Improving Health Outcomes Through Patient Empowerment

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Improving Health OutcomesThrough Patient EmpowermentThomas L. Powers PhD a & Dawn Bendall PhD ba Graduate School of Management and School ofHealth Related Professions, University of Alabama atBirmingham , Birmingham, AL, 35494, USAb University of Montevallo , Montevallo, AL, 35115,USAPublished online: 25 Sep 2008.

To cite this article: Thomas L. Powers PhD & Dawn Bendall PhD (2003) ImprovingHealth Outcomes Through Patient Empowerment, Journal of Hospital Marketing &Public Relations, 15:1, 45-59, DOI: 10.1300/J375v15n01_05

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Improving Health OutcomesThrough Patient Empowerment

Thomas L. Powers, PhDDawn Bendall, PhD

ABSTRACT. The concept of empowerment can be successfully used inthe healthcare industry to positively influence patient participation andcompliance with their program of treatment. This paper examines the litera-ture that has developed in the area and presents a model that incorporatespatient empowerment into the healthcare delivery process. Managerial im-plications and directions for future research are also presented. [Article cop-ies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> © 2003 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Empowerment, patient satisfaction, compliance, healthoutcomes

INTRODUCTION

The role of marketing in the healthcare industry has expanded to in-volve and empower patients in their healthcare treatment programs(Howe and Anderson, 2003). Empowerment has recently emerged in

Thomas L. Powers is Professor of Marketing, Graduate School of Management andSchool of Health Related Professions, University of Alabama at Birmingham, Bir-mingham, AL 35494 (E-mail: [email protected]).

Dawn Bendall is Assistant Professor of Marketing, The University of Montevallo,Montevallo, AL 35115 (E-mail: [email protected]).

Journal of Hospital Marketing & Public Relations, Vol. 15(1) 2003http://www.haworthpress.com/web/JHMPR

© 2003 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J375v15n01_05 45

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the healthcare literature as the industry has moved toward the use of pa-tient-centered care. Patient-centered care is intended to improve out-comes by involving the patient in treatment decisions, increasingpatient communication with providers, and improving patient under-standing of what to expect from treatment plans (Bechel, Myers, andSmith, 2000). Empowering the patient to play an integral part in diseasemanagement is crucial to the future of health care delivery, and willgreatly influence both clinical and financial outcomes.

Empowerment is an effective organizational tool that can be appliedto the healthcare setting (Jean-Charles and Kollias, 2000; Spreitzer,1995). The focus on prevention and self-care has made patient empow-erment an important healthcare marketing issue. The dimensions of pa-tient empowerment, such as patient participation, patient control, andpatient education have been recognized by service marketers (Ouschan,Sweeney, and Johnson, 2000; Cuesta, 1994). However, they have notbeen synthesized into an overall framework leading to positive healthoutcomes. In this paper, the concept of empowerment is reviewed andapplied to the healthcare setting. A model that incorporates patient em-powerment into the healthcare delivery process is proposed and direc-tions for future research are given.

THE ROLE OF EMPOWERMENT

Patients with chronic illnesses often require lifestyle or behavioralchanges, as well as complicated medical regimens. These patients costthe health care system over three times more than individuals withoutchronic conditions (Nodhturft, Schneider, Hebert, Bradham, Bryant,Phillips, Russo, Goettelman, Aldahondo, Clark, and Wagener, 2000).While patients with chronic conditions regularly visit their doctor formedical guidance, they make daily decisions regarding self-care such asdietary needs, exercise programs, and taking medications (Dinsmoor,2000). Patients who play an active role in self-management can reducehospitalization, emergency room visits, unscheduled visits to the doctor,days off work or school, and the cost of health care and morbidity (Gib-son, Coughlan, Wilson, Abramson, Bauman, Hensley, and Walters,2000; Hennessy-Harstad, 1999).

Many factors contribute to the success of self-management of care,including patient attitudes, beliefs, and perceptions (Day, 1995). Effec-tive self-management is contingent upon the patient’s willingness andability to comply with the prescribed medical recommendations, and re-

46 JOURNAL OF HOSPITAL MARKETING & PUBLIC RELATIONS

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quires the patient’s commitment to some form of behavioral change(Hampson, McKay, and Glasgow, 1996). Unfortunately, the rate ofcompliance with self-management activities is very low (Jack, Liburn,Vinicor, Brody, Murry, 1999). Encouraging patient participation in de-cision-making and the process of goal setting is an important step to-ward obtaining the commitment necessary to empower patients to carryout their treatment plans (Bradley, Bogardus, Tinetti, and Inouye, 1999;Golin, DiMatteo, and Gelberg, 1996).

