Sage Journals: Discover world-class research

Abstract

Health literacy competencies enable physicians to communicate effectively, fostering patients’ understanding, trust, and shared decision-making. However, research has largely emphasized physicians’ views rather than patients’. This study examined how patients perceive physicians’ health literacy competencies and how these perceptions shape their views of “good communication” in family medicine. Forty-four Q-statements were developed based on established indicators of physician health literacy and professional competencies. A total of 62 patients were randomly invited from family medicine outpatient clinics at 2 medical centers in northern Taiwan, with 42 completing the Q-sorting task. Data were analyzed using Q-factor analysis, combining quantitative statistical methods with qualitative interview data to identify distinct groups of patient perspectives. The Q-factor analysis identified 5 distinct patient perspectives, accounting for 50.88% of the total variance. These perspectives were categorized as: (1) Paternalistic Model – Physician-Dependent, characterized by patient reliance on physician authority; (2) Interpretive Model – Self-Empowered, emphasizing patient autonomy and active participation; (3) Interpretive Model – Shared Decision-Making, reflecting a balance of physician expertise and patient autonomy; (4) Informative Model – Patient-Centered, prioritizing clear communication and patient rights; and (5) Deliberative Model – Physician-Respecting, balancing professional competence with empathetic patient engagement. Patients perceive “good communication” in various ways influenced by health literacy, cultural values, and expectations of the physician’s role. The findings emphasize the need for communication training that adjusts to patients’ different health literacy levels and preferences, incorporating these perspectives into physician education and practice to encourage patient-centered, health literacy–oriented care.

Keywords

Q methodology physician-patient communication patient perspectives family medicine health literacy

Introduction

Health literacy refers to a person’s ability to access, understand, and effectively use health-related information, playing a critical role in health promotion and maintenance.¹ Before 2008, healthcare professionals often saw low health literacy among patients as a crisis, focusing on improving patients’ personal skills to handle the complexity and demands of healthcare systems.² A decade later, the focus shifted to improving the skills of healthcare systems and providers, emphasizing the importance of identifying patient needs, thoroughly understanding patient concerns, and supporting patients in evaluating and applying solutions based on their health literacy and perspectives.³

Taiwan’s single-payer National Health Insurance (NHI) program, launched in 1995, provides affordable universal healthcare, covering over 99% of the population with typical copayments of less than USD 20 per visit.⁴ This accessibility has contributed to a life expectancy of 81 years by 2023 but has also encouraged frequent healthcare visits, shaping both patient expectations and physician–patient communication patterns.⁵

Most Taiwanese citizens prefer to visit medical centers directly, even for minor conditions, because of convenient transportation and the availability of advanced diagnostic and treatment services.⁶ Despite government efforts to promote a hierarchical referral system, patients remain concentrated in tertiary hospitals. Between 2011 and 2021, outpatient expenditures at medical centers increased from 33.2% to 37.2% of total NHI outpatient spending, reflecting continued reliance on large hospitals.⁷

Elderly individuals constitute the majority of outpatients and are a high-risk group for limited health literacy.⁸ As Taiwan approaches super-aging status in 2025, nearly 80% of older adults have at least 1 chronic disease, making family physicians central to ongoing management and follow-up care.⁹ Although healthcare resources are widely accessible, an estimated 13.7% to 25.3% of Taiwanese adults still have inadequate health literacy.¹⁰ These patients tend to participate less in medical decision-making, and increasing outpatient loads further shortens consultation time, reducing opportunities for physicians to identify patients with low health literacy.¹¹ Consequently, physicians’ own health literacy competencies, especially in recognizing and supporting patients with limited understanding, are essential for ensuring effective communication and quality care.

A public health team identified 4 core dimensions of physician competencies: “concept and assessment,” “empathy and acceptance,” “communication and interaction,” and “medical information and decision-making.”¹² Collectively, these 4 dimensions outline the essential components of what patients may perceive as “good communication.” However, current research mainly focuses on physicians’ perspectives, often overlooking patients’ subjective thoughts and needs.^13,14

The Q methodology, developed by Dr. William Stephenson in 1953, combines both qualitative and quantitative research approaches, making it especially effective for exploring subjective human perspectives, such as attitudes, beliefs, and values.¹⁵ Typically, Q statements are developed from relevant literature, questionnaires, individual interviews, or focus groups.¹⁶ Subsequently, random sampling is performed from the target population, recruiting approximately 40 to 60 participants who are directly relevant to the issue being studied.¹⁷ These participants are then asked to rank the Q statements (Q-sort) based on their personal perspective.¹⁸ Finally, Q-factor analysis is conducted using analytical software, such as PQ Method, to systematically identify different clusters of attitudes among respondents.¹⁹ The primary advantage of the Q methodology is its ability to identify differences in subjective perspectives among respondents, helping researchers gain a deeper understanding of individuals’ viewpoints on specific topics, such as physician-patient communication. For example, researchers used the Q methodology to investigate perceptions of what makes a “good doctor” among medical students and physicians, further highlighting the method’s potential in medical education.²⁰ Typically, individuals’ subjective opinions on various topics remain relatively stable over time, exhibiting high internal consistency, with reliability coefficients usually exceeding 0.8.²¹ Therefore, the Q methodology, which involves respondents organizing Q statements according to their subjective opinions, tends to produce statistically reliable results that are not significantly affected by time-related changes, making its findings valuable for discussion.

