Extent and Determinants of Patients’ Unvoiced Needs

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DOI: 10.1177/1010539511418354 2011 23: 690 originally published online 30 August 2011Asia Pac J Public Health

Ibrahim, Muhammad Radzi Abu Hassan and Ramanathan LetchumanLee Lan Low, Sararaks Sondi, Abu Bakar Azman, Pik Pin Goh, A. Hamid Maimunah, Mohd Yusof

Extent and Determinants of Patients' Unvoiced Needs

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Asia-Pacific Journal of Public Health23(5) 690 –702© 2011 APJPH

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DOI: 10.1177/1010539511418354http://aph.sagepub.com

1Institute for Health Systems Research, MOH, Kuala Lumpur, Malaysia2Selayang Hospital, Selangor and Clinical Research Centre, Kuala Lumpur, Malaysia3Department of Health Sabah, Sabah, Malaysia4Sultanah Bahiyah Hospital, Alor Setar, Malaysia5Taiping Hospital, Perak, Malaysia

Corresponding Author:Lee Lan Low, Institute for Health Systems Research, Ministry of Health Malaysia, Jalan Rumah Sakit Bangsar, 59000 Kuala Lumpur, Malaysia Email: [email protected]

Extent and Determinants of Patients’ Unvoiced Needs

Lee Lan Low, BSc, MA1, Sararaks Sondi, MBBS, MPH1, Abu Bakar Azman, MBBS, PhD1, Pik Pin Goh, MD, FRCS2, A. Hamid Maimunah, MBBch, MPH1, Mohd Yusof Ibrahim, MD, MPH3, Muhammad Radzi Abu Hassan, MRCP, MMed4, and Ramanathan Letchuman, MBBS, MRCP5

Abstract

Patients with issues or health problems usually plan to discuss their concerns with their health care providers. If these concerns were not presented or voiced during the health care provider–patient encounter, the patients are considered to have unvoiced needs. This article examines the extent and possible determinants of patients’ unvoiced needs in an outpatient setting. A cross-sectional study was conducted in 5 Ministry of Health Malaysia primary health facili-ties throughout the country. Of 1829 who participated, 5 did not respond to the question on planned issues. Of the 1824 respondents, 57.9% (95% confidence interval = 47.1-68.7) claimed to have issues/problems they planned to share, of whom 15.1% to 26.7% had unvoiced needs. Extent of unvoiced needs differed by employment status, perceived category of health care provider, and study center. Perceived category of health care provider, method of question-naire administration, and study center were the only significant determinants of unvoiced needs. Unvoiced needs do exist in Malaysia and there is a need for health care providers to be aware and take steps to counter this.

Keywords

health care provider–patient communication, outpatient setting, patients’ unvoiced needs, planned issues, primary health clinic

Introduction

Patient-centered care is becoming increasingly important in health care and for a good health care system.1-4 The importance of mutually exchanged information has been recognized as an essential component of a health care partnership.5 Nevertheless, in many countries, the communication between health care providers (HCPs) and patients remains the typical asymmetry

at Universiti Malaya (S141/J/2004) on August 22, 2014aph.sagepub.comDownloaded from


Low et al. 691

of paternalistic HCP–patient interactions.6 Furthermore, despite advancement in medical technol-ogy, the healing relationship between HCPs and patients remains essential to quality care.7

Relevant information provided by patients is crucial and must be obtained correctly for a HCP to successfully manage a condition. Patients who have issues or concerns related to their health problem may have planned to discuss them during their visit to their HCPs. If their issues or concerns have not been presented, shared, or voiced, but instead remain unspoken during the HCP–patient encounter, it may create a situation where the patients’ needs remain unvoiced.8,9 Patients who participate in discussions with their HCPs and who share relevant information regarding their symptoms and background of their illnesses are more likely to enable their HCP to have a better understanding of their condition. Thus, the HCP is more likely to provide better treatment. On the other hand, if patients do not disclose enough history or information about their illnesses during consultation, then the HCP may not be aware of it, which may lead to misunder-standing in clinical and prescribing decisions.10,11 Many studies have indicated that good inter-personal communication and partnership between HCPs and patients are important tools for HCPs to effectively reach a diagnosis and to develop a plan of care.12-14 Addressing patients’ concerns might lead to a more satisfactory outcome and happiness with the consultation that could indirectly improve treatment and quality of care.