Factors Influencing Patient Empowerment

Marketing plays a role in promoting effective self-management be-haviors by using information and educational materials to influence thepatient’s attitudes, beliefs, and perceptions about the seriousness oftheir chronic disease. A review of the literature indicates that patientempowerment consists of five primary areas: communication, informa-tion/education, satisfaction, participative goal setting, and compli-ance/adherence. These aspects of empowerment all contribute to theachievement of positive health outcomes.

Communication. Communication plays a vital role in the empower-ment process. Effective communication is one of the most importantcomponents of the physician-patient relationship, particularly when thegoal is to achieve patient empowerment. In order to participate success-fully in treatment decisions, patients need information (Ong, DeHaes,Hoos, and Lammes, 1995). Meeting patients’ information needs is posi-tively and significantly associated with patients’ satisfaction (Kinmonth,Murphy, and Marteau, 1989; Larson, Nelson, Gustafson, and Batalden,1996). Many physicians underestimate patients’ desire for information(Waitzkin, 1984), and have been criticized by patients for not takingenough time to answer all questions or listen to their feelings (Dietrich,1996). Patients desire adequate information with clear instructions innon-technical language (Cameron, 1996), and are known to be morecompliant when physicians give them more information and positivecomments (Hall, Roter, and Katz, 1988).

At the core of every health care experience is the physician-patientencounter. This interaction is a prerequisite and an influential compo-nent in the process leading to positive health outcomes. Physicians areincreasingly being encouraged to involve patients in their medical deci-sions (Barry, 1999). Physicians, as part of a team approach to chronicdisease management, have the opportunity to motivate, endorse, andsupport the behavioral changes necessary for patient self-care in

Thomas L. Powers and Dawn Bendall 47

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chronic diseases (Hampson et al., 1996). Many studies have found therelationship between physician-patient communication and positivehealth outcomes to be mediated by patient satisfaction and patient com-pliance (Comstock, Hooper, Goodwin, and Goodwin, 1982; Francis,Korsh, and Morris, 1969; Imanaka, Araki, and Nobutomo, 1993; John,1991; Segall and Burnett, 1980; Swartz and Brown, 1989; Willson andMcNamara, 1982).

Previous research has documented the importance of interactions withother caregivers as well (Reidenbach and Sandifer-Smallwood, 1990).The relationship between the physician, medical staff, and patient is animportant component of patient education. Understanding this relation-ship and the influence of each member on healthcare treatment is criticalto the success of marketing’s role in empowering the patient (Boughtonand Jacquin, 1994). Patient satisfaction and perceptions of hospital qual-ity are defined by communication and understanding of nurses and othermedical staff as well as physicians (John, 1990). Patients are unable tojudge the technical aspects of the care they receive, so they rely on moresubjective aspects of the medical encounter involving interpersonal rela-tions between themselves and the medical staff (Lytle and Mokwa, 1992;Zifko-Baliga and Krampf, 1997). The empowerment process dependsheavily on the successful interpersonal relations and effective communi-cation between the patient and medical staff.

While physicians play a key role in educating the patients about theseriousness of chronic disease at the time of diagnosis, nurses play animportant role in teaching patients effective and accurate techniques forself care and daily disease management activities (Patel, 1993). Simi-larly, while education should empower patients to successfully self-manage the effects of their disease, training and educational programsshould be targeted to all people involved in the delivery of patient care(Day, 2000).

In a recent study identifying the barriers to dietary adherence in indi-viduals with diabetes, lack of education, lack of empowerment, andmisinformation from family members regarding diabetes were cited assome of the greatest contributors to nonadherence to treatment regi-mens (Williamson, Hunt, Pope, and Tolman, 2000). Family membersprovide social support for patients with chronic disease. Research indi-cates that family members have a significant influence on the self-carebehaviors of patients with diabetes (Albright, Parchman, and Burge,2001; Toljamo and Hentinen, 2001). Empowering both family mem-bers and patients will result in better adherence and outcomes, particu-


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larly for adolescent children diagnosed with juvenile diabetes (Florianand Elad, 1998; Kyngas and Rissanen, 2001).

