The effects of patient-centered communication,social capital,and internet use on patient empowerment: a cross-sectional study in China

Abstract

Patient empowerment is a relatively new concept in the context of the Chinese health care system. Based on Street’s ecological framework of communication in healthcare settings, this study examined the social, clinical and media factors that could empower patients. Results from a survey of 401 Chinese adults (response rate, 34%) showed that respondents felt more empowered as health care consumers when they reported having more social capital bonding and bridging, and used the Internet for health purposes more often. Importantly, having had more positive patient-centered communicative experiences with health care providers not only predicted patient empowerment, it also moderated the effects of bridging social capital and Internet use on empowerment. Specifically, the more positive the experience of interacting with health care providers, the weaker the effects of bridging social capital and Internet use on patient empowerment. The findings have important implications for patient empowerment in health care, particularly within the context of China.

Keywords

patient empowerment bonding bridging patient-centered communication Internet use China social capital survey

Introduction

On 25 October 2013, in Wenling, a city in the Zhejiang province of China, a man who was dissatisfied with the results of an operation stabbed a doctor to death and wounded two others. This attack was the third incident in a single week, and one of many that have occurred to Chinese doctors in recent years (1). Tension in doctor–patient relationships in China has become a serious social problem. According to China’s Ministry of Health, 9831 such ‘grave incidents’ occurred in 2006. This number doubled between 2006 and 2008 (2). Another national survey conducted by the China Hospital Association in 316 hospitals from 30 provinces found that 48% of hospitals reported experiencing patient or family member assaults on doctors in 2008, and that this percentage escalated to 73% in 2012 (3).

Although scholars have explored various reasons for the deterioration of doctor–patient relationships (e.g. deficits in regulations to tackle the violence in hospitals, biased media coverage on doctors, unfair judicial system to evaluate medical disputes and deficient health insurance system), very few have focused on the patients themselves. In fact, a complicating factor in understanding the unresolved conflict in doctor–patient relationships is that Chinese patients usually play (and are expected to conform to) a subordinate role in the encounter, thereby failing to reconcile differences they have with doctors regarding their health care (4). Serious doctor–patient differences (e.g. regarding type of treatment needed, appropriate diagnostic tests) can fester in ways that lead to dissatisfaction, animosity, and in some cases, violence (5). Empowering Chinese patients at the point of care to more proactively address their health-related needs may be one way to mitigate this problem. More empowered patients are more likely to become more actively engaged in medical consultations (e.g. asking more questions, managing uncertainty), and their participation can in turn lead to a better understanding of their illness and improved patient satisfaction, fostering a harmonious healing relationship.

Patient empowerment has received considerable scholarly attention among health promoters (6). A patient is considered empowered when he/she perceives having some mastery and control over health-related issues in life (7). Patient empowerment processes are multifaceted, multilevel and influenced by context (8). Although most previous studies have been done within Western cultures, the empowerment mechanism could take different forms for people in other cultures. For example, due to the culture of collectivism, as compared with Western societies, the social aspects of empowerment (e.g. family, close friends) could exert stronger impacts upon Chinese people, who see themselves as relational beings that are socially situated within an interdependent context (9). In China, the concept of patient empowerment is still novel. A fundamental step in the examination of empowerment processes in China is the systematic analysis of what factors enable patients to become activated.

To explore the possible contributing factors to patient empowerment, Street’s ecological framework of communication in health care settings might provide a theoretical framework for the current study (10). Street’s model posits that clinician-patient communication behavior is situated in and influenced by different social contexts, such as personal, interpersonal, media, organizational and cultural contexts (10). Recent extensions of the model suggest that medical communication is both dynamic and complex, and the interplay of various contextual factors may moderate the effects of communication on health-related outcomes (11).

