Discourse patterns of affective stance in paediatric online consultative encounters

1 Introduction

The unprecedented crisis of the COVID-19 pandemic necessitated a dramatic shift in traditional doctor-patient interactions to digitally-enabled remote consultations even in developing countries, like Nigeria. The pandemic necessitated a virtual healthcare system to reach patients and physicians who were refraining from in-person visits to avoid infection. Online health discussion forums are used by different patient groups to share advice and information. Therefore, this paradigm has significantly changed the way health information is sought (Yang and Gao 2018). Recently, online health communities have become an important channel for users to seek health information and share their experiences with medical treatments. Patients do not only interact with peers, who have similar experiences but also consult doctors about their diseases in online communities which form a new communication channel between patients and doctors nowadays. Meanwhile, searching for health or medical information is one of the most popular online activities for healthcare consumers (Akerkar and Bichile 2004; Gallant et al. 2007). E-encounter is a two-way, web-based exchange of clinical information between a patient and their caregiver that involves a closed-loop conversation about a specific clinical question or problem the patient is experiencing. It can be initiated by either the patient or the caregiver. Moderated (mediated) health forums, where healthcare professionals provide accurate information, are an alternative that has been shown to be superior to repeated consultations (Sinha et al. 2018). Online forums offer quick and friendly access to physicians and the opportunity for a large number of people to comment on a topic. Sinha et al. (2018) argue that the Internet is a widely available source of health-related information. Recent research has also found that approximately 70 % of Internet users have used the Internet to search for health information, underscoring the public’s high demand for medical information. It is therefore not surprising that paediatrics has been included in this telemedicine initiative. This study focuses on the issues of online paediatrics in Nigeria.

Nigerian children face myriad health problems such as malnutrition, malaria, pneumonia, diarrhoea, measles, cholera, convulsion, acute respiratory infections, vaccine-preventable diseases and other harmful traditional practices leading to high infant mortality (Balogun et al. 2021; UNICEF 2021). According to UNICEF (2021), “more than 2, 300 Nigerian children die every day from diseases that can easily be treated or prevented.” This is because some of the patients do not have access to treatment due to shortages in health care. This is the reason one in seven Nigerian children die before their fifth birthday. Olaniyan and Sunkanmi (2012) point out that the likelihood of seeking healthcare increases with household size and that the demand for healthcare for children in Nigeria is not linear. These are all serious problems for Nigerian paediatricians who are specially trained in child health, well-being and development.

One of the ways to find solutions to the myriad health problems of Nigerian children, in the face of bottlenecks in access to hospitals and physicians is through the online consultative forum, especially during the COVID-19 pandemic. Balogun et al. (2021) confirm this by arguing that “the COVID-19 lockdown posed challenges to accessing health services for a significant proportion of women”. The above background justifies why this study is interested in online child health encounters by examining the linguistic resources of Nigerian mothers’ affective stance in expressing their worries about their children’s health status in asynchronous discourse. It is given that the children’s sickness can be very stressful for parents, especially for mothers, who are saddled with the responsibility of child rearing in Africa. They often await consultation with the paediatricians with apprehension. A few studies have examined the experiences of mothers in paediatric encounters. Gemmiti et al. (2017), for example, investigate whether the medical interview in the paediatric context generates a stressful response in parents. The study concludes that the medical encounter was stressful for parents; and that paediatricians’ affective communication can modulate this stress through supportive communication. In this connection, scholars have argued that online space needs to be continuously studied from a linguistic perspective, to see how interactions change and how social actors take a stance on health issues (Diessel & Coventry 2020). Stance, a discourse concept of positioning, is conceived as an umbrella term for expressions of opinions, evaluations, judgments, attitudes, feelings, and emotions in texts. Stancetaking in this study describes how social actors position themselves with others through their words or assume a stance on paediatrics-related matters. Zhang (2020) argues that the e-healthcare context is ideal for studying the affective aspect of communication between doctors and patients/patients’ caregivers. In this study, the affective expressions of mothers in paediatric interactions on Facebook are examined.

The Facebook account of the online paediatrics consultative forum examined for this study represents asynchronous communication where both parties do not need to be “live” at the same time. It is, therefore, less disruptive and more accessible for both physicians and patients. In the Nigerian context, perhaps, it facilitates patients to have easier, more direct access to physicians because of the usual unnecessary bureaucracy associated with the on-site situation. Previous studies on online health consultative forums have only documented the range of health-related behaviours and content of health-related discourse on social media to the exclusion of linguistic behaviour in both child health and telemedicine studies. The present study complements these studies and focuses on the linguistic resources on affective stance in the discourse. However, it does not presume to identify the actual internal states of the speakers (mothers) on the basis of affective forms they may or may not employ; rather, it analyses these forms as linguistic realisations of affective stances in the online forum.