The issue of patients’ unvoiced needs has been the subject of study in several countries. The extent of unvoiced needs ranged from 9% in the United States to 88.6% in the United Kingdom.8,9 According to the study by Bell et al,15 those who had unexpressed desires tended to be young, undereducated, and unmarried. Apart from sociodemography factors, there are also other reasons or possibilities as to why patients do not share all their problems, such as their past experience and their perception toward HCP they had consulted previously.

In Malaysia, the vision for health promotes individual responsibility and community partici-pation toward an enhanced quality of life.16 However, little is known about unvoiced needs. This article aims to examine the extent and determinants of patients’ unvoiced needs in selected Ministry of Health (MOH) clinics. Factors postulated to contribute to the extent of unvoiced needs were age, gender, ethnicity, education level, marital status, employment status, frequency of clinic visit, frequency of seeking treatment, and perceived category of HCPs seen. Patients’ background may also influence their perception and belief about what is appropriate to be shared with HCPs during the counsultation.17,18 The perceived category of HCPs consulted by the patient was included in this study as the researchers hypothesized that patients would be more willing to share their concerns with the category of HCPs that they were comfortable with. Studies had reported that relationship between HCP and patient plays an important role in com-munication. They noted that beside sensitivity of topic, patients may opt to remain silent if they were not sure of the category of their attending HCPs.15,19,20 In addition, type of clinic visit, such as first visit to a new clinic may also have an influence on their unvoiced needs. Frequency of seek-ing treatment for the same condition can also lead to unvoiced needs.

MethodsA cross-sectional exploratory study was conducted in 5 MOH health care facilities in Malaysia. The choice of facility in this study attempted to include a range of primary health care clinic settings, with centers from urban and rural localities, and centers that were outpatient specialist care in noncomputerized and computerized hospitals that used electronic medical records (EMRs). Characteristics of the facilities are described in Table 1.

The minimum estimated sample required for each center was calculated based on the formula for estimating a population proportion with specified relative precision.21 Previous studies had shown that unvoiced needs range from 9% to 88.6%.8,15,22-24 Thus, the research team calculated



692 Asia-Pacific Journal of Public Health 23(5)

Table 1. Study Centers

Center Study Center Clinic Setting LocationType of Provider

A Gastroenterology Clinic Outpatient specialist care

Urban (West Malaysia)

Specialist and MO

B Diabetes and Endocrinology Clinic

Outpatient specialist care


Specialist and MO

C Ophthalmology Clinic Outpatient specialist care with EMR system


Specialist and MO

D Primary Health Clinic Primary care Urban (East Malaysia)

FMS and MO

E Primary Health Clinic Primary care Rural (East Malaysia)

MO and Paramedics

Abbreviations: MO, medical officer; EMR, electronic medical record; FMS, family medicine specialist.

the minimum sample size based on an estimated proportion of 25% for this study, at 95% confi-dence level and a relative precision of 20%. A minimum sample size of 288 was required. A target of 300 was set for each center to account for nonresponse. Selection of respondents was based on convenience and willingness of respondents to answer the questionnaire.

Data collection was carried out simultaneously throughout all centers between March and August 2006 using a pretested questionnaire by a group of paramedics at each study center. Respondents were asked if they had issues that they planned to ask and whether they were able to share these planned issues with their HCPs. Individuals aged 18 years and older who had seen a HCP at a participating clinic were approached and verbal consent was obtained prior to admin-istration of the questionnaire. Illiterate patients who agreed to take part in the study were inter-viewed whereas those who were able to understand the languages used in the questionnaire (either Malay or English language) answered on their own or were assisted if necessary. Respondents were assured of anonymity and confidentiality of all information provided by them.

OutcomesPatients’ unvoiced needs in an outpatient setting was measured based on the number of patients who had issues they had planned to share with their HCPs during consultation but did not man-age to share all their concerns. Figure 1 shows the framework of this study.