Inspired by the ecological model and its derivative research, the present study aimed to examine different contextual influences on patient empowerment. At the interpersonal level, social capital serves as a supportive environment that can enable patients to engage more actively in their health care (12). Social capital can be divided into two distinct forms: bonding social capital and bridging social capital, and these two types of social capital can influence health-related outcomes differently (13). Bonding social capital centers on the homogeneity of one’s core social network, such as immediate family and close friends. These close social networks can affect health and empowerment through mechanisms such as providing emotional support and improving self-efficacy (13). On the other hand, bridging social capital focuses on the heterogeneity of one’s diffuse social network, such as loose friendships and workmates. Bridging social capital may influence health and empowerment by offering informational support, and diverse ideas and perspectives (14).

Within the clinical context, patient-centered communication consists of providing care that is respectful of and responsive to patients’ needs, values and preferences (11). Physicians who use a more patient-centered communication style can facilitate patient empowerment by encouraging patient involvement in their care and decision-making; and by providing clear, understandable information to augment the patients’ knowledge base for more proactive health management (11). At the media level, health-related Internet use could empower patients through various mechanisms, such as learning medical information and increasing levels of autonomy, self-acceptance and environmental mastery (15). In addition to the main effects, we also explore the possibility of moderation effects of patient-centered communication in empowering patients, based on the hypotheses proposed in Figure 1.

Figure 1.

Conceptual framework.

H1: Patients’ (a) bonding and (b) bridging social capital is positively related to patient empowerment.

H2: Patients’ health-related Internet use is positively related to patient empowerment.

H3: The quality of patients’ past patient-centered communication experiences is positively related to patient empowerment.

H4: Patient-centered communication moderates the effects of social capital and Internet use on patient empowerment.

Methods

Sample

This survey study was conducted in April 2015 in China. Participants were recruited by a Chinese online survey company (www.sojump.com) with > 2.6 million online panel members. This research company recruited panel members from social network sites, via online banners and search engine advertisements. Panelists participated in academic or commercial research in return for cash payments. When recruiting respondents, the survey company performed a quota sampling that reflected the age ratio of Chinese Internet users. That is, sample respondents fit Chinese Internet users’ age ratios (20.1% in the age group of 10–19 years, 30.4% in 20–29 year olds, 24.2% in 30–39 year olds, 74.7% in the age group 40 years or above) (16).

The survey company sent emails including a link to the questionnaire to 1190 people who had visited a doctor or doctor’s office during the past 12 months. Of these, 401 people completed the survey, providing a completion rate of 34%. Although this response rate may seem small, prior research indicates that email response rates may only approximate 25–30% (17). Thus, the response rate in this study was slightly higher than average.

Measurement

Table 1 lists the variables included in the main data analyses. Social capital was measured using the Social Capital Scales (18). Items in this scale have been widely used to assess both online and offline social capital. The current study adapted the scale to assess social capital in offline settings. The 15 items used to measure social capital (a 5-point scale ranging from 1 = strongly disagree to 5 = strongly agree) included seven items for bonding social capital (M = 4.01, SD = 0.52, Cronbach’s alpha = 0.79) and eight items for bridging social capital (M = 4.19, SD = 0.49, Cronbach’s alpha = 0.81).

Table 1.

Items for the key variables.

