COMMUNICATION AND EMOTIONAL HEALTH 1
How Does Patient-centered Communication Improve Emotional Health?
An Exploratory Study in China
Shaohai Jiang, PhD
Department of Communications and New Media
National University of Singapore
Blk AS6, #03-41, 11 Computing Drive, Singapore 117416
Abstract
In China, people’s emotional health is concerning. The patient-centered communication during medical consultations may play an important role in improving people’s emotional well-being. However, the relationship between communication and health is one of the least developed areas in communication research. This study empirically tested a pathway linking communication to health. Based on survey data collected from 483 Chinese patients, the results showed that patient-centered communication directly improved emotional health. Also, patient-centered communication had an indirect effect on emotional health through uncertainty management skill. In addition, patient trust positively moderated the effects of patient-centered communication on uncertainty management skill and emotional health. Also, one’s Internet health information seeking positively moderated the effect of communication on health. The findings have significant theoretical and practical implications for health education and promotion in the context of China.
Keywords: patient-centered communication, uncertainty management skill, emotional health, moderated mediation, China
How Does Patient-centered Communication Improve Emotional Health?
An Exploratory Study in China
Introduction
Emotional health is a catch-all term related to an individual's everyday experience of joy, affection, anxiety, sadness, anger, stress, and depression (Kahneman & Deaton, 2010). In China, people’s emotional health is concerning. According to the 2012 Regus-Commissioned Global Survey, 75% of respondents in China said that they felt increased stress and pressure in the past year, well over the global average of 48% (Chen & Shi, 2012). Another national survey among 16,866 Chinese people showed that in 2014, 22.5% of respondents reported the median level of stress, and 26.2% experienced severe stress (Wang et al., 2015). One’s emotional well-being can significantly contribute to his or her overall mental and physical health. For example, stress and anxiety can cause a series of psychological symptoms, such as obsessive-compulsiveness, interpersonal sensitivity and hostility (Duan, Ho, Siu, Li, & Zhang, 2015), and physiological symptoms, such as headache, fatigue, pain, and sleep problems (American Psychological Association, 2014).
Patients in the course of care face greater emotion-related burdens. The patient-centered communication during medical consultations may pose a formidable communication channel for improving people’s emotional health. Patient-centered communication emphasizes that doctors’ communication should respect and respond to individual patient preferences, needs, and values, and ensures that patient values guide all clinical decisions (Institute of Medicine, 2001). When a patient feels known, validated, hope and comforted in medical encounters, he or she may have enhanced emotional well-being- fewer negative states (e.g., anxiety, worry), and more positive ones (e.g., self-worth, optimism). For example, a survey study among 260 Chinese women with breast cancer found that patients who had better communicative experiences in their past medical visits self-reported better emotional health condition (Zhou et al., 2013). Another qualitative interview of 29 HIV-positive Chinese patients also indicated that patients considered health care providers as helpful to meet their emotional needs during consultations and the treatment process (Chen et al., 2007). In fact, patient-centered communication is especially important to Chinese patients given the deteriorating doctor-patient relationshipas a result of low patient satisfaction, patient mistrust, and patient passivity, and other challenges many Chinese people face in the course of health care (e.g., long waiting time, short consultation time, high medical cost) (Jiang & Street, 2017).
Despite the documented benefits of patient-centered communication on emotional health, prior research, at times, produced null or mixed results. For example, one study among diabetic patients found that patient-centered communication has not been related to patients’ reduced stress (Bridges & Smith, 2015). Another survey study among Chinese cancer patients indicated that doctor-patient communication had no significant impact on patients’ emotional states (Liu, Mok, & Wong, 2005). However, a systematic review concluded that the overall effect size of doctor-patient communication on health outcomes was small, but significant (Kelley et al., 2014).