In this study, Q methodology was used to explore the perspectives of Taiwanese patients regarding physicians’ health literacy–related competencies within family medicine outpatient settings. By classifying these perspectives, the study aimed to identify how patients define and prioritize elements of “good communication” and to provide evidence for developing patient-centered communication strategies tailored to different patient groups.

Materials and Methods

Development of the Q-Sample

The study design is a Q-methodology study, which combines quantitative and qualitative elements to explore subjective viewpoints. From September to November 2023, a total of 400 outpatients from 2 family medicine clinics at medical centers in northern Taiwan were randomly invited to participate in the study. Of these, 62 eligible individuals provided informed consent. After excluding participants who did not complete the Q-sort or whose data could not be classified during Q-factor analysis, 42 participants were included in the final analysis. The recruitment and inclusion process is illustrated in Figure 1.

Figure 1.

Process flow diagram of this study.

Participants

Among the participants in this study, 18 were male (42.9%) and 24 were female (57.1%). In terms of age distribution, 24 participants (57.1%) were aged 65 years or older, categorized as older adults, while 18 (42.9%) were aged 30 to 64 years, representing middle-aged adults. Regarding educational background, 16 participants (38.1%) had completed a high school education or less, whereas 26 participants (61.9%) held a university degree or higher. As for the primary reason for clinical visits, 6 participants (14.3%) reported general chronic conditions, 14 (33.3%) were diagnosed with 1 or more components of metabolic syndrome (ie, hypertension, hyperglycemia, or hyperlipidemia), and 9 (21.4%) sought care for diabetes or cardiovascular diseases. The remaining 13 participants (31%) visited for nonspecific complaints such as headaches, colds, or routine health checkups.

The participants’ perspectives were grouped into 5 distinct factors using Q-factor analysis. Demographic and clinical background information, as shown in Table 1, was integrated to provide context for each factor and enhance the understanding of the different viewpoints across the patient groups.

Table 1.

Background Information on the Patients Within Each of the 5 Factors.

Variables	Factor I (n = 12)		Factor II (n = 16)		Factor III (n = 6)		Factor IV (n = 4)		Factor V (n = 4)
Variables	n	%	n	%	n	%	n	%	n	%
Age (years)
65+	7	58.3	8	50	4	66.7	3	75	2	50
30-64	5	41.7	8	50	2	33.3	1	25	2	50
Gender
Male	7	58.3	6	37.5	2	33.3	1	25	2	50
Female	5	41.7	10	62.5	4	66.7	3	75	2	50
Education level
College or above	7	58.3	12	75	3	50	2	50	2	50
High school or vocational school	5	41.7	4	25	1	16.7	2	50	2	50
Junior high school	0	0	0	0	1	16.7	0	0	0	0
Elementary school or below	0	0	0	0	1	16.7	0	0	0	0
Primary reason for visit
Chronic disease	5	41.7	0	0	0	0	0	0	1	25
Cardiovascular disease or diabetes	2	16.7	4	25	2	33.3	1	25	0	0
Follow-up for hypertension, hyperlipidemia, or hyperglycemia	3	25	5	31.3	2	33.3	2	50	2	50
Nonspecific complaints	2	16.7	7	43.8	2	33.3	1	25	1	25

Q Statements and Procedure

The Physician Health Literacy Competency Indicators, developed by Liu et al¹² through focus group interviews and the modified Delphi method, comprise 44 assessment criteria designed to evaluate physicians’ health literacy competencies. This framework is designed for use in medical education and professional training to enhance physicians’ knowledge, attitudes, and communication abilities in physician-patient interactions. These 44 indicators were converted into Q-statements (Table 2) and arranged on a Q-sorting grid (Figure 2) following a quasi-normal distribution. The grid used a 9-point scale, from “most important” (+4) to “least important” (−4), with participants placing each statement into a cell that reflects its perceived importance.

Table 2.

The 44 Q-Statements and the Factor Array Scores of the 5 Factors.

