Politeness Strategies of the General Practitioners at Community Health Center in Semarang

Communication which occurs between general practitioners and patients is meant to meet the patient's medical needs. In carrying out communication, general practitioners and patients always pay attention to their speech in order to reduce the threat of the face of the hearer and to establish a good relationship. Based on this, this study examines the use of general practitioners' politeness strategies in community health centers and aims to describe the politeness strategies used by general practitioners in establishing communication with patients. This politeness strategy study is a qualitative descriptive research in which data were obtained through the observation method and then were analyzed. The results of data analysis showed that general practitioners used three Brown and Levinson’s politeness strategies, namely Bald on Record strategies, positive politeness strategies, and negative politeness strategies.


Introduction
Communication is a process of conveying message both verbally and nonverbally by two or more participants. Through the communication process, people convey their ideas, information, desire, and even their feelings in the form of messages in order to fulfil their needs. In human life, communication becomes a very important activity This study discusses how politeness strategies are applied by general practitioners in community health centers in communicating with patients or the patients' families who represent them. Byrne and Long in Wynn (1995) explained that in a consultation occurs between doctors and patients, the doctors' actions tends to be seen as 'cause', while patients' as 'effect'. Hence, the researchers used the general practitioners, not the patients, as the focus of research.
Studies related to communication between medical personnel or paramedics and patients have been conducted by a number of researcher; such as Nurhayati (2010) who analyzed the register used by paramedics and Pramujiono (2011) who analyzed cohesion device in consultations between doctors and patients on a radio program. Some studies meanwhile focus on a particular type of speech used by medical personnel or paramedics; as in Supriadi's study (2013) which focuses on imperative speech by analyzing speech structure and patient responses and Arifin and Agustina's study (2017) which focuses on persuasion speech by analyzing the form of persuasion speech produced by nurses.
Communication between medical personnel or paramedics was also analyzed based on the use of maxims as is conducted by Suaedi (2013) who used Grice's maxims for his study and Puspitasari, Cahyono, and Winarsih, (2015) who used Grice's maxims and Leech's maxims of politeness for their study. The communication was also analyzed based on the use of speech acts, as is conducted by Darmayanti, Nurhadi, and Yubiliana (2014) and Chairul (2018).
Several studies was focused on the politeness use in communication occurred between medical personnel or paramedics and patients. Mubarak (2017) conducted research about politeness in Dirgahayu Village's community health center. Mubarak analyzed not the politeness strategies but the politeness principles, and thus made use of Leech's politeness principles theory, and not Brown and Levinson's. The politeness strategies research were conducted by Pramujiono (2008) and Yuni (2016). Pramujiono (2008) analyzed politeness strategies in doctor-patient communication on radio program. Applying Brown and Levinson's politeness theory, the study was focused on the positive politeness strategies. Yuni (2016), meanwhile, analyzed politeness strategies in nurses' speech at a hospital and found four Brown and Levinson's politeness strategies applied in nurse's speech namely Bald-on Record, positive politeness strategies, negative politeness strategies, and Off-Record strategies.
Doctor-patients communication occurred on a radio program and at a hospital may differ from the doctor-patients communication which occurred at community health centers. Thus this research pay attention to the politeness strategies at community health centers. This paper is expected to be able to answer the main question, that is, how the politeness strategies are used by general practitioners in communicating with patients (as well as patients' families representing them) at community health centers. Starting from the research problem, this study aims to explain the use of politeness strategies by general practitioners in community health centers.

