Introduction
Cardiovascular diseases are the most common cause of death worldwide, with a mortality of approximately 17.9 million people per year. Risk factors for their development include lack of physical activity, unhealthy diet, smoking, and alcohol use. The impact of these factors may manifest as elevated blood lipid or glucose levels, increased blood pressure, overweight, and obesity (WHO, 2024). Therefore, it is important that risk factors, treatment recommendations, and disease management are adequately communicated to patients.
Communication of risk factors increases awareness, but also reduces the patient's risk level and cholesterol and blood pressure levels after 6–12 months (Bakhit et al., 2024). Communication and trust, together with a patient-centered approach, have a positive impact on improving health outcomes as well as overall patient satisfaction with healthcare, which is associated with treatment adherence and compliance with medical recommendations. It is important that communication is bidirectional between doctor and patient, includes open-ended questions, and is based on shared decision-making (Ward, 2018). Active involvement of the patient, as well as formal and informal healthcare providers, is important in communication, as such engagement positively affects the reduction of anxiety and depression levels compared to passive strategies (Smith et al., 2009). Open communication also leads to a better understanding of the disease mechanism and prevention of deterioration. Lack of knowledge and distrust of doctors on the part of patients is associated with lower motivation to adhere to both pharmacological and non-pharmacological treatment (Bukstein, 2016).
Negative emotions such as depression, anxiety, and hostility have a higher prevalence in cardiovascular patients than in healthy individuals (Moser et al., 2010), and it is therefore important to consider them in communication with the patient. Higher levels of anxiety, for example, are associated with dissatisfaction when the doctor asks too many psychological questions (Graugaard et al., 2003) or communicates negative prognoses without adequate tact and sensitivity (Stortenbeker et al., 2018). Similarly, hostility can affect communication between doctor and patient. A tendency toward hostility in patients, amplified by anger, can lead to aggression toward doctors (Liu et al., 2024). Several studies describe that ethnicity, or race, also plays a significant role in cardiovascular disease and hostility. Hostility was associated with cardiovascular mortality in African American patients compared to white patients (Assari, 2017). In addition to hostility, an association between the development of cardiovascular disease and depression was also observed in this group of patients. The combination of these risk factors often leads to worse health outcomes in such patients (Mwendwa et al., 2013) and thus to higher mortality and poorer quality of life.
In Slovakia, Roma constitute a large ethnic group with a population of approximately 450,000 (Ravasz et al., 2020). Previous research has shown that Roma may have up to 3 times higher risk of developing cardiovascular disease compared to the majority population (Piko et al., 2021). A higher prevalence of depressive disorders is described in Roma compared to the majority (Kajanová et al., 2017); they experience high levels of anxiety, shame, and inferiority, which may be fueled by cultural, social, and minority differences (Gouva et al., 2015). Similarly, experiencing negative expressions from the majority may lead to an increase in hostility among them (Schaafsma and Williams, 2012). In the healthcare environment, they appreciate clear communication and relationships based on trust, but sometimes they experience misunderstanding of specialized medical terms, which subsequently leads to feelings of discomfort (Condon et al., 2021).
The aim of this study is to describe the perceived manner of medical communication in association with hostility, anxiety, and depression in Roma and non-Roma patients with ischemic heart disease.
Methods
Study Population The study population consisted of 878 patients with ischemic heart disease (123 Roma and 755 non-Roma patients) who were treated at the Eastern Slovak Institute for Cardiovascular Diseases (VÚSCH) in Košice. Inclusion criteria for the study included: ischemic heart disease, patient age up to 75 years, and signed informed consent. Exclusion criteria included: other diseases than ischemic heart disease (severe atrial or ventricular septal defects, acute coronary syndrome including acute myocardial infarction, pericarditis or myocarditis, severe valvular disease, ischemic cardiomyopathy, pulmonary embolism), severe cognitive disorders (e.g., dementia), severe comorbidity (e.g., dialysis patients, neurological diseases, malignancies), psychiatric disorders (e.g., bipolar disorder, schizophrenia, depression).
Measures
Sociodemographic and Clinical Variables Sociodemographic data, specifically age, sex, education, and ethnicity, were collected using a structured interview. Clinical data: NYHA/CCS, systolic blood pressure, diastolic blood pressure, HDL cholesterol, and LDL cholesterol, were obtained from patients' medical records. Functional status (NYHA/CCS) describes the severity level of ischemic heart disease. It was measured by a cardiologist using the scales: CCS – Canadian Cardiovascular Society (Campeau, 1976), which assesses the severity of chest pain; and the NYHA classification – the New York Heart Association (Criteria Committee of the New York Heart Association, 1994), which assesses symptoms of dyspnea. Each of these scales describes 4 levels, where a higher level indicates worse health status. Functional status was calculated using both scales. The higher score from each scale was combined into an aggregate measure of functional status to characterize the severity of ischemic heart disease.