Q statements	Factor array scores
Q statements	F I	F II	F III	F IV	F V
1. Understand the definition of physicians’ health literacy and professional competence	4	0	4	0	2
2. Comprehend the concept of effective utilization of medical resources	3	1	3	0	1
3. Recognize the importance of physicians’ health literacy and professional competence	4	−1	3	−2	3
4. Acknowledge the value of physicians’ health literacy and professional competence	3	0	3	−1	1
5. Recognize the importance of patients’ health literacy awareness and assessment	3	0	4	−1	4
6. Be aware of the signs and common scenarios associated with patients who have low health literacy	2	1	0	−2	0
7. Use appropriate tools to assess health literacy	1	0	1	0	4
8. Apply suitable physician-patient interaction models based on patients’ levels of health literacy	2	1	2	0	3
9. Accept patients from diverse socioeconomic and cultural backgrounds	1	−1	−1	−2	1
10. Accept patients with varying levels of health literacy	1	−1	0	0	1
11. Empathize with and accept patients’ feelings and emotional responses	1	2	1	1	2
12. Respect patients’ expressions and rights	1	2	−1	4	0
13. Protect patients’ privacy rights	1	1	−1	3	2
14. Provide social support to patients	−1	−3	−2	2	−1
15. Arrange an environment conducive to communication	0	−1	0	2	0
16. Allow sufficient time for communication	2	0	−3	1	0
17. Demonstrate approachability and warmth	0	1	−1	1	2
18. Gain the patient’s trust	0	2	−2	1	2
19. Avoid using complex medical jargon that patients may find difficult to understand	1	0	−4	−3	2
20. Use metaphors or concrete explanations	0	−1	−4	−3	2
21. Use the patient’s everyday language and familiar expressions as much as possible	0	−1	−3	4	0
22. Control the speed and volume of communication	−1	−2	−3	3	−1
23. Provide an appropriate amount of information	−1	−1	−2	3	0
24. Emphasize key messages and clarify any misconceptions	0	−2	−2	−4	−1
25. Make appropriate use of nonverbal communication	−1	−4	−2	−2	−1
26. Use appropriate materials (e.g., outpatient educational handouts, images, videos, models)	−1	−2	0	-1	−2
27. Provide readable educational materials or resources	−2	−3	0	0	−2
28. Facilitate communication with the help of family members	0	0	0	2	0
29. Facilitate communication with the help of fellow patient.	−4	−4	0	1	−1
30. Facilitate communication with the help of other personnel	−2	−3	1	2	−4
31. Choose appropriate timing and methods for giving feedback or demonstrations	−2	0	−1	1	−2
32. Guide patients to repeat the taught content or demonstrate techniques	−3	−2	0	−2	2
33. Verify the accuracy of patients’ responses or demonstrations	−4	0	−1	−3	−1
34. Clarify the content of health education or demonstrations	−3	−2	−1	−4	0
35. Affirm patients’ correct actions or responses	−2	2	0	−1	−1
36. Discuss and confirm the medical goals with patients	2	2	1	0	0
37. Confirm relevant patient information such as medical history and lifestyle habits	−1	1	2	1	0
38. Consider patients’ consultation needs and preferences	−3	0	1	2	−2
39. Explain the progression of the disease	2	4	0	−1	−3
40. Analyze the pros, cons, and risks of various	0	3	2	0	−3
41. When necessary, discuss referral or consultation information with the patient	0	1	1	0	−3
42. Allow patients sufficient time for decision-making	−1	3	1	−1	−2
43. Respect and fully encourage patients to express their preferences	−2	4	2	0	3
44. Confirm and implement the agreed-upon medical decisions	0	3	2	−1	−4

Note. Positive and negative scores indicate the relative importance of each Q statement in defining good communication, ranging from +4 (“most important”) to −4 (“least important”).

Figure 2.

A Q-sort grid for rank-ordering the 44 Q-statements.

This study used an in-person Q methodology design. Each Q-sorting session was guided by 3 trained research team members who provided immediate assistance as needed. Participants received a large-format Q-sorting board (full sheet poster), 44 Q-statement cards (3.5 × 2 inches each), and a statement explanation sheet with conceptual definitions and practical examples to ensure proper understanding of each Q-statement. Participants then sorted the statements based on their personal views, arranging them on the grid according to their perceived importance.

After participants completed the Q-sort, their final arrangements were photographed for documentation. The research team then conducted brief follow-up interviews, asking each participant 2 open-ended questions:

“Why did you position these two statements in the most important places?”

“Why did you assign these two statements to the least important positions?”

This follow-up step encouraged participants to reflect on and confirm their sorting decisions, ensuring that the final Q-sort arrangement truly reflected their perspectives. Each session usually lasted approximately 30 to 60 min.

Data Analysis

Quantitative analysis was conducted using PQ Method software version 2.35.²² Factors with an eigenvalue over 1.0 were retained, following standard criteria. The analysis included calculating eigenvalues, explained variances, and factor loadings. Q-factor analysis was performed using principal component analysis, followed by Varimax rotation to identify and interpret shared viewpoints among participants. The research team consisted of public health and family medicine educators experienced in health literacy research; potential bias was mitigated through collaborative interpretation and peer debriefing.

Ethics Approval and Consent to Participate

This study was approved by the Institutional Review Board of National Taiwan Normal University in October 2023 (Approval Number: 202305HS057). All participants provided written informed consent prior to participation.

Result

In the Q-factor analysis, 5 distinct factors were extracted from the Q-sorts of 42 participants, collectively explaining 50.88% of the total variance. Specifically, Factor 1 contributed 20.85%, Factor 2 contributed 10.47%, Factor 3 accounted for 8.74%, Factor 4 for 5.99%, and Factor 5 for 4.83%. This level of explained variance demonstrates a meaningful representation of the participants’ shared viewpoints. The composite reliability coefficients for Factors 1 through 5 were 0.98, 0.985, 0.96, 0.94, and 0.941, respectively. All values exceed the commonly accepted threshold of 0.7, confirming that the extracted factors are both statistically reliable and conceptually coherent.^23,24 Each factor was then analyzed and labeled based on the participants’ rankings of the 44 Q-statements, referencing established theories of physician-patient communication.^25,26 Demographic and clinical background information, as shown in Table 1, was also used to contextualize the 5 viewpoints and gain a deeper understanding of each patient group’s perspective. These findings offer valuable implications for future research and practice in health communication and health literacy.

