The Relationship between Internal Marketing and Patient Oriented Behavior ¡XThe Evidence from Kaohsiung Municipal Hospital In 21th century , not only the life quality but also medical care is perfect was requested by the people. The quality of service is highly related to the front-line worker. According to the literature review, the internal marketing has am important impact on the customer-oriented behavior. This article is empirical study to prove the influence of internal marketing on the patient-oriented behavior of front-line employees in medical care. The results showed that: 1.Adopting the conduct of internal marketing has an positive impact on affective and normative commitment of organization; but management support has a negative impact on continuance commitment, while thinking highly of staff has no effect on continuance commitment. 2.Adopting the internal marketing conduct has positive impact on organization climate for service. 3.Affective commitment, normative commitment and organization climate for service has positive impact on patient-oriented serving behavior. However, affective commitment and organization climate for service has negative impact on staff-oriented serving behavior. While there is no significance both in continuance commitment comparing with patient-oriented serving behavior and normative commitment comparing with staff-oriented serving behavior. 4.Adopting the internal marketing has a positive impact on patient-oriented serving behavior. However, management support has a positive impact on staff-oriented serving behavior; but thinking highly of staff has no effect on staff-oriented serving behavior. The study also indicated that internal marketing show a positive influence on patient-oriented serving behavior through normative commitment and organization climate for service. So the managers must concern the mediators such as normative commitment and organization climate for service while put internal marketing on the hospital to make sure patient-oriented serving behavior will perform. Key Words: Internal Marketing, Patient-Oriented, Staff-Oriented, Serving Behavior

As we discussed in our first editorial in the December 2018 issue (Polaha & Sunderji, 2018), an emerging science of knowledge translation (also known as implementation and dissemination science) aims to bridge the disconnect between evidence and practice. Researchers are increasingly engaging with knowledge users and other stakeholders as a key strategy to promote uptake. This may include policymakers, payers, and—the focus of this editorial—patients. Patient-oriented research is featured in national research agendas around the world including in Canada (Canadian Institutes of Health Research, 2018) and the United States (Patient-Centered Outcomes Research Institute, see https://www.pcori.org/), in part as it may contribute one solution to the “bench to bedside” gap (Greenhalgh, Jackson, Shaw, & Janamian, 2016; Jull, Giles, & Graham, 2017; McGavin, 2017). In this editorial, we provide a general introduction to research, its potential, and its realized value. We also suggest strategies for conducting patient-oriented research effectively, including a description of common barriers and how they can be dealt with. We hope this background will inspire you to get started with patient-oriented research and to learn more, as well as to share your patient-oriented research through Families, Systems, & Health.

Background: Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) despite the fact that most of them do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem. Physicians perceive that patients’ expectations influence their antibiotic prescribing practice. Methods: As the first phase of the thesis, we conducted a systematic review to determine the effectiveness of patient-oriented interventions to reduce unnecessary use of antibiotics for URTIs. As the second phase, we conducted a qualitative descriptive study to explore patients’ views about URTIs and identify ways they manage them by using semi-structured interviews based on Common Sense-Self-Regulation Model (CS-SRM). Results: Our systematic review included 14 studies which based on their interventions were classified into two major categories: delayed prescriptions and patient/public information and education interventions. Our meta-analysis revealed that almost all studies with delayed prescription significantly reduced use of antibiotics for URTIs. Our subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects regarding antibiotic use. The small number of included studies in the patient/public information and education group did not allow us to make a definite conclusion on their effectiveness. For the qualitative study, 15 individuals were interviewed. almost all participants mentioned that they only visited their doctor if their symptoms got progressively worse and they could no longer self-manage URTI symptoms. When visiting a doctor, most participants reported that they expected to receive an examination and an explanation for their symptoms. Discussion: Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic use or prescription for URTIs in patients. Further research is needed to investigate the costs and feasibilities of implementing these interventions as part of routine clinical practice. Our participants reported good knowledge regarding the likely lack of benefit from antibiotics for URTIs. The results suggest a discrepancy between our participants’ reported reasons for visiting doctors and doctors’ perceptions about patients’ reason for their visit identified in previous studies. Focusing on interventions that facilitate the communication between patients and doctors, instead of providing more education to public may help in reducing the use of unnecessary antibiotics.