Bonding social capital (Strongly disagree = 1 to Strongly agree = 5)
The people I interact with would be good job references for me
The people I interact with would share their last dollar with me
The people I interact with would help me fight an injustice
There are several people I trust to help solve my problems
There is someone I can turn to for advice about making very important decisions
When I feel lonely, there are several people I can talk to
If I needed an emergency loan of $500, I know someone I can turn to
Bridging social capital (Strongly disagree = 1 to Strongly agree = 5)
Talking with people makes me curious about other places in the world
Interacting with people makes me feel like part of a larger community
Interacting with people makes me feel connected to the bigger picture
Interacting with people reminds me that everyone in the world is connected
Interacting with people gives me new people to talk to
Interacting with people makes me interested in things that happen outside of my town
Interacting with people makes me want to try new things
Interacting with people makes me interested in what people unlike me are thinking
Patient-centered communication (Never = 1 to Always = 4)
My wishes were respected
I got the information I needed, when I needed it
I got clear, understandable information
I knew who to contact if I had a question or concern
I felt optimism and hope from my doctors and nurses
I was involved in making decisions as much as I wanted
I knew who in the healthcare system I could reach out to, if I was worried that something had gone wrong with my care
I was treated with sensitivity and respect
I felt listened to
I felt comfortable asking questions and voicing my concerns
I felt that everyone worked together as a team in taking care of me
Health-related Internet use (Hardly at all = 1 to Most of the time = 4)
Instant messaging for health-related purposes
Website browsing for health-related purposes
Search engine for health-related purposes
Social media for health-related purposes
Patient empowerment (Strongly disagree = 1 to Strongly agree = 5)
I will make use of necessary means and goods to effectively manage health
I can understand my disease better than anyone
I can motivate myself to manage my health and make a better life
I can make every possible effort to achieve health goals
I am enthusiastic about my own efforts to manage health
I know where I can ask for help to manage my disease
I can manage my disease conditions
I can make a realistic health plan

Patient-centered communication was measured by asking respondents to report the degree to which patient-centered outcomes were accomplished during past visits with health care providers. We employed the doctor–patient communication scale developed from Epstein and Street’s functional model of patient-centered communication (11). Although its scale has not been validated in the context of China, previous studies have examined various functions of patient-centered communication in China (e.g. information exchange, establishing rapport, shared decision-making) (19,20). We used 11 items to measure patient-centered communication, with a 4-point Likert scale ranging from never to always (M = 3.01, SD = 0.52, Cronbach’s alpha = 0.90).

Health-related Internet use was operationally defined as the frequency of use of different kinds of online tools or platforms for health purposes. Respondents were asked how often they use various types of Internet applications for health-related activities, including search engines, instant messaging, website browsing and social media. We used a 4-point Likert scale, ranging from ‘hardly at all’ to ‘most of the time.’ The total of Internet use was summed up and then averaged for analysis (M = 2.84, SD = 0.66, Cronbach’s alpha = 0.79).

Perception of patient empowerment was measured with the Psychological Health Empowerment Scale (PHES) (21). This scale assessed perceptions of patient empowerment across three domains: motivation to achieve goals, sense of confidence and sense of control. Respondents were asked to identify the degree to which they agreed with eight statements related to the perception of patient empowerment, using a 5-point Likert scale ranging from strongly disagree = 1 to strongly agree = 5 (M = 4.21, SD = 0.46, Cronbach’s alpha = 0.79).

Demographics were controlled in this analysis, to reduce confounding effects. Demographics included age, gender (Female = 0, Male = 1), education (ranging from Middle school or below = 1 to Postgraduate = 4), and monthly personal income (ranging from 500 US dollars (USD) or below = 1 to 3001 USD or above = 6).

Data analysis

We used hierarchical multiple regression analysis to test the hypotheses. Hierarchical multiple regression can evaluate changes in explained variance and the regression coefficients; thus, provide information about the main effects and moderate effects. Specifically, in the first step, we regressed patient empowerment on control variables and four main predictor variables after being mean centered, to test for the main effects. Mean-centering the variables has often been advocated as a means to reduce multicollinearity. In the second step, we created three interaction terms by multiplying the centered moderator and centered main predictors. Creating the interaction term is a widely adopted method to test moderation. That is, the effect of a main predictor variable depends on the level of a moderator variable. Then we separately entered each interaction term into the model to address the potential multicollinearity problem (22). The inclusion of each interaction term at one time provided the tests for the potential moderating effects.

