| [Purpose] With the advancement of medical science and the acceleration of the global aging process,the number of prescriptions and health care products worldwide will increase exponentially.Unreasonable medications lead to unnecessary adverse drug reactions,rapidly increasing drug resistance,and billions of dollars in drug costs each year,so there is an urgent need to optimize drug use in patients.Due to the lack of appropriate theoretical framework models and the complexity of communication needs,there is a lack of research on how pharmacists communicate with patients and how patient communication affects patient outcomes.Based on the research status quo at home and abroad,the communication model of pharmaceutical care needs to be studied.The research objectives of this study are as follows: 1.Literature review of the pharmacist-patient communication model;2.Develop and validate communication model tools of pharmaceutical care and validte the communication model of pharmcetuical care;3.Develop intervention strategies for communication of pharmaceutical care based on Intervenrtion mapping and empirical results.[Methods] The systematic review method was used to collect and screen related articles on the pharmacist-patient communication model,and the included communication models was classified according to the interpersonal communication theory model proposed by Baxter and Braithwaite et al: individually centered,interaction-centered and relationship-centered model.The model was evaluated based on Fawcett's model theory evaluation framework with five dimensions: conceptual clarity,comprehensiveness of content,logical congruence,model abstraction,and clinical utility.Based on the results of the model evaluation,the TGA model is still considered to be the most appropriate communication model of pharmaceutical care at the time.The nominal group technique was applied to develop the core dimension of TGA model—Mutual goal setting.Exploratory and confirmatory factor analysis was used to test the reliability and validity of the questionnaire.Parallel analysis and MAP test were applied to determine the number of factors retained,and filter the questionnaire entries according to the factor loadings.The confirmatory factor analysis evaluateed the measurement validity and discriminant validity of the measurement model and screens the items.The internal consistency of the questionnaire was tested using Cronbach's alpha coefficient.At the same time,multi-group CFA models were used to verify whether the TGA communication model scale used in the study was invariant in different groups.Structural equation model was applied to verify the relationship between the pharmacist-patient communication model and patient outcome measures.Considering that the influences of sociological characteristics of individuals on the communication process,Multiple Indictors Multiple Causes Model(MIMIC)was constructed to include individuallevel confounding variables in the process of establishing mathematical models.Multi-group SEM models explore the relationship between control variables and the various elements of the communication model:(1)Whether the different group measurement models are invariant;(2)Whether the different grouping structure models are invariant;(3)Whether the different path-specific path coefficients or covariance coefficients are invariant;(4)Whether the average number of latent variables in different groups is invariant.Finally,Bartholomew's Intervention Mapping(IM)method was used to guide the construction of communication interventions with the empirical result of model vaildiation of pharmaceutical care.[Results] According to the literature review,a total of 13 communication models were included.The model evaluation results of the experts grading method show that the TGA model is optimal in the five dimensions of conceptual clarity,comprehensiveness of content,logical congruence,model abstract and clinical utility.It is considered that currently TGA model is the most appropriate communication model of pharmaceutical care.Construction of communication measurement tool of pharmaceutical care based on TGA model: After completing the MGS development process by nominal group technology,the final inclusion of 4 items was included in the original ATS scale with a total of 20 items.Patient outcome measures were measured using patient satisfaction.A total of 600 patients were investigated on-site during the questionnaire survey,and the final qualified number of questionnaire was 589.Two ATS items and one PES satisfaction questionnaire item were deleted following exploratory factor analysis principles.The results of the confirmatory factor analysis showed that the expected communication process ATS's 4-factor model(14 items)and PES's single-factor(6-items)model were validated with good model adaptation indices,measuring the initiation and response of pharmacist-patient communication,problem identification,mutual goal setting,exploring means and agreeing on means to achieve goals and patient satisfaction in five dimensions.The results of multi-group CFA showed that the communication model of pharmaceutical care were invariant to the measurement of latent variables at different ages,genders,educational levels,chronic disease groups,and survey locations.Construction of communication model of pharmaceutical care based on TGA model: As originally proposed,initating and response had a direct impact on identifying problems.Identifying problems had a direct impact on mutual goal settign.The mutual goal setting directly affected exploring and agreeing on means to achieve goals.As for the link between the communication process and patient satisfaction,exploring and agreeing on means to achieve goals and reaching consensus directly affected patient satisfaction.The final SEM model showed a good model fit index(TLI = 0.99,CFI = 0.99,RMSEA = 0.06).The MIMIC model results showed survey locations and chronic conditions were significant predictors of “identification of problems” and “patient satisfaction”.The level of higher education is significantly related to “mutual goal setting” and “patient satisfaction”.Age and gender were significantly associated with “initiating and responding”.Multi-group SEM results showed that the four path coefficients of the TGA communication model of different survey locations,gender,and chronic disease groups were also significant,but the grouping path coefficients were not identical.Construction of pharmacy service communication intervention strategy based on intervention mapping: The results of the needs assessment showed that the key factors affecting the communication of pharmaceutical care included: knowledge,attitudes,skills and self-efficacy.Under the overall goal of improving the communication behavior of mutual goal setting between the pharmacist and the patient,the specific objectives of the focus group discussion results under the overall goal(Performance objectives,PO)settings included: PO1 pharmacists and patients identify problems together;OP2with patients Emotional communication;PO3Discuss treatment plan information with patients;PO4Ask patient preferences during communication(for example,whether the medication expense is reimbursable);PO5Summary the conversation and provide the feedback.Obtaining the data from need assessment and focus interview groups,the behavior change matrix was formed by crossing the influencing factors and performance objectives,and the appropriate basic methods and practical strategies were selected for the specific behavior change objectives of the previous stage.According to the behavior change matrix,basic method and practical strategy design,the three-stage pharmaceutical care communication training was designed aiming to achieve behavior change goals through basic methods and specific practical strategies.