1. art and entertainment
2. music
3. music genres
4. easy listening

ABSTRACT
FACTORS CONTRIBUTING TO THE PERCEPTION OF PHYSICIANS’ LISTENING
By
Adam Delgado
May 2015
This study analyzes different demographic groups and the ability to understand a
physician and how this contributes to feeling carefully listened to. There are four
hypotheses being tested, each predicting a different group within each variable will feel
the most carefully listened to. The Statistical Package for Social Services (SPSS) was
used to analyze data from the California Health Interview Survey (CHIS). The portion of
the survey that focused on adults was utilized in this study. Data was analyzed using ttests and ANOVA tests. The results of the study determined that the elderly, males, and
participants that could understand their physician felt the most carefully listened to for
each variable. As for race, Whites, African American, and participants that identified as
more than one race felt more carefully listened to when compared to Asians and
participants that identified as a race not specified. These finding only supported one
hypothesis, participants that understood their physician would feel that most carefully
listened to. Theses result are a valuable tool that can be used to being quality
improvement efforts focused on patient centered communication.
FACTORS CONTRIBUTING TO THE PERCEPTION OF PHYSICIANS’ LISTENING
A PROJECT REPORT
Presented to the Department of Health Care Administration
California State University, Long Beach
In Partial Fulfillment
of the Requirements for the Degree
Master of Science in Health Care Administration
Committee Members:
Grace Reynolds, Ph.D.
Sandhya Shimoga, Ph.D.
Tony Sinay, Ph.D.
College Designee:
Tony Sinay, Ph.D.
By Adam Delgado
B.A., 2013, California State University, Long Beach
May 2015
UMI Number: 1585634
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
UMI 1585634
Published by ProQuest LLC (2015). Copyright in the Dissertation held by the Author.
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Copyright 2015
Adam Delgado
ALL RIGHTS RESERVED
TABLE OF CONTENTS
Page
LIST OF TABLES.......................................................................................................
v
LIST OF FIGURES .....................................................................................................
vi
LIST OF ABBREVIATIONS .....................................................................................
vii
CHAPTER
1. INTRODUCTION ............................................................................................
1
Background ...............................................................................................
Contributing Factors ...........................................................................
Age ......................................................................................................
Race ....................................................................................................
Gender .................................................................................................
Understanding the Physician ..............................................................
4
5
5
6
9
9
2. METHOD .......................................................................................................
11
Data Overview ..........................................................................................
Survey Scope and Design ....................................................................
Participants ..........................................................................................
Hypothesis ................................................................................................
Dependent Variable .............................................................................
Independent Variables ........................................................................
Age ................................................................................................
Race ..............................................................................................
Gender ...........................................................................................
Understanding the Physician ........................................................
Statistical Analysis ..............................................................................
11
11
12
13
13
14
14
14
15
15
15
3. RESULTS .......................................................................................................
17
Descriptive Statistics .................................................................................
17
CHAPTER
Page
Hypothesis Testing ...................................................................................
22
4. DISCUSSION AND CONCLUSION ..............................................................
27
Discussion .................................................................................................
Descriptive Review..............................................................................
Bivariavte Review ...............................................................................
Limitations ..........................................................................................
Future Research ...................................................................................
Conclusion ................................................................................................
27
27
29
31
32
33
REFERENCES ............................................................................................................
34
!
LIST OF TABLES
Table
Page
1. Hypotheses .........................................................................................................
16
2. Analysis .............................................................................................................
26
!
LIST OF FIGURES
Figure
Page
1. Age of participants .............................................................................................
18
2. Race of participants ...........................................................................................
19
3. Gender of participants ........................................................................................
19
4. Difficulty understanding provider, last visit ......................................................
20
5. Perception of listening .......................................................................................
21
6. Mean perception of listening by age group .......................................................
23
7. Mean perception of listening by race .................................................................
24
!
LIST OF ABBREVIATIONS
ACA
Affordable Care Act
ANOVA
Analysis of Variance
CHIS
California Health Interview Survey
RDD
Random-Digit-Digital
SSPS
Statistical Package for Social Services
!
CHAPTER 1
INTRODUCTION
Patient-centered care is the inspiration for many of the quality improvement
initiatives being developed and executed in conjunction and response to the Patient
Protection and Affordable Care Act (ACA). It shifts the focus of care onto the
stakeholder receiving the care, as opposed to the person or organization delivering it.
This shift attempts to change the overall culture of health care to help improve the quality
of care. Patients have become more aware of the cultural shift and expect services that
focus on them as consumers. Patient-centered care is an element of health care that
transcends demographics and patient groups (de Boer, Delnoil, & Rademakers, 2013).
Kitson, Marshall, Bassett, and Zeitz (2013) found three themes tied to patientcentered care. The themes cited were patient participation and involvement, the
relationship between the patient and the health professional, and the context where care is
delivered. All three themes require an element of communication between patient and
provider to be successful. Elwyn et al. (2014) describe two methods, motivational
interviewing and shared decision making, to improve patient-centered care. Motivational
interviewing uses evoking and planning to understand, listen to, and support motives and
changes. Shared decision making emphasizes option talk and decision talk to explain,
listen to, and support an informed patient to make the appropriate decision for themselves.