2 Stance in online encounters

The study adopts the views of Du Bois (2007) and Kiesling et al. (2018) on stance as a theoretical framework. Stance is a veritable tool in applied linguistics to determine a speaker’s position on the subject of discourse. Biber and Finegan (1988) describe stance as “the linguistic features of the expression of the attitudes of writers or speakers towards their proposition”. Similarly, Du Bois (2007: 139) suggests that stance can be viewed as a linguistically articulated form of social action whose meaning is to be construed within the larger framework of language, interaction and socio-cultural value. He further argues that stance is not something one has, not a property of the interior psyche, but something one does - something one takes. That is why, a stance is a public act by a social actor, achieved dialogically through overt communicative means, of simultaneously evaluating objects, positioning subjects (self and others), and aligning with other subjects, with respect to any salient dimension of the sociocultural field (p. 171). In sum, a stance is an act of evaluation owned by a social actor. In his stance triangle, Du Bois claims that there are three important aspects in taking a stance, namely stance subject, stance predicate and stance object. The stancetaker: evaluates an object, positions a subject (usually the self), and aligns with other subjects (p. 163). It is therefore both a linguistic and a social act. In Du Bois’ sense, stancetaking refers to the speaker’s relationship to the topic of discussion, to the interlocutor or audience, and to the conversation itself.

Kiesling et al. (2018) suggest that stance should be investigated in technological encounters. In online encounters, especially in asynchronous discourse such as the Facebook forum considered in this study, social actors such as mothers enact certain stances when presenting their distress. Some general classifications of stance available in literature are the epistemic stance (Biber and Finegan 1989; Biber 2004), evidential stance (Chafe and Nichols 1986), the evaluative stance (Du Bois 2007; Hunston and Thompson 1999), and the affective stance (Du Bois 2007; Ochs and Schieffelin 1989). The epistemic stance refers to how social actors present themselves as knowledgeable or ignorant; and the certainty of social actors about what is being expressed. The evidential stance describes the social actor’s attitude towards reality and the assessment of the reliability of the source of information being expressed. The evaluative stance indexes how a stancetaker orients to an object of stance and characterises it as having some specific qualities or values.

The affective stance indicates the feelings and beliefs of social actors and the degree of engagement with the interlocutors. Ochs (1996: 410) defines affective stance as “a mood, attitude, feeling and disposition, as well as the degree of emotional intensity vis-à-vis some focus of concern.” He further argues that in all communities, affective stances are socio-culturally linked to social acts in the minds of speakers (illocutionary acts), of hearers (perlocutionary acts), or of both speakers and hearers. According to Logren (2024), “affective stance is particularly salient in storytelling, in which the tellers display the emotional valence of the events they experienced, and thus provides means for the recipient to understand what it was like to experience it.” This study examines the expressions of affective stance in Nigerian mothers’ Facebook posts in describing their children’s health conditions. While previous studies on affective stance have captured assessments and rejections (Du Bois and Karkkainen 2012), refusals and compliance (Goodwin et al. 2012), complaining, blaming and pain displays (Robles and Weatherall 2021), the present study examines how mothers express “worry” and “concern” in an effective manner in online paediatric interactions. In this case, the study contextualises affective expressions as lexical resources that describe affective states of speakers in positioning themselves to objects in the discourse. In addition, Hyland’s (2005) linguistic stance markers are used to foreground the analysis.

Hyland (2005) identifies four linguistic stance markers: hedges, boosters, attitude markers and self-mention. Hedges are words such as would, could, possible, which emphasise that a statement is presented based on a writer’s interpretation rather than a fact. They are used to indicate tentativeness in communication and lessen the degree of confidentiality. Boosters involve words like actually, surely, clearly, which emphasize or de-emphasize certainty by allowing social actors to avoid conflicting views. Attitude markers clearly express social actors’ opinions or affective attitudes towards the proposition that convey importance, surprise, frustration, etcetera (Hyland 2005). Self-mention indicates the degree of overt social actors’ presence in the utterance, thereby projecting authorial identity. The specific objectives of the study are: to determine the discourse patterns of affective stance and examine the linguistic stance markers that foreground affective stance in this discourse. This sociolinguistic contextual framework is used to highlight the social experiences of Nigerian mothers in dealing with paediatric issues in telemedicine encounters. Consequently, it complements the studies on telemedicine and child health in linguistic scholarship.