Background: Patients with head and neck cancer (HNC) carry a clinically significant symptom burden, alterations in function (e.g. impaired ability to chew, swallow, and talk), and decrease in quality of life. Furthermore, treatment impacts social activities and interactions as patients report reduced sexuality and high rates of depression. Patients may suffer undue anxiety because they find treatment incomprehensible, which is partially a function of limited, understandable information. This can be particularly challenging for patients with limited health literacy. Furthermore, a globalized world consisting of cultural differences increases the need to enhance transparent communication of risk. Research on risk literacy and medical decision-making validates that across different cultures, people often have severe obstacles in grasping a host of prerequisite concepts for understanding health-related risk information such as numbers, graphs, and basic medical facts. Patients’ perceptions of having obtained adequate information prior and during treatment are predictive of positive outcomes. Providing patient-centered decision-support, utilizing visual images, may increase understanding of treatment options and associated risks to improve satisfaction with their decision and consultation, while reducing decisional conflict. A scoping review was conducted on electronic, decision aids (DAs) for oncology patients that returned 4217 articles, but only 167 for HNC, with 12 meeting the inclusion criteria. Three themes were identified: (1) both patients and physicians valued the DA; (2) DAs should be visually supported by images; and (3) use of a DA lessened decisional conflict and anxiety while improving knowledge, satisfaction and shared decision-making. This informed the design of a prototype DA. Semi-structured interviews were conducted with 12 survivors of HNC who completed treatment at BC Cancer- Victoria on their experiences, feedback on the utility of a DA, and insights into design features. Thematic analysis resulted in 12 themes that were organized into 3 categories. The first category, “the patient experience,” included three themes: “patients have high, through varying information needs”; “an emotional experience”; and “stories of coping, strength and resiliency.” The second category, “electronic DAs and decision support,” also included three themes: “familiarity with decision aids”; “support of concept: usefulness and of visual aids”; and “versatility of the prototype.” The last category, “evaluation of prototype”, contained six themes: “reaction to prototype”; “favourited features”; “complexity”; “preference for customizability”; “suggestions for improvement”; and “presentation device.” Key Message: The use of DAs have been shown to better inform and increase patients’ knowledge, accuracy of risk perception, and congruency between informed values and care choices allowing them to take part in active decision-making, compared to usual care. Survivors of HNC were in unanimous support of using visual images to help explain treatment and assist in decision making on treatment options. Furthermore, they contributed invaluable feedback on the prototype design, demonstrating the value of a co-design methodologies. / Graduate

