The Influence of Doctor ’ s Communication Skill and Patient Characteristics on Patient THE INFLUENCE OF DOCTOR ’ S COMMUNICATION SKILL AND PATIENT CHARACTERISTICS ON PATIENT COMPREHENSION OF CAESAREAN SECTION IN RSIA PURI BUNDA MALANG

The new era of health culture is concerned about patient safety, where the patients have the right to obtain information from doctors about the actions & treatment for them. Preliminary study results show that comprehension level of Caesarean section patients is still low (56%) and there is a big risk for the hospital to get medical litigations. This study aims to determine the influence of physician communication skills and patient’s characteristics against the patient’s comprehension of caesarean section. This study was an observational study with the cross sectional approach with 70 post-cesarean patients samples using purposive sampling. Data were collected by a questionnaire containing questions about physician communication skills, patient’s comprehension and patient’s characteristics and this study using logistic regression analysis. The test results showed that simultaneously, there is significant influence between doctor’s communication skills, age, a level of education and experience of the patient against the patient’s comprehension. Partially, showed a significant influence of physician communication skills and patient experience on the patient’s comprehension of a caesarean section, with the most dominant factor is physician communication skills.Therefore, the hospital can improve physician communication skills by doing communication training.

Nowadays, the era of health culture prioritizes patient safety.To carry out patient safety, we can use the principles of good clinical governance.One of the pillars of clinical governance is openness, which means that client is entitled to know all kinds of treatment and care given to her/ him, or get information from a doctor as health service called medi-cal information (Starey 2001).Even medical information is frequently provided by a doctor to patients, it still cannot be understood well by patients.One of the factors which have a crucial role is doctor-patient communication.The failure of the doctor in carrying out medical action will not lead to dispute if it is communicated well, and otherwise, if the success of the medical action is not well communicated and makes patient disappointed, it can cause a dispute or medical dispute.
Before patient decides to accept or refuse the action that will be given by the medical personnel or doctor, a doctor should convey enough infor-JAM 15, 2 Yudha Rose Satiti, Lukman Hakim, Harun Al Rasyid mation about everything related to the medical action first.The includes the risks, important facts, and side effects.If the patient approves the action that will be conducted by a doctor, then it is called informed consent, and rejection is called informed refusal.One of the actions that require clear information and informed consent from the patient is caesarean section.
Caesarean section has great risks and complications; even it can cause disability and death.Yang et al. (2009) mention that there is a significant relationship between malpractice lawsuit and caesarean section, thus caesarean section has a great risk for the occurrence of the medical lawsuit.In order to avoid the dissatisfaction of patient who will undergo surgery, good understanding about an operation, the rights, and obligations of a patient is requir ed.Mother and Child Hospital (RSIA) PuriBunda Malang has 86 beds, with the average case of childbirth per month of more than 150, and the average case of caesarean section per month of more than 60 more or 40% of the total cases of childbirth; therefore, the frequency caesarean section is quite high.According to the standard of WHO, caesarean section should not exceed 15% of the total childbirth (Gibbons et al. 2010).The high number of cases of caesarean section is because RSIA PuriBunda is a referral hospital of BPJS for complications that need the caesarean section.A high number of caesarean sections, according to Yang et al. (2009), correlates with great potential of the occurrence of a medical lawsuit.
To determine patient's level of understanding on caesarean section, a preliminary study was conducted in September 2015 to 15 post-caesarean section patients in RSIA PuriBunda.The results of the preliminary study show that patient comprehension on caesarean section was only 56%.This shows that patient comprehension level on the condition of caesarean section is still low; therefore, there is a great risk for the hospital to get a medical lawsuit.
Patient comprehension of doctor-patient communication process is influenced by a variety of factors.Schermerhorn (2012) states that patient comprehension of the information delivered by doctor is influenced by factor of source (doctor), factor of recipient (patient), factor of delivery media (channel), feedback and factor of barriers (noise).Factor of the doctor which is the most influential, according to Makoul, Krupat, and Chang (2017), is the ability of the doctor to communicate.Factor of the patient which is the most influential according to Hagie (2010) is patient's age, the level of education, and experience.
From the factors above, the most dominant factor which affects the patient comprehension related to caesarean section needs to be proved; therefore, the strategies to improve patient comprehension of the caesarean section can be determined.

