Interaction Analysis System Research Articles

Communication during counseling sessions about inhaled corticosteroids at the community pharmacy.

BackgroundPharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist–patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist–patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions.MethodsPatients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider–patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting.ResultsA total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians.ConclusionPharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.

Emotional disclosure in home hospice cancer care: Implications for spouse caregiver bereavement.

54 Background: Evidence shows the benefit of positive and negative emotional disclosure for family caregivers (CG), but little is known about the impact of emotional disclosure at end of life. We assessed the effect of CG and hospice nurse disclosure during home visits on CG anxiety and depression in bereavement. Methods: As part of a larger study, nurse visits to 95 spouse CGs of cancer home hospice patients were audio recorded. An adapted Roter Interaction Analysis System was used to identify emotional disclosure: CG and nurse positive emotion (humor, gratitude), CG distress, and nurse emotional response (reassurance, validation). CGs completed demographics at hospice enrollment, and HADS anxiety scale, and Geriatric Depression Scale (GDS) at enrollment, and 2, 6 and 12 months after patient death. Growth curve analysis was conducted to predict HADS and GDS trajectories, controlling for CG gender, total talk, anxiety and depression at enrollment. Results: Average spouse CG age was 65; 60% were female and 98% were white. There were no GDS effects for CG expression of distress or nurse emotional response. Higher CG positive emotion talk predicted higher GDS at 2 months (B = .18, p < .01), but a significant decline of GDS over time (B = -.08, p = .03). There were no effects for CG emotional disclosure on anxiety. However, more nurse emotional response predicted lower anxiety at 2 months (B = -.10, p = .02) which did not significantly change over time. More nurse positive emotion did not impact anxiety at 2 months, but predicted lower anxiety over time (B = -.04, p = .04). Conclusions: Emotional disclosure during cancer hospice visits was associated with spouse CG bereavement trajectories. CG positive emotion talk may signal increased potential for depression early in bereavement, but appears to lessen over time. CGs who express more positive emotion, which includes humor, gratitude and savoring the moment, may be more sensitive to loss, but appear to recover in time. Nurse expression of reassurance and validation, and of positive emotions seems to be effective in addressing and normalizing CG anxiety during bereavement. These findings have potential implications for communication interventions.

Communication During Pediatric Intensive Care Unit Family Conferences: A Pilot Study of Content, Communication, and Parent Perceptions

ABSTRACTWhile there is a robust literature describing family conferences (FCs) in adult intensive care units (ICUs), less information exists about FCs in pediatric ICUs (PICUs). We conducted a pilot study to describe the focus of discussion, communication patterns of health care team members (HTMs) and parents, and parents’ perspectives about clinician communication during PICU FCs. We analyzed data from 22 video- or audiorecorded PICU FCs and post-FC questionnaire responses from 27 parents involved in 18 FCs. We used the Roter Interaction Analysis System (RIAS) to describe FC dialogue content. Our questionnaire included the validated Communication Assessment Tool (CAT). FCs were focused on care planning (n = 5), decision making (n = 6), and updates (n = 11). Most speech came from HTMs (mean 85%; range, 65–94%). Most HTM utterances involved medical information. Most parent utterances involved asking for explanations. The mean overall CAT score was 4.62 (using a 1–5 scale where 5 represents excellent and 1 poor) with a mean of 73.02% “excellent” responses. Update and care-planning FCs had lower CAT scores compared to decision-making FCs. The lowest scoring CAT items were “Involved me in decisions as much as I wanted,” “Talked in terms I could understand,” and “Gave me as much information as I wanted.” These findings suggest that while health care providers spend most of their time during FCs relaying medical information, more attention should be directed at providing information in an understandable manner. More work is needed to improve communication when decision making is not the main focus of the FC.