Information Provision The perceived manner of information provision to patients was assessed using the HSI (Health Services Interview). It is a set of scales developed within the EURIDISS project (Briançon et al., 1990). Patients answered eight questions asking how they perceived the information provided by the doctor: "What do you think about the information your specialist doctor provided to you about the disease, its treatment, and the possible side effects of treatment? What was this information like? A. clear and understandable, B. open, C. complete, D. explained with understanding, tactfully, E. official, impersonal, F. reassuring, G. anxiety-provoking, H. hostile, unpleasant." Patients rated each type of information provision on a scale: "0. does not correspond to reality; 1. not at all; 2. somewhat; 3. to a great extent." Cronbach's alpha for positively perceived information provision (items: explained with understanding, tactfully; open; clear and understandable; complete; reassuring) was 0.91, and for negatively perceived information provision (items: anxiety-provoking; official, impersonal; hostile, unpleasant) Cronbach's alpha was 0.82.
Hostility Hostility was measured using the Cook-Medley Hostility Scale (CMHS) (Cook and Medley, 1954). The scale contains 27 items that can be divided into three subscales: hostile affect, cynicism, and aggressive responding. Hostile affect items describe emotional experiences, cynicism items describe cognitive beliefs, and aggressive responding items describe behavior. Each item could be answered using a dichotomous scale (1 = agree, 0 = disagree). A total score was calculated, with a higher score indicating a higher level of hostility. Cronbach's alpha for this scale in our sample was 0.73.
Anxiety and Depression Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983). This questionnaire consists of 14 items, 7 of which relate to depression and 7 to anxiety. Items can be answered on a 4-point scale (0–3). The resulting subscale scores range from 0 to 21, with a higher value associated with a higher level of anxiety or depression. Cronbach's alpha for the scale was 0.75.
Statistical Analyses The collected data were processed and evaluated using descriptive and inferential statistics. Categorical variables were presented as frequencies and percentages, continuous variables as arithmetic means and standard deviations. Contingency tables, the chi-square test, and t-tests were subsequently used. Correlation coefficients were used to analyze the strength of relationships between variables. Statistical analyses were performed using IBM SPSS 26.
Results
The research sample consisted of 878 patients with ischemic heart disease (Table 1), of whom 123 (14%) were Roma patients and 755 (86%) were non-Roma patients. The mean age in the sample of Roma patients was 54.09 ± 6.98 years, and in non-Roma patients 58.41 ± 7.51 years. Roma patients were younger, had lower education and income, and had worse functional status.
Table 1: Sample characteristics (N = 878) and differences between Roma and non-Roma cardiovascular patients
In most characteristics of perceived information provision, no significant difference was found between Roma and non-Roma patients. A significant difference between Roma and non-Roma patients was found only in the perception of hostilely provided information, which Roma patients perceived with higher intensity (Table 2).
Table 2: Perceived manner of information provision and differences between Roma and non-Roma cardiovascular patients
Correlations were used to analyze the relationship between the manner of information provision and anxiety, depression, and hostility (Table 3). Hostility was negatively associated with a clear and understandable, open, complete, tactful, and understanding manner of information provision in both groups. In non-Roma patients, it was also associated with a reassuring manner. Depression was associated with a reassuring manner of information provision in non-Roma patients. Anxiety was associated with an anxiety-provoking manner of information provision only in Roma patients.
Table 3: Association between manner of information provision and anxiety, depression, hostility
Discussion
The aim of this study was to describe the perceived manner of medical communication in association with hostility, anxiety, and depression in Roma and non-Roma patients with ischemic heart disease. We found that a low level of positive information provision (clear and understandable, open, complete, tactful) is associated with increased hostility in both Roma and non-Roma patients, while in non-Roma patients this also applies when there is a lack of a reassuring manner of information provision. Similarly, official and impersonal information provision is associated with increasing hostility in Roma patients. Our results are consistent with the findings of the study by Schaafsma and Williams (2012), who found that negative expressions from the majority or other members of ethnic groups were positively associated with increasing hostility among members of the ethnicity themselves.
