The AIMS of this study are to: (1) Explore the perceptions and experiences of diabetes consultations from the perspectives of Pakistani patients, health professionals and interpreters (when one was involved). (2) Identify the processes and mechanisms which hinder or foster effective communication between healthcare professionals and their patients. (3) Provide recommendations for ways in which communication can be improved between healthcare professionals and their Pakistani patients STUDY DESIGN: A prospective qualitative study was developed, comprising three sequential components; namely: In-depth interviews with patients prior to a diabetes consultation; observation of the consultation; and, in-depth interviews with patients, health professionals and interpreters (when one was involved) following the consultation. Data were collected in the form of 10 detailed case studies. Each case study involved a Pakistani patient with type 2 diabetes mellitus (T2DM), their practitioner (s) involved in the consultation and an interpreter (if one was used). SAMPLE: Five male and five female Pakistani with T2DM (aged 41-80 years), 12 practitioners (some patients consulted with two people) and three interpreters (two professional and one lay) were recruited through health services and personal contacts within Edinburgh’s Pakistani community. Individual case studies were thematically analysed before all the case studies were compared/contrasted to identify cross-cutting themes. FINDINGS: Alongside language, a range of barriers and issues were identified which impacted upon communication between patients and health professionals in the consultations observed. Because of previous experiences of attending consultations in the UK and also in Pakistan, patients tended to come to their diabetes consultations with limited expectations; namely, to have their medication reviewed and receive test results. Consequently, patients tended not to raise health concerns and other issues unless they perceived these to be directly relevant to the consultation. In some cases, this resulted in patients not disclosing important information relating to their diabetes management and led to health professionals making inappropriate treatment recommendations. The routine and predictable nature of these diabetes review consultations meant that patients could be passive, offer very little information and ‘get by’ in their consultations; for instance, by offering responses after guessing what the professional was asking. As a result, some health professionals were unaware of patients’ poor English and of how little they had understood during the consultation. Health professionals found it difficult to establish understanding and rapport with patients who adopted a passive role in their consultations. This hindered them from identifying, and appropriately addressing, gaps in patients’ diabetes knowledge and any concerns they may have had. Interpreters did not always address the language barrier and edited and misinterpreted information. This is partly because they struggled to interpret medical terminology. However, this research also revealed how interpreters can experience dilemmas and role conflicts by virtue of being members of the same closely-knit Pakistani community as the patients they interpret for. Some of the barriers identified during this study also arose because patients tended to see different professionals at every visit which discouraged patient-provider relationships from being established. CONCLUSION: Patients would benefit from receiving ‘continuity in care’ and education and training on how to use their consultations more effectively. Providers would also benefit from education and training on more effective ways to communicate with these patients.

Aim: The overall aim of this thesis was to explore and describe patients’ and healthcare providers’ experiences of the causes, management and interaction in the care of rheumatoid arthritis (RA). Method: The thesis is based on four studies. Studies I and II contain data from an epidemiologic project involving patients who were recently diagnosed with RA. The patients answered an open-ended question about their conception of the cause of their RA (Study I). Qualitative data from 38 patients were analysed using the phenomenographic approach in order to identify variation in conceptions. The results of Study I formed the basis for categorizing the conceptions of 785 patients in the search for patterns of background factors (Study II). Study III aimed to explore how patients experienced their management of RA in everyday life. Data were collected by interviews with 16 patients and analysed according to Grounded Theory (GT). In study IV, the aim was to explore healthcare providers’ experiences of their interaction with patients’ management of RA. Data were collected by interviews with 18 providers representing different professions and analysed using GT. Findings:  Patients’ conceptions of the cause of their RA revealed new aspects from the patient perspective that can complement pathogenetic models. Two descriptive categories emerged: consequences beyond personal control and overloaded circumstances, which included six categories of conceptions (Study I). The most common conceptions of the cause of RA were unexpected effects of events followed by work and family-related stress (Study II). Background factors that influenced the conceptions of the cause were age, sex and educational level. Patient management of RA involved using personal resources together with grasping for support from others in their striving for a good life. When linking these aspects together, four ways of management emerged: mastering, struggling, relying and being resigned (Study III). Healthcare providers’ experiences of their interaction with patients’ management shed light upon the important issue of delivering knowledge and advice. The providers’ attitudes constituted one cornerstone and patients’ responses the other. The providers reported that the interaction led to different outcomes: completed delivery, adjusted delivery and failed delivery. Conclusions: The findings contribute new knowledge from both patients’ and healthcare providers’ perspectives, which could be used to develop a more person-centred approach in rheumatology care. Person-centred care involves taking patients’ beliefs and values into account in addition to creating a trusting relationship between patient and provider. A successful person-centred approach requires an organisation that supports the person-centred framework.

abstract: Chronic illness can be a stressful experience that requires coping and support. In the last twenty years, Shared Medical Appointments (SMAs) were developed in U.S. healthcare as a response to the rising rates and challenges of chronic disease management. Due to the infancy of the SMA model, however, little is known or understood about the benefits of group medical care for patients. To date, scholars have not explored or systematically observed the communicative aspects of the SMA model. Communal coping, a theoretical framework that foregrounds group interaction and communication, offers a pragmatic lens for exploring how patients collectively cope with the stressors of chronic illness in the context of SMAs. Using qualitative methods, I conducted participant observation of SMAs at a Veterans Affairs hospital to analyze the communicative, transactional nature of communal coping as it unfolded among heart failure patients, family members, and providers in context. I also conducted interviews with SMA attendees. Analysis is based on 56 hours of fieldwork and 14 hours of interviews. Findings of this dissertation revealed group members who attended heart failure SMAs engaged in communal coping to manage the stressors of chronic illness. Group members moved through four primary phases of the communal coping process: (1) establish a communal coping orientation; (2) discuss shared stressors; (3) engage in cooperative action; and (4) practice communal reflexivity. Findings suggest patients become empowered by group interaction during SMAs as they move through each phase of the communal coping process. This dissertation also highlights various communicative strategies providers' use during SMAs to facilitate communal coping and group interaction. Theoretically, this dissertation expands upon existing knowledge of communal coping by exploring how individuals embody and socially construct the communal coping process. Specifically, this dissertation extends past models of communal coping with the addition of the communal reflexivity phase and through conceptualizing communal coping as a facilitated process of empowerment. Pragmatically, this research also offers insight to the benefits patients derive from attending SMAs, such as reduced feelings of stigma and isolation and improved motivation. / Dissertation/Thesis / Doctoral Dissertation Communication Studies 2015

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Research shows that health disparities exist among patients of varying races, ethnicities, and cultures in the United States. Numerous studies have suggested that these disparities may be partly associated with physician-patient communication. The larger project that this thesis is a part of is a mixed-methods analysis of physician-patient communication across patient race, ethnicity, and culture. This thesis specifically excluded qualitative studies and focused on how such communication can affect health outcomes. Sixty-nine studies were identified and appraised for quality. Of these, only four associated physician-patient communication with the health outcomes of patients. These studies had inconsistent results, highlighting the gap in research exploring the association between communication, patient ethnicity, and health outcomes.