Interacción farmacéutico-paciente en la farmacia comunitaria, en particular, con el proceso y aplicación

Resumen

1.1 Introduction The relationship between a healthcare professional and a patient has been demonstrated to directly influence health outcomes.[1-3] Similarly, a patient-centeredness approach has proven to significantly improve patient experience of the health system.[4-8] The emerging trend for delivering patient-centred services in community pharmacy has led to an increased interest in the relationship between the pharmacist and the patient.[9-13] Research on the pharmacist-patient relationship has been approached from different perspectives, including how the relationship impacts patient satisfaction, health outcomes, or how patient’s health behaviour is modified.[8, 12, 14-22] However, no theoretical model for the community pharmacist-patient relationship appears to have been developed.[23] Theoretical models of other healthcare professional-patient relationships may be a reasonable starting point for constructing such a theory. On the other hand, the provision of professional services in community pharmacy, intended to improve health outcomes and the quality use of medicines, could also affect patients’ overall perception of the pharmacist.[24-29] This perception could be defined as the patient’s impression or idea of the community pharmacist as a healthcare professional and it has been labelled as the “Perceived pharmacist image”. However, despite some pharmacists are already providing services, some studies show that patients’ expectations of pharmacists still appear to be related to their dispensing role.[25, 30] Patients are still unaware what professional services a pharmacist is able to provide, are not interested in those professional services or prefer other professionals to deliver them.[31-33] Therefore, it is important to understand patients´ perception and expectations of the pharmacist in order to know and meet those expectations, and to provide efficient professional services.[25, 34] 1.2 Objectives The thesis approaches the relationship between the community pharmacist and the patient through the identification of healthcare professional-patient relationship theoretical models; as well as through the development and test of two conceptual models that explain patients´ perception and expectations of the pharmacist. Specifically, this Doctoral Thesis is structured into three research studies, which specific objectives are: 1. To identify healthcare professional-patient relationship theoretical models and individual influential factors that impact on this relationship and could be relevant to pharmacy practice. 2. To develop and test a conceptual model of the patient’s perception of the image of the community pharmacist 3. To develop and test a conceptual model of patient’s expectations of the role of the community pharmacist. Methods, results and discussion of these research studies are presented as a compilation of scientific articles. 1.3 Healthcare professional-patient relationships: systematic review of theoretical models from a community pharmacy perspective Abstract: Objective: To identify health care professional-patient relationship theoretical models and individual factors that may have an influence on this relationship and be relevant to community pharmacy practice. Methods: Using the recommended methodology by Prisma statement, a search was undertaken in PubMed for health care professional-patient relationship theoretical models that included individual factors. Results: Eight theoretical models met the inclusion criteria. These models were classified based on their aim, their focus on the interaction process, external factors influencing the process, and their practical applications. The most common influential modifiable factors were knowledge, needs, values, expectations, beliefs and perceptions. Conclusion: ‘The Theory of Goal Attainment‘ (TGA) appears to be the most useful model for community pharmacy practice. The perceptions and expectations of both patients and pharmacists could be the two most interesting modifiable factors to apply in pharmacy practice. These modifiable influential factors could be altered by specific training such as behavioural aspects. Practice Implications: No theoretical model has been specifically developed for analysing the community pharmacist-patient relationship. TGA may be appropriate for community pharmacy practice, since it takes into consideration both, attaining patient´s health outcomes, as well as improving patient-pharmacist relationship. 1.4 Patients´ expectations of the role of the community pharmacist: development and testing of a conceptual model Abstract Background: Community pharmacists are expanding their roles to include the provision of expanded professional pharmacy services. This role expansion is associated with a new patients´ impression of the pharmacist that could be labelled as “Perceived pharmacist image”. This particular perception of the pharmacist also has led to an increased interest of the pharmacist-patient interaction. Role Theory can be used to explain the interaction between this pair of individuals, by focusing on the roles performed by each one. Objective: To develop and test a model that relates patients´ image of the pharmacist to their expectations of pharmacist’s role, and how this then influences patients´ reactions towards the pharmacist’s role. Methods: A qualitative study was undertaken and a questionnaire was created