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Chronic Illness

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Review article

First published online June 12, 2018

Patients’ perceptions of patient–provider communication and diabetes care: A systematic review of quantitative and qualitative studies

Maryam Peimani, Ensieh Nasli-Esfahani, and Roya Sadeghi [email protected]View all authors and affiliations

https://doi.org/10.1177/1742395318782378

Abstract

Objectives

To explore the association between patients’ perceptions of communication quality with their provider and a range of patients’ outcomes in T2DM. Also, to identify barriers and facilitators to effective communication from the patients’ perspective.

Methods

English and Persian papers published from 2000 to 2017 were searched in Web of Science, Pubmed, Scopus, Embase and SID, IranMedex, and MAGIRAN databases using appropriate search terms. Twenty-two studies complied the inclusion criteria. Each study was assessed for the focus of the study, study design (cross-sectional or qualitative study), population, outcome measures, patients’ outcomes, and methodological quality.

Results

The quality of most studies was moderate to high based on the JBI Critical Appraisal Checklists. Higher perceived quality of provider–patient communication in patients with T2DM was associated with improved self-management, adherence to diabetes care and greater well-being, perceived personal control, self-efficacy, and less diabetes distress. Factors that patients with T2DM perceived as important factors in facilitating or hampering effective communication were more related to the provision of emotional support.

Discussion

The limited evidence shows patient-perceived communication quality is a significant modifiable approach for improving a range of outcomes in patients with T2DM. Due to socio-cultural differences, further high-quality research is needed for deciding the best communication style in various societies.

Introduction

Diabetes mellitus, a widespread chronic illness, affects about 415 million people worldwide and it is predicted to reach 642 million by 2040.¹ The public health burden of diabetes complications is relatively high and adults with diabetes have an age-adjusted death rate estimated to be two times higher than that of the general population.²

Care is still suboptimal despite the fact that firm evidence exists about the optimal treatment of diabetes during the past decade.³ Many patients with type 2 diabetes mellitus (T2DM) have difficulties reaching optimal blood glucose control. Nearly 50% of patients with diabetes have HbA1c levels above the recommended targets,⁴ which has risen to 75% in Iran.⁵ Big strides need to be made in care of diabetes to improve outcomes in terms of glycemic control, diabetes complications, quality of life, functional, and psychological status.⁶

A key element that seems to lead to better diabetes outcomes is the provider–patient communication.⁷ There is, in fact, a growing body of literature that shows that a good provider–patient communication supports patients with T2DM gain better control over their illness.⁸

For example, a large cross-sectional study of adults with T2DM reported a highly significant improvement in adherence to foot care and diet of self-care activities caused by improved provider–patient relationship.⁹ Also, findings from a study of 10,000 patients with T2DM have shown that there are meaningful relationships between poor communication with health care providers and difficulties taking medication.¹⁰ The DAWN 2 study showed that better provider–patient collaboration was associated with more favorable ratings on all patient-reported outcomes.¹¹

The importance of provider–patient communication and patients’ outcomes manifests itself in the most recent position statement released by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), which advocates a patient-centered care that encourages providers to employ patient-centered communication styles.¹² In general, it is obvious that patient-centered communication broadens the traditional medical approach to include patient views and promote the provider–patient partnership. Thereby, there must be a move to create a good interpersonal communication between providers and patients and a paradigm shift from authoritarian interactions to more participatory styles.¹³

Patients with diabetes who are more engaged with their providers and more involved in decision making are shown to comply with medical recommendations and self-care activities.¹⁴

Successful interpersonal communication is built based on shared constructing meaning and reaching an agreement between the health care provider and patient, both of whom bring their perceptions, prior experiences, and personal and socio-cultural orientations.¹⁵

Research has shown that the way patients perceive their communication with their provider and measures of patients’ perceptions are significantly better at predicting patients’ outcomes than either observation or providers’ perceptions.^16,17

However, previous studies addressing patients’ perceptions of communication quality have used different methodological approaches and various patient-reported instruments.¹⁸

As a result, these studies have encompassed many aspects of patients’ perceptions of communication with their provider, focused on different communication elements, and domains of the interpersonal process of care. In addition to that, survey studies with qualitative methods have provided more detailed and deeper information on factors that facilitate or impede effective provider–patient communication than quantitative surveys.^19,20

Therefore, the aim of this mixed-methods systematic review is to combine results from qualitative studies with evidence from quantitative survey studies in order to provide further insight into the association between patients’ perceptions of communication quality with their provider and a range of patients’ outcomes in T2DM. Also, this review attempts to identify a range of barriers and facilitators to effective communication from the patients’ perspective. Such an insight may help create evidence-informed recommendations for best practices in this area so as to maximize communication between the health care providers and patients with T2DM.

