Providers' perceptions of communication with patients in primary healthcare in Rwanda.

BACKGROUND: Delivery of effective healthcare is contingent on the quality of communication between the patient and the healthcare provider. Little is known about primary healthcare providers' perceptions of communication with patients in Rwanda. AIM: To explore providers' perceptions of patient-provider communication (PPC) and analyse the ways in which providers present and reflect on communication practice and problems. METHODS: Qualitative, in-depth, semi structured interviews with nine primary health care providers. An abductive analysis supplemented by the framework method was applied. A narrative approach allowed the emergence of archetypical narratives on PPC. RESULTS: Providers shared rich reflections on the importance of proper communication with patients and appeared committed to making their interaction work optimally. Still, providers had difficulty critically analysing limitations of their communication in practice. Reported communication issues included lack of communication training as well as time and workload issues. Two archetypes of narratives on PPC issues and practice emerged and are discussed. CONCLUSION: While providers' narratives put patients at the centre of care, there were indications that patient-provider communication training and practice need further development. In-depth exploration of highlighted issues and adapted strategies to tackle communication drawbacks are prerequisites to improvement. This study contributes to the advancement of knowledge related to communication between the patient and the provider in a resource-limited setting.

Implementing One Health as an integrated approach to health in Rwanda.

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. 'One Health' refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans.

The Evolving Role of Physicians - Don't Forget the Generalist Primary Care Providers Comment on "Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians".

The editorial "Non-physician Clinicians in Sub-Saharan Africa and the Evolving Role of Physicians" by Eyal et al describes non-physician clinicians' (NPC) need for mentorship and support from physicians. We emphasise the same need of support for front line generalist primary healthcare providers who carry out complex tasks yet may have an inadequate skill mix.

Student-patient communication during physical examination.

BACKGROUND: Communication during the physical examination has been understudied. Explicit, evidence-based guidance is not available as to the most effective content or process of communication while performing physical examination, or indeed how to teach this to medical students. The objective of this exploratory study was to explore how medical students communicate with patients when performing a physical examination in the absence of formal teaching on how to communicate in this situation. METHODS: We recorded 15 senior UK medical students as they performed physical examinations with real patients in general practice situations. The transcriptions were analysed for linguistic functions to identify the use of different categories of utterances. RESULTS: Student utterances fell into four categories: minimising language; using positive evaluative language; repeating the patient; and stating intentions or explanations and requesting consent. Students would often preface an explanation or action by phrases showing 'togetherness', by using 'we' rather than 'you'. They also used linguistic 'hedges' to minimise the impact of an utterance. DISCUSSION: Senior medical students speak very little during the physical examination. When they do, they use a taxonomy of utterances that reflects those reported in doctor-patient interactions. Identifying how medical students communicate when carrying out the physical examination is the first step in planning how to best teach specific communication skills. Further work is needed to identify how best to explore communication during physical examination, and how this is taught and learned.

Improving medical students' attitudes towards the chronic sick: a role for social science research.

BACKGROUND: Many medical students are negatively disposed toward the elderly and chronic sick. The present study assessed the impact of a community-based teaching initiative, the Life History Project, on students' attitudes to these groups. METHODS: A questionnaire including Likert based responses and free text comments was distributed to all first-year MBChB students after completion of their Life History coursework. Data was analysed using SPSS and content analysis. RESULTS: A high proportion of students believed the Life History Project had increased their understanding of both psychological and social aspects of health and illness and the role of the humanistic social sciences within this. We discovered that the Life History Project not only gave students first-hand experience of the elderly and chronic sick but also had a positive effect on their attitudes towards these groups. The qualitative free text comments corroborated these views. CONCLUSIONS: It is possible to positively influence medical students' attitudes towards these stigmatised groups; it is therefore important that we continue to enhance opportunities for learning about the impact of chronic illness on individuals and society throughout the curriculum.

Developing a set of quality criteria for community-based medical education in the UK.

CONTEXT: General practices educate increasing numbers of learners at various stages. Criteria for educational provision exist, but practices supporting learners at different stages and from different institutions might face different criteria. METHODS: Criteria for practice-based teaching were developed at a workshop at a national conference. An online Delphi questionnaire invited educationalists to label these criteria as 'essential', 'desirable' or 'unnecessary' for 'occasional', 'intensive' and 'foundation year' teaching. Two rounds of the Delphi were completed. The views about the criteria of a range of stakeholders were explored using focus groups and telephone interviews. RESULTS: We generated 76 criteria in five domains; physical environment, learning environment, tutor characteristics, patient involvement and departmental responsibilities. Stakeholders' views differed concerning the merits of criteria and which should take greatest priority. None felt that developing such a list was inappropriate. They proposed no new criteria to add to those identified in the Delphi process. CONCLUSION: To the best of our knowledge this is the first nationally derived list of criteria, capable of being used in both undergraduate and postgraduate practice-based medical education. These criteria can provide a benchmark against which to set local criteria.

The use of a modification of the Patient Enablement Instrument in asthma.

AIM: To ascertain if the Patient Enablement Instrument (PEI) could be adapted for use in asthma management, and to use it to evaluate "enablement" in patients with asthma randomised to either a fixed or adjustable medication dosing regime. METHODS: The original Patient Enablement Instrument was modified by making a minor change to the opening statement. 228 adults with asthma from 72 UK general practices were recruited to the study. The internal and external consistencies of the modified PEI were assessed. Individual scores were compared across treatment groups. RESULTS: The modified PEI had high internal consistency. There was a significant correlation between modified PEI total score and change in Mini Asthma Quality of Life Questionnaire. A significantly greater proportion of patients using adjustable medication dosing had a clinically relevant treatment benefit. CONCLUSIONS: The Patient Enablement Instrument can be used to measure "enablement" in asthma.