Examining the Intervening Roles of Patient-Centered Care and Patient Activation in the Health Impacts of Offline Healthcare Obstacles and Online Health Consultations Among Deaf and Hard-of-Hearing Patients

ABSTRACT

Deaf and hard-of-hearing (DHH) patients often encounter difficulties in effective communication with healthcare professionals and are less likely to receive quality medical care. However, DHH populations are understudied in health communication research. This study examined how offline healthcare obstacles and online health consultation impact DHH patients’ health, and the mediating roles of patient-centered care (PCC) and patient activation. Data from 323 DHH patients were analyzed using structural equation modeling to test the hypothesized mediation pathway model. Results indicate that offline healthcare obstacles negatively affect DHH patients’ perception of patient-centeredness, which reduces their ability and confidence in self-care (conceptualized as patient activation in this study). This reduced patient activation may jeopardize DHH patients’ physical and psychological health. Meanwhile, online health consultation is positively associated with PCC, and higher levels of PCC can increase patient activation, contributing to better physical and psychological health. Testing the same model with hearing-abled participants (n = 3542) revealed significant differences in these intervening relationships. Overall, this study provides valuable insights into the relationship between DHH patients’ healthcare experience and their health outcomes. The findings support interventions that focus on enhancing PCC and patient activation to improve the physical and psychological health outcomes of DHH patients.

Introduction

Statistics show that about 38 million Americans (approximately 15% of adults) have some sort of hearing impairment (Glassman et al., 2021), and hearing loss has become the third most common chronic physical condition in the United States (Centers for Disease Control and Prevention, 2018). Despite the fact that patients with hearing loss were as likely as the general population to use most health services, they reported unmet needs in healthcare (Mikkola et al., 2016). Deaf and hard-of-hearing (DHH) patients often encounter difficulties in effective communication with healthcare professionals and are at higher risk of receiving fewer procedures and poorer-quality medical care (James et al., 2022). Furthermore, common obstacles in offline healthcare settings such as tedious medical procedures, long waiting time, and limited time for medical consultation may present greater difficulty for DHH patients to be engaged and activated to participate in their care. Some healthcare providers are not equipped with the necessary communication skills to work with DHH patients, and they also reported difficulties and feeling less comfortable with these patients (Barnett, 2002). As a consequence, DHH patients are unable to make truly informed decisions about their healthcare, and they had worse health status than those with normal hearing (Barnett, 2002).

People who are hearing impaired face multiple obstacles when accessing healthcare services. The primary barrier to communication for these individuals is the lack of consideration by healthcare providers (Newton & Shah, 2013). Research has shown that people who are hearing impaired have concerns about communication during healthcare appointments, including a lack of privacy when another person helped with communication, and worries that critical information may be misheard or missed (Saunders & Oliver, 2022). These concerns can lead to increased anxiety and stress, which can further exacerbate the impact of hearing impairment on health outcomes (Newton & Shah, 2013). In addition, DHH patients, with or without hearing aids, have different preferences when communicating with healthcare providers, including lip-reading, using sign language, writing notes, or bringing an interpreter (McKee et al., 2015). However, not all healthcare providers are equipped to communicate effectively with patients who communicate in these different ways, which can lead to misunderstandings and difficulties in obtaining appropriate care (McKee et al., 2015; Newton & Shah, 2013).

Effective patient-provider communication and accessible health services are integral to the quality and efficient patient care, and are closely related to patients’ health (Liu & Yeo, 2021;P. L. Liu et al., 2022). In this regard, the rise of information communication technologies in healthcare delivery has provided new opportunities for DHH patients to communicate effectively with healthcare professionals and access higher-quality and more efficient health services. Online health consultation offers a wide range of benefits, such as increased accessibility to accurate health-related information (Murero & Rice, 2013), patient activation and empowerment (Liu & Yeo, 2021; P. L. Liu et al., 2022), increased patient satisfaction (Jiang, 2019; Xing et al., 2020; Yang et al., 2015), enhanced offline healthcare quality (Xing et al., 2020), and better patient health (Liu & Yeo, 2021). However, despite the well-known potential of internet-facilitated healthcare services, research addressing how online health consultation impacts DHH patients’ health is lacking.

This study thus sought to examine the influence of offline healthcare obstacles on DHH patients’ psychological and physical health, and how online health consultations affect DHH patients’ health outcomes. Drawing from the health communication pathway model proposed by Street et al. (2009), we focused on the mediating mechanisms through which offline healthcare obstacles and online health consultation impact DHH patients’ physical and psychological health. An indirect effects paradigm was applied to examine the mediating role of patient-centered care (PCC) and patient activation. PCC entails “respecting and responding to patients’ wants, needs, and preferences, so that they can make choices in their care that best fit their individual circumstances” (Levinson et al., 2010). Offline healthcare obstacles may undermine PCC, leading to lower patient activation and unfavorable health outcomes. In contrast, online health consultation may enhance PCC, leading to higher patient activation and better physical and psychological health outcomes.

