Chapter 14 HEALTH COMMUNICATION: MESSAGES AND MEANINGS

1
Chapter 14HEALTH COMMUNICATION MESSAGES AND
MEANINGS

• D.F.Marks, M.Murray,
• B.Evans, C.Willig, C.Woodall
• C.M. Sykes (2005)
• Health Psychology Theory, Research Practice
• (2nd edition). London Sage.
• Starred authors feature in video-clips

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HEALTH COMMUNICATION MESSAGES AND MEANINGS

• Introduction
• Approaches to the study of doctor-patient
  communication
• Methods used to study doctor-patient
  communication
• General criticisms of work in doctor-patient-inter
  action
• Recent trends
• Summary

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What is health communication?

• Health communication is communication in any form
  that contributes to the promotion of health.
• According to Ratzan (1996)
• Health communication is concerned with the
  use of ethical, persuasive means to craft and
  deliver campaigns and implement strategies that
  promote good health and prevent disease (p.v)

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Introduction

• In this chapter, we will focus on interpersonal
  health communication (for public health
  communication, see Chapter 11?)
• The bulk of the literature in this field is
  concerned with doctorpatient communication
  within the surgery setting.
• However, it is necessary to bear in mind that
  health promotion activities are carried out in
  some form by all health-care professionals (HCPs)
• HCP-patient communication is a key issue for
  health psychologists.
• Today, we will critically review the major
  theories and research methods, and introduce
  recent trends and future directions.

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The importance of doctor-patient communication

• Communication is an essential route to
  information about a patients physical and/or
  mental state.
• It also has been suggested that effective
  communication can have a therapeutic effect in
  itself (e.g. Radley, 1994).

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Limitations of doctor-patient communication

• Doctorpatient communication is not always
  effective.
• Patients understanding and memory of what they
  have been told by the doctor is limited.
• Compliance with doctors advice is another issue
  (for further discussion, see Chapter 15).
• A substantial proportion of patients problems
  remain undisclosed and undetected (Maguire,
  1984).
• The proportion of dissatisfied patients remained
  surprisingly, and disappointingly, constant over
  25 years (Ong et al., 1995).

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Improvements in doctor-patient communication

• Improvements in the quality of doctorpatient
  communication could generate significant benefits
  for both patients and service providers.
• Greater patient satisfaction with health-care
  services
• Increased patient adherence to treatment regimens
• Decreases in anxiety and distress on the part of
  patients
• Better mental health in doctors
• Improved health promotion and disease prevention
• Quicker recovery from surgery
• Shorter lengths of stay in hospital

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APPROACHES TO THE STUDY OF DOCTORPATIENT
COMMUNICATION
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The deviant patient perspective

• Early studies focused on patient characteristics
  in their attempt to account for failures in
  doctorpatient communication.
• For example, Balints (1964) psychoanalytic study
  assumed that patients were routinely masking the
  real problem and that it was the doctors task
  to uncover it.
• Another popular early research question was -
• what is it about the patient that makes
  him/her a defaulter?

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The deviant patient perspective

• The search for patient characteristics
  responsible for non-adherence to treatment
  regimens met with little success.
• Instead, it was found that there was a link
  between patient satisfaction and compliance or
  adherence (e.g. Ley, 1982)
• Traditional concepts of authority were challenged
  and led to a shift of focus onto the role of the
  doctor.

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The authoritarian doctor perspective

• This approach focuses at the ways in which
  doctors use their authority in order to control
  the doctorpatient interaction.
• In a classic study, Byrne and Long (1976)
  identified different communication styles among
  doctors.
• These constitute a continuum from
  patient-centred to doctor-centred styles
• Patient-centred style uses the patients
  knowledge and experience through techniques such
  as silence, listening and reflection
• Doctor-centred style uses the doctors knowledge
  and skill, for example, through asking questions

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The authoritarian doctor perspective

