Doctors in a Southeast Asian country communicate sub-optimally regardless of patients' educational background

Empathy ability and influencing factors among pediatric residents in China: a mixed-methods study

BACKGROUND

Empathy is one of the fundamental factors enhancing the therapeutic effects of physician-patient relationships, but there has been no relevant research in China on the pediatric resident physicians' capacity for empathy or the influencing factors.

METHODS

A mixed-methods study was undertaken. The student version of the Jefferson Scale of Empathy was used to assess 181 postgraduate residents at Shanghai Children's Medical Center and Shanghai Children's Hospital. Differences in empathy ability among pediatric resident physicians of different genders and specialties were analyzed using independent sample t-tests and Mann-Whitney U tests. A one-way analysis of variance was used to analyze the differences in empathy ability at different educational levels and years of medical residency training. Seven third-year postgraduate pediatric residents from Shanghai Children's Medical Center participated in semi-structured interviews exploring the influencing factors. We analyzed the interview transcripts using thematic analysis.

RESULTS

The scale was completed by 154 pediatric residents. No statistically significant differences in empathy were found between educational level, postgraduate year, gender, or specialty. The factors influencing empathy in doctor-patient communication included the person who accompanied the child to see the doctor, how the children cooperated with doctors for medical treatment, the volume of pediatric outpatient and emergency visits, and the physician's ability to withstand pressure. All interviewed resident physicians regarded learning empathy as important but rarely spent extra time learning it.

CONCLUSIONS

The evaluation results of resident physicians on changes in empathy after improving clinical abilities vary according to their understanding of empathy, and the work environment has an important impact on pediatricians' empathy ability. Their empathy score is relatively low, and this requires exploration and intervention.

Bridging the Gap: Comparing Patient-Clinician Views on Treatment Goals and Communication in the Management of Atopic Dermatitis Within the Asia-Pacific Region

INTRODUCTION

It remains unclear how patients with atopic dermatitis (AD) and clinicians perceive the level of patient-clinician communication and if there could be potential lapses. This cross-sectional study aims to compare perspectives between patients with AD and dermatologists regarding communication and treatment expectations in Asia.

METHODS

Moderate-to-severe patients with AD and practicing dermatologists were recruited from eight Asia-Pacific territories, including Mainland China, Hong Kong, India, Japan, Singapore, South Korea, Taiwan, and Thailand. Patients and dermatologists completed separate surveys designed to elicit their expectations regarding AD management, and their perceived level of patient-clinician communication. Patients were also asked about their treatment satisfaction and whether they prefer additional treatment beyond what was prescribed. Demographic information and responses were analyzed using descriptive statistics. The study was reviewed by the institutional review board in each territory, and all participants provided informed consent.

RESULTS

A total of 1103 patients and 271 dermatologists completed the surveys. Both patients and dermatologists were largely aligned in their top treatment goals in AD management. However, greater proportions of patients prioritized the prevention of exacerbation (78.0% versus 47.2%), minimization of treatment adverse effects (46.4% versus 9.1%), and improvement in mental health (16.0% versus 4.9%), compared with dermatologists. Although patient-clinician communication was observed to be generally good, 10.9% of patients reported dissatisfaction with communication in AD management. The majority of patients were either "very satisfied" or "satisfied" with their latest acute AD treatment, but 65.5% of patients still desired additional treatment.

CONCLUSIONS

This multinational study has provided insights on the perspectives of Asian patients and dermatologists in treatment goals, AD management, and communication. In general, both patients and dermatologists were aligned in treatment goals and there was satisfactory patient-clinician communication in most aspects. However, potential areas of improvement have been identified to further enhance patient-centered care.

Hospitalised patients as stewards of their own antibiotic therapy: a qualitative analysis informing the strategic design of interventions to encourage shared decision-making in tertiary hospital settings in Singapore

Background

Shared decision-making (SDM) on antibiotic therapy may improve antibiotic use in tertiary hospitals, but hospitalised patients are apprehensive about being involved in it. Understanding the facilitators and barriers to SDM can inform the design and implementation of interventions to empower these patients to engage in SDM on their antibiotic therapies.

Methods

We conducted qualitative interviews with 23 adult patients purposively sampled with maximum variation from the three largest tertiary-care hospitals in Singapore (April 2019─October 2020). Thematic analysis was conducted using the Theoretical Domains Framework and Capability, Opportunity, Motivation, Behaviour (COM-B) model to identify areas for intervention.

Results

Hospitalised patients lacked comprehensive knowledge of their antibiotic therapies and the majority did not have the skills to actively query their doctors about them. There was a lack of opportunities to meet and interact with doctors, and patients were less motivated to engage in SDM if they had a self-perceived paternalistic relationship with doctors, trusted their doctors to provide the best treatment, and had self-perceived poor knowledge to engage in SDM. To empower these patients, they should first be educated with antibiotic knowledge. Highlighting potential side effects of antibiotics could motivate them to ask questions about their antibiotic therapies. Environment restructuring, as facilitated by nurses and visual cues to nudge conversations, could create opportunities for interactions and motivating patients into SDM on their antibiotic therapies.

Conclusion

Education and environmental restructuring should be explored to empower hospitalised patients to engage in SDM on their antibiotic therapies.