Conceptual framework

Our conceptual framework linking offline healthcare obstacles and online health consultation to DHH patients’ health is guided by the health communication pathway model (Street et al., 2009). Street et al. (2009) contend that the delivery of medical care is an inherently communicative enterprise in which healthcare providers and patients are engaged in the diagnostic process, decide on the medical treatment options, and make plans for follow-up care. As such, patient-provider communication is likely to impact the patient’s health and well-being both directly and indirectly. On the one hand, obstacles that inhibit effective patient-provider communication may engender patient dissatisfaction, patient noncompliance and non-adherence, and even medical errors and patient harm (Tiwary et al., 2019). On the other hand, effective patient-provider communication is an integral part of clinical practices that underpins patient-centered care, and ultimately determines patients’ health. Patients who are more communicatively engaged in their healthcare and have more patient-centered interactions with doctors, experience more favorable health outcomes (Liu & Yeo, 2021; Street et al., 2009).

A key assumption of Street et al. (2009) health communication pathway model is that patient-provider communication will be linked to patients’ health through mediated routes. Effective patient-provider communication leads to proximal outcomes, such as patients’ perceptions of physicians’ patient-centeredness (e.g., feeling “known”, patient engagement, patient-provider agreement, and understanding). These proximal outcomes, in turn, generate more intermediate outcomes (e.g., patient activation, improved self-care skills, and quality medical decisions) that eventually contribute to the improvement of patients’ physical and psychological health (Street, 2013; Street et al., 2009). In this study, we extend this line of argument to examine how online health consultation and offline healthcare obstacles impact DHH patients’ health outcomes. The details of the conceptual framework are depicted in Figure 1 Specifically, we propose and test an integrated framework, which hypothesizes that (a) online health consultation is positively associated with DHH patients’ psychological and physical health; (b) offline healthcare obstacles are negatively related to DHH patients’ psychological and physical health; and (c) patient-centered care (PCC) and patient activation are two sequential intervening variables that bridge the impact of online health consultation and offline healthcare obstacles on DHH patients’ psychological and physical health.

Figure 1. Conceptual framework.

A serial mediation model with offline health obstacles and online health consultations as the independent variables, patient-centered communication and patient activation as the serial mediators, and physical health and psychological health as the dependent variables.

In the sections below, we review the state of the literature about the constructs and their relationships in our conceptual model. Given the paucity of empirical evidence in extant literature specific to DHH patients as it relates to each construct, except for healthcare obstacles, the hypotheses proposed below are mostly based on prior works conducted with hearing-abled individuals. To investigate hearing impairment differences in the hypothesized relationships and outcomes, this study conducted separate analyses plus a multi-group analysis of the model with DHH participants and hearing-abled ones in the dataset.

Offline healthcare obstacles, online health consultation, and PCC

Due to the uneven distribution of medical resources, patients often had frustrating experiences in offline healthcare settings when communicating with healthcare providers, such as long waiting time for consultation, long waiting time for test results, and short time of treatment (Y. Liu et al., 2019). The underutilization of electronic health records also causes inconvenience to patients in that they sometimes were required to redo a test or procedure because the earlier test results were not available, and they have to provide medical history again because their chart could not be found (Patel et al., 2014). These problems are particularly pronounced for DHH patients as most clinicians are unprepared to accommodate a patient’s hearing needs. A survey result showed that 77% of DHH patients had difficulty communicating with healthcare professionals (Abou-Abdallah & Lamyman, 2021). O’Hearn (2006) found that, compared with their hearing-abled counterparts, hearing-impaired patients had fewer medical care appointments and reported receiving less information from doctors. These offline healthcare obstacles encountered by DHH patients are likely to reflect the absence of patient-centeredness in health service delivery. We, therefore, hypothesize that:

H1:

Offline healthcare obstacles will be negatively associated with PCC.