Methods

Search strategies

This systematic review was carried out based on the Joanna Briggs Institute (JBI) review manual.²¹ The literature search was conducted via multiple electronic databases and completed by a manual search of references. The search terms included “provider–patient communication” OR “provider–patient relationship” OR “physician–patient communication” OR “physician–patient relationship” AND “diabetes mellitus type 2”.

For this study, international databases including Pubmed, Scopus, Web of Science, Embase as well as national databases including SID, BARAKAT (IranMedex), and MAGIRAN were searched from 2000 up to 2017. For search in national databases equivalent Farsi search terms were used. Following the search strategy, 1705 records were acquired. Then after excluding duplicate and unrelated records, meeting abstract, personal opinions, comments, and reviews according to the title and abstract (1560), a total number of 145 articles remained. In the next step, remaining 145 articles were evaluated based on the full text and finally, 19 articles were obtained. Moreover, the references sections of the obtaining 19 articles were hand-searched and three additional studies were identified as relevant. At last 22 articles (17 written in English and 5 in Persian) were evaluated for extraction of data. The number of records identified in each phase of the research process is provided in Figure 1, PRISMA flow diagram.

Figure 1. The process of screening article for systematic review.

Inclusion criteria

Since this review aimed to assess patients’ perceptions, survey studies with quantitative and qualitative methods were included. To select the publications for the review, following criteria were applied:

Studies that aimed to investigate patients’ views and perceptions of their provider interactions and quality of communication with their provider.

Studies that included adherence or compliance to diabetes treatment and self-care activities as one of the main outcomes in diabetes care.

The language of the publication was English or Persian.

The article was published in a peer-reviewed journal.

Exclusion criteria

Articles were excluded if:

They were related to nondiabetes patients and non-type 2 diabetes patients.

They sought to determine only the associations between provider communication behaviors such as empathy and patients’ trust or satisfaction.

They aimed to investigate providers’ views and experiences of difficulties in communicating with their patients.

Studies in which data were collected through types of recording.

They had not referred to validity and reliability of measurement instruments in detail.

Quality appraisal and data extraction

For the articles that met the inclusion criteria, quality assessment was performed using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies and JBI Critical Appraisal Checklist for Qualitative Research. Methodological qualities of the included studies were assessed independently by two authors. Lack of consensus between the authors was resolved by discussion or by a third author. Cut-off scores between one and ten were established for evaluating the methodological quality of the articles. So 1, 2, 3, 4 scores represented articles with low methodological quality; 5, 6, 7, scores represented articles with moderate quality; and 8, 9, 10 scores represented articles with high quality.

Specified data was extracted from each of the articles so as to compare them: publication year, the focus of the study, study design (qualitative or quantitative methods), study population (number and characteristics of the study group), outcome measures, and outcome effects for patients.

Results

A total of 22 studies met the review criteria and were included. Regarding the type of the studies, out of 22 reviewed articles, 16 studies were cross-sectional (Table 1)^{4,9,10,22–34} with the sample size ranging from 105 to 9377 patients with type 2 diabetes in which five of them were multinational or large national surveys.^{10,22,23,29,35} The remaining were qualitative studies using in-depth interviews and focus group discussions (Table 2).^36–41 More than half of the English language studies were conducted in United States.^{4,9,10,23,25,26,29,36–38}

Table 1. Included studies with cross-sectional design.

