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The effect of health care provider persuasive strategy on patient compliance and satisfaction.

Abstract: This study hypothesized that both female and male health providers would elicit the greatest patient/consumer satisfaction when using "pro-social" compliance gaining strategies. Female providers were expected to be less likely than male providers to gain patient compliance and satisfaction when using verbal strategies that appear more negative, or anti-social. The participants consisted of 180 undergraduate students at a large western university. Results indicated that a combination of positive regard followed by negative regard after noncompliance elicited the greatest patient satisfaction for both male and female providers. These results suggest that gender stereotypes are not as prevalent in provider-patient communication as they may be in other communication contexts due the to relative power and status relationships between a provider and patient. In addition, patients may prefer a negative reaction from the provider after admitting to noncompliance because it confirms their expectations and may be perceived as provider concern for the patient.

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Although health communication covers a wide range of topics, a central focus of the literature is provider-patient communication, specifically, issues involving patient compliance and patient satisfaction. Patient compliance is defined as "the extent to which patients follow clinical prescriptions" (Burgoon, Bark, & Hall, 1991, p. 178) and includes all types of behavior and behavior modifications recommended by a doctor for the purpose of helping, curing or preventing various medical problems. Patient satisfaction is less easily defined, as it is highly dependent upon what the patient considers satisfying.

Understanding the behaviors that lead to both patient compliance and patient satisfaction could be the key to experiencing medical encounters with more positive outcomes for both the patient and the provider. Clearly most health care providers hope that their patients comply with the treatment prescribed. Equally, patients desire to be treated in a way that leaves them satisfied with the experience. However, investigations regarding the provider-patient relationship over the past 50 years have resulted in little consensus, establishing the need for more research in this area.

Recent estimates indicate that anywhere from 46% to 62% of patients fail to comply with drug regimens (Burgoon et al., 1991). Specifically, compliance rates for such ailments as diabetes, hypertension and asthma range from only 30-50% (O'Brien & McLellan, 1996). Such drastic numbers lead to the conclusion that "noncompliance is the most significant problem facing medicine today" (Eraker, Kirscht, & Becker, 1984, p. 259).

Most current researchers agree that provider communication has the potential to significantly increase patient compliance. In a study on compliance with mammogram referrals, Fox, Siu and Stein (1994) found that compared to other variables such as age, race and medical history, "Only the communication variables significantly predicted a recent mammogram" (p. 2,058) to such an extent that "Women whose physicians discussed mammography with some or a great deal of enthusiasm were over four and a half times more likely to report having had a mammogram in the previous year than women whose physicians had little or no enthusiasm" (p. 2,063).

The extent of a providers responsibility for patient compliance is an area of heated debate in health communication literature, and has resulted in various perspectives ranging from paternalistic to deliberative. Regardless of the perspectives implemented in their practices, doctors as a group are clearly an important force behind the health status of the country in which they practice. Whether their motives are money, prestige, or benevolence, it is largely the work of providers that leads to the control and prevention of disease. Patient noncompliance can be seen, to some extent, as counterproductive to medical progress. As suggested by Ley (1988) and Farberow (1986), "In economic terms, the expense of noncompliance is staggering ... in human terms, the expense is tragic."

Aimed at highlighting those behaviors that constitute a successful medical encounter, this study is guided by the premise that compliance-gaining and patient satisfaction should be accorded the same stature as goals in provider-patient interactions. Based on the reinforcement expectancy approach, independent strategies that are likely to increase patient compliance and those that are likely to increase satisfaction will be examined, with the view that both satisfaction and compliance are necessary ingredients for a successful, ethical, and mutually beneficial medical encounter.

PATIENT COMPLIANCE

Research addressing patient compliance originally focused on patient-centered explanations for noncompliance such as patients' age, sex, intelligence and severity of illness. More recently, researchers have concluded that there is no single patient attribute that determines or predicts patient compliance (Hanson, 1986; Burgoon & Burgoon, 1990; Burgoon et al., 1991; Fox et al., 1994). A recent re-conceptualization of noncompliance has thus shifted the research focus to the behaviors of health care providers as one of the main predictors of patient behavior (Burgoon et al., 1991; Klingle & Burgoon, 1995; Klingle, 1996).