Considering that PCC is rooted in favorable patient-provider communication, online health consultation is likely to contribute to PCC in many ways (Eijk et al., 2013; Liu & Yeo, 2021; Snyder et al., 2011). Online health consultation is the consultation between patients and healthcare providers carried out remotely, via electronic means such as smartphones, e-mail, and patient portals (Jiang, 2019; Liu & Yeo, 2021; Xing et al., 2020). Such consultation offers benefits such as patient-tailored care, better chances of identifying patient symptoms, easier patient data management, and easy access regardless of time and space (Jahan et al., 2017; Liu & Yeo, 2021). Other functional advantages of online health consultation that contribute to PCC have also been documented in the literature, including better information exchange, more responsiveness to patient emotions, reduced patient uncertainty, and enhanced patient trust (Delbanco & Sands, 2004; Roter et al., 2008; Street et al., 2009; Xing et al., 2020). For example, Liu and Yeo (2021) found that communication with healthcare providers through the internet increased PCC because online consultation allows more locational flexibility, enables patients to better express their puzzles and concerns, and provides more opportunities for patients to engage in their healthcare decision-making. Similar findings were also documented in Roter et al. (2008) study supporting that online health consultation is likely to prompt PCC because the asynchronous nature of the exchanges allows patients to express any health-related concerns and ask questions without worrying about the time pressures of an office visit, and physicians can be patient-centered in delivering healthcare. Wallwiener et al. (2009) explained that currently available messaging systems not only allow asynchronous patient-provider communication but also support functions such as the integration of patient messages into medical records, which can also facilitate offline healthcare delivery and contribute to PCC. These self-directed tools and features of online health consultations are particularly important for addressing the communication needs of DHH patients and their significant others, as well as support the implementation of PCC (Meyer et al., 2022). We thus hypothesize that:

H2:

Online health consultations will be positively associated with PCC.

PCC and patient activation

Patient activation emphasizes patients’ willingness, knowledge, skills, and confidence to take independent actions to manage their health (Totzkay et al., 2017). The positive impact of PCC on patient activation is a well-established fact in the health communication literature and has been the focus of numerous research (Finney Rutten et al., 2016; Lee & Lin, 2010; Lein & Wills, 2007; Liu & Yeo, 2021; P. L. Liu et al., 2022, 2023; Reynolds, 2009). PCC occurs when healthcare providers develop good communication skills and attend to patients’ needs effectively (Reynolds, 2009). Six core functions of PCC have been addressed including information exchange, uncertainty management, patient-provider relationship establishment, decision-making, responding to patients’ emotions and feelings, and activating patients for the self-care (Epstein & Street, 2007; P. L. Liu et al., 2023). Healthcare providers who can better respond to individual patient preferences, needs, and values by using patient-centered strategies while communicating with patients and delivering medical care are likely to motivate patients to engage in their health and care (Reynolds, 2009; Totzkay et al., 2017).

PCC changes the dynamic of decision-making in the clinical encounter, by empowering patients with confidence, autonomy, independence, confidence, and ability in their healthcare (Saha & Beach, 2011). Previous research has documented empirical evidence to support that cancer survivors who received medical care in a patient-centered manner reported improved patient activation in managing their physical and psychological health (P. L. Liu et al., 2022). Finney Rutten et al. (2016) found that PCC plays a pivotal role to implement effective care coordination that facilitates information exchange and support provision which is essential for activating patients in self-care management. Similar findings were also documented in a recent study examining patient-centered communication in affecting old adults’ health competence (P. L. Liu et al., 2023). In their 10-year longitudinal study, P. L. Liu et al. (2023) found consistent evidence to support that PCC is positively associated with patient activation because PCC involves effective communication, increases patients’ health literacy, and contributes to enhanced health management skills. Applying this logic to PCC, as DHH patients receive more PCC, they will be well-informed about their health, build a trustworthy relationship with providers, and become activated to take care of their health. Thus, the following hypothesis was proposed:

H3:

PCC will be positively associated with patient activation.

Patient activation and DHH patients’ health

Personal autonomy and patient activation are highly valued in patient health management (Entwistle et al., 2010; Greene & Hibbard, 2012). Healthcare providers are increasingly using strategies such as PCC to improve the quality of care and encourage patient activation to take care of their own health (Greene & Hibbard, 2012). This is because activated patients play a crucial role in determining their individual needs for care and the outcomes of care. Activated patients are more aware of their health, more willing to communicate with providers, and more likely to engage in health-promoting and health-maintaining behaviors, while avoiding health-damaging behaviors. They are also more likely to comply with medications and seek help promptly when needed (Greene & Hibbard, 2012; Hibbard & Greene, 2013; Liu & Yeo, 2021; P. L. Liu et al., 2022). For instance, Mosen et al. (2007) found that among chronically ill patients, those with higher levels of patient activation were more likely to follow through on medication recommendations and manage their health problems more effectively. At a lower level of patient activation, individuals are passive recipients of care and are unable to realize their active role in determining individual health. However, at a higher level of patient activation, people are proactive about their own health and more likely to follow recommended health behaviors (Hibbard et al., 2004). Silva et al. (2018) found that activated patients who perceived themselves to be competent in managing their own health were more likely to maintain a good quality of life.