Prior to the coronavirus disease-2019 (COVID-19) pandemic people with chronic obstructive pulmonary disease (COPD) were already experiencing social isolation due to the complex intersection of symptoms, and perceptions towards the illness. COPD is a chronic lung illness characterized by progressive shortness of breath, and decreasing lung function, with influenza and other respiratory illnesses more likely to have fatal consequences for this population. Societal beliefs and assumptions around behavioural risk factors, and in particular smoking, contribute to perceptions that COPD diagnosis, outcomes and experiences are self-inflicted and an individual responsibility. This is a perspective that fails to take into the account the complex contextual factors of the social determinants of health, where structural inequities result in higher smoking rates among populations with lower socioeconomic status. Further, these underlying societal values may compound the isolation experienced with COPD in which ongoing stigma towards the illness discourages people from identifying with a COPD diagnosis. The lack of identity may discourage developing a community where people can share experiences and strategies in living with COPD, and form a collective group that can advocate for change. Digital technologies (DTs), such as Facebook and Zoom offer new avenues to support social connectedness. However, little focus has been given on how people with COPD may (or may not) be using DTs to support their illness. This study explored the role DTs could serve in addressing social connectedness and experiences and outcomes for the COPD community. The study was informed by Mertens (2003, 2007) transformative approach where the knowledge of people living with COPD was prioritized in finding out what DTs they may be using to maintain social connectedness and to support their illness. The three stage mixed methods research design consisted of interviews, patient-reported outcome measures, patient-reported experience measures and a DT survey. Bazeley's (2018) approach was used to guide the integrative mixed analysis on data collected across the three stages. The overall findings were: 1) Participants’ experiences in living with COPD had uniquely prepared them for the COVID-19 pandemic, and it was the community that lacked capacity; 2) Dominant discourse around technology may be creating further harms to the COPD population that extend beyond the digital world; 3) Current digital health monitoring strategies for other chronic illnesses do not fully translate to the interests and needs for people living with COPD; 4) People living with COPD are using DTs, but prefer to keep their virtual world separate from their illness world; and 5) Considerations for DTs for COPD should move beyond managing outcomes, and include supporting experiences of living. Conducted between December 2018 and July 2020, and concurrent with the COVID-19 pandemic, the study demonstrated even greater importance with the onset of the pandemic in understanding how DTs may support social connectedness for people living with life-limiting chronic lung conditions. / Graduate / 2022-02-07

As youth with disabilities age and transition to adulthood, they will often need to learn how to manage their healthcare. Siblings are members of the family who can provide support to their sibling with a disability, but their roles during transition have not been well described in the literature. Typically developing (TD) siblings identified that they require information and resources in their roles. The overall objectives of the research studies in this doctoral dissertation are: 1) to synthesize existing resources and programs to support TD siblings of individuals with a disability; and 2) to develop a deeper understanding about the experiences of TD siblings. The findings from these studies are summarized in six scholarly manuscripts prepared for peer review and publication. All studies were conducted in partnership with siblings with lived experiences. Results from the review and qualitative document analysis of online resources to support TD siblings (Chapter 2) identified that limited resources are available to support TD siblings with healthcare management of their sibling with a disability. The scoping review (with the protocol described in Chapter 3 and results presented in Chapter 4) identified that programs for TD siblings are focused on knowledge development and skill acquisition for the TD siblings themselves or on empowerment by training TD siblings in skills that they can apply with their sibling with a disability. In addition to synthesizing existing knowledge, the qualitative study provided an in-depth understanding of the experiences of TD siblings (with the protocol described in Chapter 5) in two distinct areas: their roles and responsibilities (Chapter 6) and the influence of their sibling and family relationships on their identity formation during developmental stages (Chapter 7). Overall findings from this dissertation suggest areas for future directions, including knowledge transfer to share synthesized resources with target audiences, co-creation of resources to support siblings in their roles, and enhancement of programs to involve siblings and the whole family. / Dissertation / Doctor of Philosophy (PhD) / As youth with a disability transition to adulthood, many will assume greater responsibility for their own health management, activities often supported by family members, including siblings. Little information is available about the roles that siblings have to their sibling with a disability in this process. Siblings have mentioned that they need information and resources for their roles. The purpose of this work is to summarize resources and programs in Canada and internationally for siblings, as well as better understand the experiences of siblings of an individual with a disability. The information from this work can be helpful by sharing the summary of resources with siblings and families, create new resources to support siblings of an individual with a disability, and build on programs that allow for siblings and the whole family to participate.

