Physician behaviours that optimize patient‐centred care: Focus groups with migrant women

Abstract Background No prior research studied how to implement patient‐centred care (PCC) for migrant women, who face inequities in health‐care quality. This study explored migrant women's views about what constitutes PCC and how to achieve it. Design We conducted a qualitative study involving three focus groups with migrant women living in Toronto, Canada, recruited from English language classes at a community settlement agency, used constant comparative technique to inductively analyse transcripts and interpreted themes against a published PCC framework. Participants Twenty‐three migrant women aged 25‐78 from 10 countries participated. Results Women articulated 28 physician behaviours important to them across six PCC domains: foster a healing relationship, exchange information, address concerns, manage uncertainty, share decisions and enable self‐care. They emphasized the PCC domain of exchanging information, which included 13 (46.4%) of 28 behaviours: listen to reason for visit, ask questions, provided detailed explanations, communicate clearly, ensure privacy and provide additional information. Women said that instead of practising these behaviours, physicians rushed through discussions, and ignored or dismissed their concerns and questions. As a result, women said that physicians may not fully understand their problem, and they may refrain from stating important details or avoid seeking care. Conclusions This research characterized the lack of PCC experienced by migrant women and revealed specific physician behaviours to optimize PCC for migrant women. Research is needed to develop and evaluate the impact of strategies targeted at migrant women, physicians and health‐care systems to support PCC for migrant women.

The World Health Organization, in collaboration with the United Nations and the International Organization for Migration, generated the Global Action Plan, a framework of priorities to promote the health of migrants. 1 The Plan emphasizes the need to improve the quality, acceptability, availability and accessibility of health-care services for all migrants, and in particular, advocates for improving the health and well-being of women given considerable evidence of persistent gendered inequities in health-care quality in both developed and developing countries. Patient-centred care (PCC) is one approach to reduce gendered inequities in health-care quality that was emphasized in 1995 by Women of the United Nations, in 2009 by the World Health Organization, and in 2018 by the United Nations report Gender Equality in the 2030 Agenda for Sustainable Development. [6][7][8] PCC is a multidimensional approach to care that is proven to enhance a range of patient-important and clinical outcomes. 9 PCC refers to partnership with patients and care partners to tailor care to clinical needs, life circumstances and personal preferences, and equip them with skills, knowledge, and awareness of services to optimize self-care and quality of life. 9 The intent is that applying actions across the multiple dimensions of PCC optimizes the care experience and tailors care by taking into account the unique characteristics and skills of individuals. Thus, PCC could improve migrant health-care experiences, particular for women who face inequitable quality of care.
A scoping review (83 studies, 1990-2015) of interventions used to improve the health of migrants revealed that most were prevention strategies for diabetes and cardiovascular disease. 10 A systematic meta-review (28 reviews, 2011-2017) identified informational and educational interventions for patients or clinicians that can support PCC. 11 However, neither review defined PCC or employed a PCC model by which to describe or assess PCC, or identified interventions that support PCC for women. A clinical guideline on preventive health care for migrants addressed women's health by noting the need to provide culturally sensitive, patient-centred counselling for contraception, human papillomavirus vaccination and screening of cervical abnormalities. 12 However, the guideline, based on research published from 1996 to 2010, is not current; lacks specific behaviours for delivering PCC to migrant women; and narrowly focuses on reproductive health, when women's health has evolved to include health issues across the lifespan. 13 There is limited guidance on how to deliver PCC for migrants.
Another scoping review to identify determinants of PCC specifically for migrant women revealed a paucity of research on this topic (16 studies, 2010-2019

| Approach
Given few prior studies on PCC for migrant women, we used a basic qualitative descriptive research design to thoroughly explore women's PCC views and recommendations. 15 This approach does not employ or generate theory; instead, it elicits insight from participants about health services and how services can be improved based on their lived experience. We conducted in-person focus groups rather than individual interviews because group discussion encourages synergistic conversation about novel or complex issues. 16

| Sampling and recruitment
We used convenience sampling to recruit migrant women aged 18 + from a community settlement agency that assists newcomers to <city name>, <country's> largest city, which features a diverse multicultural population. The agency serves 20 000 immigrants and refugees annually by offering programs that support family development, healthy lifestyles and employment skill-building. Eligible women were participants of scheduled women's only English Conversation Circles, an informal, drop-in group setting to practise English conversation skills held twice weekly. The agency coordinator suggested two dates when we could attend Circles and informed each of the two groups in advance about the study. On agreed upon dates, the agency coordinator introduced C (MSc, female, research associate with qualitative experience) and B (BSc, female, research coordinator) to participants at the end of the Circle session, then C and B briefly described the purpose of the study, and invited interested women to remain in the classroom for the focus group, all of whom did. C or B read an informed consent statement, and participants gave verbal consent. We planned to conduct two focus groups with a minimum total of 20 women, a common recruitment target for focus groups, who varied by age, education and country of origin. 17 We gave women a $50 grocery chain gift card upon conclusion of the focus group. We had no prior relationship with the agency coordinator or participating women.

