why does this happen?

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sama doktor, terus lupa dan bila keluar baru ingat...” ... doktor tapi bila sudah asyik doktor tanya dan ... mau cakap apa yang dalam hati, jadi saya tunggu saja ...
Patient’s Unvoiced Needs 1

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why does this happen? 6

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Low LL , Sararaks S , Azman AB , Mohd Yusof I , Carol Lim KK , Goh PP , Radzi AH , Letchuman R , Abdul Jamil A 1

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Institute for Health Systems Research, MOH; 2 Negeri Sembilan State Health Department ; 3 Sabah State Health Department ; 4 Likas Hospital; 5Selayang Hospital; 6Alor Setar Hospital; 7 Taiping Hospital; 8 Sultanah Nur Zahirah Hospital

Results ( cont’ )

Introduction Effective communication among health care provider and patient is essential for providing quality care. Many studies have demonstrated the importance of health care provider (HCP) sharing information with their patients. However, the information or actual history shared by the patient themselves is equally important. Issues that patients plan to share with their health care provider during a consultation but didn’t manage to share are a patient’s unvoiced needs. When these unvoiced needs are not voiced, they cannot be addressed by the attending health care provider.

c. Feeling Embarrassed and Nervous: FGD participants voiced that they feel “shy” to share their problems and are uncomfortable with opposite gender HCP, especially for personal or Gynaecological problems. “Feeling nervous” during consultation also prevents them from voicing out their problems. “…malu, mungkin kerana terlampau private, personal jadi malu...”

“…malu kalau doktor tu lelaki tidak berani kasi keluar apa difikir, kalau saya jumpa doktor perempuan kasi keluar (share)…”

Objective To explore the reasons for the existence of patient’s unvoiced needs.

“…Kadang-kadang merancang ni tidak kesampaian, kadang-kadang kaku depan doktor...”

Methods A study was undertaken in a hospital and two health clinics in the state of Sabah. An exploratory qualitative method using the focus group discussion (FGD) approach was conducted amongst the patients those who had sought care at government hospitals and health clinics. Six sessions were conducted involving in-patients and out-patients with each group having 4-6 participants. A total of 10 in-patients and 21 out-patients participated, which consist of 10 males and 21 females.

d. Expect HCP to Enquire: The traditional paternalistic model still plays an important role. Patients still expect their HCP to probe. Many participants had expressed that they wait for HCP to ask, rather than they initiating the discussion. “…saya pernah pertama kali jumpa doktor, sebab belum biasa jadi segan mau cakap apa yang dalam hati, jadi saya tunggu saja dari pertanyaan dia, tunggu saja (doktor tanya)...”

Prior to the sessions, an outline of issues for discussion was prepared covering areas such as their “experience during consultation”, “concept of planning before consultation” and “patient’s ability to convey their problems or concerns” and “perceived barriers”. To elicit facts and explore the reasons for unvoiced needs, a “saturation” process was applied in the discussion whereby multiple probes were used with different approaches. The audio-taped conversations and rapporteurs’ notes were transcribed verbatim. These were then analysed to identify themes and coded using qualitative content analysis.

Tunggu doktor tanya la.. Segan nak cakap..

“…kalau doktor tanya kita jawab, semua kasi cerita, kalau doktor tidak tanya tak boleh la. Dia tanya dulu baru jawab...”

e. Do not want to waste doctor’s time: Patients feel that they can’t waste their doctor’s time. This discouraged them from voicing additional concerns.

Results People often have difficulty in fully expressing their concerns or problems during HCP-patient encounter and some issues go unvoiced at the end of the consultation. Six main themes expressed by FGDs’ participants.They would not share all their problems/concerns that they had planned to share because,

Doktor terlampau sibuk, segan nak tanya. Nantilah...

a. they had “forgotten” them;

“…panjang cerita, dia (HCP) ada patient ramai lagi nanti, memang kita tidak boleh cakap lagi, lambat sudah, mau kasi cepat masa ...”

