Some aspects of culturally competent communication in health care in the republic of macedonia.

AIM: To examine the existing situation, barriers and consequences of the intercultural communication in health institutions and to offer training models for strengthening and improving communication skills of health professionals in the Republic of Macedonia.
METHODS: A cross-sectional survey was conducted to assess the relationship between patients and health professionals. A total of 813 health professionals (302 physicians and 511 other medical staff) from different healthcare institutions, and 1016 patients participated in cross-sectional survey performed in autumn 2010.
RESULTS: The research has showed that each third examined patient thought that his/her physician or the other medical personnel had no understanding for his/her emotions and gave no answer to all of his/her questions. From the other side, 60% of the physicians declare that they have a good communication with patients speaking other language than their mother tongue. Only 60% of physicians said that they know good the culture of their patient and 52% of the other medical staff said that they adjusted the treatment to the patient culture (religion, attitudes, language, life style).
CONCLUSION: There are some gaps in current provision of health care practice in an aspect of effective interactions and communication skills of health professionals to meet patient needs in a multicultural and multilingual setting. A training model is proposed for strengthening communication skills of health professionals.

INTRODUCTION

A key role in providing quality healthcare services is played by the medical staff and management. Regarding the issue of healthcare management in the Republic of Macedonia, health professionals show considerable lack of knowledge in this field. Besides the necessary basic education, human resources in healthcare should have some additional skills. As a priority in this context, countries of the European Union specified the following issues: skills for using information and communication technology (ICT), entrepreneurial and social skills, such as communicability, leadership and teamwork. Although higher education institutions educate health professionals, both managers and real leaders are necessary to achieve these high standards and expectations. For this purpose vocational and professional training is necessary (1).

Currently, managers in health and healthcare workers, in addition to professional competence, should pay special attention to the question of mutual communication and behavior of healthcare workers and patients. The tendency for the development of a democratic society, also presents the need for re-considering the circumstances in healthcare services with the purpose of overcoming the problems stemming from the ethnic and cultural diversity. It is expected that such problems will lead to reduced work capacity of health workers and reduced quality in the provision of healthcare services, which would mean reduced satisfaction of health insurers and patients.

It is rather hard to try and give the best definition about what is communication.. Some authors, state that communication is interactional process which occurs in any environment where people share meaning verbally and non verbally. Moreover, she continues to argue that since communication is a dynamic and ever-changing process, one can never move backward (2). Others suggest that “Communication is not everywhere and at all times the same thing. In other words, is neither an either-or choice, which one does or does not perform: nor is it a continuum along which one may do more or less, better or worse. Rather, communication is a ubiquitous aspect of human functioning, constitutive of being human” (3).

In the Republic of Macedonia, as a country that is historically characterized with ethnic and cultural diversity, despite the engagements in mitigating the obvious barriers, they are still present in many different forms. In the country and in the region, this issue is going to be a priority in the field of health policy. Finding the most appropriate models of education and training in this field remains to be a priority in different health and educational institutions and professional associations.

AIM OF THE STUDY

The aim of this study was to examine the existing situation of the intercultural communication in health institutions of the Republic of Macedonia and to offer a training model for strengthening and improving communication skills of health professionals. In order to design an appropriate model, it was previously necessary to diagnose the present state concerning the existing models and instruments in the field of communication in the entire health sector as well as to diagnose the present state concerning the conditions and concrete specifics of the multiethnic (multicultural environment) Macedonia.

METHODS/PARTICIPANTS

In 2010, a research entitled as “Communication skills and quality of healthcare services” was conducted (4, 5). Applying three instruments, the following has been analyzed: attitudes, opinions and behavior of the health personnel and patients. Questionnaires and scales, analysis of the content, interview and tests were used as research techniques. This was followed by an interview with health workers and managers discussing the prepared model of training.

This research had two tenacities: methodological/scientific and practical/applicative:

Methodological/scientific aim: based on examination and verification of the existing models and instruments, to design new models and instruments in the field of communication;

Practical/applicative aim of the research related to concrete suggestions for composing and conducting programs and activities in the field of communication, with a special focus on the system of education and training of health professionals. A transversal study was realized, consisting of two components:

Descriptive – referring to description/assessment of the level of communication competencies of the health workers in R. Macedonia;

Analytical – referring to assessment of the determining factors of communication competencies of the health workers in R. Macedonia.

The stratified sample was taken based on two subsets of data: the subset of the health statistical data from the Institute for Public Health for the number of hospital staff and the subset of the number of annual hospital admissions. In this stratified sample the sampling frame is divided into non-overlapping groups or strata, e.g. municipalities of Skopje, Bitola, Tetovo, Stip, Kumanovo and Struga. A simple random sample is taken from each subset within each stratum, That’s why the method of sampling is referred to as stratified random sampling.

The research included a total of 813 physicians and other medical personnel (nurses, laboratory workers, radiologists, physiotherapists, etc.) from different healthcare institutions, that is, 302 physicians and 511 other health professionals and 1016 patients in Skopje, Bitola, Tetovo, Stip, Kumanovo and Struga.