Results

Patient characteristics

As shown in Table 2, the 401 respondents had an average age of 31.1 years (ranging from 18 to 66 years), with 46.1% of them being of male gender. Of the sample, 48.9% had a monthly income of > 1000 USD. It is notable that 87.3% of respondents were either undergraduate students or had obtained a bachelor’s degree, whereas this percentage in the general population in China is 8.93%. The overrepresentation of highly educated participants is likely due to the tendency for respondents with higher levels of education and digital literacy to be more likely to participate in web-based studies (23). Among these four demographic variables, only age had a significant association with patient empowerment. Older respondents reported a higher level of patient empowerment (β = 0.12, p < 0.001).

Table 2.

Participant characteristics.

	N	Unweighted %
Age (years)
18–29	183	45.6
30–39	176	43.9
40–49	33	8.2
50 or older	9	2.2
Gender
Female	216	53.9
Male	185	46.1
Education
Middle school or below	0	0
High school	24	6.0
Undergraduate	350	87.3
Postgraduate	27	6.7
Monthly personal income
500 USD or less	95	23.7
501–1000 USD	110	27.4
1001–1500 USD	107	26.7
1501–2000 USD	40	10.0
2001–3000 USD	33	8.2
3001 USD or more	16	4.0

USD: US dollars.

Factors predicting patient empowerment

As indicated in Table 3, both bonding social capital (β = 0.22, p < 0.001) and bridging social capital (β = 0.31, p < 0.001) positively predicted patient empowerment. Patients reporting more social capital were more likely to perceive themselves as empowered. The higher coefficient value of bridging social capital suggests that patients’ diffuse social network may be a stronger predictor of empowerment than their core social network.

Table 3.

Hierarchical regression models predicting patient empowerment.

Block 1: Main Predictors	Model 1	Model 2	Model 3	Model 4
Age	0.12***	0.13***	0.13***	0.14***
Gender	0.03	0.03	0.04	0.04
Education	−0.07	−0.07	−0.07	−0.07
Income	0.06	0.06	0.07	0.07
Bonding social capital (Bonding)	0.22***	0.22***	0.23***	0.22***
Bridging social capital (Bridging)	0.31***	0.31***	0.28***	0.31***
Patient-centered communication (Comm)	0.27***	0.27***	0.27***	0.29***
Health-related Internet use (Internet)	0.17***	0.17***	0.17***	0.13**
Block 2: Interaction Terms
Comm*Bonding	−	0.03	−	−
Comm*Bridging	−	−	0.09*	−
Comm*Internet	−	−		0.10**
R ²	54.6%	54.7%	55.4%	55.5%
Adjusted R²	53.7%	53.7%	54.4%	54.5%
Overall F	59.03	52.55	54	54.12
df	8392	9391	9391	9391
F Change	−	0.89	6.78	7.31
R² Change	−	0.1%	0.8%*	0.8%**

p < 0.05. **p < 0.01. ***p < 0.001.

As displayed in Table 3, the quality of past patient-centered communication experiences was positively associated with patient empowerment (β = 0.27, p < 0.001), as the more patients perceived their past encounters as being patient-centered, the more they reported feeling empowered.

The relationship between health-related Internet use and perceived patient empowerment was positive and significant (β = 0.17, p < 0.001). The more frequently patients used the Internet for health-related purposes, the more likely they reported feeling empowered.

The moderating effect of patient-centered communication

This study predicted that patient-centered communication would moderate the relationship between social capital and patient empowerment. As shown in Table 3, the interaction term between bridging social capital and patient-centered communication had a significant and negative association with patient empowerment (β = − 0.09, p < 0.05). This interaction term explained 0.8% of variance in patient empowerment, and the overall model accounted for 55.4% of the variance. Patient-centered communication weakened the positive impact of bridging social capital on patient empowerment. Regarding the bonding social capital, its interaction term with patient-centered communication was not significant (β = − 0.03, p = 0.35).

The interaction between patient-centered communication and health-related Internet use was also examined. As seen in Table 3, this interaction term was negative and significant (β = − 0.10, p < 0.01). This interaction term explained 0.8% of the variance in patient empowerment, and the whole model accounted for 55.5% of the variance. Health-related Internet use exerted less influence on patient empowerment for people reporting more positive experiences with patient-centered communication.