• The major criticism of doctors traditional
  communication style was that it was characterized
  by working to rigid agendas, little listening to
  patients accounts and little open discussion of
  treatment options.
• However, there are also conflicting findings
  regarding patient-centred styles and patient
  satisfaction (see Stewart, 1984 Winefield et
  al., 1996).
• Kreps (1996a) advocated a consumer orientation to
  health care and health promotion in order to
  address the imbalance of power between providers
  and consumers.
• Until this power imbalance is corrected, training
  in communication skills is unlikely to succeed
  (Meeuwesen et al., 1991). for further
  discussion of issues relevant to health
  communication, see Kreps, 2001, Reading 18 in
  Marks (2002)

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The interactive dyad perspective

• In the 1990s researchers began looking at the
  communicative event to which both doctor and
  patient contribute.
• Thus, both doctor and patient are seen to be
  shaping the conversation by using discursive
  resources in order to achieve interpersonal
  objectives.
• The importance of non-verbal communication in the
  form of eye contact, facial expression, gestures
  and other forms of communication has also been
  highlighted (Bensing, 1991).
• A focus on the communicative event also allows
  the role of culture specificity in doctorpatient
  interactions to be explored.

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METHODS USED TO STUDY DOCTORPATIENT COMMUNICATION

• Interaction analysis systems (IAS)
• The interaction analysis system is the most
  widely used research tool in doctorpatient
  communication to date.
• It is an observation instrument that allows the
  researcher to identify, categorize and quantify
  features of the doctorpatient encounter.

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Example of a study using IASStreet (1991)

• Objective
• To explain systematic differences in information
  giving by doctors
• Variables tested
• Patients communicative style
• question asking, affective expressiveness and
  opinion giving
• Patient characteristics
• education, age, sex, anxiety
• Physicians partnership-building utterances
• utterances that invite patients questions,
  concerns/opinions

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Example of a study using IASStreet (1991)

• Video recordings of doctorpatient interactions
  at a family practice clinic at a teaching
  hospital in the USA were transcribed.
• The following five verbal behaviours were coded
• Physicians information giving
• Physicians partnership building
• Patients opinion giving
• Patients affective expressions
• Patients question asking

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Example of a study using IASStreet (1991)

• FINDINGS
• Patients asked few questions (only 4.1 of all
  patient utterances) and offered few opinions
  (6.4).
• Physicians rarely solicited the patients
  concerns, opinions and questions (2.3).
• More anxious patients received significantly
  more information from their doctors.
• Younger and more educated patients were more
  likely to receive more diagnostic information.

• Differences in physicians information giving are
  partially mediated by differences in patients
  communicative style (i.e. via question asking).
• However, it would be wrong to conclude that
  patients communicative style is the cause of
  physician information giving, since patients
  question asking is largely a response to
  physicians partnership-building utterances.

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Limitations of IAS

• It does not allow us to analyse sequencing in
  conversation
• IASs can only tell us what types of utterances
  were made, by whom and how often.
• It does not allow us to explore who initiates
  particular turns and with what consequences.
• It relies upon a literal reading of statements.
• Rhetorical strategies such as irony or sarcasm
  and their communicative functions cannot be
  identified and analysed.

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METHODS USED TO STUDY DOCTORPATIENT COMMUNICATION

• Questionnaire studies
• A number of questionnaires have been developed to
  measure various aspects of the doctor-patient
  communication.
• This can include the patients perceptions of
  doctors communication style and patient
  satisfaction.
• Questionnaires are predominantly used to study
  the doctors rather than the patients
  communication styles.

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Example of a questionnaire study Makoul et al.
(1995)

• Objective to study discrepancies between
  perceived and actual communication.
• They video-recorded 903 consultations involving
  39 GPs and their patients in Oxford, UK.
• After the consultation, patients were asked to
  complete a questionnaire that included a section
  about their perceptions of communication during
  the consultation.
• Doctors questionnaires included questions about
  their patients characteristics as well as their
  own communication styles.
• Analysis of the video-recordings involved the use
  of checklists that allowed the researchers to
  record mention of a particular topic, as well as
  who initiated discussion of the topic.

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Example of a questionnaire study Makoul et al.
(1995)

• FINDINGS
• Physicians most frequently mentioned the product
  name (in 78.2 of consultations) and instructions
  for use of the medication (86.7), whereas
  patients remained extremely passive.
• There was little discussion of issues such as
  side effects or the patients opinion about the
  medication.
• Analysis of the questionnaires revealed that both
  doctors and patients overestimated the extent to
  which these issues had been discussed during the
  consultation.