Family presence and participation during medical visits of heart failure patients: An analysis of survey and audiotaped communication data

ObjectiveTo describe the frequency, roles, and utility of family companion involvement in the care of patients with Heart Failure (HF) care and to examine the association between audiotaped patient, companion, and provider communication behaviors. MethodsWe collected survey data and audiotaped a single medical visit for 93 HF patients (36 brought a companion into the examination room) and their cardiology provider. Communication data was analyzed using the Roter Interaction Analysis System. ResultsThere were 32% more positive rapport-building statements (p<0.01) and almost three times as many social rapport-building statements (p<0.01) from patients and companions in accompanied visits versus unaccompanied patient visits. There were less psychosocial information giving statements in accompanied visits compared to unaccompanied patient visits (p<0.01.) Providers made 25% more biomedical information giving statements (p=0.04) and almost three times more social rapport-building statements (p<0.01) in accompanied visits. Providers asked fewer biomedical and psychosocial questions in accompanied versus unaccompanied visits. Providers made 16% fewer partnership-building statements in accompanied versus unaccompanied visits (p=0.01). ConclusionsOur findings are mixed regarding the benefits of accompaniment for facilitating patient-provider communication based on survey and audiotaped data. Practice implicationsStrategies to enhance engagement during visits, such as pre-visit question prompt lists, may be beneficial.

Examining Jurors: Using Conversation Analysis to Explore the Influence of Race on Prosecutor Speech in North Carolina Capital Jury Selection

Stereotypes about which demographic groups are more or less likely to sentence a defendant to death operate as implicit starting hypotheses in capital cases, informing how attorneys examine jurors during voir dire. This hypotheses-influenced information reinforces the starting stereotypes and potentially exacerbates the influence of the stereotypes themselves on strike decisions. Evidence also suggests that both prosecutors and defense counsel use race as a proxy for bias despite the constitutional prohibition. In these instances, voir dire may serve as a tool to develop race-neutral justifications for the anticipated race-based strikes. In either instance, the voir dire process itself might contribute to the improper influence of race. This study of jury selection for 600 potential jurors across twelve randomly selected North Carolina capital cases uses conversation analysis to look behind the race effects observed in the exercise of peremptory strikes for evidence of ways race influences the process that produces those decisions. We adapted the Roter Interaction Analysis System, a widely used framework for understanding the dynamics of patient–clinician communication during clinical encounters and a framework with well-established reliability and predictive validity, to the legal setting for the first time. Under this rigorous and exacting method of conversation analysis, we assigned one of 46 mutually exclusive codes to every complete thought any speaker expressed. In the analysis presented here, we grouped these codes into mutually exclusive categories of speech based on content and affect. This created a “conversation profile” with four distinct components: education/orientation speech, data gathering speech, relationship building speech, and conflict speech. The findings presented here focus on prosecutors’ conversations with 179 black and white jurors eligible to be dismissed by a state peremptory strike. These findings begin to suggest ways in which the evaluation of fitness for jury service itself is skewed and contributes to racial disparities in jury selection. Prosecutors not only struck potential black jurors at a higher rate, they spoke differently to the black potential jurors they struck, and showed more conflict with black potential jurors overall. Moreover, the racial diversity of the panel of jurors affected the discourse: when the proportion of black potential jurors was bigger, prosecutors engaged in less education and orientation and more data gathering with the black potential jurors. While these findings echo or perhaps restate the overwhelming evidence of racial bias shown by disparate strikes, they provide new insight into ways in which prosecutors may be approaching the decision-making process differently for black and white potential jurors. The results presented here provide an important foundation for future research.

Physicians’ Reactions to Patients Taking a Position: Sequence Analysis of Admission Interviews in Orthopedic Rehabilitation

ABSTRACTLittle is known about how patients influence health care providers’ communication behavior, although this knowledge may contribute to the understanding of the reciprocal influence of patient and provider communication and the pathways between communication and health care outcomes. Therefore, the aim of this study was to explore patients’ active communication behaviors and how this affects the immediate communication behavior of physicians. We coded 27 admission interviews from three German orthopedic rehabilitation centers with an adapted version of the Roter Interaction Analysis System. The data were analyzed using correlations and sequence analysis, specifically lag analysis. In this article, we report findings in relation to patients taking a position and physicians’ reactions. The analysis showed that while all patients took up a position during their consultation, they very rarely contradicted the physician. Moreover, many instances of patients’ expression of opinion were strongly determined by physicians’ behavior. When physicians asked patients for their opinions they often used alternative questions or closed questions that limited patients’ answering possibilities. While the lag analyses showed that patient communication behavior can influence physician communication, in the majority of instances patients’ expression of opinions did not lead to a discussion or shared decision making.

