Power imbalance and consumerism in the doctor-patient relationship: health care providers' experiences of patient encounters in a rural district in India

How power shapes behavior: Evidence from physicians

Power-the asymmetric control of valued resources-affects most human interactions. Although power is challenging to study with real-world data, a distinctive dataset allowed us to do so within the critical context of doctor-patient relationships. Using 1.5 million quasi-random assignments in US military emergency departments, we examined how power differentials between doctor and patient (measured by using differences in military ranks) affect physician behavior. Our findings indicate that power confers nontrivial advantages: "High-power" patients (who outrank their physician) receive more resources and have better outcomes than equivalently ranked "low-power" patients. Patient promotions even increase physician effort. Furthermore, low-power patients suffer if their physician concurrently cares for a high-power patient. Doctor-patient concordance on race and sex also matters. Overall, power-driven variation in behavior can harm the most vulnerable populations in health care settings.

On power and its corrupting effects: the effects of power on human behavior and the limits of accountability systems

Power is an all-pervasive, and fundamental force in human relationships and plays a valuable role in social, political, and economic interactions. Power differences are important in social groups in enhancing group functioning. Most people want to have power and there are many benefits to having power. However, power is a corrupting force and this has been a topic of interest for centuries to scholars from Plato to Lord Acton. Even with increased knowledge of power's corrupting effect and safeguards put in place to counteract such tendencies, power abuse remains rampant in society suggesting that the full extent of this effect is not well understood. In this paper, an effort is made to improve understanding of power's corrupting effects on human behavior through an integrated and comprehensive synthesis of the neurological, sociological, physiological, and psychological literature on power. The structural limits of justice systems' capability to hold powerful people accountable are also discussed.

"It's like asking for a necktie when you don't have underwear": Discourses on patient rights in southern Karnataka, India

BACKGROUND

Ensuring patient rights is an extension of applying human rights principles to health care. A critical examination of how the notion of patient rights is perceived and enacted by various actors through critical discourse analysis (CDA) can help understand the impediments to its realization in practice.

METHODS

We studied the discourses and discursive practices on patient rights in subnational policies and in ten health facilities in southern Karnataka, India. We conducted interviews (78), focus group discussions (3) with care-seeking individuals, care-providers, health care administrators and public health officials. We also conducted participant observation in selected health facilities and examined subnational policy documents of Karnataka pertaining to patient rights. We analyzed the qualitative data for major and minor themes.

RESULTS

Patient rights discourses were not based upon human rights notions. In the context of neoliberalism, they were predominantly embedded within the logic of quality of care, economic, and consumerist perspectives. Relatively powerful actors such as care-providers and health facility administrators used a panoply of discursive strategies such as emphasizing alternate discourses and controlling discursive resources to suppress the promotion of patient rights among care-seeking individuals in health facilities. As a result, the capacity of care-seeking individuals to know and claim patient rights was restricted. With neoliberal health policies promoting austerity measures on public health care system and weak implementation of health care regulations, patient rights discourses remained subdued in health facilities in Karnataka, India.

CONCLUSIONS

The empirical findings on the local expression of patient rights in the discourses allowed for theoretical insights on the translation of conceptual understandings of patient rights to practice in the everyday lives of health system actors and care-seeking individuals. The CDA approach was helpful to identify the problematic aspects of discourses and discursive practices on patient rights where health facility administrators and care-providers wielded power to oppress care-seeking individuals. From the practical point of view, the study demonstrated the limitations of care-seeking individuals in the discursive realms to assert their agency as practitioners of (patient) rights in health facilities.

Nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment process in an intensive care unit

AIMS

To explore nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment in an intensive care unit.

BACKGROUND

In South Korea, withholding or withdrawing life-sustaining treatment is legalised by the enforcement of the Hospice, Palliative Care and Life-sustaining Treatment Decision-making Act (2018). The Act (2018) is the first legal ground for making decisions regarding life-sustaining treatment in South Korea.

DESIGN

Focused ethnography. The standards for reporting qualitative research checklist is used.

METHODS

Interview data are collected between August 2018 and January 2019 using semi-structured interviews with 23 nurses, 10 physicians and four family members in a South Korean intensive care unit. The interview data are analysed following the thematic analysis of Braun and Clarke.

RESULTS

An overarching theme of 'constructing death' is identified from the experiences of nurses, physicians and family members regarding withholding or withdrawing life-sustaining treatment in a South Korean intensive care unit. Family members had the strongest power in the withholding or withdrawing life-sustaining treatment process whilst the process had to be based on medical consideration. All the research participants shared the purpose and motivation of withholding or withdrawing life-sustaining treatment as the dying patient's dignity. Due to the South Korean national health insurance system, the relationships between medical staff and family members were driven by customer ideology.

CONCLUSION

The impact and linkage of the context of familism culture and health insurance with the process of withholding or withdrawing life-sustaining treatment in South Korea are shown in this research. The findings of this research inspire future studies to uncover the impact of the cultural context in the decision-making process of a patient's death, to explore the dynamics of family members under cultural values and to explore the influence of the healthcare system and medical costs on the relationships between medical staff and family members.

RELEVANCE TO CLINICAL PRACTICE

By integrating the experiences of nurses, physicians and family members, the findings of this study inform the shared values in the context of familism culture and the health insurance system. In particular, understanding family dynamics when a patient's dying and death as a result of withholding or withdrawing life-sustaining treatment informs nurses to provide quality of care in the intensive care setting. Therefore, the findings of this research contribute to distinguishing the priority in care when withholding or withdrawing life-sustaining treatment, rapidly changing the aims of care from the patient's recovery to a dignified death.