We also found that anxiety-provoking information is associated with higher levels of anxiety in Roma patients. Similar results are reported by the study of Graugaard et al. (2003), which describes that when a patient had higher levels of anxiety, the doctor provided less biomedical information, asked more psychosocial questions, and exhibited emotional communication, which subsequently led to greater patient tension after the consultation. Sensitive communication is needed especially in Roma patients, who exhibit high levels of anxiety, which may be fueled by the creation of negative self-representations due to shame and internal difficulties (Gouva et al., 2015).
In our study, we found that perceived reassuring information provision is associated with lower levels of depression in non-Roma patients. Similar findings are reported by the study of Schenker et al. (2009), which points to a link between inadequate doctor communication and depressive symptoms in patients with ischemic heart disease. Other studies addressing this issue have concluded that depression can also affect the perception of information provided by the doctor, where depressed patients perceived the doctor's communication as suboptimal, regardless of whether they were patients from the majority or an ethnic minority (Haerizadeh et al., 2016).
We found that Roma patients perceive hostile information provision at a significantly higher level than non-Roma patients. Similarly, Hungarian Roma patients report experiencing prejudice from healthcare staff, such as longer waiting times, remarks, or other met communication elements. However, these prejudices are not specifically directed only at Roma patients, but generally at patients from poorer socio-economic backgrounds or patients who use drugs or alcohol (Marek et al., 2023). From the perspective of healthcare staff, the greatest problems in working with Roma patients are described as insufficient education and manner of communication (Miženková and Horňáková, 2024).
Negative communication in healthcare is a multifactorial phenomenon in which behavioral, cultural, and social factors play a significant role; on the patient's side, factors include undiagnosed health problems, problematic behavior, non-adherence to medical prescriptions, illiteracy, and social problems. Furthermore, factors related to the healthcare system also play a role, including inadequate equipment in healthcare facilities, administrative problems, and an unpleasant work environment. On the part of doctors, factors may include burnout, emotional state, professional failure, and lack of tools or authority (Riaz et al., 2023). Patience, non-judgmental listening, empathy, and tolerance help doctors manage difficult communication. Increasing experience of doctors also helps reduce negative communication, as previous experience allows them to anticipate the possible impacts of different types of communication. When managing difficult communication, doctors rely more on their own experience compared to training courses on handling difficult communication, of which there have been very few during their education (Sandikci et al., 2017).
Conclusion
Communication with patients conducted in an appropriate manner is an important part of the treatment process. Healthcare staff should focus on providing information that aligns with the patient's psychological needs. For patients with higher levels of hostility, they should use communication that is clear, reassuring, open, tactful, and complete, thus helping the patient to better accept the medical recommendations necessary for effective treatment. A sensitive approach in communication with Roma patients is essential, where it is important to avoid an official and impersonal manner of communication, which increases their fear, worries, and anxiety. Communicating in the healthcare environment is not easy, and therefore it is important to provide accessible training to healthcare staff that would facilitate everyday communication with patients. One form of more effective communication is the so-called motivational interview. Effective listening improves the quality of communication and increases patient satisfaction, and applying the principles of motivational interviewing in everyday medical practice can potentially lead to a reduction in hostility, increased treatment adherence, and improved health status in cardiovascular patients.
This work was supported by the Slovak Research and Development Agency under contract No. APVV-22-0587.
Authors: Mgr. Jana Kozáková Institute of Social and Behavioural Medicine, Faculty of Medicine, UPJŠ, Košice Mgr. Pavol Mikula, PhD. Institute of Social and Behavioural Medicine, Faculty of Medicine, UPJŠ, Košice doc. MUDr. Martin Studenčan, PhD. Eastern Slovak Institute for Cardiovascular Diseases, a. s., Košice Mgr. Iveta Nagyová, PhD., FABMR Institute of Social and Behavioural Medicine, Faculty of Medicine, UPJŠ, Košice
Correspondence address: Mgr. Iveta Nagyová, PhD., FABMR Institute of Social and Behavioural Medicine Faculty of Medicine, UPJŠ Trieda SNP 1, 040 11 Košice iveta.nagyova@upjs.sk
References
ASSARI, Shervin. 2017. Hostility, anger, and cardiovascular mortality among Blacks and Whites. In Research in Cardiovascular Medicine. Vol. 6, no. 1, p. 1-9.
BAKHIT, Mina, et al. 2024. Cardiovascular disease risk communication and prevention: a meta-analysis. In European Heart Journal. Vol. 45, no. 12, p. 998–1013.
BRIANÇON, S., et al. 1990. European research on incapacitating diseases and social support (EURIDISS). In International journal of health sciences. Vol. 1, p. 217-228.