Rising caesarean section rates and factors affecting women's decision-making about mode of birth in Indonesia: a longitudinal qualitative study

INTRODUCTION

Caesarean section (CS) rates in Indonesia are increasing rapidly. Understanding women's preferences about mode of birth is important to help contextualise these rising rates and can help develop interventions to optimise CS. This study aimed to explore Indonesian women's preferences and decision-making about mode of birth, and how their preferences may change throughout pregnancy and birth.

METHODS

We conducted a longitudinal qualitative study using in-depth interviews with 28 women accessing private and public health facilities in Jakarta, the region with the highest CS rates. Interviews were conducted two times: during the woman's third trimester of pregnancy and in the postpartum period, between October 2022 and March 2023. We used a reflexive thematic approach for analysis.

RESULTS

We generated three themes: (1) preferences about the mode of birth, (2) decision-making about the mode of birth and (3) regrets about the actual mode of birth. Most women preferred vaginal birth. However, they were influenced by advertisements promoting enhanced recovery after CS (ERACS) as an 'advanced technique' of CS, promising a comfortable, painless and faster recovery birth. This messaging influenced women to perceive CS as equivalent or even superior to vaginal birth. Where women's preferences for mode of birth shifted around the time of birth, this was primarily due to the obstetricians' discretion. Women felt they did not receive adequate information from obstetricians on the benefits and risks of CS and vaginal birth and felt disappointed when their actual mode of birth was not aligned with their preferences.

CONCLUSION

Our study shows that despite rising CS rates, Indonesian women prefer vaginal birth. This highlights the need for better communication strategies and evidence-based information from healthcare providers. Given the rising popularity of ERACS, more work is urgently needed to standardise and regulate its use.

Evaluating a pilot community-based self-management program for adults with spinal cord injury

OBJECTIVE

To evaluate outcomes and perceptions of participating in a pilot spinal cord injury (SCI) specific community-based self-management program.

DESIGN

A program evaluation conducted through the review of retrospective data.

SETTING

An outpatient vocational rehabilitation service in Singapore.

PARTICIPANTS

Adults with SCI who completed a self-management intervention.

INTERVENTION

A self-management educational program was delivered by healthcare professionals with involvement of peer mentors. Up to six self-selected topics were covered using a multi-modal teaching approach.

OUTCOME MEASURES

Retrospective data collected at baseline, post-intervention, and three-month follow-up were analyzed. Outcome measures included the University of Washington Self-Efficacy scale (UW-SES), SCI Secondary Conditions Scale (SCI-SCS), Community Integration Questionnaire (CIQ), and employment. Post-program survey findings were also reviewed.

RESULTS

Data from fifteen participants revealed positive changes over time for the UW-SES (η² = .27), SCI-SCS (η² = .21), and CIQ (η² = .23). Self-efficacy scores increased from baseline to post-intervention with a large effect size (Hedge's g = 0.89), and from baseline to follow-up with a medium effect size (Hedge's g = 0.50). Participants reported overall perceived benefit and satisfaction with the program's design and relevance. They valued access to useful information, effective instructional methods, program customization, and participant empowerment and affirmation. Suggestions for program refinement included: more peer support, psycho-emotional support, and continued program adaptability and accessibility.

CONCLUSION

A SCI-specific community-based self-management program was associated with short-term improvements in self-efficacy and was well-received. Further research is required to determine its effectiveness, essential program features that promote successful outcomes, and cost-effectiveness of program implementation.

Qualitative study on barriers and coping strategies for dental care in autistic children: Parents' perspective

BACKGROUND

Children with autism spectrum disorders (ASD) face challenges in home oral care, accessing a dentist and accepting dental treatment.

AIM

To determine the barriers to dental care for autistic children in Singapore through the experiences and opinions of their parents.

DESIGN

A qualitative exploratory approach comprising semistructured interviews and a focus group discussion was used. Audio recordings were transcribed and coded into themes using NVivo 12 software.

RESULTS

Participants were 23 parents of autistic children aged 3-12 years. The following barriers were identified: (1) Sensory, physical and parental knowledge issues are related to toothbrushing difficulties and use of nonoptimally fluoridated toothpaste in autistic children. (2) Accessing dental services was hindered by a lack of parental knowledge on the importance of an early dental home, parental apprehension about the child's acceptance of dental care, lack of information on specialised dentists and perceived high cost of dental visits. Parental suggestions for improvements included understanding the child's sensory profile, more information on finding a suitable dentist and subsidisation of costs for multiple acclimatisation visits.

CONCLUSION

Caregivers' education, information about specialised dentists and the availability of specific dental care resources for autistic children in Singapore are needed for optimising their dental care.

Development and validation of the Adult cirrhosiS Knowledge Questionnaire

BACKGROUND

Assessing a patient's knowledge regarding liver cirrhosis is important to improve patient outcomes. This study aimed to develop and validate the Adult cirrhosiS Knowledge Questionnaire (ASK-Q) to assess patients' knowledge regarding liver cirrhosis from multiple aspects.