METHOD
This research used an observational method with cross sectional approach.This research measured the influence of doctor 's communication skills, age, and level of education on patient comprehension of caesarean section.Primary data were collected by distributing research questionnaires to respondents for one (1) month, starting from April 2016 to May 2016 in RS PuriBunda in Malang city.The populations in this study were all post-caesarean section patients who met the criteria of research.Inclusion criterion in this study is elective Caesarean section patients through poly obstetrics, the exclusion criteria are patients who have the medical background as doctor, midwife, and nurse.The sampling technique used was purposive sampling method; there were 70 respondents used in this research.The instrument used in this study was a questionnaire, in which the validity and reliability had been tested.The data were analyzed by using logistic regression.

Characteristics of Respondents
Table 1 shows that from 70 post-caesarean section patients, most of the patients (80%) are 26 years old and above.In addition, based on the level of education, most of the patients (54%) have a high level of education.There are 60% of patients who have had caesarean section once.
The results of this research show that the average score of a variable of doctor's communication The Influence of Doctor's Communication Skill and Patient Characteristics on Patient skill (X1) as a whole is 3.83, which means that doctor's communication skill still needs to be improved.According to patients, doctor's communication skills are good, which the when doctor welcome them well a so they feel comfortable; doctor treats patients respectfully; patients agree that doctor explains the next step, including the action planned (91.5%); patients agree that doctor shows their care to patients' complaints; respondents agree that the doctor involves them in decision-making related to action will be made; doctor understands the problems of their disease.Doctor's communication skills which still need to be improved include: doctor interrupts when patient is talking; doctor uses language or term which cannot be understood well by patient; doctor only gives short consultation time; doctor provide as much information as asked by respondents; doctor asks whether respondents have understood all things described; doctor sees respondents (see, listen carefully); doctor asks respondents to ask the things that they do not understand well; doctor shows attention and understanding.
Table 2 shows that there are 55 patients (78.6%), who have relatively less comprehension of caesarean section.There are only one (1) of 5 (five) patients who have good comprehension of caesarean section.

Logistic Regression Analysis Simultaneous Significance Testing
Simultaneous significance testing generates the value of Chi-square equals to 21.207 with P <0.001, which shows the probability <level of significance (= 5%).This means that there is significant influence simultaneously of doctor's communication skill, patient's age, the education level of the patient, and experience of caesarean section on patient's comprehension of the post-caesarean section.

Partial Significance Testing
Table 3 shows that there is an influence of doctor's communication skill and experience of caesarean section on patient comprehension of caesarean section, with P <0.Hanifah (2015), Destria (2010), and Wiria (2007), which found that age has no effect on patient comprehension of the information provided by the doctor.The lack of relationship between age and patient comprehension of the caesarean section can be influenced by advanced technology and information, so the young often use and access technologies and information like the internet; therefore, they have the higher level of knowledge and comprehension.

Patient's Education Level Doesn't Affect Patient Comprehension of Caesarean Section
The results of this research indicate that patient's education level does not affect the understanding of the patient on caesarean section.It is not in accordance with the opinions of Hargie (2010), Khairiyah (2013), and Wiria (2007), that education level affects patient's comprehension of

DISCUSSIONS The influenceof Doctor'sCommunication Skill and Patient Characteristics (Age, Level of Education, Experience) onPatient Comprehensionof Caesarean Section in RSIAPuri Bunda Malang Simultaneously
This research shows that doctor's communication skill and patient characteristics together affect patient comprehension of caesarean section.It is in line with the studies conducted by Makoul, Krupat and Chang (2007) and Hargie (2010) that those four variables together contribute positively to a patient comprehension of caesarean section.A patient who is an adult has high level of education, has experienced caesarean section for more than once, and is supported by good doctor's communication will have a good understanding of caesarean section.