Information and Education. The concept of empowerment dependsgreatly on the patient’s access to health information. Consumer aware-ness and education are important issues, particularly in situations ofchronic disease. The patient’s management of chronic disease is con-ducted at home on a daily basis (Hampson et al., 1996). Educating pa-tients in self-management activities is a life-long process (Day, 1995),and it will make a positive, lasting change in their health status and qual-ity of life (Nodhturft et al., 2000). Many people do not realize the seri-ousness of chronic disease. For example, when questioned about theseriousness of diabetes, less than half of the patients surveyed thoughtdiabetes would have a significant impact on their future health(Kinmonth et al., 1989). Previous research has found that noncompliantpatients are more likely to believe the disease will not affect the even-tual outcomes of their lives, and less likely to seek additional informa-tion from their physician or follow their physician’s instructions(McCord and Brandenburg, 1995). Research on the factors influencingpatient attitudes regarding diabetes indicates that the physician’s reac-tion at the time of diagnosis influenced the patient’s attitude toward thedisease (Dietrich, 1996). If the physician downplayed the seriousness ofthe disease, it was perceived as being less serious by the patient. If thephysician exhibited caring behaviors and provided information aboutdisease control, the patient was more inclined to be firmly in control ofthe disease from the beginning. Patients who were given only writteninformation, without verbal discussion, felt they had not been ade-quately informed of the disease. This study provides support for the im-portance of physician influence on patient perceptions of chronicdisease, and ultimately their attitude toward disease management andresulting health outcomes.

Education is the most powerful tool physicians have to convince pa-tients of the serious complications that can result from uncontrolled dia-betes (Butler, Rubenstein, Gracia, and Zweig, 1998). According to theHealth Belief Model, behavior is influenced by patient perceptions ofperceived susceptibility, perceived severity, perceived benefits of dis-ease management, perceived costs of management, social prompts toadherence, and greater self-efficacy (Wdowik, Kendall, Harris, andKeim, 2000). Educating patients toward empowerment will increaseself-efficacy and performance (Jean-Charles and Kollias, 2000). Thegoal of education is behavior change; enabling patients to modify oldbehaviors and initiate new ones (Peyrot, 1999).


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Satisfaction. Patient satisfaction, particularly with the amount of infor-mation given during the interaction between the patient and physician,plays an integral part in the encouragement and success of patient em-powerment. The satisfaction process by which physician performancemeets a patient’s expectations has been found by many researchers to beimportant to the patient’s intention to comply or adhere to medical regi-men (Bartlett, Grayson, and Barker, 1984; DiMatteo, Taranta, and Fried-man, 1980; Francis et al., 1969; Freemon, Negrete, and Davis, 1971;Kinsey, Bradshaw, and Ley, 1975; Ley, Kinsey, and Atherton, 1976;Wolf, Putnam, and James, 1978). Patient satisfaction with the interper-sonal quality of the physician-patient relationship is positively related toadherence to medical recommendations (Sherbourne, Hays, Ordway,DiMatteo, and Kravitz, 1992), and patients’ health outcomes often dependon their adherence to what has been recommended to them by their physi-cians (DiMatteo, 1994). Because the patient may choose to comply withor ignore the physician’s recommendations as a result of their level of sat-isfaction, the patient’s evaluation of the physician becomes critical to thesuccess of the physician-patient relationship (Segall and Burnett, 1980).

The relationship between information giving and satisfaction is of greatimportance since many patients frequently do not possess all the informa-tion they need to follow a prescribed regimen (Becker, 1985). Kaplan,Greenfield, and Ware (1989) found that more information provided byphysicians during office visits was associated with better health status re-ported at follow-up visits. Many other studies have found information giv-ing by the physician to be positively correlated with patient satisfaction(Bertakis, 1977; Kinsey et al., 1975; Korsch, Gozzi, and Frances, 1968;Linn, 1975; Roter, Hall, and Katz, 1987). In a comparison of patient satis-faction with self-care information provided by direct mail approaches andby physicians during routine office visits, Terry and Healey (2000) foundpatients who received a self-care booklet from their physicians were signif-icantly more satisfied with their medical encounter than those who receivedinformation by mail. These findings indicate that interpersonal aspects ofthe physician-patient relationship, particularly communication and infor-mation giving, have an effect on patient compliance as well. If a patientfully understands medical recommendations and is satisfied with theamount of information received, the patient will be more empowered to-ward effective disease management, more likely to comply with the pre-scribed regimen, and more likely to experience improved health outcomes(Howorka, Pumprla, Wagner-Nosiska, Grillmayr, Schlusche, and Schab-mann, 2000).


