Essential Skills for Health Communication, Barriers, Facilitators and the Need for Training: Perceptions of Healthcare Professionals from Seven European Countries

Many healthcare professionals are unaware of the necessary skills and barriers hindering interpersonal health communication. This study aimed to evaluate the healthcare professional’s perception regarding health communication training’s necessity, barriers, facilitators and critical skills in health communication. Data from a cross-sectional online survey in the framework of the H-Com project were utilized. The study included 691 healthcare professionals (physicians, nurses, students and allied health professionals) from seven European countries. Only 57% of participants had participated in health communication training, while 88.1% of them indicated a willingness to be trained in health communication. Nurses were more likely (OR = 1.84; 95% CI 1.16, 2.91) to have received such training, compared to physicians. Most examined communication skills, barriers and facilitators of effective communication, and perceived outcomes of successful communication were considered crucial for most participants, although physicians overall seemed to be less concerned. Most agreed perceived outcomes were improved professional–patient relations, patient and professional satisfaction, physical and psychological health amelioration and patients’ trust. Nurses evaluated the importance of these communication skills and communication barriers, facilitators and outcomes higher than physicians. Physicians may underestimate the importance of communication skills more than nurses. Health communication should become an integral part of training for all health professionals.


Introduction
Interpersonal communication between patients and their doctors is crucial as it can significantly improve prognosis, therapy and patient satisfaction, while reducing healthcare

Study Design
The H-Com Project was an Erasmus+ co-funded multi-partner initiative aiming to build and strengthen communication skills among healthcare professionals. The project's objectives were to map the existing HCT opportunities across Europe; explore the needs and perceptions of healthcare professionals concerning communication; and develop, test and evaluate an HCT initiative through the provision of vocational education to healthcare pro-fessionals. Within the context of the H-Com Project, a cross-sectional survey was conducted, targeting health professionals (including physicians, nurse practitioners and other allied health professionals). An online questionnaire was developed to elucidate the intricacies of relationships between health professionals and patients, particularly concerning health communication. The purpose-made pilot questionnaire was based on an in-depth review of the literature and the outcomes of a qualitative study on physician-patient communication perceptions, barriers and the training needs of healthcare professionals [19].
The online questionnaire, comprising 35 close-ended questions, included components regarding demographic characteristics, educational experience, professional status, experience with HCT, assessment of the necessity and willingness to participate in HCT and barriers and facilitators of implementing health communication across different healthcare settings. Professionals were asked to rank the importance of various communication skills and practices, potential barriers and facilitators to effective health communication using a Likert scale, with possible answers ranging from 1 (not important at all) to 5 (very important). The questionnaire was developed in English and was then translated by professionals in the field of health communication working in the project's partner organizations into the consortium languages, i.e., German, Greek, Polish and Spanish.

Setting
The H-Com Consortium Partners represented five European countries, namely Cyprus, Germany, Greece, Poland and Spain. Health professionals in the consortium countries, as well as in other European countries, were invited to participate in the online survey. More specifically, participants were invited to take part between September 2016 and April 2017, during which 750 healthcare professionals in Greece and Cyprus and 1200 contacts in other EU countries from hospitals, universities, medical associations and academics were contacted to fill in the questionnaire. Participants were contacted via email and participation was anonymous. The collected data were stored by the leading organization in data collection (Prolepsis Institute) and all data were password protected. Participants were informed about the data management procedures.

Study Sample
The original study sample included 743 health professionals. Participants who did not specify health specialty/training or age were excluded from further analysis (n = 41; 5.5%). Hence, the final study sample consisted of 702 participants, of whom 691 specified if they had ever received HCT.

Statistical Analysis
Statistical analysis was performed with IBM SPSS statistics, version 23. Qualitative characteristics are presented overall and by profession, as number of observations (n) and percentages (%). The differences among professional groups were assessed using the Pearson's chi-square test. Healthcare professionals' perceptions are presented as percentages for categorical variables and as mean (standard deviation) for continuous variables. Analysis of variance (ANOVA) was utilized to compare healthcare professionals' all quantitative variables among professional groups. The Bonferroni correction for post hoc analyses was performed.
The association of healthcare professionals' characteristics and the likelihood of having received HCT was evaluated through a univariate logistic regression model (all case analysis). A further multivariate logistic regression model was constructed, adjusting for all the confounders. We considered all characteristics that indicated differences between the professional groups as potential confounders for every possible predictor (excluding the examined predictor each time).