Authors/ Year/Location	Design/ Sample	Objectives	Variable(s) measured/ Instrument	Patient outcomes	Quality level
Beverly et al.⁴ (2012), United States	Cross-sectional survey, 316 patients with diabetes from the Joslin Clinic in Boston.	Examining diabetic patients’ relationships with their physicians and willingness to discuss self-care. Also factors associated with patients’ difficulties communicating self-care information.	A survey on communication in the doctor–patient relationship (by Talking With Your Doctor (TWYD) measure) and a battery of psychosocial: measuring frequency of diabetes self-care, diabetes-related distress, depressive and anxiety symptoms, emotion-based and self-controlled coping styles, and diabetes quality of life. Sociodemographic factors and HgA_1c.	Patients were positive about their diabetes doctors, with 97% liking and having confidence in their doctor, and 93% reporting a good working relationship with them. 97.5% of patients rated honest communication with their doctor as “very important”. However, one-third of patients endorsed being reluctant to discuss self-care with their doctor. Reluctant patients compared to nonreluctant frequently misrepresented or withheld self-care information. More reluctant patients reported feeling like they had to say what their doctor wanted to hear (p = 0.001), misrepresented or withheld information for fear of their doctor getting annoyed or frustrated with them (p = 0.001), and did not understand their doctor’s treatment recommendations (p = 0.006). More reluctant patients rated honest communication with their doctor as “somewhat important” compared with nonreluctant patients (p = 0.001). Reasons for not discussing self-care were “not wanting to disappoint doctor or not wanting to feel judged by doctor” (38%), “shame, guilt, and embarrassment” (35%), “not wanting to admit their lack of self-care to their doctor” (31%), “denial of diabetes” (21%), and “fear about diabetes and/or its complications” (10%).	High
Bridges and Smith²⁷ (2015), United Kingdom	Cross-sectional study, 117 individuals with diabetes which was hosted by SurveyMonkey.	Investigating illness perceptions as mediators of the association between the doctor–patient relationship and diabetes-related distress.	Validated questionnaires were included to measure patient–doctor relationship (PDRQ), diabetes-related distress (PAID) and illness perceptions (IPQ-R).	The doctor–patient relationship is associated with psychological well-being in diabetes patients, with patient reports of their relationship with their doctor being associated with diabetes-related distress. Furthermore, a more positively rated doctor–patient relationship was associated with greater perceived personal control over the patient’s diabetes, and a perception that the symptoms of their illness will last for a shorter duration.	High
Detz et al.²⁵ (2014), United States	Cross-sectional survey, 250 Latino adults with diabetes and 31 primary care physicians.	Determining the association among patient-provider communication, language concordance, patient evaluation of Interpersonal process of care )IPC( and participation in diabetes self-care activities.	Patient evaluation of communication quality by the Interpersonal Processes of Care (IPC)scale in 3 areas communication, decision-making, and interpersonal style. Patient–provider language concordance.	Patients gave favorable scores for the domains of communication, decision making, and interpersonal style of IPC, particularly when there was patient–provider language concordance. Language-concordant providers were more likely to be viewed as communicating clearly (p<0.001), eliciting and responding to concerns (p = 0.03), and explaining results (p = 0.008) and to be seen as respectful and compassionate (p = 0.007). language concordance plays a key role in patient views toward provider communication.	Moderated
Heisler et al.²³ (2007), United States	National cross-sectional survey among 1588 older community-dwelling adults with diabetes.	Examining association between patients’ evaluation of their provider’s communication-provision of information and participatory decision-making with patients’ reported diabetes self-management.	Satisfaction with patient–provider communication (PCOM questionnaire) and Provider Participatory Decision-making Style (PDM style questionnaire), and Diabetes Self-management Scale.	Patients’ evaluation of their provider’s communication and participatory decision-making style was associated with better patients’ understanding of their diabetes care or confidence in their self-care abilities.	High
Franciosi et al.²² (2004), Italy	National cross-sectional study, in the context of an Italian nation-wide outcomes research program on type 2 diabetes. 3563 patients were recruited by 101 diabetologists and 103 general practitioners (GPs).	Investigating the contribution of both patient and setting-related factors to patient satisfaction with their relationship with their physicians.	Interpersonal relationship between patients and their physicians by the American Board of Internal Medicine (ABIM) satisfaction questionnaire. General health perception, Other variables: Depressive symptoms, diabetes-related worries and stress, patients’ attitudes to delegate disease management responsibility to the physician, patient involvement in the decision-making process, and quality of life.	Patients’ satisfaction of the interpersonal relationship with their physicians is mainly influenced by personal characteristics rather than selected physician characteristics, and setting-related characteristics. “Self-reliant” subjects who did not tend to delegate decisions regarding diabetes care were less satisfied with the provider–patient relationship. More satisfied patients had a better perception of their general health status, higher levels of worries and concerns about the diabetes consequences and more frequent encounters with their provider.	High
Linetzky et al.³⁵ (2017), Argentina	Multinational Cross-Sectional Survey at primary care and specialty practice sites in 18 countries across Asia, Europe, South and North America. 4341 patients with T2DM.	Investigating how aspects of the patient–physician relationship are associated with diabetes-related distress, insulin adherence, and glycemic control.	Patients’ perspective and perception regarding their interactions with their physician using the IPC survey. Other variables included diabetes-related distress and insulin adherence and glycemic control.	Higher scores in the two negative IPC domains (hurried Communication and discrimination) and lower scores on one of the positive IPC domains (less time spent having medical tests and results explained) were linked with greater diabetes-related distress and poor insulin adherence.	High
White et al.²⁶ (2015), United States	Cross-sectional study, 408 low income diabetes patients.	Assessing the perception of the quality of communication during clinical encounters by diabetes patients and the association among patients’ perception of the quality of communication and reports of self-care behaviors, treatment satisfaction, self-efficacy, and glycemic control.	Patients’ perception of provider communication was measured by the IPC Survey. Patients’ diabetes self-care behaviors were assessed by Personal Diabetes questionnaire and the Adherence to Refills and Medications Scale. Other variables: Diabetes treatment satisfaction, diabetes-related self-efficacy, and health literacy.	Higher communication, decision making, interpersonal style (i.e. IPC domains) were associated with near twice the odds of greater diabetes treatment satisfaction and near half the odds of higher medication nonadherence. Significant associations were seen between patient’s perceptions of the quality of provider communication and several diabetes-related outcomes.	Moderated
