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In China, the utilization of medical resources is tense, and most hospitals are highly congested because of the large population and uneven distribution of medical resources. Online health communities (OHCs) play an important role in alleviating hospital congestions, thereby improving the utilization of medical resources and relieving medical resource shortages. OHCs have positive effects on physician-patient relationships and health outcomes. Moreover, as one of the main ways for patients to seek health-related information in OHCs, physician-patient communication may affect patient compliance in various ways. In consideration of the inevitable development of OHCs, although they have several shortcomings, identifying how physician-patient communication can impact patient compliance is important to improve patients’ health outcomes through OHCs.
This study aimed to investigate the impact of physician-patient communication on patient compliance in OHCs through the mediation of the perceived quality of internet health information, decision-making preference, and physician-patient concordance, using an empirical study based on the self-determination theory.
A research model was established, including 1 independent variable (physician-patient communication), 3 mediators (perceived quality of internet health information, decision-making preference, and physician-patient concordance), 1 dependent variable (patient compliance), and 4 control variables (age, gender, living area, and education level). Furthermore, a Web-based survey involving 423 valid responses was conducted in China to collect data, and structural equation modeling and partial least squares were adopted to analyze data and test the hypotheses.
The questionnaire response rate was 79.2% (487/615) and the validity rate was 86.9% (423/487); reliability and validity are acceptable. The communication between physicians and patients in OHCs positively affects patient compliance through the mediation of the perceived quality of internet health information, decision-making preference, and physician-patient concordance. Moreover, physician-patient communication exhibits similar impacts on the perceived quality of internet health information, decision-making preference, and physician-patient concordance. Patients’ decision-making preference shows the weakest impact on patient compliance compared with the other 2 mediators. Ultimately, all 3 mediators play a partially mediating role between physician-patient communication and patient compliance.
We conclude that physician-patient communication in OHCs exhibits a positive impact on patient compliance; thus, patient compliance can be improved by guiding physician-patient communication in OHCs. Furthermore, our findings suggest that physicians can share high-quality health information with patients, discuss benefits, risks, and costs of treatment options with patients, encourage patients to express their attitudes and participate in health-related decision making, and strengthen the emotional connection with patients in OHCs, thereby decreasing patients’ misunderstanding of information and increasing concordance between physicians and patients. OHCs are required to not only strengthen the management of their published health information quality but also understand users’ actual attitudes toward information quality and then try to reduce the gap between the perceived and actual quality of information.
As a type of virtual community, online health communities (OHCs) are developed with the Web 2.0 technology [
In OHCs, patients can conveniently ask for physicians’ help anytime and anywhere in 2 main ways: posts and one-to-one communication. Therefore, patients can diagnose some simple symptoms by themselves on the basis of the information obtained from OHCs, and their privacy can be protected as the communication is not face to face [
In China, the utilization of medical resources is tense, and most hospitals are highly congested because of the large population, uneven distribution of medical resources, and low treatment efficiency. Moreover, medical resources cannot meet the daily needs of residents in some regions of China. OHCs can help alleviate hospital congestions, improve the utilization of medical resources, and relieve medical resource shortages to a certain extent [
OHCs can influence physician-patient relationships [
This study aimed to identify the impact of physician-patient communication in OHCs on patient compliance from the perspective of psychology, attempting to guide patient compliance through communication in OHCs. As a complex field, behavioral psychology has received attention from researchers in recent years, especially for its application in the study of health [
Collaborative medical interactions exhibit considerable relevance to health care outcomes [
OHCs are one of the main channels for patients to communicate with physicians on the Web. On the one hand, patients can engage with physicians without going to hospitals instead of only seeking health-related information from the internet. In addition, patients can also obtain additional information about their physicians if they contact the physicians before going to the hospital, which may reduce the uncertainty and sense of risk [
Generally, the effect of treatments depends on 2 aspects: (1) whether the treatment proposed by physicians is the correct remedy and (2) whether patients comply with the treatment [
High compliance is conducive to patients’ health outcomes, whereas low compliance or noncompliance may cause negative consequences related to patients, the economy, and the society. Diseases may be hard to treat if patients refuse to comply with physicians. According to Varleta et al [
Benefitting from the development of the internet [
Individuals with different health literacy levels exhibit different levels of ability to distinguish the quality of internet health information and perceive different information quality. From the perspective of information users, the perceived quality is different from the actual quality. Sporadically, a person may encounter a piece of high-quality health information related to a specific topic but may consider this information low in quality, in other words, the perceived quality is low. This situation may result from many factors. For instance, the channel that publishes this information may be low in quality and cannot convince users. In addition, the person’s cognition on this topic may be wrong; thus, he or she may consider the information to be low in quality.
