The present study builds on theoretical advancements concerning the conceptualization of
health literacy and patient empowerment and on how these concepts are related to each other.
We aimed to test the proposed distinction of the concepts by considering health literacy and
patient empowerment as two independent yet equally important determinants of health-related
activities and health outcomes [8]. Applied to the context of a specific chronic disease, i.e.
cLBP, the lack of a significant correlation between health literacy and patient empowerment
supported the assumed independency between the two concepts challenging the widely shared
understanding of health literacy as an empowering tool [22–25]. We subsequently classified
patients into four different types based on their levels of health literacy and patient empowerment.
These types differed from each other not only in their socio-demographic characteristics,
but also in their activities related to the management of cLBP and health outcomes. However,
significant differences could only be attributed to health literacy, as in the case of age and educational
attainment, or patient empowerment, as in the case of patients’ involvement in the
doctor-patient encounter. No significant differences were evident for gender, medication nonadherence,
and health outcomes. Given these results, health literacy and patient empowerment
do not interact when associating these concepts with socio-demographic characteristics and
health-related activities. Especially with regards to health-related activities and outcomes, the
question remains whether this finding is specific to the sample of cLBP patients and measures
at hand, or whether it holds true across various health contexts and patient populations. Thus,further empirical studies are needed to evaluate the applicability of Schulz and Nakamoto’s [8]
conceptual patient classification.
Drawing our attention to the significant differences between patients with low and high
empowerment with regards to their self-reported involvement during the medical encounter,
we can conclude that patients with low empowerment show a preference for what is termed the
“paternalistic approach” in the doctor-patient-relationship as described by Roter and Hall [37].
As patients with low empowerment do not engage in the medical encounter, they leave the
medical expertise and decisions to their healthcare provider. However, we think that whereas
needlessly dependent patients want their healthcare provider to assume the role of guardians,
high-needs patients need their healthcare provider to assume this role as they not only lack the
intrinsic motivation to become involved in their treatment plan but also the necessary knowledge
and skills to do so. On the contrary, patients with high empowerment seem to prefer a patient-
centered approach where the doctor-patient-relationship can either be characterized by
mutuality or consumerism [37]. One can expect that effective self-managers prefer a mutual
relationship with healthcare providers negotiating their treatment plan, whereas dangerous
self-managers may more likely act as consumers challenging the advisory role of healthcare
providers as these patients lack the knowledge and skills to engage in a fruitful mutual relationship.
Our significant findings with regards to differences in cLBP patients’ involvement in the
medical encounter as a function of perceived empowerment are a good starting point to confront
different types of patients with different styles of doctor-patient communication [38, 39].
But further studies using refined measures and accounting for healthcare providers’ characteristics
are needed to draw theoretically and empirically grounded conclusions.