Student-centered tutoring as a model for patient-centeredness and empathy.

BackgroundCurriculum planners and medical teachers attempt to enhance medical students’ empathy and patient-centeredness. Despite educational efforts, there is stability in medical students’ empathy and patient-centered medicine during the preclinical stage and a decline in both of them throughout the clinical years. Student–tutor relationship plays a key role in students’ learning. This study tests the effect of learner-centered tutoring on students’ empathy, patient-centeredness, and behavior.Participants and methodsThe cohort of 55 students was divided into groups of seven or eight. The experimental group’s tutors underwent LC mentoring. Empathy was assessed with the Jefferson Scale of Physician Empathy for Students; PC attitude was assessed with the Patient–Provider Orientation Scale (PPOS). Behavior was assessed by simulations of doctor–patient encounters with 32 students at the end of the third year. Each student participated in three such simulations, during which we analyzed ten aspects of physician–patient communication via Roter interaction analysis system (RIAS)-coded audiotapes.ResultsA significant group difference was found for three RIAS categories: building a relationship and patient-centeredness, where the mean percentage of the experimental group was significantly higher than that of the control group, and gathering data, where the mean percentage of the experimental group was significantly lower than that of the control group. A significant correlation was found in the experimental group between empathy and positive talk and between PPOS and three of the RIAS categories: gathering data, psychosocial talk, and patient-centeredness. A significant negative correlation was found in the experimental group between PPOS and two of the RIAS categories: negative talk and doctor–centeredness. Two significant negative correlations were found in the control group: between empathy and patient-centeredness and PPOS and negative talk.ConclusionThe LC approach supports two of the RIAS categories, corresponding to clinical empathy and PC care and the link between certain behaviors and the PPOS.

Computer use, language, and literacy in safety net clinic communication.

Objective: Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. Materials and Methods: We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. Results: Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (−0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (−0.9, P < .01), fewer clinician psychosocial statements (−3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. Conclusion: Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. Discussion: Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.

Communication predictors and consequences of Complementary and Alternative Medicine (CAM) discussions in oncology visits

ObjectiveCancer patients use complementary and alternative medicine (CAM), but do not routinely talk about it with their clinicians. This study describes CAM discussions in oncology visits, the communication patterns that facilitate these discussions and their association with visit satisfaction. Methods327 patients (58% female; average age 61) and 37 clinicians were recorded during an oncology visit and completed post-visit questionnaires. All CAM discussions were tagged and the Roter Interaction Analysis System (RIAS) was used to code visit dialogue. ResultsCAM was discussed in 36 of 327 visits; discussions were brief (<one minute), the majority patient initiated (65%) and more common for patients in early stages of cancer care. Longer visits (35 vs 29min; p<0.05), greater patient engagement in visit dialogue, lowered clinician verbal dominance and a more patient-centered pattern of visit communication were significantly related to visits with CAM discussions (all p values<0.01). Both patient and clinician visit satisfaction was higher with CAM discussion (p<0.05). ConclusionsCAM discussions do not occur at random; they take place in visits characterized by patient-centered communication and are associated with higher visit satisfaction. Practice implicationsCAM discussions are perceived positively by both patients and clinicians and are facilitated by patient-centered visit communication.

Predictors of patient communication in psychiatric medication encounters among veterans with serious mental illnesses.

