How do national cultures influence lay people’s preferences toward doctors’ style of communication? A comparison of 35 focus groups from an European cross national research

Participating countries

The international multicentre study draws its name (Guliver) from the four centres involved: Gent University (Belgium), Utrecht University/NIVEL (the Netherlands), Liverpool University (United Kingdom) and the University of Verona (Italy).

Figure 1 shows some of the variables that describe the cultural background of the four countries from different perspectives, like Hofstede’s dimensions and geographic region.

Regarding the geographical location of the enrolled nations, although none of them is located in the Eastern Europe, the other three macro-regions (North, West and South) are present, assuring a wide variety of cultural backgrounds. As suggested by previous studies [11, 16, 17], health care public funding, quality of primary care and general practitioners gatekeeping role have been also reported in the table as possible moderator variables. These may effect modulate lay peoples’ preferences and expectations towards doctor-patient communication. In Italy and the UK, the National Health Service is based on Beveridge model [17] in which health care is provided and financed by the government through tax payments. The Netherlands and Belgium follow another model, named Bismarckmodel [17] that uses an insurance system with different health cost insurers who offer slightly different types of insurance packages.

Panel sample

A sample of 259 participants was recruited from the general population. This was balanced by a number of factors. Firstly, age, so that at least two persons were in the classes 18–30, 31–49 and >50 years of age, for a total of 6–8 participants, in order to guarantee a heterogeneous distribution in each group. Secondly, gender, with 117 males and 142 females. Finally there was a country balance with 64 in the Netherland, 72 in Italy, 75 in UK and 48 in Belgium.

The overall sample presented a satisfactory mixture of socio-demographic characteristics: marital status (45 % married, 44 % single, other 11 %); education (13 % primary, 40 % secondary, 47 % higher school); and, occupation (57 % employed, 20 % student, 5 % unemployed, 4 % unable to work through disability, 14 % housewife/retired). The frequency distribution of these variables within each country, shows statistically significant differences in the education level (X² 23.4 df = 6; higher school range: 36–60 % respectively for IT and UK) and occupational status (X² 58.24 df = 12; employed: 29–87 % respectively for NL and UK). More details of the participants sample clinical characteristics are reported elsewhere [18]. Recruitment took place in public areas, via calls in free local newspaper and by word of mouth. The protocol was approved by the Medical Education Research Ethics Committee of the University of Liverpool. The written informed consent of the participants was obtained in all four countries.

Study design and focus groups

Figure 2 illustrates the study design. A set of 35 focus group discussions (nine for each country, except Belgium with eight) were conducted following the same procedures, according to a detailed protocol [19]. Participants attended a 1-day-meeting where they watched four videotaped consultations and carried out different tasks [19]. The videotapes were standardized medical OSCE (Objective Structured Clinical Examination) consultations, in which eight different 4th year medical students from Liverpool Medical School -from now on called ‘doctors’- were assessed during their final examination. Consultations lasted on average 10 min. The maximum variation in the quality of doctors communication, was guaranteed by the combination of simulated patient ratings on a 10-point Likert scale (Global Simulated Patient Rating Scale, GSPRS) and examiners’ assessments on a checklist that included pre-established expert defined abilities defined by experts (Liverpool Communication Skills Assessment Scale, LCSAS). Two different scenarios were used, both about gynaecological problems associated with high levels of emotional distress. One was vaginal discharge related to unsafe sex- a Sexually Transmitted Disease (STD), the other was menstrual period pain (PP). As previously stated, participants were balanced by gender, anyway in order to encourage the free expression of opinions given the “gender sensitive” health problems shown in the videos, they attended gender specific focus groups.

As a prompt for the focus group discussion, participants watched four videos, based on the same scenario, in which the quality of doctors’ communication varied according to different scores of GPRS and LCSAS evaluations. Focus group discussions of 1 h followed, in which they were invited to explain their assessments from the first-round session, share their likes and dislikes regarding the doctors’ communication approach and provide underlying reasons.