METHODS

A 24-item ASK-Q with four domains: self-understanding (5 items), aetiology (5 items), complications (5 items) and management (9 items) of liver cirrhosis was developed based on literature review and expert panel input. It was then piloted in five English-speaking patients with liver cirrhosis. These patients commented that the font size was too small. Hence, the font was enlarged and the final version of the ASK-Q was administered to English-speaking patients with liver cirrhosis, aged ≥18 years, with or without decompensation, at a tertiary hospital, from September 2020 to November 2021, at baseline and fortnight later. Patients with encephalopathy were excluded.

RESULTS

120/135 patients agreed to participate (response rate = 88.9%). The overall median score was 59.1 (45.6-68.2). A total of 7/22 (31.8%) items were "easy", 14/22 (63.6%) items were "moderately easy" and 1/22 (4.5%) items were "difficult". Exploratory factor analysis extracted nine factors, and two items were omitted. The ASK-Q was able to discriminate the knowledge level of patients with and without tertiary education [59.1 (50.0-72.7) vs. 54.5 (36.4-63.6); P < 0.05]. The overall Kuder-Richardson coefficient was 0.760, indicating adequate internal consistency. At retest, 77/120 patients participated (response rate = 64.2%) and 15/22 items were not statistically significant, indicating adequate reliability.

CONCLUSIONS

The ASK-Q was found to be a valid and reliable questionnaire for evaluating the knowledge of liver cirrhosis among English-speaking adult patients.

The interactional communication of feedback in clinical education: A focused ethnographic study in a hierarchical and collectivist culture

Background

The definition of feedback in clinical education has shifted from information delivery to student-teacher dialogue. However, based on Hofstede's theory, countries with large power distance or a robust social hierarchy and collectivistic cultural dimensions can reduce the feedback dialogue to a minimum. Indonesia is classified in this group, with some Asian, African, Mediterranean, and Latin American countries. This study explores the interactional communication of feedback during clinical education in a hierarchical and collectivistic context.

Methods

The focused ethnographic approach was applied to the clinical rotation program in an Indonesian teaching hospital. Data sources included observations of feedback episodes during workplace-based assessments followed by interviews with clinical supervisors and students. The data were compiled within 16 weeks of observation in 7 groups of clinical departments, consisting of 28 field notes, audiotaped interviews including nine focus group discussions of students (N = 42), and seven in-depth interviews with clinical supervisors. Data were analyzed through transcription, coding, categorization, and thematic analysis using the symbolic interactionist perspective.

Results

We identified four themes representing actual interactional communication and its 'meaning' or interpretation. The interactional communication in feedback is described in the first and second themes, such as 1) Students play the subordinate roles in a feedback dialogue; 2) The feedback content is focused on explanation and students' limitations. The third and fourth themes represent the clinical supervisors' and students' interpretation of their feedback experience, such as 3) Clinical supervisors' perspectives are mostly on dissatisfaction and teaching authority; 4) Students' acceptance of reality and negative affection.

Conclusions

This study shows that the social gap between students and clinical supervisors in Indonesia, and other countries in the same cultural classification, potentially causes communication barriers in the feedback dialogue. The adaptation of 'feedback as a dialogue' requires further effort and research to develop communication strategies in feedback that consider the national culture and context.

An exploratory study of communication training for Chinese medicine practitioners in Hong Kong to integrate patients' conventional medical history

BACKGROUND

Despite Traditional Chinese medicine's (TCM) historical roles in Chinese society, few research has been investigated the nature of TCM practitioner-patient interactions. Improved communication skills among TCM practitioners will result higher-quality interactions and better clinical outcomes.

METHODS

To investigate the changes in TCM practitioners' communication practices after communications training focused on promoting their awareness of integrating a patient's medical history from conventional medicine in TCM treatment, Eight registered Cantonese-speaking TCM practitioners in Hong Kong were randomly recruited from local clinics and randomised into control (n = 12) and experimental groups (n = 12), with a total of 24 consultations. The experimental group was given training focused on patient-centred communication, with an internationally recognised and communication framework validated in global consultation settings (i.e. the Calgary-Cambridge Guide) on how to take a patient's medical history from conventional medicine and communicate diagnosis and treatment plans. Consultations before and after training were audio-recorded and rated. The efficacy of the training was evaluated by comparing the two groups before training (pre-test), immediately after training (post-test) and after a 3-month delay (delayed post-test). Using validated scales, the primary outcomes were measured for the practitioners' clinical communication skills and the quality of interactions.

RESULTS

The communication training significantly improved the TCM providers' patient-centred communication and communication proficiency. The results indicate that the team developed an effective communication model for integrating TCM and conventional medicine in Hong Kong. The framework helps trained TCM practitioners to integrate their patients' conventional medical history when delivering patient care. The findings shed light on how interpersonal relationships between TCM practitioners and patients can be constructed after communication training to better care for patients' psychological concerns in addition to their physical needs.

CONCLUSION

Trained TCM practitioners can provide an integrated model that takes patients' conventional medical history into account when delivering a holistic patient-centred care. The findings can enhance our understanding of better ways to train the future TCM practitioners and to develop a continuing professional training for the current TCM practitioners to expand our understanding of TCM communication in acute clinical contexts and, thus offer a firm evidence-based foundation upon which to develop communication strategies that improve their clinical cpractices.

