1Socio-demographic determinants of patient enablement at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/494
Institutional aspects and visiting pattern The likelihood ratio test (Table 2) shows the contribution of each institutional-related variable to the model. Familiarity with the provider, comfortable seating, privacy during consultation, relaying one’s personal concerns related to the condition and the language of the interview contributed significantly (p < 0.05). The pseudo R-square value showed that the model explained about 31.1% of the variance.
2Institutional determinants of patient enablement at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/495
Perceived empathy, technical competency and non-verbal communication Respondents’ perception of health care providers’ empathy, technical competency and non-verbal communication is shown in Table 3. Results showed that 51.3% and 51.6% of the respondents rated provider empathy and technical competency, respectively, as medium, while 53.0% rated non-verbal communication as highly favourable. Of the total number of respondents, 406 (52.9%) reported to have been told their illness, but only 287 (37.4%) reported that they were also told its cause. Only 254 (33.3%) of the respondents were given advice on how to prevent reoccurrence or development of a similar condition in the future. Close to half the respondents (n = 347, 45.2%) were told to return if their symptoms worsened or no improvement occurred.
3Perceived empathy, technical competency, non-verbal communication and consultation length at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/496
The results also showed that the mean duration of consultations was 6.26 ± 2.55 min (range = 2min – 20 min) and that 447 (62.1%) of the respondents reported consultation lengths below the mean value. Most of the consultations (n = 624, 81.3%) were shorter than patients had expected. A small percentage (n = 101, 13.2%) were longer than expected.The variables shown in Table 3 were entered into a multinomial logistic regression of which the summarised output is presented in Table 4. The model’s prediction accuracy was found to be 64.9%. The current model was uncertain in predicting overall patient enablement (p < 0.05). As shown in Table 4, perceived technical competency, non-verbal communication and empathy, advice on preventing future development of similar conditions, and encouraging follow-up visits were statistically significantly associated with patient enablement (p < 0.05) and contributed significantly to the model. For instance, compared to those who experienced intermediate enablement, respondents who perceived unfavourable non-verbal communication were 6.69 times more likely to feel low enablement than those who perceived highly favourable non-verbal communication (AOR = 6.69, 95% CI = 1.89–23.67, p = 0.003). On the other hand, explanation of the cause of the illness was significantly associated with low enablement but not with high enablement. Conversely, consultation length was significantly associated with high enablement but not with low enablement.
4Communication and perceived interaction process as determinants of patient enablement at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/497
Predictors of patient enablement The fourth model was developed by entering all the variables shown to have statistically significant association (p < 0.05) with patient enablement in the earlier models. The summary of the predicted variable and predictors and the relative importance of each predictor are displayed in Table 5(a) and 5(b). In this model, the pseudo R-square implied that the model explained about 72% of the variance and it fitted the data adequately (p > 0.05). Familiarity with the providers, advice on how to prevent development of similar conditions in the future, being encouraged to return, non-verbal communication, empathy and technical competency were found to be significant predictors (p < 0.05) of both low and high patient enablement. However, residence and explanation of the cause of the illness were significant predictors of low patient enablement but not high enablement. Educational status, occupational status, and privacy during consultation were significantly associated with high levels of enablement.