EXPECTANCY VIOLATION THEORY

Two variables that have received little attention in the literature, but have the potential to significantly affect compliance, are the patient's expectations for and perceptions of the providers communication behavior. A complete comprehension and utilization of effective strategies for increasing patient compliance must consider not only provider communication behavior, but also the expectations and perceptual processes occurring within the mind of the patient. Taylor and Crocker (1981) note, "Communication expectancies function as perceptual filters that influence whether receivers accept or reject a communicator's message." Acknowledging the crucial role of patient expectations in compliance leads to a better understanding of the lack of consensus within the literature on provider-patient compliance gaining. The expectancy violation theory (EVT) (Burgoon & Hale, 1988) explains patient compliance in terms of whether or not the providers communication behavior adheres to the expectations of the patient, thus integrating the patient back into the formula for compliance. The theory proposes that "Language is a rule-governed system ... and people develop expectations and preferences concerning the language or message strategies employed by others in persuasive strategies" (Burgoon et al., 1991, p. 191). More specifically, EVT asserts that adherence to patient expectations is requisite for compliance to occur unless the violation is positive. Expectancy violation theory can be used as a theoretical foundation for discussing many of the variables that affect each persuasive situation.

According to EVT, patient expectations for gender-appropriate communication behavior can have significant effects on patient compliance (Burgoon & Burgoon, 1990; Conlee, Olvera & Vagim, 1993; Klingle & Burgoon, 1995). In the past, research indicated that females were most often expected to use instrumentally unaggressive strategies (Burgoon, Dillard & Doran, 1983); deviating from such strategies resulted in a negative expectancy violation, and thus less chance of compliance. Males were expected to use strategies that were either verbally aggressive or neutral (Burgoon et al., 1983), although when they used either more affiliative or more verbally aggressive tactics, a positive violation occurred and compliance increased. More recently, Klingle and Burgoon (1995) found that in the medical context, negative regard strategies used by male providers were perceived by a third party as more appropriate than when the same strategies were used by a female provider. Specifically, "Physician gender interacted with strategy effectiveness such that male physicians were persuasive if they used either positive or negative regard strategies, whereas females were limited to using positive regard strategies" (p.148). Therefore, the first and second hypotheses of this study are the following:
 H1: Male providers' use of positive regard followed
 by negative regard will be perceived by
 observers as eliciting significantly greater patient
 compliance compared to female providers' use of
 the same strategies.

 H2: Male providers' use of neutral regard followed
 by negative regard will be perceived by observers
 as eliciting greater patient compliance compared
 to female providers' use of the same strategies.


REINFORCEMENT EXPECTANCY THEORY

Counterintuitively, research indicates that a friendly bedside manner does not always result in a happy or satisfied patient. Hall, Roter, and Rand (1981) report that, "When the physician sounds more negative--more angry, more anxious, and less as though the patient would return--the patients are more content" (p. 18). Their explanation for these results is that patients perceive a negative tone as "probably reflecting perceived seriousness and concern on the part of the physician" (p. 18). Research also indicates that providers who engage in a consistently friendly approach do not always gain patient compliance. A continual use of positive regard without changing regard type in response to patient compliance shows disinterest and little concern on the part of the provider, resulting in patients developing "nonmotivating reinforcement expectations because they come to believe that their behavior does not influence the physician's behavior" (Klingle & Burgoon, 1995, p. 154). Consequently, an overuse of affiliative behavior can reduce a provider's ability for reward value, and thus decrease the patient's motivation to comply. This concept can best be explained by reinforcement expectancy theory, which states, "Motivation to comply is based on a perceptual process in which the patient perceives the potential for receiving a certain type of communication message if he or she responds in an appropriate manner" (Klingle, 1996, p. 209).