Peoples' expectations of healthcare: A conceptual review and proposed analytical framework

Expectations shape how one experiences the healthcare one receives. In this paper we argue that the current conceptualisations of expectations within the healthcare literature have much to gain from the many recent and adjacent conceptual developments in other disciplines. The concept of expectations has been extensively studied across disciplines - we review the key texts on the subject in the business, management, social psychology, and sociology literatures to provide a conceptual overview and propose an integrative analytical framework for better understanding individuals' expectations in healthcare. We argue that peoples' expectations of a care encounter are usefully understood as being shaped by their social locations at particular points of time, which is at the intersection of multiple social structures and relations. Peoples' future expectations of care may also be influenced by the experiences of past and current care encounters, framed again by intersecting social structures and relations at that point in time. We demonstrate how an intersectional, translocational and relational analytical approach can allow researchers and practitioners to consider how peoples' social locations shape their expectations of care, not only within a given social environment, but at certain points in time and over time. We emphasise that, given the mobilities and mixing societies are experiencing globally, such an approach is particularly useful for understanding healthcare-related expectations and experiences of all.

"So, when a woman becomes ill, the total structure of the family is affected, they can't do anything…" Voices from the community on women with breast cancer in India: a qualitative focus group study

Background

Psychological symptoms are common in women with breast cancer and profoundly affect their role in the family and wider community, varying across cultural backgrounds. Breast cancer is becoming the most common cancer among women in India. We aimed to understand the cultural context within which Indian women with breast cancer living in India, experience psychological concerns from the perspectives of healthcare professionals, volunteers and church members.

Methods

Five focus groups were conducted in South India (clinicians (2 groups)) lay public (3 groups). A topic guide was explored: understanding of breast cancer, experiences of patients with regard to diagnosis and treatment and psychological impact. Groups were audio-recorded and verbatim transcribed. Lay groups were conducted in Malayalam with translation and back-translation. Transcripts were subjected to thematic analysis using “cultural task analysis” as a lens for analysis.

Results

Forty-five (oncologists (5), nurses (10), church members (16) and community volunteers working in a palliative care unit (14) participated. Three major themes psychosocial issues related to diagnosis, psychosocial impact of cancer treatment and coping with diagnosis and treatment and nine subthemes emerged from the two groups. All described psychological impact on women with breast cancer including body image, change of family role and their need for support. Family and faith were recognised as the major framework providing key support but also significant stress. Clinicians were also concerned about financial implications and issues around early cancer detection. Laypeople and nurses also commented that poor communication and lack of empathy from doctors aggravated distress.

Conclusion

Clinical and lay communities were aware of the widespread psychological impact affecting women with breast cancer which are amplified by the patriarchal context within which they live, which extends into clinical practice. Family and faith provide a strong support structure and are a cause of distress, as core roles and expectations are challenged by this disease of womanhood.

A wellbeing skill: moving attentively in hospital yoga practice

Yoga is sometimes interpreted as medical therapy and the evidence from biomedical research indicates that it can be useful in a broad range of health conditions. Yoga, however, can also be pursued as a process-oriented contemplative practice. This article draws on participant observation-based research with yoga practitioners at two hospitals, one in Pondicherry, India, and one in Fukui, Japan. It explores how patients and their families at these healthcare institutions are invited to move without anticipating an outcome and to cultivate attitudes such as contentment and non-violence. Taking cues from research participants' approaches to yoga as a skill and from anthropological understandings of skill, yoga is considered here as a capacity of moving with awareness. A skill-based approach allows practitioners to try out yogic techniques according to their personal abilities and needs. The analysis suggests that, in the contexts discussed, yoga practitioners pursue wellbeing not as an individual therapeutic goal but as mutual explorative learning.

The Social Construction of Incompetency: Moving Beyond Embedded Paternalism Toward the Practice of Respect

This article illustrates the less-acknowledged social construction of the concept of 'incompetency' and draws attention to the moral concerns it raises in health care encounters in the south Indian city of Chennai. Based on data drawn from qualitative research, this study suggests that surgeons subjectively construct the idea of incompetency through their understanding of the perceived circumstantial characteristics of the patients and family members they serve. The findings indicate that surgeons often underestimate patients and family members' capacity based on constructed assessments, which leads to paternalistic practice. In this article, I illustrate how these assessments influence the surgeons' practices and provide the moral and practical justifications for their actions. The constructed knowledge becomes a source for drawing normative justification for surgeons' actions and, in conjunction with socially enforced power relationships, results in patients and family members to be on the receiving end of disrespectful attitudes. Based on the data analysis and by drawing on philosophical analysis, I emphasize the need to focus on 'respect for persons,' to rethink the framework of 'capacity,' and to practice respect in hospital settings.

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review

INTRODUCTION

Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review.

METHODS

The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 th April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed.

ETHICS AND DISSEMINATION

The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal.

REGISTRATION NUMBER

PROSPERO 2020 CRD42020176939.

Participants’ Perspectives on Healthcare Service Quality in Multispecialty Hospitals: A Qualitative Approach

Professional services like healthcare operate with high degree of information asymmetry, where usually the seeker of service lacks knowledge and skills, and as a result, they cannot evaluate the benefits. Alternative indicators in the service delivery are sought by the seekers to bring evenness in their evaluation, which might not be reflective of providers’ perspectives of care. This study attempts to explore perspectives of both the participants in healthcare service delivery in multispecialty hospital settings. Semi-structured interviews were conducted using snowball sampling with doctors, paramedical staff and managers in multispecialty hospitals and patients and their attendants who have visited the same set of hospitals during past one year. The narratives of the respondents based on a priori interview themes were converted into textual data. Template analysis technique was used to thematically analyse and present the results. Differing accounts of two participants emerged out of the analysis and a gap between providers’ and seekers’ perspectives of each other’s expectations and perceptions of performance was observed. This study is a novel attempt to simultaneously account for both the participants’ perspectives to present a holistic picture rather than a one-sided view of healthcare service quality.

