This study provided a unique opportunity to document and examine the steps mental health patients undertook in the process of becoming “activated” by learning how to formulate questions and develop decision-making skills in relation to their mental health treatment. Findings from the study suggest that patient activation and empowerment are interdependent. Using Finfgeld’s (2004)
empowerment model as a guiding tool to identify and analyze these qualitative processes involved in patient activation, we were able to document ways in which patient activation—through RQP-MH—involved the four elements of empowerment (i.e., participating, choosing, supporting, and negotiating). However, the short duration of the study and lack of postintervention follow-up data prevent us from determining whether patient activation transcended the intervention to become more than just a rote skill practiced during a short period or indeed evolved to be a more overarching occurrence involving a pervasive attitudinal shift in the lives of the patients. In other words, we do not know whether participants continued applying the lessons learned through RQP-MH beyond the study’s limited duration. Participatory learning strategies such as RQP-MH that treat people as active participants of their own learning can have the effect of changing patterns of dependence and passivity by providing and reinforcing engaged and empowering experiences (Roter, Stashefsky-Margalit, & Rudd, 2001
). Empowering experiences foster the competence and confidence necessary for personal transformation and the realization of critical consciousness, and they further support the use of learned skills over time (Roter et al., 2001
). Psychosocial intervention research has similarly found that individuals continue to make gains in using new skills when measured months or years after an intervention and after an opportunity for further integration into regular practice (McGurk & Mueser, 2006
). Our study did not provide an opportunity to further measure these “delayed” but potential ongoing outcomes and stages (Bowles, 2006
) related to empowerment. However, a future longitudinal research design with longer postintervention follow-up could be helpful in assessing the impact that patient activation may have on psychological outcomes. More important, such a research design would allow us to further examine whether long-lasting and sustainable patient activation is comparable to empowerment. If so, then patient activation could become a patient–provider communication paradigm that is more germane, tangible, and accessible for mental health patients than is empowerment.
The study design also did not provide extensive opportunities to document the role of antecedents in patient activation. However, a few lessons were learned during the process. For example, when thinking about the antecedents of empowerment in the clinical encounter with Latino patients, we need to consider the influence of culture on the interpersonal context. Although patient activation is an opportunity for growth and enrichment, it can also cause discomfort, as shown through some of the participants’ concerns about hurting the providers’ feelings or offending them by using the RQP-MH skills with their providers. It was demonstrated that tension can arise when different health belief systems confront one another and common responses to the unknown or unfamiliar (i.e., anxiety, wariness, and fear) emerged.
As shown through the Spanish interviews, findings also highlighted that linguistic and culturally distinctive patients may be at risk of difficult or negative communication interactions within health care systems even after exposing them to training purposely designed to change or improve patient–provider relations. This was evident among some patients who reported that asking questions to health care providers is not acceptable for them, considering their views of providers as figures of authority and repositories of specialized knowledge that participants are unable to question. Cultural studies have identified differences in interactive patterns across cultures that could potentially affect the mental health care encounter. Although a thorough discussion of this literature is beyond the scope of this article, theorists point to cultural factors that influence communication patterns, such as differences between low- or high-context cultures, collectivist versus individualistic approaches, differences in perceptions of social position and authority (e.g., respeto
among Latinos), and varying attitudes toward personal space and physical contact (Beaulieu, 2004
; Castro & Hernández Alarcón, 2002
; Zhu, Nel, & Bhat, 2006
). Shifting the patterns of communication within the therapeutic encounter may require closer attention to such cultural differences in patterns of interaction for some patients, and further research is needed to understand how these differences may manifest themselves within the structure of a therapeutic encounter.
Furthermore, although the sources of a relational pattern in which patients are reluctant to ask questions may be culturally normative, the pattern could also be a by-product of contextual or systemic factors. For example, the degree of familiarity with the U.S. health care system, which generally presents formidable navigational obstacles among historically underserved populations such as Latinos, could also influence relational patterns between patients and providers. That is, these systems may be perceived as intimidating or perpetuate power differentials between patients and providers.
Although cultural factors might play a role in the way individuals interact with their providers, other factors might influence such interactions. For example, a patient who has navigated the health care system for an extensive period and who has come into contact with numerous providers might feel more comfortable asking questions to his or her provider than someone who has had limited access to services. In addition, there might be instances in which an individual’s beliefs about treatment decisions may run counter to treatment guidelines. In those instances, interventions such as RQP-MH could provide the necessary tools for patients to recognize if and when the provider’s input and expertise are necessary to make an informed treatment decision.
