Increasing patient participation in reproductive health consultations: an evaluation of “Smart Patient” coaching in Indonesia
Introduction
Patients can improve the quality of their reproductive health care by actively communicating with doctors, nurses, and other providers. Research shows that when patients fully disclose their concerns, expectations, and preferences, providers can assess their problems more accurately and offer better advice [1], [2]. Similarly, when patients request information from providers, they make better informed decisions, feel more control over those decisions, and are more committed to implementing them [3], [4], [5]. When patients check their understanding of instructions, they are better able to recall them and more likely to take action [6], [7], [8]. Yet studies have found that patients in both developed and developing countries generally participate little in consultations: they rarely express all of their concerns, ask few questions, keep their responses brief, and seldom clarify information [9], [10], [11], [12].
In Indonesia, patients must overcome stiff psychosocial barriers to participate actively in family planning and health consultations. Patients in Asian cultures may participate less, not because they are less assertive or lack self-efficacy, but because cultural norms emphasizing conflict avoidance and respect for people of higher status make patient participation socially inappropriate [5], [13], [14]. These norms reinforce the conventional model of medical care, in which doctors play an authoritarian role and assume total control of the consultation while patients are supposed to be passive [15]. Wide disparities in education and social class create a profound social distance between patients and providers in Indonesia that may constrain the flow of information [12], [16], [17], [18]. Finally, many women in Indonesia have had providers ignore, dismiss, or become annoyed by their questions and concerns in the past. There is no reason for them to take the difficult step of speaking out unless they believe providers will respond positively and the quality of their care will improve [5].
To encourage patients to participate more fully in health care visits, researchers in developed countries have tested various patient education interventions for the waiting room. Patients have been given print materials to read [1], [2], [6], [8], [19], [20], [21], videotapes or computer programs to view [22], [23], or individual coaching by a patient educator [3], [7], [10], [24]. A few interventions have reached patients at home or in the community with print materials [19], [25], telephoned instructions [20], or group educational programs [26].
Most of these interventions have focused on teaching patients specific communication skills, such as how to ask questions, disclose information about symptoms and medical concerns, and check understanding of the diagnosis and treatment plan. Legitimizing patients’ right to speak also has been a key component of some projects [6], [8], [21], [25].
The results of these interventions have been largely, although not entirely, positive [27]. In some studies, brief training of patients in communication skills before they see a provider has helped them ask more questions [7], [8], [10], [22], disclose more information about their health problems [19], [20], [22], elicit more factual information from providers [3], [19], [24], [28], and recall treatment plans more accurately [6], [7]. Other studies have found no impact on question asking [3], [21], [24], [28] or recall of treatment plans [8]. The impact on patient satisfaction and anxiety levels has been inconsistent.
In Indonesia, the State Ministry of Population/National Family Planning Coordinating Board (BKKBN) is committed to improving the quality of patient–provider interactions in reproductive health care. Initial efforts focused on providers. Experts developed a curriculum on interpersonal communication and counseling (IPC/C) skills for nurse-midwives and nurses working at local clinics (puskesmas). Part of the curriculum discussed how providers could encourage patient participation. Providers in East Java and Lampung provinces attended refresher workshops on IPC/C in 1998 and 1999, after which some also participated in innovative self-assessment and peer review activities to reinforce that training. This training and reinforcement program markedly improved provider communication but had a more limited impact on patient behavior [13].
In response to these results, BKKBN shifted its attention to patient education. Planners decided on a waiting room intervention, in part, to take advantage of patient waiting time at clinics and, in part, to maximize the impact of the intervention by reaching patients immediately before they saw a provider. Individual patient coaching was used to overcome potential literacy problems posed by print materials and to allow the intervention to be tailored to individual patient needs. The content of this “Smart Patient” intervention was based on prior research into patient–provider communication in Indonesia, which suggested the importance of giving patients explicit permission to speak out and of coaching them on how to ask questions, express concerns, and request clarification [13], [29].
The present study tests the impact of Smart Patient coaching on patient participation and provider communication during family planning counseling sessions in Indonesia. Specific research questions include:
- •
Does coaching increase patients’ belief that they can and should speak out?
- •
Does coaching increase the number of questions asked, concerns expressed, and requests for clarification made by patients?
- •
Does coaching affect some patients more than others, depending on their age, education, assertiveness, or other characteristics?
- •
Does coaching have an indirect effect on providers, increasing the amount of tailored information they give patients?
- •
Does coaching contribute to contraceptive method continuation at 8 months?
Section snippets
Research design
The study was conducted in 64 clinics in two districts of East Java province (Jombang and Mojokerto) that have a similar socioeconomic make up and are roughly the same distance from the provincial capital of Surabaya. The clinics were randomly selected from those that had participated in a previous study of IPC/C training and reinforcement [13]. One provider per clinic was invited to participate. In most cases, they were the only provider at the clinic who concentrated on family planning
Barriers to patient participation
According to patient interviews, poor communication skills pose the most common psychosocial barrier to communicating with the provider: 78% of patients reported sometimes or often forgetting to ask questions, while 66% found it hard to think of questions. Other barriers reflect the unequal relationship between patients and providers. More than half of patients worried that: they were taking up the provider’s time, their questions were not important, the provider would not be interested or
Complementary strategies
Smart Patient’s two-pronged strategy—overcoming psychosocial barriers to participation while also teaching effective communication skills—was key to its success. Educators and print materials explicitly gave patients permission to speak, a tactic that has proven powerful in other studies [8], [25]. Patients in focus groups agreed that this was one of the most valuable aspects of the intervention. They also confirmed other research which has suggested that conducting patient education in the
Acknowledgements
This study was made possible by financial support from the US Agency for International Development under Cooperative Agreement HRN-A-00-98-00012-00, through the Population Council/Frontiers Project, Small Grants. The authors thank Leslie B. Curtin, Molly Gingrich, Lana Dakan, Pam Wolf, and Bambang Samekto (USAID/Indonesia); Sugiri Syarief, Eddy Triatmodjo, Siti Fathonah, Wahyuni, Endah Winarni, Mudjianto of National Family Planning Coordinating Board (BKKBN); Nurfina Bachtiar, Endang Iradati,
References (34)
- et al.
Empowering the patient in the consultation: a pilot study
Patient Educ. Couns.
(1996) - et al.
Improving the efficiency of patients’ comprehension monitoring: a way of increasing patients’ participation in general practice consultation
Soc. Sci. Med.
(1985) Information-giving in medical consultations: the influence of patients’ communicative styles and personal characteristics
Soc. Sci. Med.
(1991)- et al.
The effects of patient communication skills training on patients’ participation during medical interviews
Patient Educ. Couns.
(2000) Encouraging patient question-asking: a clinical trial
Patient Educ. Couns.
(1988)- et al.
Encouraging outpatients to make the most of their first hospital appointment: to what extent can a written prompt help patients get the information they want?
Patient Educ. Couns.
(1999) Empowering older patients to communicate more effectively in the medical encounter
Clin. Geriatr. Med.
(2000)- et al.
Improving patient and provider communication: a synthesis and review of communication interventions
Patient Educ. Couns.
(1991) - et al.
Client communication behaviors with health care providers in Indonesia
Patient Educ. Couns.
(2001) - et al.
Evaluation of a patient education leaflet designed to improve communication in medical consultations
Patient Educ. Couns.
(1995)