What does patient-centred communication mean in Nepal?
Malcolm Moore, BP Koirala Institute of Health Sciences, Dharan, PO Box 7053, Kathmandu, Nepal.
Tel: 00 977 25 525555; Fax: 00 977 25 520251;
Objectives To ascertain the expectations of Nepalese patients regarding aspects of doctor–patient communication and to review a model of patient-centred care for its appropriateness to Nepalese medical communication training.
Methods A cross-sectional survey, using an adapted version of the Patient−Practitioner Orientation Scale (PPOS), was undertaken with a random sample of patients attending a general outpatients department in rural Nepal. An alternative survey instrument, derived from the PPOS, was also used.
Results The following issues were most important to patients: being treated in a friendly and respectful manner; being fully informed, and being given adequate consultation time. Patients were happy for the doctor to be in charge and did not want to seek information outside the doctor’s advice. They expressed a strong preference for receiving advice about preventative care. Patient responses were significantly more ‘doctor-centred’ than those found in comparable studies in the USA.
Discussion Patients expressed strong preferences for some aspects of patient-centred communication (PCC), but were not very concerned with sharing power and control. Models of PCC in Nepal require modification to reflect these local preferences. The importance of good communication techniques requires emphasis in clinical training and practice. Methods of disseminating information need to be enhanced in this low-literacy setting.
There has been increasing interest in concepts of patient-centredness since Edith Balint defined patient-centred medicine as ‘understanding the patient as a unique human being’.1 Patient-centred communication (PCC) is now an accepted part of the curriculum in the medical schools of most developed countries. This movement has grown largely in contrast to the traditional biomedical model of health and disease. Henbest and Fehrsen speak of ‘putting the patient at the centre of the consultation’ and shifting from ‘thinking and responding in terms of disease and pathology towards understanding and caring for people and their problems’.2
Researchers have sought to define the essential elements that make up the concept of PCC. One representative model, proposed by Epstein et al., describes patterns of communication that are operationalised into 4 areas: eliciting and understanding the patient’s perspective; understanding the patient within his or her unique social context; reaching a shared understanding of the problem and its treatment, and helping patients to share power and responsibility through involvement in making choices.3 A variety of survey and observational instruments have been used to measure PCC.4,5
Patient-centred communication has been promoted in western countries for a variety of reasons. There is evidence that PCC is associated with improved outcomes,2,6–9 although this finding is inconsistent.10,11 It is also linked with perceptions of higher quality medical services and increased satisfaction with, and use of, those services.12–16 The development of medical ethics,17 the rise in medical litigation and developing ideas about ‘consumer rights’ have all contributed to the rise of PCC.
The PCC model has received limited attention in southern Asia, except where family medicine (general practice) departments have been established. Medical training is still focused on the traditional biomedical model of health and disease.18 Workforce shortages and heavy patient loads, a constant problem in developing country medicine, do not encourage otherwise.2,19
These general features of southern Asian medical training and practice are clearly displayed in Nepal. Nepal is a poor country of around 28 million people, situated on the Himalayan range between India and China. Economic development is centred around the capital, Kathmandu, and some larger towns on the southern plains. Most Nepalese live in rural areas and practise subsistence farming. There are several factors that hinder the development of PCC in this setting. The society is highly structured according to tribe, caste and economic wealth. Doctors usually come from the highest levels of the socio-economic and caste structures, whereas most Nepalese are farmers and have low levels of literacy.20 The ideas of consumer rights and medical litigation are not yet strongly present in Nepalese society.
Studies in developing countries have measured patient satisfaction, perceptions of quality and some aspects of doctors’ behaviour.2,9,12–16 However, there appear to have been no studies assessing patient preferences concerning aspects of PCC. Western studies show different preferences for various aspects of PCC across demographic, gender and ethnic groups.21–24 Women, younger people and people who are better educated are generally more aware of the issue of patient-centredness. Whether or not similar differences exist in non-Western populations remains to be determined.
The present study had 2 objectives. The first was to ascertain the preferences of Nepalese patients in relation to doctor–patient communication. Understanding these preferences is important because it cannot be assumed that patients in different cultures will have the same expectations of communication styles. The second objective was to use the findings about preferences to assess the model proposed by Epstein et al. as an appropriate model of PCC for use in Nepalese medical communication training. This information is not only of value to medical educators. It is potentially valuable in informing the attitudes of treating doctors, researchers and health planners.