Both methods require effective communication between the provider and patient.
(
Patient-centered care dictates that it is the provider’s responsibility to facilitate this
communication.
Communication is a necessary element of delivering services to a patient.
Patients need to know what is happening during treatment and what to expect from
different procedures. Providers can also learn from listening to the needs of patients.
Without a steady stream of open communication, the patient’s overall experience can
suffer (Woods, 2013). One of the cornerstones of communication is listening. There are
many benefits a provider can have from listening to the needs of a patient. Active
listening leads to positive clinical outcomes and increases patient satisfaction (Grandi,
Mazzola, Angelini, & Chiappedi, 2012; Trumble, O’Brian, O’Brian, & Hartwig, 2006).
Both outcomes positively reflect on the organization’s commitment to patient-centered
care.
Active listening is a necessary tool for any provider to have positive clinical
outcomes. One of the most basic, but vital, uses of listening is gathering clinical data
from the patient to form a diagnosis. Patients understand that it is important to be heard
when offering information that can aid the provider in prescribing the proper treatment.
Patients also view a listening physician as a healing and therapeutic agent. Both were
identified as two of the three important elements of provider’s listening to patients
(Jagosh, Donald Boudreau, Steinert, MacDonald, & Ingram, 2011). Listening has also
been used to aid in managing stress in high-risk antepartum patients. Through listening
to the needs of these patients, clinicians were able to provide higher quality care (Richter,
Parkes, & Chaw-Kant, 2007). Patients with implantable cardioverter-defibrillator have
been found to have a better quality of life when there is effective listening and sharing
)
between patients and providers (Hauptman, Chibnall, Guild, & Armbrecht, 2013). When
patients truly feel that they are being listened to they are more likely to follow providers’
recommendations. Carter, Moles, White, and Chen (2014) studied the willingness of
patients to use an organization’s services. They found that patients that felt that
clinicians were listening to them were more willing to use medication management
services. It is important for physicians to remember patient involvement leads to better
outcomes (Elwyn, Buetow, Hibbard, & Wensing, 2007).
Clinically, there are many positive outcomes listening can achieve. Patientcentered care emphasizes positive clinical outcomes, but also stresses the importance of
patient satisfaction. Under the Patient Protection and Affordable Care Act,
reimbursement of various services is affected by patient satisfaction. Heje, Vedsted, and
Olesen (2011) tied physician awareness of patient satisfaction to the attempts to improve
practices. Patients’ view of a listening physician can help improve their relationship with
their physician (Jagosh et al., 2011). Mercieca, Cassar, and Borg (2014) demonstrate that
listening to a patient can aid the organization in improving the patient’s experience.
Some flaws in service cannot be deciphered through medical charts or clinical diagnostics.
This is why listening to patients at every point of delivery is an important tool to help
improve the quality of services. Clinicians who excel in listening to their patients create
positive experiences for their patients. Listening gives the patients a sense of importance,
which is tied to their overall satisfaction with services (Hancock, Bonner, Hollingdale, &
Madden, 2012).
*
Background
It is not always clear which group of people are in most need when attempting to
improve a service. A difficulty with any quality improvement program is focusing on the
population in most need. Implementation of the Pareto Principle can be beneficial when
trying to improve quality for high-risk populations. The idea behind the principle is to
identify the group that accounts for the largest amount of adverse experiences. Through
identifying the population in most need, quality initiatives can be developed specifically
for that population. The Pareto Principle has been used in areas such as drug therapy
safety issues to identify high-risk populations with a high volume of adverse experiences
in order to focus improvement efforts. Muller et al. (2014) found in their study that 33
drugs attributed to 76% of the total adverse events. Focusing on the population that takes
one of the 33 drugs could be a possible way to reduce 76% of adverse experiences. In
this particular case the Pareto Principle could be applied to drug therapy safety. This is
does not always work with all cases. Lessons can still be learned from focusing on the
group or groups most affected by poor service. When looking at a patient’s perception of
their physicians listening skills, there is the possibility that certain populations feel they
are not being listen to. Identifying theses groups is the focus of this study. Through
identifying theses groups, quality initiatives can begin to be developed to improve
physician’s listening skills, and hopefully, from improving listening skills, improve both
clinical outcomes and patient satisfaction. Age, race, gender, and patents understanding
their physicians will be explored to help identify high-risk groups.
+
Contributing Factors
Age
Patients of all ages may find it difficult to communicate with a physician at
different points of care. This can lead to a lack of understanding and an overall negative
experience with a physician. Knowing that a provider is listening can help alleviate some
of the uncertainty and frustration that may come with a visit to the doctor’s office.
Communication in general may be more difficult for certain age groups. Combining this
with the potential uncertainty of a treatment or diagnoses, the feeling that a physician is
listening may become easily lost. Adjustments may be necessary for providers to make
the patient feel like they are being heard.