Quality of life in atopic dermatitis in Asian countries: a systematic review

Atopic dermatitis (AD) is a common chronic inflammatory skin condition which impacts psychological wellbeing and social relationships. There have been studies of AD's impact on quality of life (QoL) in Western countries, but these findings cannot be directly extrapolated to Asian populations with genetic, environmental and cultural differences. Therefore, we aimed to systematically review the literature pertaining to QoL impairment in AD in East and Southeast Asia to characterize the impact of AD on patients and their families, and to identify the factors affecting the degree of QoL impairment. A search of English language papers was conducted on MEDLINE, EMBASE, PSYCInfo, Global Health and Web of Science. Observational studies measuring QoL using single or multi-item instruments in people with self-reported or physician diagnosed atopic dermatitis were included. 27 studies from 29 articles were included and synthesized. There is data documenting QoL impairment in AD sufferers and their families, across a wide range of Asian countries, healthcare settings and ages. Aspects of QoL impacted to a greater extent included symptoms of itch, feelings of embarrassment, and sleep disturbance. Severity of disease affects the degree of impairment of QoL, but there is no apparent link between QoL impairment and patient demographic factors, or other medical factors such as age at diagnosis or duration of illness. Our findings also highlighted the need for clinicians to actively explore the impact of patient's symptoms, especially in an Asian context where healthcare communications are traditionally doctor-centric.

Experience of Indonesian medical students of ethical issues during their clinical clerkship in a rural setting

Although ethics is an essential part of medical education, little attention has been paid to ethics education during the clerkship phase, where medical students observe how physicians make decisions regarding various ethical problems. Specific nuances and cultural contexts such as working in a rural setting can determine ethical issues raised. This phenomenology study aimed to explore ethical issues experienced by Indonesian students during clinical clerkship in a rural setting. In-depth interviews were used to explore students’ experiences. Participants were ten students, selected on gender and clerkship year variations. Data saturation was reached after eight interviews, followed by two additional interviews. Thematic analysis was used in this study, and trustworthiness was ensured through data and investigator triangulation, member checking, and audit trail.

Three main themes found in this study were limited facilities and resources, healthcare financing and consent issues, as well as unprofessional behavior of healthcare providers. Many ethical issues related to substandard care were associated to limited resources and complexities within the healthcare system in the rural setting. Early exposure to recurrent ethical problems in healthcare can help students prepare for their future career as a physician in a rural setting.

Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial

BACKGROUND AND PURPOSE

Health-Related Quality of Life (HR-QOL) is an important patient-reported domain in patients with rheumatoid arthritis (RA). The uptake of multidisciplinary team (MDT) care in RA is generally low, due to initial high demand for resources. We hypothesised that whilst pharmacological treatments are effective in controlling disease activity, a multipronged intervention in an MDT may have a positive impact on HR-QOL.

METHODS

This was a single-centre randomized parallel group, single-blind controlled trial of MDT vs. usual care in an established RA clinic. Data were collected through face-to-face questionnaires, medical records review, and joint counts by a blinded assessor at 0, 3 and 6 months. Adult RA patients were randomly assigned in a single visit to a 6-member MDT (rheumatologist, nurse, social worker, physiotherapist, occupational therapist, and podiatrist) or usual care. MDT providers prescribed medications and counselled patients on managing flares, medication adherence, coping, joint protection, exercise, footwear. The primary outcome was minimal clinically important difference (MCID) in HR-QOL (increase in European QOL-5-Dimension-3-Level, EQ-5D-3L by 0.1) at six months.

RESULTS

140 patients (86.3% female, 53.4% Chinese, median (IQR) age 56.6 (46.7, 62.4) years); 70 were randomized to each arm. Median (IQR) disease duration was 5.5 (2.4, 11.0) years and disease activity in 28 joints (DAS28) was 2.87 (2.08, 3.66). 123 patients completed the study. Twenty-six (40.6%) MDT vs. 23 (34.3%) usual care patients achieved an MCID in EQ-5D-3L, OR 1.3 (0.6, 2.7). In multivariable logistic regression, baseline EQ-5D-3L was the only predictor of achieving MCID. There was more disease modifying anti-rheumatic drug escalation in MDT (34.4% vs. 19.4%). Patients with high disease activity were more likely to achieve MCID in the MDT arm.

CONCLUSIONS

A single visit by stable patients with low disease activity to an MDT failed to achieve MCID in the EQ-5D-3L; however, did achieve small but significant improvements in the EQ-5D-3L, DAS28, pain, coping and self-efficacy. To be sustainable, MDT care should be targeted at patients with high disease activity or those with a new diagnosis of RA.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov, identifier: NCT03099668.

Physician-patient communication in decision-making about Caesarean sections in eight district hospitals in Bangladesh: a mixed-method study

Background

Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation.

Methods

We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis.

Results

In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication.

Conclusions

Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

My health, myself: a qualitative study on motivations for effective chronic disease self-management among community dwelling adults

BACKGROUND

Chronic diseases continue to be a significant cause of morbidity and mortality despite modifiable risk factors. This suggests that current primary healthcare provision needs to delve beyond patient education, to understand the motivators that drive patients to undertake chronic disease self-management. Understanding these motivations within the context of a multi-cultural community can facilitate tailored support for chronic disease self-management.