Descriptive Characteristics
The characteristics of the study sample and subgroups according to their professional expertise are presented in Table 1. About 64% of the sample was female. Most participants were employed in Greece (21.2%), while the rest were employed in Italy, Spain, Germany, Poland, Portugal, Cyprus and other countries, including 14 European and 6 non-European countries. The majority were physicians (45%), followed by nurses, other allied health professionals (i.e., psychologists, paramedics, health administration staff, nursing assistants, social workers, dentists/dental hygienists, dietitians/nutritionists, health promotion specialists, public health specialists) and students from health-related sectors. Among students, nurses and allied health professionals, the majority of them were female, as opposed to physicians (p < 0.001). Nurses and students seem overall of younger age (<35 years old) compared to physicians and allied health professionals (p < 0.001). About two in five physicians reported that they had attained a PhD or equivalent degree, while nurses and allied health professionals reported lower academic achievements than PhD level (p < 0.001; 10.3% and 22.6%, respectively).

Perceptions Regarding the Need and Willingness to Participate in HCT
More students and nurses had received HCT in the past (Table 2), compared with allied health professionals and physicians (p < 0.001). Most healthcare professionals received HCT during residency training, at the postgraduate level or graduate level, in the form of continuous education training, or other sources. The vast majority of the participants were willing to participate in HCT and about 9 out of 10 recognized that training physicians or nurses on health communication skills is necessary ( Table 2).
HC is considered more important in (n (%))

The Benefits of Effective Communication and the Importance of Communication Skills-Reported Perceptions
More than 97.5% of the participants agreed that successful health communication is predominantly associated with improved physician/nurse-patient relations, followed by increased patient satisfaction (97.4%) ( Table 3). Other beneficial outcomes attributed to effective communication were enhanced patient trust (agreement rate: 96.6%), prescribed medication adherence (94.6%), patients' physical and psychological health amelioration (94.3%) and increased physician/nurse satisfaction (93.9%). More nurses and allied health professionals and fewer physicians and students reported that efficient health communication strategies are associated with lower costs for the healthcare system (p < 0.001) and a lower number of patient readmissions/revisits (p = 0.038).
Overall, the following communication skills ranked among the five most crucial: the ability to listen to patients (agreement rate: 80.6%), to deliver unfortunate news regarding a diagnosis (78.8%), to effectively obtain medical history (78.9%), to answer patients' questions clearly (78.4%) and to explain in simple language a health problem or treatment plan to the patient (75.6%) ( Table 3). Showing empathy towards the patients' emotional concerns was also highly evaluated by most healthcare professionals.
When subgroup analysis was performed according to the participant's profession, a different ranking was observed. Physicians considered the significance of effectively obtaining medical history as more important than other professions. On the other hand, physicians evaluated the following communications skills as less important compared to nurses (all p < 0.05): handle patient anger/disappointment/fear, assess the patient's disease and treatment complications and react accordingly, explore the patient's concerns and effectively prompt questions, discuss practical difficulties regarding the treatment plan and effectively include patients in decision-making. A lower percentage of students (61.5%) assessed the ability to listen to patients as very important compared to the other groups (p < 0.001).