Older adults and elders are potentially in the age group that could have the most
difficultly communicating with their physician. Different developmental elements point
to a growing difficulty with communication as one gets older. One of the elements that
contribute to challenges of effective communication are communication disorder. The
prevalence of communication disorders is greater among the elder population (Yorkston,
Bourgeois, & Baylor, 2010). Challenges with communication may also create difficulties
with perceived listening. Other afflictions such as cerebral palsy, MS, sensory loss, and
aphasia are also tied to an increased difficulty with communication in the elder
population. These problems can get worse or begin to develop, as one gets older, and
greatly effect communication (Yorkston et al., 2010). As aging increases the risk of
developing new conditions and the worsening of preexisting conditions, this population
requires greater patience, understanding, and attention from providers. Vieder, Krafchick,
Kovach, and Galluzzi (2002) found that elders favored direct and interactive
,
communication. Along with direct, interactive communication, eye contact is a major
factor in convincing a patient they are being listened to (Gorawara-Bhat & Cook, 2011).
It helps providers communicate that they are not just hearing but listening to the needs of
the patient. Jonas-Simpson, Mitchell, Fisher, Jones, and Linscott (2006) found that is a
long-term care setting elderly patients needed to be listen as an essential part of quality of
life. Participants in the study saw listening as a nurturing, relationship building, and
validating experience as human beings.
Another age group that may have difficulties feeling listened to are young adults.
Exiting adolescents and entering early adulthood may be a difficult transition for some
individuals. Knowing that a physician is listening can be very beneficial for both clinical
and mental health. Even though there is a need for effective listening, young adults do
not feel they are receiving it. Younger adults were found to be the least satisfied with
communication with their physician (Jensen, King, Guntzviller, & Davis, 2010). Young
adults are also the lowest responders to surveys and the least satisfied with care.
Communication difficulties are one of the major factors that contributed to low
satisfaction scores. For the patients that had positive experiences with their physicians,
listening was an aspect of care that contributed to this experience (Davey, Asprey, Carter,
& Campbell, 2013). Creating a thoughtful, open relationship between providers and
patients will help promote communicating and positive experiences. This relationship can
be facilitated through listening to these patients.
Race
Health disparities exist in the United States for minorities (Coelho & Galan, 2012).
There may be multiple deficiencies in care that contribute to below average quality of
-
services. Poor communication can create an environment that inherently disadvantages
minorities in the United States. Gordon, Street, Sharf, Kelly, and Soucheck (2006) found
that among lung cancer patients, Black patients trusted their physicians less than White
patients. When treating a severe illness, such as lung cancer, patients should feel like
they can trust their physicians. Knowing that the best decisions are being made can be
essential to physical and mental well-being. Researches discovered that poor physicianpatient communication lead to Black patients’ distrust of their physician. Further
research shows among Blacks, Hispanics, Asians, and Whites, listening was most
important to the Black population (Saha, Arbelaez, & Cooper, 2003). Knowledge of the
needs of different groups can help physicians become better communicators.
Understanding that communication serves a higher function than just relaying
information, it is important to the delivery of quality health care services.
Disparities in health care affect most minority groups, not just African Americans.
Basanez, Blanco, Collazo, Berger, and Crano (2013) researched perceptions of
attentiveness during communication for different ethnic groups and how this impacted
health. Caucasians had better health outcomes than African Americans and Hispanics.
Across ethnic groups, there was no evidence that demonstrated that the physicians’
recommendations to diet and exercise contributed to Caucasians having better health
outcomes. They did find that both Hispanics and African Americans viewed their
physicians as less attentive during communication than Caucasians. Poor physician
attentiveness has therefore contributed to lower improvements in health achieved by
African Americans and Hispanics.
.
Asians were also found to be less satisfied with the quality of health care than
Caucasians. Caucasian and Asian physicians had more or the same amount of difficultly
decoding key elements of communication, such as facial expressions and vocal tone,
among the Asian community compared to the Caucasian community. Asian patients
were also found to be less likely to adhere to medical treatment. Lower satisfaction and
adherence to medical treatment may be a result of patient not feeling like they are being
acknowledged or understood by physicians (Coelho & Galan, 2012). These findings
point to issues that may originate higher than the organization level, possibly the health
system as a whole. Medical students in Germany participated in an international
exchange program with students from Ethiopia. Participants felt more competent in the
area of communication and contributed it to their participation in the exchange program
(Jacobs, Stegmann, & Siebeck, 2014). Creating a system that promotes the development
of cross-cultural communication in medical school curriculum can help improve
communication with patients in and out of a physicians ethnic group.
Some research suggests that Whites, not minority groups, report lower satisfaction
with communication (Jensen et al., 2010). Other research attributes higher minority
satisfaction not to effective patient-centered communication, but to patients and
physicians being the same race. Rather than improving communication skills, hiring a
diverse group of providers is recommendation to improve patient satisfaction (Cooper et
al., 2003). A majority of the research still suggests effective communication promotes
patient satisfaction and minority groups are the least satisfied with physician
communication.
