heart attack, congestive heart
failure, stroke, neurological disease, depression, diabetes,
and high blood pressure. This percentage of participants
reporting health conditions is similar to a study by Rudd et
al. (2004), in which 77% of participants reported no health
conditions. However, in this health literacy study, partici-
pants without significant health conditions achieved higher
health literacy test scores than those with health conditions.
The difference in these findings could be related to the dif-
ferent methods used in the investigations (i.e., ethnographic
vs. experimental study).
In contrast to the positive relationship found between
health conditions and health care communication, a nega-
tive relationship was found between specific items on the
HCCP and health status, suggesting that as health condi-
tions increase, self-ratings for questioning during health
47
care interactions decrease. The quality of health care
satisfaction a patient has is dependent on adequate commu-
nication skills, and questioning is considered the strongest
predictor of positive health outcomes (Cooper & Roter,
2003; Hoffman et al., 2005). By asking questions, patients
compel health care providers to discuss health matters that
otherwise would not be addressed during the communica-
tion interaction (Street, 2003). By seeking information from
the provider, patients not only gain information but may
also affect the direction of the interaction (Street, 2003).
The ability to be an active member during health care
visits by asking questions is important for older adults
because they are often faced with multiple and complex
health problems (Cooper & Roter, 2003; Wolf et al., 2005).
Moreover, reports have indicated that asking questions dur-
ing provider–patient interactions is one of the most direct
ways of remaining active in one’s health care management
(i.e., gathering information and gaining clarification; Street,
2003). Taken together, the present findings on health status
suggest that although patients with poor health status may
provide information regarding their medical conditions
during health care encounters, they experience a circular
problem with health care in which they ask fewer ques-
tions, resulting in less health care information given and
decreased understanding of health conditions. Decreased
understanding of health conditions results in lower health
literacy to adequately manage health problems, thereby
resulting in decreased health care satisfaction and possibly
poorer health outcomes.
Finally, a positive relationship was found between age
and understanding health information on the HCCP. This
item involved the participant’s reported frequency of un-
derstanding the provider’s explanation concerning his or
her health condition. Reports indicate that the presentation
of complex materials during health care visits with older
adults may decrease the patient’s ability to understand
information regarding his or her health (IOM, 2004; Street,
2003; Thompson et al., 2004). Therefore, the finding that
age was positively related to understanding health informa-
tion was an unanticipated finding in the present study. One
explanation for this result could be the higher education
levels of the participants in the present study. Although no
significant differences emerged for education levels in the
preliminary analysis, visual inspection of the data indicated
more participants with bachelor’s and master’s degrees in
the 73–82 age group.
Clinical Implications
Results of the present investigation suggest that pragmatic
skills may be used to examine health literacy within com-
munication contexts because pragmatic skills used in social
communication tend to be related to pragmatic skills used
in the health care context. Although family members usu-
ally accompany clients with communication disorders to
doctor visits, these clients, for example, may have difficulty
engaging in effective provider–patient interactions. Older
patients with voice disorders, mild dementia, mild aphasia,
and traumatic brain injury may experience communication
challenges during health care visits. A noted concern is that
48 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE
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providers may stereotype these individuals as unable to
participate in the health care visit, precipitating a clinician-
centered environment where the provider uses close-ended
questions, does the bulk of the talking, and interrupts the
patient (Street, 2003).
In the field of communication disorders, negative ste-
reotypes and attitudes toward the elderly have been noted
(Searl & Gabel, 2003). Such stereotypes and attitudes may
affect the type of interaction that occurs with older adults,
and in turn, impact communication of valuable information.
Also, due to time constraints placed on health care visits,
patients may not have enough time, due to their disorder,
to present a detailed health account, ask questions, and for-
mulate responses. Furthermore, providers often use medical
terminology that is difficult for individuals to understand,
which may particularly affect the comprehension of people
with communication disorders and result in potential misun-
derstandings about health care information.
In addition to factors associated with the provider’s com-
munication style, individuals with communication disorders
may present multiple deficits including executive function-
ing, memory, and processing that may impede successful
communication during health care encounters. These defi-
cits may be characterized by decreased ability to sequence