“…pesakit lain lagi mau juga cerita itu ini kan, (jadi) tak boleh lama juga dalam bilik (doktor) tu. Masa terhadkan...”

b. their perception that the HCP’s attitude “prevents” them from sharing; c. their feelings of embarrassment and nervousness; d. expecting HCP to enquire (but they don’t); e. feeling the need not to waste the HCP’s time; f. they claimed “HCP did not give them a chance to ask”.

a. Forgotten Issue: One of the main reasons that surfaced for unvoiced needs was that patients had forgotten a particular issue/concern. Majority of participants shared that they would have liked to ask but they tend to forget.

Participants also felt that sometimes HCP seemed in a hurry and appeared not interested to listen. This feeling restricted their opportunity for further discussion. “...bila berbincang dengan doktor kami rasa perlu bangkit baru kami bangkit itu pun tengok keadaan kalau macam (setengah) doktor, baru kita mau tanya sudah macam dia…layanan…”

Oh! Terlupa tanya doktor...

“…ada merancang, tapi saya selalu lupa, bila jumpa, bercakap-cakap sama doktor, terus lupa dan bila keluar baru ingat...” “… dalam fikiran saja mau tanya doktor tapi bila sudah asyik doktor tanya dan doktor menjawab, pertanyaan kita yang kita mahu tanya terlupa begitu saja sebab tiada dituliskan...”

Bla...bla...bla...bla... bla...bla...bla...bla...

Doktor ni laju..macam tergesa - gesa. Saya tak sempat bagi tahu..

“…masa jumpa doktor sakit perut tapi bila saya bagitau sakit kepala juga, saya dapati doktor tu, dia laju, pantas, cepat macam seolah-olah dia tergesa-gesa. Jadi menyebabkan saya tak sempat bagi tau yang saya ada juga sakit kepala...”

Conclusion

b. Perceived HCP’s attitude: Another reason that is perceived to prevent patients from voicing all their concerns with HCP is HCP’s unfriendly and unapproachable attitude. “…Mungkin tengok keadaan doktor, kalau doktor friendly baru kita dapat (tanya)…” “…kalau kita cerita pun dia tidak ambil peduli, macam kita rasa sakit mungkin disebabkan…mungkin dia (doktor) cakap oh itu tiada apa-apa tu...” “...Ada saya pernah terfikir mahu tanya doktor, tapi itulah kita takut dan rasa tidak sesuai pertanyaan kita, takut kena marah dengan doktor...” Poster presented at :

f. Doctor did not give a chance to ask:

Patient’s unvoiced needs do exist. Various contextual factors contribute to it, such as perception, attitudes and verbal/non-verbal cues. Patient’s forgetfulness is a common factor. In addition, many patients have difficulty expressing their concerns fully when they feel nervous or embarrassed, especially with provider of the opposite gender. On the other hand, patient’s perception affect their reaction in the consultation and body language of the provider plays a major role. Unvoiced needs could have a negative impact to the patient’s experience with the provider and the health care system.

Bibliography 1. Barry CA, et al (2000). Patients’ unvoiced agendas in general practice consultations: Qualitative study, BMJ, 320, 1246-1250 2. Bell RA, et al (2001). Unsaid but not forgotten–Patients’ unvoiced desires in office visists. Arch of Internal Medicine,161, 1977-1984 3. Britten N, et al (2000). Misunderstanding in prescribing decisions in general practice: Qualitative Study. BMJ, 320, 484-488 4. Bugge C, et al (2006). The significance for decision-making of information that is not exchanged by patients and health professionals during consultations, Social Science & Medicine, 63, 2065-2078 5. Cox K, et al (2004). A Systematic review of communication between patients and health care professionals about medicine taking and prescribing, Medicines Partnership 6. Little P, et al (2001). Preferences of patients for patient centred approach to consultation in primany: observational study, British Medical Journal.; 322:468 7. Sharf BF. The physician’s guide to better communication.Glenview, IL: Scott, Foresman.1984

Acknowledgement We thank the patients who participated and sharing their experiences in FGD sessions. We also acknowledge and thank the staff of study facilities for their valuable support in carried out FGD and thus making this study possible. th

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7th MOH-AMM Scientific Meeting & 10th NIH Scientific Meeting 2007 , 6 – 8 September 2007, Bayview Beach Resort, Penang