AnalysisQuestionnaires were coded and manually entered into a database using SPSS version 14.0. Generation of pooled estimates and 95% confidence intervals were done using meta-analysis in STATA SE version 10, using random effects model.

Logistic regression was run using “Enter” model among respondents who reported to have issues they planned to share during consultation with their HCPs.

Ethical ConsiderationsThis study was approved by the Medical Research and Ethics Committee, MOH. Verbal consent was obtained from all respondents.



Low et al. 693

* denominator

Total Respondents

Issue Planned:Not sure/cannot remember

Issue Planned:None

* Issue Planned:YES

Shared Issue: Missing

Shared Issue : DID NOT share any UnvoicedNeeds

Shared Issue: Partially Shared

Shared Issue: YesVoiced

Issue Planned: Missing

Figure 1. Patients’ unvoiced needs framework for analysis

Results

The results reported here reflect data from 5 participating centers, the identities of which we do not reveal to preserve anonymity. A total of 1829 adult patients were included in the study. Of these, 391 were from center A, 295 from center B, 544 from center C, 299 from center D, and 300 from center E.

Respondent CharacteristicsComparison of the characteristics of these respondents with the general population as estimated in 2006 is shown in Table 2. Mean age was 45.5 years (SD = 1.48) and the median was 45.0 years. The majority were Malays (36.5%), followed by Chinese (23.6%). Almost half (49.0%) completed secondary education. The vast majority of respondents were married (75.8%), and up to 45.2% reported to be employed. Significant differences in distribution were seen for gender, age, ethnic group, and education level, with more females and more of those aged 60 years or older. Malays were underrepresented and other Bumiputera ethnic group overrepresented. Primary and lower education level were also overrepresented.

Patients’ Unvoiced NeedsA total of 1829 patients participated in this study with 5 not responding to the question on planned issues. Of those who responded, 57.9% (95% confidence interval [CI] = 47.1-68.7)



694

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67

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Tabl

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(co

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claimed they had issues or problems they planned to share with their HCPs during consultation. Of these, 20.9% (95% CI = 15.1-26.7) had unvoiced needs.

Table 3 shows the pooled estimates from the 5 centers for unvoiced needs, with differences seen across employment status, perceived category of HCP, and study center. Working respon-dents reported higher unvoiced needs compared with housewives; 24.9% (95% CI = 18.4-31.5), and 13.9% (95% CI = 9.6-18.1) respectively. Higher unvoiced needs were also noted among those who were not sure of the category of HCPs they had consulted, 31.2% (95% CI = 20.8-41.5) compared to those who perceived to have been seen by a specialist 14.9% (95% CI = 10.7-19.2).

Across study centers, unvoiced needs ranged from 14.1% to 32.1%. Rural primary health clinic had significantly higher unvoiced needs 32.1% (95% CI = 25.1-39.2) compared with 2 of the clinics in urban settings.

Determinants of Unvoiced NeedsTable 4 shows the logistic regression results for unvoiced needs. The model only accounted for a very small percentage of variation (pseudo R2 = .0729). Significant determinants include per-ceived category of HCP, study center, and method of questionnaire administration.

Patients’ unvoiced needs was significantly higher (odds ratio [OR] = 2.5, 95% CI = 1.4-4.6, P = .002) among those who were not sure about the category of their HCPs compared with those who per-ceived they had been seen by a specialist, after adjusting for the effects of age, gender, ethnicity, level of education, marital status, employment status, type of clinic visit, frequency of seeking treat-ment for the same condition, method of questionnaire administration, and study center. Patients who were not sure of the category of their HCPs had 1.4 to 4.6 times more unvoiced needs com-pared with those who had perceived they were treated by a specialist.

People who were interviewed were less likely to have unvoiced needs compared with those who answered on their own (OR = 0.4, 95% CI = 0.3-0.7, P < .001). The study also showed that respondents from outpatient specialist clinics that used EMR (center C) were 1.1 to 2.8 times more likely to have unvoiced needs (OR = 1.7, 95% CI = 1.1-2.8, P = .029) compared with respondents from outpatient specialist clinic without EMR. Patients from a rural primary health clinic (center E) were more likely (OR = 9.8, 95% CI = 2.1-45.6, P = .003) to have unvoiced needs compared with outpatient specialist clinic without EMR.

