BRAC University (Joarder, Ahmed, Rashid, Sarker); Johns Hopkins Bloomberg School of Public Health (Joarder); University of Western Cape (George)
Derived from the fields of medical ethics, human rights, and human development, the concept of responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. Observing that responsiveness plays a critical role in ensuring continuity and effectiveness of care within people-centred health systems, the researchers qualitatively explored the perceptions of outpatient users and providers regarding what constitutes responsiveness in rural Bangladesh. Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust, and optimising benefits.
As reported here, studies show that poor responsiveness may dissuade patients from early care seeking, diminish their interest in adopting preventive health information, and decrease their trust in health service providers. Literature also indicates that discourteous behavior from physicians often inhibits care-seeking by the elderly, patients suffering from non-communicable diseases, expectant and new mothers, and the lesbian-gay-bisexual-transgender (LGBT) community, leading to compromised wellbeing. Responsiveness is also critical to the specific context of Bangladesh. According to three surveys, carried out in 1999, 2000, and 2003, the most important predictor of satisfaction of patients with health providers was the behaviour of the providers (expressed in the form of respect and politeness) with the patients, rather than their clinical competence.
An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews (IDIs) of physicians (n = 17) and users (n = 7), focus group discussions (FGDs) with users (n = 4), and observations of patient-provider interactions (3 weeks). This study was conducted in rural areas, where most of the service seekers belonged to a lower socio-economic and educational group. It was conducted in an outpatient setting. The researchers found that there were multiple dimensions of responsiveness - for some, stakeholders had a consensus; context was an important factor to understand them. Key results in sum:
- In terms of friendliness, patients expected physicians to greet them before starting consultations by giving salam, a Muslim way of saying hello, introducing him/herself, asking about the patient's wellbeing, addressing the patient appropriately, and asking them to take a seat. Physicians acknowledged the importance of greetings as they read about this in their textbooks, but they perceived this to be out of local custom. Patients also expected physicians to hold social talks during consultations, which was uncommon. It was commonly expected by interviewed patients that the physician's behaviour would not show the hierarchical difference. However, in observations, there were several nonverbal cues indicating the physician’s supposed superiority.
- With regard to respect, patients expected physicians to not only refrain from disrespecting them in various ways but also to show respect explicitly. Physicians admitted that they did not particularly encourage their patients through their gestures or verbal cues to ask questions. In observations, it was found the physicians answered patients' questions very briefly, even in a single word.
- Patients also had expectations related to informing and guiding: They desired explanation on at least the diagnosis, seriousness of illness, treatment, and preventive steps. Many physicians in Bangladesh did not find enough time to explain things to their patient. So, they delegated this to their assistants and untrained pharmacists. Yet patients expected that the physician himself or herself would explain everything to them.
- In gaining trust, contrary to patients' expectations, physicians often avoided seeking assistance from other colleagues when they experienced confusion. Patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centres, or accepting gifts from pharmaceutical representatives. Patients did not express great concern over confidentiality. One physician said, "Patients in our country, contrary to western notions, rather preferred their information to be shared." He gave the example of the nationwide surveillance against polio eradication campaign. Physicians had to share the patients' information with several national and international agencies, and patients were appreciative of this. They supposedly thought they would get better attention and treatment if their information had been shared with different stakeholders.
- In terms of optimising benefits: Home visits by physicians were culturally expected from the patients. Yet interviews with formal sector physicians revealed they were reluctant to visit patients at home, leaving this practice mostly for the village doctors. Patients expected that physicians should be financially sensitive and consider individual need of patients.
This being an exploratory study, further research is recommended to validate the nuances of the findings. "Once further research clarifies the nature of responsiveness across social groups and health care settings, policy measures can be developed for provider training and assessment. Research on responsiveness can inform reforms in the medical curriculum that integrate the social expectations of the patients during care seeking pathway. This can be further strengthened through practical experiences during the internship-training period and beyond. Effectiveness of such trainings have been demonstrated in several studies and systematic reviews....Subsequent to training, introducing responsiveness as one of the indicator for performance could improve the physician's approach and behavior towards the patients."
PLoS ONE 12(12): e0189962. https://doi.org/10.1371/journal.pone.0189962. Image credit: Mehedi Hasan