Validation of the Interpersonal Quality of Family Planning Scale in a rural Indian setting

Objectives

The provision of high-quality family planning (FP) counseling can both enhance clients' experience of care and improve their ability to make and act on their contraceptive decisions. The Interpersonal Quality of Family Planning (IQFP) scale measures FP counseling quality and has been validated in the United States. We aimed to explore whether it remains appropriate for use in a low-/middle-income country (LMIC).

Study design

We surveyed 1201 nonsterilized married women ages 18-29 in Maharashtra, India, between September 2018 and June 2019. Respondents rated their FP provider from "poor" (1) to "excellent" (5) across 11 IQFP items. We assessed scale reliability via Cronbach's α test and used exploratory factor analysis to evaluate unidimensionality and regression models of plausibly related outcomes to assess construct validity.

Results

Five hundred four women (42%) had seen an FP provider within the past year, 491 (97%) of whom answered all items. Mean IQFP score was 2.62 out of 5 (SD 0.94, range 1-5). Scale reliability was high (α = 0.97). Exploratory factor analyses support unidimensionality (all factor loadings > 0.4). A 1-point increase in average IQFP score was associated with nearly double the odds of current modern contraceptive use (adjusted odds ratio = 1.73, 95% confidence interval = 1.36-2.19).

Conclusions

The IQFP scale shows good reliability and construct validity in this context, and its use in LMIC settings should be broadly considered. A higher IQFP score was associated with greater odds of contraceptive use. The reported FP counseling quality was low, so future public health efforts should aim to increase counseling quality to better meet the needs of women in low-resource settings like rural India. Measurement tools like IQFP can support success evaluation of the quality of care provided by family planning programs.

Implications

The Interpersonal Quality of Family Planning scale is a useful tool in rural India, a different context than the one in which it was developed. Use of the IQFP scale should be considered in other low-/middle-income countries to better measure the quality of family planning care provided.

Health care service quality: a journey so far

Purpose

Health care service is a widely researched area. Several established models and instruments measuring health care service quality (HCSQ) are available in the published academic literature. The objective of this article is to summarize this vast pool of available knowledge under the themes of HCSQ, its determinants and measurement strategies.

Design/methodology/approach

Sixty-three available published studies in peer reviewed journal combed in EBSCO and Google Scholar database have been examined and presented in exemplary literature review.

Findings

The findings have been segregated under the themes of HCSQ, its dimensions and determinants. It can be deduced from the findings that in spite of health care being a professional service, the user defined service quality takes center stage.

Originality/value

Rather than the seeker of care, the authors call for further research by taking a dyadic view of professional exchanges and including providers' perspectives of care in service quality evaluations as well.

Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons

BACKGROUND

High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness.

MATERIALS AND METHODS

Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016.

RESULTS

Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing".

CONCLUSIONS

Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.

User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review

BACKGROUND

Tuberculosis affected 2.7 million people in India in 2017. The Revised National TB Control Programme has achieved milestones in coverage, however quality of TB care remains highly variable and often poor, with significant gaps in provider knowledge, practices, and patients consistently lost to follow-up. These quality gaps are largely informed by studies on provider practices or objective chart abstractions and case data. Per the knowledge of the author, no review has been conducted on first-hand patient perspectives on the quality of TB care they receive. This mixed-methods literature review aims to synthesize evidence on user-experience and patient satisfaction with TB care in India and inform areas for service quality improvement.

METHODS

Five medical databases, including PubMed, EMBASE, Global Health (Ovid), Web of Science, and CINAHL were searched for empirical studies on patient perspectives on TB health services published between January 1st, 2000 to December 31st, 2017. Studies in English with adult patients with any form of TB in the public or private health system were included. Studies prior to entering the health system, on distance to health facilities and cost were excluded. Seven Indian journals were hand searched and a grey literature search was conducted in GoogleScholar. Studies were assessed for methodological quality and thematic analysis was conducted by categorizing data using NVivo 12.

RESULTS

A total of 498 studies were screened, of which 23 met the inclusion criteria. 16 supplementary studies were identified from Indian journals and grey literature. Of the 39 total studies included most were quantitative (29; 74%), based in South India (17; 44%) and focused on drug-sensitive TB patients (19; 49%) within the public health system (25; 64%). Data collection methods were highly heterogenous which limited synthesis and comparisons across population demographics, health sectors, or regions. Overall quantitative patient satisfaction measured in seven studies was high. Two major themes identified were provider-related factors (n = 26 studies) and convenience (n = 25), and six minor themes were supplies and equipment availability (n = 12), confidence (n = 10), information and communication (n = 10), waiting time (n = 8), stigma (n = 4), and confidentiality (n = 4). Each reported positive and negative user-experiences. Most significantly, DOTS did not fit the daily needs and obligations of many patients, particularly due to conflicts with employment and frequency of visits; while positive provider support, information, and flexibility helped patients adhere to treatment.

CONCLUSION

Although quantitative patient satisfaction was found to be high, data were not collected using robust, validated tools. Qualitative and quantitative user-experiences in each theme were variable, making them both barriers and facilitators of good quality TB care. Poor user-experiences were often responsible for patients interrupting treatment or dropping out of TB care. Patient-centeredness, or user-friendliness of TB care can be improved by introducing individualized or flexible DOTS that is responsive to user circumstances and needs. User-experience data should be systematically collected using a standardized, national tool for identification of specific bottlenecks and successes in quality of TB care from the patients' perspective.

Perceptions of people with respiratory problems on physician performance evaluation-A qualitative study

BACKGROUND

Despite increasing calls for patient and public involvement in health-care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention.

OBJECTIVE

The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence.