Integral to the use of the reinforcement expectancy approach is the providers communication of one of three types of regard strategies. Positive regard signals approval of others and their actions, negative regard signals disapproval of others and their actions, and neutral regard refers to simple directives for action. After assessing whether or not the provider communicates appropriately and whether or not he or she has high reward value, the patient perceives the provider's communication style as positive, negative or neutral. If the patient perceives positive regard on the first visit, and then receives neutral or negative regard as a result of noncompliance, he or she will most likely change his or her behavior in order to re-establish the reward of positive regard, and reduce the punishment of negative regard. Finally, if the patient receives neutral regard on the first visit, and negative regard on the second visit after noncompliance, he or she will most likely change his or her behavior to reduce the "punishment" and gain back neutral regard from the provider. The most effective use of the reinforcement expectancy approach appears to differ for males and females. Males are likely to be persuasive when using first positive then neutral regard after noncompliance, first positive then negative regard after noncompliance, or first neutral then negative regard after noncompliance. Females, however are most likely to be persuasive with the use of positive then neutral regard after noncompliance (Klingle & Burgoon, 1995). These findings can be attributed to the societal expectations discussed earlier. However, this approach is lacking in that it does not include any information on when and how often a provider must use the reinforcement strategies to obtain effective results. The above assumptions indicate that providers should therefore consider prior communication attempts when devising strategies by which to gain patient compliance. Consequently, the first research question proposed for this investigation is: Which strategy combination results in observers' perceptions of the greatest likelihood of patient compliance?

PATIENT SATISFACTION

There is a clear distinction between satisfaction and compliance by virtue of the fact that one is an internal mental and/or affective state and the other an overt behavior. Some studies report that satisfaction and compliance are positively correlated (Hall et al., 1981; Hanson, 1986; Conlee et al., 1993), while other studies have found the two to be only moderately related (Burgoon, Pfau, Parrott, Bark, Coker & Burgoon, 1987; Burgoon & Burgoon, 1990). A popular argument is that the feeling of satisfaction leads to compliant behavior, although this argument is weakly supported. A different perspective is offered by Klingle and Burgoon (1995), who suggest that the relationship is indirectly causal, such that "Adequate satisfaction with the interaction and favorable provider evaluations determine the reward value of the communicator, which influences the effectiveness of suasory attempts" (p.152). Hence, dissatisfaction could affect the providers ability to persuade the patient because it creates a lack of provider reward value, which is a mandatory feature for compliance to occur. Unfortunately, provider reward value is difficult to assess because it is highly dependent on the idiosyncratic personality traits of the patient. One patient may consider a provider to have extremely high relative status and power while another may not. Some variables that may affect these different perceptions are past medical experiences, religious beliefs and the influence of others' opinions. Such patient differences may help to explain why research results regarding patient satisfaction are often inconsistent. Thus, a second research question that will be investigated in this study is the following: Which strategy combination results in observers' perceptions of the greatest likelihood of patient satisfaction?

Research consistently indicates that patient satisfaction is somehow related to provider communicator style, especially affect and immediacy behaviors (Buller & Street, 1991). A review of the literature indicates that behaviors which communicate positive regard, or pro-social behaviors, such as openness, interest, willingness to listen, involvement, warmth, similarity and equality (Ben-Sira, 1980; Hall et al., 1981; Leventhal, Zimmerman & Guttman, 1984; Burgoon et al., 1987), result in greater levels of patient satisfaction than those which are negative, or anti-social. These strategies should, of course, be used in accordance with the limits outlined by the reinforcement expectancy approach, so as not to reduce compliance through affiliative satiation. When used in conjunction with the compliance-gaining strategies previously discussed, these behaviors should add increased overall satisfaction to patient compliance. Therefore, the final hypothesis is the following:
 H3: Both male and female providers using positive
 regard followed by neutral regard will be perceived
 by observers as eliciting significantly greater
 patient satisfaction than when using any other
 combination of regard strategies.


METHODS

PARTICIPANTS

The sample for the present study consisted of 180 undergraduate students from a large western university who were enrolled in a beginning speech communication course. This allowed for 30 participants per condition. Participants were pair matched for gender. Participant age ranged from 18-24 years old, with a mean age of 18.47. Eight percent of the respondents were African-American or Black, 30% were Asian-American or Asian, 29% were European-American or White, 28% were Latin-American or Hispanic, and nine percent were other non-specified ethnicities.