Literature Review
Politeness cannot be separated from social life, as every participant in a communication is expected to apply politeness in conversation. Holmes (2013) explained that the notion of polite language is often associated with the choice of linguistic forms; both linguistic form which shows the appropriate degree of social distance and linguistic form which recognize the differences in power or status of the participants. Meanwhile, the concept of politeness in linguistics is defined by Yule (1996) as the way a speaker shows his awareness to the face of his speech partner.
Based on these explanations, the concept of politeness cannot be separated from the concept of face. The term 'face' was coined by Goffman (1982:5) and was ASIAN TEFL, Vol. 4 No.2, 2019, www.asian-tefl.com interpreted as a self-image described in relation to agreed social attributes. Brown and Levinson (1987) associated a person's face with his/her desires and classify the faces into two, namely negative face and positive face. Negative face is related to a person's wants that his actions are not hindered by others, while positive face is related to one's desires that his wants are understood and are desired by others. Brown and Levinson (1987) proposed several politeness strategies commonly used in communication, namely Bald on Record Strategy, Positive Politeness Strategy, Negative Politeness Strategy, and Off-record Strategy. Brown and Levinson (1987) describe Bald-on-Record strategy as a strategy that refers to the way of speaking which is conveyed directly and straightforwardly without any ambiguity which may lead to multiple interpretations. Bald-on-Record strategy is often used in special situations, such as situations where the speaker and hearer agree that urgency and accuracy of the message are considered to be more important than face saving acts, situations where the potential threat to face the speech partner is very small as in offers, and situations where the power of the speaker is far higher the that of the hearer.

Positive Politeness Strategy
Positive politeness is closely related to positive face. Brown and Levinson (1987) explain that a positive politeness strategy is implemented by indicating that hearer and speaker are members of the same group and that the hearer's wants is well understood and is desired by the speaker as well. Brown and Levinson (1987) explain further that positive politeness can be applied through fifteen strategies. The fifteen strategies are: (1) pay attention to hearer's interests, wants, and needs; (2) show sympathy by exaggerating intonation and stress; (3) strengthen the hearer's interest by involving the hearer on an event being discussed and by exaggerating the facts; (4) use group identity markers; (5) seek agreement by looking for conversation topics which will easily generate agreements and by repeating what the hearer said; (6) avoid disagreements by covering up disagreements, using pseudo agreement markers, lying to protect the face of the speech partner, and using hedges to disguise opinions; (7) raise common ground between speaker and hearer through a casual conversation that draws the attention of the speech partner; (8) use jokes; (9) state and imply speaker's knowledge of what the hearer wants; (10) make offers and promises; (11) show optimism that the hearer wants what the speaker wants; (12) include speakers and hearer in the activities by using inclusive 'we'; (13) give or ask for reasons; (14) assume or states reciprocity; (15) give gifts to hearer in form of objects, sympathy, understanding, and cooperation.

Negative Politeness Strategy
Negative politeness, on the other hand, is focused on negative face and is applied by showing awareness and respect towards the hearer wish, that is, the wants to act without being hindered by the others (Brown and Levinson, 1987). Based on this, negative politeness strategies tend to show more formality than positive politeness which shows solidarity.
Negative politeness is applied in communication through ten strategies proposed by Brown and Levinson (1987). Those ten strategies are (1) use indirect speech acts; (2) use questions and hedges; (3) be pessimistic; (4) minimize the imposition on the hearer by using expressions with low threat; (5) show deference; (6) apologize; (7) impersonalize speakers and hearers; (8) state that the face-threatening act is a general rule; (9) nominalize the utterance to make the speech become more formal; and (10) state clearly that the speaker incurs or does not incur a debt to the hearer.

Methodology
This study is descriptive research with a qualitative approach. Based on this, this research is intended to describe the use of politeness strategies found in general practitioners' speech via a series of words and not numbers.
The data of this study are the general practitioners' utterances toward patients which indicate the use of politeness strategies. The data was obtained from conversations that occurred between general practitioners and patients in several non-inpatient community health centers in Semarang City.
Data obtaining was conducted by applying the observation method accompanied by the note-taking technique (Sudaryanto, 2015). The researcher observed the conversation that occurred between the general practitioner and the patients during the community health centers' service hours and takes note of utterances that indicate the use of politeness strategies.
Data of the general practitioners' utterances that were obtained underwent some analysis process initiated by Miles, Huberman, and Saldana (2014) namely data condensation, data display, and conclusion drawing. The analysis is done by identifying speech that implies the use of bald on record strategy, positive politeness strategy, and negative politeness strategy, classifying which utterance belongs to positive politeness strategy and which utterance belongs to negative politeness strategy based on their sub-strategies, interpreting, and drawing conclusions.