Other characteristics such as gender, age, ethnicity, level of education, marital status, employ-ment status, type of clinic visit, and frequency of seeking treatment for the same condition did not show any significance in the model.

DiscussionThe Extent of Unvoiced Needs

Approximately half (47.1% to 68.7%) of the patients in this study had issues they had planned to ask their HCPs, of whom 15% to 26.7% had unvoiced needs. Studies conducted internation-ally have indicated a wide range in the extent of unvoiced needs. A study in the United Kingdom claimed that about 88.6% had unvoiced needs.8 In the United States, a study indicated that only 9% of patients had one or more unvoiced desire(s).15 A qualitative study undertaken to discover the unvoiced concerns of older adults with type 2 diabetes mellitus about their prescription medications reported that 13.6% of patients interviewed wanted to further discuss their issues but were unable to do so during their consultation.23 Back in 1979, Stewart et al22 reported that



Low et al. 697

Table 3. Pooled Estimates for Extent of Unvoiced Needs

Group Total No. of Centers Percentage Unvoiced Needs (95% CI)

Overall (n = 219) 5 20.9 (15.1-26.7)Gender Male (n = 93) 5 21.4 (13.4-29.3) Female (n = 123) 5 20.1 (15.0-25.2) Missing (n = 3) Age (years) 18-29 (n = 49) 5 22.8 (17.1-28.6) 30-39 (n = 42) 5 21.6 (15.6-27.5) 40-49 (n = 51) 5 23.0 (13.9-32.0) 50-59 (n = 36) 5 18.9 (8.9-28.9) ≥60 (n = 41) 4 16.6 (10.3-22.9) Missing (n = 0) Ethnicity Malay (n = 74) 5 18.9 (11.7-26.0) Chinese (n = 45) 5 18.6 (13.6-23.7) Indian (n = 24) 3 17.9 (11.3-24.5) Other Bumiputera (n = 73) 3 27.2 (17.1-37.4) Others (n = 3) 2 24.6 (0.0-51.2)Education level No schooling (n = 26) 4 22.1 (11.8-32.3) Primary school (n = 53) 5 21.0 (10.4-31.6) Secondary school (n = 108) 5 19.9 (15.1-24.8) Tertiary (n = 32) 5 22.5 (15.5-29.5) Missing (n = 0) Marital status Single (n = 38) 5 25.2 (18.1-32.3) Married (n = 164) 5 19.7 (13.4-25.9) Separated/divorced (n = 16) 5 20.8 (7.3-34.3) Missing (n = 1) Employment status Still studying (n = 6) 3 18.2 (4.0-32.3) Housewife (n = 38) 5 13.9 (9.6-18.1) Working (n = 126) 5 24.9 (18.4-31.5) Retired (n = 22) 4 12.6 (3.4-21.8) Not working (n = 26) 5 18.4 (9.8-27.1) Missing (n = 1) Clinic visit First visit (n = 45) 5 21.0 (15.4-26.6) Second visit or more (n = 174) 5 21.0 (14.9-27.2)Sought treatment First visit (n = 40) 4 18.0 (11.6-24.5) Second visit or more (n = 179) 5 21.8 (14.8-28.9)Perceived category of health care provider Specialist (n = 64) 3 14.9 (10.7-19.2) MO (n =73) 4 19.4 (14.4-24.5) Not sure/don’t know (n = 25) 3 31.2 (20.8-41.5) MA/nurse (n = 26) 2 26.0 (17.3-34.7) Multiple provider (MO/MA/nurse) (n = 30) 2 23.6 (0.0-56.6) Unknown (n = 1) 1 25.0 (0.0-74.0)

(continued)




Group Total No. of Centers Percentage Unvoiced Needs (95% CI)

Study centera A (n = 42) — 14.1 (10.1-18.1) B (n = 23) — 17.8 (11.2-24.5) C (n = 68) — 23.4 (18.5-28.2) D (n = 32) — 18.5 (12.7-24.3) E (n = 54) — 32.1 (25.1-39.2)Administration of questionnaire Self-administered (n = 107) 5 21.6 (15.7-27.5) Assisted (n = 35) 5 19.2 (13.3-25.1) Interview (n = 76) 5 14.7 (4.4-25.0) Missing (n = 1)

Abbreviations: CI, confidence interval; MO, medical officer; MA, medical assistant.aAll were estimated by meta-analysis in STATA except for study centers.