The inconsistency of these findings might be due to the paucity of research on social mechanisms underlying the effects of patient-centered communication on health outcomes. Researchers have only started to model pathways through which communication contributes to improved health (Jiang, 2017). Epstein and Street (2007) contended that the relationship between doctor-patient communication and health, from a conceptual standpoint, is one of the least developed areas of communication research. In the current literature, there remains two important gaps. First, previous studies have mainly focused on physical health outcomes, while emotional health has been largely ignored in this line of research. Second, to the best of our knowledge, research that has explicated any fundamental pathways linking communication to health in the context of China is virtually non-existent. Thus, to fill these gaps in the literature, the current study aims to illustrate a moderated mediation model that includes both direct and indirect effects of communication on emotional health among Chinese patients.
Conceptual Framework
The conceptual framework generally draws from Street and colleagues’ (2009) pathway model linking communication to health. Their proposed pathways include both direct and indirect effects of doctor-patient communication. In some situations, communication may have direct effects on people’s health. A clinician who encourages, reassures and offers clear and understandable explanations may reduce a patient’s anxiety level, sleep better, and have an enhanced appetite immediately after the medical consultation (Street et al., 2009). However, in most situations, communication affects health indirectly, mediated by proximal outcomes and intermediate outcomes.Specifically, doctor-patient communication would have immediate effects on proximal outcomes (e.g., shared understanding, patient satisfaction, clinician-patient agreement) within the consultation environment, which in turn merge into post consultation intermediate outcomes (e.g., access to care, commitment to treatment, and self-management skills ) when patients leave the medical encounter. The intermediate outcomes then can lead to distal health outcomes (e.g., health improvement, lifestyle change, and prevention action). Although the Street et al.’s model provides a framework to examine both main effects of communication and mediation effects of proximal and/or intermediate outcomes, it neglects any possible moderation effect. As the experiences of patients and health care providers over the course of care continuum are both dynamic and complex, it is important to take into account factors that may moderate the effects of communication on outcomes of interest. To identify possible moderators in the context of medical communication, Street’s (2003) ecological framework of communication in medical encounters may offer a suitable theoretical foundation. This model posits that the interaction between patients and clinicians is situated within and influenced by various social contexts, including the personal, interpersonal, media, organizational, and cultural. That is, contextual influences may work through personal and partner communication factors. For example, a patient’s participation in the consultation may be more if the patient has done research on his/her health problem from the Internet before seeing the doctor (Dedding, van Doorn, Winkler, & Reis, 2011), and/or if the patient has more interpersonal trust towards the doctor (Kraetschmer, Sharpe, Urowitz, & Deber, 2004).
As doctor-patient communication is situated within the broader context of personal and social determinants of health, once patients leave the consultation, any number of factors may affect subsequent health. Thus, the current study aims to examine how the relationship between communication and health may be mediated through proximal outcomes of the interaction (e.g., shared understanding, uncertainty management, self-management skills), and how social contexts might moderate this relationship. Specifically, this study (a) proposes an indirect pathway linking patient-centered communication to emotional health outcomes through the mediator of uncertainty management skill; (b) argues how communication could also directly improve emotional health, and (c) explores the possibility of moderating effects of contextual factors at the interpersonal level (patient trust in doctors), and at the media level (Internet health information seeking). (Figure 1)
Patient-centered Communication, Uncertainty Management Skill, and Emotional Health