The study used 2 cross-sectional surveys, the first an adapted version of the Patient−Practitioner Orientation Scale (PPOS), and the second an alternative instrument derived from the PPOS.
The PPOS takes the form of an 18-item questionnaire. The original version of the questionnaire can be self-administered, but the low literacy levels of the subjects in this study required that the questionnaire be presented in the context of a structured interview. One of the translators, who was highly competent in both Nepali and English, was recruited and trained as interviewer.
The study was undertaken in a 700-bed teaching hospital in regional Nepal. Communication training in the attached medical school is performed by the Departments of Family Medicine and Psychiatry. There is a general outpatients department (GOPD) that is staffed by house officers and by trainees and faculty of the Department of Family Medicine. Patients present directly to the GOPD and pay a consultation fee. Most patients are charged for medication and investigations. There is a small budget to provide free care to the poorest people.
The sample was drawn from the population of all adults presenting for treatment, of themselves or their children, at the GOPD. When patients registered at the GOPD office their file was retrieved and placed, according to their order of registration, in the pile of waiting patients’ files. Subjects were called for interview if their file was on the bottom of the pile when the interviewer was ready for the next subject. This method was chosen as the most practical way of generating a random sample in these circumstances.
The consent of subjects was obtained orally after an information sheet had been given to them and its contents explained and the individual subject’s understanding checked. The interviewer took them through the survey individually while they waited for their consultation. Only 1 patient declined to participate.
The main demographic characteristics of the sample subjects are shown in Table 1. The data in Table 1 correspond closely to the known figures for age and sex of the hospital GOPD registrants.
Table 1. Demographic characteristics of the Patient−Practitioner Orientation Scale sample
|Female||145 (47.1)||16–25||117 (38.0)||No school||59 (19.2)|
|Male||163 (52.9)||26–35||99 (32.1)||Years 1–5||44 (14.3)|
|Total||308 (100)||36–45||53 (17.2)||Years 6–10||121 (39.3)|
| || ||46–55||29 (9.4)||Intermediate||59 (19.2)|
| || ||56–65|| 8 (2.6)||Graduate||23 (7.5)|
| || ||66 +|| 2 (0.6)||Post-graduate||2 (0.6)|
Several instruments were considered for use in the study. The PPOS was selected for several reasons: it has been validated and used in a number of studies;21,25–27 it enables across-population comparisons to be made, and it covers the main domains of PCC.3,4 In addition, its statements are generally expressed with a ‘doctor-centred’ orientation. This avoids any bias of the results towards patient-centredness that might arise as a result of the subjects’ possible propensity to agree with survey statements (courtesy bias) – a factor noted in other Asian studies.14 It does not ask, however, about health promotion – an element of models of patient-centred consultations.28 This deficiency is offset in the present study by the inclusion of an item about health promotion in the supplementary survey.
The scale asks the subjects to rate 18 statements on a 6-point Likert scale, where 1 = strongly agree and 6 = strongly disagree. Three of the items (9, 13 and 17) are reverse-scored because they are worded in patient-centred terms. Therefore, for all items, scores of 1 represent the most ‘doctor-centred’ and 6 the most ‘patient-centred’ orientation. The scale items form 2 sub-scales, each of 9 items: a ‘sharing’ and a ‘caring’ scale. The ‘sharing’ scale contains items about sharing power and information in the consultation. The ‘caring’ scale rates the extent to which psychosocial issues are seen as important in the treatment process. The 18 PPOS statements are set out in Table 2.