[Conclusions] Based on the results of literature review and model evaluation,the TGA model is considered to be the most appropriate model for pharmaceutical care communication.The model evaluation results provided the research basis for constructing and developing communication measurement tools based on TGA model and verifying the communication model of pharmaceutical care based on TGA.First,the revised ATS tool measures and verified the communication process for the first time in the field of pharmaceutical services.The verification results showed that the revised communication process tool has good reliability and validity(content validity and discriminant validity).The tool also provided insights into the measurement of other communication processes in the medical field.First,the revised ATS tool measures and verified the communication process for the first time in the field of pharmaceutical services.The verification results showed that the revised communication process tool has good reliability and validity(content validity and discriminant validity).The tool also provided insights into the measurement of other communication processes in the medical field.Multigroup CFA showed that the CFA model maintains measurement invariance at different ages,genders,educational levels,and survey locations,which meaned the TGA communication measurement tool has the same factor number,factor load,and item intercept in different groupings.At the same time,Multi-CFA models were tested by structural model invariance: the relationship between the five factors of the TGA communication model are invariant among patients with different genders,ages,educational levels,chronic disease patients and survey locations.Second,the results of the TGA model validation showed that the model framework provides an valid framework for guiding pharmaceutical care communication.This study validated the TGA communication model through empirical investigation.The model results quantitatively explored the direct and indirect relationship between the various elements of the pharmaceutical care communication model based on TGA.The results showed that: The elements of mutual goal setting and exploring and agreeing on ways to achieve goals are the two most closely related.The communication process was directly related to satisfaction.The study found consistent with the results of the TGA model application in the previous studies.Multi-group SEM results showed that the communication model had good model indexes in different genders,chronic diseases status and different survey locations.However,the communication model was variant at different ages and educational levels.On the other hand,the TGA framework provided new insight for health policy makers,such as designing new interventions in the medical staff and patient communication process elements to improve patient communication outcomes.The SEM model verification results show that the relationship between the common goal setting and the exploration target achievement mode and the consensus dimension in the TGA communication process was the strongest.Information exchange involves mutual goal setting,exploring ways to achieve goals and reaching consensus.With the close connection between the elements of information exchange,the role of common goal setting was emphasized and seen as a key element in interfering with the pharmacist-patient communication process and improving patient outcomes.Therefore,this study was based on the TGA theoretical model,especially with the mutual goal setting as the core to develop a pharmacist-patient communication intervention strategy.IM is a time-consuming process,it allowed us to capture this complexity and enable us to develop training and written materials based on behavioral change goals,covering both versatile and targeted approaches.These methods can be integrated into current pharmaceutical service practices.Further research is needed to assess the acceptability and sustainability of these interventions.[Strengths and Limitations] Systematic review and expert interview was applied to review and evaluate the pharmaceutical care communication model.TGA is considered to be currently applicable to the pharmaceutical service communication model.The communication model of pharmaceutical care was validated using empirical survey data based on structural equation model.The results enrich TGA theory,but also provided new insights in the construction of communication model of pharmaceutical care.The validation of the model of pharmaceutical care can be used to guide the communication of pharmaceutical care by providing an effective framework and develop key elements of measurement items and testing communication measurement tools to make up for the deficiencies of measurement tools by empirical study,while at the same time provide ideas for doctor-patient,nurse-patient and other health care provider-patient communication.On the other hand,the TGA framework provided a new way for health decision makers to construct intervention strategies based on common results based on empirical results in this study,and to provide a new perspective for designing new intervention programs among medical staff and patient communication process elements.There were some limitations in this study.Considering the lack of research on the communication model of pharmaceutical services,the literature review results did not evaluate quality of the included literature.At this stage,the process is hard to achieve due to lack of quality research.The expert scoring method and the nominal group technique method are subjective evaluation methods.The background of the pharmacy service communication and the nursing background of the TGA original tool application were considered for election of experts.The authority and experience of the experts may affect the research outcome,as the focus of this study,the next step is to evaluate the impact of expert quality on the results.Although communication interventions of pharmaceutical care were constructed based on structural equation model results,further research is needed to assess the acceptability and sustainability of these interventions.In addition,the empirical research on the pharmacy service communication model was mainly carried out in tertiary medical institutions.The results of the pharmaceutical service communication model need to be verified in the primary medical institutions.The problem of insufficient sample size exists in the construction of Multi-group CFA model and Multi-group SEM model.In addition,more influencing factors can be included to analyze its impacts on the communication model,which can make the SEM model results more comprehensive.Patient adherence is one important indicator of pharmaceutical care and theory of goal attainment.As this indicator was not available in cross-sectional survey,further researches are needed to include the indicator. |
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