Client communication behaviors with health care providers in Indonesia
Introduction
The quality and quantity of patients’ communication with health care providers is critical to their ability to manage chronic conditions and may affect health outcomes [1], [2], [3]. Family planning clients face demands similar to those of patients with chronic medical problems. They must select a contraceptive method from among many options, and they are responsible for effective method use (e.g. taking the pill daily or checking IUD strings each month), monitoring side effects, and returning for scheduled check-ups and re-supply [4], [5].
Studies have found that patients or clients who articulate their needs, concerns, and symptoms during consultations are more likely to supply the information providers need to make an accurate diagnosis, select effective treatment, and offer appropriate advice. Clients who ask for information, for clarification, and for providers’ opinions may get a better understanding of their situation and therefore, are able to make well informed decisions. As a result, they may have more confidence in and a greater commitment to the treatment plan [1], [2], [6], [7], [8], [9], [10], [11]. Moreover, clients who receive more information from their providers, more social and positive talk, and more facilitation of partnership in their communication are more satisfied, have higher levels of recall and understanding, and are more compliant [12].
While few of the studies directly observing medical communication have been conducted outside of the developed world or in non-medical settings, there is some evidence that the interpersonal dynamics of these medical encounters are generalizable to diverse settings and health contexts. For instance, an analysis of family planning consultations in Egypt concluded that client-centered visits were associated with greater client satisfaction and method continuation [13]. Analysis of primary care medical consultations in Trinidad and Tobago [14] and in Honduras [15] similarly show an association between patient-centered communication and patient satisfaction.
Despite the importance of their participation, health care patients and family planning clients in both developed and developing countries generally play a passive role in consultations [13], [14], [16], [17]. Many factors contribute to limited client participation, including the social distance between client and provider and long held medical conventions about doctor–patient relations. Differences in the medical knowledge, educational level, and socioeconomic status of provider and client create a highly unequal relationship between them [18]. Clients tend to defer to providers’ expertise and higher social standing. This inherently unequal relationship is reinforced by the conventional medical model of provider-centered care, in which doctors assume an authoritarian role [17], [19].
Both providers and clients tend to undervalue client participation. Doctors and other health care providers do not always appreciate the importance of the information clients have to offer and also underestimate clients’ need for information and desire to participate [20], [21], [22]. Although, most clients want to know more about their condition than providers tell them and to discuss their concerns [23], [24], clients fear that providers will dismiss or devalue their comments and questions. They also worry about taking up providers’ time and lack the communication skills needed to deal with providers [25].
In Indonesia, local cultural norms reinforce the dynamic of client–provider interaction. Two basic principles permeate social life and influence the way people interact: conflict avoidance and respect [26]. The Indonesians’ desire to maintain “rukun”, or social harmony, and to avoid conflict results in a high-context communication style that is indirect, often ambiguous, and affectively neutral [27]. Indonesians’ respect for people of higher status extends to health care providers and reinforces the authoritarian model typical of medical care. Clients are keenly aware of their lesser hierarchical position in the client–provider dyad and defer to providers both to show respect and to avoid conflict. Thus, the cultural context hinders clients from freely voicing disagreement, concern, or confusion and largely limits them to responding to providers [28].
Over the past two decades, however, client-centered models of care and shared decision making have gained increasing acceptance among health professionals [8], [19], [23], [29]. These new approaches recognize that clients have valuable information to contribute to health consultations and that they have the right and the ability to make their own health care decisions. The client-centered approach to health care requires changes in client as well as provider behavior: clients must take greater responsibility for their care, and they must make greater efforts to communicate their interests and concerns to providers.
Despite the increased importance attached to client communication, few studies have examined client behavior. The limited data available suggest that clients participate in health care consultations in three ways: (1) by providing information to providers; (2) by asking questions or using other techniques to elicit information from providers; and (3) by verifying the information they receive. Many clients employ passive rather than active strategies to achieve these three goals, for example, waiting for specific cues from service providers before speaking [6], [7], [9], [24].
The main objective of this study is to analyze the determinants of active communication in Indonesia in order to devise client education and provider training interventions to encourage active client communication. This study applies the roter interaction analysis system (RIAS) to assess client and provider communication dynamics.