Empirical evidence supports a direct association between patient activation and patients’ health outcomes (Bachmann et al., 2016; P. L. Liu et al., 2022, 2023; Silva et al., 2018). For instance, longitudinal data by P. L. Liu et al. (2023) verify that patient activation is positively associated with the psychological and general health of older adults. In another study, P. L. Liu et al. (2022) examined the role of patient activation in the relationship between PCC and cancer survivors’ psychological and physical health outcomes. The study found that cancer survivors who received patient-centered medical care and were well-informed about their health reported better psychological and physical health, and were more competent at self-care skills. Therefore, it is reasonable to assume that patient activation is positively related to the psychological and physical health of DHH patients. Thus, the following hypothesis was posited:

H4:

Patient activation will be positively associated with patients’ (a) physical health and (b) psychological health.

Furthermore, building on the above literature review and Street et al. (2009) health communication pathway model, this study developed a serial mediation model to investigate how PCC and patient activation serve as sequential mediators between offline healthcare obstacles and DHH patients’ health outcomes, as well as between online health consultations and DHH patients’ health outcomes. Two hypotheses were proposed:

H5:

The relationship between offline healthcare obstacles and patients’ (a) physical health and (b) psychological health will be mediated through PCC and patient activation in sequence.

H6:

The relationship between online health consultation and patients’ (a) physical health and (b) psychological health will be mediated through PCC and patient activation in sequence.

Method

Participants and procedure

A dataset from the National Cancer Institute’s Health Information National Trends Survey collected in 2020 (HINTS 5 Cycle 4) was employed to examine the research hypotheses. HINTS is a biannual cross-sectional, nationally representative survey of U.S. adults (18+ years) and is available for public use. The survey collected data on U.S. adults’ attitudes, knowledge, and behaviors related to health. A total of 3,865 participants completed the survey, among which 323 respondents identified as deaf or with serious difficulty hearing. Table 1 showed the demographic details of the DHH participants alongside hearing-abled participants. DHH participants had an average age of 68.69 (range: 18–104, SD = 14.65), were mostly identified as female (51.4%), educated at the level of some college or above (55%), and reported an annual household income between $35,000 to $74,999 (41%).

Table 1. Descriptive statistics.

	DHH participants N = 323	Hearing-abled participants N = 3542
Age in years, mean (SD)	68.69 (14.65)	55.94 (16.47)
Gender, n (%)
Male	157 (48.6)	1404 (39.6)
Female	166 (51.4)	2138 (60.4)
Education, n (%)
Less than 8 years	13 (4.0)	67 (1.9)
8 through 11 years	25 (7.7)	168 (4.7)
12 years or completed high school	76 (23.5)	629 (17.8)
Post high school training other than college	29 (9.0)	235 (6.6)
Some college	98 (30.3)	862 (24.3)
College graduate	48 (14.9)	931 (26.3)
Postgraduate	34 (10.5)	650 (18.4)
Annual income (USD), n (%)
0 to 9,999	32 (9.9)	196 (5.5)
10,000 to 14,999	19 (5.9)	178 (5.0)
15,000 to 19,999	25 (7.7)	174 (4.9)
20,000 to 34,999	44 (13.6)	407 (11.5)
35,000 to 49,999	37 (11.5)	423 (11.9)
50,000 to 74,999	95 (29.5)	914 (25.8)
75,000 to 99,999	25 (7.7)	378 (10.7)
100,000 to 199,999	35 (10.8)	652 (18.4)
200,000 or more	11 (3.4)	220 (6.2)
Online health consultation	1.14 (1.29)	1.26 (1.33)
Offline healthcare obstacles***	.58 (.87)	.40 (.73)
PCC	3.42 (.59)	3.41 (.59)
Patient activation***	3.59 (.91)	3.88 (.81)
Physical health***	2.54 (1.17)	3.15 (.95)
Psychological health**	3.36 (.76)	3.52 (.69)

*p < .05; **p < .01; ***p < .001. DHH = deaf or hard-of-hearing. For patient-centered care, Cronbach’s α = .93 with DHH participants and α = .93 with hearing-abled participants. For psychological health, Cronbach’s α = .87 with DHH participants and α = .88 with hearing-abled participants.

Measures

Online health consultations (OHC) were measured using five items adapted from previous research of similar measures (Yang et al., 2021). The five items encompass asynchronous means of electronic consultation: “use e-mail or the Internet to communicate with a doctor or a doctor’s office,” “use your tablet or smartphone in discussions with your health care provider,” “use your online medical record to securely message health care provider and staff (for example, e-mail),” “electronically sent your medical information to a health care provider,” and “share health information via electronic devices (e.g., smartphone) with a health professional.” Responses were dichotomous (0 = no, 1 = yes) and added up to represent OHC.

Offline healthcare obstacles (OHO) consisted of four statements that assessed the common problems with in-person health consultations that patients may have experienced when getting care for a medical issue. The four items included: “had to bring an X-ray, MRI, or other types of test result with you to the appointment,” “had to wait for test results longer than you thought reasonable,” “had to redo a test or procedure because the earlier test results were not available,” and “had to provide your medical history again because your chart could not be found.” The dichotomous answers (0 or 1) were combined to represent OHO.

