Health communication in the Caribbean and beyond: a reader

Providies a comprehensive, well researched and up-to-date discussion of the local and international health communication literature and provides a theoretical and practical framework for teaching health and/or medical communication skills. It reviews, explains and applies health communication concepts and principles and provides contexts for their application in both the classroom and in the health professions.

Gender differentials on breaking bad news: implications for communication skills training in medical school

Tactfully breaking news is an essential communication skill in the health professions. By the end of medical undergraduate training, the majority of students should be competent at breaking bad news in standardized patient examinations. Recent studies, however, suggest that this skill is not easily learned and there are notable differences in the strategies employed by males and females, even among practising professionals. These findings point to the possibility of gendered performance within medical school and raise questions about the efficacy of communication skills training. This chapter evaluates gendered achievement patterns and overall competence at breaking bad news on OSCE stations in years 2 and 5 for three cohorts of students at the School of Medicine, Faculty of Medical Sciences, University of the West Indies (UWI), St Augustine. Gender differentials were calculated for: (1) station scores, (2) item categories, and (3) item scores and evaluated on (1) statistical and practical significance, (2) variability, and (3) gendered impact. More than 25 percent of the students scored below the minimum level of competence for three of four years. However, there were few statistically or practically significant gender differentials on individual skills and process tasks. Nevertheless, by year 5, some females had a significant lead over males in the employment of socio-emotional/supportive strategies. It may be that the formal communication skills training (CST) programme, in the early years, did not lead to final-year mastery for some males. There is also the possibility that males and females prefer different strategies. There may be a need for contextualized training that allows both males and females to adopt a more patient-centred approach.

The need to teach non-verbal skills with multicultural sensitivity

The communication models that have been framed to guide medical practitioners through the determinative medical interview have primarily been conceived, evaluated and approved in the west. However, the student population at the Faculty of Medical Sciences at the University of the West Indies (UWI) in Trinidad and Tobago, where this material is concentrated, come from a number of Caribbean countries, as far north as the Bahamas and as far south as Trinidad. Consequently, the faculty at St Augustine is a very diverse campus. Interaction and fusion among Caribbean cultures have facilitated a great deal of intra-and inter-cultural diversity in the region. The non-verbal communication skills that theorists advocate, however, often cannot be easily applied to the Caribbean context. As a result, health communication educators encounter a number of problems in implementing so-called Western-based non-verbal communication skills in the classroom. This chapter is based on data collected at the Faculty of Medical Sciences at UWI. Thirty-six registered year 1 students from eight Caribbean countries were selected from the class list and asked to participate in focus group discussion between individual Caribbean territories and that put forward by the Calgary-Cambridge Guide to the doctor-patient interview. Here, the results of this study and its implications for health communication education in the region are interrogated. Ultimately, the chapter develops an approach from which regional health communication educators and medical practitioners can draw to achieve cultural competence in the classroom and in Caribbean medical practice.

Health communication skills: promoting better practice through education

It is the job of the physician to clearly and accurately provide health advice to a patient presenting with an illness. Consequently, it is important that communication skills training continue to grow in strength in our universities so that the doctors of the future are trained in the core function of communication. Health communication programmes in medical schools are, however, faced with many challenges such as ensuring student motivation and providing a relevant and stimulating learning environment. A difficulty initially faced by communication skills educators was the view held by medical students that communication skills are inherent and not learned (Steele 2000). Another problem was the lack of endorsement of communication skills teaching by faculty members who did not feel it was an essential part of the medical curriculum. In a climate where the main reason for complaints against doctors is that of poor communication (Anderson, Allan and Finucane 2001; Meryn 1998, 1922), the General Medical Council of the United Kingdom included communication skills as a core competency expected of all medical graduates (BMA 2004). At the University of the West Indies (UWI), St Augustine campus, communication skills training was introduced into the medical curriculum in 1995 to first-year (preclinical) medical students. A review of the assessment of these students in year 3 (preclinical) and later in the final year (clinical) revealed that many students performed poorly in the area of health communication and communication skills. In light of this, communication skills training in the final clinical year was revised expanded in an attempt to help students acquire the necessary communication skills. This chapter examines the methods employed in teaching undergraduate medical students communication skills in the final clinical year (year 5). This programme is based on an interactive approach, which provides students with role-play activities with or without a simulated patient. The programme utilizes feedback and reflective exercises that aim to change physician behavior. Students are also given the opportunity to present health information to varied audiences, which encourage them to develop good health communication skills. The programme promotes professionalism as a work ethic. In addition to describing this programme, the chapter also shares the lessons learned fromtraining students at UWI, St. Augustine, Trinidad.