DESIGN

A qualitative study based on semi-structured interviews.

SETTING AND PARTICIPANTS

The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling.

METHODS

Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment.

RESULTS

The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor-patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance.

DISCUSSION AND CONCLUSION

Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback.

Tobacco Cessation Among Acute Coronary Syndrome Patients in Kerala, India: Patient and Provider Perspectives

Tobacco cessation is an important intervention to reduce mortality from ischemic heart disease, the leading cause of death in India. In this study, we explored facilitators, barriers, and cultural context to tobacco cessation among acute coronary syndrome (ACS, or heart attack) patients and providers in a tertiary care institution in the south Indian state of Kerala, with a focus on patient trajectories. Patients who quit tobacco after ACS expressed greater understanding about the link between tobacco and ACS, exerted more willpower at the time of discharge, and held less fatalistic beliefs about their health compared to those who continued tobacco use. The former were motivated by the fear of recurrent ACS, strong advice to quit from providers, and determination to survive and financially provide for their families. Systemic barriers included inadequate training, infrequent prescription of cessation pharmacotherapy, lack of ancillary staff to deliver counseling, and stigma against mental health services.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Integrated management of non-communicable diseases in low-income settings: palliative care, primary care and community health synergies

Palliative care is recognised as a fundamental component of Universal Health Coverage (UHC), which individual countries, led by the United Nations and the WHO, are committed to achieving worldwide by 2030-Sustainable Development Goal (SDG) 3.8. As the incidence of non-communicable diseases (NCD) in low-income and middle-income countries (LMICs) increases, their prevention and control are the central aspects of UHC in these areas. While the main focus is on reducing premature mortality from NCDs (SDG 3.4), palliative care is becoming increasingly important in LMICs, in which 80% of the need is found. This paper discusses the challenges of providing comprehensive NCD management in LMICs, the role of palliative care in addressing the huge and growing burden of serious health-related suffering, and also its scope for leveraging various aspects of primary care NCD management. Drawing on experiences in India and Nepal, and particularly a project on the India-Nepal border in which palliative care, community health and primary care-led NCD management are being integrated, we explore the synergies arising and describe a model where palliative care is integral to the whole spectrum of NCD management, from promotion and prevention, through treatment, rehabilitation and palliation. We believe this model could provide a framework for integrated NCD management more generally in rural India and Nepal and also other LMICs as they work to make NCD management as part of UHC a reality.

Demography and the dual epidemics of tuberculosis and HIV: Analysis of cross-sectional data from Sub-Saharan Africa

Background

Convergence of tuberculosis (TB) and HIV epidemics is associated with higher morbidity and mortality risks and understanding their distribution across key demographic factors is essential for prevention and control. This analysis examines the prevalence of TB, HIV and TB-HIV coinfection across age and gender in patients with presumptive TB seeking care at the National TB and Leprosy Training Center in Nigeria.

Methods

Samples from 1603 presumptive pulmonary TB cases who provided informed consent were evaluated with a sequential testing algorithm that included a smear microscopy, cultures in liquid and broth media and then genotyping by Hain line probe assays. HIV was serially tested with two HIV rapid assays and retested with a third assay in non-conclusive samples.

Results

Twenty-three percent (375/1603) had confirmed pulmonary TB infection, 23.6% (378/1603) were positive for HIV infection and 26.9% (101/375) of the confirmed TB cases were HIV co-infected. Males had a higher prevalence of TB: 27.6% vs. 18.0%, p < .0001; and a lower prevalence of HIV: 19.0% vs. 29.6%, p < .0001. In the age range of 25–29 years, males were twice as likely to have TB (OR = 2.2; 95% confidence interval [CI]: 1.3–3.9, p = 0.0032) while females were five times more likely to have HIV (OR = 4.8; 95% CI: 2.6–8.9, p < .0001). Persons with TB-HIV coinfection were more likely to be young, female and less likely to be married.

Conclusion

Younger females with a high burden of HIV may be under-diagnosed and under-reported for TB in Nigeria. Community programs for intensified and early detection of TB and HIV targeting younger females are needed in this setting.

Effect of informed consent on patients undergoing gastrointestinal surgery and living donor liver transplantation and on their relatives in a developing country

Background

Informed consent is a systematic process for obtaining permission before conducting a healthcare intervention. In a developing country, gaining informed consent is generally perceived to be a ritual only to comply with legal requirements. The present study examined this by assessing the process of informed consent in patients undergoing gastrointestinal surgery or living donor liver transplantation (LDLT) and their relatives, based on their comprehension and overall satisfaction, in India.

Methods

All patients undergoing any gastrointestinal surgery or LDLT procedure between August 2015 and July 2016 and their relatives were included, and were administered a structured questionnaire 5 days after the procedure.

Results

The majority of patients (94·2 per cent) could recall the nature of their disease, the surgery performed (81·6 per cent) and anticipated complications (55·6 per cent). Among their relatives, these proportions were 97·8, 87·3 and 58·5 per cent respectively. Recall was associated with age, occupation and education among both patients and relatives. Patients undergoing LDLT, their donors and their relatives had better recall than those who had other gastrointestinal procedures (P < 0·001). Many patients found the process of informed consent useful and reassuring.

Conclusion

The details and risks of an operation were understood by most of the patients, especially those undergoing liver transplantation. Patients from developing countries can generally understand ‘informed consent’, and value it.