Person-centered psychiatric services rely on consumers actively sharing personal information, opinions, and preferences with their providers. This research examined predictors of consumer communication during appointments for psychiatric medication prescriptions. The Roter Interaction Analysis System was used to code recorded Veterans Affairs psychiatric appointments with 175 consumers and 21 psychiatric medication prescribers and categorize communication by purpose: biomedical, psychosocial, facilitation, or rapport-building. Regression analyses found that greater provider communication, symptomology, orientation to psychiatric recovery, and functioning on the Repeatable Battery for the Assessment of Neuropsychological Status Attention and Language indices, as well as consumer diagnostic label, were positive predictors of consumer communication, though the types of communication impacted varied. Provider communication is the easiest variable to intervene on to create changes in consumer communication. Future research should also consider how cognitive and symptom factors may impact specific types of consumer communication in order to identify subgroups for targeted interventions. (PsycINFO Database Record

Shared decision-making in pediatric otolaryngology: Parent, physician and observational perspectives

ObjectiveTo describe physician and parent behavior during pediatric otolaryngology surgical consultations, and to assess whether perceptions of shared decision-making and observed behavior are related. MethodsParents of 126 children less than 6-years of age who underwent consultation for adeontonsillectomy or tympanostomy tube insertion were prospectively enrolled. Parents completed the Shared Decision-Making Questionnaire-Patient version (SDM-Q-9), while surgeons completed the Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) after the consultation. Visits were video-recorded and analyzed using the Roter Interaction Analysis System to quantify physician and parent involvement during the consultation. ResultsPerceptions of shared decision-making between parents (SDM-Q-9) and physicians (SDM-Q-Doc) were significantly positively correlated (p = 0.03). However, there was no correlation between parents' perceptions of shared decision-making and observations of physician and parent behavior/involvement (proportion of physician socioemotional talk, task-focused talk, or proportion of parent talk). Surgeons' perceptions of shared decision-making were correlated with physician task-focused talk and proportion of parent talk. ConclusionsParents and physicians had similar perceptions of the degree of shared decision-making to be taking place during pediatric otolaryngology consultations. However, there was variability in the degree to which parents participated, and parent perceptions of shared decision-making were not correlated with actual observed involvement.

Starting the conversation: Patient initiation of weight-related behavioral counseling during pregnancy

ObjectiveTo examine the relationship between patient initiation and weight-related behavioral counseling during pregnancy. MethodsWe examined audio recordings of prenatal visits between 22 obstetricians and 120 patients for behavioral counseling using the Roter Interaction Analysis System and the 5A’s behavioral counseling framework. We used multivariate regression models to examine the relationship between patient initiation and communication outcomes. ResultsOverall, 55% of prenatal visits included any behavioral counseling. Patients initiated counseling episodes 45.5% of these visits. Patients were less verbally dominated by their clinicians in prenatal visits with patient-initiated behavioral counseling episodes (difference in clinician verbal dominance ratio=0.73, 95% CI=0.16–1.30). Patient-initiated counseling episodes included more socioemotional communication relative to those initiated by clinicians (p=0.02). The total duration of counseling was 28s longer (95% CI 0.27–56.0s) and clinicians were more likely to use two or more 5A’s strategies (OR=3.61, 95% CI=1.01–12.88) when patients initiated discussions. ConclusionsPatient initiation may lead to behavioral counseling that is longer in duration and includes more 5A’s strategies, possibly mediated by socioemotional communication. Practice implicationsParticipatory prenatal care communication may lead to more effective counseling that is responsive to women’s concerns.

Ambivalence and motivational interviewing with adolescents: ensuring that the baby does not get thrown out with the bathwater.

Ambivalence and motivational interviewing with adolescents: ensuring that the baby does not get thrown out with the bathwater.

Family Conferences in the Neonatal ICU: Observation of Communication Dynamics and Contributions.

Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences. We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication. An urban academic children's medical center with a 45-bed level IV neonatal ICU. Neonatal ICU parents and clinicians. None. We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue. We collected a novel repository of audio-recorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted.