3 Methodology

Data for the study included 80 Facebook posts collected between May and June 2020 on the group account of paediatricians tagged “Ask the Paediatricians”. One of us had to join the group to make the data accessible. The choice of this focus is justified by the fact that paediatric issues account for about 40 percent of health problems in Nigeria (UNICEF 2021) and that Nigerian children are particularly vulnerable to health challenges due to inadequate health facilities, especially during the pandemic. Therefore, the months studied were the peak period of the COVID-19 pandemic in Nigeria when a strict lockdown was in place. The group is an online health consultative forum, created by Nigerian paediatricians as a platform to interact with Nigerian mothers whose children have health-related issues to provide professional answers to their questions and rightly educate them on their concerns. The group has more than 600 thousand members, and the information of the group is as follows:

Ask The Paediatricians Facebook group is a forum for the Children’s doctors-Paediatricians and other children’s health care professionals to provide professional answers to child-health related questions. We provide health education and information to mums, dads and everyone involved in caring for children. Our goal is to improve child survival by promoting child health intelligence. Kindly read this POST and click the relevant links for detailed information to avail yourself all the benefits of joining us. here: https://m.facebook.com/groups/askthepaed/permalink/2581473795471389/. To visit our website www.askthepaediatricians.com

A total of 40 posts, by the concerned mothers, were randomly selected and captured through screenshots for each month. Only the mothers’ posts were considered in this study because their posts are obviously public, whereas the paediatricians often prefer to respond privately to mothers’ posts. In most cases, they ask the posts authors to contact them privately. Using the Brandfolder online text extractor, text was extracted from each of the screenshots. Substantively, the posts are predominantly centred on issues like breastfeeding/weaning, childhood immunization, stools abnormalities, child nutrition, malaria, child development, refluxing babies, sleep-related matter, paediatric surgery, and fever among others. The study adopted a qualitative descriptive-analytic method to investigate the linguistic features of affective stance in this discourse. Methodologically, the study adopted the overt lexical and syntactic design of stance. The study examines the discourse pattern of affective stance and the stance markers used by Nigerian mothers in describing the health status of their children.

4 Analysis and findings

In line with the objectives of the study, the analysis is conducted in two sections. The first (4.1) deals with the discourse patterns of affective stance, and the second (4.2) is concerned with the linguistic markers of affective stance in the sampled online platform. Two lexical items, “worry” and “concern”, underscore the construction of affective stance as post-writers’ oriented features in the sections of the analysis. The discourse patterns and linguistic markers are analysed in turn with specific excerpts as representatives of the entire corpus.

5 Conclusions

This study examined the discourse patterns and linguistic markers of Nigerian mothers’ affective stance in online paediatric encounters. The findings of the study suggest that the extensive use of affective stance in the discourses examined reveals the social experiences of Nigerian mothers in dealing with paediatric issues and the pattern of inquiry in telemedicine encounters. In particular, the dominant presence of highly emotive words, worry and concern, justifies the use of affective stance by mothers who use the platform to pour out their feelings and ask for help. Linguistically, the self-mentions as a linguistic marker of affectivity in this study represent the stance subject, a marker of presentation of self, reference to the agent of emotional feelings to overtly index commitment to the propositional content and the stance focus. The attitude markers identified in this study are classified as deontic verbs, attitude adverbs, attitude adjectives, and cognitive verbs. They are used to express the speaker’s attitude towards the affective situations being described or presented. Furthermore, some grammatical infidelities in the composition of the sampled posts obviously show a cyber language and style. Perhaps, due to technological factors and anxiety, the emphasis is more on the message or idea being conveyed rather than the grammatical rules. The data also project Nigerian English usage with lexical items that point to specific socio-cultural realities of ailments common to children in Nigeria and the linguistic behaviour of mothers when faced with paediatric-related issues; especially how they use indigenous linguistic codes to describe the symptoms of the illnesses. The data also reveal the culture of respect and politeness marked by affectionate greetings and the predominant use of “please”. The study thus adds to the existing literature on telemedicine and child health studies in linguistic scholarship. As with any other study, there are some limitations to this study that could be considered in further studies. In the present study, due to its focus, only the features of affective stance in the posts of the mothers were considered. Future research could expand this scope and look at the interactional stancetaking of both mothers and the doctors from a pragmatic perspective to unfold stancetaking in the flow of action interaction.