Exploration of the patient’s voice

Finding deeper meaning in the linguistic cues used by adults living with diabetes


  • Phillip Cox Wake Forest University
  • Shannon L Mihalko Wake Forest University
  • Suzanne C Danhauer Wake Forest School of Medicine
  • Julienne K Kirk Wake Forest School of Medicine
  • Mollie Rose Canzona Wake Forest University
  • Heather L Black Merck Sharp & Dohme Corp.
  • Sally A Shumaker Wake Forest School of Medicine




adherence, agency, diabetes, multidimensional analysis, non-adherence, self-management


Diabetes self-management is a complex process in which individuals are asked to modify established health behaviors. Healthcare providers are instrumental in enhancing individual self-management and are encouraged to consider the patient perspective, often expressed indirectly. Using multidimensional analysis, this study analyzed talk to compare linguistic features used by adherent and non-adherent individuals with diabetes. In-depth telephone interviews were conducted with 108 individuals. Recruitment was stratified by sex, race and glycated hemoglobin (A1C) score. Interviewer contributions were removed from the transcripts, leaving only the participants’ contributions. Using A1C score (<7%, >7%) the texts were divided into adherent and non-adherent datasets. Based on computer-assisted, quantitative analysis, ten linguistic features had a significant difference in frequency of use between the two groups. The participants in the adherent group used a greater frequency of linguistic features related to personal stance than the non-adherent group, and these expressions of personal stance were considered in relation to the participant’s sense of agency. A better understanding of the way in which different subsets of individuals talk about diabetes self-management would facilitate greater healthcare provider understanding of the patient’s perspective during clinical encounters to improve adherence.

Author Biographies

Phillip Cox, Wake Forest University

Phillip Cox, MS, MBA, is a Research Assistant in the Health and Exercise Science Department at Wake Forest University. His research interests include health psychology and psychosocial determinants of health.

Shannon L Mihalko, Wake Forest University

Shannon L. Mihalko, PhD, is a Professor in the Health and Exercise Science Department at Wake Forest University. Her research focuses on adherence and quality of life in adults with chronic disease. Specifically, her work examines determinants and consequences of behavior change and adherence, with a specific focus on building self-efficacy. She holds a joint appointment in the Department of Social Sciences and Health Policy within the Division of Public Health Sciences at Wake Forest University School of Medicine.

Suzanne C Danhauer, Wake Forest School of Medicine

Suzanne C. Danhauer, PhD, is a tenured Professor in the Department of Social Science and Health Policy in the Division of Public Health Sciences at Wake Forest School of Medicine. She also holds a joint appointment in the Department of Internal Medicine, Section on Hematology and Oncology. She is a clinical health psychologist whose work has investigated potential benefits of behavioral and mind-body modalities, with an emphasis on symptom management, for cancer survivors and adults with other chronic illnesses.

Julienne K Kirk, Wake Forest School of Medicine

Julienne K. Kirk, PharmD, CDE, is a Professor in the Department of Family and Community Medicine at Wake Forest Baptist Health. She is a Certified Diabetes Care and Education Specialist in the Department of Endocrinology. She has worked as a clinician, researcher and educator for the past 35 years. Her research focus includes patient adherence, minority health and chronic disease management. 

Mollie Rose Canzona, Wake Forest University

Mollie Rose Canzona, PhD, uses a lifespan developmental lens to examine how patient–provider communication and family relationships are tied to health behavior and outcomes. She conducts interdisciplinary, narrative-based, mixed-method research to inform behavioral interventions in a cancer prevention and control context. Her current research examines sexual and reproductive health, end of life care, health disparities and cancer caregiving. She is an Assistant Professor and Zachary T. Smith Faculty Fellow in the Department of Communication at Wake Forest University.

Heather L Black, Merck Sharp & Dohme Corp.

Heather L. Black, PhD, is the Director of Healthcare Quality Research within the Center for Observational Real-World Evidence (CORE) at Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. She studies human behavior in the context of the quality of healthcare delivery, medication adherence, navigating systems of care, health technology assessment and the impact of healthcare policies.

Sally A Shumaker, Wake Forest School of Medicine

Sally A. Shumaker, PhD, is a nationally and internationally recognized expert in clinical research. She is a tenured Professor in the Department of Social Sciences and Health Policy. Her primary areas of expertise include women’s health, behavioral science, health-related quality of life and the conducting of multicenter clinical trials.


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How to Cite

Cox, P., Mihalko, S. L., Danhauer, S. C., Kirk, J. K., Canzona, M. R., Black, H. L. ., & Shumaker, S. A. (2022). Exploration of the patient’s voice: Finding deeper meaning in the linguistic cues used by adults living with diabetes. Communication and Medicine, 17(3), 215–229. https://doi.org/10.1558/cam.18160