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

Background The evidence that inspires and fosters communication skills, teaching programmes and clinical recommendations are often based on national studies which assume, implicitly, that patients’ preferences towards doctors’ communication style are not significantly affected by their cultural background. The cross-cultural validity of national results has been recognized as a potential limitation on how generally applicable they are in a wider context. Using 35 country-specific focus group discussions from four European countries, the aim of the present study is to test whether or not national cultures influence lay people’s preferences towards doctors’ style of communication. Methods Lay people preferences on doctor’s communication style have been collected in Belgium, the Netherlands, the United Kingdom and Italy. Each centre organized between eight and nine focus groups, where participants (n = 259) were asked to comment on a video of a simulated medical interview. The discussions were audiotaped, transcribed and coded using a common framework (Guliver Coding System) that allowed for the identification of different themes. Results The frequency distribution of the topics discussed highlights lay people’s generally positive views towards most part of doctors interventions. The regression model applied to the Guliver categories highlighted slight national differences and the existence of a cross-cultural appreciation, in particular, of five types of intervention: Doctors attitudes (both Task-Oriented and Affective/Emotional), Summarizing, Structuring and Providing solution. Conclusion Lay panels valued doctors’ communication style in a similar manner in the countries selected. This highlights the existence of a common background, which in the process of internationalization of heath care, might foster the implementation of cross-national teaching programmes and clinical guidelines.


Background
The long-lasting and multifaceted phenomenon of internationalization of heath care, has led to the development of an increasing number of educational courses that targeted at international clientele and has promoted the dissemination of cross-national medical curricula [1]. In a similar way, clinical practice has also started to implement worldwide guidelines in healthcare delivery [2]. The evidences that inspire and foster these teaching programmes and clinical recommendations, are often based on national studies. Papers are written from the implicit assumption that there are no significant differences between countries in the way doctors and patients relate to each other. However, it is unclear whether this is a valid approach. For example, a partnership doctorcommunication style, that is thought appropriate in most of Western medical schools and generally advocated by Western patients in their contacts with doctors, appears to be quite difficult to apply in a South-East Asian culture. There conflict avoidance and accepted social differences leads to a one-way, paternalistic, doctors' style of communication prevailing [3]. How far the results from such single-country studies can be transferred and how applicable these results are in other countries is hardly ever discussed as a potential limitation of the reported studies. This leads to concerns about the quality and the trans-cultural consistency of the existing evidence. Several studies have demonstrated systematic and relevant differences between countries in medical communication [4][5][6][7]. Patients' ethnic/cultural background -meant here as the expression of belonging to a specific ethnic group - [8,9], or their linguistic proficiency [10], have been demonstrated to have an impact on clinical outcomes and patients' expectations. Cross-national differences in doctor-patient communication have been attributed to the characteristics of the health care system, in particular GP's gatekeeping role [11], or to cultural difference [12]. Among the key predictors of communication factors related to culture suggested by Schouten [13], is the Hofstede model [14,15]. It is one of the most frequently used to highlight differences in cultural values, as it enables a quantification of the dimensions that characterize this complex concept. Hofstede's theory on national cultures, identifies four culture dimensions: power distance (PDI), uncertainty avoidance (UAI), individualism verses collectivism (IDV), masculinity verses femininity (MAS), later supplemented with a fifth dimension: long term vs short term orientation (LTO) [15].
In the present study this model will be applied in order to interpret national differences in the preferences regarding doctor's behaviour when communicating. These were expressed by lay people in 35 country-specific focus groups, in four different European countries, Belgium, the Netherlands, United Kingdom and Italy. The immediate purpose of the study is to test whether or not crossnational differences exist. These relate both in terms of favorite topics, because they are most frequently discussed, and preferences relating to doctors' communication performances. The ultimate aim is to provide evidence on how applicable results from single-country studies on doctor-patient communication are to other countries.
In particular the research questions explored are as follows: 1. Which are the similarities and differences between lay focus groups, by country, in the issues and topics raised during the discussions with regard to doctors' performance in communication? 2. Which are the similarities and differences between lay focus groups, by country, in the preferences expressed regarding doctors' performance in communication?

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 (X 2 23.4 df = 6; higher school range: 36-60 % respectively for IT and UK) and occupational status (X 2 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. 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 10point 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.

Study design and 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].  [15] and Health Care System [16] indicators in the four participating countries 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 classificationsub-category).
The exploration of the bivariate frequency distribution between content communication categories and participant nationality was performed using chi 2 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  [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 designrepeated measures within participantsthe 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.

