Impact of the bidirectional relationship between communication and cognitive efficacy on orthopedic patient adherence behavior

Dong Shang Chang, Wil Lie Chen, Rouwen Wang

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background: There is growing interest in patient autonomy, and communication between physicians and patients has become the essential cornerstone for improving the quality of healthcare services. Previous research has concentrated on the direct effect of physician-patient communication on service outcomes. In the present study, we examined the influence among constructs in the service process and the impact on healthcare outcomes. The present study used behavioral theory to expand the process aspect of the Donabedian healthcare service quality structure-process-outcome model to examine the impact of cognitive changes and communication feedback on patients’ adherence behavior. In addition, the moderating effect of hospital facility levels is examined. Methods: A conceptual model was developed and tested using a questionnaire administered to patients in eight hospitals. A total of 397 respondents returned usable surveys, with a response rate of 92.11%. Structural equation modeling was used to analyze the data in two steps that involved a measurement model and a structural model. The former was applied to estimate the Cronbach’s alphas, intercorrelations of factors, and descriptive statistics; the latter was used to test the hypothesized relationships of the constructs. Results: The results identified three mediators of the healthcare process within the healthcare services framework: physician-patient communication, cognitive efficacy, and adherence behavior. Physician-patient communication influenced cognitive efficacy (β = 0.16, p < 0.001), and cognitive efficacy influenced physician-patient communication (β = 0.18, p < 0.001). The effect of this bidirectional relationship on adherence behavior was positive (β = 0.38, p < 0.001). The healthcare structure influenced healthcare outcomes via these three healthcare process constructs. The adherence behavior of patients who were treated in the medical center has greater influences by the structure and physician-patient communication than it was treated in the regional hospitals. Conclusions: This study revealed a complex pattern in relationships among process constructs for healthcare services. The findings of this study acknowledge the important potential interrelationships among the healthcare service constructs to improve the quality of healthcare outcomes. Trial registration: CRREC104107. Date: 22/01/2016. Prospectively Registered.

Original languageEnglish
Article number199
JournalBMC Health Services Research
Issue number1
StatePublished - Dec 2022


  • Adherence behavior
  • Bidirectional relationship
  • Cognitive efficacy
  • Physician-patient communication
  • Quality of healthcare services
  • Structural equation modeling


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