Barriers , Challenges and Way Forward for Implementation of Person Centered Care Model of Patient and Physician Consultation : A Survey of Patients ’ Perspective from Eastern Mediterranean Countries

(1) Department of Family Medicine, Aga Khan University, Karachi, Pakistan (2) Director General, Executive Board, Health Ministers’ Council for Cooperation Council States (3) Professor of Public Health, Director, WHO Collaborating Centre, Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine Imperial College London, UK (4) University of Dammam, Saudi Arabia (5) Department of Family & Community Medicine, Arabian Gulf University, Bahrain (6) Vice Dean for Clinical Affairs, Oman Medical College, Sultanate of Oman (7) Family Physician, Bahrain (8) Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia (9) Department of Family Medicine, Cairo University, Egypt (10) Senior Specialist Family Physician, Baghdad, Iraq (11) Family Physician, Amman, Jordan (12) Head of the Primary Health Care Faculty at the Kuwait Institution for Medical Specialization. (13) Assistant Program Director in Family Medicine Residency Program-Qatar.


Introduction
Person-Centered Care (PCC) and its application in patient/ physician consultation is considered a mandatory approach in some health systems and is gaining popularity.It is the focus on Patients and their needs along with placing them at center point of Patient-Physician Consultation, which has made its place indispensible in health care delivery with better health outcomes.It offers a much needed platform for agreement on intervention and treatment plans between Patients and their physicians, and it improves Patient satisfaction and health care related outcomes.(1,2) Despite proven benefits of Person Centered Care (PCC), significant challenges still persist in its implementation across the globe.Its integration into clinical practice is often found to be patchy and inconsistent even in developed countries.(1,3) The situation in Eastern Mediterranean Region (EMR) is no different.A recently conducted multi-country, crosssectional study across six countries of EMR found that 36% of the patients and 62.6% of physicians preferred a personcentered model of medical care.(4) Better acceptability of this model among physicians, in comparison to patients, is most likely due to incorporation of PCC model of patient/ physician consultation in training programs for physicians.
There is scientific evidence to suggest that significant barriers exist in the implementation of PPC model in clinical practice even in developed countries and there are ways in which these barriers and challenges can be overcome.(5) This information provides us with the guide to enforce this model in EMR.
Several evidence based barriers and challenges to PCC implementation in clinical practice have been identified.(6)Time constraint is an identified barrier since PCC model takes more time to practice.In order to expect a patient to make informed decisions about a treatment, it is necessary that the condition is explained in simple and understandable language.Weakening of professional power with staff experiencing reduction in professional status, compromise in decision making power and in autonomy to practice, are considered other significant challenges for enforcement of PCC model of patient/physician consultation in clinical practice.(7) The decision-making process by clinicians using synthesized approaches must involve the patient.It also reduces errors.(Figure 1 -see next page).
Lack of clarity exists about what constitutes PCC, making it more difficult to practice and to explain to patients.(7,8) Its implementation is even more challenging among patients with communication difficulties (language barrier or learning difficulties).Institutional policies and nonconducive physical environments of care make practice of

Study Setting:
This cross-sectional study was conducted across six countries (Iraq, Saudi Arabia, Jordan, Egypt, Bahrain and Pakistan) of the EMR, from May 2014 to September 2014.These countries were selected to obtain patient's perception on PCC, from diverse cultures and socioeconomic backgrounds.

Selection of Patients:
Family Physicians from different countries were invited to participate in the study.They were informed about the study protocol and requested to recruit patients coming to their clinics, older than 18 years and with one or more presenting problems.Patients were excluded if they were too ill to answer questions, were agitated or in severe pain.

Informed Consent:
Written informed consent was obtained from all participants after explaining about the study protocol.The study was conducted in accordance with the Helsinki Declaration.

Study tools:
A questionnaire was formulated after compiling important domains of PCC through extensive Medline search and by taking suggestions from experts in the field.The questionnaire focused on the barriers (increased cost, time constraints, religious & cultural barriers) of implementing PCC, as perceived by the patients.The questionnaire was also translated in Arabic, being a common language in the region.The questionnaire was then pre-tested and ambiguities were removed.The questionnaire was composed of 2 sections: The first section was composed of demographic details of the participants while the second section had questions on barriers and their possible remedies.

Sample Size:
Data analysis was conducted using Statistical Package for Social Sciences (SPSS) version 19.A post hoc analysis generated a power of 80% when 234 patients were selected at 5% level of significance.

Analysis:
Descriptive and inferential statistics were performed.Descriptive analysis was conducted by obtaining frequencies of all the variables.Later, Logistic regression analysis was performed to identify the barriers associated with implementation of PCC in EMR.Univariate analysis was done to obtain the independent effects of barriers on preference of PCC by patients.Since none of the variables were found to be significant at the Univariate level, therefore, multivariate regression was not performed.The results were reported in the form of proportions, unadjusted odds ratio along with their 95% confidence interval.Throughout the analysis a P value of < 0.05 was considered statistically significant.