Patient-centered care (PCC) was measured using seven items derived from previous research (P. L. Liu et al., 2023). Individuals were asked to rate the medical care they received while interacting with doctors, nurses, or other health professionals from seven aspects: (1) give you the chance to ask all the health-related questions you had; (2) give the attention you needed to your feelings and emotions; (3) involve you in decisions about your healthcare as much as you wanted; (4) make sure you understood the things you needed to do to take care of your health; (5) explain things in a way you could understand; (6) spend enough time with you, and (7) help you deal with feelings of uncertainty about your health or healthcare. Participants were given response options ranging from 1 = “always” to 4 = “never.” The answers were reversely coded and then averaged to present PCC.

Patient activation was measured by a single item similarly used in Totzkay et al. (2017), “Overall, how confident are you about your ability to take good care of your health?,” which provides a summary measure of what it means to be “activated” (Hibbard et al., 2004). Responses ranged from 1 = “completely confident” to 5 = “not confident at all.” The answers were reversely coded with a high score indicating a higher level of patient activation.

Psychological health was measured using four items borrowed from previous research (P. L. Liu et al., 2022). Respondents were asked, over the past two weeks, how often they have been bothered by the following psychological problems: (1) little interest or pleasure in doing things, (2) feeling down, depressed, or hopeless, (3) feeling nervous, anxious, or on edge, and (4) not being able to stop or control worrying. A four-point scale was used (1 = nearly every day, 4 = not at all). Answers to the four statements were averaged to create the scale of psychological health, and a higher value represented better psychological health.

Physical health was measured using four items on comorbidities adapted from P. L. Liu et al. (2022). Respondents were required to indicate whether they had the following medical conditions: (1) diabetes or high blood sugar; (2) high blood pressure or hypertension; (3) a heart condition such as heart attack, angina, or congestive heart failure; and (4) chronic lung disease, asthma, emphysema, or chronic bronchitis. The dichotomous answers (0 = yes, 1 = no) were added up, and a higher score suggested better physical health.

Respondents’ socio-demographic variables were used as control variables, including age (ranging from 18 to 104), gender (0 = female, 1 = male), education levels (1 = less than 8 years, 7 = postgraduate), and household annual income (1 = $0 to $9,999, 9 = $200,000 or more).

Statistical analysis

Statistical analyses in this study were performed using R. We replaced incomplete data with the mean score of participants’ completed items, as the missing cases ranged from 1% to 12.3%, which is below the recommended 20% threshold for person mean substitution (Downey & King, 1998). A bivariate correlation analysis was first conducted to illustrate the zero-order correlations among pairs of focal variables (see Table 2). Structural equation modeling (SEM) was then used to examine the pathway model. A model is considered to acceptable according to the following fit indices: a non-significant χ², comparative fit index (CFI) ≥ .95, the Tucker-Lewis index (TLI) ≥ .95, the root mean square error of approximation (RMSEA) ≤ .06, and standardized root mean residual (SRMR) ≤ .10 (Hu & Bentler, 1999). Fit indices of the originally proposed model (see Figure 1) indicated relatively poor model fit (χ²/df = 11.92, p = .036, CFI = 0.958, RMSEA = 0.065, SRMR = 0.025, and TLI = 0.748). The structural model was revised based on the modification indices (Anderson & Gerbing, 1988), which suggested the inclusion of a direct path from offline healthcare obstacles to patient activation. This inclusion meant that the model would account for the impact of offline obstacles on both other-directed (patient-centered care) and self-directed (patient activation) healthcare actions. We adjusted the model accordingly and the revised model (see Figure 2) had all fit indices meeting the recommended values (χ²/df = 3.549, p = .315, CFI = .997, RMSEA = .024, SRMR = .012, and TLI = .967).

Figure 2. SEM test results (deaf or hard-of-hearing participants).

SEM test results for the research model among deaf or hard-of-hearing (DHH) participants. Offline healthcare obstacles negatively affect patient-centered care (PCC), which reduces patient activation and eventually jeopardizes DHH patients’ physical and psychological health. Online health consultation is positively associated with PCC, and higher levels of PCC can increase patient activation, contributing to better physical and psychological health.

For efficiency and clarity, control variables (age, gender, education, and income) are not shown. Solid lines indicate statistically acknowledged paths (p < .05), and dotted lines indicate statistically unacknowledged paths (p ≥ .05). *p < .05, **p < .01, ***p < .001.Model fit indices: χ²/df = 3.549, p = .315, CFI = .997, RMSEA = .024, SRMR = .012, and TLI = .967.

Table 2. Zero-order correlations among focal variables (N = 323).