/
Gender
Gender can contribute to the way patients and physicians communicate. Not
much research has been done on how the gender of only the patient influences perceived
listening. When researchers look at gender and communication, they typically analyze
how communication is affected by the gender of the physician or how it is affected by the
relationship between the genders of the patient and physician (Bertakis, 2009; Hall,
Gulbrandsen, & Dahl, 2014). In a gender concordance study completed by Bertakis,
Franks, and Epstein (2009), female patients participated in more patient-centered
communication than men. Female physicians also participate in more patient-centered
communication than male physicians (Hall et al., 2014). Females in general, are more
likely to participate in communication that promotes acknowledgement and thoughtful
listening. Providers should focus on creating environments that are conducive to males
participating in patient-centered communication.
Understanding the Physician
Not understanding a physician can be an obstacle for a patient when they want to
feel listened to. Language can often times be a barrier to understanding a physician.
Physicians report difficulties in achieving patient-centered communication with patients
that speak a different language (Karliner, Hwang, Nickleach, & Kaplan, 2011). Jain and
Krieger (2011) interviewed international physicians that were completing their medical
school training in the United States. They found language to be their major obstacle
when trying to communicate with their patient. Some of the physicians reported speaking
English, but found it difficult to understand the words used by patients. Some other
factors that contributed to poor understanding of both patients and physicians were accent,
0
vocabulary, and conversational norms. To help promote patient-centered communication
many of the physicians developed strategies, such as repeating information, supportive
touching, and eye contact, to aid with communication. As previously discussed, eye
contact can benefit the patient’s perception of a physician listening. Adapting and
improving is necessary for any physician with language as a barrier to communication.
The lack of preparation to deal with these situations points to a deficit in training and
education needed to properly handle language barriers. It is the responsibility of the
provider to convey that they are listening to the patient in any situation.
('
CHAPTER 2
METHOD
Data Overview
Secondary data will be utilized in this study to determine the factors associated
with feeling like one is being listened to carefully by a provider. Data will be drawn from
the California Health Interview Survey 2011-2012 (CHIS) conducted by the UCLA
Center for Health Policy Research. CHIS is one of the largest health surveys in the
nation. It collects information on all age groups with an emphasis in the areas of health
status, health insurance coverage, health-related behaviors, access to health care services,
health conditions, and other health and health related issues (CHIS, 2014a).
Survey Scope and Design
CHIS 2011-2012 data is a population-based survey that is collected continuously
over a 2-year period. Surveys were conducted via telephone using random-digit-digital
(RDD) and telephone directories. The RDD sample was comprised of 80% landline and
20% cellular service. The landline portion of the RDD sample grouped the 58 California
counties into 44 geographic sampling strata. The two largest counties, Los Angeles and
San Diego, were broken down into 14 sub-strata, eight in Los Angeles and six in San
Diego. Specific ethnicities were oversampled to help understand the needs of these
groups. Group specific surnames were selected from telephone directories to help sample
this population. The interviews conducted using cellular service were not able to be
((
precisely stratified using the same geographic strata. The cell RDD sample was grouped
using seven CHIS regions and area codes into 28 strata. Unlike previous CHIS data that
used cellular samples, CHIS 2011-2012 counted the cellular sample as a part of the
overall and county sample sizes (CHIS, 2014a).
Participants
Adults (18 and over), children (12 and under), and adolescents (12-17) were the
three groups in CHIS 2011-2012. There were a total of 42,935 adults, 7,334 children,
and 2,799 adolescents that participated in the survey. Both the adult and adolescent
groups answered the interviews for themselves; the child surveys were completed by the
adult with the most knowledge of the child’s health. The UCLA Center for Health Policy
used Westat, a private firm that specializes in large-scale surveys, to collect data. Staff
from Westat could interview a possible three participants, adult, adolescent, and child via
adult response, for each randomly selected household. A computer program assisted
Westat staff when a participant spoke a language other than English. CHIS 2011-2012
was conducted in five different languages. The languages of English, Spanish, Chinese,
Korean, and Vietnamese were selected based on an analysis of the 2000 Census. There
were more than 14% of adults, 7% of adolescents, and 27% of children surveys that were
completed in a language other than English. There was a 31.6% response rate for
landlines and a 33% response rate for cell phones. Participants who were over the age of
65 who were unable to complete the extended adult interview received proxy interviews
in order to reduce bias (CHIS, 2014a).
()
Hypothesis
The study will test four hypotheses using the data from the adult respondents in
the CHIS 2011- 2012 data set. To help understand different groups that do and do not
feel listened to by their physician four factors will be analyzed, age, race, gender, and
understanding the provider, to determine these groups. This study will focus only on how
these factors contribute to adults feeling like they are being listened to carefully.
The four hypotheses that will be analyzed are:
The mean feeling of listening will be higher in the non-elderly than the mean
feeling of listening in the elderly.
The mean feeling of listening will be higher in Whites than the mean feeling of
listening in non-Whites.
The mean feeling of listening will be higher in females than the mean feeling of
listening in males.
The mean feeling of listening will be higher in individuals that do understand
their provider than the mean feeling of listening in individuals that do not understand
their provider.