Communication and adherence in the Caribbean: teaching skills for concordant management of care

Effective treatment of contemporary chronic and communicable illnesses can require increasingly complex degrees of adherence. This means that new approaches should be developed to manage the age old problem of adherence or, as it is often called, compliance with medical protocols. Promotion of care-giver and patient concordance as a partnership to address these contemporary concerns must include the development of the requisite communication skills. Within the Caribbean culture, lack of adherence may be exacerbated by a number of issues, including patients' literacy levels, religious and cultural beliefs, perceptions of health care providers, and even attitudes to generic medications. The differences that exist among individual patients/clients, and among the health care providers require the identification and management of the psychosocial factors and communication skills influencing adherence in the Caribbean context. Unfortunately, the exploration of these issues and the teaching of communication skills have not been a standard part of traditional educational programmes for health care providers in the Caribbean. In the introduction to Medical Practice curriculum and as part of the personal and professional development theme, medical students at the University of the West Indies (UWI), Mona, Faculty of Medical Sciences, are asked to examine their experiences of adherence to medical treatment in order to identify common issues as well as those unique to certain patient populations. The issues commonly identified as affecting compliance with medical protocols include the personality of the provider, misunderstanding of instructions, the impact of side effects, and the cost of the medication. Students are then taught four key communication skills geared to increase their competencies in communicating with their patients. These are organizational skills, rapport building skills, data gathering skills, and patient education and management skills. The factors affecting adherence to therapy are examined, such as the patient's condition, treatment prescribed, the clinician, the patient and socioeconomic conditions. The importance of the relationship (including the level of trust and confidence shared) and the quantity and quality of the communication between the patient and the provider are stressed. This chapter makes recommendations on how to improve communication competencies and techniques for effective adherence management. It addresses, in particular, opportunities within the curriculum for supervised communication skills training especially with clinical settings.

Counselling, culture and communication for change

The contemporary landscape of mental health services is changing rapidly with a proliferation of training programmes in counseling and psychotherapy based primarily on North American/Eurocentric theories and cultures. With culture acting as an interpretive frame for behavior and given the multicultural nature of Caribbean society, there is therefore the need for a culturally relevant review of therapeutic communication if practitioners are to successfully engage Caribbean people in the therapeutic process. This chapter addresses some of the cultural factors in the Caribbean which influence this communication process, particularly, how people engage or avoid engaging in the process of counseling and therapy, and suggests strategies and skills for facilitating the needed engagement. Issues examined include clients' past experiences of helping relationships, belief about how change occurs, expectations of counseling/psychotherapy as providing a "quick fix", expectations that the therapist will play a primarily didactic role and that they will be passive learners, the impact of religious beliefs on clients' decisions whether or not to seek help and the challenges of dual relationships (circumstances whereby the therapist and the client interact with each other outside of the therapy context). Concepts are based on a series of presentations made at case conferences at the University Counselling Service at the UWI, Mona, and the authors' thirty-odd years of experience in various clinical settings. The University Counselling Service provides counseling and psychotherapy to a diverse range of clients within the university community, inclusive of students, staff at all levels, faculty members and administrators.