Several factors have the potential to affect client communication. First, providers may or may not encourage the client to play an active role, either by asking questions or by using other verbal strategies, such as partnership building. Second, client characteristics, such as age, education, and ethnicity, may influence their willingness to speak out. Third, the context and content of the consultation may prompt client participation. For example, longer sessions may be less rushed and give clients more opportunity to speak, while the need to explain symptoms may give them the motivation. Our hypotheses are
- •
facilitative communication by providers that fosters dialogue and rapport will increase active communication by family planning clients;
- •
certain client characteristics will increase active communication, including higher education, older age, and non-Javanese ethnicity;
- •
the rate of client active communication will be greater in longer sessions;
- •
the more actively clients communicate, the more satisfied they will be with their level of participation.
Section snippets
Methods
Data were collected on 1203 family planning consultations in Indonesia. Sessions were audiotaped and later coded to measure client and provider communication, providers and clients were interviewed and clinic records were examined. Qualitative analysis was also employed: researchers reviewed the audiotapes and extracted verbatim examples of various types of communication. This analysis uses existing data that were collected over a 6-month period to evaluate the impact of interpersonal
Client active communication
Clients had a one-third share of the total conversation during family planning consultations. On average, 12% of their communication was active, which is equivalent to 5.7 of the average 49 client utterances per consultation. However, levels of client active communication varied widely between consultations, ranging from 0 to 67 utterances. The percentage distribution of client active communication (Table 2) shows that it consisted mostly of questions (44%) and social talk (25%), but the
Maximizing client active communication
Despite generally low levels of participation, clients did actively participate in consultations in at least five different ways: by asking questions, asking for clarification, expressing opinions, expressing concerns, and engaging in social talk. The first four promote a fuller exchange of information between client and provider, while the fifth builds rapport that may encourage clients to talk freely. The fact that providers “accepted” the behavior even of unusually assertive clients shows
Acknowledgements
The study report was carried out by the Quality Assurance Project (QAP), which is managed by the Center for Human Services (CHS), Bethesda, MD, and funded by the US Agency for International Development (USAID) contract number HRN-C-00-96-90013. The study report was done through the Johns Hopkins University Center for Communication Programs (JHU/CCP), a sub-contractor of QAP. The authors thank Leslie B. Curtin and Bambang Samekto (USAID/Indonesia), Pudjo Radandjo, Maman Sudjana, and Sugiri
References (33)
Physician–patient interaction in reproductive counseling
Obstet. Gynecol.
(1996)- et al.
The effects of communication skills training on patients’ participation during medical interviews
Patient Educ. Couns.
(2000) - et al.
Doctor–patient communication: a review of the literature
Soc. Sci. Med.
(1995) - et al.
Shared decision making in the medical encounter: what does it mean? (or it takes at least two to tango)
Soc. Sci. Med.
(1997) Information-giving in medical consultations: the influence of patients’ communicative styles and personal characteristics
Soc. Sci. Med.
(1991)- et al.
Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes
J. Intern. Med.
(1988) - et al.
Assessing the effect of the physician–patient interaction on the outcomes of chronic disease
Med. Care
(1989) - et al.
Patient exposition and provider explanation in routine interviews and hypertensive patients’ blood pressure
Health Psychol.
(1987) - et al.
Through the patient’s eyes: strategies toward more successful contraception
Obstet. Gynecol.
(1996) - et al.
Expanding patient involvement in care: effects on patient outcomes
Ann. Intern. Med.
(1985)
Patient participation in the patient–provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance
Health Educ. Monogr.
The patient–physician relationship: communication patterns of primary care physicians
JAMA
Effective physician–patient communication and health outcomes: a review
Can. Med. Assoc. J.
Effectiveness of interventions to improve patient compliance: a meta-analysis
Med. Care
The effectiveness of a continuing medical education program in interpersonal communication skills on physician practice and patient satisfaction in Trinidad and Tobago
Med. Educ.
Cited by (44)
Deficient Health Care Services as Barriers to Meet Care Needs of Gynecological Cancer Survivors in Indonesia: A Qualitative Inquiry
2021, Seminars in Oncology NursingCitation Excerpt :The phenomenon in which patients are in an insubordinate position and easily become the subject of blaming attitude of health providers and hospital administrative staffs is common in limited settings of Indonesia.29 Public health care services are used to adopt an authoritarian model of medical care in which health professionals allocate themselves in a higher position than patients.29 Patients usually aware of this proposition, but most have to tolerate these providers’ behaviors and show respect because they usually do not have alternative options of health care facilities or providers.
Nurse responsiveness to cancer patient expressions of emotion
2009, Patient Education and CounselingSix Recommendations for Provider Behavior Change in Family Planning
2023, Global Health Science and PracticeRegistered nurse–patient communication research: An integrative review for future directions in nursing research
2023, Journal of Advanced Nursing