Dependent Variable
The dependent variable is feeling like the provider is listening carefully. Question
QA11_J6 of CHIS 2011-2012 provides data for this variable. QA11_J6 asks, “How often
does your doctor or medical provider listen carefully to you?” The respondent is given
the options to answer 1 (never), 2 (sometimes), 3 (usually), 4 (always), -7 (refused to
answer), and -8 (don’t know; CHIS, 2014b). This variable is ordinal and the responses
(*
1,2,3, and 4 will be the only responses included. The variable code, 1,2,3 and 4, will
mirror the value used in statistical analysis.
Independent Variables
Four independent variable, age, race, gender, and understanding the provider, will
be used in this study. Each variable has a corresponding hypothesis that relates to the
focus of the study.
Age. Question QA11_A3 of CHIS 2011-2012 asks, “What is your age, please?”
The respondent can answer a number between 0 and 120, -7 (refuse to answer), or -8
(don’t know) (California Health Interview Survey, 2014). Question QA11_A3 and
QA11_J6 will be used to test the first hypothesis, the mean feeling of listening will be
higher in the non-elderly than the mean feeling of listening in the elderly. This variable
will be broken into three categories, young adult, middle-aged, and elderly. Young adult
will contain participants ages 18-35, middle-aged will contain participants ages 36-64,
and elderly will contain participants will contain participants 65 and up.
Race. Question QA11_A8 of CHIS 2011-2012 asks, “Would you describe
yourself as Native Hawaiian, Other Pacific Islander, American Indian, Alaska Native,
Asian, Black, African American, or White?” The respondent is asked to choose all that
apply. The possible responses are 1 (White), 2 (Black or African American), 3 (Asian), 4
(American Indian or Alaskan Native), 5 (Other Pacific Islander), 6 (Native Hawaiian), 91
(other specified race), -7 (refuse to answer), or -8 (don’t know; CHIS, 2014b). The
second hypothesis, the mean feeling of listening will be higher in Whites than the mean
feeling of listening in non-Whites, will be tested using question A11_A8 and QA11_J6.
(+
Gender. Question QA11_A5 of CHIS 2011-2012 asks, “Are you male or female?”
Respondents can choose 1 (male), 2 (female), or -7 (refuse to answer; CHIS, 2014b).
Hypothesis three, the mean feeling of listening will be higher in females than the mean
feeling of listening in males, will be tested using QA11_A5 and QA11_J6.
Understanding the provider. Question QA11_J12 asks, “The last time you saw a
doctor, did you have a hard time understanding the doctor?” The possible responses were
1 (yes), 2 (no), -7 (refuse to answer), or -8 (don’t know; CHIS, 2014b). The last
hypothesis, the mean feeling of listening will be higher in individuals that do understand
their provider than the mean feeling of listening in individuals that do not understand
their provider, will be tested using QA11_J12 and QA11_J6.
Statistical Analysis
Data will be analyzed using the Statistical Package for Social Services (SPSS)
version 19. The first two hypotheses, with the independent variables of age and race, will
use an ANOVA statistical test. The last two hypotheses, with the independent variables
of gender and understanding the provider, will use a t-test in statically analysis. For each
variable, responses of -7 and -8 will be recoded to system missing.
(,
TABLE 1. Hypotheses
Hypothesis
The mean feeling of
listening will be higher
in the non-elderly than
the mean feeling of
listening in the elderly.
The mean feeling of
listening will be higher
in Whites than the mean
feeling of listening in
non-Whites.
The mean feeling of
listening will be higher
in females than the
mean feeling of
listening in males.
The mean feeling of
listening will be higher
in Individuals that do
understand their
physician than the mean
feeling of listening in
individuals that do not
understand their
physicians.
Dependent Variable
Feeling like the provider
is listening carefully
Independent Variable
Age
Statistical Test
ANOVA
Feeling like the provider
is listening carefully
Race
ANOVA
Feeling like the provider
is listening carefully
Gender
t-test
Feeling like the provider
is listening carefully
Understanding the
provider
t-test
(-
CHAPTER 3
RESULTS
Descriptive Statics
The adult portion of the CHIS 2011-2012 survey was the chosen data set for this
study. Every participant that responded to the adult questionnaire was considered in this
sample of adults. There were a total of 42,935 respondents that make up the independent
and dependent variable used in this study. Basic demographics, age, race, and gender,
and understanding the doctor were used as independent variables to help better
understand who feels providers are listening them to carefully.
Participants were grouped into three categories, young adult (18-35), middle-aged
(36-64), and elderly (65+). There were 7,201 (16.8%) young adults, 21,619 (50.4%)
middle-aged, and 14,115 (32.9%) elderly (see Figure 1). The researcher determined these
groups for this study. Question QA11_A3 of CHIS 2011-2012 asks the respondent their
age and serves as source of data to create the groupings. The participants ranged from
the age of 18 to 85 with a mean age of about 55.
For race, participants were able to select Pacific Islander, American
Indian/Alaskan Native, Asian, African American, White, Other Single Race, and More
Than One Race. Question QA11_A8 asks respondents to select all races they identify
with. Of the 42,935 respondents, 82 (0.2%) were Pacific Islander, 790 (1.8%) were
American Indian, Alaskan Native, 4,302 (10%) were Asian, 2,102 (4.9%) were African
(.