Units of analysis and measures

In order to compare the qualitative data gathered through the focus group discussions, a content analysis was performed. This aimed at creating a coding system that would allow us to synthesize, and systematically organize, participants comments. The application of quantitative techniques to qualitative data, is one of the possible use of the Mixed-Method approach [20, 21].

Each centre adopted the same set of systematic and transparent procedures for arranging and processing the raw data in order to obtain valid and reliable inferences [18]. The researchers from each centre, two from the Netherlands (J.B., L.V), three from Italy (F.M., M.R., G.D.), and one from the UK (I.F), applied an inductive content analysis of a selected set of focus group discussions. These were previously videotaped, transcribed and translated into English by researchers, who are all fluent in the English language, and checked by a native speaker. This was in order to derive a common coding framework (“Guliver coding system”) with which to classify each participant’s statement. Details about the inter-rater reliability have been published elsewhere [18].

The resulting coding system, is divided into three levels, the area, category and sub-category, to which each statement has to refer. Specific examples of the Guliver coding system categories selected in the present paper are provided in an Appendix.

When a judgment was expressed in a participants’ comment, its value was coded as positive, negative or neutral. Figure 2 indicates the variables on which the analysis have been performed in order to answer each research question.

All the focus group transcripts have been coded in their original language and also translated into English in order to make them accessible to researchers in all four centres.

Statistical analyses

The analyses have been performed at the category level of the Guliver coding system in order to have a sufficient sample size in the comparisons between countries (Table 1 shows the consistency of the cells at the third level of classification – sub-category).

The exploration of the bivariate frequency distribution between content communication categories and participant nationality was performed using chi² test and the adjusted residual analysis [22].

Two logistic regression models were estimated in order to investigate, both in terms of main effects and their interaction, the relationship between the outcome variable (positive and negative participant specific judgments) and the two independent ones which are, Guliver categories and participants’ country. Since the two independent variables are categorical, a reference category was needed for each of them; therefore Collecting information was the reference category for the coding system and the Netherlands for the country. The coefficients estimated by the models were expressed according to the odds ratio interpretative approach [23]. Therefore in the first model the main effects were expressed in terms of OR (that inform on the odds of positive statements of each category in relation to a specific reference category); while the interaction effects estimated in the second model were expressed in terms of odds (that indicate the increase of positive comments for each negative produced - calculated using Margins and Marginsplot STATA commands). This methodological choice was taken in order to facilitate the interpretation of the results.

To take into account the nested structure of the study design – repeated measures within participants – the cluster option of STATA commands, was adopted in the regression models.

A count of the frequency of positive and negative statements at the level of sub-category will be provided to describe better the results obtained.

All the analysis were performed using STATA13.0 [24].

Cross-national similarities and differences in the issues and topics raised during the focus group discussions

National differences emerge in the comparison among countries regarding the issues and topics raised during the discussions (X² test = 179.61, df 27; p < 0.01). The exploration based on the adjusted residuals allows for the identification of categories that are specifically prevalent in one of the participating countries. This is indicated by a positive gap between the observed and the expected frequencies.

Cross-national similarities emerged in the four countries during the discussion of the categories. These were: Non-verbal behaviour (especially the sub-category of Other Behaviours and Reading and writing -see Table 1); Giving information (especially the sub-category, Medical,); Patient involvement, (in particular the sub-category Sharing plans or ideas); and Summarizing.

Two topics received particular attention in the Dutch sample: Speaking peculiarities (6 %- in particular Repetition) and Collecting information (12 %- mainly due to Biopsychological)., Affective-oriented attitudes (32 %)were frequently discussed among the Italian sample, in particular Showing interest Reassuring, Inviting attitude and Facilitating. UK citizens devoted more space to doctors’ Task-oriented attitudes (28 %), in particular the sub-categories Competency and Self-confident. Finally, the Belgian group talked more than the other countries about Structuring (17 %), especially those interventions labelled as Flexibility and Time issues.

