Listening in HIV counselling and testing: hearer signals in rural patient-counsellor HIV consultation
Date
2016-12
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
Stellenbosch : Stellenbosch University
Abstract
AFRIKAANS OPSOMMING: MIV en VIGS is sedert die 1980s ’n kommerwekkende nasionale gesondheidskwessie in
Suid-Afrika. Na beraming het daar teen 2014 ʼn getal van 6,8 miljoen mense tussen die
ouderdomme van 15 en 49 met MIV geleef (UNAIDS, 2015). Vrywillige Berading en
Toetsing (VBT) is in 2004 landwyd geïmplementeer om die verspreiding van MIV te beperk.
Die VBT-dienste is ingestel om die MIV-status van individue te bepaal en om diegene wat
positief toets met berading by te staan ten einde tydige toegang tot die nodige behandeling en
gepaardgaande verbetering van lewenskwaliteit te bied.
Binne die groter genre van mediese diskoerse, is mediese konsultasie uitgewys as ʼn
belangrike diskoerstipe wat reëlmatig gestruktureer is en dus in eie reg bestudeer behoort te
word. So is daar reeds wetenskaplike aandag aan verskillende instansies van kommunikasie
tussen gesondheidsorgdeskundiges en pasiënte gewy. As ’n gespreksubtipe binne mediese
diskoers, is pre-toets MIV-berading in VBT tot dusver nie in wetenskaplike publikasies
beskryf nie. Die protokol waarvolgens pre-toets VBT-berading gedoen word, verplig beraders
om pasiënte in te lig aangaande verskeie MIV-verwante onderwerpe terwyl hul ook moet
verseker dat pasiënte genoegsame begrip van hierdie informasie toon om ’n ingeligte besluit
te kan neem rakende hulle instemming tot MIV-toetsing. Die doel van hierdie studie is om die
generiese eienskappe van hierdie spesifieke mediese gesprekstipe te identifiseer.
Hierdie studie is gesetel in die terrein van Taalwetenskaplike Pragmatiek en bied ’n
kwalitatiewe analise van data wat ingesamel is by twee staatsbeheerde
gesondheidsorginstansies in landelike dorpe in die Wes-Kaapse Wynlanddistrik. Die data
bestaan uit 14 pre-toets MIV-beradingsessies wat in Afrikaans uitgevoer is. Die deelnemers is
beraders en pasiënte. Beraders is in die plaaslike gemeenskap gewerf; hulle het geen mediese
opleiding nie, maar het minstens graad 12 geslaag. Hulle het wel beperkte, MIVberadingstoegewyde
voorbereiding vir die werk wat hulle in die klinieke doen. Pasiënte
vertoon diversiteit ten opsigte van die rede vir hulle besoek aan die kliniek. Verder verseker
die ligging van die klinieke ʼn redelik hoë mate van talige diversiteit onder die pasiënte.
Met behulp van metodes ontwikkel binne die teoretiese raamwerk van Gespreksanalise
(Conversation Analysis (CA)) (sien Sacks, Schegloff & Jefferson, 1974), ondersoek hierdie
studie die organisatoriese elemente onderliggend aan die opeenvolging van taalhandelinge ten
einde herhalende patrone te herken op grond waarvan generiese kenmerke van pre-toets MIV
beradingsgesprekke geïdentifiseer kan word. Die manier waarop beraders deurentyd die rol
van spreker inneem en gesprekke oorheers deur die meerderheid taalhandelinge te sentreer en
orden rondom die oordrag van inligting, verseker ’n ongelyke verdeling van spreekbeurte.
Aan die pasiënte wat nie met die konteks en prosedures vertroud is nie word dan ’n passiewe
luisteraarsrol in die gesprek toegeken. In só ’n geval waar die pasiënt primêr ʼn luisteraarsposisie inneem, bestaan hoorderbydraes tipies uit betekenisvolle tekens wat as
“hoordertekens” aan die spreker gerig is.
Aangesien hierdie gesprekstipe kenmerkend ʼn hoë konsentrasie van sulke hoordertekens
bevat, word hierdie tekens gekarakteriseer met verwysing na hulle vorm en funksie. Binne dié
hoordertekens word verbale en nie-verbale kategorieë onderskei wat op kontekstuele,
pragmatiese en intuïtiewe vlak op verskeie maniere bydra tot die gesprek. Die meerderheid
van hierdie tekens is nie-verbaal (soos kopknikke of kort spraakklankuitings) en word meestal
geproduseer ter erkenning of bevestiging van die sprekerbydraes, in aanmoediging van die
voortsetting van die gesprek of in reaksie op spesifieke taalstimuli van die spreker/berader.