Polonsky et al.²⁹ (2017), United States	Retrospective cross-national study in 26 countries across Africa, Asia, Europe, Latin America, the Middle East, North America and Oceania (IntroDia)/3628 people with T2DM.	Investigating patient experiences during the diagnosis of T2DM, focusing on how physician–patient communication influences patients’ psychosocial stress and subsequent self-management and outcomes.	Reported experiences during the diagnosis conversation were measured by the Patient Assessment of Chronic Illness Care scale. Overall perception of physician–patient communication was assessed by combining eight items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS), the Trust In Physician Scale (TIPS), and the IPC questionnaires.And current attitudinal and behavioral outcomes were measured using theWHO-5 Well-being Index, the Diabetes Distress Scale and the Summary of Diabetes Self-Care Activities (SDSA).	Patients’ impressions of the quality of their communication with their physician at diagnosis of T2DM are linked to their current well-being and self-care behavior. The encouraging and/or collaborative factors were associated with better communication quality, while the discouraging factor was linked to poorer communication quality. In turn, better communication quality, as perceived by the patient, was significantly associated with less current diabetes-related distress, greater wellbeing and greater adherence to diabetes self-care behaviors.	High
Rose et al.²⁴ (2009), Australia	Cross-sectional survey design, 105 patients with T2DM in a disadvantaged region of Sydney, Australia.	Assessing patients’ self-reported beliefs towards their physician communication skills and investigating their behaviors about diabetes self-management.	Validated questionnaire were included Summary of Diabetes Self-Care Activities Scale, Diabetes Self-efficacy Scale, the General Practice Assessment Questionnaire (GPAQ) a GP communication skills scale.	Diabetes patients who believed they could manage their diabetes (i.e. had high self-efficacy) and perceived their GPs to have good communication skills showed high levels of blood glucose testing. However, there was no moderation effect of GP communication on general diet or exercise.	Moderated
Piette et al.⁹ (2003), United States	Cross-sectional survey, 752 diabetes patients.	Examining general and diabetes-specific communication processes and patients’ self-care behaviors.	Measured variables included general communication style by the IPC scale, diabetes specific communication by an unpublished scale, and self-care behaviors by SDSA.	General and diabetes specific communication were related but unique facets of patient-provider interactions, and improving either one may improve self-management.	Moderated
Ratanawongsa et al.¹⁰ (2013), United States	A cohort cross-sectional analysis of 9377 patients in the Diabetes Study of Northern California (DISTANCE).	Investigating whether poorer patient ratings of overall communication, shared decision-making, and trust would be associated with poor adherence to cardiometabolic medications.	Communication was measured with CAHPS and the Trust in Physicians and the IPC instruments. Poor adherence for cardiometabolic medications was measured objectively using pharmacy utilization data.	Poor communication ratings were independently associated with objectively measured inadequate cardiometabolic medication adherence, particularly for oral hypoglycemic medications.	High
Bigdeli et al.³⁴ (2015), Iran	Cross-sectional analysis among 500 type II diabetes patients referred to the health houses under the supervision of Abyek health center in Iran.	Examining the relationship between doctor and patient and self-care behaviors.	Article I. Validated questionnaire included: Summary of Diabetes Self-care Activities (SDSA), Patient Health Questionnaire (PHQ-9), Patient–Doctor Relationship Questionnaire (PDRQ-9).	There was a significant association between doctor and patient relationship and parameters like age, presence of diabetes complication and symptoms of depression. Doctor and patient relationship after the duration of diabetes was the strongest predictor of self-care behavior.	Weak
Tol et al.³² (2012), Iran	Cross-sectional survey among 600 patients with T2DM referring to affiliated hospitals of Tehran University of Medical Sciences in Iran.	Assessing communication between health care providers and type 2 diabetes patients as an obstacle to adhering.	Communication between providers and patients as an obstacle to self-care adherence was measured by the Diabetes Obstacles Questionnaire (DOQ).	Mean±SD of communication between health care providers and patients as an obstacle were 56.78± 7.17. There were statistically significant relationships between sex, disease duration, level of education, type of treatment, age, income, marital status, HbA1C, and communication with health care provider as an obstacle.	Weak
Tahmasebi et al.³³ (2013), Iran	Analytic cross-sectional study in 396 patients with diabetes from the outpatient Department of the Endocrinology Unit in Iran.	Testing the effects of individual and environmental factors on diabetes self-management (patients beliefs and opinions).	Variables which were measured included diabetes self-management, diabetes knowledge, illness perception, diabetes self-efficacy, personality, social support, and provider–patient communication by the Chronic Illness Resources Survey (CIRS).	The results demonstrated that the participants had low levels of self-efficacy of DSM, medium levels of illness perception, social support, diabetes knowledge and high levels of provider–patient communication. In this study, the most effective factors in DSM were illness perception and provider–patient communication. Provider–patient communication had a positive direct and indirect effect through knowledge, self-efficacy and illness perception in DSM.	Moderated
Zahednezhad et al.³¹ (2011), Iran	Correlational, cross-sectional study with 115 adults with T2DM in Tabriz, Iran.	Investigating the relationship between health locus of control, slip memory, and physician–patient relationship with adherence to therapy.	Variables and instruments included patient–doctor relationship by PDRQ-9 questionnaire, the general adherence scale (GAS), prospective and retrospective memory questionnaire (PRMQ), and multidimensional health locus of control (MHLC).	There existed a positive significant relation between external and internal health locus of control and desired physician–patient relationship with adherence to therapy in patients with type 2 diabetes.	Weak
Rahimian et al.³⁰ (2011), Iran	Correlational, cross-sectional study with 500 patients with diabetes in Tehran, Iran.	Studying predictive role of self-efficacy, belief of treatment effectiveness, social support and doctor–patient relationship on diabetes self-management.	Variables included diabetes self-care activities, self-efficacy, perceived beliefs of treatment effectiveness, social support, and provider–patient communication.	There was a significant and positive relationship between self-efficacy, belief of treatment effectiveness, doctor–patient relationship, social support and diabetes self-management.	Moderated