for the development of the model, based on the Role theory. The content, dimensions, validity and reliability of the questionnaire were pre-tested qualitatively and in a pilot mail survey. The reliability and validity of the proposed model were tested using Confirmatory Factor Analysis (CFA). Structural Equation Modelling (SEM) was used to explain relationships between dimensions of the final model. Results: A final model was developed. CFA concluded that the model was valid and reliable (Goodness of Fit indices: x²(109) = 227.662, p = 0.000, RMSEA=0.05, SRMR=0.05, GFI=1.00, NNFI=0.90, CFI=0.92). SEM indicated that “Perceived pharmacist image” was associated positively and significantly with both “Professional expectations” (the standardized path coefficient of (H) = 0.719, p<0.05), as well as “Courtesy expectations” (the standardized path coefficient of (H) = 0.582, p<0.05). At the same time, “Professional expectations” were associated positively and significantly with “Positive reactions” (the standardized path coefficient of (H) = 0.358, p<0.05), but negatively with “Negative reactions” (the standardized path coefficient of (H) = -0.427, p<0.05). “Courtesy expectations” were associated positively and significantly with “Positive reactions” (the standardized path coefficient of (H) = 0.081, p<0.05), as well as “Negative reactions” (the standardized path coefficient of (H) = 0.450, p<0.05). Conclusions: A valid and reliable model of the patients´ image of the pharmacist related to their expectations and reactions to the pharmacist´s role was developed and tested. When the perceived image of the pharmacist is enhanced, patients´ expectations of the pharmacist are heightened; in turn, these expectations were associated with reactions of patients. 1.5 Modelling elderly patients´ perception of the community pharmacist image when providing professional services Abstract Professional pharmaceutical services may impact on patient’s health behaviour as well as influence on patients´ perceptions of the pharmacist image. The Health Belief Model predicts health-related behaviours using patients’ beliefs. However, health beliefs could transcend beyond predicting health behaviour and may have an impact on the patients’ perceptions of the pharmacist image. This study objective was to develop and test a model that relates patients’ health beliefs to patient’s perception of the image of the pharmacist, and to assess if the provision of pharmacy services (Intervention group-IG) influences this perception compared to usual care (Control group-CG). A qualitative study was undertaken and a questionnaire was created for the development of the model. The content, dimensions, validity and reliability of the questionnaire were pre-tested qualitatively and in a pilot mail survey. The reliability and validity of the proposed model were tested using Confirmatory Factor Analysis (CFA). Structural Equation Modelling (SEM) was used to explain relationships between dimensions of the final model and to analyse differences between groups. As a result, a final model was developed. CFA concluded that the model was valid and reliable (Goodness of Fit indices: x²(80) = 125.726, p = 0.001, RMSEA=0.04, SRMR=0.04, GFI=0.997, NFI=0.93, CFI=0.974). SEM indicated that “Perceived benefits” were significantly associated with “Perceived Pharmacist Image” in the whole sample. Differences were found in the IG with also “Self-efficacy” significantly influencing “Perceived pharmacist image”. A model of patients’ health beliefs related to their image of the pharmacist was developed and tested. When pharmacists deliver professional services, these services modify some patients’ health beliefs that in turn influence public perception of the pharmacist. 1.6 Perception of the polymedicated elderly patient about the community pharmacist’s role. [Percepción del paciente mayor polimedicado sobre el rol del farmacéutico comunitario] Abstract Introduction: Currently, almost the 80 percent of the health expenditure in Spain corresponds to people over 65 years old. This population has become polypharmacy as a result of their multiple diseases. Community pharmacists, due to their proximity and accessibility, are one of the health agents who could improve the quality use of medicines and help to control this expense. However, pharmacists are still known by their dispenser role. Materials and methods: An exploratory method was used based on the qualitative research. The Role Theory and Health Belief Model were used as theoretical frameworks. Semi-structured interviews were conducted as a means to get information. Results: Polypharmacy elderly patients tend to associate the role of the healthcare professional with their general practitioner and community nurse, giving less priority to the function of the pharmacist. Patients still identify the role of the pharmacists with the supplying of drugs and healthcare products, i.e., with their dispenser role. However, patients highlight the great accessibility and trust that they have towards these professionals. Conclusion: The polypharmacy elderly patients expect from the pharmacist in Spain a good treatment as well as a dispenser role. This might be due to the low expectations that they have about the pharmacist providing professional pharmacy services. They should extend their current role and also provide professional services in order to modify patients´ perception of the pharmacist.   REFERENCES 1. 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