• The observed pattern of communication about
  prescription medication does not contribute to
  the development of patients decision-making
  competencies.
• The observed discrepancies between interactants
  perceptions and actual communication cast doubt
  on communication studies that use self-report
  methods alone.

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Limitations of questionnaire studies

• Reliance on participants memories of their
  perceptions of the interaction.
• Memory may be faulty
• Participants perceptions at the time of the
  interaction may have been distorted
• The use of closed, multiple-choice items does not
  allow participants to generate their own criteria
  for evaluating doctorpatient communication.
• Patients may be reluctant to be critical of their
  doctors.

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METHODS USED TO STUDY DOCTORPATIENT COMMUNICATION

• Qualitative textual analysis
• Qualitative approaches to doctorpatient
  communication recognize that both doctor and
  patient shape the communicative event.
• Qualitative textual analysis aims to identify the
  discursive strategies that speakers use in order
  to manage their discursive objectives.
• It can also be used to explore the ways in which
  meaning is constructed and negotiated by
  participants.

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Example of a discourse analytic studyCoupland
et al. (1994)

• Objective to explore how the opening phases of
  consultations between doctors and elderly
  patients are achieved and how participants enter
  a medical frame of talk.
• They analysed 85 audio-taped consultations at a
  geriatric outpatients clinic in the UK

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Example of a discourse analytic studyCoupland
et al. (1994)

• FINDINGS
• Consultations were typically initiated by some
  form of socio-relational talk
• Summons/approach (e.g. Come in.)
• Greetings (e.g. Hello there.)
• Dispositional talk (e.g. Do sit down. Wont
  keep you a minute.)
• Familiarity sequence (e.g. I think I saw you
  two weeks ago, didnt I, Mrs Smith?)
• Holding sequence (e.g. Lets have a look at
  your notes.)
• How-are-you type exchange (e.g. How are you
  feeling?).

• Patients as well as doctors played significant
  parts in negotiating how and when they should
  move into medically framed talk.
• This is vital within the context of geriatric
  care since many of the consequences of illness
  for elderly patients are experienced socially
  (e.g. reduced mobility or reduced independence).

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Limitations of qualitative textual analysis

• Qualitative textual analysis is extremely time
  consuming.
• It also does not allow us to generalize.
• It conceives of the doctorpatient interaction as
  an entirely localized event, which fails to take
  into account power relations that pre-exist the
  doctorpatient encounter.
• We need to look beyond the text in order to
  identify such factors.

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METHODS USED TO STUDY DOCTORPATIENT COMMUNICATION

• Triangulation
• Triangulation involves the combination of
  different methods of data collection and
  analysis.
• This approach allows the researcher to gain more
  than one perspective on the same phenomenon.

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Example of a study using triangulationOBrien
and Petrie (1996)

• Objective to examine the nature of patient
  participation in the medical consultation and its
  effect on patient understanding, recall and
  satisfaction
• Variables measured
• Frequencies of types of patient participation
  (quantitative)
• Content of patient participation (qualitative)
• The consultations of 99 patients with joint pain
  from two hospitals in New Zealand were audiotaped
  and transcribed using the Verbal Response Mode
  (VRM) coding system (Stiles et al.,1979)

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Example of a study using triangulationOBrien
and Petrie (1996)

• Patients ability to remember and understand
  information presented during the consultation as
  well as patient satisfaction with the
  consultation were assessed immediately after the
  consultation via two verbally administered
  questionnaires.
• Transcripts from patients with the highest (n
  10) and the lowest (n 10) scores on
  participation were selected for a qualitative
  analysis of the content of their consultations.

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Example of a study using triangulationOBrien
and Petrie (1996)

• QUANTITATIVE ANALYSIS
• Majority of patient utterances in the
  history-taking section of the consultation
  provided information - the doctors contribution
  to this part of the consultation consisted
  largely of questions and reflection.
• During the examination section, patients offered
  information while doctors began to move from
  questions to edification, disclosure and
  interpretation.
• Patients asked more questions in the conclusion
  section than in any other part of the
  consultation.
• The conclusion section contained most of the
  doctors information provision utterances.

