Impact of Patient Communication Preferences on the Patient Trust in Physicians: A Cross-Sectional Study in Iranian Outpatient's Clinics

Study Design and Setting

This is a cross-sectional study conducted over 6 months from July to December 2019 at 2 specialized outpatient clinics associated to the public and private hospitals of Tabriz (Northwest Iran). The services offered by each type of clinic are varying widely, focuses on medical fields such as cardiology, dermatology, ear, nose, and throat (ENT), gastroenterology, gynecology and obstetrics, neurology, oncology, podiatry, and urology. A fee-for-service (FFS) system was the payment model of these clinics and about 1000 patients per month were the average number of patients at each clinic.

Participants and Data Collection

Participants included outpatients who provided the “cardiology, obstetrics and gynecology, and oncology” services at selected clinics. All outpatients were eligible to participate in this study if they were aged 18 years and above, and had the wellness and ability to participate. Severely diseased patients were not capable of giving information, with an acute neuropsychiatric condition or language deficit that would prevent informed consent or accurate evaluation were omitted. The sample size (SS) was measured clinically. The infinite SS equation (SS = (z2 × p × q)/d2) was used according to the entire patient population at the contributing clinics, with a confidence interval of 95% (α = 0.05), therefore a z-score of 1.96 and an absolute precision of d = 0.05. A SS was calculated to be 380 patients in each clinic. However, given an attrition rate of 10%, the sample size was raised to 420 patients in each clinic. A total of 840 patients were invited for this study using convenience sampling from the clients waiting for their doctors’ visits at the clinics. A trained research assistant performed personal interviews using a structured questionnaire shortly after the patient's visit with the doctor was over.

Measures

The questionnaire consisted of 2 parts. Part one: We utilized the KOPRA (communication preferences of chronically ill patients, ‘‘Kommunikationspraeferenzen,’’ in German), to measure the communication preferences of patients. KOPRA has been developed by Farin et al (12) and has 32 items in 4 sub-scales. “Patient participation and patient orientation” (PPPO, 11 items) measure patient communication interests regarding the patient's participation in therapies and considerateness of their ideas and interests. “Effective and open communication” (EOC, 10 items) is a measure of interests in terms of effective collection, conveyance, and share of information and open communication concerning adverse occasions. “Emotionally supportive communication” (ESC, 6 items) assesses interests concerning emotionally supportive communication. “Communication about personal circumstances” (CPC, 5 items) evaluates interests about a personal communication manner that also comprises private facets. The PPPO and EOC scales typically concentrate on implemental aspects of communication, while the ESC and CPC scales deal with affectional elements of communication.

The items of KOPRA were categorized on a Likert scale ranging from 1 to 5 (1 = not so important and 5 = extremely important). The questionnaire has been utilized in multiple studies (13,14) and Cronbach's α had been computed previously for this scale, and the reliability coefficient for scale was between 0.80 and 0.92. The 1 to 5 metric of responses to questionnaire items was maintained through transforming the entire scores of the questionnaire and its dimensions into a 1 to 5 scale via dividing the scores by the number of the corresponding items. Then, the high total score is interpreted as an important communication preference.

Part two: The patient trust was measured using the trust in physician scale for a developing country setting developed by Gopichandran et al (1) with 12 items. The patients were asked to rate the items on a 5-point Likert scale with scores ranging from 1 to 5 (1 = strongly disagree and 5 = strongly agree). The Cronbach's α of the scale was 0.928. In the trust scale, the resultant scores were divided into 4 categories: low trust (scores  < 3), moderate trust (average scores of 3 - 3.99), high trust (average scores of 4-4.99), and blind trust (scores averaging 5.0).

The patients’ demographic information was gathered using a cover page comprising open-ended questions including age, gender, marital status, ethnicity, education status, employment status, place of residence, insurance coverage (yes/no), and hospital ownership.

Data Analysis

Analyses were performed using IBM SPSS Statistics for Windows, Version 25, Armonk, NY: IBM Corp. Descriptive statistics were presented as frequency and percent for categorical variables and mean and standard deviation (SD) for continuous variables. Student's t-test was used to compare the mean of patients’ groups at the public and private hospitals regarding their perception of patient–communication preference and trust. Linear regression analysis (R²) was used to test the association of the independent variable (patient–communication preference) with the dependent variable (trust) making adjustments for patients’ socio-demographic characteristics.