Discussion

Using an adaptation of Street’s ecological frameworks of communication in healthcare settings, and its derivative research (11,12,24), the present study examined the interplay of clinical (patient-centered communication experiences), social (bonding and bridging social capital), and media (health-related Internet use) factors that could influence patient empowerment. It also expanded upon the original ecological framework by testing the potential moderation effects. It is notable that we applied our analysis in the context of health care in China, adding new empirical evidence to patient empowerment literature in China, the most populous country in the world.

As predicted, patients who obtained more social capital, bonding and bridging, felt more empowered as health care consumers. Previous studies document the benefits of social capital on health behaviors such as smoking cessation (25), physical activities (26), and diabetes prevention (27). Our findings demonstrate that in addition to health-related behavioral change, social capital also has the potential to empower patients. Patients become passive and less engaged due to various factors, such as limited medical knowledge, poor emotional support, and lack of resources to assist decision-making and self-management. Social capital may serve as a supportive environment to empower patients, by offering useful suggestions and tangible assistance that could improve the patients’ self-care skills and confidence in managing their health. The inclusion of social resources in the empowerment process is particularly crucial in China, due to its culture of collectivism. This reflects the fundamental Confucian value in a family-based, harmony-oriented model, emphasizing that the family and close ties play a cardinal role in the course of health care (e.g. decision-making, survivorship). Compared with Western societies, the social structure of empowerment might exert stronger impacts on the Chinese people, who see themselves as relational beings socially situated within an interdependent context (11).

In addition, while stronger social capital may result in higher levels of patient empowerment, little is known about the effects of different types of social capital in empowering patients. The current study specifically tested bonding social capital, which is one’s more homogenous and core social network; and bridging social capital, which is a more heterogeneous and diffuse social network. These two distinct types of social capital significantly predicted patients’ reports of empowerment, but bridging social capital exerted stronger effects. One possible explanation is that bonding social capital may offer stronger, more homogeneous relational ties that can enhance empowerment. Bridging social capital, on the other hand, provides patients with access to more diverse viewpoints and thus, offers more varied informational support to deal with health issues, which in turn may help a patient to feel more empowered (28).

As expected, patients who used the Internet for health purposes more frequently felt an elevated sense of empowerment. This result is consistent with the existing literature on the influence of Internet use on health-related outcomes, such as increasing medical knowledge, helping change health behavior, and activating patients to participate in shared decision making (29,30); however, compared with social capital and patient-centered communication, Internet use had a weaker effect. One plausible explanation is that the interpersonal communication via face-to-face interactions is a stronger driving force of patient empowerment than that in online settings. Of course, while Internet use can facilitate information seeking (e.g. via search engine, netizens), patients are more likely empowered in the context of their proximate world (e.g. friends, family and doctors).

Also as predicted, patient-centered communication increased one’s sense of patient empowerment, a finding in line with prior research on the effects of patient-centered care (31,32). Patients become empowered in their interaction with physicians, when both the doctors and patients are mutually active, respect one another’s needs and work together to achieve a satisfactory result (32). Considering the well-documented benefits of patient-centered communication in western cultures (33), the current study provides a new empirical contribution to this stream of research, demonstrating that across different cultures (in this case, China), communication with doctors matters. Patient empowerment is directly influenced by the quality of patients’ communicative experiences with health care providers (34). It is, for this reason, important that health care organizations and physicians should provide care that is respectful of and responsive to patient preferences, needs, and values.

The more interesting and potentially significant finding in this study pertains to our model’s statistical moderation. Specifically, although bridging social capital increased patient empowerment, its effect was weakened when respondents reported having had more patient-centered communication experiences while receiving care. Similarly, health-related Internet use was associated with less patient empowerment for people who perceived their physicians as more patient-centered. With less satisfactory health information-seeking experiences from social networks and the Internet, some patients would instead depend on doctors for more accurate and useful health-related resources (35). In short, relationships between doctors and patients are more important, and these results emphasized the responsibility of physicians to empower patients.