Om op te som: sowel die analises van die generiese eienskappe van VBT-gesprekke as van
die hoordertekens wat in die pre-toets MIV-beradingsgesprekke voorkom, bevestig dat hierdie
gesprekke oorweldigend beradergesentreerd is. Beraders se rigiede strukturering van hierdie
gesprekke om protokol na te kom, plaas beperkinge op die gesprek wat die pasiënte tot
passiewe deelnemers reduseer wat almal eenders behandel word ten spyte van waargenome
diversiteit in terme van kennis en behoeftes. Hulle word byvoorbeeld selde ’n spreekbeurt
gegun, word maklik in die rede geval of verplig om hulle beurt vinnig te beëindig. Gevolglik
is bevind dat beraders nie die kommunikatiewe doelwitte van die gesprekstipe ten volle
verwesenlik nie.
Hierdie studie bied ’n gespreksanalitiese karakterisering van VBT-konsultasies en ’n
pragmatiese karakterisering van hoordertekens wat voorkom in VBT. Dit kan bydra tot beter
begrip en bestuur van ’n area in MIV-sorg waar die behandeling van kwesbare pasiënte
afhanklik is van wedersydse begrip tussen gespreksdeelnemers. Die bevindinge kan toegepas
word in byvoorbeeld die ontwikkeling van nuwe opleidingsprogramme met die oog op
toerusting van VBT-beraders om ’n pasiëntgesentreerde benadering in konsultasies te volg.
Dit sal behels dat die fokus van die konsultasies verskuif van ’n geroetineerde vorm van
inligtingoordrag na die skep van geleenthede waarbinne pasiënte op bevryde wyse meer
onafhanklike bydraes tot die gesprek kan maak.
ENGLISH ABSTRACT: HIV/AIDS has been a major public health concern in South Africa since the late 1980s. By 2014 approximately 6.8 million people (aged 15 - 49) were estimated to be living with HIV (UNAIDS, 2015). In order to address the rapid proliferation of HIV throughout the country, Voluntary Counselling and Testing (VCT) services were implemented nationally in 2004 in order to establish individuals’ HIV status and manage and counsel patients who tested positive for the virus to receive treatment and improved quality of life timeously. Within the medical discourse genre, the importance of distinguishing medical consultations as a significant and regularly structured discourse in itself has been emphasised. Accordingly, different instances of health care professional-patient communication have received attention in research. As a conversational subtype of medical discourse, pre-test VCT counselling in VCT has not yet been characterised in scholarly work. The aim of this study is to identify the generic features of this particular form of medical conversation in which counsellors are required to follow protocol in informing patients regarding various HIV-related topics as well as ensuring that the patient sufficiently understands this information in order to make an informed decision regarding giving consent for the test to be administered. Situated in the subfield of Linguistic Pragmatics, this study provides a qualitative analysis of data collected from two state health care facilities in rural towns in the Western Cape Winelands district consisting of 14 pre-test VCT counselling sessions conducted in Afrikaans. Participants include counsellors and patients. The counsellors have no medical training but passed at least grade 12 at school and have limited, dedicated preparation for counselling in HIV care. They are recruited from the local community. Patients show diversity in terms of the reason for their visit to the clinic; depending on the area where the clinic is situated, there is mostly also considerable linguistic diversity. By applying methods set out in the theoretical framework of Conversation Analysis (CA) as developed by Sacks, Schegloff and Jefferson (1974), this study investigates the sequential organisation of speech acts in order to find recurring patterns on the basis of which generic features of pre-test VCT counselling sessions are identified. A clear imbalance of spoken participation between participants indicates that counsellors dominate these conversations by mostly taking the role of speaker in centering the bulk of the conversation around information-giving sequences. Then the patient, who is unfamiliar with the context and its procedures, mostly takes a passive role as listener in the conversation. When the listener role is the primary one within a particular interaction as in this case, the hearer contributions typically take on a form that is identified as meaningful signs and signals addressed at the speaker, termed “hearer signals”. Since a concentrated presence of hearer signals is a generic feature of these conversations, this study further uses Corpus Linguistics in order to recognise and characterise the hearer signals according to form and function. These signals are divided into verbal and nonverbal categories and are contextually, pragmatically and intuitively found to contribute to the conversation in many ways. While the majority of signals produced in this conversation take the form of nonverbal signals such as head nods as well as short verbal utterances, they are mostly produced to function as acknowledgers, continuers, confirmation of received speech and reactions to specific prompts in the counsellor’s speech. In summary, both the analyses of the generic features of VCT and hearer signals used in these pre-test VCT counselling sessions reveal the counsellor-centred nature of these conversations. By rigidly structuring the conversation according to protocol, counsellors create constraints through which patients are constructed as passive participants and are all treated similarly despite showing diverse levels of knowledge and needs. They are, for example not often granted a speaking turn, are easily interrupted or brought to close their turns quickly. the communicative aims of this type of conversation were found not to be fully accomplished. This study gives a conversational analytic characterisation of VCT consultations and a linguistic pragmatic characterisation of the hearer signals that occur in VCT. It can contribute to better understanding and managing an area of HIV health care where treatment of relatively vulnerable patients is dependent on achieving mutual understanding between interactants. The findings can be applied (e.g.) in developing new training programs aimed at equipping VCT counsellors to develop a patient-centred approach by shifting the focus from almost rote distribution of information to transferring more agency to the patient within these consultations.