OBJECTIVES

To explore the motivations behind effective chronic disease self-management in community dwelling adults in Singapore.

METHODS

A qualitative descriptive study was carried out in five clinics in a large medical centre. Twelve participants who were assessed to be optimally managing their chronic diseases were recruited using purposive sampling. Individual in-depth interviews were conducted until data saturation, with data thematically analysed.

RESULTS

Three salient themes emerged from the data. Firstly, 'Regaining self-control, avoiding complications' describes the participants' journey towards personal mastery in self-management, as well as a fear of debilitating complications resulting in their desire for good health. Secondly, 'Preserving social identities and roles' illustrates how participants yearn to maintain their pre-existing roles and functions through maintenance of their health. Finally, 'Accessing proximal support systems' highlights resources and supports surrounding the participants that encourage continued chronic disease self-management. Within each theme, specific motivators and challenges encountered by participants in their self-management journey were discussed.

CONCLUSIONS

Findings can prompt primary healthcare providers to leverage on the patients' life goals and social roles in chronic disease self-management support. This may empower patients to engage in self-management and strengthen primary care provision.

Exploring the dimensions of patient experience for community-based care programmes in a multi-ethnic Asian context

Introduction

The aim of this study is to explore patients’ experiences with community-based care programmes (CCPs) and develop dimensions of patient experience salient to community-based care in Singapore. Most countries like Singapore are transforming its healthcare system from a hospital-centric model to a person-centered community-based care model to better manage the increasing chronic disease burden resulting from an ageing population. It is thus critical to understand the impact of hospital to community transitions from the patients’ perspective. The exploration of patient experience will guide the development of an instrument for the evaluation of CCPs for quality improvement purposes.

Methods

A qualitative exploratory study was conducted where face-to-face in-depth interviews were conducted using a purposive sampling method with patients enrolled in CCPs. In total, 64 participants aged between 41 to 94 years were recruited. A deductive framework was developed using the Picker Patient Experience instrument to guide our analysis. Inductive coding was also conducted which resulted in emergence of new themes.

Results

Our findings highlighted eight key themes of patient experience: i) ensuring care continuity, ii) involvement of family, iii) access to emotional support, vi) ensuring physical comfort, v) coordination of services between providers, vi) providing patient education, vii) importance of respect for patients, and viii) healthcare financing.

Conclusion

Our results demonstrated that patient experience is multi-faceted, and dimensions of patient experience vary according to healthcare settings. As most patient experience frameworks were developed based on a single care setting in western populations, our findings can inform the development of a culturally relevant instrument to measure patient experience of community-based care for a multi-ethnic Asian context.

Key factors influencing the prescribing of statins: a qualitative study among physicians working in primary healthcare facilities in Indonesia

OBJECTIVES

To elicit key factors influencing physicians' decision to prescribe statins.

DESIGN

A qualitative study using a phenomenological approach within a pragmatism interpretive framework. A combination of purposive and snowball sampling was used to recruit physicians. Data were collected through face-to-face, semistructured interviews with physicians working in primary healthcare facilities in a capital of a province in Indonesia. We recorded and verbatim transcribed the interviews. Coding was done independently by two researchers and data were analysed using phenomenological data analyses. Key factors influencing physicians' decision to prescribe statins were classified into factors at the microlevels, mesolevels and macrolevels according to the structural model by Scoggins et al. PARTICIPANTS AND SETTING: Physicians working in primary healthcare facilities in a capital of a province in Indonesia.

RESULTS

Ten physicians were included in the study. Key factors at the microlevel were that physicians knew guidelines in general, but there was uncertainty how to take into account the level of total cholesterol in combination with other cardiovascular risk factors such as diabetes and hypertension. At the macrolevel, the new National Health Insurance System (NHIS) that appeared to facilitate the prescription of statins though more clinical information should be integrated in the system's platform to support appropriate prescribing.

CONCLUSIONS

The findings indicate lack of awareness of specific details in current guideline recommendations. Appropriate prescribing of statins should be enhanced using the new NHIS.

The role of pharmacists in the pharmaceutical care of asthma patients in Yogyakarta, Indonesia: the patients' views

Introduction: Community pharmacists are one of the most frequently accessed health professionals who can be involved in the provision of ongoing asthma management within the primary care setting. The aim of this study was to identify patients' views regarding current asthma care provided by their pharmacists and their perspectives on future pharmacy-based asthma services.Methods: This is a qualitative approach with an interview guide. Asthma patients were purposively selected. Interviews were conducted from April to June 2017. Patient's opinions about asthma and its management and their experiences regarding asthma care provided by pharmacists were collected. Data were analyzed using content analysis.Results: Thirty-three interviews were conducted. Asthma literacy was low. There was dis-engagement with the health care system, with only a few participants trusting conventional health care professionals. Alternative medicine systems and practitioners were better trusted and participants had strong preferences for family/peer involvement in their asthma care. Participants also had misunderstandings regarding their asthma disease and medications. Participants had experienced little pharmaceutical care provided by pharmacists but would welcome it in the future.Conclusion: Given the accessibility of community pharmacy venues and readiness of the profession for more involved care of chronic disease patients, it may be recommended that Indonesian community pharmacists should adopt the provision of pharmaceutical care models for asthma. Such pharmaceutical care models need to incorporate patients' unique sociocultural health beliefs, preferences for alternative medicines and family/social peer involvement as well as stronger collaboration between pharmacists and physicians.