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Participative Goal Setting. Patient participation in medical deci-sion-making is any behavior, initiated by the physician or patient, whichfacilitates the inclusion of the patient’s perspective or the patient’s pref-erences into the medical plan (Golin et al., 1996). When a patient ac-tively participates in the treatment decision, and commits to behavioralchange by participating in goal setting, the patient is brought into an em-powerment process. Expanding patient participation during the medicalvisit will influence patient satisfaction, improve adherence to self-man-agement medical regimens, and improve health outcomes (Bechel et al.,2000; Golin et al., 1996). Patients feel better when they are able to playan active role in the relationship with their physician, particularly ex-pressing their concerns and arriving at an agreement with the physicianas to the treatment plan (Rosenberg, Lussier, and Beaudoin, 1997).

To effectively influence chronic disease management with their pa-tients, physicians must invite patients to play an active role in the treat-ment plan. The patient is a key player in the team approach to chronicdisease management (Hampson et al., 1996). Goal setting is a valuableconcept to assist and encourage patient adherence to a specific medicalregimen. By involving the patient in setting goals for self-managementactivities, they will be more likely to accomplish their tasks as agreedupon (Hampson et al., 1996). For goal setting can be effective, the pa-tient must be committed to the goals. The importance of participation ingoal setting is that it can lead to the setting of difficult goals, and it has asignificant effect on performance, regardless of the level of goal diffi-culty (Erez and Arad, 1986). Goal setting can motivate higher perfor-mance than if goals were not set (Strecher et al., 1995). Performance ishighest when the process of participative goal setting incorporates dis-cussion, involvement, and information among participants (Erez andArad, 1986). When patients are able to communicate their concerns,lifestyle, and other priorities to the provider, a treatment plan is morelikely to be appropriate and realistic for each patient (Golin et al., 1996).Patients are influenced by their perceived ability to actually do the vari-ous regimen tasks (Wdowik et al., 2000), and greater self-efficacy is as-sociated with setting higher goals (Strecher et al., 1995).

Compliance/Adherence. The empowerment process centers on a pa-tient’s commitment to comply or adhere to the prescribed medical treat-ment. Adherence refers to the extent to which a person’s behaviorcoincides with medical or health advice (Haynes, Taylor, and Sackett,1979). Noncompliance with medical treatment is a major problem inmedical care (Comstock et al., 1982; O’Brien, Petrie, and Raeburn,1992), particularly for more long-term and costly chronic diseases.


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About one half of all patients with chronic disease comply with health-care provider recommendations (Jack et al., 1999). Patient education onthe front end of the diagnosis is important, since noncompliance at thebeginning of a chronic diagnosis is a strong predictor of noncompliancelater in life (Sherbourne et al., 1992).

While patient education is an important component of patient adher-ence to a prescribed medical regimen, patient compliance will not comefrom education alone (Travis, 1997). A newly diagnosed patient needsextra support and information to lessen the shock of being forced toadapt an altered lifestyle (Dittbrenner, 1997). Successful treatment of-ten depends upon the extent to which a patient’s behavior adheres withmedical advice (Becker, 1985). Compliance, or the patient’s willing-ness and ability to follow health-related advice, take medications as pre-scribed, or attend scheduled clinic appointments (Murphy and Coster,1997), is an intermediate outcome measure that presumes that a positivehealth outcome will follow (Morris and Schulz, 1993).

Compliance is greater when patients feel their expectations havebeen fulfilled, and when the physician demonstrates certain interper-sonal skills such as respect, responsive information, sincere concern,and sympathy (Becker and Rosenstock, 1984). Patient compliance is in-fluenced by patient satisfaction with health care, particularly with com-munication and quality of interaction in the physician-patient relation-ship (Cameron, 1996; Imanaka et al., 1993). While research has not yetfound a simple, direct correlation between patient satisfaction and im-proved outcome, satisfied patients seem more likely to comply withtheir medical treatment (Aharony and Strasser, 1993). As a result, it ispresumed that levels of patient satisfaction and patient compliance sub-sequently affect the patient’s health outcome (Lochman, 1983).