• QUALITATIVE ANALYSIS
• Patient participation was not necessarily
  constructive - patients with high levels of
  participation tended to report symptoms in a
  random, unfocused manner and expressed anger and
  frustration.
• These were also characterized by tensions and
  misunderstandings between doctor and patient, low
  levels of patient satisfaction and low levels of
  recall scores.
• By contrast, patients with the lowest
  participation levels showed very little emotion,
  complained little and confined their comments and
  questions to the specific symptoms that brought
  them to the clinic.

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Example of a study using triangulationOBrien
and Petrie (1996)

• The authors suggest that there may be an optimal
  level of patient participation required for a
  constructive medical interview.
• They conclude by discussing possible ways in
  which constructive patient participation may be
  facilitated.

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Limitations of triangulation

• The use of triangulation constitutes a
  methodological challenge for most researchers
  since it requires considerable research skills in
  more than one research method.
• There is a risk of using a methodological
  approach with which researchers are not familiar
  and of which they have limited experience.
• As a result, a study using a combination of
  methods can be lopsided in the sense that only
  one part of the study carries any scientific
  weight.

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GENERAL CRITICISMS OF WORK IN DOCTOR-PATIENT
INTERACTION

• Most research attempts to identify general laws
  or categories
• Different theories should be developed for
  different types of doctorpatient interactions,
  including diverse patient groups with
  communication needs
• Children, the elderly, people with AIDS, disabled
  people in general and people with cognitive,
  sensory and communication disabilities
• The vast majority of research takes place in the
  GPs surgery
• Other relevant settings and health-professionals
  should be included
• Hospital wards, home visits or family planning
  clinics
• Nurses, health visitors, midwives, dentists,
  receptionists, therapists, benefit agency
  assessment doctors and hospital doctors.
• Researchers have tended to use limited outcome
  measures
• Further measures of health status and quality of
  life should be used

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RECENT TRENDS The role of gender

• A number of studies have identified gender
  differences in doctors communication.
• Female doctors are generally found to adopt more
  patient-centred communication styles whereas
  their male colleagues tend to be more directive
  and controlling (van der Brink-Muinen et al.,
  2002).
• Both male and female patients seem to feel more
  empowered by communicating with female doctors
  (Hall and Roter, 2002).
• These findings resonate with the general
  literature of gender differences in communication
  (Paludi, 1992).
• Future research requires exploration of the
  relationship between physicians gender and
  communication style and patient communication
  needs.

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RECENT TRENDS The role of culture

• Cultural differences may be reflected in the ways
  in which health care professionals and patients
  communicate with each other (eg. van den
  Brink-Muinen et al., 2002).
• Discrepant, culturally specific explanatory
  models of health and illness may lead to
  misunderstandings between patients and
  health-care providers.
• Cultural differences play a role in how patients
  perceive and evaluate their doctors conduct.
• When working with patients from ethnic
  minorities, doctors have poorer interpersonal
  skills, provide less information and use a less
  participatory decision-making style (Ashton et
  al., 2003).
• As Western societies are becoming increasingly
  multicultural, more research is needed in order
  to study the role communication may play in
  perpetuating health inequalities (see Ashton et
  al., 2003).

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RECENT TRENDS Disability and communication

• The medical model is involved extensively in the
  management and control of the lives of disabled
  people, as doctors represent the gatekeepers to
  medical and non-medical resources.
• This power dynamic influences communication and
  potentially generates strained interactions.
• Disabled people may be afraid to express
  themselves for fear of being refused services or
  having them taken away.
• Doctors stereotypes and personal opinions about
  different impairments also have significant
  effects on interactions.

Disabled people are also more likely to have had
bad experiences with doctors and have lower
expectations of having their needs addressed.
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RECENT TRENDS Disability and communication

• The very nature of sensory, communication, and
  cognitive impairments can result in interactions
  that are even less appropriate.
• This represents a communication barrier for which
  few health professionals are adequately trained
  in handling
• The presence of third parties (e.g. interpreters,
  personal assistants/carers, community team
  members etc) can further disrupt communication
  with people with these impairments.
• Cultural and language issues may interact with
  the other aspects of communication.
• Issues regarding informed consent also become
  problematic.