The social determinants of chronic disease management: perspectives of elderly patients with hypertension from low socio-economic background in Singapore

Background

In Singapore, the burden of hypertension disproportionately falls on the elderly population of low socio-economic status. Despite availability of effective treatment, studies have shown high prevalence of sub-optimal blood pressure control in this group. Poor hypertension management can be attributed to a number of personal factors including awareness, management skills and overall adherence to treatment. However, these factors are also closely linked to a broader range of community and policy factors. This paper explores the perceived social and physical environments of low socio-economic status and elderly patients with hypertension; and how the interplay of factors within these environments influences their ability to mobilise resources for hypertension management.

Methods

In-depth interviews were conducted in English, Chinese, Chinese dialects and Malay with 20 hypertensive patients of various ethnic backgrounds. Purposive sampling was adopted for recruitment of participants from a previous community health screening campaign. Interviews were translated into English and transcribed verbatim. We deductively analysed leveraging on the Social Model of Health to identify key themes, while inductive analysis was used simultaneously to allow sub-themes to emerge.

Results and discussion

Our finding shows that financing is an overarching topic embedded in most themes. Despite the availability of multiple safety nets, some patients were left out and lacked capital to navigate systems effectively, which resulted in delayed treatment or debt. The built environment played a significant role in enabling patients to access care easily and lead a more active lifestyle. A closer look is needed to enhance the capacity of patients with mobility challenges to enjoy equitable access. Furthermore, the establishment of community based elderly centres has enabled patients to engage in meaningful and healthy social activities. In contrast, participants’ descriptions showed that their communication with healthcare professionals remained brief, and that personalised and meaningful interactions that are context and culturally specific are essential to advocate for patients’ overall treatment adherence and lifestyle modification.

Conclusion

Elderly patients with hypertension from lower socio-economic background have various unmet needs in managing their hypertension and other comorbidities. These needs are closely related to broader societal factors such as socio-demographic characteristics, support systems, urban planning and public policies, and health systems factors. Policy decisions to address these needs require an integrated multi-sectoral approach grounded in the principles of health equity.

Patient-centered communication of community treatment assistants in Tanzania predicts coverage of future mass drug administration for trachoma

OBJECTIVE

Prevention of Trachoma, the leading cause of infectious blindness, requires community treatment assistants (CTAs) to perform mass drug administration (MDA) of azithromycin. Previous research has shown that female CTAs have higher MDA coverage, but no studies have focused on the content of conversation. We hypothesize that female CTAs had more patient-centered communication and higher MDA coverage.

METHODS

In 2011, CTAs from 23 distribution sites undergoing MDA as part of the Partnership for Rapid Elimination of Trachoma were selected. CTA - villager interactions were audio recorded. Audio was analyzed using an adaptation of the Roter Interaction Analysis System. The outcome of interest was the proportion of adults receiving MDA in 2011 who returned in 2012.

RESULTS

58 CTAs and 3122 interactions were included. Sites with female CTAs had significantly higher patient-centeredness ratio (0.548 vs 0.400) when compared to sites with male CTAs. Sites with more patient-centered interactions had higher proportion of patients return (p = 0.009).

CONCLUSION

Female CTAs had higher proportion of patient-centered communication. Patient centered communication was associated with higher rates of return for MDA.

PRACTICE IMPLICATIONS

Greater patient-centered connection with health care providers affects participation in public health efforts, even when those providers are lay health workers.

Strategies for enhancing medical student resilience: student and faculty member perspectives

OBJECTIVES

To improve programs aimed to enhance medical student resiliency, we examined both medical student and faculty advisor perspectives on resiliency-building in an Asian medical school.

METHODS

In two separate focus groups, a convenience sample of 8 MD-PhD students and 8 faculty advisors were asked to identify strategies for enhancing resilience. Using thematic analysis, two researchers independently examined discussion transcripts and field notes and determined themes through a consensus process. They then compared the themes to discern similarities and differences between these groups.

RESULTS

Themes from the student suggestions for increasing resilience included "Perspective changes with time and experience", "Defining effective advisors," and "Individual paths to resiliency". Faculty-identified themes were "Structured activities to change student perspectives," "Structured teaching of coping strategies", and "Institution-wide social support". Students described themselves as individuals building their own resilience path and preferred advisors who were not also evaluators. Faculty, however, suggested systematic, structural ways to increase resilience.

CONCLUSIONS

Students and advisors identified some common, and many distinct strategies for enhancing medical student resilience. Student/advisor discrepancies may exemplify a cultural shift in Singapore's medical education climate, where students value increased individualism and autonomy in their education. As medical schools create interventions to enhance resilience and combat potential student burnout, they should consider individually-tailored as well as system-wide programs to best meet the needs of their students and faculty.