The primacy of patient-centered communication found in this study highlights the need for more patient-centered outcomes research (PCOR) in China. PCOR emphasizes the voice of patients in assessing health care options, and has been playing a significant role in engaging patients in the course of care in the USA (36). Prior research has indicated that a well-performed PCOR analysis enables clinicians to understand their patients’ perspectives and to facilitate patient adherence, a vital step in achieving patient activation and empowerment (37). Therefore, the Chinese health care system should take steps to produce and promote high-quality research that is guided by patients, caregivers, and the broader healthcare community.

Implications

The findings from this study have several important implications. First, the current study has broadened the conceptual scope of possible effects on patient empowerment, by examining the predictors from diverse social (bonding and bridging social capital), mediated (Internet use), and clinical (doctor–patient communications) contexts. Second, the finding of a moderating effect of a variable (patient-centered communication) within one context on the predictive power of variables in other contexts not only has theoretical implications for further refinement of Street’s ecological framework, but also has practical implications for designing health promotion resources that need to take into account multiple layers of possible influences on patient empowerment. For example, an Internet-based intervention to provide informational and supportive resources for patient activation may work best when packaged with health care system resources promoting stronger clinician-patient relationships (38). Finally, the interplay of social capital, patient-centered communication, and health-related Internet use fits nicely within the important tenets of the Chronic Care Model (CCM). The CCM holds that the quality of health care service is linked to productive interactions between patient-centered health care providers and activated/empowered patients, all of which must be situated within the health care systems that provide resources, both interpersonal such as social capital, and technological such as Internet use, to support these relationships (39).

Limitations

There are several limitations in this study. First, there are limitations of having non-probability samples recruited from online panels. Although the Internet penetration rate has increased rapidly in China and reached 51.7%, there is a selection bias that makes it impossible to apply our conclusion from the Internet survey to general populations. Also, participants in this study were predominantly highly educated and relatively young, thus reducing the representativeness of our sample with the larger population. Future research should use probability sampling or weight the study sample segments, to reflect the greater population’s attributes (e.g. age distribution and education level). Second, the response rate was somewhat low, at 34%. Although it is acceptable for web surveys, it is below the average of 45% that is more characteristic of mail surveys (40). This could weaken the representativeness of our sample. Third, because this study used cross-sectional data, the causal relationships among variables can only be inferred. Longitudinal data can overcome this limitation. For example, future studies can investigate patient-centered communication and the immediate outcome of this medical interaction (e.g. increases in knowledge, self-efficacy and perceived emotional support), which then can contribute to the post-consultation outcomes collected at a later point in time (e.g. sense of empowerment, self-management and health improvement). Fourth, this study only proposed one framework where social capital, doctor–patient communication and the patient’s Internet use exerted the main and moderating effects on patient empowerment. It is also plausible that mediation effects may be present. For example, Internet use might increase social capital, which in turn may empower patients. Thus, future studies can test or compare different models. Finally, this study only measured the patient’s health-related Internet use in terms of its frequency. Future research should consider the diversity of Internet application use or the attention paid to Internet use. Also, the items used for social capital in this study were not developed in the health context. Future research can create social capital scales for studies of social factors that are related to health and behavior (41).

Conclusions

Patient empowerment has long been accepted as a Western concept. The value of autonomy is embedded in the strong individualism of Western societies. Chinese culture, however, is often described as less individualistic. Thus, the empowerment processes may vary significantly across cultures. The current study fills a gap in the literature by providing additional empirical evidence about patient empowerment in a collectivist culture. Patient empowerment is a particularly important concept in Chinese society, considering the increasing tension between doctors and patients in China. When patients are empowered, they are more likely to take an active role in medical encounters, have a better understanding of different treatment options and participate more in the shared decision-making (9). Through this process, patient satisfaction can be enhanced, thereby potentially reducing the likelihood of violence towards doctors.

