Examining the Content and Context of African American Men's Active Communication during Primary Care Medial Visits

Background: Research is clear that physicians are generally more responsive to actively involved patients. Broadly, African American patients demonstrate fewer participatory verbal and nonverbal behaviors during medical visits.  For example, studies show that black patients have lower levels of eye contact when compared to white patients. Physicians are more patient centered with patients they believe are good communicators, leading to higher quality patient-provider information exchange and better health care delivery overall. Thus, it’s important to understand and address how African American patients engage in “active participation”, or prescribed preferred participatory behaviors for medical visits, such as asking questions, making assertions, or expressing concerns. Consideing that African American men experience disproportionate disparities in health care experiences and outcomes, the purpose of this study was to characterize active participation behaviors for African American male patients during their primary care medical visits.

Methods: This study involved a secondary analysis of medical visit transcripts resulting from video-recorded data captured between 2007 and 2008. Participants were 29 African American male patients of a family medicine clinic in Detroit, MI, who consented to have their medical visits recorded as part of a larger study on doctor-patient communication. Transcripts were analyzed using classical content analysis and a constant comparative approach; yielding the frequency, content, and context of codes for “instances of patient active participation” or IPAP. IPAP consisted of three operationalized behaviors: patient information seeking, assertiveness, and expressions of concern. DeDoose, a web-based platform, was utilized for thematic analysis of the text.

Results: Participants ranged in age from 25 to 81 years old (mean 47.7 years), 50% of men had an income over $40,000 annually and nearly 45% had at least some college education. There were 235 instances of IPAP coded and “patient information-seeking” constituted 45.2% of such behaviors; “assertiveness” constituted 28.5%, and “expressions of concern” comprised 26.3%. Interestingly, discussions about physical pain accounted for 13% of IPAP codes. Men were most assertive when physicians were explaining a course of action and patient’s information seeking was often in the context of asking for recommendations for treatment. Selected participant quotes were extracted to foreground IPAP themes.

Conclusions: African American men in this sample were most likely to actively participate in their medical visit by seeking information or recommendations from their doctors, or by actively voicing opinions about their treatment options; these behaviors constituted nearly 74% of the total IPAP observed. Men were least likely to express emotional or psychosocial distress, though a deeper analysis of mental health discussions revealed a range of communicative strategies and language used by African American men that could be of interest to mental health clinicians seeking more accurate ways to assess depressive symptomatology in this population. Men’s IPAP behaviors trended toward reinforcing a perception of competence or assertiveness, often betraying their observable physical or emotional pain, and confusion or insecurity about a course of treatment. This work has implications for community health and primary care clinicians working to improve patient-centered communication with marginalized populations, particularly men of color.