Preparatory graduate professional training in general practice by using the 'experiential learning' framework

BACKGROUND

General practitioners (GPs) in Indonesia are medical doctors without formal graduate professional training. Only recently, graduate general practice (GP) is being introduced to Indonesia. Therefore, it is important to provide a framework to prepare a residency training in general practice part of which is to equip GP graduate doctors to deliver person-centered, comprehensive care in general practice. Experiential learning theory is often used to design workplace-based learning in medical education. The aim of this study was to evaluate a graduate professional training program in general practice based on the 'experiential learning' framework.

METHODS

This was a pre-posttest study. The participants were 159 GPs who have been practicing for a minimum of 5 years, without formal graduate professional training, from two urban cities of Indonesia (Yogyakarta and Jakarta). A 40-week curriculum called the 'weekly clinical updates on primary care medicine' (WCU) was designed, where GPs met with clinical consultants weekly in a class. The participant's knowledge was assessed with pre-posttests involving 100 written clinical cases in line with each topic in the curriculum. Learning continued with a series of group discussions to gain reflection to reinforce learning.

RESULTS

Participants' knowledge regarding clinical problems in general practice was moderately increased (p < 0.05) after the training from a mean score of 50.64-72.77 (Yogyakarta's doctors) and 39.37-51.81 (Jakarta's doctors). Participants were able to reflect on the principles of general practice patient-care. Participants reported satisfaction during the course, and expressed a desire for a formal residency training.

CONCLUSIONS

A graduate educational framework for GP based on the 'experiential learning' framework in this study could be used to prepare a graduate GP training; it is effective at increasing the comprehension of general practitioners towards better primary care practice.

Clinical empathy in medical students in India measured using the Jefferson Scale of Empathy-Student Version

PURPOSE

The purpose of this study was to assess the clinical empathy of a cohort of medical students spanning 4 years of undergraduate study and to identify factors associated with empathy.

METHODS

A cross-sectional study to assess the empathy of undergraduate medical students at the University College of Medical Sciences and GTB Hospital in Delhi, India, was conducted using the Jefferson Scale of Empathy-Student Version. Demographic data were obtained using a pre-tested, semi-open-ended questionnaire.

RESULTS

Of the 600 students, 418 participated in the survey (69.7%). The mean empathy score was 96.01 (of a maximum of 140), with a standard deviation of 14.56. The empathy scores decreased from the first to the third semester, plateaued at the fifth semester, and rose again in the seventh semester. Empathy was found to be significantly associated with the gender of the participant, with females having higher scores (P<0.001). The age of the participant, place of residence, whose decision it was for the student to enroll in an MBBS (bachelor of medicine and bachelor of surgery) program, and the choice of future specialty were not significantly associated with students' empathy scores.

CONCLUSION

The study found significant gender differences in empathy among the participants. The empathy scores tended to decline initially and then rebound over time. The mean empathy levels found in this study are lower than those reported in most similar studies around the world; therefore, further studies are needed to analyze and address the underlying factors associated with this discrepancy.

To Share or Not to Share: Malaysian Healthcare Professionals' Views on Localized Prostate Cancer Treatment Decision Making Roles

Aim

To explore the views of Malaysian healthcare professionals (HCPs) on stakeholders’ decision making roles in localized prostate cancer (PCa) treatment.

Methods

Qualitative interviews and focus groups were conducted with HCPs treating PCa. Data was analysed using a thematic approach. Four in-depth interviews and three focus group discussions were conducted between December 2012 and March 2013 using a topic guide. Interviews were audio-recorded, transcribed verbatim, and analysed thematically.

Findings

The participants comprised private urologists (n = 4), government urologists (n = 6), urology trainees (n = 6), government policy maker (n = 1) and oncologists (n = 3). HCP perceptions of the roles of the three parties involved (HCPs, patients, family) included: HCP as the main decision maker, HCP as a guide to patients’ decision making, HCP as a facilitator to family involvement, patients as main decision maker and patient prefers HCP to decide. HCPs preferred to share the decision with patients due to equipoise between prostate treatment options. Family culture was important as family members often decided on the patient’s treatment due to Malaysia’s close-knit family culture.

Conclusions

A range of decision making roles were reported by HCPs. It is thus important that stakeholder roles are clarified during PCa treatment decisions. HCPs need to cultivate an awareness of sociocultural norms and family dynamics when supporting non-Western patients in making decisions about PCa.

How do trained raters take context factors into account when assessing GP trainee communication performance? An exploratory, qualitative study

Communication assessment in real-life consultations is a complex task. Generic assessment instruments help but may also have disadvantages. The generic nature of the skills being assessed does not provide indications for context-specific behaviour required in practice situations; context influences are mostly taken into account implicitly. Our research questions are: 1. What factors do trained raters observe when rating workplace communication? 2. How do they take context factors into account when rating communication performance with a generic rating instrument? Nineteen general practitioners (GPs), trained in communication assessment with a generic rating instrument (the MAAS-Global), participated in a think-aloud protocol reflecting concurrent thought processes while assessing videotaped real-life consultations. They were subsequently interviewed to answer questions explicitly asking them to comment on the influence of predefined contextual factors on the assessment process. Results from both data sources were analysed. We used a grounded theory approach to untangle the influence of context factors on GP communication and on communication assessment. Both from the think-aloud procedure and from the interviews we identified various context factors influencing communication, which were categorised into doctor-related (17), patient-related (13), consultation-related (18), and education-related factors (18). Participants had different views and practices on how to incorporate context factors into the GP(-trainee) communication assessment. Raters acknowledge that context factors may affect communication in GP consultations, but struggle with how to take contextual influences into account when assessing communication performance in an educational context. To assess practice situations, raters need extra guidance on how to handle specific contextual factors.

