Transforming Practitioner/Patient Communication in Hong Kong

1. Summary of the impact

Dr. Olga Zayts’ pioneering linguistic research aims to improve healthcare communication in settings connected to genetic counselling, prenatal screening and mental health services. Zayts’ research on the effects of sociocultural and linguistic factors on successful healthcare delivery and healthcare outcomes has influenced professional practice in the region and has led to the building of vital networks connecting professionals, organisations, and researchers across different disciplines. As a result of her research, Zayts has helped to establish and further develop genetic counselling as a professional field in Asia and organised research-based communication training for healthcare professionals, including genetic counsellors, paediatricians, obstetricians, and mental health workers. Through her active collaboration with mental health organisations, Zayts has further transformed how mental health issues are addressed in workplaces and educational settings by disseminating and raising awareness of culture-specific strategies for creating beneficial mental health environments for working professionals and youth. Together with her team, Zayts has contributed to improved information resources for patients and medical practitioners, including a Hong Kong government leaflet on a common genetic disorder and bilingual online materials for mental health professionals, patients, and caregivers.

2. Underpinning research

Zayts joined the University of Hong Kong in 2006 and is an Associate Professor in the School of English. Her research in interactional-oriented approaches to healthcare communication has demonstrated that crucial activities in healthcare, such as information- and advice-giving, decision-making, and diagnosis delivery are contingent on sociocultural context, including language use (English and Chinese), and that training healthcare professionals in culture-specific communication strategies raises their cultural awareness and improves healthcare outcomes [3.1, 3.2, 3.6]. Her examination of healthcare communication within the unique linguistic landscape of Hong Kong distinguishes her work from previous health communication-oriented research and applications, which were largely centred on English-dominant contexts. Using an innovative translational approach that centres on qualitative analyses of audio and/or video recordings of real-life clinical interactions supplemented by quantitative methods [3.1–3.6], Zayts’ research has generated the largest databases internationally on real-life clinician-patient and clinician-clinician interactions in Hong Kong clinical settings. These are used to develop training materials and disseminate findings to professional practitioners. Zayts’ use of real-life data in training instead of role-plays and other artificial scenarios has received positive feedback from professionals, and her rigorous research methodology has helped to validate the research findings among clinicians.

Communication practices in genetic counselling are a particular focus of Zayts’ research. Genetic counselling as a profession is developing in South East Asia. Since practices differ across regions, there are culture- and language-specific issues that need to be addressed through communication research. Zayts’ research has highlighted the impact of familial piety, cultural practices (such as the use of traditional Chinese medicine), religious beliefs, socioeconomic factors, and linguistic differences on patient decision-making. It has identified an overwhelming use of a directive approach in consultation settings in Hong Kong, with patients expecting medical professionals to tell them what to do, and observed how the use of English influences the rapport between medical professional and patient. Zayts’ research reveals how a greater level of understanding of complex genetic information can be achieved if professionals are more aware of the kind of language they are using. Overall, many studies in health communication have now shown that in clinical settings 80% of adverse scenarios are attributable to ineffective communication. Ineffective communication can lead to patient dissatisfaction with provided services, non-adherence to recommendations, and, in some contexts, even patient death. Zayts organised two colloquia (2010, 2012), which culminated in two seminal publications co-authored by Zayts and leading genetic professionals in 11 countries in Asia and published by the Journal of Genetic Counselling, a leading academic journal for genetic counselling professionals. The papers summarise culture- and context-specific genetic counselling practices in Asia and affirm the importance of effective communication practices in genetic counselling [3.6].

As an expert on health communication, Zayts was invited to join the Boards of two non-governmental organisations (NGOs): Mind Hong Kong (Mind HK) and City Mental Health Alliance Hong Kong. This has allowed Zayts to widen the outreach of her research to the general public and Hong Kong corporate communities. In June 2019, Zayts launched the Research and Impact Initiative for Communication in Healthcare (RIICH) at HKU (www.hkuriich.org). RIICH is the founding member of the International Consortium for Communication in Healthcare, alongside other key stakeholders, namely Harvard University Medical School, Australian National University, Nanyang Technological University, University College London and Lancaster University. RIICH builds on more than a decade of interdisciplinary collaborative work by Zayts and her team at HKU with clinicians and scholars in Hong Kong and overseas, and aims to continue to improve healthcare practices through evidence-based translational research on communication in healthcare.