Table 2. Mean scores (standard deviations) for the individual items of the modified Patient−Practitioner Orientation Scale (n = 308); 1 = most doctor-centred; 6 = most patient-centred
| 1 I want the doctor to decide what we talk about in the consultation||3.2 (2.1)|
| 2 It is more important that the doctor uses the latest tests and medicines than takes a personal interest in me||3.2 (2.1)|
| 3 It is more important that the doctor physically examines me than talks with me about my health||2.4 (1.8)|
| 4 It is often better for me if I do not have a full explanation of my medical condition||5.6 (1.2)|
| 5 I should rely on the doctor’s knowledge and not try to find out about my condition on my own||2.1 (1.8)|
| 6 If the doctor asks a lot of questions about my background, he or she is prying too much into personal matters||3.0 (2.0)|
| 7 If the doctor is truly good at diagnosis and treatment, the way he or she relates to me is not very important||4.5 (2.0)|
| 8 Many patients ask too many questions even when the doctor has already explained things||2.7 (1.9)|
| 9 The doctor should treat me as a partner, equal in power and status||5.3 (1.6)|
|10 I prefer to get reassurance about my health rather than information||2.9 (2.1)|
|11 If the doctor mainly relies on being open and warm, the doctor will not have a lot of success||1.6 (1.4)|
|12 If I disagree with the doctor, this is a sign that I do not respect and trust the doctor||2.2 (2.0)|
|13 A treatment plan cannot succeed if it is in conflict with my lifestyle or values||4.0 (2.2)|
|14 I want to get in and out of the doctor’s office as quickly as possible||4.7 (2.1)|
|15 The patient must always be aware that the doctor is in charge||1.7 (1.5)|
|16 The doctor does not need to know my culture and background in order to treat my illness||3.3 (2.3)|
|17 The doctor’s friendly manner is an important part of the way that he or she treats me||5.8 (0.8)|
|18 If I look for medical information on my own, this usually confuses more than it helps||1.6 (1.6)|
The 2 sub-scales align with the classification of PCC used by Epstein et al.3 The caring sub-scale corresponds to the first 2 areas described in that model (understanding the patient’s perspective – items 2, 3, 7, 11, 14,17 – and understanding the unique social context – items 6, 13, 16). The sharing sub-scale corresponds to the last 2 areas (reaching a shared understanding – items 5, 8, 10, 18 – and sharing power and responsibility – items 1, 4, 9, 12, 15).
An initial translation of the PPOS was trialled by administering it in the structured interview format to 14 representatives of the target population. The trial revealed that many respondents experienced difficulty with items that required them to make judgements about how other people in general would think, as opposed to how they themselves thought. Therefore, most of the original PPOS items were modified slightly to express concepts in first-person rather than third-person terms (e.g. ‘I want’ and ‘I prefer’ rather than ‘Patients should’).
Of the 18 statements, items 2 and 3 were the ones that required the greatest modification. In the original form of the PPOS, items 2 and 3, respectively, read: ‘Although health care is less personal these days, this is a small price to pay for medical advances’ and ‘The most important part of the standard medical visit is the physical exam.’ The modified versions of these items (Table 2) were found to be more meaningful to Nepalese respondents while preserving the basic meanings of their parent versions. In item 17 the phrase ‘humour’ was replaced by ‘the doctor’s friendly manner’, because humour is used infrequently in Nepalese consultations and this was the closest appropriate substitution. Items in the scale were translated and back-translated by 2 translators until both agreed that an accurate and understandable translation had been produced. The scale was trialled successfully with a further sample of 12 patients.
The PPOS data were analysed by calculating the means and standard deviations (SDs) for individual items as well as for the overall survey scores. One-way analysis of variance (anova) was used to identify any differences in overall and sub-scale scores attributable to age, gender and education characteristics of the sample. The sub-scales were compared using a paired t-test.
A supplementary survey of 69 subjects was undertaken in order to check the validity of the PPOS responses. An alternative survey design was chosen because of the subjects’ unfamiliarity with surveys and Likert scales. In addition, this allowed the insertion of an item concerning health promotion, as described below. In this second survey, patients were presented with a set of 9 paired, opposing statements derived from the PPOS. This was generally done by pairing an existing PPOS statement with a reverse-worded counterpart (Table 3). Subjects were asked to select the item that they agreed with more strongly. The demographic profile of the 69 subjects who undertook the supplementary survey was almost identical with that of the subjects involved in the main survey. The survey was performed after completion of the PPOS survey and subjects were selected in the same manner.
