Should patients have control over their own health care?: empirical evidence and research issues

Impact of Pharmacists' Interventions and Patients' Decision on Health Outcomes in Terms of Medication Adherence and Quality Use of Medicines among Patients Attending Community Pharmacies: A Systematic Review

Community pharmacists are responsible for providing the appropriate information on the use of medications to patients, which may enhance their medication adherence. The extent of control that patients have on their health care preferences creates many challenges for community pharmacists. This study aimed to determine the impact of pharmacist interventions and patient decisions on health outcomes concerning medication adherence and the quality use of medicines among patients attending community pharmacies. Appropriate studies were identified in a systematic search using the databases of Medline, Scopus, Google Scholar, and PubMed. The search included literature published between 2004 and 2019. The database searches yielded 683 titles, of which 19 studies were included after the full-text analysis with a total of 9313 participants. Metaprop command in Stata software version 14 was used for the analysis. This study was undertaken based on the general principles of the Cochrane Handbook for Systematic Reviews of Interventions and subsequently reported according to the Preferred Reporting Items for Systematic Reviews (PRISMA) extension. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was directly used to rate the quality of evidence (high, moderate, low, or very low). The results revealed the effective interaction between patients and community pharmacists, the importance of pharmacist intervention on medication adherence and quality use of medicine, and the role of community pharmacists in counselling patients. Decision/choice of patients in self-care and self-medication is a factor contributing to health outcomes. Effective interaction of community pharmacists with patients in terms of medication adherence and quality use of medicines provided a better health outcome among patients. The community pharmacists influenced the decision/choice of patients in self-care and self-medications.

Using a Personal Health Library-Enabled mHealth Recommender System for Self-Management of Diabetes Among Underserved Populations: Use Case for Knowledge Graphs and Linked Data

Background

Traditionally, digital health data management has been based on electronic health record (EHR) systems and has been handled primarily by centralized health providers. New mechanisms are needed to give patients more control over their digital health data. Personal health libraries (PHLs) provide a single point of secure access to patients' digital health data and enable the integration of knowledge stored in their digital health profiles with other sources of global knowledge. PHLs can help empower caregivers and health care providers to make informed decisions about patients’ health by understanding medical events in the context of their lives.

Objective

This paper reports the implementation of a mobile health digital intervention that incorporates both digital health data stored in patients’ PHLs and other sources of contextual knowledge to deliver tailored recommendations for improving self-care behaviors in diabetic adults.

Methods

We conducted a thematic assessment of patient functional and nonfunctional requirements that are missing from current EHRs based on evidence from the literature. We used the results to identify the technologies needed to address those requirements. We describe the technological infrastructures used to construct, manage, and integrate the types of knowledge stored in the PHL. We leverage the Social Linked Data (Solid) platform to design a fully decentralized and privacy-aware platform that supports interoperability and care integration. We provided an initial prototype design of a PHL and drafted a use case scenario that involves four actors to demonstrate how the proposed prototype can be used to address user requirements, including the construction and management of the PHL and its utilization for developing a mobile app that queries the knowledge stored and integrated into the PHL in a private and fully decentralized manner to provide better recommendations.

Results

To showcase the main features of the mobile health app and the PHL, we mapped those features onto a framework comprising the user requirements identified in a use case scenario that features a preventive intervention from the diabetes self-management domain. Ongoing development of the app requires a formative evaluation study and a clinical trial to assess the impact of the digital intervention on patient-users. We provide synopses of both study protocols.

Conclusions

The proposed PHL helps patients and their caregivers take a central role in making decisions regarding their health and equips their health care providers with informatics tools that support the collection and interpretation of the collected knowledge. By exposing the PHL functionality as an open service, we foster the development of third-party applications or services and provide motivational technological support in several projects crossing different domains of interest.