American, 30,110 (70.1%) were White, 4,585 (10.7%) were Other Single Race, and 964
(2.2%) were More Than One Race (see Figure 2).
Gender was addressed in question QA11_A5 of CHIS 2011-2012. There were a
total of 17,848 (41.6%) males and 25,087 (58.45%) females that responded to the survey
(see Figure 3). Male and female were the only two options selected when responding to
question QA11_A5.
The last independent variable came from question QA11_J12. This question asks
the respondent to decide if they had a hard time understanding their provider the last time
they visited them. Participants responded 1,277 yes, 38,738 no, 2,699 found this question
as inapplicable, and 221 had this question skipped by the proxy. Of the respondents that
found the question applicable and did not skip it, 40,015 participants, 3% said yes and
97% said no (see Figure 4).
),'''
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)''''
(+((,
(,'''
(''''
.)'(
,'''
'
%
FIGURE 1. Age of participants. (N = 42,935).
(/
#
&
! ,1
)1
2
'1
)1
((1
('1
.'1
FRGURE 2. Race of participants. (N = 42,935).
+)1
,/1
FIGURE 3. Gender of participants. (N = 42,935).
(0
! *1
0.1
FIGURE 4. Difficulty understanding the provider, last vist. (N = 40,015).
)'
The dependent variable for this study was feeling like the provider listened
carefully. This was derived from question QA11_J6 of CHIS 2011-2012. Never was
selected by 388 participants, 2,412 selected sometimes, 6,955 selected usually, 24,039
selected always, 8,920 found this question as inapplicable, and 221 had the question
skipped by the proxy. Of the participants that found the question applicable and did not
skip it, 33,794 participants, 1.1% responded never, 7.1% responded sometimes, 20.6%
responded usually, and 71.1% responded always (see Figure 5). After the responses were
coded for numerical interpretation the mean score was 3.62 with a minimum of 1 and a
maximum of 4, one corresponding to never, 2 to sometimes, 3 to usually, and 4 to always.
!
(1
.1
#
)(1
"#
.(1
FIGURE 5. Perception of listening. (N = 33,794).
)(
Hypothesis Testing
Hypothesis 1 predicts that the non-elderly feel the most carefully listened to by
providers. The age groups derived from question QA11_A3 and the dependent variable
from QA11_J6, concerning the perception of listing carefully, were used the compare the
means of the different age groups. An ANOVA test and the Tukey post hoc test were
used in statistical analysis. An analysis of variance showed that effect of age on the
perception of listening was significant, F(2,33791) = 130.124, p = .000. Post hoc
analyses using the Tukey test indicated that the average perception of listening was
significantly higher in the elderly (M = 3.69, SD = 0.669) than in the other two age
groups middle-aged (M = 3.59, SD = 0.683) and young adults (M = 3.52, SD = 0.75). The
middle-aged group also had a significantly higher perception of listening than the young
adult group. Even though the findings were significant, they failed to reject the null
hypothesis, the elderly would feel more carefully listened to than the non-elderly, because
the elderly felt the most carefully listened to. The mean perception of listening can be
seen by age group in Figure 6.
Hypothesis 2 predicts that Whites feel the most carefully listened to by providers.
The participant used question QA11_A3 to identify their race. An ANOVA test and the
Tukey post hoc test were used in statistical analysis to compare means between the
different races. An analysis of variance showed that the effect of race on the perception
of listening was significant, F(6,33787) = 23.010, p = .000. Post hoc analyses using the
Tukey test indicated that the average perception of listening was significantly higher in
Whites (M = 3.64, SD = 0.644) as compared to Asians (M = 3.52, SD = 0.736) and other
single race (M = 3.53, SD = 0.762), in African Americans (M = 3.66, SD = 0.682) as
))
compared to Asians and other single race, and in more than one race (M = 3.63, SD =
0.69) as compared to Asians and other single race. All other comparisons were not found
to be statically significant. Whites did not have the highest mean perception of listening
and failed to reject the null hypothesis, non-Whites would feel more carefully listened to
than Whites. The means perception of listening by race can be seen in Figure 7.
*$.,
*$-0
*$.
*$-,
*$,0
*$-
*$,,
*$,)
*$,
*$+,
*$+
%
#
FIGURE 6. Mean perception of listening by age group.
Hypothesis 3 predicts that females feel they are being listen to better than males.
A It-test was performed to compare the means of females’ perception of listening and
males’ perception of listening. Question QA11_A5 address gender and QAll_J6 asks
about the providers level of listening. The t-test of the difference between means
between males and females produced statistically significant results (t (33792) = 2.308, p
)*
= .021). Mean perception of careful listening for males was higher (M = 3.63, SD
= .674) than the mean perception of careful listening for females (M =3.61, SD = .666).
These results were significant, but failed to reject the null hypothesis, women would feel
more carefully listened to than men, because males felt the provider listened to them
more carefully.