Illness Experiences, Collective Decisions, and the Therapeutic Encounter in Indian Oncology

Social science scholarship on cancer has been almost exclusively focused on Organization for Economic Cooperation and Development (OECD) countries, despite a significant epidemiological transition taking place in many non-OECD contexts, with cancer emerging as a prominent, and strongly feared, illness experience. With cancer gaining an increasingly high profile in India, there is an urgent need to explore how experiences of cancer may be socially and culturally embedded, and in turn, how localized practices may shape the therapeutic encounter. Here, drawing on interviews with 40 people living with cancer in Hyderabad, India, we focus on some specific components of their therapeutic journeys, including diagnostic and prognostic disclosure, collective versus individual decision making, the dynamics of medical authority, and the reception of cancer within their social milieu. These participants' accounts provide insight into a range of cultural sensibilities around illness and care, and reinforce the importance of understanding the cultural inflections of communication, decisions, and illness experiences.

Migration as a risk and a livelihood strategy: HIV across the life course of migrant families in India

Migrant workers are understood to be vulnerable to HIV. However, little is known about the experience of migration-based households following HIV infection. This qualitative study examined the migration-HIV relationship beyond the point of infection, looking at how it affects livelihood choices, household relationships and the economic viability of migrant families. We conducted semi-structured interviews with 33 HIV-positive migrant men and women recruited from an anti-retroviral therapy (ART) centre in north India. Following infection among the migrant men, contact with free, public-sector HIV services was often made late, after the development of debilitating symptoms, abandonment of migrant work and return to native villages. After enrolment at the ART centre participants’ health eventually stabilised but they now faced serious economic debt, an inflexible treatment regimen and reduced physical strength. Insecure migrant job markets, monthly drug collection and discriminatory employment policies impeded future migration plans. HIV-positive wives of migrants occupied an insecure position in the rural marital household that depended on their husbands’ health and presence of children. The migration-HIV relationship continued to shape the life course of migrant families beyond the point of infection, often exposing them again to the economic insecurity that migration had helped to overcome, threatening their long-term survival.

Limits of 'patient-centredness': valuing contextually specific communication patterns

CONTEXT

Globally, doctor-patient communication is becoming synonymous with high-quality health care in the 21st century. However, what is meant by 'good communication' and whether there is consensus internationally remain unclear.

OBJECTIVES

Here, we characterise understandings of 'good communication' in future doctors from medical schools in three contextually contrasting continents. Given locally specific socio-cultural influences, we hypothesised that there would be a lack of global consensus on what constitutes 'good communication'.

METHODS

A standardised two-phase methodology was applied in turn to each of three medical schools in the UK, Egypt and India (n = 107 subjects), respectively, in which students were asked: 'What is good communication?' Phase I involved exploratory focus groups to define preliminary themes (mean number of participants per site: 17). Phase II involved thematic confirmation and expansion in one-to-one semi-structured interviews (mean number of participants per site: 18; mean hours of dialogue captured per site: 55). Findings were triangulated and analysed using grounded theory.

RESULTS

The overarching theme that emerged from medical students was that 'good communication' requires adherence to certain 'rules of communication'. A shared rule that doctors must communicate effectively despite perceived disempowerment emerged across all sites. However, contradictory culturally specific rules about communication were identified in relation to three major domains: family; gender, and emotional expression. Egyptian students perceived emotional aspects of Western doctors' communication strikingly negatively, viewing these doctors as problematically cold and unresponsive.

CONCLUSIONS

Contradictory perceptions of 'good communication' in future doctors are found cross-continentally and may contribute to prevalent cultural misunderstandings in medicine. The lack of global consensus on what defines good communication challenges prescriptively taught Western 'patient-centredness' and questions assumptions about international transferability. Health care professionals must be educated openly about flexible, context-specific communication patterns so that they can avoid cultural incompetence and tailor behaviours in ways that optimise therapeutic outcomes wherever they work around the globe.

'Multiple-test' approach to the laboratory diagnosis of tuberculosis -perception of medical doctors from Ujjain, India

Background

Delay in diagnosis is one of the most important factors for the control of tuberculosis (TB) in endemic countries like India. As laboratory diagnosis is the mainstay for identification of active disease, we aim to explore and understand the opinions of medical doctors about the laboratory diagnosis of TB in Ujjain, India.

Methods

Sixteen qualified specialist medical doctors from Ujjain were purposefully selected for the study. Individual interviews with the doctors (13 men and 3 women), were conducted. As one interview could not be completed, data from15 interviews were analyzed using manifest and latent content analysis.

Results

Based on perception of the doctors, the theme; ‘challenges and need for the laboratory diagnosis of TB’ emerged from the following subthemes: (i) Relationship between basic element of the TB diseases process such as ‘Symptoms prior to diagnoses’ and ‘Clinical characteristics of TB’, which were not specific enough to diagnose TB (ii) The prevailing conditions such as lack of explicit diagnostic tools, lead to the doctors using the ‘multiple tests’ or ‘empiric treatment’ approach (iii) The doctors proposed that there is a need for access to a rapid, single and simple diagnostic test, and a need for awareness and knowledge of the practitioners regarding specific TB investigations, and early referral to improve the situation at resource-limited settings.

Conclusion

The medical specialists use a ‘multiple test’ or ‘empiric treatment’ approach to diagnose TB. According to the participants, there is a low dependence and uptake of the available laboratory TB investigations by medical practitioners. There is an urgent need to have a specific, simple and reliable test, and a protocol, to improve diagnosis of TB and to prevent development of resistant TB.