Ethical Considerations

Ethical clearance was sought from the Ethics Committee of Tabriz University of Medical Science (IR.TBZMED.REC.1397.541). Verbal consents were received from the contributors because the data were collected by using a questionnaire and thus did not involve any personal data. The Ethics Committee approved the use of verbal consent.

Communication Preference

In this study, emotionally and supportive communication preference was the most important communication style perceived by participants with their physicians. The results are similar to findings reported in a qualitative study among patients in Indonesia (15), which stressed an overall interest in a partnership manner, and those in Nepal (16) that reported contributors understood the doctor–patient communication mutually. However, a study implemented in 5 countries indicated that a plethora of patients had a feeling of receiving inadequate emotional support. At the same time, they were hospitalized and underwent problems to discuss their disquiets and apprehensions with healthcare specialists (17). In cases of emotional and physical difficulties, patients often anticipate assistance. Still, studies demonstrate that hospitals obtain average to high scores regarding attending physical wellbeing, but that they were able to support patients emotionally adequately (18,19).

Our result also indicated that the effective and open communication style was the second important communication preference perceived by participants with their physician, followed by patient participation and patient orientation style. Recently, an Iranian study has shown that moderate general patient gratification with patient–doctor communication is not desired (20). Regrettably, the issue of communication skills has received less consideration in Iran despite its growing in medical training worldwide. One reason may be that training and role modeling of communication and interpersonal skills in medical education is presently rather concise, considered in the first syllabus, and is not frequently strengthened in the final steps of training (21).

Moreover, people have wide variability in their interest in a communication manner. Given that culture has a significant contribution to organizing and interpreting a person's experiences, its contribution should not be ignored in interpreting and transmitting messages. In fact, communication is inherently culture-dependent. People may be members of multiple cultural groups at the same time. In fact, the entire communication occurs not only inside a sizable cultural milieu but also within diverse micro-cultural backgrounds (22). Ignorance of culture or lowering it to “race” or “ethnic” classes has a tendency in neologization of sociocultural issues, maintaining health dissimilarities, and discriminating the healthcare and elsewhere (23).

The cooperation between patients and health provisioners can be improved when patients are provided with adequate information about their situations (24); on the other hand, patients may experience adverse outcomes when the information is not shared with them. Patients who are unaware of their conditions are more likely of neglecting doctors’ orders (25,26). The peril of overlooking therapeutical orders is reduced by mobile applications, which promote the observance of the orders (27). Furthermore, the availability of patient's information to doctors is improved through the availability of electronically recorded health documents. Observance of confidentiality codes also further encourages the patient for sharing their information and, as a result, diminishes the perils.

Regarding hospital ownership, it has been revealed that in private clinics an “Emotionally supportive communication,” “Effective and open communication” as well as “Patient participation and patient orientation” style of communication are perceived much more critical than public ones. Given the increasing expectations of people in recent years from health systems as in the past, patients are not indifferent to the services they receive in the hospital. Especially patients referring to private hospitals pay a lot of money, and they know the opportunity cost and want better services (28). Patients want the service providers ‘relationship with them to be participatory so that patients’ perspectives can be used in their therapeutic processes.

As has been shown previously, the level of responsiveness especially in communication and autonomy dimensions perceived higher by patients in Iranian private clinics than in public ones (29). Therefore, it might conclude that communication and patient-centered have gotten a lot of attention in private clinics in service previous study showed that Iranian physicians could have a determining contribution to a patient’s choice of a hospital. Such a doctor may be working in a hospital being governmental or privately owned, with highly or poorly qualified conditions, or in proximity or farness from a patient's home (30). Clienteles expect provisioners not only to perform their tasks technically but also to be considerate, well mannered, gracious, and sociable, to present esteem, compassion, sensibility, and gentleness, and to exhibit empathy and kindness for patients.

Trust in Physicians

Findings of this study indicated that outpatients generally had high trust in their physicians. More than 50% of participants in the present study have high or blind trust in the physician. While those of a national cross-sectional study indicated that nearly half of the participants in the survey had a moderate level of trust (31). The differences in the results can be attributed to different participants or different tools.