*$.
*$-.
*$--
*$-+
*$-,
*$-
*$-*
*$,0
*$,,
*$,*
*$,)
*$,
*$+,
*$+
2 & !
FIGURE 7. Mean perception of listening by race.
Hypothesis 4 predicts participants that did not have a hard time understanding
their provider at their previous visit will feel the provider listens to them more carefully
than those that did have a hard time understanding their provider. A t-test was used to
compare the mean perception of listening for those that did and did not have a hard time
understanding their provider, question QA11_J12. The t-test of the difference between
means among those that did and those that did not understand the provider produced
)+
statistically significant results (t (33109) = -28.021, p = .000). Mean perception of
careful listening for those that did not have a hard time understanding their provider was
higher (M = 3.64, SD = .973) than the mean perception of careful listening for those that
hand a hard time understanding their provider (M=3.01, SD = .645). These findings
supported the hypothesis, therefore, the null hypothesis, those that understood their
physician would feel more carefully listened to than those that did not understand their
physician, was rejected.
Hypothesis 4 was the only hypothesis supported by the findings. Each test was
statistically significant, but the group or groups hypothesized to have the highest mean
perception of listening were, for the most part, incorrect. Chapter 4 will discuss the
outcomes, limitations, implications, recommendations, and suggestions for further
research.
),
TABLE 2. Analysis
Hypothesis
The mean feeling
of listening will
be higher in the
non-elderly than
the mean feeling
of listening in
the elderly.
The mean feeling
of listening will
be higher in
Whites than the
mean feeling of
listening in nonWhites.
The mean feeling
of listening will
be higher in
females than the
mean feeling of
listening in
males.
The mean feeling
of listening will
be higher in
Individuals that
do understand
their physician
than the mean
feeling of
listening in
individuals that
do not
understand their
physicians.
Dependent
Variable
Feeling like the
provider is
listening
carefully
Independent
Variable
Age
Statistical Test
p value
ANOVA
.000
Sample
Size
33,794
Feeling like the
provider is
listening
carefully
Race
ANOVA
.000
33,794
Feeling like the
provider is
listening
carefully
Gender
t-test
.021
33,794
Feeling like the
provider is
listening
carefully
Understanding the
provider
t-test
.000
33,111
)-
CHAPTER 4
DISCUSSION AND CONCLUSION
Discussion
This study focused on how different demographics and levels of understanding
impact the feeling of being carefully listened to by a provider. The adult group was the
sample selected from CHIS 2011-2012 for this study. Age, race, gender, and
understanding the provider were used as independent variables when determining the
feeling of careful listening. Each independent variable corresponded to a hypothesis that
was tested using statistical analysis.
Descriptive Review
Age was separated into three different categories young adult, middle-aged, and
elderly. The middle-aged group accounted for about half of the total sample, the elderly
was a third of sample, and young adults accounted for the remaining sixth. The average
age of all the participants was 55. Outliers could have affected the average, but with a
majority of the sample falling in the middle-aged group this measurement of central
tendency seems to be strong.
Race was broken down into seven different groups. It can be assumed that this
sample is fairly representative of the state of California due to the steps taken to ensure
randomization by the creators of the survey and the number of participants. Whites made
up the majority of the sample at 70%. The next closest group was other single race at
).
11%. The Asian population might be the only group that is not accurately represented
because the survey oversampled this group to understand differences in different Asian
subgroups. This may have skewed the results because the sample weights were not used.
Gender was split into male and female. About 58% of the participants
identified as female and about 42% identified as male. All participants identified as
either male or female when prompted. There is no information on other genders because
participants were not given that option. The participant was directly asked if they were
male or female. The only other possibility was that the participant refused to answer the
question, which was not the case for any of the respondents.
Understanding the provider was the last independent variable used in this study.
This was the only independent variable in which the question was inapplicable or skipped
by the participant of proxy. When ask if it was difficult to understand their doctor, out of
the participants that responded, only 3% responded yes while 97% responded no. There
were more responses of inapplicable than yes to this question.
The dependent variable, feeling like the provider listened carefully, was initially
classified as ordinal by the survey, but transformed into numeric for the purpose of this
study. The potential responses always, usually, sometimes, and never were assigned
values of 4, 3, 2, and 1. This question also had the possibility of being skipped or
inapplicable to the participant. Almost the same amount of participants that answered
never, sometimes, or usually found this question as inapplicable. The average perception
of listening for the whole sample was a score was 3.62, which reflects the large
proportion of respondents answering always, or 4, to this question.
)/
Bivariate Review
The first hypothesis predicted that the non-elderly felt the most carefully listened
to by providers. The results of the ANOVA test and Tukey post hoc determined the exact
opposite. The elderly group felt the most listened to followed by the middle-aged, and
finally the young adults. Jensen, et al. (2010) supported these findings in their research
citing young adults as the least satisfied with overall communication with their physician.