	2	3	4	5	6
1. Online health consultations	.20***	.13*	.03	.06	−.02
2. Offline healthcare obstacles		−.27***	−.17**	−.03	−.22***
3. Patient-centered care			.26***	.06	.20***
4. Patient activation				.24***	.28***
5. Physical health					.16**
6. Psychological health

*p < .05; **p < .01; ***p < .001.

We ran the same model with hearing-abled participants in the dataset to examine whether the hypothesized relationships among the variables hold and if they lead to similar patterns of health outcomes. To evaluate differences in parameters between DHH and hearing-abled participants, we further conducted a multi-group analysis using the lavaan R package (Rossel, 2012), which involves constructing a two-group model and imposing equality constraints to test whether there is a significant increase in chi-square.

Results

Findings pertaining to direct relationships among variables for DHH participants are indicated in Figure 2 These results support H1 and H2, which state that offline healthcare obstacles have a negative association with PCC (β = −.21, p < .001), while online consultation has a positive relationship with PCC (β = .09, p < .01). Additionally, H3 suggests a positive association between PCC and patient activation, which is illustrated in Figure 2 (β = .34, p < .001), providing support for H3. H4 predicts that patient activation has a positive impact on DHH patients’ physical and psychological health, which is also supported by the results in Figure 2 (β = .28, p < .001 and β = .19, p < .001, respectively). Apart from the predicted relationships, Figure 2 also reveals a direct and negative association between offline healthcare obstacles and DHH patients’ psychological health (β = −.13, p < .01), and a negative relationship between offline healthcare obstacles and patient activation (β = −.13, p < .05). However, no direct relationship was found between offline healthcare obstacles and DHH patients’ physical health. Moreover, no significant direct association between online health consultation and DHH patients’ health outcomes was observed.

Meanwhile, the results regarding indirect relationships among variables are reported in Table 3. These findings support H5 and H6, which hypothesize that PCC and patient activation mediate the relationship between offline healthcare obstacles, online health consultation, and DHH patients’ physical and psychological health. Table 3 shows that offline healthcare obstacles have a negative association with DHH patients’ physical and psychological health, which is mediated by PCC and patient activation (β = −.02, 95% CI: [−.034, −.004] and β = −.01, 95% CI: [−.023, −.003], respectively). Similarly, online health consultation has a positive association with DHH patients’ physical and psychological health, which is mediated by PCC and patient activation (β = .01, 95% CI: [.002, .015] and β = .01, 95% CI: [.001, .010], respectively).

Table 3. Mediation results.

	Group 1 (Deaf or hard-of-hearing) N = 323			Group 2 (Hearing-abled) N = 3,542
	β	SE	95% CI	β	SE	95% CI
Offline healthcare obstacles (OHO) and health:
OHO→Patient activation→Physical health	−.03	.018	[−.070, .001]	−.01	.003	[−.020, −.007]
OHO→Patient activation→Psychological health	−.02	.012	[−.047, .001]	−.02	.004	[−.027, −.011]
OHO→PCC→Patient activation→Physical health	−.02	.008	[−.034, −.004]	−.01	.001	[−.013, −.007]
OHO→PCC→Patient activation→Psychological health	−.01	.005	[−.023, −.003]	−.01	.002	[−.017, −.011]
Online health consultations (OHC) and health:
OHC→PCC→Patient activation→Physical health	.01	.004	[.002, .015]	.002	<.001	[.001, .003]
OHC→PCC→Patient activation→Psychological health	.01	.002	[.001, .010]	.003	.001	[.002, .004]

Covariates: gender, age, education, and income; PCC = patient-centered care.

As for hearing-abled participants, the SEM results pertaining to direct and indirect relationships are indicated in Figure 3 and Table 3 respectively. In contrast to the results for DHH participants, all direct relationships were found to be statistically significant (see Figure 3) as were the indirect relationships between offline healthcare obstacles and health outcomes via patient activation (see Table 3). The multi-group analysis further revealed that when all parameter estimates were constrained across both groups, the change in chi-square was not significant (∆χ² = 9.86, p = .87). However, when the indirect paths were constrained and the direct paths were unconstrained, the chi-square difference test was significant (∆χ² = 959.82, p < .001). These findings indicate statistically significant differences in the proposed intervening relationships that link offline healthcare obstacles and online health consultations to health outcomes among DHH participants compared to hearing-abled participants.

Figure 3. SEM test results (hearing-abled participants).

SEM test results for the research model among hearing-abled participants. Both Offline healthcare obstacles and online health consultations were directly and negatively associated with physical health and psychological health. Besides, Offline healthcare obstacles negatively affect patient-centered care (PCC), which reduces patient activation and eventually jeopardizes physical and psychological health. Online health consultation is positively associated with PCC, and higher levels of PCC can increase patient activation, contributing to better physical and psychological health.