Table 3. The number (%) of subjects choosing the patient-centred statement in each of the items used in the supplementary survey (n = 69)
|A||1||It is more important that the doctor uses the latest tests and medicines than takes a personal interest in me (2)*|| |
|2||It is more important that the doctor takes a personal interest in me than uses the latest tests and medicines||37 (53.6)|
|B||1||It is best if I am always given all the information about my medical condition||65 (94.2)|
|2||It is not important if I do not receive all the information about my medical condition (4)|| |
|C||1||If the doctor does not know my culture and background, he or she cannot treat me successfully||53 (76.8)|
|2||The doctor does not need to know my culture and background in order to treat me successfully (16)|| |
|D||1||I should rely on the doctor’s knowledge and not try to find out about my condition on my own (5)|| |
|2||I should not only rely on the doctor’s knowledge, but also find out about my condition on my own||36 (52.2)|
|E||1||It is very important that the doctor is friendly and respectful towards me||56 (81.2)|
|2||If the doctor is truly good at diagnosis and treatment, the way in which he or she relates to me is not very important (7)|| |
|F||1||The doctor is the one who should decide what gets talked about during a consultation (1)|| |
|2||The patient is the one who should decide what gets talked about during a consultation||19 (27.5)|
|G||1||It is most important that the doctor does a complete physical examination of me (3)|| |
|2||It is most important that the doctor listens to everything that I have to say||36 (52.2)|
|H||1||I want the doctor to teach me how I can stay healthy in the future (N/A)||64 (92.8)|
|2||When I am well I do not want to think about planning for my future health|| |
|I||1||Doctors should treat patients as if they were partners, equal in power and status (9)||34 (49.3)|
|2||The patient must always be aware that the doctor is in charge (15)|| |
A contrasting pair of statements relating to preventative advice (health promotion) was included in the supplementary survey (item H). Although health promotion is not specified in the Epstein model of PCC, most clinical models of patient-centred consultations include this activity.28,29 It is also an activity that many think is not practical to focus on in areas of high patient caseloads. It was therefore desirable to assess the attitudes of Nepalese patients towards receiving preventative advice.
In addition to these 2 surveys, there was regular debriefing of the interviewer and a detailed meeting at the conclusion of the study. Many subjects made spontaneous comments pertinent to the survey items during the interviews. This provided a useful third source of data that helped to clarify several issues.
The PPOS survey
The means and SDs for responses to the statements comprising the PPOS are set out in Table 2. The sample mean derived from the data in Table 2 was 3.34 (SD = 0.52).
Several PPOS items stand out as being scored well above or below the mid-point of the range. Most patients disagreed strongly with statements that supported the following: incomplete information-giving (item 4); rapid consultations (14), and the idea that communication is less important than technical prowess (7). Patients agreed strongly with the idea of being treated as partners (9) and being treated in a friendly manner (17). They were very happy for the doctor to be in charge (15) and did not want to seek information outside the doctor’s advice (18).
The general thrust of these findings was corroborated by comments made by the interviewer. She reported that the most common spontaneous complaint was of being rushed and not listened to. She also stated that subjects volunteered that they were happy for the doctor to take charge and to control the flow of information.
The mean ‘caring’ and ‘sharing’ PPOS sub-scale scores were 3.62 (SD 0.67); and 3.06 (SD 0.63), respectively. These means are significantly different (t = 12.4, P = 0.000). This result indicates that the subjects were less concerned with sharing power and information than they were with their doctors recognising the importance of psychosocial factors.
The analysis of PPOS full- and sub-scale scores in relation to demographic characteristics yielded mixed results. Whereas there was no difference in male and female PPOS mean scores (3.30, SD 0.52; 3.39, SD 0.51, respectively), in the caring sub-scale the female mean score (3.73) was significantly higher than the male (3.52), (F = 7.6, P = 0.0062), indicating a stronger preference for recognition of psycho-social factors.
The figures in Table 4 show that PPOS mean scores did not differ according to age and education. Differences in age- and education-related mean scores for the sharing and caring sub-scales also failed to reach significance, although the sharing mean for the more highly educated group of subjects is clearly higher than the caring mean, with a difference closely approaching significance (F = 2.07, P = 0.0684).
Table 4. Patient−Practitioner Orientation Scale scores according to age and education
|16–25||117||3.34 (0.50)||No school||59||3.37 (0.47)|
|26–35||99||3.36 (0.57)||Years 1–5||44||3.36 (0.46)|
|36–45||53||3.27 (0.47)||Years 6–10||121||3.27 (0.55)|
|46 +||39||3.38 (0.50)||Intermediate||59||3.40 (0.51)|
| || || ||Graduate +||25||3.49 (0.54)|
The supplementary survey
The results of the supplementary survey are displayed in Table 3.
The survey revealed clear preferences in relation to 5 of the 9 sets of paired statements. There was strong agreement with the importance of the following: full information-giving (item B); the need to understand culture and background (C); a friendly, respectful doctor (E); the doctor being in control (F), and preventative health advice (H).