In addition, providers themselves appeared to play important roles during the early stages of the project (i.e., supporting the initiative) and throughout the implementation process. As evidenced by participants’ reports related to confidence building processes, providers generally supported patients as they were shifting their relational paradigm. Although we do not have additional data from providers to document the role they played in the process of patient activation, the current study underscores the importance of the interaction between providers and patients in the process of patient activation and increasing patient participation in decision making. The participants’ narratives illustrate that as communication patterns shift, patients’ perceptions of their relationship with their provider also appear to undergo change. The role of the provider in understanding and facilitating this process is an area for continued research.
This qualitative study provides important information to consider in future adaptations of the RQP-MH intervention strategy. Given that the study found limited impact on the levels of empowerment illustrated by the two higher levels of Finfgeld’s (2004)
model, adaptation in future research may be necessary. It may be that extended trainings, a modified curriculum, or additional sessions are necessary for certain individuals, particularly those with memory or other cognitive problems. Future examination of the RQP-MH strategy should more explicitly test for the influence of these factors and the effectiveness of RQP-MH across different diagnoses. Including a screening tool to assess cognitive functioning in future trials could facilitate this investigation.
Furthermore, there may be measurement issues to consider, including expanding both our qualitative and quantitative measures of empowerment in future studies. Given that the intervention evaluation for this analysis specifically focused on assessing the applications of the RQP-MH in the provider encounter, it may have limited potential for discussion of applications in other areas of the respondents’ lives, thus failing to pick up more nuanced application of the process in the areas of supporting and negotiating. Furthermore, even though the study included three measurement points, an important limitation of this study is that we did not measure outcomes longitudinally beyond the original study period itself. We thus have no way of knowing whether the qualitative successes reported regarding involvement in the patient–provider relationship persisted beyond the period of the study or whether patients eventually returned to prior patterns of communication with their providers.
Based on these findings, it may be useful to consider adding a provider component for the RQP-MH, given that, for some respondents, explicit encouragement from the provider may be necessary to counteract cultural attitudes such as treating the provider as an all-knowing authority. It may also be important to address issues of belief regarding authority and personalismo
with the provider, who may expect such attitudes from certain groups and unknowingly further discourage activation within the patient–provider relationship as a result. Within the health care setting, personalismo
-oriented patients may be more likely to expect providers to be friendly and to demonstrate interest in the patient as a person (Kennedy, 2004
). Thus, in this relational context, it is important to teach how to ask questions in a way that does not jeopardize the “personal” relationship with the provider. Furthermore, an educational component regarding the mental health system as a whole (a “new patient orientation”), including information about what types of providers conduct what types of treatment and the nature of a person’s mental illness and psychiatric medication, may provide didactic information that could particularly help first-generation immigrants who may carry attitudes and beliefs regarding the health care system in their country of origin into their experiences with their providers here in the United States.
In many respects, the RQP-MH strategy runs counter to stereotypical models of Latino relational patterns documented in health and mental health research, which emphasize at times a high degree of respect or power distance (Benavides, Bonazzo, & Torres, 2006
; Castro & Hernández Alarcón, 2002
) for authority as a determining factor in patient–provider relationships for this population (Lagomasino et al., 2005
) and fatalism (Benavides et al., 2006
), thus rendering many Latinos as passive actors in relation to figures of authority, their health, and surrounding environment. As documented in this study, RQP-MH challenged widely accepted and documented cultural values that have characterized Latinos as having a culturally determined preference for more directive approaches on the part of providers (Pomales & Williams, 1989
; Ponce & Atkinson, 1989
) and feeling uncomfortable responding to open-ended questions (Folensbee, Draguns, & Danish, 1986
Moreover, RQP-MH questions culturally driven assumptions about how Latinos interact with service providers. Given that many of the participants in this study embraced RQP-MH, we see these findings as challenging an approach wherein cultural patterns are readily accepted as a given in mainstream health practices instead of potentially modifiable with easily adapted strategies for change (Armstrong et al., 2006
) such as the process of asking questions to obtain information that is crucial to make decisions about one’s own health (Wiltshire, Cronin, Sarto, & Brown, 2006
). We further suggest that the enthusiastic integration by some participants of these strategies could be in part because of a strong and yet potentially transformative reaction to a previous lack of agency in many other areas of these participants’ lives.