Result and Discussion
Analysis of the data obtained shows that in establishing communication with their patients, general practitioners apply bald-on-record strategy, positive politeness strategy, and negative politeness strategy. Bald-on-record strategy was used by general practitioners through the use of direct, straightforward, and unambiguous utterances. The use of positive politeness strategy indicates solidarity. This strategy was implemented by pay attention to hearer's needs, showing sympathy, using group identity markers, making offers and promises, show optimism, including hearer in activities, and giving reasons for producing directive speech. The general practitioners' negative politeness strategy indicated respect and formality towards the patients and was implemented by using indirect speech acts, using questions, minimizing the impositions, showing deference or respects, and by not mentioning the speakers and hearers in orders and prohibition.

Bald on Record Strategy
One of politeness strategies used by general practitioners is Bald on Record strategy.
(01) GP: ini obatnya ya P: ya GP: jangan kena air dulu P: niki teng apotek? Niki kontrole berapa hari? GP: ng.. empat, tiga hari lah (Context: Conversation involves a general practitioner and a thirty-year-old female patient.) The utterance Jangan kena air dulu in (01) is a prohibition which means that the general practitioner forbids the patient to let his injury getting wet. In some conversations between general practitioners and patients, the accuracy of speech delivered to patients without any misinterpretation is considered to be more important than face-saving act. This leads the utterance Jangan kena air dulu to be uttered directly, concisely, and unambiguously.
General practitioners often use bald-on record strategy, especially in orders. This shows that both nurses (Yuni, 2016) and general practitioners use bald-on record strategy in communicating with the patients.

Positive Politeness Strategy
Positive politeness strategy used by general practitioners is shown as follows.

Pay Attention to Hearer's Interests, Wants, and Needs
The strategy of paying attention to the interests, desires, and needs of the hearer is carried out by the general practitioner by giving something, such as promises or offers, which are beneficial to the patients. In conversation (02), the general practitioner informs the patient about the patient's high cholesterol level and leads to the patient's face-threat. To reduce the threat, general practitioner offers to give medicines to patients. Hence, the general practitioner said Apa tak kasih obat-e sekalian nggih pak? in (02) indicates that the general practitioner shows concern for the patient's needs; namely the need to reduce cholesterol levels.
Strategy 'pay attention to hearer's interests, wants, and needs' was not found in doctor's speech in radio program (Pramujiono, 2008); and on the contrary it was found in nurses' speech (Yuni, 2016).

Show Sympathy by Exaggerating Intonation and Stress
In communication between the general practitioner and the patient, the general practitioners shows his attention and sympathy for the patient's condition by exaggerating the intonation. (Context: The conversation occurred between a general practitioner and a patient's mother. The utterance was uttered by the general practitioner when she examined the patient's tongue.) In conversation (03), the utterance o... nggih, sampe gitu.. uttered by the general practitioner indicates sympathy towards the patient. The act of giving attention and sympathy to the patient's condition shows that the general practitioner granted the patient's positive face, that is, the wants to be understood.
Showing sympathy strategy also appeared both in Pramujiono (2008) and Yuni (2016). This shows that general practitioners, the doctor in a radio program, and nurses in a hospital shows sympathy towards their patients, and hence indicates that the medical personnel as well as paramedics implement this strategy when establishing communication with patients.