| Data collection
We developed questions based on a comprehensive PCC framework that was rigorously developed by McCormack et al. 9 with patients and clinicians, and then tailored based on interviews about PCC with diverse women who were largely Caucasian. [18][19][20] The Framework of PCC for Women is organized in six domains (foster a healing relationship, exchange information, address concerns, manage uncertainty, share decisions and enable self-care) and identifies strategies that clinicians can use to achieve each domain (File S1). We used a semi- Prior to focus groups, A (PhD, female, senior scientist/professor with many years of qualitative research experience) met with C and B to review the question guide, and discuss approaches for asking questions and probing for additional information. We held three 1-hour focus groups. C and B each led a separate focus group on 21 July 2019 because the drop-in group that day was too large for a single focus group. After the first two simultaneous focus groups, A met with C and B to review how thoroughly each question was addressed and suggest additional probes. C and B jointly led a third focus group on 31 July 2019. Focus groups were audio-recorded and transcribed verbatim by a professional transcriptionist.

| Data analysis
C, B and A derived themes inductively from the data using constant comparison in iterative fashion, 21 and used Excel to organize data.
All three independently analysed one transcript to identify and code all themes, then compared and discussed themes to create a codebook of themes and exemplar quotes (level one coding). C and B independently analysing the remaining two transcripts, compared and discussed coding, then expanded or merged themes to refine the codebook (level two coding). No new themes emerged, suggesting that thematic redundancy was achieved. ARG reviewed all transcripts and the codebook to resolve flagged differences or uncertainties. We mapped themes from inductive constant comparison to PCC domains, and tabulated quotes by PCC domain and theme, described themes with exemplar quotes and noted women's experiences of each domain. We transformed positive and less positive PCC experiences reflecting behaviours of importance to women into approaches that physicians can employ to optimize PCC for migrant women.

| Participants
In total, 23 women participated in three focus groups (Table 1)

| PCC experiences and recommendations by domain
File S3 includes data by PCC domain and theme. We describe themes (in italics) here by PCC domain with select quotes. Table 2 summarizes 28 themes, referring to approaches of importance to migrant women that physicians can adopt to optimize PCC across six domains.  Given English as a second language, many women underscored that physicians should communicate clearly by using plain language rather than medical jargon, and by speaking slowly to facilitate comprehension, although not all physicians did so.

| Exchange information
I asked him to talk slowly with me but he was very busy and he didn't accept and continued his manner (group 2) A few women said that it was ideal when physicians communicated in their first language, but if that was not possible, they wanted physicians to ensure privacy and hence expressed reluctance to using a third party interpreter. Privacy concerns also meant that physicians should moderate speaking volume to prevent those in adjacent rooms from overhearing discussions.
We have the language barrier and they can bring an interpreter to help out. The privacy, maybe some woman they don't want to let the third party to know as a woman we have problem (group 3) And then when the doctor says something and the next room the patient can hear and this is not good, not professional and I will expect the doctor will have the privacy and don't speak loud or have the room is more privacy Approaches for ensuring privacy recommended by women included using a private room or space for discussions or examinations, and preventing exposure to others during physical examinations.
He should respect when he exam the woman and he should take the privacy of them, they shouldn't be exposed to the other people…some nurses or some receptionist (group 3) Another approach to privacy was offering access to women physicians or involving women nurses in discussing the reason for the visit before seeing the physician. Notably, women uniformly referred to he/ him when speaking of physicians, suggesting they may have little to no interaction with women physicians.
Some people maybe don't like to go for a man doctor (group 2) Maybe they have some special nurses for the woman to take a history before they meet the family doc-

| Address concerns
Women said that physicians did not typically probe for concerns, referring to feelings or reactions about their health issue or its treatment.