Factor I: Paternalistic Model – Physician-Dependent

Participants within this factor tend to follow traditional authoritarian thinking, placing primary responsibility for their health entirely in their physicians’ hands. Despite interactions that might be authoritarian, unilateral, or formal, these patients inherently prefer to rely heavily on physicians for medical information, resources, and treatment decisions (+3). As a result, such patients often have limited health literacy, requiring physicians to recognize their dependence (+4) and proactively facilitate communication (+2), clarify vital medical information, and correct misconceptions about illnesses (+2).

Even if the doctor is strict or harsh, as long as they have sufficient knowledge and good skills, I’d still be willing to see them for treatment. (Participant #29)

We expect to understand our illness through the doctor or hospital. . . Actually, we follow whatever the doctor instructs us to do. Just follow the medical advice, that’s enough. (Participant #31)

I know doctors are very busy, so I think it’s not easy to bother them with too much talk. (Participant #50)

If the doctor is making decisions based on their professional expertise, then I think it’s not always necessary to respect the patient’s preferences. (Participant #54)

This perspective closely matches the paternalistic model described by Emanuel and Emanuel²⁵ and the active-passive model by Szasz and Hollender,²⁶ leading to its designation as the “Paternalistic Model – Physician-Dependent Type.”

Factor II: Interpretive Model – Self-Empowered

Participants in this factor show a strong desire for autonomy and prefer receiving detailed and explicit information regarding their medical conditions (+4), including disease progression and treatment options with their respective benefits, disadvantages, and risks (+3). Despite illness, these patients aim to maintain control over their health decisions. For such patients, physicians who recognize the patient’s need for sufficient information and resources to make autonomous decisions (+3), and are willing to provide extensive explanations and discussions (+2), foster cooperative physician-patient relationships and higher patient satisfaction.

Respecting and fully allowing the patient to express their wishes. Hmm.. This is one of the most important responsibilities of a doctor. Yes, absolutely. You (the physician) need to respect whatever he (the patient) wants to express or the difficulties he’s facing. If the patient tells you something that isn’t feasible, you can explain why. But at the very least, you must allow communication. Especially for some people whose mental state might not be entirely stable, you can use other (approaches). . . .but still let them speak. That’s how I see it. It’s essential! (Participant #5)

As a patient, what we really want is to know all the pros and cons and the risks of treatment options. And, of course, to be able to express our own preferences. (Participant #14)

This factor reflects the interpretive model,²⁵ highlighting active patient involvement and control. Therefore, it is named the “Interpretive Model – Self-Determined Type.”

Factor III: Interpretive Model – Shared Decision-Making

Participants associated with this factor highly value their relationship with physicians, actively cooperating and seeking to build rapport (+4). They want physicians to thoroughly understand their background, including medical history, lifestyle, living conditions, and socioeconomic status (+2). With this understanding, patients trust physicians to provide more tailored and appropriate medical advice. Physicians who respect patient autonomy, empower patients, and proactively share health literacy resources (+3) foster feelings of mutual respect and involvement in decision-making (+2).

Sometimes doctors use medical jargon that the average person simply cannot understand. I think that if they explained things using plain and simple language, it would be easier for everyone, including older adults, to understand. Also, doctors should listen to what the patient wants, first understand the patient’s needs, their actual condition, and the real cause of their discomfort. (Participant #27)

When the doctor diagnoses a disease, they ask questions like: ‘What did you eat today? Why is your blood sugar so high?’ The doctor provides us with clear knowledge. Today, there’s too much information online. For example, some people say you can eat oatmeal, while others say you can’t. The doctor will tell me, ‘Don’t eat oatmeal; your cholesterol is too high. (Participant #49)

This factor highlights both physician expertise and patient autonomy, aligning with the mutual participation model²⁶ and the interpretive model of Emanuel and Emanuel,²⁵ thus referred to as the “Interpretive Model – Shared Decision-Making Type.”

Factor IV: Informative Model – Patient-Centered

This factor emphasizes the quality of physician-patient communication, focusing on details such as tone, speed, volume (+3), and the use of clear language (+4). Additionally, these patients highly value their rights to express themselves (+4), privacy protections (+3), and supportive communication environments (+2). When physicians acknowledge these needs by providing emotional support (+2) and clear, sufficient information (+2), patients feel respected and secure, which enhances collaborative medical decision-making.

Patients need to first understand what will happen next. The content of the decision must be made completely clear, and they should be given enough time to consider and decide before moving forward. (Participant #12)

It’s important to respect the patient’s right to share their feelings and their privacy. Some people don’t want others to know they’re ill. For example, a woman with breast cancer once told me angrily that I absolutely must not tell anyone about her condition. (Participant #42)

Because it highlights communication quality, physician attitude, language, and patient rights, this factor aligns with the informative model described by Emanuel and Emanuel²⁵ and is labeled the “Informative Model – Patient-Centered Type.”

Factor V: Deliberative Model – Physician-Respecting

Participants in this group highly respect physicians’ professional judgments and recommendations (+4). While these patients may downplay their own needs and health literacy levels when physicians do not explicitly acknowledge them, this does not indicate a lack of underlying need. They have implicit expectations that physicians recognize their health literacy levels (+3) and assist them in decision-making that is beneficial to their health. If physicians demonstrate friendliness and patience (+2) and encourage patient involvement and inquiry (+3), effective two-way communication and timely health literacy education can occur.