Do Patients Want Control over their Own Health Care? A Review of Measures, Findings, and Research Issues

Across a wide variety of medical settings, patients report that they want detailed information about their condition and their treatment whereas stated desire for input into decision making is skewed more in the direction of physician-only or at least collaborative decision-making. These results, along with the contextual and individual difference factors associated with increased willingness to relinquish control (lower educational level, more serious illness, increasing age), indicate that patients want to assume control if they feel it will be beneficial to them to do so. The findings, however, are based largely on the relationship of patients’ mean scores to arbitrarily determined scale midpoints on measures with little or no criterion-related validity. These measures also show insufficient overlap with better validated measures of desire for health care control, which indicate more normally distributed scores and a broader range of individual differences among respondents. Findings are discussed in terms of the need for further research on the structure (dimensionality) and stability of the construct desire for health care control and issues involved in conducting needed criterion-related validational work.

Patients Know Best: Qualitative Study on How Families Use Patient-Controlled Personal Health Records

Background

Self-management technologies, such as patient-controlled electronic health records (PCEHRs), have the potential to help people manage and cope with disease.

Objective

This study set out to investigate patient families’ lived experiences of working with a PCEHR.

Methods

We conducted a semistructured qualitative field study with patient families and clinicians at a children’s hospital in the UK that uses a PCEHR (Patients Know Best). All families were managing the health of a child with a serious chronic condition, who was typically under the care of multiple clinicians. As data gathering and analysis progressed, it became clear that while much of the literature assumes that patients are willing and waiting to take more responsibility for and control over their health management (eg, with PCEHRs), only a minority of participants in our study responded in this way. Their experiences with the PCEHR were diverse and strongly shaped by their coping styles. Theory on coping identifies a continuum of coping styles, from approach to avoidance oriented, and proposes that patients’ information needs depend on their style.

Results

We identified 3 groups of patient families and an outlier, distinguished by their coping style and their PCEHR use. We refer to the outlier as controlling (approach oriented, highly motivated to use PCEHR), and the 3 groups as collaborating (approach oriented, motivated to use PCEHR), cooperating (avoidance oriented, less motivated to use PCEHR), and avoiding (very avoidance oriented, not motivated to use PCEHR).

Conclusions

The PCEHR met the needs of controller and collaborators better than the needs of cooperators and avoiders. We draw on the Self-Determination Theory to propose ways in which a PCEHR design might better meet the needs of avoidance-oriented users. Further, we highlight the need for families to also relinquish control at times, and propose ways in which PCEHR design might support a better distribution of control, based on effective training, ease of use, comprehensibility of data security mechanisms, timely information provision (recognizing people’s different needs), personalization of use, and easy engagement with clinicians through the PCEHR.

Impact of medicine-related information on medicine purchase and use by literate consumers

Aims:

To measure impact of information, education, and communication intervention (IEC) on rational medicine use, purchase, and stocking behavior.

Materials and Methods:

This was a pre- and post-design, interventional study. Base data were collected in first visit, using pre tested questionnaire from 500 respondents, who were of either gender, English speaking, at least graduates, permanent residents, and willing to participate. IEC was framed based on problems identified from this data. First intervention was handouts distributed in the second visit, containing information on cost saving in medicine purchase. Second intervention was a lecture session on medicine prices, rational use of medicines, and tips on saving on medicine purchase. Five articles about medicine use and price differences were published in the local newspaper, over 10 days, formed third intervention. After 1 month, post-intervention data was collected using same instrument with some additional questions. Results were analyzed by Chi-square test using Graph Pad prism Version 3.0.

Results:

Awareness about price variation, self-medication, expiry period, generic and brand quality increased post-intervention. Attitudes toward new, costly, brands, injections, sharing and reusing old prescriptions changed post-intervention. Behavioral changes in stocking habits, adherence to doctors’ advice, getting cash memo, comparing prices, reading labels, were seen post-intervention.

Conclusion:

People carry false notions about medicines which influence their use and habits. This intervention successfully changed behavior and could bring awareness on many aspects of medicine use.