| Manage uncertainty
Women uniformly said that physicians described testing or treatment options, but did not take the time to discuss benefits and risks of tests, treatment or other management options as a way of addressing concerns or preparing women to be involved in decision making.
Usually they don't have enough time, maybe few minutes, it's finished. For me, it's happened a lot (group 2)

| Share decisions
Some women said that physicians did provide information to support shared decisions, whereas other women did not routinely receive such information. One woman thought it may be ill-advised to involve patients in decisions.
When I got some problem and then he suggests some

| Enable self-care
Most women agreed that physicians provided instructions for tests or treatment, and for next steps such as follow-up appointments.
She explain me exactly what medicine I have to take and which hour. And she ask me come next week (group 1) A few women said that physicians should offer brief counselling when they attend appointments for specific health-care issues to ensure that women adopted healthy lifestyle behaviours to prevent illness and anticipated recommended screening.
We go to physician for some specific problems, but for overall general health there should be some information provided to the woman in advance. So not specific to disease but overall general health as a woman, they should advise us (group 2)

| Key themes and implications
Here we report overarching themes and the impact of those themes

| Summary of findings
Through three focus groups with 23 migrant women who varied by age and country of origin, we identified 28 approaches across six PCC domains that physicians can adopt to optimize health-care experiences for migrant women. The approaches represent behaviours that women considered important, but most women said their physicians did not employ those approaches. In particular, women emphasized the PCC domain of exchanging information, which comprised the majority of themes. However, we probed for preferences across all PCC domains, and approaches women valued across those domains pertained to physicians allocating sufficient time to discussion. Instead, women said physicians were rushed, and ignored or dismissed their questions and concerns. As a result, women said it was likely that physicians would not understand their health issue, and they would refrain from articulating health issues or details, or even avoid seeking care.

| Comparison to other research, and implications for practice and research
These findings confirm and build upon prior research. Previous studies showed that migrants are less likely than the general population to experience high-quality care, 2,3 in part due to language barriers among migrants, and lack of knowledge and skill among physicians about how to communicate with migrants. 4,5 Previous studies also showed that women in general, including migrant women, face gendered inequities in health-care quality. 1,[6][7][8] However, no earlier research provided insight on strategies to specifically optimize PCC for migrant women. 10 Migrant women in this study said they would feel more comfortable speaking with and being examined by a woman physician.
Most referred to physicians as he or him, suggesting they largely had experience with men physicians. Previous research also found that immigrant women favour a woman physician. 27 A 2015 report noted that women comprised 55% of family medicine trainees in the United States, 26 but women are underrepresented in rural areas and other specialties. 28,29 The issue is controversial due to concerns about shortfalls in medical human resources. A systematic review of 34 studies published from 1991 to 2013 found that women primary care physicians self-reported fewer hours of work, patient encounters, and services delivered compared with men physicians, but longer visit time and discussion of multiple problems with individual patients, qualities desired by migrant women in this study. 30,31 Future research is needed to ascertain how to support and retain women physicians and how to enhance access to women physicians for migrant women.

| Study strengths and limitations
The study features multiple strengths. We employed rigorous research methods and complied with qualitative research reporting criteria. [15][16][17] We included migrant women of diverse age and country of origin who expressed strong agreement, which supports broad relevance of the findings. We mapped findings to a PCC framework as a means of thoroughly exploring elements of the health-care experience important to migrant women. 9,[18][19][20] In so doing, we further validated the Framework of PCC for Women and revealed key elements of PCC desired by migrant women. As a practical output, we generated 28 approaches that physicians can adopt to optimize PCC for migrant women. Some limitations must also be mentioned. Participants were volunteers, and thus possibly motivated by a particular interest in PCC or a desire to share poor health-care experiences. In our attempt to explain PCC, we may have failed to convey its full meaning, leading women to focus on the exchanging information domain. However, we did prompt migrant women to discuss each of the PCC domains, and these findings confirm and elaborate on prior similar research that involved largely Caucasian women, underscoring the importance of two-way communication. 18 Participating migrant women were highly educated, so their views and experiences may not reflect those of migrant women with less education. The women all lived in <city, country>, so findings may not be transferrable to migrant women elsewhere in <country>, or in other countries with different health-care systems. While PCC may also be a relevant issue for migrant men, this study specifically focused on the aspects of PCC that migrant women value.

| CON CLUS IONS
Twenty-three migrant women aged 25-78 from 10 origin countries who participated in three focus groups identified 28 approaches across six domains that they viewed as essential elements of PCC, but largely did not experience in interactions with physicians.
Instead, they said physicians rushed through discussions, and ignored or dismissed their concerns and questions. In particular, women emphasized the domain of exchanging information, which included 13 (46.4%) of 28 total approaches across the following six themes representing physician behaviour: listen to reason for visit, ask questions, provided detailed explanations, communicate clearly, ensure privacy and provide additional information. Women identified potential adverse consequences as a result of poor PCC: physicians may not fully understand their health issue, and they may refrain from articulating important details or even avoid seeking care. By revealing specific physician behaviours to optimize PCC for migrant women, this research addresses a void in prior research.
Future research is needed to develop and evaluate the impact of women, physician and system-level strategies to support PCC for migrant women.

ACK N OWLED G EM ENTS
None.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data are available in article Supplementary material.