When the physician handles something, they must be the one who understands it best. No matter how little the patient knows, at the very least the physician must fully understand how to proceed—only then will things stay on the right track. (Participant #17)

We visit the hospital to see a doctor because we believe the doctor can provide advice about our symptoms or condition. It should be a mutual process. For example, if I have questions, the doctor will answer them. That’s good communication. That’s the part I care about most. (Participant #56)

This perspective emphasizes the importance of physicians applying health literacy assessment tools and adjusting their interactions accordingly, blending aspects of paternalistic, deliberative, instructional, and collaborative models. Therefore, it is called the “Deliberative Model – Physician-Respectful Type.”

Discussion

The diversity of perspectives identified in this study shows that good communication is not a single ideal model but a continuum influenced by patients’ health literacy, values, and expectations of the physician’s role. Although the Q statements were developed based on the Physician Health Literacy Competency Indicators proposed by Liu et al,¹² the factor extraction and interpretation in this study were entirely data-driven, reflecting participants’ subjective viewpoints rather than researchers’ assumptions. Each viewpoint represents a different balance between physician guidance, patient autonomy, emotional support, and information exchange. These perspectives are discussed below, together with relevant demographic patterns and supporting literature.

Factor I

Participants aligned with Factor I place high importance on physicians’ opinions, preferring physician-led decision-making and showing minimal proactive engagement or self-expression during consultations. Although modern healthcare increasingly emphasizes patient-centered communication and patient empowerment, paternalistic medical interactions still hold significant influence in certain cultural contexts.²⁷ Notably, demographic data revealed that most participants in this group held a university degree or higher, suggesting that their preference for physician-led interactions is rooted more in cultural attitudes and trust in professional judgment than in health literacy issues.

Furthermore, this group mainly consisted of older adults aged 65 or above (58.3%), aligning with previous research that highlights Taiwanese seniors’ deep respect for and dependence on medical professionals, which promotes a physician-authoritative interaction model.²⁸ Despite their relatively high education levels, these participants’ interaction styles remain deeply influenced by earlier cultural medical norms. Therefore, even when patients have sufficient health literacy, their active engagement in healthcare decisions might still be limited by cultural beliefs, role expectations, and traditional power dynamics between physicians and patients.^29,30

The Q-sort patterns for this group revealed consistent agreement with statements emphasizing clear and trustworthy communication, concise explanations using plain language, and physicians taking responsibility for treatment decisions (Table 2). Participants also valued being given sufficient time to process information and opportunities to ask questions in a calm and respectful setting. At the same time, they preferred physicians to lead shared decision-making by confirming patients’ needs and expectations rather than encouraging independent decision-making. These patterns suggest that, for this group, good communication is grounded in professional authority, reliability, and reassurance rather than autonomy. Thus, effective interaction with these patients requires physicians to provide clear, structured explanations while maintaining a supportive, trust-based relationship.

Factor II

Participants categorized under Factor II demonstrated a strong desire for autonomy and active engagement, clearly favoring equal status with physicians and involvement in treatment decisions. This communication approach aligns well with modern healthcare principles promoting Shared Decision-Making (SDM), wherein physicians and patients collaboratively clarify treatment options, evaluate risks and benefits, and respect each other’s perspectives to reach a consensus.³¹

Demographically, Factor II participants showed the highest educational levels, with 75% holding university degrees or higher. This aligns with studies suggesting that highly educated patients often expect doctors to show professional skill while also wanting to actively participate in decision-making.³² These patients generally have a better ability to understand medical information and prefer treatments that match their personal values and lifestyle goals.

As shown in Table 2, the Q-sort analysis showed that participants in this group strongly agreed with statements highlighting empathetic dialog, mutual respect, and physicians’ recognition of patients’ reasoning. They valued physicians who invite patients to share their opinions and participate in discussions about treatment options, including benefits and risks. This group’s conception of “good communication” focuses on collaboration, in which physicians guide decisions while respecting patients’ autonomy and judgment. Effective strategies to engage these patients include providing balanced information, promoting reflective dialog, and jointly setting medical goals to ensure decisions match patients’ preferences and expectations.

Therefore, when implementing shared decision-making, physicians must carefully address these patients’ informational needs and their willingness to participate, creating an open environment that enables patients to fully understand treatment options and risks, thereby achieving truly patient-centered communication.

Factor III

Participants aligned with Factor III exhibited a hybrid communication style, combining elements of physician-led and patient-autonomous approaches. Although seemingly contradictory, literature indicates these styles can coexist in practice, adapting flexibly based on patients’ health conditions, communication preferences, and interaction settings.³³ Although Factors II and III both reflect a desire for collaborative communication, they differ in emphasis. Factor II participants demonstrate a strong sense of autonomy and expect equal participation in decision-making, while Factor III participants prefer a more balanced approach that combines patient input with physician guidance and emotional reassurance. This distinction highlights that “good communication” can vary between active partnership and guided collaboration depending on patients’ expectations and confidence in their own decision-making abilities. When patients feel listened to and understood by their physicians, they experience increased respect and care, which enhances their acceptance and trust in medical recommendations. This underscores the importance of personal values and situational sensitivity in shaping patient expectations of healthcare communication.