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

BackgroundNurse-led care is well established in Rheumatology in the UK and provides follow-up care to people with inflammatory arthritis including treatment, monitoring, patient education and psychosocial support. AimThe aim of this study is to compare and contrast interactional style with patients in physician-led and nurse-led Rheumatology clinics. DesignA multi-centre mixed methods approach was adopted. SettingsNine UK Rheumatology out-patient clinics were observed and audio-recorded May 2009–April 2010. ParticipantsEighteen practitioners agreed to participate in clinic audio-recordings, researcher observations, and note-taking. Of 9 nurse specialists, 8 were female and 5 of 9 physicians were female. Eight practitioners in each group took part in audio-recorded post-clinic interviews. All patients on the clinic list for those practitioners were invited to participate and 107 were consented and observed. In the nurse specialist cohort 46% were female; 71% had a diagnosis of Rheumatoid Arthritis (RA). The physician cohort comprised 31% female; 40% with RA and 16% unconfirmed diagnosis. Nineteen (18%) of the patients observed were approached for an audio-recorded telephone interview and 15 participated (4 male, 11 female). MethodsForty-four nurse specialist and 63 physician consultations with patients were recorded. Roter's Interactional Analysis System (RIAS) was used to code this data. Thirty-one semi-structured interviews were conducted (16 practitioner, 15 patients) within 24h of observed consultations and were analyzed using thematic analysis. ResultsRIAS results illuminated differences between practitioners that can be classified as ‘socio-emotional’ versus ‘task-focussed’. Specifically, nurse specialists and their patients engaged significantly more in the socio-emotional activity of ‘building a relationship’. Across practitioners, the greatest proportion of ‘patient initiations’ were in ‘giving medical information’ and reflected what patients wanted the practitioner to know rather than giving insight into what patients wanted to know from practitioners. Interviews revealed that continuity of practitioner was highly valued by patients as offering the benefits of an established relationship and of emotional support beyond that of the clinical encounter. This fostered familiarity not only with their particular medical history, but also their individual personal circumstances, and this encouraged patient participation. In contrast, practitioners (mis)perceived waiting times to have a greater impact on patient satisfaction. However, practitioner interviews also revealed that clinic structure is often outside of the practitioner control and can undermine the possibility of maintaining patient–practitioner continuity. ConclusionsThis research enhances understanding of nurse specialist consultation styles in Rheumatology, specifically the value of their socio-emotional communication skills to enhance patient participation.

Analysis of pedagogical communication and interaction of lessons with tablet application

The article describes possibilities of lessons evaluation by means of structured observations. Our study took an interest in the use of information and communication technologies in teaching of mathematics on elementary school. Concrete it was case tablets implementation in standard lessons on elementary school. The aim of the submitted project was to find out if tablets application in lessons would influence pedagogical communication and interaction. We selected structured FIAS (Flanders Interaction Analysis system) observation as a basic research method. This method was spread on 16 categories in total, which we used for structured observation of lessons. The results were successively processed to interaction characteristics.

Evaluation of a Communication Skills Training Program for Companion-Animal Veterinarians: A Pilot Study Using RIAS Coding.

Effective veterinarian communication skills training and the related key outcomes provided the impetus for this study. We implemented a pre-experimental pre-test/post-test single-group design with a sample of 13 veterinarians and their 71 clients to evaluate the effects of a 6.5-hour communication skills intervention for veterinarians. Consultations were audiotaped and analyzed with the Roter Interaction Analysis System (RIAS). Clients completed the Consultation and Relational Care Measure, a global satisfaction scale, a Parent Medical Interview Satisfaction Scale, and the Adherence Intent measure. Veterinarians completed a communication confidence measure and a workshop satisfaction scale. Contrary to expectation, neither veterinarian communication skills nor their confidence improved post-training. Despite client satisfaction and perceptions of veterinarians' relational communication skills not increasing, clients nevertheless reported an increased intent to adhere to veterinarian recommendations. This result is important because client adherence is critical to managing and enhancing the health and well-being of animals. The results of the study suggest that while the workshop was highly regarded, either the duration of the training or practice opportunities were insufficient or a booster session was required to increase veterinarian confidence and integration of new skills. Future research should utilize a randomized control study design to investigate the appropriate intervention with which to achieve change in veterinarian communication skills. Such change could translate to more effective interactions in veterinarians' daily lives.

