SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
April, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Communication problems in healthcare may arise if healthcare providers focus on diseases and their management, rather than people, their lives and their health problems. Training healthcare providers to be more ‘patient centred’ could improve communication in consultations, increase patient satisfaction with care and improve health outcomes.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Communication problems between healthcare providers and patients are common, with providers often focusing more on diseases and their management, rather than on the person and his or her wider health issues.
Patient-centred care is one approach to address these problems. It has been defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts.
| Review objectives: To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials of interventions for healthcare providers that promote PCC in clinical consultations |
43 randomised trials. All studies assessed interventions that included training related to a variety of PCC skills, using diverse teaching techniques and lengths of training. 20 of the 43 studies included additional interventions: - training or general educational material for patients (7) - health condition-specific training or materials for providers (7) - condition-specific materials or training for both providers and patients (6). |
| Participants | Any types of healthcare providers, including those training to qualify as healthcare providers |
Most of the studies included primary care physicians or nurses practicing in community or hospital outpatient settings. |
| Settings | Clinical consultations of any type |
Community or outpatient settings in the USA (16), UK (10), Germany (3), Switzerland (2), Netherlands (2), Spain (2), Australia (2), Canada (1), France (1), Holland (1), Norway (1), Israel (1) and Taiwan (1). There were no studies from low- and middle-income countries. |
| Outcomes |
a) Consultation processes, including the extent to which patient-centred care was judged to be achieved in practice b) Patient satisfaction with care c) Patient healthcare behaviours, e.g. concordance with care plans and service utilization d) Patient health status and well-being: physiological measures (e.g., blood pressure); clinical assessments (e.g., wound healing); patient self-reports of symptom resolution or quality of life; and patient self-esteem |
Most of the studies assessed the impacts on consultation processes and many also evaluated the impact on patient satisfaction. Patient health behaviours were less frequently assessed and patient health status was evaluated quite frequently. |
| Date of most recent search:June 2010 | ||
| Limitations:This is a well-conducted systematic review with only minor limitations. | ||
Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, Lewin S, Smith RC, Coffey J, Olomu A. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD003267. DOI: 10.1002/14651858.CD003267.pub2.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 43 studies from a range of high-income countries. The included studies assessed a wide range of PCC training strategies for providers. Some studies compared general training for providers with no intervention. In other studies training was accompanied by co-interventions, including education for patients or condition- specific training or materials for providers and/or patients.
- may improve consultation processes, including the extent to which care is patient centred, compared with no intervention. The certainty of this evidence is moderate.
- may slightly improve patient satisfaction with care, compared with no intervention. The certainty of this evidence is low.
- may slightly improve patient health behaviours, compared with no intervention. The certainty of this evidence is low.
- probably improves patient health outcomes, compared with no intervention. The certainty of this evidence is moderate.
|
Patient-centred care (PCC) training for providers compared with no intervention |
|||||||||
|
|||||||||
|
Outcomes |
Impact |
Number of (studies) |
Certainty of the evidence (GRADE) |
||||||
|
Consultation process (extent to which patient-centred care achieved; provider consultation skills and behaviour) |
PCC training may improve consultation processes, including the extent to which care is patient centred |
1922 (16 studies) |
Low |
||||||
|
Patient satisfaction with care |
PCC training may slightly improve patient satisfaction with care |
1801 (11 studies) |
Low |
||||||
|
Patient health behaviours (including concordance with care plans, attendance at follow-up consultations, health service utilization) |
PCC training may slightly improve patient health behaviours |
1385 (7 studies) |
Low |
||||||
|
Patient health status (including physiological measures, clinical assessments, patient self-reports of symptom resolution or quality of life; and patient self-esteem) |
PCC training probably improves patient health outcomes |
1634 (10 studies) |
Moderate |
||||||
|
GRADE: GRADE Working Group grades of evidence (see above and last page) |
|||||||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
This review did not find any studies conducted in LMICs.
|
Patient-centredness may be an objective of care in many settings. However, it is unclear to what extent the interventions and effects reported are applicable to low-income countries, to settings other than primary care and to the full range of healthcare providers involved in primary care. Interventions to promote patient-centred care may have varying acceptability and impact across different healthcare and cultural settings; may involve different components from training to organisational restructuring; and may impact in different ways on consumer and provider satisfaction across different settings. Human resource constraints in some health systems, and low motivation to deliver patient-centred care, may limit the feasibility and potential of this approach for improving provider practices and health outcomes. |
| EQUITY | |
| The included trials did not provide data regarding differential effects of the interventions for disadvantaged population. |
The additional resources needed to provide patient-centred training and materials for providers and patients may be less easily available in disadvantaged settings, particularly where access to health services is poor. Low literacy levels in some settings may also limit the applicability of written materials for patients. If training in patient centredness is incorporated into undergraduate programmes, the resources needed may be less and may be more affordable and feasible for low-income countries. |
| ECONOMIC CONSIDERATIONS | |
| The studies included no direct evidence of the cost-effectiveness of interventions to promote patient-centred care. |
The costs of implementing training interventions to promote patient-centred care are uncertain and are likely to vary across settings. Costs may be reduced if this training is combined with existing pre- and in-service training programmes for healthcare providers. If interventions to promote patient-centred care result in improved healthcare behaviours and outcomes, such as improved adherence to treatment, then these interventions may result in savings for the health system. |
| MONITORING & EVALUATION | |
|
No evidence from low-income countries was identified. None of the studies reported whether patients were consulted regarding the outcomes that they considered most important for assessing the effects of interventions to promote patient-centred care. |
Rigorous evaluations of locally appropriate training interventions to promote patient-centred care are needed in low-income countries to inform decisions regarding scaling up. These studies should assess outcomes considered important by users of health services as well as the acceptability and costs of the interventions. More studies are needed of the impacts on training interventions to promote patient-centred care on providers other than primary care physicians. |
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: |
|
Hobbs JL. A dimensional analysis of patient-centered care. Nurs Res. 2009;58(1):52-62.
Khanal S, Elsey H, King R, Baral SC, Bhatta BR, Newell JN. Development of a Patient-Centred, Psychosocial Support Intervention for Multi-Drug-Resistant Tuberculosis (MDR-TB) Care in Nepal. PLoS One. 2017;12(1):e0167559.
Kogan AC, Wilber K, Mosqueda L. Person-Centered Care for Older Adults with Chronic Conditions and Functional Impairment: A Systematic Literature Review. J Am Geriatr Soc. 2016;64(1):e1-7.
Rathert C, Wyrwich MD, Boren SA. Patient-Centered Care and Outcomes: A Systematic Review of the Literature. Med Care Res Rev. 2013; 70(4):351-79.
Shields L, Zhou H, Pratt J, Taylor M, Hunter J, Pascoe E. Family-centred care for hospitalised children aged 0-12 years. Cochrane Database Syst Rev. 2012;10: CD004811.
Peñaloza B. Health Policy and System Research Unit. Pontificia Universidad Catolica de Chile, Chile
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Stacie Stender and Francesca C. Dwamena.
Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, Lewin S, Smith RC,
Coffey J, Olomu A. Interventions for providers to promote a patient-centred approach in clinical consultations.
Cochrane Database of Systematic Reviews 2012, Issue 12.
Peñaloza B. Does training for healthcare providers in patient-centred care improve patient outcomes?
A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org
Keywords
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care
patient-centred care, person-centred care, patient satisfaction, medical education
This summary was prepared with additional support from:
Pontificia Universidad Catolica de Chile