As presented in Table 2, the Q-sort results indicated that participants in this group valued physicians who communicate clearly about disease information and treatment plans while maintaining an empathetic and respectful tone. They preferred open discussions where they could share personal or observed experiences and receive professional feedback that integrates their perspectives into care decisions. This group’s concept of “good communication” emphasizes both informational clarity and emotional connection, as patients seek structured guidance but also expect acknowledgment of their viewpoints. Therefore, effective communication with these patients involves providing well-organized explanations, inviting their input, and using dialog to collaboratively refine treatment decisions.

Notably, Taiwanese patients generally exhibit high trust in medical centers, often choosing large hospitals even for minor conditions.³⁴ This healthcare-seeking behavior results in high patient volumes and limited interaction time per patient, which hinders the practical implementation of hybrid communication models that require extended dialog and emotional exchange. Conversely, utilizing community-based primary care clinics with longer consultations and established patient-provider relationships might better serve these patients, promoting truly patient-centered healthcare communication.

Factor IV

Patients in Factor IV placed high importance on the clarity and understandability of medical information, preferring physicians who communicated using everyday language and avoided complex medical terms. This preference indicates that patients want to understand their health conditions and treatments clearly, using straightforward language. Studies indicate that patient-centered communication, which avoids complex medical jargon, significantly enhances patient understanding and involvement in decision-making.^35,36 Although half of this group had a university-level education or higher, their strong preference for clear information suggests that the complexity of medical details can create significant comprehension challenges, even for well-educated individuals. If doctors do not adapt their communication methods to match patients’ understanding, patients may misinterpret information, make poorer decisions, and subsequently experience less effective treatment and reduced trust in healthcare providers.³⁷

As shown in Table 2, the Q-sort results indicated that participants in this group emphasized physicians’ ability to provide comprehensive and accurate explanations of diseases and treatments while respecting patients’ autonomy in decision-making. They preferred physicians who communicate with empathy, verify patients’ understanding, and, when necessary, involve family members or close companions to ensure that information is fully understood. This group’s concept of “good communication” centers on transparency and mutual respect, as patients expect physicians to act as reliable sources of information rather than as decision-makers. In clinical practice, this suggests that physicians should focus on explaining medical information in plain language, confirming understanding, and supporting patients’ independent choices while safeguarding their privacy and dignity.

Factor V

Participants aligned with Factor V highlighted a dual expectation of professional competence and interpersonal empathy in physician-patient communication. They valued physicians’ professional judgment and treatment capabilities, along with empathetic and approachable attitudes that foster patient comfort and engagement in the treatment process. This perspective reflects the modern focus of healthcare on balancing technical skills with holistic patient care.

According to Table 2, the Q-sort results showed that participants in this group value physicians who communicate clearly and with warmth, provide understandable medical explanations, and respect patients’ emotions and perspectives. They emphasized the importance of physicians recognizing patients’ health literacy levels and adapting communication using appropriate language, tone, and supplementary materials such as visuals or models. This group’s concept of “good communication” combines professionalism with empathy, as patients trust physicians’ expertise but also expect emotional responsiveness and mutual respect. For these patients, effective communication means attentive listening, clear explanations, and creating an environment of trust that encourages open dialog.

However, using health literacy assessment tools might unintentionally cause sensitivity issues. Research indicates that identifying low patient health literacy through assessments can evoke shame, negatively affecting patient adherence and trust.³⁸ This emphasizes that simply conducting assessments without proper follow-up could hinder effective communication. Therefore, it is crucial to improve physicians’ own health literacy skills, enabling them to adjust their communication styles and strategies as needed based on each patient’s comprehension levels, thereby improving physician-patient interactions and mutual trust.³⁹

Overall, these findings emphasize the important link between health literacy and communication styles in shaping effective physician–patient interactions. To improve healthcare results, physician training programs should include interaction techniques tailored to patients’ different levels of health literacy. In the age of healthcare digitization, providing patient-friendly, easy-to-understand medical information and digital tools is essential to enhance health literacy and patient engagement. Addressing diverse patient expectations can improve satisfaction, treatment adherence, and trust in the healthcare system.⁴⁰ However, patient-centered communication curricula are still limited in medical education.⁴¹ These findings support the development of structured communication training and educational materials that can be integrated into medical clerkships, providing students with real-world healthcare experience. Such initiatives have been shown to foster a positive, patient-centered approach⁴² and to improve physicians’ ability to recognize and respond to variations in patients’ health literacy. Beyond medical education, these insights may also inform institutional communication guidelines and health initiatives to promote equitable, health-literate healthcare environments.

Limitation

This study employed the Q methodology to explore patients’ perspectives; however, its findings should be viewed with some limitations in mind. The sample was drawn only from family medicine outpatient departments at 2 medical centers in Taipei and was relatively small, which limits how well the results apply to patients in other regions or specialties. Additionally, the range of Q statements may not have encompassed all relevant factors, and biases in interpretation among participants with lower health literacy could have influenced the outcomes.

Conclusion

This study employed the Q methodology to explore the perspectives of Taiwanese family medicine outpatients on physicians’ professional competencies. Using Q-sorting, patient opinions were categorized into 5 distinct groups based on their priorities for physician competencies, enabling an in-depth understanding of what each group values. The results revealed a diverse range of patient perspectives, encompassing complete reliance on physician authority, respect for physician expertise, shared decision-making, a focus on doctor-patient communication and interaction, and patient self-management. These insights are valuable for developing curricula and educational materials that aim to improve physician-patient interactions within Taiwan’s medical education system, ultimately enhancing physicians’ health literacy competencies, strengthening the doctor-patient relationship, and improving healthcare service quality.