The interviewer feedback generally corroborated these results. The desire for information was very strong (B): people want to know information ‘all of the time, at whatever stage of the disease – if they are dying, if they have cancer’. Subjects made comments on the preventative health item (H), saying that ‘they worry inwardly about their future health – but may not tell the doctor; they are happy when the doctor addresses this’.
The feedback was less supportive of the result for ‘culture and background’ (item C). Whereas the figures in Table 3 indicate strong agreement with the proposition that doctors need to take background attributes into account, the informal feedback indicates that interpreting this finding is not straightforward. The subjects gave the concept of ‘background’ a variety of meanings ranging from financial status to past medical history. It is not clear, therefore, just what aspects of background the patients wanted doctors to take into account. There was an indication in the informal feedback that subjects did not expect that doctors would ask questions about psychosocial aspects of their lives. Several subjects stated, however, that the doctor needed to know their backgrounds so that they would be given access to free care.
Other items in the survey produced mixed results. Subjects were divided over the relative importance of the doctor using the latest technology and taking a personal interest in them (item A). Item G, which asked subjects to compare the importance of a physical examination and the doctor’s listening skills, produced a similarly mixed result. Subjects were also divided on the issue of seeking information on their own (item D). However, the interviewer reported that subjects understood ‘information-seeking’ as finding out more details about their illness to tell the doctor, not to gain information for their own purposes. Therefore, this result may overstate the subjects’ desire to seek information outside the consultation.
The divided response to the item about partnership and doctors’ control (item I) seems to contradict item F, which clearly placed the doctor in charge. The feedback indicated that the idea of being ‘partners, equal in power and status’ was often interpreted in terms of not being discriminated against on the basis of low social status. Therefore, item F could be taken as the more accurate reflection of the subjects’ preference for the doctor to control the consultation. It also emerged that the patient’s ‘party’ (relatives and friends) was an important third actor in discussions about control and decision making. Neither survey in this study recognised the existence of such a group. This deficiency was reported to have contributed to the varied responses to items I and F and PPOS item 1.
Priorities for medical communication
The primary aim of this study was to examine the type of communication that Nepalese patients expect from their doctors. The PPOS results are supported by the supplementary survey and interviewer feedback in showing a strong expectation in 3 main areas: being given full information about their condition; being treated in a friendly, respectful manner, and being given adequate time for consultation. There was very strong support in the PPOS responses for partnership with the doctor. The informal feedback suggests that partnership was thought of in terms of a respectful social relationship between the patient and doctor. This idea of partnership probably does not involve equal status in making medical decisions. Subjects were happy for the doctor to control the consultation and be the main source of information. These findings were as true for older, illiterate patients as for younger, educated patients. Patients were not primarily concerned with changing the existing hierarchical power structures in medical consultations.
On the single item about preventative health, the supplementary survey also suggested a strong interest in preventative health education. Although this finding is based on only one survey item, it is not altogether surprising. Parents support childhood immunisation programmes in Nepal. In addition, a broad range of preventative strategies are undertaken within the cultural and religious spheres of Nepalese life. People still see Western medicine as a curative activity and therefore do not generally seek preventative advice from doctors. This study suggests that patients may welcome a change in this situation.
One of the assumptions underlying the study was that data obtained in Western studies on communication cannot be assumed to hold across cultures. This assumption is supported by the study results. Nepalese and Western subjects share expectations of receiving good information, respect and adequate time. However, the Nepalese results were significantly more doctor-centred than those obtained in North America.21,25 The studies carried out in the USA show significant variation, in overall and sub-scale scores, across age, gender and education groups. Subjects who are more aware of the issues of patient-centredness have tended to be younger, female and better educated. The Nepalese results are very different by the limited variation in responses across gender and education groups, with no significant changes across age. The US studies show little difference in scores between the caring and sharing sub-scales. Again, this is quite different to the Nepalese results, in which the caring sub-scale result was significantly more patient-centred than that of the sharing sub-scale. This supports the conclusion that Nepalese subjects are less concerned with changing the existing power structure in consultations. This is further supported by a comparison with a Canadian study, in which only half as many subjects agreed with the statement ‘I prefer to rely on my doctor’s knowledge and not try to find out about my condition on my own’.22
Models of PCC in Nepal
The second aim of the study was to assess the appropriateness of an existing model of PCC to the Nepalese context. The model proposed by Epstein et al.3 is typical in that it encourages the doctor to promote PCC in 4 areas (the patient’s perspective, social context, shared understanding, and sharing power). The differences identified between Western and Nepalese results suggest the need to closely examine the validity of this model.