Researchers have extensively studied the relationship between uncertainty management skill and emotional health. Uncertainty management skill is one’s ability to cope with uncertain situations, by allowing space for hope, and managing information problems (Brashers, 2001). According to Uncertainty Management Theory (UMT), responses to uncertainty are shaped by appraisal and emotional reactions to the experience. In appraising uncertainty as offering hope, people might feel optimistic or perceive a positive outcome in the uncertain situation. For example, patients who are uncertain about their health condition, yet believe that a bright future is one possibility, would feel hope. On the other hand, in appraising uncertainty as danger, individuals may feel fear or anxiety about the potential outcomes. For instance, uncertainty can cause anxiety if it precludes effective decision making and fear if it threatens health and safety (Brashers, 2001, 2007). Therefore, to effectively manage uncertainty, it is important to foster an optimistic outlook, which can help reduce anxiety related to the health condition. Previous studies showed that uncertainty management skill played a significant role in improving emotional health through various mechanisms, such as assisting patients with health information seeking and avoiding, providing instrumental support, facilitating skill development, giving acceptance or validation, and encouraging perspective shifts (Brashers, Neidig, & Goldsmith, 2004). When patients become capable of identifying the correct diagnosis and treatment plan during medical encounters, they will later have better adherence to the treatment and self-care, which, in turn, could lead to better health outcomes (Epstein & Street, 2007). Empirical evidences on positive impacts of uncertainty management skill have been found. For example, Mishel and colleagues (2005) conducted an uncertainty management intervention among 509 breast cancer survivors in the United States, and demonstrated that compared with patients in the control group, those who had training on cognitive-behavioral strategies to deal with uncertainty, had lower levels of emotional distress. In China, an intervention among 295 patients with chronic obstructive pulmonary disease showed that those in the intervention group had significant improvement in coping with anxiety, depression and other emotional health domains of quality of life (Jiang & He, 2012). Thus, consistent with prior research, the following hypothesis is advanced:
H1: Uncertainty management skill is positively related to emotional health.
Patient-centered communication has long been considered as an effective channel to improve patients’ uncertainty management skills. During medical consultations, doctors provide explanations about treatment, answer questions in an understandable way, check for questions or concerns, and thus facilitate effective uncertainty management (Epstein & Street, 2007). For example, a study in a cardiology clinic found that doctors’ provision of adequate information significantly reduced patients’ post-visit illness uncertainty(Sheer & Cline, 1995). In another study that interviewed 60 cancer survivors, many participants reported seeking information from physicians as a major means of managing their uncertainty, and specifically patients turn to their health care providers to make sure they understand the treatment correctly, reassure information found from the Internet, and discuss about the right steps for their future healthcare (Miller, 2014). McCormack and colleagues (2011) conducted a systematic review of research on patient-centered communication in cancer care, and found that doctor-patient communication can help patients manage uncertainty by constructing and defining uncertainty to patients, assessing and analyzing uncertainty to patients, emotion-focused management strategies, and problem-focused management strategies. Given the importance of doctor-patient communication, the study predicts that communication may enhance patients’ uncertainty management skills.
H2: Patient-centered communication is positively associated with uncertainty managementskill.
In light of the above, one pathway of the effect of patient-centered communication on improved emotional health outcomes will likely be indirect through mediation related to uncertainty management skill. Previous studies have demonstrated the mediation effects of uncertainty management on various health outcomes, such as relieving stress (Keeley, Wright, & Condit, 2009), coping with breast cancer (Mishel et al., 2005), and improving quality of life for people living with HIV or AIDS (Brashers et al., 2004). Thus, consistent with prior research, the following hypothesis is put forth:
H3: Uncertainty management skill mediates the effect of patient-centered communication on emotional health.
Despite the indirect effects discussed above, as suggested in Street et al.’s model, in some situation, doctor-patient communication can directly improve health. Across various illnesses and health conditions, patients who are more actively involved in their medical visits, and who have more patient-centered medical visit experiences, often experience better health outcomes (Street et al., 2009). Van Dam and colleagues (2003) systematically reviewed eight studies on provider-patient interaction in diabetes care, and three studies that examined emotion-related issues showed that patient-centered communication was directly associated with various outcomes, including better well-being, improved perceived mental health, and less diabetes depression. Another systematic review of empathy in medical consultations also supported that the empathic communication lowers patients’ anxiety and distress (Derksen et al., 2013). Therefore, in line with previous studies, the following hypothesis is posited:
H4: Patient-centered communication has positive and direct effects on emotional health.