The internet provides patients with opportunities to contact physicians and obtain health information. Thus, some patients’ health literacy can be improved, and they may be willing to play active roles in health-related decision making [
Actually, physicians are willing to discuss benefits, risks, and costs of treatment options with patients, encourage patients to positively participate in decision making, and make decisions after considering patients’ views [
Patients’ preference for participating in making decisions is dynamic [
Physician-patient concordance indicates that patients and physicians equally discuss treatment options [
A considerable number of researchers have conducted surveys on physician-patient concordance, comprising its pattern of manifestation, advantages, shortcomings, and influencing factors. Shin et al [
The self-determination theory was proposed by Deci and Ryan [
Autonomous self-regulation plays a critical role in health care, and Ng et al [
This paper intended to explore the impact of physician-patient communication in OHCs on patient compliance by establishing the research model (see
Research model. H1-H6: hypothesis number.
Patient compliance is a dynamic parameter, and noncompliance or low compliance may be involuntary [
Promoting physician-patient communication means encouraging patients to inform physicians of their health conditions and urging physicians to discuss treatment options with patients instead of making decisions themselves. A patient’s preference of participating in making decisions is dynamic [
Physicians and patients tend to have differences in their cognitions [
Perceiving internet health information as high in quality may make patients think that their physicians are professional and indeed share health-related information with them, thereby enabling patients to feel being allowed or inspired by physicians to participate in medical decision making, and their perceived autonomy support is increased. Under the guidance of the self-determination theory [
From the perspective of patients, a high decision-making preference does not mean that they prefer to make decisions by themselves rather than consider physicians’ advice. Generally, physicians mainly decide the final medical options, and patients’ decision-making preference represents the degrees at which patients participate in making decisions. Highly participating in health-related decision making means patients tend to be more autonomous. According to the self-determination theory, autonomy may encourage patients to behave positively in treatments, such as medicine adherence. Therefore, patients who prefer to participate in decision making are likely to perceive autonomy support from their physicians, which may help enhance their internal sense of health care and develop their ability of self-regulation [
High concordance between physicians and patients is the ideal consequence of treatments. In this situation, patients will highly agree with their physicians; thus, complying with physicians also means following their own choices. Similar to the discussion of the perceived quality of internet health information, patients assume positive attitudes toward their physicians, and they assume a perception of high supportive autonomy that promotes self-regulation of healthy behaviors [
To guarantee reliability and validity, we adopted the previous scales validated by published works to measure variables in the research model (see
The next step involved translating the instrument into Chinese, given that the survey would be conducted in China and our subjects were Chinese individuals who have communicated with physicians in OHCs. Referring to the similar translation process by previous studies [
Structural equation modeling (SEM) is useful in analyzing the causal relationships of research models, including mediators, and accommodating intricate causal networks [
The subjects of this investigation were Chinese individuals who have communicated with physicians in OHCs within the previous month to ensure that they could recall their relevant experiences. With the help of a medical association in China, the formal investigation was conducted in May 2018, and the questionnaires were sent to 615 participants. The participants’ informed consent was secured, and we committed that their privacy would be strictly protected. We used a Web-based platform to create and maintain the questionnaire, and participants also filled this questionnaire through the platform. This platform can help record the completion time of each response; therefore, the response, whose completion time is obviously lower than the average time, is regarded as invalid. In addition, the response that was not completed or that missed at least 1 answer is also invalid. Finally, we received 487 responses, and 423 of them were valid. Therefore, the response and validity rates were 79.2% (487/615) and 86.9% (423/487), respectively.
Sample demographics (N=423).
Demographic characteristics | n (%) | |
<20 | 19 (4.5) | |
20-29 | 127 (30.0) | |
30-39 | 124 (29.3) | |
40-49 | 97 (22.9) | |
50-59 | 49 (11.6) | |
60 and above | 7 (1.7) | |
Male | 203 (48.0) | |
Female | 220 (52.0) | |
Urban | 240 (56.7) | |
Rural | 183 (43.3) | |
Junior middle school | 22 (5.2) | |
High school | 60 (14.2) | |
Junior college | 124 (29.3) | |
Bachelor’s degree | 159 (37.6) | |
Master’s degree | 48 (11.3) | |
Doctorate | 10 (2.4) |
To identify the effect of demographic factors on relationships in the research model and to adjust the results, we added age, gender, living area, and education level into the research model as control variables. Although this study used previous validated scales to measure variables, we reevaluated the reliability and validity because of differences in backgrounds and participants. We calculated the Cronbach alpha of each construct using SmartPLS software version 3.2.8, as shown in
Cronbach alpha of constructs.