PROCEDURES

Each participant was given a packet containing the Bem Sex Role Inventory (1974) (to control for extreme gender beliefs), a script of a hypothetical medical dialogue, and a questionnaire that measured the dependent variables. Participants were told that the transcript was an actual dialogue of a medical encounter between a provider and a patient. They were also told that when reading the transcript they should imagine themselves as the patient. A transcript was used instead of a video to eliminate confounding variables such as nonverbal behavior and attractiveness. The average time it took for participants to complete their participation was 20 minutes. A pilot study was conducted to determine the comprehensiveness of the questionnaire and to examine preliminary data. No changes were made to the survey as a result of the pilot study; therefore this data was included in the final results.

OPERATIONALIZATION OF REGARD TYPES

Three types of regard strategies were manipulated in this study: positive, negative, and neutral, used in three different combinations by both male and female providers (see Table 1).

VALIDATION OF STRATEGY TYPES

Regard types were adapted from scripts developed by Klingle and Burgoon (1995). The positive regard strategies were characterized by the use of supportive requests (e.g., "After the tests you'll already feel so much better about yourself because you'll know you're doing what it takes to feel better and prevent problems in the future"), validation requests (e.g., "A lot of patients have difficulty making these changes, but with your determination I know you can do it"), and goal commonality requests (e.g., "I really like you and would like to see you feeling better"). Negative regard was depicted through the use of disapproval in the form of nonsupportive requests (e.g., "You really have two choices: change your diet, or spend the rest of your life wishing you had"), invalidation requests (e.g., "A responsible person would know that now is the time to take charge and make all the changes necessary"), and negative consequence requests (e.g., "If you don't make these changes immediately you could end up with a very serious situation and wish you had taken the time out of your schedule while there was still hope"). Finally, neutral strategies were characterized by justifications for action and simple directives (e.g., "I want you to have a number of tests done") and did not validate or invalidate the patient.

These regard types were consistent with those outlined by Klingle and Burgoon (1995) as indicative of positive, negative or neutral regard, and underwent manipulation checks in their study to ensure differences in respondents' perceptions of regard. Specifically, 25 students evaluated each script, and results indicated a significant main effect for type of regard strategy (p<.001), such that the positive regard strategies were the most positively valenced (M=5.02), followed by the neutral (M=4.48) then negative regard strategies (M=3.61). Klingle and Burgoon (1995) also reported a significant linear effect for approval, with the positive strategies showing the most approval, followed by the neutral strategies, and finally the negative strategies showing the least approval.

DEPENDENT MEASURES

A questionnaire was used to measure participants' likelihood of compliance and satisfaction. The questionnaire included eighteen questions asking the respondents to imagine themselves in the role of the patient and then rate their satisfaction with the medical encounter and the likelihood that they would comply with the prescribed treatment.

To measure the patient's perceived satisfaction with communication, participants responded to eight 7-point items used by Klingle and Burgoon (1995), derived from Smith, Falvo, McKillip and Pitz's (1984) Patient-Doctor Interaction Scale, Hecht's (1978) Interpersonal Satisfaction Measure, and Wolf, Putnam, James and Stiles's (1978) Medical Interview Satisfaction Scale. The respondents' mean rating of all the items related to satisfaction served as the measure for patient satisfaction. In the present study the reliability for the portion of the survey measuring patient satisfaction was [alpha] = .80.

Perceived likelihood of patient compliance was assessed by having the participant respond to a ten item 7-point Likert-type scale. The respondents' mean ratings of all the items related to compliance served as a measure for patient compliance. In the present study the reliability for the portion of the survey measuring patient compliance was [alpha] = .92.

RESULTS

The results of this study were analyzed through a 3 (regard strategy combination) x 2 (sex of the provider) multivariate analysis to determine whether or not observers' perceptions of patient satisfaction and patient compliance depended on the combination of strategy type and sex of the provider. The follow-up analysis included ANOVAs that used the LSD (least significant difference) test for the purpose of determining which strategy combination and which sex of the provider resulted in observers' perceptions of the greatest patient satisfaction and greatest patient compliance.

HYPOTHESES

Contrary to expectations, t-tests showed that the first hypothesis was not supported; there was no difference in observers' perceptions of the likelihood of patient compliance based on the sex of the provider when using positive strategies on the first visit followed by negative strategies on the second visit (conditions 1 and 4). Hypothesis two was not supported, based on the results of the same t-test. The results for this prediction were statistically nonsignificant. Hence, there were no differences in observers' perceptions of the likelihood of Patient compliance based on the sex of the provider when using neutral strategies on the first visit followed by negative strategies on the second visit (conditions 2 and 5).