Cross-national similarities and differences in the participants’ preferences expressed during lay focus groups

The logistic regression showed that the British sample was more critical compared to Netherlands (OR = 0.46; p < 0.05) while Italians shown a more positive attitude (OR = 2.07; p < 0.05). The results for cross-cultural positive appreciation, in particular of five types of intervention were as follows: Providing solution (OR = 5.92 p < 0.05; 95 %), Giving Information (OR = 4.08 p < 0.05; 92 %),, doctors’ attitudes (both Task-oriented OR = 7.41 p < 0.05; 96 % and Affective-oriented OR = 11.37 p < 0.05; 97 %) and Structuring (OR = 2.15 p < 0.05; 86 %). The category that resulted less appreciated was Speaking Peculiarities (OR = 0.11 p < 0.05; 28 %).

Although, analyses were limited to the category level, due to their sample size, a description of the frequency distribution of the sub-categories (Table 1), will enable a better understanding of the categories commented on above.

Focusing on the positive comments referring to Giving Information, the Medical content was particularly valued by participants (66 %; range UK 45 % and IT 86 %), among Task-oriented attitudes, Competency resulted in being the most appreciated (38 %; range UK 30 % and IT 45 %). Country specific preferences emerged among Affective-oriented attitudes: Reassurance was the most appreciated by Dutch and Belgians (29 and 26 % respectively). Italians also valued interventions that Show interest or commitment (24 %) while British subjects regarded, positively, expressions indicating a Pleasant attitude of the doctor (29 %). Finally, within the category, Structuring, which was also valued positively by panel samples, Flexibility got the highest percentage of comments (48 %; range NL 27 % and BE 67 %).

On the other hand, the negative evaluation of Speaking Peculiarities relies mainly on the sub-category Asking permission (25 % of positive comments; range IT 9 % and UK 44 %).

Alongside the above described main effects, the second logistic regression estimated the interaction between the variables category and country, in terms of odds (see Fig. 3). The plots for each category suggest that no significant differences emerged between countries, since all the confidence intervals overlapped; the only exception is for the category Structuring where British sample showed a more critical attitude compared to the Belgians (Odds UK 2.2; 95%CI: 1.1;3.3 versus Odds BE 8.8; 95%CI: 3.9;13.7). In few cases, the limited number of negative comments referred to a specific category, determined not calculable or extremely wide confidence intervals.

Strength and weaknesses

The present study is based on a multi-centric dataset obtained through the fruitful collaboration of different international experts in the field of communication in medicine from Northern, Southern and Western Europe. The convenience sampling criteria limited the space to include Eastern countries in the study, which may have reduced the variety of cultural background represented. While these macro geographical divisions at the country level are, of course, too broad from an individual cultural perspective, it is yet important to analyze differences at the country level. This is because in Europe health care systems and medical curricula are organized at the country level. For policymakers as well as medical teachers it is therefore important to be aware of country-specific elements of lay people’s appreciation of doctor-patient communication.

Another possible weakness is that we were not able to check for focus group participants’ individual cultural differences, such as country of birth or religion. It is known from the literature that within countries, large cultural differences may exist between its inhabitants, which have a certain impact on doctor-patient communication [8, 9]. However, studying these individual differences was not the aim of the study.

A particular strength of this study is also that all participants had the same stimuli to react to, as they watched the identical set of videos, guaranteeing that the research for cultural differences is not contaminated by other frames of references.

The analogue patients methodology, treating laypeople as patient proxy, can be seen as a strength and a weakness at the same time. A strength is that it enables standardization of procedures and material so that the ratings are comparable (see also above). A possible limitation is that these participants are not the real patients of these doctors, which could hamper the ecological validity of the study. However, this particular methodology has been often applied in studies assessing patient perceptions [33, 34] and is recently validated [35, 36].