Abstract
Objectives: To explore concerns, beliefs, and expectations of patients who attend Family Medicine clinics in the University of Jordan Hospital, Amman, Jordan.
Methods: A qualitative descriptive design was used. Semi-structured interviews were conducted with 143 patients (84% females, mean age 45.3±17.8 years) between September and December 2016. A validated patient’s agenda form included open-ended questions on patients’ main concerns, beliefs, and expectations was used. A qualitative content analysis of answers was completed by coding answers into categories.
Results: A good aggregate inter-rater reliability for coding categories was found (κ-values ranging from 0.76-0.88). The most common concern of participants were the need to receive treatment for an acute illness, followed by the desire for clarification on health condition. Forty percent of participants believed that their symptoms were caused by a health condition rather than lifestyle, while 32.5% had no speculations related to the causes behind their symptoms. The highest percentage of patients expected doctors to provide information related to their health condition.
Conclusion: The most prominent needs of participants were the need for information and explanation regarding health condition. Family doctors are encouraged to use agenda forms to enhance patient communications and improve outcomes of consultations.
Understanding patients’ concerns, beliefs, and expectations that lead to visit family doctors is a core component of patient-centered communication (PCC).1 Patients usually have specific agenda to be addressed during their visit to a family medicine clinic (FMC); yet, when they are not encouraged to express their needs, most of their expectations are not met.2,3 Previous research showed that using a pre-consultation sheet enhances doctors ability to recognize patients’ views, which led to provide management in accordance to patients’ concerns and expectations.4 In addition, patients who discussed their agenda with their doctors reported greater satisfaction with services and improvement in general health.5 Agenda-setting was found to have a positive effect on the doctor-patient interaction and helped doctors to tailor plans of care to meet patients’ needs.6
Patient-centered care is emerging in medical practice in Jordan, and research related to this area is lacking. The aim of this study, therefore, is to explore agendas of patients who visited FMCs in order to describe their concerns, beliefs, and expectations prior to a consultation visit.
Methods
The ethical approval was obtained, according to the principles of Helsinki Declaration, from the Scientific Research Committee of School of Medicine, University of Jordan, Amman, Jordan, and the participants were provided written consent.
A qualitative descriptive design carried out in the FMC at Jordan University hospital, Amman, Jordan. A convenient sample of 143 patients participated in the study. Inclusion criteria were patients older than 18 years old and attended the FMC at the University of Jordan, Amman, Jordan between September and December 2016.
Exclusion criteria were patients who were complaining of severe acute problems or pain that needed immediate care, and patients who were accompanied by a helper due to mental health problem. Table 1 shows the participants’ characteristics.
Patients’ characteristics (N=143).
A questionnaire that complied information related to participants’ age, gender, level of education, medical file number, and chronic illnesses. An Arabic-translated version of the Middleton Patient’s Agenda Form (PtAF) was used in the study.7 The original PtAF form was translated to Arabic using the World Health Organization guidelines (WHO, 2019)8 for translation and adaptation of instrument. These guidelines included 4 steps: forward translation, the original PtAF was translated independently by the first 2 researchers, who were fluent in English, and native speakers of Arabic; expert panel back-translation, the forward translated version was discussed by the team of researchers conducting the study to make sure natural and culturally-acceptable language was used. The approved version was sent to an independent translator, who is a native English speaker, for backward translation. The 2 versions were then compared by the panel and adjustments were made; pre-testing and cognitive interviewing, the final version of the PtAF was piloted on 20 patients and minor changes related to the wording of the form were made; and final Arabic-PtAF was approved by the expert panel. Similar to the PtAF, the Arabic-PtAF included 4 open ended questions on concerns, beliefs, expectations, and other concerns.
All participants were interviewed by a research assistant while they were waiting for their appointments. The research assistant was a health professional with 10 years of clinical experience who passed a training on patient interviewing skills prior to data collection. Data were collected through semi-structured interviews which lasted between 15-30 minutes. The research assistant explained the aim of the study and obtained informed consent from the patient. The semi-structured interview started with the completion of the demographic form, followed by the Arabic-PtAF questionnaire. At the end of the interview, the patient was asked to read and review the answers.
Data analyses
All the interviews were conducted, recorded, verbatim typed, and reviewed by the research assistant who conducted the interviews. Inductive content analysis was used which is a qualitative method used for exploring textual information in order to identify, code, and report categories within data, their frequency, and their relationships. First, the content analysis started with the researchers independently reading the interviews to gain a primary understanding, then frequent terms were underlined to identify codes that existed in the interview text. Second, the researchers grouped similar codes and merged them to form a final list of categories for each question. Finally, coding the patients’ agenda forms was performed in an iterative fashion by 2 independent family medicine specialists who did not participate in categories development. Disagreements were discussed with the researchers and consensuses were reached. Data collection were continued until saturation, when adding new data showed no new information. Frequencies of patients’ statements for each category were reported.
Results
Table 2 shows coding and categories for patients’ concerns, beliefs related to the cause of the illness, expectations, patient’s quotations, and the frequency of each theme. Kappa values for the inter-rater comparison (measure of agreement) ranged from 0.76-0.88, indicating good agreement between the 2 coders in categorizing patients’ answers.