Appraisal of Desire for Control over Healthcare: Structure, Stability, and Relation to Health Locus of Control and to the 'Big Five' Personality Traits

This study addressed the question of whether the traditional tripartite distinction between cognitive, decisional and behavioral control is meaningful as applied to desire for healthcare control. Subscales of the Krantz Health Opinion Survey and the Autonomy Preference Index were administered to 680 undergraduates along with the Multidimensional Health Locus of Control Scales and the NEO-FFI Five-Factor Inventory. These measures were readministered to 523 of these subjects approximately seven weeks later. Confirmatory factor analysis of the data indicated that desire for healthcare control is best conceptualized as having three separate components. Desire for information was clearly unrelated to either desire for behavioral or decisional control; however the latter two forms of control, which are indicative of more active engagement by the individual, overlapped to a moderate degree. The three-factor model was stable over time and the component factors (particularly desire for decisional and behavioral control) were also stable. No strong relationships were found between the component factors and measures of health locus of control or the basic personality trait dimensions measured by the NEO, suggesting that the factors represent largely situation-specific traits. Findings were discussed in terms of how they may have been influenced by variability in the instruments that were used to measure the separate desire for healthcare control components, and in terms of the need for criterion-related validational work especially in the crucial area of decisional control.

Bedside information technology to support patient-centered care

PURPOSE

Patients and health care providers often lack real time access to information at the bedside required to provide safe patient-centered care. Both groups identified pertinent information needed at the patient's bedside. The purpose of our research was to identify the essential data elements that will be used to define requirements for a useful bedside communication tool in the acute care hospital setting.

METHODS

Descriptive research methods were used to identify bedside information requirements through group and individual interviews. Data from patients and health care providers were analyzed to identify common themes, compiled into a survey, and validated by both groups.

RESULTS

Thirty-seven information requirements were identified and classified under five themes: (1) plan of care, (2) patient education, (3) communication of safety alerts, (4) diet, and (5) medications. A survey completed by 30 patients and 30 health care providers confirmed 36 specific bedside information requirements (mean ≥ 5 on an 11-point scale). Patients and health providers each identified 24 specific information requirements that were similar in importance. When compared with nurses, significant differences were noted in the degree to which patients identified knowing the "daily routine schedule," e.g. when their doctor typically sees patients as a key requirement for the electronic bedside communication tool, t=3.52, p=.001.

CONCLUSION

Patients and health care providers identified information requirements at the bedside to promote self-care management of healthcare needs and an understanding of the hospital environment. Accurate, easily accessed information at the bedside is needed for providing safe patient-centered care.

Progress in medicine: autonomy, oughtonomy and nudging

RATIONALE

In this article, I argue that we need a new perspective in the debate on autonomy in medicine, to understand many of the problems we face today - dilemmas that are situated at the intersection of autonomy and heteronomy, such as why well informed and autonomous people make unhealthy lifestyle choices. If people do not choose what they want, this is not simply caused by their lack of character or capability, but also by the fact that absolute autonomy is impossible; autonomous individuals are 'contaminated' by heteronymous aspects, by influences from 'outside'. Consequently, there are many good reasons to question the widely accepted hierarchical opposition of autonomy (progress) versus heteronomy (paternalism) in medicine. In an earlier article an analysis is made of the neologism 'oughtonomy' to support the thesis that when it comes down to human existence, autonomy and heteronomy are intertwined, rather than being merely opposites.

METHODS

In this article, I reflect upon how social conditions might improve our 'choice architecture', what Thaler & Sunstein have called 'nudging': how to change individual health choices without being paternalistic? I explore the extent to which both oughtonomy and nudging are able to challenge the question of autonomy in today's medicine.

RESULTS AND CONCLUSIONS

Autonomy may and should be a shared target in today's medicine, but we should never forget that it is always intertwined with heteronomy. Starting from this perspective, progress in medicine demands far more than the increase of autonomy.

Cognitive-emotional decision making (CEDM): a framework of patient medical decision making

OBJECTIVE

Assistance for patients faced with medical decisions has largely focussed on the clarification of information and personal values. Our aim is to draw on the decision research describing the role of emotion in combination with health behaviour models to provide a framework for conceptualizing patient decisions.

METHODS

A review of the psychological and medical decision making literature concerned with the role of emotion/affect in decision making and health behaviours.

RESULTS

Emotion plays an influential role in decision making. Both current and anticipated emotions play a motivational role in choice. Amalgamating these findings with that of Leventhal's (1970) SRM provide a framework for thinking about the influence of emotion on a patient medical decision.