For efficiency and clarity, control variables (age, gender, education, and income) are not shown. Solid lines indicate statistically acknowledged paths (p < .05), and dotted lines indicate statistically unacknowledged paths (p ≥ .05). *p < .05, **p < .01, ***p < .001. Model fit indices: χ²/df = 17.306, p = .001, CFI = .993, RMSEA = .037, SRMR = .008, and TLI = .927.

Discussion

Drawing on Street et al. (2009) health communication pathway model, this study examined PCC and patient activation as two mediation mechanisms linking offline healthcare obstacles and online health consultation on DHH patients’ physical health and psychological health. Through a nationally representative survey of 323 DHH patients in the United States, the findings of this study found that offline healthcare obstacles were negatively associated with DHH patients’ health outcomes through the serial mediation effect of PCC and patient activation. Meanwhile, online health consultation was positively related to DHH patients’ health outcomes via the serial mediators of PCC and patient activation. Moreover, offline healthcare obstacles were also directly and negatively related to patient activation and DHH patients’ psychological health. Detailed results are discussed below.

First, as expected, offline healthcare obstacles were negatively associated with PCC, while the internet provides an alternative avenue for health consultations that can positively impact PCC. DHH patients tend to be marginalized and neglected by the healthcare system, and they are at a higher risk of experiencing communication and behavioral barriers to obtaining needed medical care (James et al., 2022). Offline healthcare obstacles such as ineffective communication that causes inadequate information exchange, long waiting time for consultation and test results, and short time for diagnostic and therapeutic conversations with providers, are likely to frustrate DHH patients with hearing difficulties and language barriers to express their concerns and feelings. For instance, when DHH patients seek offline medical services, an on-site interpreter is needed for their medical interactions. However, most healthcare facilities do not supply interpreters when DHH patients attend appointments. In this case, the stressful, frustrating, and time-consuming experience of negotiating for communication access may impede their ability to interact with providers, reduce DHH patients’ understanding of their health condition, and lower their perception of patient-centeredness in medical care. As such, DHH patients who encountered greater difficulties in offline healthcare would perceive a lower level of patient-centeredness.

Meanwhile, online health consultations can help increase PCC, and this finding was congruent with previous research (Liu & Yeo, 2021; Roter et al., 2008). Given DHH patients’ high likelihood of encountering offline healthcare obstacles and receiving ineffective communication, online health consultations can potentially play a complementary role in helping to reduce health inequities for DHH patients. Online health consultations that enable asynchronous means of message exchange can help DHH patients obtain patient-tailored care, better describe their health symptoms, and manage their patient data easily (Delbanco & Sands, 2004; Liu & Yeo, 2021). Moreover, the messages from online health consultations can also be integrated into medical records that facilitate offline medical care, and this helps DHH patients to better communicate with providers while on office visit (Wallwiener et al., 2009).

Second, PCC was positively associated with patient activation. This finding was consistent with prior research supporting that PCC respects patient autonomy, empowers patients, provides reliable information and support to facilitate patients’ health management, reduces patient uncertainty, engages patients in decision-making, patient attention to patient feelings and emotions, and equips patients with needed self-care skills (Epstein & Street, 2007; P. L. Liu et al., 2023). PCC endorses the rule of advocating medical beneficence that incorporates patients’ values and perspectives. As DHH patients’ needs and preferences are met, uncertainties are reduced, and values are respected, they are likely to be motivated and activated to engage in their health and care (Reynolds, 2009; Totzkay et al., 2017).

Third, this study lends support for the serial mediating role of PCC and patient activation in the negative association between offline healthcare obstacles and DHH patients’ health, and the positive relationship between online health consultation and DHH patients’ health outcomes. As suggested by Street et al. (2009), communication-based healthcare delivery can eventually impact patients’ health through mediated routes. Offline healthcare obstacles that encompass ineffective patient-provider communication reduce patients’ perception of physicians’ patient-centeredness when delivering medical care, and a low level of PCC impedes DHH patients’ ability and confidence to take care of their own health, which consequently results in unfavorable physical and psychological health outcomes. Meanwhile, online health consultation, which is particularly helpful for DHH patients with hearing difficulties and verbal communication barriers, allows more effective communication between DHH patients and providers. As a result, the improved PCC and enhanced patient activation contribute to improved physical and psychological health among DHH patients.

This study contributes to the literature on patient-provider communication by examining the impact of offline healthcare obstacles and online health consultation on DHH patients’ health outcomes. It is one of the first studies to provide empirical evidence addressing DHH patients’ offline healthcare obstacles and suggests online health consultation as a possible solution for improving DHH patients’ healthcare experience, patient activation, and health outcomes. The findings support the negative association between offline healthcare obstacles and DHH patients’ health, and the positive relationship between online health consultation and DHH patients’ health. This study also identified the mediating role of PCC and patient activation, highlighting the importance of understanding the underlying mechanisms that explain how patient-provider communication affects DHH patients’ health. Notably, comparisons between DHH participants and their hearing-abled counterparts suggest that most of the hypothesized relationships remain similar, but certain relationships are more enhanced for DHH participants, particularly the proposed serial mediating roles of PCC and patient activation in the associations between online health consultations and health outcomes. In addition, the findings highlight the importance of effective patient-provider communication for shared decision-making and empowering DHH patients to take good care of their health. Personal autonomy, patient activation, and favorable health outcomes can be achieved through physician beneficence and patient-centered care. Overall, this study provides valuable insights that can inform the development of interventions to improve patient-provider communication and reduce health inequities for DHH patients.