Positive Health Outcomes. Positive health outcomes are the ultimategoal of patient empowerment. Patient empowerment has proven to im-prove health outcomes for chronic diseases such as diabetes (Anderson,Funnell, Butler, Arnold, Fitzgerald, and Feste, 1995; Howorka, Pumprla,Wagner-Nosiska, Grillmayr, Schlusche, and Schabmann, 2000). Patientcompliance is essential in the effectiveness of treatment regimens and im-proved patient outcomes (Cameron, 1996). There is supporting evidencethat patients who adhere to recommended treatments have better healthoutcomes than those who do not (Murphy and Coster, 1997). Becausecommunication is the fundamental instrument by which the physicianand patient relate to each other and attempt to achieve therapeutic goals,the relationship between the physician and patient is central to the processof healthcare delivery (DiMatteo, 1994). Several studies have found an


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association between physician-patient communication and positive healthoutcomes (Bass, Buck, and Turner, 1986; Greenfield, Kaplan, and Ware,1988; Hulka, Kupper, Cassel, and Mayo, 1975; Kaplan et al., 1989; Orth,Stiles, and Scherwitz, 1987; Starfield, Wray, and Hess, 1981; Stewart,McWhinney, and Buck, 1979). Compliance research is converging on thephysician-patient relationship, and it is now recognized that the processesthat occur within this interaction are critical to patient outcomes(O’Brien, Petrie, and Raeburn, 1992).

A Model of Patient Empowerment

Based on the literature, a model that incorporates patient empower-ment into the health care delivery process, and leads to improved healthoutcomes is shown in Figure 1. The model of patient empowerment,based on the review of the literature, emphasizes the five primary areas(communication, information/education, satisfaction, participative goalsetting, and compliance/adherence) of the health care delivery processthat contribute to the achievement of positive health outcomes. The em-powerment process begins with effective communication between thephysician, as well as other medical staff, and the patient. When ade-quate information and education about the disease and the treatment


Communication

Satisfaction

Compliance/Adherence

Positive HealthOutcomes

Informationand Education

ParticipativeGoal Setting

FIGURE 1. Improving Patient Health Outcomes Through Empowerment

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process is given, the patient is more satisfied with the medical encoun-ter, and is more likely to comply with the treatment regimen. Encourag-ing patient participation in the processes of decision making and goalsetting regarding treatment plan will increase patient commitment to theprescribed regimen and increase the likelihood of patient compliance,which will ultimately improve health outcomes.

There are several implications for health care managers based on in-formation the model developed from the literature review. Managersshould develop educational materials for patients and develop guide-lines for health care personnel to make certain that patients review andunderstand the information provided. Health care personnel should beencouraged to take time to effectively communicate with patients andensure that each patient’s questions and concerns are adequately ad-dressed. Health care personnel can also be trained to promote patient in-volvement and participation in healthcare decisions by implementinggoal setting for disease management and treatment plans. Finally, callback programs can be developed to provide follow up assistance to pa-tients to ensure both understanding and implementation of the treatmentplan that was discussed.

SUMMARY AND CONCLUSIONS

Patient empowerment is a useful tool that can enhance the care deliv-ery process and improve health outcomes through effective diseasemanagement. Increasing patient awareness and education about the se-riousness of chronic disease and the benefits of daily self-managementactivities will help patients understand the importance of adhering toprescribed medical regimens. Effective communication and adequateinformation are important aspects of the physician-patient relationshipthat enable the patient to successfully achieve treatment goals. Encour-aging patient participation in decision-making and goal setting pro-cesses will enable patients to play a more active role in disease manage-ment, increasing both satisfaction and compliance, which will ulti-mately lead to improved health outcomes.

This paper represents a literature review and synthesis of the area.From the literature review, there are several areas that warrant future re-search. The impact of information and education on patient compliance,as well as the impact of participative goal setting on improving healthoutcomes requires investigation. In addition, future research is neededto examine the links between physician-patient communication, satis-


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faction, compliance/adherence, and positive health outcomes. Finally,further examination of the relationship between patient empowermentand health outcomes based on patient characteristics, chronic diseasediagnosis, and health status is needed.

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Documents

Improving Health Outcomes Through Patient Empowerment