Improving communication skills in the Southeast Asian health care context

The aim of these two PhD thesis are to develop a guideline on doctor-patient communication skills based on cultural characteristics of Southeast Asian context and to develop communication skills training for nurses to enhance their contribution to the informed consent and shared decision making process, in the same context. These studies started with qualitative methods; including grounded theory methodology, by exploring doctors', patients', medical students' and nurses' perceptions on the current and desired communication skills in which influenced by culture. Based on the results, we design communication skills training and evaluate the training with quantitative methods, using pre and post test studies. Southeast Asian desired ideal partnership style in communicating with their doctors. More emphasize on basic skills such as listening to subtle non-verbal cues are needed for doctors and nurses. A guideline on doctor-patient communication tailored to local culture was developed as well as training for nurses using 4CID design to enhance their contribution to the shared decision making process. To promote two-way interaction between doctors and patients and between health professionals require mastering basic skills in communicating with people, such as explorations on the unspoken concern. In a culturally hierarchical context of Indonesia, this two-way interaction is quite a challenge. To generalize our studies to other culture, more studies with rigorous methods should follow. To promote the use of basic skills in communicating with patients to approach the desired partnership communication style in Southeast Asian context, we need to use local evidences.

Gender and performance of community treatment assistants in Tanzania

OBJECTIVE

To examine the effects of gender and demographics of community treatment assistants (CTAs) on their performance of assigned tasks and quantity of speech during mass drug administration of azithromycin for trachoma in rural Tanzania.

DESIGN

Surveys of CTAs and audio recordings of interactions between CTAs and villagers during drug distribution.

SETTING

Mass drug administration program in rural Kongwa district.

PARTICIPANTS

Fifty-seven randomly selected CTAs, and 3122 residents of villages receiving azithromycin as part of the Kongwa Trachoma Project.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Speech quantity graded by Roter interaction analysis system, presence of culturally appropriate greeting and education on facial hygiene for trachoma prevention from coded analysis of audio-recorded interactions.

RESULTS

At sites with all female CTAs, each CTA spent more time and spoke more in each interaction in comparison with CTAs at sites with only male CTAs and CTAs at 'mixed gender' sites (sites with both male and female CTAs). At 'mixed gender' sites, males spoke significantly more than females. Female CTAs mentioned trachoma prevention with facial cleanliness more than twice as often as male CTAs; however, both genders mentioned hygiene in <10% of interactions. Both genders had culturally appropriate greetings in <25% of interactions.

CONCLUSIONS

Gender dynamics affect the amount of time that CTAs spend with villagers during drug distribution, and the relative amount of speech when both genders work together. Both genders are not meeting expectations for trachoma prevention education and greeting villagers, and novel training methods are necessary.

Doctor-patient communication in Southeast Asia: a different culture?

Studies of doctor-patient communication generally advocate a partnership communication style. However, in Southeast Asian settings, we often see a more one-way style with little input from the patient. We investigated factors underlying the use of a one-way consultation style by doctors in a Southeast Asian setting. We conducted a qualitative study based on principles of grounded theory. Twenty residents and specialists and 20 patients of a low or high educational level were interviewed in internal medicine outpatient clinics of an Indonesian teaching hospital and two affiliated hospitals. During 26 weeks we engaged in an iterative interview and coding process to identify emergent factors. Patients were generally dissatisfied with doctors' communication style. The doctors indicated that they did not deliberately use a one-way style. Communication style appeared to be associated with characteristics of Southeast Asian culture, the health care setting and medical education. Doctor-patient communication appeared to be affected by cultural characteristics which fell into two broad categories representing key features of Southeast Asian culture, "social distance" and "closeness of relationships", and to characteristics categorized as "specific clinical context". Consideration of these characteristics could be helpful in promoting the use of a partnership communication style.

Are patient-centered care values as reflected in teaching scenarios really being taught when implemented by teaching faculty? A discourse analysis on an Indonesian medical school's curriculum

BACKGROUND

According to The Indonesian Medical Council, 2006, Indonesian competence-based medical curriculum should be oriented towards family medicine. We aimed to find out if the educational goal of patient-centered care within family medicine (comprehensive care and continuous care) were adequately transferred from the expected curriculum to implemented curriculum and teaching process.

METHODS

Discourse analysis was done by 3 general practitioners of scenarios and learning objectives of an Indonesian undergraduate medical curriculum. The coders categorized those sentences into two groups: met or unmet the educational goal of patient-centered care.

RESULTS

Text analysis showed gaps in patient-centered care training between the scenarios and the learning objectives which were developed by both curriculum committee and the block planning groups and the way in which the material was taught. Most sentences in the scenarios were more relevant to patient-centered care while most sentences in the learning objectives were more inclined towards disease-perspectives.

CONCLUSIONS

There is currently a discrepancy between expected patient-centered care values in the scenario and instructional materials that are being used.