Evaluating the effectiveness of patient education and empowerment to improve patient–provider interactions in antiretroviral therapy clinics in Namibia

ABSTRACTIn order to increase patient active engagement during patient–provider interactions, we developed and implemented patient training sessions in four antiretroviral therapy (ART) clinics in Namibia using a “Patient Empowerment” training curriculum. We examined the impact of these trainings on patient–provider interactions after the intervention. We tested the effectiveness of the intervention using a randomized parallel group design, with half of the 589 enrolled patients randomly assigned to receive the training immediately and the remaining randomized to receive the training 6 months later. The effects of the training on patient engagement during medical consultations were measured at each clinic visit for at least 8 months of follow-up. Each consultation was audiotaped and then coded using the Roter Interaction Analysis System (RIAS). RIAS outcomes were compared between study groups at 6 months. Using intention-to-treat analysis, consultations in the intervention group had significantly higher RIAS scores in doctor facilitation and patient activation (adjusted difference in score 1.19, p = .004), doctor information gathering (adjusted difference in score 2.96, p = .000), patient question asking (adjusted difference in score .48, p = .012), and patient positive affect (adjusted difference in score 2.08, p = .002). Other measures were higher in the intervention group but did not reach statistical significance. We have evidence that increased engagement of patients in clinical consultation can be achieved via a targeted training program, although outcome data were not available on all patients. The patient training program was successfully integrated into ART clinics so that the trainings complemented other services being provided.

Non-specific Mechanisms in Orthodox and CAM management of back pain (MOCAM)

Introduction: Non-specific effects can have substantial effects on pain and disability. We have designed a major mixed-methods cohort study to investigate and compare non-specific components in physiotherapy, osteopathy, and acupuncture for low back pain (LBP). This project will extend current evidence by identifying the most powerful non-specific components, providing a deeper understanding of the pathways through which they generate positive patient outcomes. Aims: • Identify the most powerful non-specific treatment components (largest effect on patient outcomes) • Compare the magnitude of non-specific effects across orthodox and CAM therapies • Test which theoretically-derived mechanistic pathways explain their effects • Compare patient-practitioner interactions across the three therapies Methods: We will recruit 1548 adults with LBP attending acupuncturists, physiotherapists, and osteopaths in private and NHS clinics. A quantitative longitudinal questionnaire-based study will use multi-level modelling to test hypothesized relationships between non-specific components, key theoretically derived mediators and patient outcomes. A randomised sample of 63 consultations (21 per treatment) will be audio-recorded and analysed using the quantitative Roter Interactional Analysis System and inductive qualitative analysis, to identify treatment-enhancing communication practices. Conclusions: Evidence suggests that non-specific components are important for patient outcomes across diverse conditions including LBP. The context of CAM therapies may contribute to their effectiveness and CAMs might be particularly good at enhancing non-specific components. To better understand the role of non-specifics in the management of LBP we will study multiple non-specific factors simultaneously, comparing them within different treatments and relating the findings to pain theories, to understand to how they contribute to the consultation.

The impact of a primary care e-communication intervention on the participation of chronic disease patients who had not reached guideline suggested treatment goals

ObjectiveTo evaluate the efficacy of two web-based educational approaches on doctor-patient communication. The study focused on chronic disease (CD) patients in a lengthy relationship with their family physician (FP) who had not reached guideline suggested treatment goals (off-target) for their CDs. Methods322 hypertensive, diabetic, or dyslipidemic patients of 18 FPs were randomised into three groups: Usual Care (UC), e-Learning (e-L) and e-Learning+Workshop (e-L+W). Interventions were based on Cegala’s PACE system: Prepare, Ask questions, Check understanding, Express concerns. Communication was evaluated using the Roter Interaction Analysis System (RIAS), MEDICODE and questionnaires. ResultsEncounter length was similar across groups. RIAS showed that e-L+W group engaged in more socio-emotional talk and PACE-like utterances. MEDICODE showed that interventions increased frequency, initiative and dialogue for selected CD medication themes. Quality of communication was perceived as satisfactory at baseline and did not change. ConclusionFollowing interventions, CD patients were more activated even in well-established doctor-patient relationships. Practice implicationsPACE web-based interventions are accessible and effective at increasing CD patients’ participation. They increase legitimacy to express the patient experience. FPs should present this type of training to CD patients as an integral part of their routine practice and consider referring patients to complete it.