Health literacy and control in the medical encounter: a mixed-methods analysis

J Natl Med Assoc. 2009 Jul;101(7):677-83. doi: 10.1016/s0027-9684(15)30976-7.


Background: Physician-patient communication can be described according to 4 prototypes of control--paternalism, mutuality, consumerism, or default. Patients with inadequate health literacy skills may be less-active participants in their care and more likely to have paternalistic encounters.

Methods: Two independent coders analyzed 31 transcribed outpatient medical visits between physicians and African American patients with diabetes according to the 4 prototypes of control. Differences in communication and the balance of power by level of patients' health literacy were analyzed by quantitative and qualitative methods.

Results: Fourteen patients (45%) had inadequate health literacy, and most of them (N=8, 57%) had paternalistic encounters. Among patients with marginal or adequate health literacy skills, only 4 (23%) had paternalistic visits (p = .06), and encounters marked by mutuality were most common (N= 9, 53%).

Conclusion: Patients with inadequate health literacy appear more likely to have paternalistic interactions with their physicians.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • African Americans / statistics & numerical data*
  • Chi-Square Distribution
  • Communication*
  • Diabetes Mellitus, Type 2 / ethnology
  • Diabetes Mellitus, Type 2 / psychology
  • Diabetes Mellitus, Type 2 / therapy*
  • Educational Status
  • Female
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Male
  • Physician-Patient Relations*
  • Power, Psychological*