Constructs | Cronbach alpha |
Physician-patient communication | .909 |
Perceived quality of internet health information | .919 |
Decision-making preference | .749 |
Physician-patient concordance | .750 |
Patient compliance | .787 |
Composite reliability and average variance extracted.
Construct | Composite reliability | Average variance extracted | Square root of average variance extracted |
Physician-patient communication | .940 | .527 | .726 |
Perceived quality of internet health information | .947 | .528 | .727 |
Decision-making preference | .866 | .519 | .721 |
Physician-patient concordance | .869 | .570 | .755 |
Patient compliance | .864 | .561 | .749 |
Correlations between each of the 2 constructs.
Construct | PPCOMa | PQIHIb | DMPc | PPCONd | PCe |
PPCOM | 1.000 | —f | — | — | — |
PQIHI | .724 | 1.000 | — | — | — |
DMP | .624 | .665 | 1.000 | — | — |
PPCON | .705 | .722 | .617 | 1.000 | — |
PC | .725 | .700 | .595 | .686 | 1.000 |
aPPCOM: Physician-patient communication.
bPQIHI: Perceived quality of internet health information.
cDMP: Decision-making preference.
dPPCON: Physician-patient concordance.
ePC: Patient compliance.
fNot applicable.
According to the results by SmartPLS 3.2.8, we corroborated that age positively affected patient compliance in OHCs. Specifically, older patients were more willing to comply with medical regimens and treatments recommended by physicians compared with younger patients. In terms of gender, females were more likely to perceive high-quality health information in OHCs and exhibited high compliance with physicians compared with males. Furthermore, the educational level positively affected decision-making preference, indicating that patients who were highly educated would be more likely to participate in health-related decision making. This study used Cohen ƒ2 [
Results of the PLS-SEM can be observed in
Multivariate coefficient of determination (
Variables | Control variable effects | ||||
With control variables | Without control variables | ∆ |
ƒ2b | Effects | |
Perceived quality of internet health information | 0.532 | 0.524 | 0.008 | 0.017 | Insignificant |
Decision-making preference | 0.394 | 0.389 | 0.005 | 0.008 | Insignificant |
Physician-patient concordance | 0.501 | 0.496 | 0.005 | 0.010 | Insignificant |
Patient compliance | 0.588 | 0.570 | 0.018 | 0.044 | Small |
a
bƒ2: Cohen ƒ2.
Research model with path coefficients. H1-H6: hypothesis number.
Hypothesis testing.
Hypothesis | Path coefficient | ||
Physician-patient communication has a positive impact on patients’ perceived quality of internet health information | .700 | 18.693 | <.001 |
Physician-patient communication has a positive impact on patients’ decision-making preference | .620 | 16.629 | <.001 |
Physician-patient communication has a positive impact on physician-patient concordance | .684 | 19.677 | <.001 |
Patients’ perceived quality of internet health information has a positive impact on patient compliance | .333 | 4.569 | <.001 |
Patients’ decision-making preference has a positive impact on patient compliance | .151 | 3.002 | .003 |
Physician-patient concordance has a positive impact on patient compliance | .321 | 3.951 | <.001 |
Partial least squares effect size analysis.
Constructs | ∆ |
ƒ2c | Effect size | |||
In | Out | |||||
Perceived quality of internet health information | 0.588 | 0.545 | 0.043 | 0.104 | Small | |
Decision-making preference | 0.588 | 0.577 | 0.011 | 0.027 | Small | |
Physician-patient concordance | 0.588 | 0.543 | 0.045 | 0.109 | Small | |
Physician-patient communication | 0.532 | 0.094 | 0.438 | 0.936 | Large | |
Physician-patient communication | 0.394 | 0.050 | 0.344 | 0.568 | Large | |
Physician-patient communication | 0.501 | 0.083 | 0.418 | 0.838 | Large |
a
b∆
cƒ2: Cohen ƒ2.
Path coefficients by bootstrapping.
Effect | Path coefficients (SD) | ||
PPCOMa→PQIHIb | 0.703 (0.038) | .000 | |
PPCOM→DMPc | 0.623 (0.038) | .000 | |
PPCOM→PPCONd | 0.687 (0.035) | .000 | |
PQIHI → PCe | 0.215 (0.066) | .001 | |
DMP→PC | 0.094 (0.045) | .04 | |
PPCON→PC | 0.209 (0.082) | .010 | |
PPCOM→PC | 0.339 (0.067) | .000 | |
PPCOM→PC | 0.693 (0.035) | .000 |
aPPCOM: Physician-patient communication.
bPQIHI: Perceived quality of internet health information.
cDMP: Decision-making preference.
dPPCON: Physician-patient concordance.
ePC: Patient compliance.
