Variations in patients’ ability and willingness to engage
diabetes
DIABETES
Participants reported that many patients did not open or read, let alone reflect and write in care planning letters before their appointments. In the early stages of PACE-D they estimated that up to 30% of patients did not read the letter at all. They reported that this improved after it was agreed that PACE-D coordinators would check and provide more active assistance when patients came into the clinic (see below) and as patients became more familiar with the process.Health professionals further experienced many patients as reticent or lacking confidence to engage in conversation about their diabetes in the context of their life. They mostly explained this with reference to some combination of language diversity, education and culture, although some somewhat judgementally also suggested a lack of interest on patients’ part, and some more sympathetically recognised that a long social history of medical practice Care planning letters were issued in whichever of three languages (English, Chinese or Malay) a patient preferred. However, many older adults in Singapore received little education and literacy rates among people over 55 are relatively low [All participants were used to conducting consultations in at least two languages, but several explained that language skills that sufficed for ‘usual’ consultations were not necessarily up to the more nuanced demands of open, broad-ranging and potentially emotional CSP conversations. Patients, too, might have limited ability and confidence to express complex thoughts and feelings in the language of the conversation, and the limitations of interpreters could be particularly problematic for CSP consultations.Several participants commented that aspects of Singaporean or more broadly Asian cultures meant many people were not used to being asked for their opinion, particularly in healthcare contexts where (to a greater extent than in the UK or more broadly Western cultures within which CSP originated) doctors are deferred to as authority figures and families and family hierarchies are influential in healthcare decision-making. The CSP approach represented a big cultural-behavioural shift within polyclinic service provision. People with diabetes who had attended clinics for many years were likely to be strongly habituated to ‘usual’ consultation practices in which they were assessed quickly and sent away with medication and instructions. While all participants showed some awareness of the diversity of patients’ educational and cultural backgrounds and socioeconomic circumstances, some reflected these less clearly and sensitively than others in their accounts of CSP conversations. Not all recognised that patients might need substantial encouragement and experience of a few rounds of CSP to adapt to the expectation that they engage as ‘equal’ partners with the health professional in conversation. Not all seemed particularly able or willing to cede their biomedical priorities and authority to facilitate such partnerships.The reticence and perhaps limited ability of many patients to engage in CSP recurred in participants’ accounts as a challenge that would tend to limit achievement of the approach’s theoretical promise, particularly in relation to biomedical health outcomes. Some participants quite quickly got “stuck” when patients volunteered little in the way of ideas and opinions (this was perhaps more likely if the health professionals were encouraging a focus on biomedical test results). These health professionals described often ending up with a CSP conversation that was more like a “usual consult”. Those who were also less inclined to recognise other potential benefits considered patients who were less able or willing to engage “less suitable” for CSP. Other health professionals, in contrast, were apparently more determined to hear and work with patients’ perspectives and persisted as constructively as they could with whatever little they could elicit from patients’ initial responses, expressing hope that patients would become more confident and open with more experience of the CSP approach. A few described developing and refining their questioning over time to help patients reflect on and express what was important to them.