Balancing authority, deference and trust across the public-private divide in health care: tuberculosis health visitors in western Maharashtra, India

While concepts such as ‘partnership’ are central to the terminology of private–public mix (PPM), little attention has been paid to how social relations are negotiated among the diverse actors responsible for implementing these inter-sectoral arrangements. India's Revised National Tuberculosis Control Programme (RNTCP) has used intermediary agents to facilitate the involvement of private providers in the expansion of Directly Observed Therapy, Short-Course (DOTS). We examine the roles of tuberculosis health visitors (TB HVs) in mediating working relationships among private providers, programme staff and patients that underpin a PPM-DOTS launched by the RNTCP in western Maharashtra. In addition to observations and informal interactions with the programme and participating health providers, researchers conducted in-depth interviews with senior programme officers and eight TB HVs. Framed by a political discourse of clinical governance, working relationships within the PPM are structured by the pluralistic context, social and professional hierarchies and paternalism of health care in India. TB HVs are at the nexus of these relationships, yet remain undervalued partly because accountability is measured through technical rather than social outcomes of the ‘partnership’. Close attention to the dynamics of power relations in working practices within the health system can improve accountability and sustainability of partnerships.

Gender-related barriers and delays in accessing tuberculosis diagnostic and treatment services: a systematic review of qualitative studies

Background. Tuberculosis (TB) remains a significant global public health problem with known gender-related (male versus female) disparities. We reviewed the qualitative evidence (written/spoken narrative) for gender-related differences limiting TB service access from symptom onset to treatment initiation. Methods. Following a systematic process, we searched 12 electronic databases, included qualitative studies that assessed gender differences in accessing TB diagnostic and treatment services, abstracted data, and assessed study validity. Using a modified “inductive coding” system, we synthesized emergent themes within defined barriers and delays limiting access at the individual and provider/system levels and examined gender-related differences. Results. Among 13,448 studies, 28 studies were included. All were conducted in developing countries and assessed individual-level barriers; 11 (39%) assessed provider/system-level barriers, 18 (64%) surveyed persons with suspected or diagnosed TB, and 7 (25%) exclusively surveyed randomly sampled community members or health care workers. Each barrier affected both genders but had gender-variable nature and impact reflecting sociodemographic themes. Women experienced financial and physical dependence, lower general literacy, and household stigma, whereas men faced work-related financial and physical barriers and community-based stigma. Conclusions. In developing countries, barriers limiting access to TB care have context-specific gender-related differences that can inform integrated interventions to optimize TB services.

Unpacking the psychiatric advance directive in low-resource settings: an exploratory qualitative study in Tamil Nadu, India

BACKGROUND

Psychiatric advance directives, a tool to document preferences for care in advance of decisional incapacity, have been shown to benefit persons with mental illness in a number of countries through improving medication adherence, reducing symptoms from escalating in a crisis, accelerating recovery, and enhancing service user autonomy. While concepts such as autonomy are important in a number of high-income country settings, it remains unclear whether tools like psychiatric advance directives are suitable in a different context. The recent introduction of the psychiatric advance directive into draft legislation in India prompts the question as to how feasible psychiatric advance directives are in the Indian context. The aim of this study is to explore the feasibility and utility of PADs in India, with a focus on the need for individual control over decision making and barriers to implementation, by exploring views of its central stakeholders, service users and carers.

METHODS

Qualitative semi-structured interviews (n = 51) with clients (n = 39) and carers (n = 12) seeking mental health treatment at outpatient clinics in urban and rural settings provided by a non-profit organisation in Tamil Nadu, India.

RESULTS

Clients engaged in a number of forms of decision-making (passive, active, and collaborative) depending on the situation and decision at hand, and had high levels of self-efficacy. Most clients and carers were unfamiliar with PADs, and while some clients felt it is important to have a say in treatment wishes, carers expressed concerns about service user capacity to make decisions. After completing PADs, clients reported an increase in self-efficacy and an increased desire to make decisions.

CONCLUSIONS

The introduction of psychiatric advance directives in India appears to be associated with positive outcomes for some service users, however, there is a need to better understand how this tool can be adapted to better suit the care context in India and hold meaning and value for service users to complete.

Factors influencing trust in doctors: a community segmentation strategy for quality improvement in healthcare

BACKGROUND

Trust is a forward-looking covenant between the patient and the doctor where the patient optimistically accepts his/her vulnerability. Trust is known to improve the clinical outcomes.

OBJECTIVES

To explore the factors that determine patients' trust in doctors and to segment the community based on factors which drive their trust.

SETTING

Resource-poor urban and rural settings in Tamil Nadu, a state in southern India.

PARTICIPANTS

A questionnaire was administered to a sample of 625 adult community-dwelling respondents from four districts of Tamil Nadu, India, chosen by multistage sampling strategy.

OUTCOME MEASURES

The outcomes were to understand the main domains of factors influencing trust in doctors and to segment the community based on which of these domains predominantly influenced their trust.

RESULTS

Factor analysis revealed five main categories, namely, comfort with the doctor, doctor with personal involvement with the patient, behaviourally competent doctor, doctor with a simple appearance and culturally competent doctor, which explained 49.3% of the total variance. Using k-means cluster analysis the respondents were segmented into four groups, namely, those who have 'comfort-based trust', 'emotionally assessed trust', who were predominantly older and belonging to lower socioeconomic status, those who had 'personal trust', who were younger people from higher socioeconomic strata of the community and the group who had 'objectively assessed trust', who were younger women.

CONCLUSIONS

Trust in doctors seems to be influenced by the doctor's behaviuor, perceived comfort levels, personal involvement with the patient, and to a lesser extent by cultural competence and doctor's physical appearance. On the basis of these dimensions, the community can be segmented into distinct groups, and trust building can happen in a strategic manner which may lead to improvement in perceived quality of care.

Dimensions and determinants of trust in health care in resource poor settings--a qualitative exploration

BACKGROUND

Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different.

OBJECTIVES

This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings.

METHODOLOGY

The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach.

RESULTS

The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients' willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care.

CONCLUSIONS

The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants.

