Paper short abstract:

Direct observation of encounters between patients and health workers reveals aspects of communication that are not captured by post-hoc evaluations. Based on a study in Ethiopia, we investigate the implications of patients’ education for successful communication in the clinic.

Paper long abstract:

For people in rural settings with little access to schooling, clinics and hospitals may feel like very alien environments. Recent research suggests that certain routines important to navigating health systems - such as waiting in line, and how to address figures of authority - are learned in schools. Greater familiarity with these routines makes the experience of navigating biomedical systems more predictable and reliable, and should instill confidence. While this idea is supported by survey research, it has yet to be tested by direct observations in clinical settings. We observed 30 encounters between clinicians and patients in rural communities near Bahir Dar, Ethiopia. Six patients (20%) had some school experience (range 1-8 years), the remainder had no formal education. We analyzed transcripts of conversations to investigate differences in communication for patients with schooling compared to those without: for example, the length of the conversations, and patients' readiness to ask questions of the clinician. We focus on one clear instance of miscommunication, between a clinician and a woman (without schooling) whose child was diagnosed with malaria. The variation in styles of communication we observed was not reflected in interviews conducted after each clinical encounter, in which patients consistently rated their levels of satisfaction as high. This study calls into question the validity of research that evaluates the successful communication in clinical settings on the basis of retrospective interviews, and draws attention to the social distance that separates patients and medical providers in some of the settings where global health needs are highest.