Studies looking at the communication experiences
of disabled people in a range of contexts are
urgently required.
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RECENT TRENDS Reconceptualization of compliance

• Compliance is defined as -
• the extent to which the patients behaviour ...
  coincides with medical or health advice (Haynes,
  1979)
• However, researchers have questioned the
  traditional conceptualizations of compliance.
• Today the term concordance is thought to be a
  more appropriate term than compliance.
• More detailed discussion of this topic follows
  in Chapter 15

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RECENT TRENDS The impact of computer
technologies on communication

• In recent years the use of computers during the
  consultation process has become increasingly
  widespread.
• So far, studies (eg. Greatbatch et al., 1995)
  suggest that the use of the computer does indeed
  change the nature of the interaction.
• The use of e-mail in doctor-patient communication
  constitutes another example of how computer
  technologies can impact doctor-patient
  communication.

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RECENT TRENDS Non-verbal communication

• Non-verbal communication in the health-care
  setting has received surprisingly little
  attention to date.
• Body posture, facial expressions including nods
  and blinks, voice quality and tone, hand
  gestures, gaze/eye-contact, laughter/crying,
  proximity, touch, etc.
• Miller (2002) notes that non-verbal dimensions of
  the doctor-patient interaction can contribute to
  the quality of the patient experience by
  generating a sense of comfort, relaxation and/or
  pleasure.

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RECENT TRENDS The role of communication in
coping with illness

• Recently, health psychologists have begun to
  explore the ways in which communication mediates
  the illness experience itself.
• For example, the Relational Model of Health
  Communication Competence (Query and Kreps, 1996)
  proposes that physiological and psychological
  health outcomes are influenced by health-care
  participants level of communication competence.
• Competence is characterized by provider and
  consumer skills, such as empathic listening,
  verbal and non-verbal sensitivity, encoding and
  decoding skills and interaction management.
• Communication practices can help avoid further
  depression of their immune system and cope better
  with their illness (Frey et al., 1996).

More research into the effects of communication
practices upon quality of life as well as
physical health outcomes is needed.
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RECENT TRENDS Counselling within a medical
context

• The development of increasingly sophisticated
  diagnostic tests and screening procedures has
  highlighted the need for informed consent and
  patient choice.
• As new forms of screening and treatment emerge,
  health psychologists need to study the ways in
  which communication is used in their management.
• This is particularly important when screening
  practices and policies are still new and
  undeveloped and potentially open to psychological
  input.

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Summary

• There are three major approaches to the study of
  doctorpatient communication (i) the deviant
  patient (ii) the authoritarian doctor (iii)
  the interactive dyad.
• Questionnaires, interaction analysis systems and
  qualitative textual analysis are methods with
  which to study doctorpatient communication.
• Both doctors and patients communicative styles,
  demographic as well as personal characteristics,
  can influence the nature and quality of the
  communicative event.
• Typically, patients ask few questions and rarely
  offer their opinions during consultations with
  the doctor. Doctors do little to solicit
  patients questions, concerns and opinions.
• In Byrne and Longs terms, doctorpatient
  communication remains doctor-centred.

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Summary (continued)

• Qualitative approaches to doctorpatient
  communication recognize that both doctor and
  patient shape the communicative event.
• Gender differences have been identified in
  doctors communication styles.
• In recent years the use of computers during the
  consultation has become increasingly widespread.
  Studies suggest that the use of the computer
  changes the nature of the doctorpatient
  interaction.
• Health psychologists have begun to explore the
  ways in which communication mediates the illness
  experience. It has been suggested that
  physiological and psychological health outcomes
  can be influenced by health-care participants
  communicative style, skills and practices.
• Future research in doctorpatient communication
  should focus on the communication needs of
  different patient groups, the role of the setting
  in which communication takes place, the
  relationship between communication and health
  status and the implications of new technologies
  for doctorpatient communication.