Results
All the participants comments, stratified by judgment value (positive, neutral and negative), content (Guliver coding systemsub-category level) and country are listed in Table 1.
Cross-national similarities and differences in the issues and topics raised during the focus group discussions The other half was focused largely on specific communication behaviours such as Structuring (13 %), Collecting information (9 %) and Non-verbal behaviour (8 %). National differences emerge in the comparison among countries regarding the issues and topics raised during the discussions (X 2 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: Nonverbal 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 frequency distribution of positive and negative comments (Table 3) suggest the presence of a general appreciation of the majority of doctors interventions. The percentage of positive comments is 87 %; range: 79-88 % for UK and BE respectively.
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.

Discussion
The study has shown more similarities than differences in positive and critical opinions expressed by our sample of European citizens. This suggests that doctors' performance Affective emotional attitude of the doctor Inviting attitude Hofstede's model, and the translation of its cultural dimensions into communication styles, might offer a possible cultural explanation of this juxtaposition of communication features. All European nations here selected, scored high on the dimension 'Individualism vs Collectivism' , which is characterized by a tendency towards autonomy and the exaltation of the individual and his personal resources and goals. In an earlier study, this dimension proved to be the most important in cross-national differences in doctorpatient communication [12]. This finding can be translated into a clinical approach that takes into account patient's needs and that actively promotes his or her involvement in the decision-making process [12]. To boost this trend, there is also another cultural aspect that seems shared to a fair degree within our sample. This is the low score in the scale of 'Power distance' , which denotes a validation of patient initiative and a reduction in the dominance of the doctor in the doctor-patient relationship [14]. Taking the assumption that participants moved from a common cultural background that oriented them to take an active role in the healing process, one might wonder why they choose among their favorite interventions, Giving Information or Providing solution, which can be considered directive doctor's intervention and why Patient involvement did not result in being significantly more appreciated that other interventions.
The shift from the patient's expectation of involvement and their acceptance of doctors' suggestions may probably, have been made possible by the synergistic coexistence of the other four elements composing our five-point structure. Thus, patients are willing to accept solutions that come from an external source, the doctor, only to the extent that these are perceived as the fruit of a competent, flexible, empathetic and careful listening [25][26][27].
The wide cross-national appreciation of affective interventions does not find an immediate explanation in the scores of another Hofstede dimension usually correlated to 'emotional expression': Masculinity/Femininity. In this scale, the Netherlands is placed in the polarity Femininity, diverging from the other three countries with an higher grade for Masculinity. In communication terms, Masculinity is assumed to be translated in instrumental, or curing behavior, disease centred communication and biomedical talk, while Femininity is related to caring behavior [14]. In a previous study, using Hofstede's dimensions for predicting crossnational differences in doctor-patient communication, the Masculinity-Femininity dimension also was the odd one which did not fit within the predicted pattern [12]. One possible hypothesis that might explain this absence of differences in country's orientation towards Affective-oriented attitudes based on Hofstede scores, is that cultural differences might emerge at the micro-level of specific skills used to deliver the emotional content. Indeed, participants from   the Netherlands, which has the highest scores of Femininity, often discussed Reassurance, which requires a high emotional involvement of the doctor in order to be perceived as being authentic by the patient [28]. By contrast, the UK and Italy, with higher scores in the scale of Masculinity, were, in their comments, more oriented towards Showing interest and a Pleasant attitude, which imply a lower level of personal or emotional participation by the doctor, who is asked in this case to be polite, gentle and attentive but not necessarily compassionate [29]. However, Belgium has the same tendency to Masculinity as the UK and Italy have, and yet its study participants behaved more like the Dutch did, commenting positively on the way doctors practices Reassurance.
Of course much more can be said about the impact of national cultures on how doctor and patient communicate in the medical consultation room, and what is, or is not, appreciated by people from different countries. The literature on this issue is still scarce although the pressure to internationalize paths of care and education is growing. Our results suggest that at a macro-level, citizens present quite similar preferences towards doctors' communication styles, and therefore, teaching programmes and clinical guidelines that stick to general recommendations might not require cultural adaptations if applied in the four countries selected here.
Anyway, previous studies [3] have highlighted that the implementation of a communicative approach (i.e.partnership relationship) in different cultures (i.e. Western versus Southeast Asian), although generally acknowledged, requires adaptations when shifting to the microlevel of doctors' specific actions carried out during the consultation, as they can have a different impact according to the nationality of the patient. In the sample here analysed, this might be the case of doctors' affective expressions, where how far, what patients consider, a "good intervention" can be generally applicable seems to be affected by their cultural background, and consequently, a more careful approach should be followed in the implementation of cross-national clinical and educational interventions on "patient's emotion handling".
International comparative cross-cultural studies based on a wider range of cultural backgrounds that assess citizens' preferences on doctors' communication styles, according to the specific functions of the clinical encounter, would encourage the development and promotion of culturally competent health care [30][31][32].