The Moderating Role of Contextual Influences
As noted above, patient-centered communication is expected to have both direct and indirect effects on emotional health. However, the effect size could vary vastly depending on one’s contextual influences. Street’s (2003) ecological framework of communication in medical encounters underscores the interplay of doctor-patient communication and other factors at different levels, and its subsequent effects on health outcomes. Therefore, the present study investigated whether the impact of patient-centered communication on emotional health might be moderated by variables that manifest within patients’ interpersonal and media contexts.
At the interpersonal level, patient trust in doctors is an important factor in the health care. Patient trust is a belief that doctors will provide reliable information, and act in the patient’s best interests (Mechanic & Schlesinger, 1996). If a patient who had considerable trust in the doctor was not as anxious as a less trusting patient when the doctor expressed reassurance about a favorable prognosis, then the relationship between reassurance and lower anxiety/stress would have been moderated by trust. Particularly, when patients need to make up for inadequate medical knowledge during encounters, they would rely on cognitive shortcuts, such as trust (Lee, Scheufele, & Lewenstein, 2005). That is, the greater patient trust in doctors, the more active participation in information exchange with doctors, which could lead to better outcomes of interest. In fact, numerous studies have demonstrated the moderating effects of patient trust on different health-related outcomes, such as medication adherence (Piette, Heisler, Krein, & Kerr, 2005), frequency of visiting doctors (Lee & Hornik, 2009), and patient participation during medical encounters (Lee & Kim, 2013). The inclusion of patient trust is particularly crucial in China, which is facing a crisis of trust in the health care sector. According to an online survey conducted by Sohu(2007), a popular Chinese web portal, among 1,268 respondents, only 27% stated that they trust their doctors. When examining the causes of doctor-patient mistrust, patients’ perception of injustice within the medical sphere, knowledge imbalances, and disagreement with physicians were three important contributing factors.
In the current study, one might expect that patients who trust their doctors may place a higher value on the medical communication, and become more willing to proactively engage in communication with doctors, which would strengthen the impact of doctor-patient communication on uncertainty management and emotional health outcomes.
H5a: Patient trust in doctors will positively moderate the direct effect of patient-centered communication on emotional health.
H5b: Patient trust in doctors will positively moderate the effect of patient-centered communication on uncertainty managementskill.
H5c: Patient trust in doctors will moderate the positive and indirect effect of patient-centered communication on emotional health, through the mediator of uncertainty management skill.
In the media context, Internet use has superior capabilities for patients to accumulate health-related resources. Internet health information seeking is defined as the use of Internet applications to find information about a particular health topic (Niederdeppe et al., 2007). For example, people can use a search engine to seek specific health information, or post health-related questions to online platforms. After seeking health information (e.g., regarding symptoms and treatment options) via the Internet, patients could have a better understanding of their conditions and treatment expectations, and thus during the medical consultation, they may participate more effectively in interactions with clinicians to reduce uncertainty (Hesse et al., 2005; Street, 2003). Prior research contended that the role of doctor-patient communication in influencing health-related outcomes, such as increased medical knowledge, shared understanding, better medical decisions, and enhanced patient agency, may be more effective for patients with more Internet health information seeking experience (Epstein & Street, 2007; Street & Rimal, 1997).
It is of emerging importance to take into account factors related to Internet use when examining health care quality in China. Compared with developed countries, Internet use for health purposes is still relatively new to many Chinese people. According to a national survey, in 2013, 33.2% of Chinese adults have sought health information online (Wang, Viswanath, Lam, Wang, & Chan, 2013), while this percentage in the United States is higher. A National Cancer Institute survey showed that in 2013, 78.8% of U.S. citizens searched for health information via the Internet(National Cancer Institute, 2014). On the other hand, Internet health information seeking is especially important to Chinese people given the difficulty in making medical appointments, long waiting time, short consultation time, and high expenses accessing health care services (Hao, 2015).