CONCLUSION

Our framework suggests that a patient must cope with four sets of elements. The first two relate to the need to manage the cognitive and emotional aspects of the health threat. The second set relate to the management of the cognitive and emotional elements of the decision, itself.

PRACTICE IMPLICATIONS

The framework provides a way for practitioners and researchers to frame thinking about a patient medical decision in order to assist the patient in clarifying decisional priorities.

Roles of sex and ethnicity in procurement coordinator--family communication during the organ donation discussion

CONTEXT

Interpersonal relations with health care providers influence families' decisions to consent to solid-organ donation. However, previous research has been based on retrospective interviews with donation-eligible families and has not directly examined the interpersonal interactions between families and organ procurement coordinators.

OBJECTIVE

To increase understanding of the interpersonal interaction between procurement coordinators and families during the organ donation discussion, with special attention to the influence of the sex and race of the procurement coordinator and the race of the potential donor's family.

DESIGN

A descriptive study in which standardized patients portrayed family members interacting with actual procurement coordinators in simulated donation request scenarios.

SETTING AND PARTICIPANTS

Thirty-three videotaped interactions between standardized patients and 17 procurement coordinators involving 2 different scenarios depicting deceased donation were evaluated.

MAIN OUTCOME MEASURES

Video recordings were rated by independent coders. Coders completed the Impact Message Inventory-Form C, the Participatory Style of Physician Scale, and the Siminoff Communication and Content and Affect Program-Global Observer Ratings scale.

RESULTS AND CONCLUSIONS

African American procurement coordinators, particularly African American women, were rated as more controlling and work-oriented than white procurement coordinators. Male procurement coordinators were more affiliative with the white family than the African American family, whereas female procurement coordinators were slightly less affiliative with the white family. African American procurement coordinators expressed more positive affect when interacting with the African American family than the white family, whereas the opposite was true for white procurement coordinators. Research is needed to cross-validate these exploratory findings and further examine cultural mistrust between procurement coordinators and families of ethnic minorities, especially given the negative attitudes of many minorities toward donation.

Roles of Sex and Ethnicity in Procurement Coordinator—Family Communication during the Organ Donation Discussion

Context

Interpersonal relations with health care providers influence families' decisions to consent to solid-organ donation. However, previous research has been based on retrospective interviews with donation-eligible families and has not directly examined the interpersonal interactions between families and organ procurement coordinators.

Objective

To increase understanding of the interpersonal interaction between procurement coordinators and families during the organ donation discussion, with special attention to the influence of the sex and race of the procurement coordinator and the race of the potential donor's family.

Design

A descriptive study in which standardized patients portrayed family members interacting with actual procurement coordinators in simulated donation request scenarios.

Setting and Participants

Thirty-three videotaped interactions between standardized patients and 17 procurement coordinators involving 2 different scenarios depicting deceased donation were evaluated.

Main Outcome Measures

Video recordings were rated by independent coders. Coders completed the Impact Message Inventory-Form C, the Participatory Style of Physician Scale, and the Siminoff Communication and Content and Affect Program–Global Observer Ratings scale.

Results and Conclusions

African American procurement coordinators, particularly African American women, were rated as more controlling and work-oriented than white procurement coordinators. Male procurement coordinators were more affiliative with the white family than the African American family, whereas female procurement coordinators were slightly less affiliative with the white family. African American procurement coordinators expressed more positive affect when interacting with the African American family than the white family, whereas the opposite was true for white procurement coordinators. Research is needed to cross-validate these exploratory findings and further examine cultural mistrust between procurement coordinators and families of ethnic minorities, especially given the negative attitudes of many minorities toward donation.

Preference assessment of recruitment into a randomized trial for adolescent idiopathic scoliosis

BACKGROUND

Randomized controlled trials are powerful tools to evaluate the outcomes of clinical treatments. However, these trials tend to be expensive and time-consuming, and their conclusions can be threatened by several limitations. This study estimated the strength of three common limitations (underenrollment, selective enrollment, and nonadherence to protocol) in a proposed study of adolescent idiopathic scoliosis.

METHODS

Patients with scoliosis and their parents were asked to complete a web-based survey about their preferences concerning a hypothetical randomized trial. Adolescents without scoliosis and their parents also participated. Surveys included questions about treatment preference, likelihood of participation, required risk reduction, and propensity to drop out or choose a different treatment while enrolled in the study.