Footnotes

Acknowledgements

The authors would like to sincerely thank Hsien-Liang Huang, MD, and Jen-Kuei Peng, MD, from the Department of Family Medicine at National Taiwan University Hospital, for their assistance with participant recruitment, and Shun-Hui Su, PhD, a counseling psychologist at Puchen Hsinyu Space, for guidance on qualitative narrative analysis. Their valuable support was instrumental in completing this research.

Author Note

The Q-statements in this study were adapted from the Physician Health Literacy Competency Indicators developed by Liu et al. (2020), and as several authors of that work also contributed to this study, permission for adaptation was inherently granted through shared authorship and intellectual ownership.

ORCID iDs

Pei-Ling Tseng

Hui-Fang Yang

Shao-Yi Cheng

Hsiang-Ru Lai

Chiu-Mieh Huang

Jia-yi Chen

Chen-Yin Tung

Ethical Considerations

This study was approved by the Institutional Review Board of National Taiwan Normal University in October 2023 (Approval Number: 202305HS057).

Consent to Participate

All participants provided written informed consent prior to participation.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: National Science and Technology Council, Taiwan supported this study under Grant Number 112–2410-H-003-133-MY2. The funder had no role in this study.

Declaration of Conflicting Interests

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

Data Availability Statement

The data that support the findings of this study are openly available at Google Drive via the following link:

References

Brach

Harris

. Healthy people 2030 health literacy definition tells organizations: make information and services easy to find, understand, and use. J Gen Intern Med. 2021;36(4):1084-1085.

Nutbeam

. The evolving concept of health literacy. Soc Sci Med. 2008;67(12):2072-2078.

Sørensen

. Shifting the health literacy mindset to enhance people-centred health services. Prev Policy Matters Blog. 2018;10:1.

Po-Chang

. Introduction to the National Health Insurance of Taiwan. In: Lee

Wang

Chen

Peng

, eds. Digital Health Care in Taiwan: Innovations of National Health Insurance. Chapter 1. Springer International Publishing; 2022:1-15.

Tseng

P-L

Chang

C-C

Yen

Z-S

, et al Educational Intervention to improve adolescents’ knowledge, attitude, and practice regarding accessing emergency medical resources. Asia Pac J Public Health. 2024;36(2-3):272-275.

Yan

Y-H

Kung

C-M

Yeh

H-M

. The impacts of the hierarchical medical system on national health insurance on the resident’s health seeking behavior in Taiwan: a case study on the policy to reduce hospital visits. Int J Environ Res Public Health. 2019;16(17):3167.

Chi

Liang

L-L

Lee

J-L

Núñez

Tuepker

. Healthcare for all - a critical review of Taiwan’s national health insurance system through a social institution lens. J Formos Med Assoc. 2024;123 Suppl 3:S228-S233.

Xie

Zheng

Zhao

Wang

. Multidimensional health literacy profiles and health-related behaviors in the elderly: a cross-sectional survey. Int J Nurs Sci. 2022;9(2):203-210.

Wang

Y-H

H-C

Liao

K-Y

Chen

T-J

Hwang

S-J

. Family physicians working at hospitals: a 20-year nationwide trend analysis in Taiwan. Int J Environ Res Public Health. 2021;18(17):9097.

10.

Duong

Chang

. Topics included in Health Literacy Studies in Asia: a systematic review. Asia Pac J Public Health. 2024;36(1):8-19.

11.

Palumbo

Annarumma

Manna

Musella

Adinolfi

. Improving quality by involving patient. The role of health literacy in influencing patients’ behaviors. Int J Healthc Manag. 2021;14:144-152.

12.

Liu

Chang

Lai

Tsai

Ming

Tung

. Study of constructing indicators of physician’s professional competence on health literacy by Delphi method. Taiwan J Public Health. 2020;39(3):292-310.

13.

Moldt

J-A

Festl-Wietek

Madany Mamlouk

Nieselt

Fuhl

Herrmann-Werner

. Chatbots for future docs: exploring medical students’ attitudes and knowledge towards artificial intelligence and medical chatbots. Med Educ Online. 2023;28(1):2182659.

14.

Park

Kim

H-K

Lee

. An analytic hierarchy process analysis for reinforcing doctor-patient communication. BMC Prim Care. 2023;24(1):24.

15.

Watts

Stenner

. Doing Q Methodology: Theory, Method and Interpretation. Qualitative Research in Psychology. Vol. 2. Taylor & Francis; 2005:67-91.

16.

Stephenson

. The Study of Behavior: Q-technique and its Methodology. University of Chicago Press; 1953.

17.

Stenner

Watts

Worrell

. Q methodology. In: Willig

Stainton-Rogers

, eds. The SAGE Handbook of Qualitative Research in Psychology. Sage; 2008:215-239.

18.

Herrington

Coogan

. Q methodology: an overview. Res Teach Educ. 2011;1(2):24-28.

19.