3. References to the research

3.1 Zayts, O., Shipman, H., Fung, L.-F. J., Liu, P.-Y A., Kwok, S.-Y., Tsai, C.-H. A., Yung, T.-C., Chung, H.-Y. B.. The different facets of ‘culture’ in genetic counseling: A situated analysis of genetic counseling in Hong Kong. American Journal of Medical Genetics, 181(2): 187–195. (2019)

3.2 Pilnick, A. & Zayts, O.. The power of suggestion: Examining the impact of presence or absence of shared first language in the antenatal clinic. Sociology of Health and Illness, 41(6): 1120-1137. (2019)

3.3 Zayts, O., Sarangi, S. & Schnurr, S.. The management of diagnostic uncertainty and decision-making in genetics case conferences. Communication and Medicine, 13(1): 37–50. (2016)

3.4 Pilnick, A. & Zayts, O.. Advice, authority and autonomy in Shared Decision Making in antenatal screening: The importance of context. Sociology of Health and Illness, 38 (3): 343–359. (2016)

3.5 Zayts, O. & Sarangi, S.. Modes of risk explanation in telephone consultations between nurses and parents for a genetic condition. Health, Risk and Society, 15 (2): 194–215. (2013)

3.6 Zayts, O., Sarangi, S., Thong M. -K., Chung H.-Y. B., Lo, F.-M. I., Kan, S.-Y., Lee, M.-H., Padilla, C. D., Cutiongco-de La Paz, E. M., Faradz M. H. S. and Wasant, P. Genetic counseling/consultation in South-East Asia: A report from the workshop at the 10th Asia Pacific Conference on Human Genetics. Journal of Genetic Counseling, 22 (6): 917–924. (2013)

Selected Grants

1) Communicating Genetic Risk and Uncertainty across an Individual’s Lifespan vis-à-vis Family: A Discourse Analytic Study of Genetic Counselling in Hong Kong. Research Grants Council (RGC), 2018–19, HK$496,465 (Project with the Departments of Prenatal Diagnosis and Counselling and of Paediatrics and Adolescent Medicine, HKU, Queen Mary & Tsan Yuk hospitals; Clinical Genetic Services of HK).

2) A Discourse Analytic Study of Telegenetic Counselling in Hong Kong. Research Grants Council, 2011–13, HK$700,256 (Project with Clinical Genetic Services of HK and several public hospitals).

3) Language, Medicine, and Culture: Using English as a Lingua Franca in Prenatal Genetic Counselling in Hong Kong. Research Grants Council, 2009–12, HK$628,314 (Project with the Department of Prenatal Diagnosis and Counselling, HKU, Queen Mary & Tsan Yuk hospitals).

4) Zayts and Dr. Brian HY Chung (Department of Paediatrics and Adolescent Medicine, HKU) are Co-Coordinators for the KE funded interdisciplinary project “Working together across Arts, Medicine and Education: Enhancing genetic literacy in genetic counselling consultations.”

4. Details of the impact

Impact on Genetic Counselling in Hong Kong and Beyond

Zayts and her team collaborated with Clinical Genetic Service (CGS), Department of Health, Government of the Hong Kong Special Administrative Region (HKSAR), to create Hong Kong-specific resources for patients and their families about G6PD deficiency, a common genetic condition in Hong Kong. The leaflet used previously had not been updated for two decades. Zayts’ team conducted research on the culture-specific customisation of patient information resources, fieldwork, and focus group interviews with professionals to validate the leaflet design and content. The leaflet has now been expanded into a 12-page information resource featured in the CGS section of the Department’s website and is used by all public hospitals in Hong Kong [5.1]. The former Head of CGS, Professor Stephen Lam, states that “Zayts’s team worked very closely with CGS to hold focus groups with nurses and medical professionals in Tsan Yuk Hospital to get their feedback on its content and layout, as well as the correlation of visual and textual information.” He adds that the G6PD leaflet is “of relevance and benefit to a wide public community in Hong Kong by giving patients and their family members a better understanding of this hereditary disease and its related risks” [5.2]. The team is currently working on general guidelines for developing patient information resources for recommendation to government bodies in Hong Kong.

Zayts collaborated with Dr. Mary Tang, Clinical Associate Professor in the HKU Department of Obstetrics and Gynaecology and Honorary Consultant at Tsan Yuk Hospital, to organise a number of local and international workshops on genetic counselling, which were attended by colleagues from the Hospital Authority, including pediatricians and obstetricians. These workshops helped to establish a genetic counselling course for healthcare professionals and improve communication at prenatal screening sessions. Zayts’ linguistic research also resulted in the development of modules for the HKU Master of Medical Sciences in genetic counselling, “Understanding Risk Calculations and Principles of Genetic Counseling” and “Communication in Genetic Counselling” [5.3]. Dr. Hannah Shipman, who was part of Zayts' team between 2016–18 and is now a genetic counsellor with the North West Thames Regional Genetics Service based at St Mark's Hospital in London, writes that she is “constantly drawing insights from that line of work in [her] current professional practice,” particularly when she is “communicating with patients from cultural backgrounds other than [her] own who have a non-native proficiency in English,” and when "thinking about the ways in which risk information can be communicated to clients and their family members in predictive and diagnostic testing, and how uncertainty surrounding genetic testing can be conveyed" [5.4].