A post-hoc LSD test revealed that the third hypothesis was not supported. Thus, neither male nor female providers' use of positive regard followed by neutral regard was perceived by observers as eliciting significantly greater patient satisfaction than when using any other combination of regard strategies.

RESEARCH QUESTIONS

The first research question asked which strategy combination results in observers' perceptions of the greatest likelihood of patient compliance. Although a one-way ANOVA revealed that no particular strategy was rated significantly higher than the others, this research question was further analyzed by comparing the mean scores for patient compliance between conditions. The strategy combination represented in condition three, which consisted of a female provider using positive regard on the first visit followed by negative regard on the second visit after patient admission to noncompliance, resulted in the highest mean rating for likelihood of patient compliance.

A multivariate analysis was used to answer to the second research question, asking, "Which strategy combination results in observers' perceptions of the greatest likelihood of patient satisfaction?" A post-hoc LSD test revealed that there was a significant difference in patient satisfaction between the use of a positive/negative strategy combination and all other strategy combinations when used by both male and female providers over two visits (Wilks' [conjunction] = .80, F=4.938, p<.001). Specifically, when female providers used positive then negative strategies over sequential visits they were rated by observers as significantly more likely to elicit patient satisfaction than when a male provider (p<.001) or female provider (p<.001) used a positive then neutral strategy.

Similarly, female providers' use of neutral followed by negative regard was perceived as producing greater patient satisfaction than female (p=.003) and male (p=.004) providers' use of positive followed by neutral regard. Male providers' use of neutral followed by negative regard was perceived as producing greater patient satisfaction than female providers' use of positive followed by neutral regard (p=.008), and male providers' use of positive followed by neutral regard (p=.009).

DISCUSSION

RESEARCH FINDINGS

Results from the present investigation indicated that the strategy type used by the provider had a significant effect on respondents' perceptions of patient satisfaction. Results indicated specifically that it was perceived that patients would be most satisfied when both male and female providers used a combination of positive regard on the first visit, followed by negative regard on the second visit after the patient admitted to noncompliance with the suggested treatment. Similarly, it was perceived that patients would be more satisfied when both male and female providers used a combination of neutral regard on the first visit, followed by negative regard on the second visit after the patient admitted to noncompliance, than when using positive followed by neutral regard. These two strategy combinations were both less "pro-social" than the strategy combination of positive followed by neutral regard.

IMPLICATIONS OF FINDINGS

Results indicating that less "pro-social" strategies are preferred by patients may be representative of communication situations involving perceived status differences. Specifically, Erger et al., (2000) suggest that "Perhaps the main factors that shape interaction in the health care setting are power and status" (p.4). People of higher relative status and power are expected to use more verbally aggressive persuasive strategies, while people of lower relative status and power are expected to use less aggressive, more person-centered and altruistic forms of persuasion (Eagly, 1978; Steffen & Eagly, 1985).

Another reason that negative regard after noncompliance was viewed favorably by respondents is explained by a concept from the expectancy violation model, which asserts that "An extreme violation, if committed by a high reward communicator, can be positively valenced, producing reciprocal communication patterns and positive outcomes such as higher credibility and attraction" (Burgeon & Hale, 1988, p. 63). Therefore, if the provider was perceived as high in relative power and status, and the provider's negative regard was still perceived as a violation of expectations, it may have been a positively valenced violation, resulting in greater patient satisfaction with the communication experience.

Results indicating no difference between perceptions of male and female providers' use of certain strategies can also be explained in terms of relative status. In the medical context, perceptions based on status may have the ability to override perceptions based on sex. Because men traditionally hold higher status and power positions, and women traditionally hold lower status and power positions, aggressive tactics have been associated with men, and non-aggressive strategies have been associated with women. However, this effect is more prevalent in earlier studies due to the changing relative status of men and women. Because it is now more common for women to be providers, women providers' behavior may not be judged according to gender norms, but rather according to relative status norms. Research indicates that women who work in traditionally male environments, tend to report an increased likelihood of employing what we consider stereotypically male influence strategies (Carothers & Allen, 1999); because this is the norm for this particular context, patients may expect this behavior. Therefore, both female and male providers alike would be expected to use neutral or negative regard, especially as a form of "punishment," because their professional position calls for communicative behaviors associated with higher status and power. For example, Steffen and Eagly (1995) found that, "if perceivers have more definitive information about status than a gender cue (for example if they are given a job title), this information would override gender and determine perceivers' beliefs about the influence style" (p. 194). Thus, it may be the case that in this particular context the relative status of the provider overrides the effect of gender stereotypes.