RESULTS

Ninety adolescents and eighty-three parents participated. Observation was preferred to bracing by the majority of subjects. Overall, 33% of the parents and adolescents would both agree to participate in the hypothetical trial. Of the subjects who would not agree to participate, the majority would rather share the decision-making responsibility with the physician than have the treatment chosen in a random fashion. Many of the subjects would consider changing treatments during the course of the trial if they were not satisfied with the outcomes; the majority of parents who preferred bracing would consider crossing over to the bracing arm if their children were randomized to observation.

CONCLUSIONS

Recruitment into a randomized trial of bracing compared with observation for the treatment of adolescent idiopathic scoliosis may well be problematic, considering the relatively small percentage of families who said they would consider randomization. Additionally, the threat of nonadherence to protocol may be strong and must be addressed in the protocol of the trial. Most families wanted to make the treatment decision with the physician in lieu of randomization; therefore, the role of the physician in patient recruitment and retention should not be underestimated.

Shared decision making in antipsychotic management

The similar efficacies of currently available antipsychotic medications (other than clozapine) make them appropriate for preference-sensitive care; therefore, prescribing these medications is amenable to shared decision-making. In this conceptual article, we describe the current state of antipsychotic prescribing based on a review of the literature from recent landmark studies and updated prescribing guidelines. Recent literature and guidelines on schizophrenia treatment in the United States do not reveal strong endorsement of the idea of shared decision-making. We suggest methods for incorporating shared decision-making into antipsychotic prescribing in the future, with an emphasis on the use of information technology.

Models based on value and probability in health improve shared decision making

RATIONALE, AIMS AND OBJECTIVES

Diagnostic reasoning and treatment decisions are a key competence of doctors. A model based on values and probability provides a conceptual framework for clinical judgments and decisions, and also facilitates the integration of clinical and biomedical knowledge into a diagnostic decision.

METHOD

Both value and probability are usually estimated values in clinical decision making. Therefore, model assumptions and parameter estimates should be continually assessed against data, and models should be revised accordingly. Introducing parameter estimates for both value and probability, which usually pertain in clinical work, gives the model labelled subjective expected utility. Estimated values and probabilities are involved sequentially for every step in the decision-making process.

RESULTS

Introducing decision-analytic modelling gives a more complete picture of variables that influence the decisions carried out by the doctor and the patient.

CONCLUSION

A model revised for perceived values and probabilities by both the doctor and the patient could be used as a tool for engaging in a mutual and shared decision-making process in clinical work.

Psychological factors associated with response to maxillofacial injury and its treatment

PURPOSE

This study evaluated symptoms of acute stress disorder (ASD), satisfaction with appearance postsurgery, and satisfaction with care in patients with maxillofacial injury at their first postsurgical physician visit. To determine the best predictors of patients' ASD symptoms and satisfaction, data also were obtained on the patients' strategies for coping with the stress of the injury, on the patients' and doctors' interpersonal appraisals of each other, and on the doctors' participatory behavior during the visits.

PATIENTS AND METHODS

A total of 47 patients who had sustained traumatic maxillofacial injury requiring emergency medical/surgical treatment were administered self-report measures immediately before and after their first postsurgical visit 10 to 12 days after trauma exposure. Doctors completed self-report measures after the visit and evaluated the patients' severity of injury.

RESULTS

Patients experienced high levels of ASD in the short-term period after surgery. Use of emotion-focused strategies by patients to cope with stress was associated with more ASD symptoms but better satisfaction with facial appearance. The more severely injured patients were less satisfied with their appearance and were viewed by their doctors as being more interpersonally controlling during the postsurgical visit.

CONCLUSIONS

Closer attention by doctors to patients' interpersonal behavior may aid in early identification of those patients with maxillofacial injury who may experience longer-term social problems related to their altered facial appearance.

Relationship of interpersonal behaviors and health-related control appraisals to patient satisfaction and compliance in a university health center

OBJECTIVE

The authors' aim was to evaluate patient-provider relationships in a college health center.