While medical consultation with clinicians remains the most trusted channel to empower patients, social capital and the Internet are also serving as important alternative media. This study suggests that in the future, Chinese healthcare organizations and health promoters should take into account the various social contexts of patients’ health experiences, and take steps to empower patients by incorporating the social network elements into health interventions, fostering a trusting doctor–patient relationship and utilizing health-oriented online tools. Understanding the confluence of social factors in the health care system can also help health practitioners to better design health promotion programs to empower their Chinese patients, improve their health outcomes and ultimately, mitigate the severe doctor–patient tension present in China.

Footnotes

Author contributions

Shaohai Jiang wrote the majority of the manuscript. Richard Street contributed expertise in patient-centered communication. Both authors provided input and reviewed the draft and final versions of the manuscript.

Conflicts of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article. Dr. Richard Street is supported in part by the Houston VA Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

Ethical approval

This study was approved by the Texas A&M University Institutional Review Board.

Informed consent

Survey respondents provided online informed consent.

References

Yao

Zeng

Peng

Ren

Chen

Wang

. Stop violence against medical workers in China. J Thorac Dis. 2014; 6: 141–145.

Liebman

. Malpractice mobs: medical dispute resolu-tion in China. Colum L Rev. 2013; 113: 181–264.

Pan

Yang

Zhan

, et al. To be or not to be a doctor, that is the question: a review of serious incidents of violence against doctors in China from 2003–2013. J Public Health. 2015; 23: 111–116.

Bennett

Smith

Irwin

. Preferences for participation in medical decisions in China. Health Commun. 1999; 11: 261–284.

Zhang

Sleeboom-Faulkner

. Tensions between medical professionals and patients in mainland China. Camb Q Healthc Ethics. 2011; 20: 458–465.

Gibson

. A concept analysis of empowerment. J Adv Nurs. 1991; 16: 354–361.

Tones

Green

. Health Promotion: Planning and Strategies. London: SAGE; 2004.

Schulz

Israel

Zimmerman

Checkoway

. Empowerment as a multi-level construct: perceived control at the individual, organizational and community levels. Health Educ Res. 1995; 10: 309–327.

Kim

Smith

Yueguo

. Medical decision making and Chinese patients’ self-construals. Health Commun. 1999; 11: 249–260.

10.

Street

RL Jr

. Communication in medical encounters: an ecological perspective. In: Thompson

Dorsey

Miller

Parrott

(eds). Handbook of Health Communication. Mahwah, NJ: LEA; 2003, pp. 63–89.

11.

Epstein

Street

Jr . Patient-centered communication in cancer care: promoting healing and reducing suffering. Bethesda, MD: National Cancer Institute; 2007.

12.

Baheiraei

Bakouei

Mohammadi

Majdzadeh

Hosseni

. Association between social capital and health in women of reproductive age: a population-based study. Glob Health Promot. 2016; 23: 6–15.

13.

Kawachi

Sankaran

Daniel

. Social Capital and Health. New York: Springer; 2008, pp. 1–26.

14.

McKenzie

Whitley

Weich

. Social capital and mental health. Br J Psychiatry. 2002; 181: 280–283.

15.

Jiang

Street

. Pathway linking Internet health information seeking to better health: a moderated mediation study. Health Commun. 2017; 32(8): 1024–1031.

16.

China Internet Network Information Center. Statistical Report on Internet Development in China. 2017. [cited 18 February 2018]. Available from: https://cnnic.com.cn/IDR/ReportDownloads/201706/P020170608523740585924.pdf

17.

Yun

Trumbo

. Comparative response to a survey executed by post, e-mail, and web form. J Comput Mediat Commun. 2000; 6: 1.