To further evaluate the mediating effects in the research model, we conducted an additional analysis using the bootstrapping method (n=5000, 95% CI). As shown in
This study is the first that explores the impact of physician-patient communication in OHCs on patient compliance, and it makes theoretical contributions and practical implications for future studies on physician-patient communication and for guiding patient compliance through OHCs from the perspective of psychology. First, we constructed a research model to clarify the mechanisms through which physician-patient communication in OHCs impacts patient compliance by employing the self-determination theory. Previous studies have mainly focused on the relationship between offline physician-patient communication and physician-patient relationship and health outcomes, whereas the impact of communication in OHCs on patient compliance remains to be more focused, as OHCs are still in the stage of development, especially in China. Therefore, this study enriches theoretical researches on OHCs and patient compliance and improves the deficiencies of studies on strengthening patient compliance through communication in OHCs in China. In addition, this study used the self-determination theory to promote hypotheses and identify the motivation of patient compliance from the perspective of OHCs, and it enriches the application of the self-determination theory in the field of health-related behavior. The communication between physicians and patients in OHCs indirectly and positively affects patient compliance through the mediations of the perceived quality of internet health information, decision-making preference, and physician-patient concordance. Therefore, physician-patient communication in OHCs is beneficial for improving patient compliance.
Second, path coefficients from physician-patient communication to the 3 mediators are similar, and physician-patient communication just has a slightly stronger impact on the perceived quality of internet health information compared with decision-making preference and physician-patient concordance. Laugesen et al [
Third, the path coefficient from a patient’s decision-making preference to patient compliance is the smallest among relationships from the 3 mediators to patient compliance, and the path coefficients from the other 2 mediators to patient compliance are similar, implying that the impact of patient’s decision-making preference on patient compliance is weaker than the impact of the perceived quality of internet health information and physician-patient concordance on patient compliance. This finding is similar to the results of Laugesen et al [
Finally, compared with the perceived quality of internet health information and physician-patient concordance, decision-making preference shows the weakest effect on the relationship between physician-patient communication and patient compliance, but it can also be a perspective to improve patient compliance. To maintain high compliance, physicians can encourage their patients to participate in decision making in OHCs. Although patients may be unable to assist in making any decision, physicians are required to inform patients of medical options and understand patients’ real ideas related to decision making. In that case, patients can perceive the support of autonomy in treatments and think that the decision that they follow is partly made by themselves and then be likely to comply with the treatment.
Several limitations and prospects in this study must be considered. First, this study used the perceived quality of internet health information, decision-making preference, and physician-patient concordance as mediators, and other variables can be discussed in future studies. Second, the development of health care is special in China because of its large population and uneven distribution of medical resources. The effect of OHCs on health care in China may be different from that in other countries. Therefore, the similarities and differences between China and other countries can be explored in further studies. Third, this study only collected data through a cross-sectional survey once; hence, we were unable to dynamically capture the changes of participants’ attitudes toward all variables. Finally, we only matched the sample with the characteristics of typical OHCs’ users but did not consider the Chinese population. We originally intended to consider Chinese census data but found it difficult because of China’s large population. Ultimately, we believe that future studies may be able to address this issue.
This study indicates that physician-patient communication in OHCs positively impacts patient compliance through mediations of the perceived quality of internet health information, decision-making preference, and physician-patient concordance. In our research model, physician-patient communication shows similar effects on the perceived quality of internet health information, decision-making preference, and physician-patient concordance, and patient’s decision making has the weakest impact on patient compliance compared with the other 2 mediators. In terms of the mediation, all 3 mediators play a partially mediating impact on the relationship between physician-patient communication and patient compliance. In addition, these findings suggest the following: (1) physicians can share high-quality health information with patients, ask patients’ real opinions about information, and make efforts to decrease patients’ misunderstanding of information; (2) physicians can discuss benefits, risks, and costs of treatment options with patients, encourage patients to express their attitudes and participate in health-related decision making, and strengthen the emotional connection with patients to provide emotional autonomy support in OHCs; and (3) OHCs can not only strengthen the management of their published health information quality but also understand users’ actual attitudes toward information quality and then try to reduce the gap between the perceived and actual quality of information.
Measurement instruments.
average variance extracted
composite reliability
online health community
partial least squares
structural equation modeling
This work was supported by the National Natural Science Foundation of China (key program; grant number 71532002), National Social Science Foundation of China (major project; grant number 18ZDA086).
All 2 authors contributed to this study. XL and RZ conceived and designed the study, developed the research model, designed the questionnaire, conducted data collection and analysis, and drafted as well as modified the manuscript. All authors approved the final version of the manuscript for submission.
None declared.