PARTICIPANTS

Eighty student patients and their health-care providers.

METHODS

Patients completed a measure of perceived health competence before a consultation and measures of provider participatory behavior and interpersonal behavior before and after the consultation. They evaluated their satisfaction with care and compliance after the consultation and again 2 weeks later. Providers completed measures of their participatory behavior and patients' interpersonal behavior after the consultation.

RESULTS

Patients preferred to be well informed and to have their preferences taken into account, and generally felt competent at managing their own health affairs. They indicated they obtained the high level of participation they desired. Patients desired and actually experienced friendly and submissive providers. Degree of match between patients' desired and actual level of involvement in their care was associated with greater satisfaction. A greater match between the extent to which they desired the provider to be affiliative and the provider's actual affiliative behavior was associated with more satisfaction. No variables were predictive of patient compliance.

CONCLUSION

The authors discuss results in terms of the influence of situational factors characteristic of a college health center.

The Psychometrics of Developing the Patient Empowerment Scale

Although patient empowerment is widely acknowledged as important by health professionals it remains a somewhat nebulous concept. An initial empowerment measure has been developed through an extensive review of literature combined with a series of in-depth interviews of cancer patients concerning their use of coping strategies. The results were analysed for major themes in relation to sense of control over the illness. A set of twenty-eight statements were formulated from themes into a Likert-type scale for self-completion by 100 cancer patients. The scale could be used in assessing level of empowerment amongst cancer patients thereby establishing through this information, the patient's ability to make decisions about coping with their illness.

Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions

OBJECTIVE

A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician-patient communication.

METHODS

Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient-physician beliefs in shared decision-making; patient-physician match, fit, or concordance; reciprocal relationship or mutuality; doctor-patient affiliation, control, relationship; match/fit between patient and physician in affiliation, control, or relationship.

RESULTS

Findings revealed varying degrees of support for the positive effects of matching patients' preferred levels of information, decisional control, and consultative interpersonal behavior.

CONCLUSIONS

Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation. PRACTICE AND RESEARCH IMPLICATIONS: Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient-physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient-physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.

Older adults' coping with negative life events: common processes of managing health, interpersonal, and financial/work stressors

This study examined how older adults cope with negative life events in health, interpersonal, and financial/work domains and whether common stress and coping processes hold across these three domains. On three occasions, older adults identified the most severe negative event they faced in the last year and described how they appraised and coped with that event, their ambient chronic stressors, and event and functioning outcomes. The stress and coping process was largely consistent across the three life domains. Individuals who appraised events as challenging and relied more on approach coping were more likely to report some benefit from those events. Individuals who experienced more chronic stressors and favored avoidance coping were more likely to be depressed and to have late-life drinking problems. Chronic stressors, as well as approach and avoidance coping, were predictably associated with overall outcomes in all three event domains. These findings provide a basis for preventive interventions that may help older adults' address the most prevalent stressors of aging more effectively.

Information and shared decision-making are top patients' priorities

Background

The profound changes in medical care and the recent stress on a patient-centered approach mandate evaluation of current patient priorities.

Methods

Hospitalized and ambulatory patients at an academic medical center in central Israel were investigated. Consecutive patients (n = 274) indicated their first and second priority for a change or improvement in their medical care out of a mixed shortlist of 6 issues, 3 related to patient-physician relationship (being better informed and taking part in decisions; being seen by the same doctor each time; a longer consultation time) and 3 issues related to the organizational aspect of care (easier access to specialists/hospital; shorter queue for tests; less charges for drugs).

Results

Getting more information from the physician and taking part in decisions was the most desirable patient choice, selected by 27.4% as their first priority. The next choices – access and queue – also relate to more patient autonomy and control over that of managed care regulations. Patients studied were least interested in continuity of care, consultation time or cost of drugs. Demographic or clinical variables were not significantly related to patients' choices.

Conclusion

Beyond its many benefits, being informed by their doctor and shared decision making is a top patient priority.