CONCLUSION

The purpose of this study was to address issues of patient compliance and patient satisfaction not in terms of their causal relationship to one another, but rather as separate functions that can be used in combination to promote ethical and mutually beneficial provider-patient communication within the medical context.

Results indicated that provider sex and regard strategy do not interact to affect observers' perceptions of a patient's likelihood of compliance or satisfaction. However, there was support for the hypothesis that the provider regard strategy would have an effect on observers' perceptions of patient satisfaction. Specifically, observers reported the highest likelihood of patient satisfaction with both male and female providers use of positive regard on the first medical visit, followed by negative regard after patient noncompliance. These findings were contrary to those expected in that the positive/negative regard combination is less "pro-social" than the positive/neutral combination, especially for female communicators. It appears that relative power and status in the provides-patient relationship may play a more important role in determining patient expectations than does gender alone. Furthermore, results indicate that overly positive and affiliative communication behavior does not always result in patient satisfaction or compliance. This study suggests that patients may expect to be verbally or nonverbally reprimanded for noncompliance, and are thus more satisfied when providers react to noncompliance with negative regard. For example, Hall et al. (1981) found that a combination of negative nonverbal affect combined with positive verbal affect results in overall patient satisfaction because these behaviors reflect perceived provider seriousness, as well as concern. Similarly, when a provider adjusts his or her regard after a patient does not comply, the patient may perceive this behavior as an indication that the provider is concerned and takes the patient's health seriously.

This investigation offers an interesting perspective for providers, contradicting some past research that has suggested providers always communicate in a supportive manner. Perhaps this study reveals a facet of human nature that does not always yearn for pro-social communication, but rather honest communication, especially when dealing with an issue as vital as one's health.
Table 1. Regard Types Used Over First and Second Visits

 Female Provider

Visit 1st scenario 2nd scenario 3rd scenario

First Positive Neutral Positive
Second Negative Negative Neutral

 Male Provider

Visit 4th scenario 5th scenario 6th scenario

First Positive Neutral Positive
Second Negative Negative Neutral

Table 2. Mean Difference in Patient Satisfaction by Strategy Type

Condition (I) Condition (J) Mean Significance
 Difference
 (I-J)

fem positive/
 negative fem neutral/negative .1833 .503
 male neuual/negative .2708 .323
 male positive/negative .3208 .242
 fem positive/neutral 1.0042 .000
 male positive/neutral .9917 .000

male positive/
 negative fem neutral/negative -.1375 .616
 male neutral/negative -5.000 .855
 fem positive/negative -.3208 .242
 fem positive/neutral .6833 .013
 male positive/neutral .6708 .015

fem neutral/
 negative male neutral/negative 8.750 .749
 fem positive/negative -.1833 .503
 male positive/negative .1375 .616
 fem positive/neutral .8208 .003
 male positive/neutral .8083 .004

male neutral/
 negative fem neutral/negative -8.750 .749
 fem positive/negative -.2708 .323
 male positive/negative 5.000 .855
 fem positive/neutral .7333 .008
 male positive/neutral .7208 .009


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HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility IV--Evaluating Effectiveness of Health Education Programs

Competency B--Carry out evaluation plans.

Sub-competency 3--Analyze resulting evaluation data.

Carrie J. Cropley, M.A. is a Doctoral Candidate in the Department of Communication at the University of California, Santa Barbara. Address all correspondence to Carrie J. Cropley, Santa Barbara, CA 93106, PHONE: 805.291.2919, E-MAIL: carriejcropley@hotmail.com
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Author:Cropley, Carrie J.
Publication:American Journal of Health Studies
Geographic Code:1USA
Date:Mar 22, 2003
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