Table 2. Included studies with qualitative design.

Authors/Year/Location	Design	Objective	Number and characteristics of subjects	Research findings	Quality level
Kokanovic and Manderson³⁹ (2007), Australia	Qualitative study using in-depth interviews with an interview guide.	To explore the perceptions of Australian immigrants about their interactions with doctors regarding the diagnosis, treatment, and management of type 2 diabetes mellitus.	16 women and16 men from backgrounds with a higher-than average incidence of T2M (of Chinese, Indian, and South and Pacific Island and Greece) were recruited by purposive sampling.	Numerous issues facilitate or inhibit constructive and positive relationships between doctors and patients with type 2 diabetes.Patients reported difficulty in absorbing all the information provided to them at early consultations, and experienced difficulty comprehending the practical aspects of management. Styles of communication and discourses of normalization and catastrophe influenced participants’ responses.	Moderated
Abdulhadi et al.⁴⁰ (2007), Oman	Qualitative study using Focus group discussions.	To explore the perceptions of type 2 diabetes patients regarding the medical encounters and quality of interactions with their primary health care providers.	14 women and 13 men were selected purposively from 6 primary health care centers in Muscat, Oman.	The patients identified some weaknesses regarding the patient-provider communication like: unfriendly welcoming; interrupted consultation privacy; poor attention and eye contact; lack of encouraging the patients to ask questions on the providers' side; and inability to participate in medical dialogue or express concerns on the patients' side; and inexperienced doctors and nurses.	Moderated
Fagerli et al.⁴¹ (2007), Norway	Qualitative study with semi-structured interviews with an interview guide.	To explore Pakistani-born persons’ expectations regarding health encounters and health-worker style, and consequences for communication.	16 Pakistani-born patients with type 2 diabetes living in Oslo, Norway were recruited by a purposive sampling strategy.	Participants expected empathy and care and a wish for cultural sensitivity and clarity in advice rather than an authoritarian style. Participants experienced that Norwegian health workers often behave in a way that may induce a feeling of not having been taken seriously. This can be interpreted as though they experience systematically distorted communication, which reduces the common ground for communicative action.	Moderated
Falke and Lawson³⁷ (2014), United States	A grounded theory qualitative study using in-depth interviews	To examine the types of relationships that patients with diabetes and their spouses prefer to form with their health care providers.	18 married couples with at least one partner who had type 2 diabetes, were sampled by convenience and snowball sampling methods.	Results revealed four major relationship preferences that differ by the nature of caregiving and decision-making power demonstrated by the physician. Related to decision making, some couples (8 of 18) preferred providers who make treatment decisions collaboratively and the slight majority (10 of 18) described wanting providers to make decisions for them. Related to caregiving, exactly half of the couples had a strong desire for a provider who offers emotional support, while the other half of couples preferred a more instrumental way of providing care.	Moderated
Ritholz et al.³⁶ (2014), United States	Qualitative study with in-depth interviews with a semi-structured interview guide.	To explore perceptions of barriers and facilitators to diabetes self-care communication during medical appointments.	35 patients with type 2 diabetes and 19 physicians who treat type 2 diabetes were selected by purposive sampling.	Physicians described some patients as reluctant to discuss their self-care behaviors because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, nonjudgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving communication.	Moderated
Matthews et al.³⁸ (2009), United States	An exploratory qualitative descriptive study via individual in-depth interviews with semi-structured interview guide.	To explore the experiences, attitudes, and beliefs of patients regarding communication with the health care provider, factors affecting adherence to treatment, expectations of care, and goals for future health.	5 adult women living with diabetes age 50 and older were chosen by convenience method.	Participants clearly identified three major themes affecting adherence to treatment regimens: communication with the health care provider, knowledge of diabetes, and the consequences of poor glycemic control. For these participants, patient–provider communication was the most important factor affecting diabetes adherence.	Moderated