Use Group Identity Markers
The implementation of the positive politeness strategy of general practitioners is also demonstrated through the use of group identity markers. The group identity markers can be found in address forms and languages that indicate a group.
(Context: Conversation took place between a general practitioner and a fiveyear-old female patient.) The general practitioner's utterance Ojo mimik es ya nduk in (04) indicates the use of group identity markers showed by the use of Javanese language accompanied by the greeting word 'nduk'. By switching the code to Javanese when speaking a prohibited speech, the general practitioner shows solidarity or kinship to the patient.
Strategy 'use group identity markers' was found in nurses' speech (Yuni, 2016). However, this strategy did not appeared in the speech of doctors in radio program.
(Context: Conversation took place between a general practitioner and a female patient in her forties. The conversation discusses the treatment of the patient's injured toenail.) Conversation (05) shows that the patient is afraid of the medical treatment suggested by the general practitioner, that is, the removal of the patient's injured toenail. The general practitioner later uttered Nanti disuntik kok anti nyerinya, which is considered as a promise, and gives the patient benefit.
This strategy did not appeared in Pramujiono's study (2008). The doctor-patient communication in Pramujiono's study was about sex consultation in a radio program in which the patients and the doctors did not meet directly (face to face). Giving a consultation in a radio program, the doctor only give information about what the patients need to do or must not do and did not give physical examination or such; and hence, their conversation did not really require making offers and promises.
This study and Yuni's study (2016), conversely, found the implementation of this strategy by the general practitioners and nurses. The general practitioners of community health centers and nurses of a hospital directly establishing communication with the patients and was hoped to serve the patients. Therefore, both the general practitioners and the nurses use promises and offers to decrease the face-threat when serving the patients.

Show Optimism
Being optimistic means that the general practitioner believes that the patient wants the same thing that the general practitioner wants and will do what the general practitioner wants.

(06) GP: nggak usah pedes-pedes, santen-santen dulu ya.
Sudah minum obat apa kamu? P: ndak minum obat GP: maeme harus mau ya (Context: Conversation occurred between a general practitioner and a sixthgrade female student complaining of a stomachache.) The general practitioner's utterance nggak usah pedes-pedes, santen-santen dulu ya and maeme harus mau ya in (06) indicates the general practitioner's optimism towards the patient. In uttering these two directive utterances, the general practitioner believed that the patient also has the same desire as the general practitioner has, that is, the desire for the patient to recover. Thus, the general practitioner believes that patient who also wants to recover will obey the general practitioner's utterances.
Strategy showing optimism was also found in Yuni (2016) and Pramujiono (2008). Both this study and Yuni (2016) shows that the speakers show optimism that the patients desire what the speakers want when making directive speech.
On the contrary, in Pramujiono (2008), the speakers show optimism by explicitly telling the patient that the patient's problem was actually easy to cure and by giving encouragement.

Include Speakers and Hearer in the Activities by Using 'Kita'
Involving not only the speaker but also the hearer in an activity reduces the distance between the two. The use of the expression "kita" to involve the hearer indicates that the hearer's cooperation is needed in carrying out the mentioned activity.
PM: sepuluh GP: kita liat mulute. GP: Haa-(Context: The communication involved a general practitioner, a ten-year-old male patient, and the patient's mother. The utterance was spoken by the general practitioner when he was about to examine the patient's mouth.) (08) P: karena apa i? GP: lha itu yang kita cari. Sebabe karena apa itu yang kita nanti cari bu. Maksudnya, kan bisa dari infeksi ini, terus melanjut P: itu biasanya tu telinga GP: telinga?
(Context: Conversation occurred between a general practitioner and a fortyyear-old female patient.) In (07) and (08), general practitioners involve patients in activities by uttering the expression "kita" and indirectly asking patients to be cooperative in these activities. The speech kita liat mulute in (07) shows that the doctor invites the patient to participate in oral examination by cooperatively opening the mouth and letting the general practitioner see the condition of his mouth. Meanwhile, the utterance lha itu yang kita cari. Sebabe karena apa itu yang kita nanti cari bu in (08) indicates that the general practitioner invites the patient to participate in the attempt of finding out the cause of her illness by giving the doctor information about the illness she suffered from and following physical examinations.
This strategy indicates that the cooperation of patients or patients' family are required in conducting an activity. The positive politeness strategy of doctors' speech in Pramujiono (2008) did not include this strategy, whereas the politeness strategy of nurses in Yuni (2016) includes this strategy. The doctor-patient communication in Pramujiono (2008) was conducted not directly, that is, the participants established conversation without having face-to-face meeting, and the conversation mainly about sex consultation. Therefore, the cooperation of the patients was not really required. On the other hand, the communication analyzed in the writer's and Yuni's study was conducted directly on which the participants meet and conduct some activities together, and thus, the cooperation of the patients was needed that the general practitioners as well as the nurses utter 'kita'. The general practitioner's utterance Lha kalo puasa kan pas kosong lama bu; kopi soalnya naikin asam lambungnya in (09) indicates the use of positive politeness strategy in the form of giving reasons. The general practitioner reduced the patient's face-threat by explaining the reasons why she prohibits the patient to drink coffee.