In particular, the fourth area of the model – helping patients to share power and responsibility through involvement in making choices – was not rated as very important by the patients in this study. There have always been subjects in Western studies who do not desire active involvement in decision making, but the findings reported here suggest that this is a prevailing attitude in Nepal. This may reflect the hierarchical nature of Nepalese society and culture.
The second area of the model – understanding the patient within his or her unique social context – was also not rated as very important by the subjects. The results and interviewer feedback suggested that subjects had diverse interpretations of the concept of ‘culture and background’ and that it was often only seen as important in determining access to free care. Subjects did not expect to talk about their work, home life or inner feelings in discussions about their health. This contrasts with findings in a sample of British patients, who expected their doctors to be receptive towards such discussion and saw such receptivity as a fundamental part of a good doctor’s approach.7 Future studies may obtain more useful results if data were gathered about specific elements of culture and background, such as financial status, beliefs about health and illness, and family structure.
The attitudes and behaviours that are measured in PCC research must reflect individual communication preferences if they are to be accurately called ‘patient-centred’. Clinicians often acknowledge this by describing the tasks to be undertaken in a patient-centred consultation, rather than assuming specific outcomes. Stewart et al. describe one dimension of PCC as ‘enhancing the doctor–patient relationship (including power-sharing and the therapeutic alliance)’.28 This allows for the fact that the doctor will seek to share power and decision making where appropriate, but that this is not an assumed goal of communication. They argue that the best judges of PCC are patients themselves.30 Several writers advocate a flexible approach to communication: ‘Patient-centred medicine means that the doctor … has the skills to handle the different types of consultations that result from that position.’31
Teaching PCC in Nepal
This study has examined the preferences of Nepalese patients through the prism of a model of PCC that has been developed in the West. It has shown that there are important commonalities across cultures, such as preferences for good provision of information and respectful relationships. It has also shown striking variations that reflect cultural differences. An obvious implication of this is that effective doctor−patient communication requires an approach that is flexible and sensitive to cultural differences and expectations. What may be a characteristic of patient-centred practice in one cultural setting, the sharing of power, for example, may not be appropriate in another. There are contexts where it is not the duty of a patient-centred doctor to force patients into a power-sharing role that they don’t yet want to adopt. This holds true not only in non-Western environments but in Western health care as well.
In those Nepalese medical schools that teach communication skills a patient-centred style is generally promoted. However, as previously noted, most medical practice is carried out along biomedical, doctor-centred lines. This study can assist Nepalese medical educators in determining the elements of PCC that are most important in their setting. The data suggest that the provision of good information, suitable for a low-literacy setting, is a high priority for patients in Nepal. This implication extends beyond the simple development of materials to the staffing and design of medical facilities. The strengthening of nurses in their educational role may be an appropriate strategy. The data are also a reminder to medical educators and clinicians of the value that patients place on simple elements of communication, such as respect and taking time. This is true even in a setting where doctors and patients generally agree on the biophysical nature of disease.
There are potential limitations to this study that follow from the use of a translated instrument, notably involving the difficulty of accurately rendering concepts such as culture and background. Translation may also have affected the comparisons with published Western data. The study population consisted of a mixture of hill and plains people, from rural and town settings, attending a hospital outpatient department. The results may differ in the more urbanised population of the Kathmandu valley and in private clinics. However, the lack of variation in these results across education groups suggests a large difference is unlikely.
Acknowledgements: the author offers sincere thanks to Professor Owen Lewis and the Department of Family Medicine BP Koirala Institute of Health Sciences, Dharan, Kathmandu, for invaluable assistance in the conduct of this study, Dr Mohammed Ali, Curtin University, Western Australia, for advice on study development, and Dr Ed Krupat, for generously sharing the Patient−Practitioner Orientation Scale.
Conflicts of interest: none.
Ethical approval: this study was approved by Curtin University of Technology, Perth, Western Australia.
What is already known on this subject
Western patients generally prefer that doctors use all the elements of a ‘patient-centred’ communication (PCC) style.
What this study adds
Western findings on PCC cannot be assumed to hold across cultures. Nepalese patients do not place equal value on all elements of PCC. Doctors should be trained to have the flexibility to manage these differing expectations.
Suggestions for further research
Future research might continue to explore Nepalese communication preferences and investigate patient preferences in other developing countries.