Zayts’ collaborative research on healthcare communication has contributed to the establishment and further development of genetic counselling as a field of professional practice in Asia. Her presentations on genetic counselling to scientists, clinical geneticists and counsellors at the Asia Pacific Conference on Human Genetics (APCHG) led to the establishment of a genetic counselling pre-conference workshop for all meetings from 2013 onwards. This workshop facilitates productive dialogue between genetic counsellors, genetic counselling students, medical doctors, nurses and researchers, operating as a forum for the professional development of medical and health practitioners. The report Zayts co-published as a consequence of the 2012 APCHG marked the beginning of the establishment of the Professional Society of Genetic Counsellors in Asia, which was officially launched on September 16, 2015, during the genetic counselling pre-conference workshop at the 11^th APCHG. The Society works to expand access to and delivery of genetic counselling in Asia, to foster partnerships, training, and professional development for genetic counselling, and to influence government policy [5.5].

Impact on Mental Healthcare Communication in Hong Kong

In 2018, Mind HK and the City Mental Health Alliance Hong Kong (CMHA) invited Zayts to serve on their respective Boards as a research expert on health communication in Asia. Zayts has been heavily involved in projects with both Mind HK and CMHA that aim to increase awareness and understanding of mental health issues among the Hong Kong community, and to influence decision makers to establish a comprehensive mental health policy. She was crucial to the organisation of the conference Mental Health Matters: Overcoming the Stigma in November 2017, which brought together over 600 professionals from various fields, including medical, educational, corporate, legal and media communications. Zayts’ team has conducted extensive interviews with mental health professionals to investigate the stigma surrounding mental health. The results have been incorporated into mental health training and the development of guidelines for translators of mental health information resources from English into Chinese. Dr. Hannah Reidy, Chief Executive Officer of Mind HK, writes that, “[Zayts’] research on healthcare communication has been vital to addressing issues related to mental health stigma, one of the priority research areas for Mind HK. The research was one of the materials that we used to develop the affordable mental health awareness training that we have since rolled out to over 700 people across Hong Kong, in English and Cantonese.” This training resulted in “significant improvements in individuals’ knowledge and confidence around mental health related topics” [5.6]. Using the translational research approach, Zayts is currently developing culture-specific strategies for creating mentally healthy workplaces in Hong Kong. Her findings are included in the development of training materials by CMHA for corporate businesses. The Chief Executive Officer of CMHA, Dr. Zoe Fortune, states that “having data from [Zayts’] research helps to ensure that recommendations provided are grounded in recent evidence with real life scenarios and data to draw on, ensuring that companies are provided with practical examples and solutions. For example, interview data stating that disclosure is an issue in the workplace due to stigma helps to provide real life case studies on why people do not disclose and what companies can do to better support individuals” [5.7].

Separately, Zayts’ team have translated mental health information resources that are featured on the website of Mind HK (A-Z of mental health), adapting them to the specific sociocultural context of Hong Kong. Content is donated by global collaborators, including Mind UK, the Charlie Waller Memorial Trust, Orygen, and the City Mental Health Alliance London. The A-Z was created in 2017; it currently features almost 4,000 pages of translated and validated information, and attracts traffic of 16,000 visits per month (https://www.mind.org.hk/mental-health-a-to-z/). Other materials include a series of four online, downloadable booklets containing mental health tips, available in English, Simplified and Traditional Chinese, which Zayts and the RIICH team reviewed [5.8]. Zayts was instrumental in securing HK$4 million in funding from Morgan Stanley to support Mind HK’s youth mental health programme CoolMinds and subsidise a full-time Mind HK PhD Scholarship at HKU. According to Dr. Hannah Reidy, “[Zayts’] research showing the mental health picture in Hong Kong, and the development of the website, allowed the funders to understand not only the situation in context, but also showed the impact that having good quality mental health information available has on the general public” [5.6]. In 2018, Zayts was involved with the first “Mental Health Media Awards,” and organised, with Mind HK, the inaugural Public Lecture on Health Communication, which featured Sue Baker OBE, the Global Director of Time to Change, the largest-ever programme to end mental health stigma and discrimination.

5. Sources to corroborate the impact

5.1 G6PD leaflet on the HKSAR Department of Health website.

5.2 Statement of Professor Stephen Lam, former Head of CGS, Department of Health.

5.3 Pamphlet for the Master of Medical Sciences OBGY6600 Genetic Counselling course.

5.4 Statement of Dr. Hannah Shipman, Genetic Counsellor, St. Mark’s Hospital, London.

5.5 A Report on Ten Asia Pacific Countries on Current Status and Future Directions of the Genetic Counseling Profession: The Establishment of the Professional Society of Genetic Counselors in Asia.

5.6 Statement of Dr. Hannah Reidy, CEO, Mind Hong Kong.

5.7 Statement of Dr. Zoe Fortune, CEO, City Mental Health Alliance HK.

5.8 Twelve “Mental Health Tips” PDF booklets from the Mind HK website.