Educational/Counseling Model Health CareAsking questions: The effect of a brief intervention in community health centers on patient activation
Introduction
Effective physician–patient communication correlates with improved health outcomes [1] but this communication is less successful for minority and lower SES patient populations [2]. Physicians tend to communicate less collaboratively with patients from these populations [3] which may limit benefit from health improvement efforts, thus contributing to health disparities [4]. Underrepresented minority patients ask fewer questions in health care settings and may have difficulty understanding information presented to them [5], [6], [7], [8]. We constructed an intervention designed to improve and increase the questions patients ask. Our intention was to increase patients’ communication and participation in their health care.
Patient activation [9] is defined as the readiness and ability to take on the role of managing both health and health care [10]. Patient activation is therefore a precursor to success in self-management and health promotion, as well as to greater engagement in patients’ decision-making concerning their health. Lower socioeconomic status (SES) individuals have been shown to have lower levels of activation [11]. Hibbard et al. developed the patient activation measure (PAM) to assess knowledge, skills and confidence in managing health [12], [13]. Higher PAM scores are associated with more satisfactory interactions with providers, more engagement with the health care system, more information-seeking, better adherence to health promoting behaviors, and improved health outcomes [14], [15], [16]. Other investigators have described activation as an outcome in itself and suggest that it is alterable [17].
Documented differences in information-seeking behavior [18], [19] have led to efforts to get patients to ask more questions [20]. Patients who ask more questions are reported to obtain more relevant information from their providers, be more engaged in their care, and feel more empowered in their office visits [21], [22]. Although programs designed to provide patients with questions to ask during medical visits have been developed [23], [24], [25], questions that do not arise spontaneously from patients may not provide the questioner with the information of greatest import and may generate answers not tailored to the level of understanding or needs of the patient. Additionally providing questions to patients carries an implicit message that the questioner lacks the ability to determine the information they most need, which may diminish patient confidence and self-efficacy.
The Right Question Project (RQP) [26] designed an approach to train people in low- and moderate-income communities to advocate for themselves by asking questions that allow for more successful participation in decisions that affect the services they receive. Building on these principles that empower patients not used to advocating for themselves [4], this project developed and implemented a patient activation intervention (PAI) to build patient's skills to ask more and better questions of their doctors and to recognize the importance of asking questions in the decision-making process.
We evaluated the intervention's impact on PAM scores, and explored the influence of individuals’ preferred role in decision-making.
Section snippets
Sites and participants
After approval by the City College of New York Institutional Review Board, project staff approached patients waiting to see their clinicians at one of the five community health centers in New York City. Consenting patients received pre-intervention surveys that captured standard socio-demographic information, health status, and presence or absence of chronic conditions, together with the PAM and the PPC. The surveys, intervention and interviews were delivered in Spanish or English based on
Patient characteristics and levels of activation
Interviewers approached 651 patients of whom 276 (42.4%) agreed to participate; data from 24 individuals were not included in the analysis due to incomplete items (n = 252). Table 1 shows the demographic characteristics of the participants. Participants had a mean age of 39 years (SD = 16.04) and were predominately Latino or African American (90.1%). Half of the participants reported a medical condition for which they saw their doctor on a regular basis.
Results of one-way analysis of variance
Discussion
In this convenient sample the PAI was associated with a significant increase in participants’ PAM scores, regardless of pre-existing attitudes towards the stated “role” they wished to assume in their interactions with physicians. Health centers deal with disenfranchised communities evidenced by the pre-intervention scores on the PAM being lower than the reported national averages [12]. This is consistent with findings from a previous health center-based study [30].
These results suggest that the
Declaration
I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
Acknowledgements
We are grateful for the efforts of medical students Karen Wat, OpeyemiOladele, Jennifer Walia, Francesse Antoine, Angie Hernandez, and Cristine Espinosa who served as research assistants in this research study. We thank also the Morris Heights Health Center, the William F. Ryan Community Health Center, Montefiore Medical Group's Castle Hill Family Practice, Bedford Stuyvesant Family Health Center, and Urban Health Plan and their patients for their generous willingness to participate in this
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