Traditional medicines, collective negotiation, and representations of risk in Indian cancer care

Cancer is emerging as a key disease in India, but there has been virtually no research exploring understandings of cancer and practices of communication within oncology settings. This is despite the fact that the Indian context presents clinicians, patients, and family members with a range of unique challenges, including those related to disease awareness, interpersonal dynamics, and the use of traditional, complementary, and alternative medicines (TCAM). Drawing on a series of qualitative interviews with 22 Delhi-based oncology clinicians, in this article we examine clinicians' accounts of communication with their cancer patients. The interviews reveal the challenges of communication given cancer's relative novelty, cultural practices around collective negotiation, and rhetorical practices evident in advice-giving regarding TCAM. We conclude that with cancer set to become a major burden in India, research exploring competing forms of expertise, the politics of representation, and the nexus between traditional beliefs and techno-scientific development is urgently needed.

Causes and determinants of inequity in maternal and child health in Vietnam

BACKGROUND

Inequities in health are a major challenge for health care planners and policymakers globally. In Vietnam, rapid societal development presents a considerable risk for disadvantaged populations to be left behind. The aim of this review is to map the known causes and determinants of inequity in maternal and child health in Vietnam in order to promote policy action.

METHODS

A review was performed through systematic searches of Pubmed and Proquest and manual searches of "grey literature." A thematic content analysis guided by the conceptual framework suggested by the Commission on Social Determinants of Health was performed.

RESULTS

More than thirty different causes and determinants of inequity in maternal and child health were identified. Some determinants worth highlighting were the influence of informal fees and the many testimonies of discrimination and negative attitudes from health staff towards women in general and ethnic minorities in particular. Research gaps were identified, such as a lack of studies investigating the influence of education on health care utilization, informal costs of care, and how psychosocial factors mediate inequity.

CONCLUSIONS

The evidence of corruption and discrimination as mediators of health inequity in Vietnam calls for attention and indicates a need for more structural interventions such as better governance and anti-discriminatory laws. More research is needed in order to fully understand the pathways of inequities in health in Vietnam and suggest areas for intervention for policy action to reach disadvantaged populations.

Humiliation or care? A qualitative study of patients' and health professionals' experiences with tuberculosis treatment in Norway

AIM

Directly observed treatment (DOT) has been implemented globally as a strategy in treatment of tuberculosis. Studies from high-endemic settings show that DOT involves social and economical burdens for patients, but little is known about experiences with practicing DOT in low-endemic settings. The present study explores patients' and health professionals' views and experiences with DOT in Norway.

METHOD

In-depth interviews were conducted with 22 patients originating from Somalia and Ethiopia and with 20 health professionals. Data from the interviews were analysed using systematic text condensation.

FINDINGS

We found that there was little room for patients to negotiate whether or not to consent to the organization of treatment (DOT). Patients told that it was difficult to question the way treatment was organized, as they got the impression that there was no other way of gaining access to medication. Both patients and health professionals reported that persuasion based on authority and subtle threats was used as means to facilitate patients' acceptance of DOT. A majority of patients experienced DOT as humiliating and discriminating, while some had the experience of being cared for. Patients who attended school or had occupational obligations reported high social costs related to the treatment. Patients with positive experiences told that they had been given an opportunity to negotiate flexible treatment schedules and emphasized the importance of continuity among health professionals. Health professionals had divergent views and practices. Some argued that patients should be treated equally, while others argued for an individualized and flexible approach.

CONCLUSION

The practice of DOT reflects societal power structures that influence the clinical interactions between health professionals and patients. To avoid experiences of disempowerment and humiliation among patients, treatment and care should be organized in a way that safeguards patients' right to consent to treatment and that allows patients to negotiate an individualized treatment schedule.

Initial commitment to pre-exposure prophylaxis and circumcision for HIV prevention amongst Indian truck drivers

Studies of HIV prevention interventions such as pre-exposure prophylaxis (PREP) and circumcision in India are limited. The present study sought to investigate Indian truck-drivers initial commitment to PREP and circumcision utilizing the AIDS Risk Reduction Model. Ninety truck-drivers completed an in-depth qualitative interview and provided a blood sample for HIV and HSV-2 testing. Truck-drivers exhibited low levels of initial commitment towards PREP and even lower for circumcision. However, potential leverage points for increasing commitment were realized in fear of infecting family rather than self, self-perceptions of risk, and for PREP focusing on cultural beliefs towards medication and physicians. Cost was a major barrier to both HIV prevention interventions. Despite these barriers, our findings suggest that the ARRM may be useful in identifying several leverage points that may be used by peers, health care providers and public health field workers to enhance initial commitment to novel HIV prevention interventions in India.

Examining sex differentials in the uptake and process of HIV testing in three high prevalence districts of India

Sex differentials in the uptake of HIV testing have been reported in a range of settings, however, men's and women's testing patterns are not consistent across these settings, suggesting the need to set sex differentials against gender norms in patient testing behaviour and provider practices. A community-based, cross-sectional survey among 347 people living with HIV in three HIV high prevalence districts of India examined reasons for undergoing an HIV test, location of testing and conditions under which individuals were tested. HIV testing was almost always provider-initiated for men. Men were more likely to be advised to test by a private practitioner and to test in the private sector. Women were more likely to be advised to test by a family member, and to test in the public sector. Men were more likely to receive pre-test information than women, when tested in the private sector. Men were also more likely to receive direct disclosure of their HIV positive status by a health provider, regardless of the sector in which they tested. More women than men were repeatedly tested for HIV, regardless of sector. These sex differentials in the uptake and process of HIV testing are partially explained through differences in public and private sector testing practices. However, they also reflect women's lack of awareness and agency in HIV care seeking and differential treatment by providers. Examining gender dynamics that underpin sex differentials in HIV testing patterns and practices is essential for a realistic assessment of the challenges and implications of scaling-up HIV testing and mainstreaming gender in HIV/AIDS programmes.

