Instrumental, Affective, and Patient-Centered Communication Between Cardiologists and Patients with Low Socioeconomic Status: An Observational Study

Figures & data

Table 1. Four examples of SES determination.

#	Education	Education score	Area-level	Area-level score	Combined assessment income, household composition, occupation	Combination score	Assigned SES-level
P1^a	Lower vocational education	1	−0.36	1	1001–1500; living together, no children; permanent disability, not mentioned	1	Low (three low-SES scores)
P2^b	Higher vocational education	3	0.16	2	1501–2000; living together, one child; fulltime employment, caregiver for the elderly	1	Middle (three different SES scores)
P3^c	Higher vocational education	3	−0.22	1	Not mentioned^d; single, no children; fulltime employment, manager	3	High (two high-, one low-SES score, but high education level → high-SES score)
P4^e	Secondary vocational education	2	0.07	2	1501–2000; living together, two children; fulltime employment, not mentioned	1	Middle (two middle-, one low-SES score)

Note: A score of 1 means low-level score, 2 middle-level score, and 3 high-level score. ^aP1 shows an example of a clear SES case in which all scores were the same. ^bP2 shows an example of a mix of all SES-levels, therefore, receiving a middle-SES score. ^cP3 shows an example of a patient with two of the same scores and one other level score, with this third score is deviating much from the other two scores. As one of the same scores includes education level (which is decisive in cases as such), the patient received a high-SES score. ^dFor this case, income was not mentioned. To determine the score for the combined assessment, we looked at household composition (single, no children), occupation situation (full time working), and profession (manager). Based on these indicators, a high-level score was assigned. ^eP4 shows an example of two of the same scores and one other level score, which does not deviate much for the other two scores. The patient therefore received a SES score corresponding with the other two scores; here middle-SES score.

Table 2. Codebook categories and examples for doctors’ utterances and Cohen’s kappa scores.

Category	Explanation	κ^a
Instrumental communication
Diagnosis	Medical condition of the patient and results from tests (e.g., ECG, scans)	.77
Generalinformation	Medical information nonspecific to the personal health of the patient, explaining biology	.47
Psychosocial talk	Overall mood and psychological problems	.44
Lifestyle talk	Food, diet, exercise, and smoking	.86
Procedural talk	Practical, logistical, and orientation parts of the consult	.62
Affective communication
Supportive talk	Sympathy and empathy, sensitivity, comforting the patient	.79
Negative talk	Critique and disapproval, indifference	.28^b
Social talk	Non-medical talk, chit-chat	.71
Verbal Attention	Paraphrasing, showing they are listening	.73
Patient-Centeredness
Understanding	Asking the patient if they understand them	1.00^b
Clarification	Asking for clarification	.88
Preference	Asking for the opinion, preferences, or wishes	1.00^b
Next steps	Asking what the patients wants with regard to treatment, testing, and next steps	.29^b

Note: ^aValues between .41 and .60 were considered moderate agreements; between .61 and .79 solid agreements; .80 and higher nearly perfect agreements (Burla et al., 2008). ^bSome values are below .41 and are therefore on the low end, some values are on the high end with 1.0. This is due to the very low number of utterances within those categories. All utterances within these categories were manually checked for acceptable levels of agreement by the first author.

Table 3. Codebook categories and examples for patients’ utterances and Cohen’s kappa scores.

Category	Explanation	κ^a
Instrumental communication
Biomedical talk	Medical condition of the patient and results from tests (e.g., ECG, scans)	.82
Psychosocial talk	Overall mood and psychological problems	.49
Lifestyle talk	Food, diet, exercise, and smoking	.88
Procedural talk	Practical, logistical, and orientation parts of the consult	.51
Affective communication
Concern expression	Expressing worries and fears	.75
Supportive talk	Expressing reassurance and gratitude	.62
Negative talk	Being critical, clearly disagreeing	.26^b
Social talk	Non-medical talk, chit-chat	.73
Verbal Attention	Paraphrasing, showing they are listening	.77
Patient-Centeredness
One-word answer	Answers a question with one word (yes/no)	.64
Clarification	Asking for clarification	.51

Note: ^aValues between .41 and .60 were considered moderate agreements; between .61 and .79 solid agreements; .80 and higher nearly perfect agreements (Burla et al., 2008). ^bThis low agreement is due to the very low number of utterances within the negative talk category. All utterances within that category were manually checked for acceptable levels of agreement by the first author.