Coding categories for patients concern regarding the illness, expectations, other concerns, and the frequency of each category (N=151)
The patients’ main concern was related to management of an acute illness (34%). Almost 25% of the concerns were related to clarifications on health condition, such as causes, treatment options, and prognosis followed by 23% related to prescription of medications. Fifteen percent of the patients requested laboratory or radiological investigations and 3% came for general checkup (preventive measures).
Our findings revealed that 32.5% of the patients did not have thoughts regarding the cause of their symptoms, while 42.3% thought that their symptoms were related to a health condition (mental or physical). Approximately 11% of the patients referred their illnesses to certain lifestyles and 8% to work or environment. Only 4.1% of the patients thought their illnesses were hereditary or related to genetics, and 1.6% related their illness to aging.
Content analysis of the patients’ expectations revealed that 36.3% expected doctors to provide information related to their health condition or treatment options, 33% expected doctors to provide a medical prescription, or to request investigations for further evaluation. Interestingly, only one patient (0.5%) expected referral for another health care professional.
Our results showed that 41.9% of the patients expressed other concerns related to their need for more clarification related to health conditions: causes, treatment options, and prognosis, and 29% were concerned regarding structural and administrative issues.
Discussion
Our findings revealed that most of the participants visited FMC mainly to receive management of an acute biomedical illness. This was expected, as FMC is a walk-in clinic that usually provides care for patients with acute illnesses. Approximately 25% of the participants were concerned on receiving information regarding their health condition, including causes, prognosis, and treatment options. Also, when participants were asked regarding other concerns, 41.9% expressed needs for information on their illness. These findings highlight the importance of providing information specific to health conditions to address patients’ agendas during their visit to FMC. Previous studies found that providing patients with explanation regarding their health problems has a positive effects on patient satisfaction, health status, and psychological well-being.9-11 Therefore, a recommendation for FMCs is to provide both verbal and written information for patients related to their health condition and management options.
Participants expressed needs for medication prescriptions as a second concern, in addition to other administrative issues especially when refilling prescriptions, such as long waiting time. Family Medicine clinics in Jordan provides follow-up services as well as prescription refill for chronically ill patients on a monthly basis. Most of the patients who attend the FMC have chronic illnesses such as hypertension, diabetes mellitus, asthma, and hypothyroidism. A suggestion for FMC administrations is to prepare a separate clinic for patients who want prescriptions refill only, consequently decreasing their waiting time.
Interestingly, only one patient visited the FMC for a general check-up examination. In addition, 11% of the participants related their medical condition to lifestyle. These finding raise a concern related to Jordanians’ awareness of the importance of regular medical exam in early detection of communicable or non-communicable diseases. An important role of FMC is to encourage patients to perform regular checkup examinations based on their risk factors. Further research is needed to examine public awareness and the ability of FMC in Jordan to improve public awareness.
Forty-two percent of the patients believed that physical or mental health conditions rather than lifestyle or genetics were the causes behind their health conditions. Patients’ beliefs on the causes of their illness are among the components of illness perception.12 Recognition of patients’ ideas by their doctors can be useful to build and improve doctor-patient relationship, performance towards their illness and health outcome, and adherence to treatment of chronic diseases.13-15 Studies reported that hopeful illness perception had a positive effect on health coping and consequence.16 More than a third of our patients had no beliefs on their illness etiology, suggesting the need for actively engaging patients in discussion related to etiology, course, and management options of their health condition.
In congruence to previous research, we found 36.3% of the patients expected doctors to provide explanation regarding causes of illness, treatment options, and prognosis. It has been found that patients’ expectations are most of the time not fulfilled by doctors’ responses. For example, one of the participants expressed that he came many times and he did not get any benefit, because his doctor did not order an x-ray for his ankle. Therefore, asking the patients on their thoughts and expectations will allow the physician to explain unnecessary investigations. It will also allow the patient to be engaged in discussing care plan with his doctor and reaching a consensus related to the management plan.
Study limitations
This study is unique in offering a breadth of knowledge regarding the patients’ agenda among FMC attenders in Jordan. Yet, this study has limitations due to the convenience sampling method represented by gender and insurance biases. Another limitation is related to the depth of data obtained, which might be affected by patient literacy, and time required to complete the interview. Future studies are recommended to examine doctors perception on using agenda forms, and to compare outcomes of consultation visits in which agenda forms are used and visits in which they are not used.
In conclusion, patients who visit FMC have needs for information regarding their health problems, and they have existing ideas and perceptions about their illnesses. Doctors’ recognition of patients’ agendas should guide their clinical judgment, save time, and improve outcomes of consultations.
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Acknowledgment
The authors gratefully acknowledge the participants for their time and commitment. We would like to thank SCIBENDI (https://www.scribendi.com/terms) for English language editing.
Footnotes
Disclosure. This study was funded and supported by the Deanship of Scientific Research from the University of Jordan, Amman, Jordan.
- Received March 21, 2019.
- Accepted June 19, 2019.
- Copyright: © Saudi Medical Journal
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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