The main aims of the cross-sectional surveys were determining the patients’ evaluation of their provider communication style and the association between patients’ perceptions of communication quality and patient-reported outcomes.

The main aims of the qualitative studies were exploring patients’ experiences and perceptions of their interactions with their provider, barriers, and facilitators to effective communication, factors affecting adherence and the types of relationships that patients with T2DM prefer to form with their provider.

The reviewed studies unanimously showed that patients’ perceptions of better communication with their provider were associated with higher levels of self-care behaviors^{4,9,10,22–34} and adherence to medication and self-care,^{10,26,28,29,31,32} and less diabetes-related distress and worries.^{4,22,27–29,34} Data from five of the included studies showed that patients who reported higher quality of communication with their provider had greater perceived personal control over their diabetes^27,31 and higher levels of self-efficacy.^23,30,33 Moreover, seven articles documented that patients’ perception of their provider communication quality was strongly related to factors including socio-demographic and psychological characteristics (e.g. level of education, patient attachment style, health beliefs), ethnic and language concordance between patients and providers, and more severe clinical conditions (e.g. presence of diabetes complications, symptoms of depression).^{4,22,24,25,32,34,39}

Furthermore, according to the included studies, fear of being judged by the provider, not wanting to disappoint the provider, guilt, embarrassment, lack of confidence in diabetes self-care abilities, patient–provider language discordance, hurried communication, discrimination, limited consultation time, authoritarian styles of communication, and lack of attentiveness were the most frequently patients-reported reasons for poor communication with their provider.^{4,22,25,26,28,29,36,39–41} On the other hand, empathy, emotional support, compassionate care, sensitivity to patients’ cultural background, matters of trust and confidence, nonjudgmental acceptance, open and honest communication, explanation of conditions, a continuing relationship with a certain provider, privacy during medical encounters, encouragement, and participatory decision-making style were rated as important factors for enhancing the communication from the point of view of the patients with T2DM.^{23,25–27,29,36,37,39–41}

Results showed that Interpersonal Processes of Care scale was the most commonly used questionnaire for assessing patient–provider communication.^{9,10,25,26,28–30}

Five out of the 22 reviewed papers were in Persian language and none was qualitative study.^30–34 Regarding the year of publication, the Persian language studies were done in recent years (after 2011) and before this year, no study was found that addressed the provider–patient communication and its effects on diabetes care.