Based on the results of this study, some practical implications can be suggested. Firstly, healthcare providers need to be aware of the negative impact of offline healthcare obstacles on DHH patients’ perception of patient-centeredness, which can lead to reduced patient activation and jeopardize their physical and psychological health. Therefore, targeted efforts should be made to reduce these obstacles and enhance patient-centered care, such as providing auxiliary aids and services – notably, sign language interpreters – for medical appointments for DHH patients and ensuring that medical information is accessible to DHH patients. Moreover, practitioners should also provide deaf awareness training programs aimed at healthcare providers working with DHH patients. It is crucial to equip providers with the necessary communication skills to better address DHH patients’ problems and be responsive to their psychological and emotional needs. Beyond ineffective patient-provider communication, offline healthcare obstacles facing DHH patients include the difficulty to have accurate and up-to-date patient-centered records to track the care continuum over the course of several years or a patient’s lifetime. Thus, greater attention should be directed to the digital information infrastructure to support both online patient-provider communication and electronic health records to improve the accessibility of quality and efficient medical care (Jiang & Liu, 2020). Furthermore, the research findings suggested that making care more patient-centered is expected to enable DHH patients to be activated to manage their health. As such, it is important to provide patient-tailored care that helps DHH patients more actively engage in maintaining good physical and psychological health.

Secondly, online health consultations can positively influence PCC, which can, in turn, improve patient activation and lead to better physical and psychological health outcomes. Thus, healthcare providers should consider incorporating electronic tools that particularly support DHH patients’ self-directed medical care. While the internet allows a variety of communication options (e.g., texts, images, and video) as an extension and enhancement to effective medical interaction, these options should account for DHH patients’ personal communication preferences, expectations, and norms. For instance, video or audio forms of electronic consultations may replicate if not exacerbate the hearing-based barriers of in-person, offline consultations unless be equally if not more inaccessible for DHH patients compared to in person consultations unless close-captioning or other visual aids are provided.

Limitations and directions for future research

Several limitations to this study should be noted. The HINTS study had a cross-sectional design, which limits our ability to draw causal inferences about the relationships between offline healthcare obstacles, online health consultation, PCC, patient activation, and the physical and psychological health of DHH patients. To better understand these relationships, scholars should conduct experimental research or collect panel data. Additionally, while online health consultation was measured as an integrated concept, we do not have a clear understanding of how and what DHH patients communicate with healthcare providers. More comparative studies are warranted to clarify the hearing-impairment differences in the pathways linking offline healthcare obstacles and online health consultations to patient health observed in this study. As this study was not designed specifically for people with hearing-impairment, it did not measure obstacles specific to DHH patients, particularly as it relates to their communication preferences. DHH patients who rely on sign language may face different barriers to offline healthcare than those who rely on lip-reading or hearing aids/cochlear implants. These two groups have different communication expectations, norms, and health beliefs and values, which likely affect their healthcare experiences and perceptions. Furthermore, navigating online consultations may also differ for these groups, particularly in their use of video/audio-based online materials. Further studies are needed to investigate the communication process, including content and styles. Furthermore, PCC and patient activation have been identified as serial mediators in the relationship between offline healthcare obstacles, online health consultation, and DHH patients’ health outcomes. However, potential moderators and mediators, such as social support and health literacy, may have been overlooked. Future research should explore these and other factors to better explain the variances in the relationship between health communication and patients’ health outcomes.

Conclusion

Although communication difficulties faced by DHH patients in healthcare settings have garnered attention, there is a lack of empirical research investigating the impact of offline healthcare obstacles and online health consultation on DHH patients’ psychological and physical health outcomes. This study suggests that offline healthcare obstacles can reduce DHH patients’ perception of patient-centeredness, which may hinder their ability and confidence in self-care (represented as patient activation in this study). Decreased patient activation may then further compromise DHH patients’ physical and psychological health. Conversely, online health consultation is positively linked to PCC, and greater PCC can enhance patient activation, leading to better physical and psychological health outcomes. Understanding these relationships can promote the use of electronic tools to support DHH patients’ medical care, improve PCC, provide patient-tailored care that meets the unique needs of DHH patients, prompt patient activation, and ultimately enhance DHH patients’ physical and psychological health.

Disclosure statement

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Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.