There are many possibilities why young adults rank the lowest when measuring careful
listening from a provider. Expectations of care may have changed with this generation,
the preventative care movement may have created more active participants that demand
more, education and understanding how to access health information could have
developed young adults into a more informed and skeptical consumers, or this could have
happened by chance. This study does not explore why these results occur, only whether
or not there is a relationship. Research suggest that the elderly have the most difficultly
with communication and the greatest prevalence of communicative disorder which lead
to the conclusion that they would be dissatisfied with the level of careful listening from
their providers. The findings suggest that poor communication ability does not
necessarily imply unsatisfactory communication. With the proper training and education
providers can effectively communicate with individual who lack some communication
skills.
The second hypothesis predicted that Whites would feel the most carefully
listened to by doctors. The results of the ANOVA test and Tukey post hoc did not
support this hypothesis. The only finding that were significant was when Whites, African
Americans, and more than one race were compared to Asians and other single race.
)0
Whites did feel carefully listened to, but only when comparing them to Asians and other
singles races. They were not the only group that felt carefully listened to when compared
to Asians and other single race. If the mean listening score was the only measure
consider they would rank third in feeling carefully listened to after Pacific Islanders and
African Americans. This data does not consistently identify minorities as having the
lowest or the highest scores. With a more diverse sample it may not be as easy as
breaking groups into Whites and non-Whites. To better understand the nuances between
and within each race more specific identifiers may be necessary to truly comprehend how
each group perceives communication.
The third hypotheses predicted that females felt the most carefully listened to by
their physician. The hypothesis was not supported by the results of a t-test. The t-test
determined that males felt the most carefully listened to by their physician. Females were
more likely to participate in patient-centered communication (Bertakis, et al., 2009).
Once again being a more adept communicator does not lead to being more satisfied with
the level of careful listening. One possible explanation for the findings is that with an
increased level of communication and awareness females tend to have higher
expectations for interactions with their physician. Having higher expectations may make
an individual more critical of the level of careful listening.
The last hypothesis predicted that the individuals that did not have a hard time
understanding their doctor would feel they were being listened to more carefully. The ttest supported this hypothesis. Participants that had a hard time understanding their
doctor had average score of 3.01 as opposed to those that did not have a hard time with
an average score of 3.64. Not understanding a physician can be a major barrier to
*'
communication. The ability to communicate seems to have an influence on the
perception of careful listening. In the first and third hypothesis the ability to
communicate seemed to have the opposite effect in the perception of careful listening.
This leads to the possibility that being an excellent communicator and lacking the ability
to effectively communicate can negatively impact the perception of careful listening.
Each hypothesis identified a group or groups that feel the least carefully listened to.
With statically significant results these groups are the most in need of attention or
understanding. It is uncertain if these groups are just being ignored or misunderstood.
What is certain is that there is a feeling that they are not being carefully listened to by
their doctor. From a quality improvement perspective these groups should be targeted
during in physician-patient communication improvement efforts. Young adults, Asians,
other races not identified, females, and those that have a hard time understanding their
physician are the groups most in need of attention when it comes to feeling listened to by
their physician.
Limitations
There are different limitations that are inherent to every study design. Using
cross-sectional data can be convenient and inexpensive, but carry various limitations.
Cross-sectional data does not allow for the study to explore causal relationships. The
survey format used opened the data up to bias from the participant and the data collector.
The participant can tailor their responses to how they wish to portray themselves rather
than the truth. The data collectors can add their own interpretation of the respondent’s
answer if they are unclear or have formulated their own opinion of the participant. Crosssectional data is easy to compile and use, but the inability to determine cause and effect
*(
along with biases from the participant and data collector can limit the strength of the
study.
Along with the study data and transformed variable, there are some other
limitations that affect this study. A group of the elderly participants are missing because
they had some questions skipped by the survey administrator, in particular the dependent
variable. This could have skewed the results by not having this group include. The focus
on specific groups in the Asian population increased the number of respondents. Sample
weights are not being used to account for the oversampling of different Asian subgroups.
Oversampling and not using sample weight may skew the results. The lack of
understanding why these results occurred makes it difficult to improve in the deficient
areas. This study only identifies that there is a difference, not why or how to improve the
perception of listening based on these differences.
Future Research
With the limitations come opportunities for future research, determining why
certain groups feel the way they do about the degree of careful is the first question that
should be answered when trying to practically apply the knowledge gained from this
study. It would also be interesting to better understand how communication adeptness
contributes to communication satisfaction. Knowing if there is a threshold or “sweet spot”
for communication that accounts for satisfying interactions may be useful for providers
when listening to different groups. Race did not have an overriding group that
significantly felt more or less listened to. Studying how race and ethnicity contributes to
the perception of listening is an area in need of further exploration. Using multivariate
analysis could produce clearer picture of the results. Completing the study on different
*)
scales can also be useful to see the bigger picture and understand more about a target
population.
Conclusion
This study identifies groups that do not feel like their physician is listening to
them. This knowledge is beneficial when trying to improve the quality of patientcentered care. It is important to remember that these results are one study’s finding and
may not hold true for every part of the county or even if the same study was completed
using more recent survey data. Knowing that something occurs is not enough to embark
on a statewide improvement plan, but it does create awareness and ability to ask why.
**
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