With regard to the methodological quality, in some studies,^23–25 ^31,32,34 the method section did not provide enough details to allow comprehending the inclusion criteria of the survey sample and all the necessary information crucial to the study. Most studies suffered for lack of clear description regarding the studied population from which the participants were recruited, including demographics, location, and time period.^{9,22,23,26,27,29,30} Also, a number of studies lacked the adequate description of potential confounding factors such as behavioral, attitudinal, or lifestyle factors, which may have effect on the results and solutions to deal with them as well.^9,31–34 Several studies did not report the response rates including details of participants who were unsuitable for the research or refused to take part.^4,29–31

Regarding the qualitative studies, the major weakness was failure to present a reflexive account of the researchers’ influence and the researchers’ cultural and theoretical orientation.^36–41 Two studies did not clearly state the theoretical premises on which the study is based.^36,41 Tree studies did not include a statement on the ethical approval process followed.^37,38,41

Discussion

This mixed-methods systematic review addressed the associations between patients’ perceptions of communication quality with their provider and a range of patients’ outcomes in T2DM. And also it attempted to identify a range of factors that patients with T2DM perceived as important factors in facilitating or hampering effective communication.

It should be noted that the approaches used in assessing the provider–patient communication in the literature were recordings (standardized observation and audiotape/videotape) and surveys using quantitative and qualitative methods.²⁰ Considering that the aim of this review was to assess patients’ perceptions and that surveys are used to assess the patients’ perceptions of key elements of providers’ communication behavior,¹⁹ this review focused only on survey studies with quantitative and qualitative methods.

The findings of this review suggest that patient-perceived communication quality may be a significant modifiable approach for improving a range of outcomes in patients with T2DM.^{9,10,22–29,34} Thus, patients’ perceptions, experiences, and contributions should be viewed and valued as important as those of providers for effective communication.¹⁹ To conclude, by understanding the provider–patient communication from the patient perspective, health care providers can modify interactions with patients with T2DM to include aspects of the exchange that their patients feel create effective communication.

In spite of the extensive empirical support for the beneficial effects of good communication in the psychological research literature,⁴² very little is known about the role of the patient–provider communication in the context of chronic physical illness, including diabetes care.⁸

In this regard, the results of most of the reviewed papers in this study showed that higher perceived quality of provider–patient communication in patients with T2DM was associated with better self-management,^{4,8,9,22–34} greater well-being,^4,22,29,34 less current diabetes-related distress,^{4,22,27–29,34} greater perceived personal control^27,31 and self-efficacy,^23,30,33 and last but not the least, greater adherence to diabetes care.^{10,26,28,29,31,32} Thus it seems, since patients with T2DM need to deal successfully with psychosocial problems such as distress and depression that may occur with the disease, a good provider–patient communication has the potential to strengthen patients’ motivation, self-confidence, and positive view of their health status, which in turn may influence their diabetes outcomes, particularly remaining adherent to treatment recommendations.^19,43 In other words, a good provider–patient communication can be realized as a “condition sine qua non” to effective treatment outcome.⁸

Our review identified a range of individual and interpersonal socio-emotional factors and also task-oriented behaviors as barriers and facilitators to effective communication experienced by patients with T2DM. Across the studies, the most frequently patient-reported barriers for effective communication were: fear of being judged and appearing ignorant, guilt, embarrassment, hurried communication, limited consultation time, poor attention, discouragement, discrimination, and authoritarian styles of communication. The most frequently reported facilitators were: nonjudgmental acceptance, open and honest communication, eliciting and responding to concerns, explaining results, encouraging and collaborating factors, compassionate care, sensitivity to patients’ cultural background, and an ongoing relationship with a provider.

What is noteworthy is that the identified factors in this review were more related to the provision of emotional support including trust, empathizing, listening, and understanding patients’ viewpoints^{4,28,29,36,38–41} than to the shared decision making.^23,25,26 Inconsistent with our results, a recent integrative review by Kornhaber et al.⁴⁴ established that listening actively, responding to patient emotions, and unmet needs were the key characteristics of effective communication between providers and patients in the acute care setting. Similarly, Pinto et al.’s systematic review found that providing emotional support, empathy, and allowing patient involvement in the consultation process enhanced effective provider–patient communication in general practices settings.⁴⁵

These findings, along with ours, indicate provider’s empathic behavior and play a key role in how patients with T2DM perceive the communication quality with their provider. This result is not surprising since these patients face a myriad of fears and daily challenges in managing their diabetes.¹¹

The point that should not be overlooked here is that although the way patients perceive and interpret events may have a greater impact on subsequent patients’ outcomes than dose provider behavior, their perceptions are subjective and prone to bias. Various factors exist affecting patients such as their personal characteristics, state of mind and health, and even difference between themselves and their provider in the way of perception.¹⁹ In this regard, Greene and Yedidia⁴⁶ in their study revealed that the extensive range of provider behaviors factored into one construct from the patient perspective. Also, they found that providers, in contrast to patients, did not consider their availability to their patients and the longer duration of time spent with them as elements of good communication. These differences in understanding underscore the need for providers, having further training in communication skills and psychological aspects of diabetes.

