Socio-economic status of the patient and doctor–patient communication: does it make a difference?

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Abstract

This systematic review, in which 12 original research papers and meta-analyses were included, explored whether patients’ socio-economic status influences doctor–patient communication.

Results show that patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterised by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. Doctors’ communicative style is influenced by the way patients communicate: patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor’s misperception of their desire and need for information and their ability to take part in the care process.

A more effective communication could be established by both doctors and patients through doctors’ awareness of the contextual communicative differences and empowering patients to express concerns and preferences.

Introduction

Health differences due to differences in socio-economical status (SES) are a matter of major concern in today’s public health research. In spite of marked health improvements of the overall population and efforts to overcome health inequalities, higher morbidity and mortality rates for the socio-economically disadvantaged are still found [1], [2], [3], [4]. Explanations for these inequalities in health are often explored but remain largely unclear [4], [5]. The causes are multiple and complex and include individual factors, such as personal history (e.g. childhood SES and living conditions) and education, structural factors, such as income and housing facilities, unequal distribution of risk factors in the population and inequalities in the accessibility of health care [5], [6], [7], [8], [9], [10], [11], [12]. An important determinant of accessibility to health care is the quality of the communication between the patient and his/her health care provider(s). Yet this factor has to our knowledge never been included in any of the explanatory models for socio-economic health inequalities.

The communication between patient and physician has a strong influence on the patient’s satisfaction and compliance [13], [14], [15], [16], [17], [18], [19], [20]. When looking at the impact of components of physicians’ behaviour during consultation, both verbal behaviour and non-verbal behaviour seem to correlate positively with patient satisfaction. [13], [14], [15], [16]. The important determinants for compliance are mainly more information giving, more positive talk and empathy and an increased participatory style [13], [17], [18], [20]. Though satisfaction and compliance are important indicators, the most important one when evaluating the effectiveness of the communication between patient and physician is the overall health outcome. In this perspective better communication (e.g. more question asking by the physician and by the patient, more information giving, shared decision making, more affective behaviour, etc.) seems to have a positive influence [19], [21].

If differences in the physicians’ communicative behaviour depend on the socio-economic status of the patient, this could be a new focus in tackling socio-economic inequalities in health.

We aimed to carry out a systematic literature review to explore the following questions:

  • Is the doctor–patient communication related to the socio-economic status of the patient?

  • If so, which aspects of the consultation are affected?

Section snippets

Methodology

MEDLINE and PsycINFO (1965–2002) were searched, using the following keywords:

  • MeSH: communication AND (physician–patient relations OR provider–patient relations OR physician–family relations) AND (social class OR socio-economic factors).

  • Text-words: (doctor–patient communication OR physician–patient communication OR provider–patient communication) AND (social class OR socio-economic status).

This resulted in a list of 42 articles of which the references were checked for other relevant articles.

To

Results

The comparison of the results of the selected studies was difficult, given the great variation in communication variables that had been tested. We considered several communication assessment approaches to cluster these variables [22], [23]. Communicative behaviour can be categorised following the axis verbal/non-verbal behaviour. The verbal elements of communication can be divided into instrumental or task related behaviour (e.g. question asking, information giving, etc.) and affective or

Conclusions

In this literature review we found that patients from lower social classes receive significantly less positive socio-emotional utterances, a more directive and a less participatory consulting style characterised by e.g. less involvement in treatment decisions; a higher percentage of biomedical talk and physicians’ question asking; lower patient control over communication; less diagnostic and treatment information, more physical examination.

These differences in the doctors’ communicative style

Acknowledgements

We would like to thank all colleagues for editorial comments on earlier versions of the manuscript.

This research has been realised with a grant from the ‘Pension Fund for Doctors, Dentists and Pharmacists’ (VKG).

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