Table 3. (continued)

54% of patients’ symptoms and 45% of their concerns failed to be identified and about 24.6% of patient concerns were not picked up by the HCP.24

This study only showed significant difference in the percentage of unvoiced needs by employ-ment status, perceived category of HCP seen, and study centers. In contrast, unvoiced needs else-where were noted to be higher among those who were young, undereducated, and unmarried.15

Determinants of Unvoiced NeedsAfter controlling for the effects of age, gender, ethnicity, level of education, marital status, employment status, type of clinic visit, frequency of seeking treatment for the same condition, perceived category of HCP, method of questionnaire administration, and study center, only per-ceived category of HCP, method of questionnaire administration, and study center were signifi-cant determinants. Though difference in extent of unvoiced needs was seen for employment status, this was not a significant factor.

Unvoiced needs were 1.4 to 4.6 times more among patients who were not sure of the category of HCPs they had consulted, compared with those who had perceived to have consulted a spe-cialist. Other studies had reported that patients with a lack of trust in the treating physician were more likely to remain silent and less likely to communicate their desires, illustrating the impor-tance of the HCP–patient relationship in any medical setting.15,25-27 There is growing evidence that HCP–patient communication is becoming very important, especially with the emphasis on patient-centered care and better clinical outcomes.28,29 Lack of trust may be the main reason why people are not willing to share their problems with their HCPs.17,30

Respondents interviewed by uniformed staff were less likely to have unvoiced needs com-pared with those who had answered the questionnaire themselves. Possibly, confidentiality might be the reason for not disclosing unvoiced needs as those interviewed might be hesitant to disclose they had unvoiced needs. Furthermore, since our questionnaire relied largely on self-reporting, the self-administrated questionnaire (SAQ) may be a more sensitive tool to capture unvoiced needs as SAQ has been proven to be a useful screening tool for capturing sensitive questions.31

There appears to be a significantly higher rate of unvoiced needs in primary health care clinics in rural areas compared with urban areas with patients at least 2 times more likely to have unvoiced needs compared with outpatient specialist care. However, caution needs to be exercised as there was only one center that was a rural primary health clinic. In the rural primary health



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Table 4. Determinants of Patients’ Unvoiced Needs (Logistic Regression)a

Variable Odds Ratio 95% CI P

Gender Male (reference group) Female 1.1 0.8-1.7 .458Age (years) 18-29 (reference group) 30-39 1.0 0.6-1.7 .903 40-49 1.4 0.8-2.6 .232 50-59 1.0 0.5-2.1 .900 ≥60 1.2 0.5-2.7 .668Ethnicity Malay (reference group) Chinese 1.1 0.7-1.8 .590 Indian 0.9 0.5-1.6 .649 Other Bumiputera 1.5 0.7-3.1 .294 Others 0.7 0.1-3.7 .716Education level No schooling (reference group) Primary school 1.1 0.6-1.9 .824 Secondary school 0.9 0.5-1.7 .845 Tertiary 1.0 0.4-2.0 .903Marital status Single (reference group) Married 0.7 0.4-1.2 .150 Separated/divorced 0.8 0.3-1.8 .542Employment status Still studying (reference group) Housewife 1.1 0.4-3.5 .826 Working 2.4 0.9-6.5 .091 Retired 1.7 0.5-5.7 .371 Not working 2.0 0.6-6.1 .245Type of clinic visit First visit (reference group) Second visit or more 1.0 0.6-1.6 .906Sought treatment First visit (reference group) Second visit or more 1.4 0.8-2.3 .190Perceived category of HCP Specialist (reference group) MO 1.4 0.9-2.2 .126 Not sure/don’t know 2.5 1.4-4.6 .002 MA/nurse 0.3 0.1-1.2 .083 Multiple provider (MO/MA/nurse) 0.7 0.2-2.5 .581 Unknown 0.5 0.0-4.9 .546Administration of questionnaire By myself (reference group) Assisted 0.8 0.5-1.4 .399 Interview 0.4 0.3-0.7 .000Study center A (reference group) B 1.2 0.6-2.3 .621 C 1.7 1.1-2.8 .029 D 1.2 0.6-2.6 .641 E 9.8 2.1-45.6 .003