Shared decision-making and evidence-based practice

Shared decision-making refers to a process of health care delivery in which practitioners and clients seeking help for problems or disorders collaborate to access relevant information and to enable client-centered selection of health care resources. Though nearly all clients express a desire for more information, preferences for participation in health care decisions vary by individual and by illness. Two common strategies to promote shared decision-making are communication training for clients and clinicians, and decision aids to provide targeted information and values clarification. Research in several areas of medicine shows that active client participation results in a variety of benefits, from increased satisfaction to decreased symptom burden. Many current mental health interventions promote client-centered care, client choice, and self-directed care, but research on shared decision-making in mental health for clients with severe and persistent mental illness is just beginning.

Promoting health literacy

This report reviews some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Several articles describe methods for assessing health literacy as well as methods for assessing the readability of texts, although generally these latter have not been developed with health materials in mind. Other studies have looked more closely at the mismatch between patients' literacy levels and the readability of materials intended for use by those patients. A number of studies have investigated the phenomenon of literacy from the perspective of patients' interactions in the health care setting, the disenfranchisement of some patients because of their low literacy skills, the difficulty some patients have in navigating the health care system, the quality of the communication between doctors and their patients including the cultural overlay of such exchanges, and ultimately the effect of low literacy on health outcomes. Finally, the impact of new information technologies has been studied by a number of investigators. There remain many opportunities for conducting further research to gain a better understanding of the complex interactions between general literacy, health literacy, information technologies, and the existing health care infrastructure.

Patient empowerment and control: a psychological discourse in the service of medicine

The discourse of the patient as an active agent in managing illness and health care has become very important in medicine. It is seen in the significance attached to patient empowerment and participation, and in the burgeoning research into patients' coping with illness. The discourse cannot be fully understood from within conventional scientific frameworks because it is part of those frameworks. Instead, its current prominence can be understood by examining how it meets the needs of those who use it. Specifically, it has combined with earlier discourses of disease in a way that allows clinicians to withdraw from responsibility for areas of patient need that are problematic for medicine, such as unexplained symptoms, chronic disease and pain. This view is supported by evidence about how the discourse of patient as agent has been used in clinical consultation to constrain doctors' responsibility for patients' suffering. This discourse and other ways in which doctors and patients influence the boundaries of medical responsibility should be subjects for, rather than constraints on, empirical research.

Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex

Following a brief overview and commentary on the physician-patient communication literature, this article summarizes and evaluates research on the relationship between physician-patient control (dominant-submissive) and affiliation (friendly hostile) behaviors as they relate to medical outcomes. Findings for both verbal and nonverbal control and affiliation measures are included. The interpersonal circumplex (together with the important interactional principles that it incorporates) is then introduced as an heuristic guide for future medical interaction research. The circumplex was constructed as a conceptual and empirical model to integrate the numerous studies that have established control and affiliation as universal dimensions of human interpersonal behavior and relationships. Next, the small group of studies that have applied circumplex inventories to analyses of practitioner-patient transactions are reviewed with emphasis on their strengths and unique aspects of their findings. The concluding section enumerates advantages and innovations that the interpersonal circumplex and its measures can provide to facilitate more heuristic studies of physician-patient interactions.

Relation of diabetic patients' health-related control appraisals and physician-patient interpersonal impacts to patients' metabolic control and satisfaction with treatment

Desire for healthcare control, health locus of control, perceived control over diabetes, satisfaction with diabetes treatment, and general personality traits were assessed in 54 Type 1 and Type 2 diabetic patients of the same male endocrinologist during a regularly scheduled office visit. At the end of the consultation, both patients and the physician completed a measure describing the interpersonal impacts produced in each by the other's control and affiliation behaviors. Patient success at diabetes control was assessed via glycosylated hemoglobin A1C (HA1C) level on the day of the visit and variability in HA1C levels across several visits. Patients' satisfaction with treatment was unrelated to diabetes control measures. Patients' desire for behavioral involvement in their own healthcare and NEO Agreeableness scores were positively associated with diabetes control. Better diabetes control also resulted when the physician perceived patients to be more controlling and less submissive, and when there was more reciprocity in patient and physician's perceptions of the other's controlling interpersonal behavior. Findings support the conclusion that both a patient's self-reported desire for involvement in his or her healthcare and the transactional fit of patient-physician interpersonal behaviors are potentially important contributors to better diabetes outcomes.