Give Reasons
Give or ask for reasons is one of positive politeness strategy. This strategy was found in this study as well as in Pramujiono (2008) and Yuni (2016). Pramujiono (2008) explained that the doctors asked for reason to patients and by doing that they pay attention to the patients, while Yuni (2016) shows that the doctors both give and ask for reasons. The appearance of this strategy in all three studies including this study indicates that 'give or ask for reasons' strategy in doctor-patient communication has function not only to convey positive politeness strategy but also to give information, or in other words to educate the patients, as well as to show that the speakers pay attention towards the patients.

Use Indirect Speech Acts
Utterances that are conveyed too directly often pose a face threat to the hearer's negative face; especially if the utterances spoken are directives intended to make the hearer perform a certain action according to the wishes of the speaker. In communication between general practitioners and patients at the community health centers, indirect speech acts are often found in directive utterances as follows.
(10) GP: Kenapa bu? P: nganu, kaki, ini kena standar. Standar Honda (Context: Conversation occurred between a general practitioner and a female patient in her forties with a cut on her toenail. As the general practitioner asking, the patient showed the general practitioner her injury.) The utterance kenapa bu? in (10) is a directive utterance which is intended to make the patient explain the illness she suffered and is an example of an indirect speech act used by a general practitioner. In conversation (10), the general practitioner did not convey directive utterance in imperatives, and said 'kenapa bu?' instead of 'jelaskan keluhan ibu'. This shows that the general practitioner use indirect speech to reduce the face-threat of the patient. The use of indirect directive speech acts in the form of questions by the general practitioner also explaining the other negative politeness strategies claimed by Brown and Levinson, namely the 'use questions' strategy.
Indirect speech strategy was also found in Yuni (2016). While in this study the indirect speech strategy was indicated by the use of indirect speech acts by the general practitioners, in Yuni (2016) the indirect speech strategy was showed by the use of modality 'tolong'.

Use Questions
Other way to apply negative politeness strategies is by use questions and hedge. While the writer does not find hedges in general practitioners' speech, the use of questions is often found in their speech.
The use of questions, as is explained earlier, is the application of indirect directive speech acts. Based on this, the frequently use of questions by general practitioners indicates that general practitioners use negative politeness strategies to show awareness of the negative faces of patients.

Minimize the Imposition on the Hearer by Using Expressions with Low Threat
Negative politeness strategies can also be applied by minimizing the imposition on the hearer. In general practitioners' speech, a way to minimize the imposition is by uttering 'sebentar' when telling the patients to wait.
(11) GP: Bisa saya lihat? Eh, tunggu sebentar ya bu.. P: sebenernya kemarin mau priksa, GP: he eh? P: hari senen kan penuh ya? GP: senen penuh, selasa juga penuh (Context: Conversation occurs between a general practitioner and a female patient. The general practitioner was about to do a physical examination but found out that the examination bed was still being used by another general practitioner. Therefore, the general practitioner asked the patient to wait.) Conversation (11) shows the way general practitioners minimize imposition on the patients. On the conversation, the general practitioner said 'tunggu sebentar ya bu' which is intended to make the patient wait. By telling someone to wait, a speaker cause face-threat on the waiting person (hearer). Thus, as is shown by (11), the general practitioner added 'sebentar' ─which imply that it would not take long time─ to her utterance in order to lower or minimize the imposition.