ENGLISH ABSTRACT: HIV/AIDS has been a major public health concern in South Africa since the late 1980s. By 2014 approximately 6.8 million people (aged 15 - 49) were estimated to be living with HIV (UNAIDS, 2015). In order to address the rapid proliferation of HIV throughout the country, Voluntary Counselling and Testing (VCT) services were implemented nationally in 2004 in order to establish individuals’ HIV status and manage and counsel patients who tested positive for the virus to receive treatment and improved quality of life timeously. Within the medical discourse genre, the importance of distinguishing medical consultations as a significant and regularly structured discourse in itself has been emphasised. Accordingly, different instances of health care professional-patient communication have received attention in research. As a conversational subtype of medical discourse, pre-test VCT counselling in VCT has not yet been characterised in scholarly work. The aim of this study is to identify the generic features of this particular form of medical conversation in which counsellors are required to follow protocol in informing patients regarding various HIV-related topics as well as ensuring that the patient sufficiently understands this information in order to make an informed decision regarding giving consent for the test to be administered. Situated in the subfield of Linguistic Pragmatics, this study provides a qualitative analysis of data collected from two state health care facilities in rural towns in the Western Cape Winelands district consisting of 14 pre-test VCT counselling sessions conducted in Afrikaans. Participants include counsellors and patients. The counsellors have no medical training but passed at least grade 12 at school and have limited, dedicated preparation for counselling in HIV care. They are recruited from the local community. Patients show diversity in terms of the reason for their visit to the clinic; depending on the area where the clinic is situated, there is mostly also considerable linguistic diversity. By applying methods set out in the theoretical framework of Conversation Analysis (CA) as developed by Sacks, Schegloff and Jefferson (1974), this study investigates the sequential organisation of speech acts in order to find recurring patterns on the basis of which generic features of pre-test VCT counselling sessions are identified. A clear imbalance of spoken participation between participants indicates that counsellors dominate these conversations by mostly taking the role of speaker in centering the bulk of the conversation around information-giving sequences. Then the patient, who is unfamiliar with the context and its procedures, mostly takes a passive role as listener in the conversation. When the listener role is the primary one within a particular interaction as in this case, the hearer contributions typically take on a form that is identified as meaningful signs and signals addressed at the speaker, termed “hearer signals”. Since a concentrated presence of hearer signals is a generic feature of these conversations, this study further uses Corpus Linguistics in order to recognise and characterise the hearer signals according to form and function. These signals are divided into verbal and nonverbal categories and are contextually, pragmatically and intuitively found to contribute to the conversation in many ways. While the majority of signals produced in this conversation take the form of nonverbal signals such as head nods as well as short verbal utterances, they are mostly produced to function as acknowledgers, continuers, confirmation of received speech and reactions to specific prompts in the counsellor’s speech. In summary, both the analyses of the generic features of VCT and hearer signals used in these pre-test VCT counselling sessions reveal the counsellor-centred nature of these conversations. By rigidly structuring the conversation according to protocol, counsellors create constraints through which patients are constructed as passive participants and are all treated similarly despite showing diverse levels of knowledge and needs. They are, for example not often granted a speaking turn, are easily interrupted or brought to close their turns quickly. the communicative aims of this type of conversation were found not to be fully accomplished. This study gives a conversational analytic characterisation of VCT consultations and a linguistic pragmatic characterisation of the hearer signals that occur in VCT. It can contribute to better understanding and managing an area of HIV health care where treatment of relatively vulnerable patients is dependent on achieving mutual understanding between interactants. The findings can be applied (e.g.) in developing new training programs aimed at equipping VCT counsellors to develop a patient-centred approach by shifting the focus from almost rote distribution of information to transferring more agency to the patient within these consultations.
Description
Thesis (DPhil)--Stellenbosch University, 2016.
Keywords
Physician and patient, HIV viruses, Doctor-patient relationships, Medical cooperation, Medical consultation, Voluntary Counselling and Testing (VCT) Services, UCTD