Akhtar-Danesh

. An overview of the statistical techniques in Q methodology: is there a better way of doing Q analysis? Operant Subj. 2017;38(3/4). https://ojs.library.okstate.edu/osu/index.php/osub/article/view/8733

20.

Coventry

Hampton

Muddiman

Bullock

. Medical student and trainee doctor views on the 'good' doctor: deriving implications for training from a Q-methods study. Med Teach. 2022;44(9):1007-1014.

21.

Brown

. Political Subjectivity: Applications of Q Methodology in Political Science, Vol. 2. Yale University Press; 1980:262-274.

22.

Schmolck

Atkinson

. PQMethod (version 2.35) [computer software and manual]. University of the Bundeswehr Munich; 2014. Accessed June 30, 2025. http://schmolck.org/qmethod/.

23.

Hair

Jr Black

Babin

Anderson

. Multivariate data analysis. 7th ed. Pearson Education; 2010:785.

24.

Cheung

Cooper-Thomas

Lau

Wang

. Reporting reliability, convergent and discriminant validity with structural equation modeling: a review and best-practice recommendations. Asia Pac J Manag. 2024;41(2):745-783.

25.

Emanuel

. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-2226.

26.

Szasz

Hollender

. A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship. AMA Arch Intern Med. 1956;97(5):585-592.

27.

Vučemilović

Mahmić-Kaknjo

Pavličević

. Transition from paternalism to shared decision making - a review of the educational environment in Bosnia and Herzegovina and Croatia. Acta Med Acad. 2016;45(1):61-69.

28.

Liu

. Building a strong and healthy empire: the critical period of building colonial medicine in Taiwan. Jpn Stud. 2004;24(3):301-314.

29.

Ohta

Ryu

Kitayuguchi

Sano

Könings

. Educational Intervention to improve citizen’s healthcare participation perception in rural Japanese communities: a pilot study. Int J Environ Res Public Health. 2021;18(4):1782.

30.

Murugesu

Heijmans

Rademakers

Fransen

. Challenges and solutions in communication with patients with low health literacy: perspectives of healthcare providers. PLoS One. 2022;17(5):e0267782.

31.

Elwyn

Frosch

Thomson

, et al Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367.

32.

Dopelt

Bachner

Urkin

Yahav

Davidovitch

Barach

. Perceptions of practicing physicians and members of the public on the attributes of a “good doctor”. Healthcare. 2021;10:73.

33.

Fernández-Ballesteros

Sánchez-Izquierdo

Olmos

Huici

Ribera Casado

Cruz Jentoft

. Paternalism vs. autonomy: are they alternative types of formal care? Front Psychol. 2019;10:1460.

34.

Wang

S-I

Yaung

C-L

. Vertical equity of healthcare in Taiwan: health services were distributed according to need. Int J Equity Health. 2013;12(1):12. doi:10.1186/1475-9276-12-12

35.

Allen

Charpentier

Hendrickson

, et al Jargon Be gone - patient preference in doctor communication. J Patient Exp. 2023;10:23743735231158942.

36.

Rooney

Santiago

Perni

, et al Readability of patient education materials from high-impact medical journals: a 20-year analysis. J Patient Exp. 2021;8:2374373521998847. doi:10.1177/2374373521998847

37.

Gotlieb

Praska

Hendrickson

, et al Accuracy in patient understanding of common medical phrases. JAMA Netw Open. 2022;5(11):e2242972.

38.

Mbanda

Dada

Bastable

Ingalill

G-B

Ralf

W S

. A scoping review of the use of visual aids in health education materials for persons with low-literacy levels. Patient Educ Couns. 2021;104(5):998-1017.

39.

Tavakoly Sany

Behzhad

Ferns

Peyman

. Communication skills training for physicians improves health literacy and medical outcomes among patients with hypertension: a randomized controlled trial. BMC Health Serv Res. 2020;20(1):60.

40.

Shih

C-I

Weng

C-C

Chen

Yang

H-F

Fan

S-Y

. Consideration factors of older adults seeking medical treatment at outpatient services in Taiwan. BMC Health Serv Res. 2021;21(1):1216.

41.

El-Sherbiny

Ibrahim

Sayed

. Medical students’ attitudes towards patient-centered care, Fayoum Medical School, Egypt. Alex J Med. 2021;57(1):188-193.

42.

Yeom

Kim

Choi

Yoo

D-M

. Experiences and perspectives on patient-centered education of medical students in Korea. Korean J Med Educ. 2022;34(4):259-271.

Patients’ Perceptions of Physicians’ Health Literacy Competencies and “Good” Communication in Family Medicine: A Q Methodology Study

Abstract

Keywords

Introduction

Materials and Methods

Development of the Q-Sample

Participants

Q Statements and Procedure

Data Analysis

Ethics Approval and Consent to Participate

Result

Factor I: Paternalistic Model – Physician-Dependent

Factor II: Interpretive Model – Self-Empowered

Factor III: Interpretive Model – Shared Decision-Making

Factor IV: Informative Model – Patient-Centered

Factor V: Deliberative Model – Physician-Respecting

Discussion

Factor I

Factor II

Factor III

Factor IV

Factor V

Limitation

Conclusion

Footnotes

Acknowledgements

Author Note

ORCID iDs

Ethical Considerations

Consent to Participate

Funding

Declaration of Conflicting Interests

Data Availability Statement

References