Table 4. Total utterances of doctors and patients.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (N = 45)
All utterances	3,272 (31.3)	3,762 (36.0)	3,410 (32.7)	10,444 (100)
Doctor	1,981 (34.2)	2,048 (35.3)	1,770 (30.5)	5,799 (100)
Patient	1,291 (27.8)	1,714 (36.9)	1,640 (35.3)	4,645 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 5. Total utterances of instrumental communication by the doctor.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (n = 45)
Instrumental	1,304 (36.6)	1,243 (34.9)	1,016 (28.5)	3,563 (100)
Diagnosis	942 (37.9)	836 (33.6)	709 (28.5)	2,487 (100)
Procedural talk	263 (35.1)	302 (40.3)	184 (24.6)	749 (100)
General information	47 (31.8)	50 (33.8)	51 (34.4)	148 (100)
Lifestyle talk	27 (22.3)	37 (30.6)	57 (47.1)	121 (100)
Psychosocial talk	26 (42.6)	19 (31.2)	16 (26.2)	61 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 6. Total utterances of instrumental communication by the patient.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (n = 45)
Instrumental	748 (28.8)	959 (36.9)	892 (34.3)	2,599 (100)
Biomedical talk	593 (30.0)	737 (37.2)	648 (32.8)	1,978 (100)
Lifestyle talk	45 (19.3)	91 (39.1)	97 (41.6)	233 (100)
Psychosocial talk	61 (29.5)	54 (26.1)	92 (44.4)	207 (100)
Procedural talk	49 (27.1)	77 (42.5)	55 (30.4)	181 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 7. Total utterances of affective communication by the doctor.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (n = 45)
Affective	720 (30.1)	858 (35.9)	812 (34.0)	2,390 (100)
Verbal attention	369 (33.5)	415 (37.6)	319 (28.9)	1,103 (100)
Supportive talk	206 (28.6)	242 (33.2)	281 (38.5)	729 (100)
Social talk	136 (25.7)	197 (37.0)	199 (37.4)	532 (100)
Negative talk	9 (21.4)	11 (26.0)	22 (52.0)	42 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 8. Total utterances of affective communication by the patient.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (n = 45)
Affective	544 (24.8)	780 (37.0)	782 (37.1)	2,106 (100)
Verbal attention	364 (31.7)	419 (36.2)	374 (32.3)	1,157 (100)
Social talk	95 (18.3)	203 (39.0)	222 (42.7)	520 (100)
Concern expression	43 (18.3)	86 (36.6)	106 (45.1)	235 (100)
Positive talk	37 (20.2)	69 (3.3)	77 (42.1)	183 (100)
Negative talk	8 (29.6)	7 (25.9)	12 (44.5)	27 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 9. Question asking and patient-centeredness (i.e., partnership building, and shared decision making) by the doctor.

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (n = 45)
Questions	352 (38.7)	299 (32.9)	258 (28.4)	909 (100)
Closed questions	279 (39.1)	233 (32.7)	201 (28.2)	713 (100)
Open questions	73 (37.2)	66 (33.7)	57 (29.1)	196 (100)
Patient-centeredness	339 (31.8)	362 (34.0)	365 (34.2)	1,066 (100)
Partnership building	224 (28.8)	284 (36.4)	268 (34.5)	776 (100)
Shared decision making	115 (39.7)	78 (26.9)	97 (33.4)	290 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Table 10. Question asking and one-word answers by the patient (patient-participation).

	Low-SES (n = 16)	Middle-SES (n = 16)	High-SES (n = 13)	Total (N = 45)
Questions	37 (21.8)	63 (37.0)	70 (41.2)	170 (100)
Closed questions	26 (22.4)	48 (41.4)	42 (36.2)	116 (100)
Open questions	11 (20.4)	15 (27.8)	28 (51.8)	54 (100)
One-word answers	82 (45.6)	57 (31.7)	41 (22.7)	180 (100)

Note: Descriptives represent absolute frequencies with percentages between parentheses.

Burla, L., Knierim, B., Barth, J., Liewald, K., Duetz, M., & Abel, T. (2008). From text to codings: Intercoder reliability assessment in qualitative content analysis. Nursing Research, 57(2), 113–117. https://doi.org/10.1097/01.NNR.0000313482.33917.7d

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