BUKSTEIN, Don A. 2016. Patient adherence and effective communication. In Annals of Allergy, Asthma & Immunology. Vol. 117, no. 6, p. 613-619.
CAMPEAU, L. 1976. Grading of angina pectoris. In Circulation. Vol. 54, p. 522-523.
CONDON, L., et al. 2021. Cancer diagnosis, treatment and care: A qualitative study of the experiences and health service use of Roma, Gypsies and Travellers. In European Journal of Cancer Care. Vol. 30, no. 5, p. 1-10.
COOK, Walter W. – MEDLEY, Donald M. 1954. Proposed hostility and pharisaic-virtue scales for the MMPI. In Journal of Applied psychology. Vol. 38, no. 6, p. 414.
CRITERIA COMMITTEE OF THE NEW YORK HEART ASSOCIATION. 1994. Functional Capacity and Objective Assessment. In DOLGIN M, eds. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels, 9th ed, Boston MA: Little, Brown and Company, 1994, p. 253-255.
GOUVA, M., et al. 2015. Shame and anxiety feelings of a Roma population in Greece. In: Journal of immigrant and minority health. Vol. 17, p. 1765-1770.
GRAUGAARD, Peter Kjær – EIDE, Hilde – FINSET, Arnstein. 2003. Interaction analysis of physician–patient communication: the influence of trait anxiety on communication and outcome. In Patient education and counseling. Vol. 49, no. 2, p. 149-156.
HAERIZADEH, Mytra, et al. 2016. Depression and doctor–patient communication in the emergency department. In General hospital psychiatry. Vol. 42, p. 49-53.
KAJANOVÁ, Alena, et al. 2017. Roma minority and depressive disorder. In Aplikovaná psychologie. Vol. 2, no. 3, p. 181-187.
MAREK, Erika, et al. 2023. Prejudices towards the Romas in Hungarian healthcare: taboos and areas to tackle inequalities. In European Journal of Public Health. Vol. 33.
MOSER, Debra K., et al. 2010. Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft. In Heart & Lung. Vol. 39, no. 5, p. 378-385.
MIŽENKOVÁ, Ľudmila – HORŇÁKOVÁ, Anna. 2024. Barriers to cooperation in the care of a Roma community patient by the emergency medical service [online]. [cited 21.5.2024]. Available on the internet: .
MWENDWA, Denee T., et al. 2013. Dispositional depression and hostility are associated with inflammatory markers of cardiovascular disease in African Americans. In Brain, behavior, and immunity. Vol. 28, p. 72-82.
PIKO, Peter., et al. 2021. Comparative risk assessment for the development of cardiovascular diseases in the Hungarian general and Roma population. In Scientific Reports. Vol. 11, no. 1, p. 1-12.
RAVASZ, Ábel. – KOVÁCS, Ľuboš. – MARKOVIČ, Filip. 2020. Atlas of Roma Communities 2019. Bratislava : VEDA, 2020. 95 p. ISBN 978-80-224-1874-4
RIAZ, Adnan – NASIR, Umair Bin – MAJEED, Salman. 2023. A Square Deal to clear the Air: Managing the Difficult Patient Encounters. In Health Professions Educator Journal. Vol. 6, no. 1.
SCHAAFSMA, Juliette – WILLIAMS, Kipling D. 2012. Exclusion, intergroup hostility, and religious fundamentalism. In Journal of Experimental Social Psychology. Vol. 48, no. 4, p. 829-837.
SCHENKER, Yael, et al. 2009. Depressive symptoms and perceived doctor-patient communication in the Heart and Soul study. In Journal of general internal medicine. Vol. 24, p. 550-556.
SMITH, Jane, et al. 2009. Cochrane review: information provision for stroke patients and their caregivers. In Clinical rehabilitation. Vol. 23, no. 3, p. 195-206.
STORTENBEKER, Inge A., et al. 2018. Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations. In Patient education and counseling. Vol. 101, no. 9, p. 1577-1584.
WARD, Paul. 2018. Trust and communication in a doctor-patient relationship: a literature review. In Arch Med. Vol. 3, no. 3:36, p. 1-7.
WORLD HEALTH ORGANIZATION. 2024. Cardiovascular diseases [online]. [cited 19.4.2024]. Available on the internet: .
ZIGMOND, Anthony S. – SNAITH, R. Philip. 1983. The hospital anxiety and depression scale. In Acta psychiatrica scandinavica. Vol. 67, no. 6, p. 361-370.