Abbreviations: CI, confidence interval; HCP, health care provider; MO, medial officer; MA, medical assistant.aTotal respondents with issues planned: n = 1065. Pseudo R2 = .0729.




clinic studied, there was only one medical officer, a few medical assistants, 3 staff nurses, and 3 community nurses. Was it the services provided in this center that had contributed toward unvoiced needs or was it the setting itself (urban vs rural)? A larger study would be required to answer this, as the results need not necessarily imply that patients who seek treatment in rural primary health clinics are likely to have higher rates of unvoiced needs.

A higher percentage of unvoiced needs was observed in the clinic with EMR (center C), implying that the use of EMR reduces communication. Many studies had documented that indi-rect or broken eye contact and indirect facial orientation are associated with less patient disclo-sure.32-34 Again, this needs to be interpreted with caution because only one center with EMR was studied. Further research is required to discern if EMR or rural clinics are more likely to have a higher rate of unvoiced needs.

The model for determinants explained only a very small percentage of variation in unvoiced needs. This is not unexpected for social and health situations. The wide variation in social and health determinants were similar to other reported studies.35,36 This means that a large proportion of determinants of unvoiced needs is at present still unknown. Though we had identified several important determinants of unvoiced needs, future studies need to consider other aspects not stud-ied here. Unvoiced needs occur in a relationship. Implicit here is the involvement of 2 parties. We had mainly studied characteristics of the patient, and HCP attributes were not covered. In addition, future studies on unvoiced needs should also consider the impact of disease or diagno-sis as a determinant.35,36

LimitationsLimitations in this study include the use of convenience sampling, the number and choice of participating centers, and multiple modes of questionnaire administration. Convenience sampling limits generalizablity of results. Second, the 5 study centers were conveniently selected and only a few samples of study center types were included. For example, only one rural primary health and one EMR center was studied; hence, the results may not be generalizable to other similar settings. Similar argument holds for other center types. Data collection was done via SAQ or interview. There may be a possible bias with the interview method as this involved staff in uni-form interviewing patients at the study facilities.

Conclusion and RecommendationsThere is a need to be aware that patients have issues that they plan to share with their HCPs and that unvoiced needs do exist in Malaysia. This exploratory study points to the need to strengthen HCP–patient communication in more specific way as communication is a 2-way process. Further research is needed to fully understand the complexity of patients’ unvoiced needs and to identify strategic ways to reduce patients unvoiced needs in outpatient setting at public health care facilities. Ideally, the HCPs should be able to improve their communication with patients, leading to better patient care as well as better quality time spent with patients. Knowing that patients could not say things to their provider could be just as important as understanding what patients do say, and the HCPs should be prepared to explore patients’ unvoiced needs. If patients are able to voice all their needs, there is a higher likelihood that their diagnosis is more accurate, since the HCPs has the benefit of having as much information as possible.

Acknowledgments

The authors thank the Director General of Health Malaysia for permission to publish this study. The authors would also like to thank the patients who had participated in this study. Our sincere appreciation



Low et al. 701

goes to all the hospital directors and medical officers in-charge of the study centers involved in this study. Thanks to Dr Tahir Aris, Dr Lin Naing, and Prof Low Wah Yun for advice on sampling, meta-analysis, and comments on this article, respectively. Last but not least, we are very grateful to the data collection team for their invaluable contribution during data collection.

Declaration of Conflicting Interests

The author(s) declared no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or pub-lication of this article:

This study was funded by the Ministry of Health Malaysia.

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Extent and Determinants of Patients’ Unvoiced Needs

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