Interpersonal and mass-mediated communication in an HIV/AIDS prevention campaign in Trinidad and Tobago

Considerable interest in the role of interpersonal and mass mediated communication in the health has evolved from a classical sender-receiver approach to one that recognizes the role of various influences on how campaign messages are decoded and interpreted. This recognition is evident in various mass-mediated and interpersonal communication studies, but the question of integrating the relative and different contributions of each field has remained elusive despite many significant, but separate findings. Using a health context, this chapter proposes a theoretical framework based on the mediating influences of talk, conversation and discourse on concepts of involvement, engagement and influence. These first three concepts are derived from theories of persuasion in interpersonal communication, and the other concepts of analytic audience, media exposure and encoded exposure are derived from two-step, diffusion of innovations, and agenda-setting theories in mass-mediated communication. Against the backdrop of the proposed theoretical framework, data from a survey evaluation of a national HIV/AIDS prevention campaign in Trinidad and Tobago, interviews with programme officials, and newspaper texts are adduced and analysed. The findings contribute insights into the proposed integrated interpersonal and mass-mediated communication (IMC) model.

Health education and health communication projects in two rural villages in Belize

This chapter describes ongoing health communication and health education efforts in two rural villages in Belize, Central America. In 2002 the Department of Communication joined efforts with the University of Louisville International services learning programme (ISLP) and began work in Belize. Our project was linked to previous ISLP work in the country and began with an initial visit to assess needs and possible service-learning projects. During this initial trip, several rural sites were visited, discussions were held with community member, meetings took place with village council members and leaders, and input from the government was solicited. In addition, a number of subsequent contacts were made, via electronic mail and telephone. Based on the analysis of all the information collected, the university's ISLP compiled a team of faculty and students from Communication, Medicine, Nursing, and Dentistry to deliver health care and health education to residents in one rural community, Gales Point (see chapter 7). This work continued for several years, and eventually the team broadened its efforts to include a second rural village, Red Bank. In this chapter, we chronicle the health communication and health education work of this interdisciplinary health team, a type of team considered particularly important in delivering health care rurally (Amundson 2001). First, we provide more specific information on the composition of the team, our approach to researching and designing health programmes and the implementation of these programmes. Second, we describe Belize and provide overviews of the communities in which we worked. Third, we detail several of our health communication and education efforts, including the topics and formats. Finally, we conclude with an assessment of the efforts to date and a discussion of best practices.

Teaching medical communication skills at the University of the West Indies, St Augustine, Trinidad

A medical communication skills programme was introduced in 1995 at the University of the West Indies (UWI), St Augustine, Trinidad. Two courses were taught to over nine hundred undergraduate first-year students in medicine, dentistry, pharmacy and veterinary medicine during this period. Issues of course design, philosophy and pedagogy attended this innovation in the medical education curriculum. In an effort to evaluate the first five years of the programme, data on student enrolment, feedback and performance were collected and analysed to assess the programme's success and the areas of improvement. The implications of the findings are discussed in light of the need for curriculum reform and development in medical communication and in medical education.

Provider-patient communication

This chapter focuses on provider-patient communication in a small rural village in Belize. For five years, the authors have worked with a collaborative, interdisciplinary health team and this chapter details the team's health care efforts. These efforts included setting up and running free medical and dental clinics as well as a number of community and school health education and health communication events. The health team included university faculty and students from medicine, dentistry, health communication and nursing. In addition, other disciplines were represented in health care efforts in some years (for example, education, engineering, audiology). The village, Gales Point, is geographically and economically isolated, and most residents have little access to health care. The chapter addresses provider-patient interactions at the clinic, during home visits and at health education and community events. We also include analysis of tailoring the clinic to resident needs (for example, shifts in hours to accommodate men's work schedules; expanding hours to ensure as many residents as possible could be seen) as well as provider and community actions to facilitate health care (for example, recruiting groups, such as teenage boys, less likely to seek out care; meetings with the village council to explore community wants and needs; soliciting resident feedback on clinic limitations as well as outcomes). The chapter also includes assessment of project limitations as well as suggestions for providing better care and events and building community relations.