Barriers to Effective Health Communication
Health professionals were also asked to evaluate potential barriers to efficient health communication, across different healthcare settings. The results are summarized in Table 4. In all healthcare settings, physicians' sex was considered the least important barrier, followed by the physicians' younger or older age (average score less than 4.00, in all setting for both barriers).   SD = standard deviation. Each barrier was scored on a scale 1 to 5 (1 = low, 5 = high importance). The mean and the standard deviation are presented in the form of mean (SD). p-value is based on univariate analysis of variance (ANOVA). Allied health professionals: psychologists, paramedics, health administration staff, nursing assistants, social workers, dentists/dental hygienists, dietitians/nutritionists, health promotion specialists, public health specialists, etc.
The barriers perceived as the most crucial ones (all received a total score higher than 3.95/5.00), in the primary healthcare and hospital settings, were the following: emotional state of patients, time restrictions, low patient health literacy, language issues, large number of patients/heavy workload/exhaustion, lack of professionals' training in health communication skills, lack of interest from the physicians'/nurses' part and lack of interest from the administration. In the private sector, the barriers mentioned above were considered slightly less critical than in the other sectors.
In primary healthcare, the emotional state of patients was evaluated as the most crucial barrier for successful communication by nurses, the large number of patients by physicians and students and the lack of professionals' training in health communication skills by allied health professionals (p < 0.001).
In hospitals, all health professionals assessed the emotional state and large number of patients as the two most critical barriers. Nurses assessed the "lack of professionals' training in health communication skills" and "lack of interest on the physicians'/nurses' part" as significantly more critical compared to physician ratings (p < 0.001).
In the private practice, all participants reported the emotional state of patients as the most crucial barrier. The lack of professionals' training in health communication skills was also reported as a common significant barrier by nurses, students and allied health professionals, but less significant among physicians in private practice (p < 0.001).

Facilitators of Effective Health Communication
The most important facilitators for effective communication (score >4.00, across all settings and all professions) were the following: training of physicians/nurses in health communication skills, an interest in health communication from higher administration, longer consultation hours/fewer patients, informed patients and the presence of cultural/language mediators (Table 5). Satisfactory remuneration of the physician or nurse was also considered an important facilitator (scores ranged from 3.82 to 3.92/5.00, across the three settings). Table 5. Healthcare professionals' perceptions regarding the facilitators of health communication in different healthcare settings (primary healthcare, hospitals and private practice), for the total sample and separately for each medical specialty (n = 691; online survey of the H-Com project). SD = standard deviation. Each facilitator was scored on a scale 1 to 5 (1 = low, 5 = high importance). The mean and the standard deviation are presented in the form of mean (SD). p-value is based on univariate analysis of variance (ANOVA). Allied health professionals: psychologists, paramedics, health administration staff, nursing assistants, social workers, dentists/dental hygienists, dietitians/nutritionists, health promotion specialists, public health specialists, etc.

Facilitators of Health Communication in (mean (SD)):
In primary healthcare settings, some facilitators were perceived as more critical by nurses compared with physicians (p < 0.05), namely the training of physicians/nurses in health communication skills, interest in health communication from higher administration and informed patients.
In hospitals, training of physicians/nurses in health communication skills was reported as more important by nurses and students when compared to physicians (p < 0.05). Nurses considered informed patients to be a more critical facilitator in effective communication compared to physicians (p < 0.001).

Predictors of Having Received HCT
The results from the logistic models investigating the effect of healthcare professionals' characteristics on the likelihood of having received an HCT program in the past are presented in Table 6. Nurses were more likely to have received HCT in the past compared to physicians (OR = 1.84; 95% CI 1.16, 2.91; adjusted model). Having 6-10 years of professional experience (OR = 0.52; 95% CI 0.27, 0.99; adjusted model) indicated a lower odds of having received an HCT program in the past compared with participants with <5 years of professional experience. Living in Cyprus, Germany, Italy, Poland and Spain indicated higher odds of having participated in a training program in the past in comparison with Greece in the final model after backward selection.