The response rate from the physicians and other medical personnel (nurses, laboratory workers, radiologists, physiotherapists, etc.) questionnaire was 78% and the response rate for the patients’ questionnaire was 82%.

Demographic characteristics of the health workers

Regarding gender, 188 (23.1%) of the participants were males and 625 (76.9%) were females. Regarding age, 222 (27.3%) of the participants were 35 or younger, 384 (47.2%) were between 36 and 50, and 207 (25.4%) were older than 50. Regarding profession, 302 (37.1%) were physicians, and 511 (62.9%) were other health personnel. Regarding education level, about half of participants have had university level education (49.3%). Regarding mother tongue, 75.9% of the participants use the Macedonian language, whereas 17.3% the Albanian language.

Demographic characteristics of the patients

There were 1016 patients included in the study. 438 (43.1%) were males and 578 (56.9%) were females. Regarding age, 44 (4.3%) were between 14 and 18 years old, 338 (33.3%) were between 19 and 30, 375 (36.9%) were between 31 and 50 and 256 (25.2%) were older than 50. Regarding education level, most participants have had university level education (41.8%). Regarding mother tongue, 64.7% of the participants use the Macedonian language, whereas 28.8% the Albanian language.

RESULTS

The research showed that each third examined patient thought that his/her physician or the other medical personnel had no understanding for his/her emotions and gave no answer to all of his/her questions (Table 1). In terms of confidence, 73.1% of the patients gave positive answer to the question “I am confident with my physician” (Table 2). At first sight it seems that this percentage is not so bed; however, it has to be pointed out that majority of the examined patients being either hospitalized or in a stress situation, gave milder statements, critics and grades influenced by the fear and dependency on the health personnel. Only 61.6% of the participants said that their physician takes into account their attitudes, needs and opportunities before suggesting treatment method (Table 3). This is vital, so we believe that this proportion is not good enough. Below refer to the tables:

Table 1

My physician encourage me to ask questions

Table 2

I ’m confident with my physician

Table 3

My physician takes into account my attitudes, needs and opportunities before suggesting treatment method

On the other side, the question “I know well the culture of my patient” was answered affirmatively by 59% of the physicians or by every second physician. This is an issue to be anxious about, having in mind the multicultural and multiethnic society of the Republic of Macedonia. The answer to the question “I adjust the therapy depending on the culture of the patient (habits, language, religion, tradition, lifestyle…)” showed that a low 48% of the physicians had behaved according to this statement. To the question “I have a good communication with patients speaking other language than my mother tongue”, 60% of the physicians gave a positive answer. However, in reality, the situation is different, since a very small number of physicians know the language of the other ethnic communities even on the basic level. According to patients’ attitudes, the interpersonal relationships between physicians and the other medical and health personnel are not on a satisfactory level. The question “I think physicians have a good communication with nurses and the other medical personnel” was positively answered by 56% of the participants.

DISCUSSION

Almost always, there are barriers in the communication, or the so-called “distractors”. Thus, the effect of the status during communication has to be taken into account. In the healthcare sector such is the case in the communication between a physician and a patient, or a physician and a medical nurse, or a physician and a pharmacist, etc. Communication obstacles very often produce conflicts as adverse phenomena in the business world.

Communication in the healthcare sector faces one additional obstacle of particular significance and influence on the quality of the healthcare services–language and culture, that is, not knowing the language of the patients and cultural aspects by the providers of the healthcare services that eventually affects the quality of the healthcare services as well as the satisfaction of both the physician and the patient. Education and training on communication competencies of the participants in the communication helps in overcoming the barriers and significantly facilitates the communication. Communication between minority patients and physicians has elements of linguistic asymmetry, self-fulfilling prophecy spirals and perception of discrimination (6). Some authors suggest that “talk is the fundamental element by which physician-patient interaction is enabled and by which therapeutic goals are achieved” (7). Thus, language is the major factor in establishing good relationship between physicians and patients. The key to successful communication among people lies in their need for mutual respect and trust. The physician-patient interactions are often characterized with a certain sense of danger, ambivalence and anxiety and hence, confidence is the key element in building the physician-patient relationship that is going to be utilized in the process of treatment, (8).

Physician-patient communication is one of the most important components of public health. Dealing with this social phenomenon clearly indicates the existence of the problem of poor mutual communication and good relationship between healthcare providers and users of health services.

The opinion that communication skills are part of the human nature (character) has started to be changed and is directed to that “communication is not a feature of the character, but a skill that can be learnt” and that “experience by itself is not sufficient to gain such a skill/ability”. Both verbal and nonverbal interactions, which are part of physician-patient communication, create a basis for their relationship (9), and “cultural competence” is a very important variable in the health sector (6).