5(a) Predictors of low patient enablement at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/498
5(b) Predictors of high patient enablement at primary health care centres in central Ethiopia. http://phcfm.org/index.php/phcfm/article/downloadSuppFile/195/499
DiscussionThe patient enablement asserts to measure patients’ ability to understand and cope with their health and illness. It indicates the quality of consultation, but without an indication of the process of the consultation. The results of this study show that consultation in primary health care is associated with a relatively low level of enablement: only 26.2% of the respondents felt that the consultation had highly enabled them. This finding is lower than findings that have been reported for other developed as well as developing countries. 19,20 The difference might be explained by the difference in socio-cultural and economic contexts, health services infrastructure, and health awareness and literacy. Moreover, the providers’ interpersonal skills and professional competency appear to have an impact on patient enablement. In the current study, perceived empathy, non-verbal communication and perceived technical competency were among the most important factors predicting the level of patient enablement. Other studies have also showed that empathy is crucial to the effective achievement of patient centredness and, hence, patient enablement.8,9,10,11,18,19,20,21,22,23 The level of familiarity with the health care provider was also significantly associated with patient enablement in this study. Patients who experienced low enablement did not know the providers well. This finding is in line with previous findings. 24,25,26 The primary health care system in Ethiopia is currently organised as part of a system for continuous health care, but with 64.6% of the respondents not being familiar with the health care provider who treated them, the situation is not reflected in the findings and may have contributed to lower enablement. Similarly, patients to whom the cause of their illness had not been explained, nor were offered advice on how to prevent similar conditions or encouraged to return for follow-up visits experienced a lower level of enablement. This is similar to a previous finding. 27The present study also showed that almost half of the patients (47.1%) were not told what their illness was and left the consultation without a sound and objective understanding of their illness. Moreover, 62.6% of the respondents reported that the cause of their illness had not been explained, which translates to a missed opportunity for health education. This finding is, however, inconsistent with a US study where 72% of the respondents reported that their health care providers gave them adequate information about their condition. 27,28 The difference may be due to the nature of the health problems, with acute infectious diseases being common in developing countries, whereas chronic conditions are more common in developed countries. However, health workers may also underestimate the importance of sharing information about the illness, thinking that patients would not be able to comprehend their explanations. Health care providers have an ethical duty to teach the patients about disease and promotion of health, as is clearly stated in the Ethiopian medical code of ethics. 29However, according to the finding of this study, only 33.3% of the respondents were given advice on how to prevent the reoccurrence of the disease or how to prevent future development of similar conditions. Of those who had been given advice, 98.1% reported that they would follow the advice, which underlines the opportunity for health education and dissemination of information. To maintain continuity of care, patients should be bound to the health care system. However, in the current study more than half the patients (about 56%) were not encouraged to return for follow-up visits. This may threaten the continuity of care. Non-verbal communication is a subtle form of communication that occurs in the initial three seconds after introduction and can continue through the entire interaction. It has as great an impact as verbal communication, but can be more easily misinterpreted. 12Thus, it is important for health care providers to be aware of the non-verbal messages that they convey to their patients. In the current study, non-verbal communication was a strong predictor of patient enablement. Patients who perceived non-verbal communication of the provider as unfavourable experienced lower levels of enablement. This finding is consistent with that of a systematic review of eight studies where non-verbal communication cues such as facial expression, nodding of the head, a forward-leaning posture, frequent hand gestures, open arm and leg positions and direct eye contact were positively associated with patient enablement. 30,31 The current study also showed that perceived technical competency was strongly associated with patient enablement. However, only 24% of the respondents reported high perceived technical competency, which resulted in the generally low enablement seen for the group. Conclusion In conclusion, perceived empathy, technical competency, non-verbal communication, being told the cause of the illness, arrangement for follow-up, advice on how to prevent future development of similar conditions, familiarity with the provider and residence were found to be the main predictors of patient enablement in this study.This suggests that the parameters discussed above should be considered in medical practice. In addition, the findings can inform policy makers and health care practitioners that interpersonal interaction (including verbal and non-verbal communication), disease information and continuity of care are crucial for improving patient enablement and should seriously be considered. This study provides a basis for better prediction of factors associated with patient enablement, particularly in resource limited countries. Limitations of the study The findings may be affected by the fact that facility-based studies produce more positive responses. This may result in a short-lived ‘halo effect’, with patients feeling more enabled after the consultation than later. 16 In addition, a lack of similar studies in the region also limits the comparison of the findings. Acknowledgements We acknowledge Jimma University for financial assistance. We are also grateful to the respondents for their participation. Competing interests The authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this paper. Authors’ contributions ZB was involved in the design, results analysis and writing of the manuscript. MW was involved in the design of the study, analysis and interpretation of the data, and review of the manuscript. TA was involved in the design of the study and analysis of the data. 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