events to produce a cohesive narrative, memory deficits,
and word retrieval deficits (Coelho, 2002; Hays, Niven,
Godfrey, & Linscott, 2004). Such deficits can impact the
patient’s ability to accurately question, explain, clarify,
understand, and inform during health care visits. These
preliminary findings suggest a need for exploring the use of
pragmatic-based therapy activities that may empower older
individuals with communication disorders during health
care visits.
Limitations of Study and
Directions for Future Research
The present study provides new information regarding
social communication and health care communication skills.
However, it is a preliminary investigation with limitations.
A major shortcoming is that the sample of participants had
limited diversity. African Americans represented only 18%
of the participants, and only 23% were males. These low
percentages limited the analysis in terms of ethnicity and
gender. The education levels of the sample also may limit
generalization of the findings. Although participants’ educa-
tion ranged from 6 to 20 years, with a mean of 14 years
for each age group, 50% of the participants had college
degrees. This high percentage of college graduates may not
be representative of older adults in the general population.
Future studies with a more diverse sample may find other
predictors and relationships between pragmatics and health
care communication skills.
There were also limitations regarding the assessments
used in the study. Research should aim to further vali-
date the HCCP using larger and more diverse samples of
individuals with and without communication disorders.
Additionally, the low but significant correlations of some
variables need further examination. One possible contribu-
tor to the low correlations could relate to the types of
AND DISORDERS • Volume 38 • 41–52 • Spring 2011
instruments used in the present study. The FACS–SC, for
example, is an assessment tool requiring observation of
communication skills, whereas the HCCP is a self-report
assessment tool. Future studies using two self-report tools
may yield higher correlations between perceived pragmatic
skills used in social and health care contexts. In contrast,
pragmatic analysis of audio- or video-taped provider–pa-
tient interactions may provide additional information on
patients’ communication behavior. Existing audio-taped
provider–patient interaction studies did not employ a prag-
matic analysis of these communicative behaviors as used in
communication sciences and disorders. In addition to sug-
gestions for assessing health care communication in future
studies, narrative assessments should be expanded as well.
Although narratives were found to be a predictor of health
care communication skills, only one narrative was elicited
in the present study. Further investigation of this relation-
ship is needed using more than one narrative task to obtain
a more extensive narrative assessment that is not limited to
one topic, as in the present study.
Future studies should include stringent classifications of
health status that could be subjected to a reliable analy-
sis. In the present study, no rating or ranking was used to
differentiate the severity of health conditions, resulting in
only speculations regarding health status and health care
communication skills.
Overall, additional studies are necessary to investigate
whether the findings from the current study regarding rela-
tionships between social communication skills and pragmat-
ic skills in the health care setting generalize to older and
younger adult clients with mild communication disorders.
The results of the present study provide important informa-
tion by suggesting that the FACS–SC has value in identi-
fying social communication skills that may be potentially
related to pragmatic skills needed in the health care setting.
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Contact author: Eva Jackson Hester, Department of Audiology,
Speech-Language Pathology & Deaf Studies, Towson University,
Towson, MD 21252. E-mail: ehester@towson.edu.
51
 APPENDIX. NARRATIVE MATURITY RATING USING STORY GRAMMAR
LEVELS
Level 1. Isolated Description:
Level 2. Temporal Sequence:
Level 3. Causal Sequence:
Level 4. Abbreviated Episode:
Level 5. Complete Episode:
Level 6. Complex/Multiple Episodes:
Level 7. Interactive Episodes:
Story limited to isolated description of people, places and events. No
sequence of events
Story limited to a temporally related sequence of events or actions.
Ideas often linked by and, so, and then.
Story is limited to a causally related sequence of events. Series of ac-
tions that are causally linked but without planning. Causal relationships
can be implied, but must characterize most of the story.
Story is goal directed with stated problem. Characters’ aim or inten-
tions are implied or stated.
Planning in story achieves clear goal with character aims stated. End-
ing brings closure.
At least one complete episode with goals stated, accompanied by ad-
ditional abbreviated or other complete episodes.
Two major characters with separate goals whose actions influence each
other. Complete episodes with clear planning indicated for characters.

Note. From The Writing Lab Approach to Language Instruction and Intervention (pp. 386–387), by N. W. Nel-
son, C. M. Bahr, and A. M. Van Meter, 2004, Baltimore, MD: Paul H. Brookes Publishing Co., Inc. Copyright
2004 by Paul H. Brookes Publishing Co., Inc. Adapted with permission.

52 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS • Volume 38 • 41–52 • Spring 2011

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