It can be seen that the situation in Republic of Macedonia is relatively good, but not at a satisfactory level. That may be a result of a low level of communication skills that the physicians and other medical staff have, and sometimes it can be a result of their low motivation level or not having enough care sense for their patients. The patients need more extensive information about their own health status from their physicians and other medical staff. This means that the medical staff does not take into account the patients’ emotions, their feelings of not being cared for enough. Kenny et al. (10) in their study comprising 91 physicians and 1749 patients came to a conclusion of a different perception of the patients related to physicians’ work. In their study, these authors included the expertise of the communication experts whose perception differed both from the perception of the healthcare providers and from the perception of the patients. This leads to lower level of doctor-patient confidence and sometimes reduced level of healthcare quality. Broadly speaking, all of the before mentioned conclusions suggest that there is no satisfactory level of readiness as well as communication skills from the medical staff’ side. There is a need for better understanding for the patient’s cultural, religion and traditional differences, including their mother tongue. If there were a defined model for training health professionals about necessary communication skills, including knowledge of the language and culture of the patient, under assumption of having necessary professional knowledge and skills in the profession, then the quality of communication among all subjects in the process of health care and service would be improved, and that would lead to better efficiency and quality of health services. WIN™(11) conducted this ground-breaking study on physician-patient communication throughout the world to provide the healthcare stakeholders with a better understanding on how patients perceive communication skills of their doctor, how patients engage their physician, how treatment choices are influenced, the frequency and preferred modes of interaction and sources of influential information. A study by Ulrey and Amason (12) examined the relations among cultural sensitivity, effective intercultural communication and anxiety for health care providers. Furthermore, Ulrey et.al, did find a positive relation between cultural sensitivity and effective intercultural communication, and there was a negative correlation between health care providers’ intercultural communication effectiveness and their levels of anxiety and providers’ cultural sensitivity and their levels of anxiety. Therefore, it is argued that since these terms are related than studies regarding these concepts can be linked and perhaps united. According to Wachler and Troein (13), “cultural competence” is defined as a “sum of acquired skills that enable broadening individual knowledge and understanding of cultural differences”.

RECOMMENDATION

Education and training on communication competencies is included in the training process organized by health, educational and professional institutions. In the education process, many theories suggest that the individual has to possess knowledge, skills and a specific type of behavior in order to be recognized as an expert in his/her profession (6). Similar studies confirm that physicians who do not have good inherent communication skills can improve them by performing their everyday profession, having in mind the specific settings. Training will be organized within the formal education system as well as other short-term and long-term trainings (within the permanent education – lifelong learning). For the purpose of improving the physician-patient communication the so-called Conceptual framework (14) has been constructed. The most utilized is the Framework of Calgary Cambridge Guide designed by the scientists from those Universities and applied in many countries. The proposed model for training in this paper contains measures for improving the communication. This model is recommended for traditional, multiethnic and multicultural communities. The model and program for training on “communication skills, built on the principles of conceptual framework” is indispensable for mitigating and overcoming the barriers identified in this field. The model consists of three groups of competencies aimed for the relevant groups for training:

The first group comprises communication skills and cultural competencies necessary for the physicians, starting from the top management of the organizational unit (Table 4).

Table 4

Module for training on communication skills: Training on communication skills of physicians

The second group includes an adequate program for the reinforcement of communication skills and cultural competencies necessary for the other health workers in health institutions (physiotherapists, language and speech therapists, biochemists, administrators, etc.) and health workers with secondary education (nurses, medical technicians, etc.) (Table 5).

Table 5

Module for training on communication skills: Training on communication skills of the other health professionals

The third group encompasses anticipated program topics for improvement of cultural competencies of all health professionals, with forms and methods of teaching about these competencies. Based on the module for training, the program gives in details the form and mode of realization of the module in duration of 5 days (30 working hours) (Table 6).

Table 6

Module for training on communication skills: Training organized for physicians and the other heath personnel on teaching the language of the other ethnic communities

The results obtained in this research and recommendations based on other researches conducted in other countries impose the need for a more active approach of all responsible institutions and organizations for monitoring and undertaking measures in order to overcome the unsatisfactory conditions in the sphere of communication in the health system. Inadequate managing of this relationship and lack of concepts for overcoming the barriers lead to reduced work capacity of health workers and poor health service delivery, with elements of breaking the equality guaranteed to all citizens, for health services as public wealth of special interest, which results in dissatisfaction of health insurers and patients.

Eventual misunderstandings and inadequate communication due to the language barrier, having in mind the specific rights of the patients guaranteed with the law, might have serious consequences (15).

In line with this, the aim and motive of this paper are clearer. Analyzing the quality of communication and identifying the obstacles in this relationship, particularly those involving language and culture, this research suggests a model for overcoming them. This model has to be an integral part of the teaching programs for the reinforcement of the communication skills at universities of medical sciences (16). It should be a part of the mandatory continuing education of professional associations and regulatory bodies (chambers) of physicians and other interested parties (institutions, societies of patients, non-governmental organizations). This will affect the quality of health professional-patient communication, conquering the barriers and hence improving health services and patient satisfaction.