Results
A total of 280 patients were approached.234 patients consented to participate in the study, yielding a response rate of 83.5% (234/280).About 60.6% of the patients were between 20 to 30 years and the majority of the patients were females (63.7%).Over half of the population had more than 10 years of schooling and 41.1% were unemployed.Approximately 18% of the patients were recruited from Egypt (Table 1 -next page).
Barriers for implementation of Person Centered Care in EMR are presented in Table 2. Slightly under three quarters of the patients believed that time constraints are a major barrier (73.9%,OR: 1.5; 95% CI: 0.86-2.78).This is followed by doctors feeling of being superior (67.1%,OR: 1.0; 95% CI: 0.58-1.76),doctors desire to control patient (OR:2.6;95% CI: 1.55-4.49),patients desire to allow doctors to decide for them (56.8%),cultural reasons (52.1%), increased cost (50.9%)and religious reasons (33.3%).Table 3 describes the possible remedies for overcoming barriers to implementation of PCC in the region.A similar proportion of patients responded that time constraints associated with PCC can be overcome by improving physician efficiency during patient physician consultation (66.2%), by improving patient efficiency by educating them about the PCC model (66.7%) and reducing number of patients seen by physician in a clinic time slot (65.4%).
Patients responded that increased cost related to practice of PCC could be reduced (58.1%) by accepting increase in cost in interest of better patient outcomes (40.6%).Half of the patients recommended that to overcome cultural beliefs and practices that hinder the practice of PCC; support can be taken from community leaders after explaining to them the benefits of PCC.Three quarters of the patients responded that doctors needs to be educated and trained to practice PCC during patient-physician consultation.

Conclusion
This is perhaps the first study from EMR that has looked at PCC from the Patient's perspective in the context of challenges, barriers and way forward.The sample is of a reasonable size even though it covers younger people and particularly more women.Most of the study participants were fairly educated yet stated to be unemployed, being housewives and looking after their families.Despite these shortcomings, the findings are relevant and have practical implications.
It is heartening to note that more than half of the respondents favor implementation of person centered model for patient physicians' consultation in the region.A study conducted in the region on patients and physicians perceptions regarding PCC also found support for PCC model among more than 50% of respondents.(4) It is not a surprise to note that "time constraint" has come out as a barrier for implementation of PCC in the region, and this is possibly because of several reasons.In order to implement PCC model for patient-physician consultation, it will be necessary to make the patient the focus of consultation through empowering them.The patient will have to be informed about his or her condition and available evidence based choices in enough detail and simple understandable language, to enable him or her to reach meaningful decisions.All these measures increase patient-physician consultation time and costs that can be curtailed.
"Increased cost" is another related barrier for implementation of this model of Patient-physician consultation, and has come out strongly in this study.There is evidence to suggest that with proper planning and execution, additional costs associated with Person-Centered model of care can be reduced.(10, 11) There is evidence that with proper implementation of PCC model, patient-physician costs can be cut in the long run.(12,13) It is not surprising that patients consider it worthwhile to invest time and cost to empower Patients and implement person centered model for patient-physician Consultation.Improving physician's efficiency and educating both patient and physicians about the process for this model of consultation will reduce time and cost required for this type of clinical encounter.
It is interesting to note that Patients consider a physicians' desire to control patient-physician consultation and their feeling of being superior, (14,15) as a barrier to implement person centered model for patient-physician consultation.Another related barrier identified in this study is the desire of patients for physicians to decide for them.(15)Such barriers can be removed by educating both patients and physicians that they are equal partners in the consultation and that the benefits of having the patient as the focus of the encounter are not only beneficial for health related outcomes, it does not compromise the respect that they have and enjoy during the Consultation process as equal human beings.
Cultural and religious reasons (16,17) have been quoted as barriers to implementation of person centered model for patient-physician consultation.In some societies, physicians have been and still are considered 'next to God'.(15) Patients are unfortunately not considered capable of making health care related decisions in our society.A physician has traditionally and historically enjoyed tremendous respect and a patient has been a passive recipient of medical care given by a physician.Against this background, introduction of patient-physician model of consultation that puts the entire focus on the patient has been and continues to be a challenge.Respondents have suggested that community leaders can be asked to support this model and education of both patients and physicians with regards to it can help overcome cultural as well as religious barriers for its implementation.

Conclusion
PCC is associated with significant barriers in its implementation in EMR.These barriers can be overcome in the interest of better health care related outcomes.It is the responsibility of all stakeholders and health care providers to ensure that barriers are removed and practice of person centered model of patient-physician consultation is enforced in EMR.

AbstractBackground:
Person-Centered Care (PCC) is now considered a mandatory approach in Patient-Physician consultation.The aim of the study was to identify patients' perception regarding barriers and possible remedies for implementation of PCC in Eastern Mediterranean Region (EMR).Methods: A cross-sectional multi-country study was conducted in six countries of EMR during May 2014 to October 2014.Expert Family Physicians from each country were identified and asked to participate in the study.The Family Physicians then recruited Patients from their own clinics (>18 years).Data analysis was performed on SPSS 19 and results are reported in the form of proportions, odds ratios and 95% confidence intervals.Results: A total of 234 patients were recruited, 60.6% were aged between 20 to 30 years and 36.3% of them were males.56% of the patients preferred Person-Centered Care model for patient-physician consultation.The major barriers identified by patients in its implementing were; time constraints (73.9%,OR: 1.5; 95% CI: 0.86-2.78),doctors desire to control patient (OR: 2.6; 95% CI: 1.55-4.49),cultural and religious reasons (52.1%), increased cost (50.9%).Patients responded that increased cost related to Person-Centered Care practice would be acceptable (58.1%), if increase proved to be in the interest of better health and care outcomes (40.6%).Conclusion: Person-Centered Care (PCC) is associated with significant barriers in its implementation in Eastern Mediterranean Region.These barriers can be overcome in the interest of better health and care related outcomes.Key words: Person-Centered Care, Physician-Patient Consultation, Primary Healthcare, Eastern Mediterranean Region.

Figure 2
Figure 2 depicts that 56% of the patients preferred PCC model for patient-physician consultation in the region.

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EAST JOURNAL OF FAMILY MEDICINE VOLUME13 ISSUE 3 APRIL/MAY 2015 O R I G I N A L CO N T R I B U T I O N A N D C L I N I C A L I N V E S T I G AT I O N