The finding corresponds to a survey conducted in China, showing that 67% of patients had the confidence or strong confidence in doctors (32). In a Canadian study, blind, high, moderate, and low accounted for 6.3%, 36.1%, 48.6%, and 9.0% of confidence-in-doctor, respectively (33). In the USA and the UK, 70% and 94% of complete trust in doctors were reported in surveyed patients, respectively (34,35). The necessity for high levels of trust in the physician is evident, given the requirement for continuous care, as well as constant communication between the physician and the patient.

Consistent with our findings, a study conducted in Pakistan found that down to 1% of patients were unconfident or untrusted in their physicians whereas around 12.5% confided the physicians to a restricted degree (36). As shown previously, blind confidence was connected to a passive role and low level of confidence with the skeptical method for sharing decision making (33). It may, therefore, be concluded that the participant's least preference for participation and orientation is because of their high trust. Based on previous research patients’ trust in physicians would increase if medical service quality, namely a safe and effective medical service, as well as patient-perceived service satisfaction, improved (37). Some activities, such as training interventions to enhance physician behavior or providing patients with greater information about their care and the opportunity to discuss choices, may be used to strengthen the patient's trust in the physician (9).

Relationship Between Communication Preference and Trust in Physicians

Findings show that trust in the physician has a significant association with patient communication preference and patient trust in physicians. For building confidence with patients, communication needs to be based on a patient-oriented procedure. This has been described as one eliciting, understanding, and validating patients’ perspectives, comprehends the patient within their background psychologically and socially, achieves a shared apprehension of patients’ problems and treatments, and enables them by presenting their meaningful participation in care-related selections (38). To achieve this, Pellegrini states it needs an incentive, or the “inner feeling” on behalf of the clinician, which is the correct task for implementation. Additionally, the doctor's duty is even superior, which is motivating patients for opening up and discussing effectively not only their indications but also their beliefs and most private opinions (39). Some actions, in particular those of the gestural area, including eye contact, attentiveness to talking, the capability to recognize hints in the patient's words, and redirection of conversations, are dependent on individual's motivating mode (40).

In our study, socio-demographic variables such as gender, marital status, ethnicity, education, occupation, or insurance status were not significant in predicting the patients’ trust in physicians, which corresponds to the findings of previous studies (41–43). However, factors affecting confidence may be varied depending upon their educational or occupational levels as reported in earlier research conducted quantitatively (1). However, patients’ trust in physicians increased with the patient's age, which was in line with the study conducted in the UK (42). In the Chinese study, it was detected that confidence in doctors was less probable in younger patients, whereas the elevated likelihood of confidence in doctors was found in those with higher educational levels or more incomes (32). Highly scored confidence can be attributed to selections or reports of biases in confidence investigations. Patients may show reluctance in admitting their aversion of their physicians, as they are concerned that this will influence their care in case of finding out this by their physician.

In our study, clients of private hospitals perception regarding trust in physicians were 13% more than those in the public one. A previous study revealed that specialty physicians, pharmacy doctors, nurses, and general physicians were most trustable among the inhabitants of Tabriz (44). Similarly, a study in Australia demonstrated varying degrees of confidence between governmental and privately owned hospitals (45). These observations do not correspond to those of qualitatively conducted research in South Australia, concluding the confidence of patients was similar in governmental and privately owned hospitals (46).

To create confidence (or non-confidence) in hospitals by patients, they should also possess some degree of confidence in the healthcare specialists working therein, the government financing it, the supportive professional organizations, etc (47). People had trust in governmental provisioners for their medical abilities, referral systems, and truthful interplays with patients. Private provisioners were confided as they supplied treatments comfortably and easily at patients’ houses; patients believed that they were sociable and compassionate that allowed patients to be indebted in case of their inability for payment when they sought for care (4).

Participants who were living in rural areas have been shown to have 14% more trust than those in urban areas. In a study conducted in Cambodia, villagers’ confidence in varying healthcare provisioners seemed to be a significant consideration that affected people's healthcare-seeking behavior, and villagers generally believed in physicians, representing that people trusted in physicians as a professional group (4).