Discussion
als [11,19,[30][31][32][33][34][35][36][37][38][39]. However, most of these studies do not examine how these barriers are understood by professionals, highlighting the novelty of the current study. Healthcare professionals' sex was perceived as the least important barrier in health communication in our study, even though sex incompatibility (e.g., male patient and female physician) is often considered a substantial barrier by the patients [33,40]. Furthermore, differences between the professions' perceived barriers and facilitators were evident. Nurses overall identified the patient's uninformed status, emotional state and low literacy and lack of a professional's interest in the interpersonal healthcare professional-patient relationship or training in health communication as more significant barriers than physicians. Such findings further reinforce the previous hypothesis that nurses value empathy highly in interpersonal communication with patients and consider the lack of HCT a substantial barrier [27], while physicians may focus more on the effectiveness of therapy. Further emphasizing this phenomenon, we also found that nurses are twice as likely as physicians to have actively sought and received HCT.
Our findings indicate that about half of physicians and many allied healthcare professionals have not received HCT. As confirmed in the literature, professionals in European medical settings have been inadequately trained in health communication for many years [41,42], a situation that led many European countries to devote financial resources to promote HCT [43,44], without evident beneficial results. In the last decades, a more patientcentered care model that emphasizes communication and shared decision-making has effectively replaced the passive information-based model in consultation practice [11,13,14]. Many European countries have recently shifted focus to an efficient person-centered care, enjoying a variety of benefits from better health outcomes and reduced expenses. Our results have indicated that younger professionals with less working experience or students from healthcare-related sectors may be more likely to have received HCT, although there is uncertainty around the results regarding students, due to the limited sample size. Nevertheless, many healthcare professionals have still not received adequate training to support this shift in healthcare practices, as many gaps in effective care and communication are evident [3,45].
A cross-sectional survey conducted a few years prior to our study with patients from 34 countries, including many European Member States, concluded that all primary healthcare systems indicated the limited potential to improve communication practices [46]. The already poor physician-patient communication was further aggravated during the COVID-19 pandemic. The high workload has led many professionals to devote even less time to patients' care and has exacerbated work-related exhaustion and consequent professionals' burnout [47]. Developing impactful strategies to resolve professionals' moral distress, improving the provider's empathy and communication skills and introducing novel and targeted communication HCT resources, may sufficiently bridge this gap of inadequate communication [47].
It should be acknowledged that the data collection took place in 2016-2017. While some may perceive this as dated, it still provides valuable insights within the realm of interpersonal health communication, particularly in the post-COVID-19 pandemic era. The pandemic highlighted deficiencies in health communication and revealed numerous barriers faced by healthcare professionals when conveying their advice [48]. They encountered difficulties in establishing the authenticity and reliability of their medical communication, which resulted in information uncertainty and even information overload as attempts were made to address this uncertainty [49]. Furthermore, telehealth services emerged as substitutes for in-person communication, finding many healthcare professionals unprepared to tackle the associated challenges [50]. Our article sheds light on the reasons why certain professionals lacked essential skills and were unable to deliver effective care or effectively convey their messages. In this post-pandemic era, policymakers should capitalize on elevated health communication awareness and provide adequate opportunities for HCT to address the communication gaps between professionals and patients.
Apart from the dated data collection, the following limitations have also been identified in this study. Due to the limited sample of physicians' and nurses' specializations and allied health professionals' occupations, findings were not classified for different specializations/professions. The distribution of all categories of healthcare professionals and students varied significantly between countries, preventing us from having a representative sample for each country. In addition, the sample of students was small, limiting the credibility of the findings around students. Future research should focus on identifying a larger sample of all healthcare professions, to identify disparities in the perceptions of various healthcare professionals, other than physicians and nurses. Since all the participating countries have differences in the organization and services provided by their healthcare systems, it may be impossible to generalize our findings to all healthcare settings. Moreover, the translation of the questionnaire to all consortium languages did not follow an established method to validate the translations. However, to minimize translation bias, only professionals in the field of health communication were involved in the translation. Finally, it is important to understand that the goal of this study was to understand the benefits, barriers and outcomes of effective health communication from the point of view of healthcare professionals. Such benefits and barriers are evident in the literature, but there is scarce evidence on how health professionals understand their importance.

Conclusions
Many healthcare professionals have yet to receive HCT, even though almost everyone identifies the beneficial effect of successful health communication on improved professionalpatient relations, professional satisfaction and patient satisfaction, trust and medication adherence. Physicians appear to be less concerned about communication skills, the barriers and facilitators of effective communication and perceived outcomes of successful communication. Healthcare professionals should be sufficiently trained in health communication to achieve a better relationship, better prognosis and treatment results among patients. It is necessary to increase understanding of the benefits and systemic barriers to efficient communication so as to intervene also at the organizational level. Healthcare professionals must realize the importance of HCT in their everyday practice and governmental policies should focus on including HCT in the core of every health-related training program, especially at the undergraduate level. Prolepsis (Greece), Technische University Dresden (Germany), Centre for Advancement of Research and Development in Educational Technology LTD-CARDET (Cyprus), Universidad de La Laguna (Spain) and Cyprus University of Technology (Cyprus).

Conflicts of Interest:
The authors declare no conflict of interest.