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].

Ethical approval
The project was approved by the Medical Education Research Ethics Committee of the University of Liverpool. Informed consent of the participants was obtained in all four countries.

Conclusions
A combination of elements, emboding a balance between doctors ability in setting up an empatheticrelationship and showing competency in the management of patients' symptoms, has been cross-culturallyvalued.-Teaching programmes and clinical guidelines that stick to general recommendations, based on thiscombination of communication skills, might not require cultural adaptations if applied in the four countrieshere selected.International comparative cross-cultural studies based on a wider range of cultural backgrounds wouldencourage the development and promotion of culturally competent health care.

Touch
..by the way he was the only one who smiled and has touched the lady before leaving. He led his hand on her arm.

Other behaviours
He was fiddling with pencil like this… Reading and writing What I find really annoying lately is the doctor sitting and typing in things on the computer while you are talking to him.

Laughing
It is not really a laughable subject, so I think that I would have thought, 'Why are you laughing?

Process-oriented expressions
Structuring Changing topics/ signposting She asked a lot) but sometimes I felt like, "where does it fit in?
Flexibility …he had learned his lesson by heart and he had to ask all these questions without exploring any further than that..

Time issues
He says to the patient: "Time is up". That is very impolite.
Open/closing interview I think only one of the doctors asked how the patient was like just as an informal introduction, hi how are you today, but not many of them did that.

Summarizing Summarizing
She did the summary for the patient, she wanted to be precise, to be sure of having understood.

Patient-involving Sharing plans/ideas
Asking patient what she thinks should be done now.

Asking permission
Now I'd like to deepen our discussion on this topic, so if you agree I'd like to ask you few questions..

Verifying
it would have been nice if, as the other three doctors have done, when patient says something the doctor in that precise moment repeats "If I understood you.."

Repetition
He repeats his questions several times.

Fillers
I did not like all these 'ok, ok,' which made me nervous.

Comprehensibility
She did not complete her sentences… Task-oriented/problemfocused expressions Attitude of the doctor Self-confident …she was quite self-confident, I would trust her.
Complete picture I just thought he was dynamic and caught everything you know that was needed to be asked and he finished off really well.

Businesslike /Straight to the point
The doctor gave straightforward answers.

Clarity of interview
The doctor expressed himself clearly.

Competency
Competent, he has taken the time to inform you that is a reassurance. It' s a edge sort of thing, the competence of the knowledge and the way he is sharing the fact with you.

Collecting information Medical
And it was the only one who asked about a Pab test, that was good, I think.
Like: did you have Pab tests before?
Biopsycho … no doctor asked whether she had had sex with her current partner recently.

Psychosocial
He thoroughly explores about the job, the family is apparently less important in his opinion, or he pays less attention to it. While I think it should come first

Giving information
Medical the main thing for me is that he tells me straight away what causes the discharge.
Biopsycho she explains that she is trying to understand whether it is a psychological problem or a physical.

Psychosocial
Doctors can orientate the patient and tell him: "probably the origin of the problem could be in part psychological". Prov. solution Providing solutions I liked her because it was interesting that she proposed how to resolve the distress of the patient at work.

Attitude of the doctor
Inviting attitude He has created the right atmosphere… so that the lady could say something more.

Pleasant attitude
The girl had a very loving glance, a very gentle glance.

Show interest /commitment
I thought that was the doctor who was most worried about the patient, who showed most involvement.

Empathic
So but I liked him I put him as my favourite because I found him very empathetic.
Facilitating .…. he let her finish without interrupting… Reassurance/trust She is my favourite. When you are the gatekeeper, then you should first of all reassure the patient that she can say anything.

Neutral/No personal remark
It is not done that a GP has an opinion about it… Listening I found him very helpful and ready to listen. He let the patient talk quite a bit..