As stated above, several reviewed studies^39–41 demonstrated that patients had a wish for cultural sensitivity. Cultural sensitivity refers to providers’ appreciation, respect, and comfort to the cultural diversity of patients.⁴⁷ However, it is noteworthy that cultural and social issues appear to be the key contributors to patients’ appreciation of their physician’s communicative behaviors.¹⁸ Therefore, due to wide cultural diversities, and also widely disparate differences within a culture, as seen in our society regarding perceived quality of communication, cultural and social aspects of provider–patient communication should be the focus of future studies, which in turn have considerable impacts on long-term diabetes outcomes such as the quality of life.

Another point is that due to the mostly cross-sectional design of included studies, the observed association between perceived communication quality and improvement in patient outcomes in T2DM should not infer as a causal relationship.

However, although patients’ preferences of communication and decision making style are mainly influenced by patients characteristics such as age, gender, cultural backgrounds, patient attachment style,^22,24,32,34 the reviewed studies showed that the participatory decision-making style was associated with better patients’ understanding of their abilities to engage in diabetes self-care activities.^23,25,26,29 This shows that the era of paternalism in medicine is ending and is being replaced with movement toward shared decision-making.¹³ But the point that remains is that most of these studies have been conducted in Western populations, where there is more emphasis on the value of independence and patients, in general, are expected to be more self-reliant and autonomous in decision making compared to Middle Eastern societies⁴⁸ such as Iran. Therefore, in deciding the best provider– patient communication style and decision-making approach to adopt in our care settings, studies with more focus on contextual factors such as the patient’s characteristic interpersonal style and the nature of the therapeutic relationship in our culture are needed.

A range of instruments is available to measure the patient–provider communication.⁴⁹ As noted by Ha et al.¹⁹ in their review due to numerous instruments, the comparisons between studies are difficult but no single instrument can cover the whole range of communication and thus some studies combine different tools.¹⁹ However, interpersonal process of care (IPC) was the most commonly used self-report instrument alone or in combination with other tools to assess patient’s perception of quality of provider–patient communication in the studies reviewed.^{9,10,25,26,28–30} The IPC, which has been widely used in Western societies, was designed to assess several sub-domains of communication (hurried communication, elicited concerns, responded, explained results, medications), patient-centered decision making, and interpersonal style (friendliness, respectfulness, discrimination, cultural sensitivity). This instrument incorporates the perspective of diverse racial and ethnic or socioeconomic groups.^50,51

Due to the increasing prevalence of diabetes in Iran,⁵² and the evidence that adherence to diabetic treatment regimens can be predicted by effective provider–patient communication,^19,33,43 and also due to the low methodological quality of most included Persian studies,^31,32,34 there is a need for empirical data and further more high-quality research on the reciprocal nature of provider–patient communication according to our context and social and cultural aspects that affect this complex interaction.⁵³ To this end, given the comprehensiveness of IPC tool, it is suggested to test the psychometric properties of the Iranian version of the IPC survey for the health care providers. However, a measurement tool can be recommended with confidence only in the presence of convincing evidence about its reliability and validity.⁵⁴

Conclusion

This review suggests that higher perceived quality of provider–patient communication in patients with T2DM is associated with improved self-management behaviors, adherence to diabetes care, greater well-being, greater perceived personal control and self-efficacy, as well as less diabetes distress. Moreover, this review identified a range of individual and interpersonal socio-emotional factors that patients with T2DM perceived as important factors in facilitating or hampering effective communication. It is noteworthy that these identified factors are more related to the provision of emotional support including trust, empathizing, listening actively, and understanding patients’ viewpoints than to the shared decision making. Further high-quality studies are needed to provide more insight into the role of socio-cultural differences in shaping patients preferences of communication and decision-making style, especially in the Middle Eastern cultural contexts such as Iran.

Acknowledgements

The authors wish to thank Tehran University of Medical Sciences for their support.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

1. International Diabetes Federation. IDF diabetes atlas. 7th ed. Brussels, Belgium: IDF, 2015, p. 51.

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