Doctor's Communication SkillAffects Patient Comprehension of Caesarean Section
This research indicates that doctor's communication skill affects patient comprehension of caesarean section.These results are in accordance with the theory of Makoul, Krupat, and Chang (2007) and Ong et al. (1995), which mention that the ability of doctor in communicating affects patients' comprehension of caesarean section.Schermerhorn (2012) states that doctor-patient communication which is supported by good delivery media and has minimal constraints will improve patient comprehension of caesarean section.The decision which is made together is very important.However, it should be noted that not all patients want to participate in decision-making about their health.In such The Influence of Doctor's Communication Skill and Patient Characteristics on Patient caesarean section.The discrepancy between theory and research results is influenced by good and twoway doctor's communication skill.Therefore, a level of education is not the determiner in gaining comprehension.This research is in accordance with the research conducted by Destria (2010), which shows that the level of education does not affect pregnant women's comprehension of caesarean section.The lack of relationship between the level of education and the comprehension of the caesarean section can be caused by the information in KIA book which is easy to understand by both well educated and low educated people.

Patient's ExperienceAffects Patient Comprehension ofCaesarean Section
The results of this research show that patient's experience affects patient comprehension of caesarean section.This is in line with the opinion of Hargie (2010) and Parker et al. (1995), that patients who have experienced caesarean section have got information on caesarean section in the previous childbirth.Therefore, in the present childbirth, the information given by doctor is just as a reminder to refresh the information that has been obtained before.Although patient does not get information directly from doctor or nurse, when a patient undergoes a caesarean section, automatically she will get the input from her senses to be saved as experience.Prathima (2014) found that the person who has been giving birth more than once has more knowledge and better understanding.Mungrue et al. (2010) show that patient who has had caesarean section has a better understanding than a patient who has not had a caesarean section.A patient who gets information directly from doctor also has a better understanding and more knowledge related to caesarean section.In addition, this study shows that there is no difference of understanding between patients who have emergency surgery and elective surgery.

RESEARCH IMPLICATION
The implication of this study is theoretically expected to strengthen the theory of interpersonal communication, particularly doctor-patient communication to implement the policies of the hospital and run the Regulation of the Minister of Health Indonesia.In addition, it is expected to provide scientific information to the other researchers to study the strategic policy of hospital and to be able to provide an overview of quality management success of hospital related to doctor-patient communication.It is also expected to be able to be used as the basis for further researchers to dig the factors that affect patient comprehension of caesarean section deeper.
The practical implication of this research is that RSIA Puri Bunda is expected to be able to improve its doctor's communication skill, in which according to Fallowfield et al. ( 2002) can be done by providing training of doctor-patient communication for medical personnel or doctors, to improve the quality and prevent the medical lawsuit.The training can be done by presenting speakers or experts to provide the material or workshop on effective communication.In this research, CAT questionnaire was used to evaluate the success rate of training.The results show that RSIA Puri Bunda does not need to provide different treatment in doctor-patient communication to provide medical information to patients based on patient's age and level of education.Doctors in RSIA Puri Bunda have to explain the information and ensure that patients (especially patients will undergo caesarean section for the first time) already know the consequences of an action that will be undergone repeatedly and as often as possible.
The limitation of this research is that the variable used does not describe all factors that affect patient's comprehension of caesarean section.The next researcher is expected to examine the other variables that affect patient's comprehension of caesarean section, such as intelligence, job, socioculture condition, economic condition, and the environment.If the most of the influential variables have been known, thus the results will be more accurate to determine the variable which is the most influential in patient comprehension of caesarean section.

CONCLUSIONS AND SUGGESTIONS
From the results of this research, it can be concluded that doctor 's communication skill and patient's experience give partial effect to a patient comprehension of caesarean in RSIA Puri Bunda Malang, in which doctor's communication skill has greater value than patient's experience.Together, the factor of communication skills, doctor, age, education, and patient's experience affect patient comprehension of Caesar section in RSIA Puri Bunda in Malang city.
From the results of this research, RSIA Puri Bunda Malang is expected to be able to provide training or workshop on communication for a doctor in order to improve patient comprehension on caesarean section.Further research is expected to add some variables such as intelligence, job, socioculture, economy, and environment which influence patient comprehension of caesarean section.
05. Patient's age and patient's education level have no effect on value of P> 0.05