18.

Williams

. On and off the ‘net: scales for social capital in an online era. J Comput Mediat Commun. 2006; 11: 593–628.

19.

Liu

Rohrer

Luo

Fang

Xie

. Doctor-patient communication skills training in mainland China: a systematic review of the literature. Patient Educ Couns. 2015; 98: 3–14.

20.

Lin

Wang

Zuo

Lin

Zhu

, et al. Health literacy, computer skills and quality of patient-physician communication in Chinese patients with cataract. PLoS One. 2014; 9: e107615.

21.

Menon

. Toward a model of psychological health empowerment: implications for health care in multicultural communities. Nurse Educ Today. 2002; 22: 28–39.

22.

Aiken

West

Reno

. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks, CA: SAGE; 1991.

23.

Callegaro

Manfreda

Vehovar

. Web Survey Methodology. Thousand Oaks, CA: SAGE; 2015.

24.

Street

Elwyn

Epstein

. Patient preferences and healthcare outcomes: an ecological perspective. Expert Rev Pharmacoecon Outcomes Res. 2012; 12: 167–180.

25.

Siahpush

Borland

Taylor

Singh

Ansari

Serraglio

. The association of smoking with perception of income inequality, relative material well-being, and social capital. Soc Sci Med. 2006; 63: 2801–2812.

26.

Lindström

Hanson

Östergren

P-O

. Socioeconomic differences in leisure-time physical activity: the role of social participation and social capital in shaping health related behaviour. Soc Sci Med. 2001; 52: 441–451.

27.

Holtgrave

Crosby

. Is social capital a protective factor against obesity and diabetes? Findings from an exploratory study. Ann Epidemiol. 2006; 16: 406–408.

28.

Wright

Sparks

O’Hair

. Health Communica-tion in the 21st Century. Oxford, UK: Wiley-Blackwell; 2008.

29.

Jiang

Beaudoin

. Health literacy and the internet: an exploratory study on the 2013 HINTS survey. Comput Human Behav. 2016; 58: 240–248.

30.

Jiang

. The role of social media use in improving cancer survivors’ emotional well-being: a moderated mediation study. J Cancer Surviv. 2017; 1: 1–7.

31.

Lee

. The effect of computer-mediated social support in online communities on patient empowerment and doctor-patient communication. Health Commun. 2012; 27: 30–41.

32.

Trummer

Mueller

Nowak

Stidl

Pelikan

. Does physician-patient communication that aims at empowering patients improve clinical outcome? A case study. Patient Educ Couns. 2006; 61: 299–306.

33.

Kettunen

Liimatainen

Villberg

Perko

. Developing empowering health counseling measurement: preliminary results. Patient Educ Couns. 2006; 64: 159–166.

34.

Jiang

. Pathway linking patient-centered communication to emotional well-being: taking into account patient satisfaction and emotion management. J Health Commun. 2017; 22: 234–242.

35.

Salmon

Hall

. Patient empowerment and control: a psychological discourse in the service of medicine. Soc Sci Med. 2003; 57: 1969–1980.

36.

Selby

Beal

Frank

. The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda. JAMA. 2012; 307: 1583–1584.

37.

Dang

Vallish

. The emerging role of patient-centered outcomes research in shaping the future of healthcare delivery in India: a brief review. Int J Med Sci Public Health. 2015; 5: 125–127.

38.

Epstein

Street

. The values and value of patient-centered care. Ann Fam Med. 2011; 9: 100–103.

39.

Wagner

Glasgow

Davis

Bonomi

Provost

McCulloch

, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Patient Saf. 2001; 27: 63–80.

40.

Shih

Fan

. Comparing response rates from web and mail surveys: a meta-analysis. Field Methods. 2008; 20: 249–271.

41.

Chen

Stanton

Gong

Fang

. Personal Social Capital Scale: an instrument for health and behavioral research. Health Educ Res. 2008; 24: 306–317.