Strategies for gender-equitable HIV services in rural India

The emergence of HIV in rural India has the potential to heighten gender inequity in a context where women already suffer significant health disparities. Recent Indian health policies provide new opportunities to identify and implement gender-equitable rural HIV services. In this review, we adapt Mosley and Chen's conceptual framework of health to outline determinants for HIV health services utilization and outcomes. Examining the framework through a gender lens, we conduct a comprehensive literature review for gender-related gaps in HIV clinical services in rural India, focusing on patient access and outcomes, provider practices, and institutional partnerships. Contextualizing findings from rural India in the broader international literature, we describe potential strategies for gender-equitable HIV services in rural India, as responses to the following three questions: (1) What gender-specific patient needs should be addressed for gender-equitable HIV testing and care? (2) What do health care providers need to deliver HIV services with gender equity? (3) How should institutions enforce and sustain gender-equitable HIV services? Data at this early stage indicate substantial gender-related differences in HIV services in rural India, reflecting prevailing gender norms. Strategies including gender-specific HIV testing and care services would directly address current gender-specific patient needs. Rural care providers urgently need training in gender sensitivity and HIV-related communication and clinical skills. To enforce and sustain gender equity, multi-sectoral institutions must establish gender-equitable medical workplaces, interdisciplinary HIV services partnerships, and oversight methods, including analysis of gender-disaggregated data. A gender-equitable approach to rural India's rapidly evolving HIV services programmes could serve as a foundation for gender equity in the overall health care system.

Conflicting accountabilities: Doctor's dilemma in TB control in rural India

OBJECTIVE

The aim of this study was to analyse how the implementation strategy of direct observed treatment short course (DOTS) has shaped and influenced patient-provider encounters in a district tuberculosis centre (DTC) in a rural district of India.

METHOD

Qualitative methods, combining observations and interviews, were carried out in a DTC focusing on the medical encounters between a TB doctor and his patients.

RESULTS

The findings showed that the TB doctor seemed to be working with a dilemma, defined as conflicting accountabilities, in the medical encounters. In an organization perceived as inefficient and resource-constrained, the doctor struggled to find a balance between meeting the obligations of the DOTS programme and meeting the needs and expectations of the patients. Strategies to deal with these conflicting accountabilities were identified as limiting patients' involvement, struggling to maintain authority, and transferring responsibility.

CONCLUSION

Professional involvement and patient participation were seen as part of a linked process in this study, and the importance of empowering doctors and health care workers who are implementing DOTS is emphasized. The development of DOTS guidelines needs to be based on the actual process of health care delivery, and staff empowering efforts should also include strengthening of public health care infrastructure.

Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan

This study presents an ethnographic account of health-seeking behaviors and determinants of health service utilization of people living in the rural Northern Areas of Pakistan. Data was gathered from 2004 to 2005 through 10 gender-specific focus group discussions. Sociodemographic characteristics, economic conditions, cultural forces, physical and environmental conditions, and health care service features form the behaviors. The complex composition of health care systems drives us to study the most intricate phenomenon of health care-seeking behaviors. Inappropriate or delayed health care-seeking could lead to undesirable health outcomes, high fertility, unwanted pregnancies, medical complications, and amplified susceptibility to future illnesses. At times it results in a significant economic burden when a simple illness becomes drawn out because of improper health-seeking behaviors. This study is an effort to present relevant information to the policy makers to reorient the health care services to make them more acceptable. It is recommended that this research be used for designing behavior change communication modules or social marketing campaigns in raising awareness about health in the community and sensitizing health care providers to the needs of their clients.

Barriers of mistrust: public and private health sectors' perceptions of each other in Madhya Pradesh, India

India has one of the most highly privatized health care systems in the world. The dominant private health sector functions alongside a traditional tiered public health sector. There has been an overall lack of collaboration between the two sectors despite international policy recommendations and local initiatives. It has been postulated that "conflicting perceptions" might contribute to the uncooperative attitude between the two sectors. But there has been little empirical exploration of the existing perceptions that the private and public health sectors have of each other. We explored these perceptions among key stakeholders (who influence the direction of health policy) in the public and private health sectors in the province of Madhya Pradesh, India. The barriers of mistrust, which hinder true dialogue, are complex, and have social, moral, and economic bases. They can be best addressed by necessary structural change before any significant long-term partnership between the two sectors is possible.

Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study

BACKGROUND

Patients' expectations and perceptions of the medical encounter and interactions are important tools in diabetes management. Some problems regarding the interaction during encounters may be related to a lack of communication skills on the part of either the physician or the patient. This study aimed at exploring the perceptions of type 2 diabetes patients regarding the medical encounters and quality of interactions with their primary health-care providers.

METHODS

Four focus group discussions (two women and two men groups) were conducted among 27 purposively selected patients (13 men and 14 women) from six primary health-care centres in Muscat, Oman. Qualitative content analysis was applied.

RESULTS

The patients identified some weaknesses regarding the patient-provider communication like: unfriendly welcoming; interrupted consultation privacy; poor attention and eye contact; lack of encouraging the patients to ask questions on the providers' side; and inability to participate in medical dialogue or express concerns on the patients' side. Other barriers and difficulties related to issues of patient-centeredness, organization of diabetes clinics, health education and professional competency regarding diabetes care were also identified.

CONCLUSION

The diabetes patients' experiences with the primary health-care providers showed dissatisfaction with the services. We suggest appropriate training for health-care providers with regard to diabetes care and developing of communication skills with emphasis on a patient-centred approach. An efficient use of available resources in diabetes clinics and distributing responsibilities between team members in close collaboration with patients and their families seems necessary. Further exploration of the providers' work situation and barriers to good interaction is needed. Our findings can help the policy makers in Oman, and countries with similar health systems, to improve the quality and organizational efficiency of diabetes care services.