Show Deference
Other strategy used by general practitioners to apply negative politeness strategies is by showing or giving the patients respect. There are two ways general practitioners show deference to the hearer; that is, by producing utterances in polite Javanese Language (Krama Language) and by using polite addressee form such as 'Bapak', 'Ibu', and 'Njenengan'. Conversation (12) is an example of showing deference strategy by using Javanese Krama Language (Javanese polite language). As is shown by the conversation, the general practitioner produce sentences in Javanese Krama when talking to elderly patients. In the Javanese community, the use of the Javanese Krama indicates respect for the listener. Thus, the utterances Monggo pak and Pripun pak? in (12) shows that the general practitioner shows deference to the patients. (Context: Conversation occurred between a general practitioner and a female patient in her fifties. The patient came to the general practitioner and told the general practitioner about her swollen leg.) Conversation (13) is an example of showing deference strategy by using polite addressee form to point the hearer (patient). In Javanese, the expression 'njenengan' is a polite form addressee; which is the opposite of the expression 'kowe'. Therefore, by using 'njenengan' on his utterance, the general practitioner shows deference for the patient.
This study indicates that the 'show deference' strategy in general practitioners' speech was implemented by using sentences in Krama Javanese language and by uttering polite addressee. Yuni (2016), on the contrary, showed that this strategy was applied through using polite addressee to refer to the patients.

Impersonalize Speakers and Hearers
The impersonalizing speaker and hearer strategy is done by avoiding the use of first person singular pronoun (for example 'Saya') and second person pronoun (for example 'Anda'). In the general practitioners' speech towards patients, this strategy is found in several directive speech acts; such as in orders and prohibitions. (Context: This conversation occurs between a general practitioner and patient's father who accompanied a ten-year-old female patient. The patient's father came to the general practitioner and showed the laboratory test results then asking about his daughter's condition.) The negative politeness strategy is shown in conversation (14) by the general practitioner's utterance makannya tolong diperhatikan. The utterance makannya tolong diperhatikan is a directive speech which is uttered without mentioning the pronoun referring to the speaker and the pronoun referring to the hearer. In some occasions, avoiding the mention of speakers and the hearer in directive speech can reduce the imposition on the hearer. Therefore, as the general practitioner uttered the directive speech without mentioning the hearer (patient's father), the imposition on the patient's father is being reduced; resulting in the face-threat being reduced as well.
By avoiding mentioning the speaker and hearer in the utterance makannya tolong diperhatikan, the general practitioner saves the negative face of patient's father. Because the general practitioner did not mention the hearer (the patient's father), the utterance can imply that the task of paying attention to the patient's meal can be done not only by the patient's father but also by the patient's mother, the patient herself, and even other family members around them. Conversely, the imposition and face threat on the patient's father would have increased if the general practitioner had said 'makannya tolong bapak perhatikan' or 'makannya tolong Anda perhatikan'.
Applying this strategy, the general practitioners save the negative face of hearers (patients or the patients' family) by not explicitly mentioned the hearer as the person who need to do the mentioned activity. Similarly, Yuni (2016) also found this strategy in nurses' speech and explained that by using the strategy, the nurses led the hearer interpret their utterances.

Conclusion
In establishing communication with patients, general practitioners in non-inpatient community health centers apply Bald-on-Record strategy, positive politeness strategies, and negative politeness strategies. The positive politeness strategy used by general practitioners is realized through seven strategies, namely (1) pay attention to hearer's interests, wants, and needs, (2) show sympathy by exaggerating intonation and stress, (3) use group identity markers, (4) make offers and promises, (5) show optimism, (6) include speakers and hearer in the activities, and (7) giving reasons. The researcher also found five negative politeness strategies used by the general practitioners; they are (1) use indirect speech acts, (2) use questions, (3) minimize the imposition on the hearer by using expressions with low threat, (4) show deference, and (5) impersonalize speakers and hearers. Conversely, the offrecord strategy is not found in general practitioners' utterances. The absence of the Off-Record strategy indicates that the general practitioners do not use ambiguous utterances on which their way of interpretation is entirely left to the hearers. This is because in the communication between general practitioners and patients, conveying the right message is considered to be very important.