Drug interactions are an important source of medical error. Studies have also shown it as a topic of particular interest to patients. To allow patients to participate in decision-making regarding their own health, they need to be empowered with information. This information must be provided through usable information systems. This thesis explored availability of drug interaction checkers in Scandinavia. It also explored the prevalence and characteristics of usability issues preventing patients from benefiting from these. Drug interaction checkers were sampled and described. Issue-based qualitative and quantitative data were gathered through heuristic evaluations. Patterns in the data were identified through descriptive statistics. Single-case and cross-case analyses explored emergent patterns in-depth. The findings were then interpreted side by side using a mixed-methods approach. The results showed the Scandinavian public faced with drug interaction checkers addressing healthcare professionals. They also showed a multitude of usability issues in these checkers. The issues were predominantly minor, but major issues were also identified in all but one of the checkers. Catastrophic usability issues were found in two of the checkers. These had the potential to lead patients to serious medical error. Results moreover showed the checkers lacking adaptive design, patient-oriented content, and a lack of adherence to basic design principles. A positive correlation was observed between system complexity and number of usability issues. This was suggested to result from lack of user-centered design approaches, or losing track of user goals while adding features over time. The result was a handful of generally professionally oriented drug interaction checkers known to be used by patients for their utility, but failing to accommodate them in terms of information and system quality. Empowering patients to participate in decision-making affecting their health asserts the need for developing patient-oriented information databases where these do not yet exist. These need to be presented through usable interfaces acknowledging patient behaviors. / Läkemedelsinteraktioner är en viktig orsak till medicinska misstag. Tidigare studier har även identifierat läkemedelsinteraktioner som ett område av särskilt personligt intresse för patienter. För att patienter ska kunna vara delaktiga i beslutsfattande beträffande sin egen hälsa, måste de ges tillgång till information genom användbara informationssystem. Denna uppsatsen undersökte tillgänglighet av interaktions­granskare för läkemedel för den skandinaviska publiken. Den undersökte också förekomst och karakteristiker av användbarhetsproblem som förhindrar patienter från att dra nytta av dessa interaktionsgranskarna. Tillgängliga interaktionsgranskare listades och beskrevs. Kvalitativa och kvantitativa data samlades in genom heuristiska utvärderingar. Mönster identifierades genom beskrivande statistik, medan kvalitativa enkelfalls- och tvärfallsanalyser undersökte frambrytande mönster på djupet. Resultat från kvantitativa och kvalitativa metoder tolkades sedan sida vid sida. Resultaten visade att skandinaviska patienter huvudsakligen möter interaktions­granskare riktade mot professionell vårdpersonal. Resultaten påvisade också en stor mängd användbarhetsproblem i dessa granskarna. Problemen var oftast av mindre vikt, men även stora problem identifierades i alla utom en av granskarna. Katastrofala användbarhetsproblem hittades i två av granskarna. Dessa hade potential att leda patienter till allvarliga medicinska misstag. Resultaten visade dessutom att granskarna saknade adaptiv design, patientorienterat innehåll och efterlevnad av grundläggande designprinciper. En positiv korrelation observerades mellan systemkomplexitet och antal användbarhetsproblem. Detta föreslogs vara ett resultat av brist på användarcentrerad designmetod eller att man har tappat fokus på användarmål över tid medan funktioner har lagts till. Resultatet var en handfull huvudsakligen professionellt inriktade granskare för läkemedelsinteraktioner som används av patienter för deras nyttja, men som inte lyckas med att ta hänsyn till dem när det gäller informations- och systemkvalitet. För att patienter ska få möjlighet att delta i beslutsfattande som påverkar deras hälsa, finns behov av att utveckla patientorienterade informationsdatabaser där dessa ännu inte finns. Dessa måste erbjudas genom användbara gränssnitt som tillgodoser patienters beteenden.

Introdução: A Medicina Baseada em Evidências, apesar da grande profusão de publicações da área, enfrenta desafios no intuito de melhorar a qualidade da assistência à saúde. O conhecimento gerado por suas publicações demora a ser posta em prática. Os softwares CDSS de apoio à decisão clínica, podem ser a solução de incorporação das evidências na prática clínica. Esses sistemas já foram associados a melhorias na qualidade de diversos aspectos da assistência à saúde, como a organização, minimização de erros, redução de custos, aumento da eficiência dos cuidados, mas pesquisas com desfechos centrados no paciente ainda são raras. Como outra qualquer intervenção em saúde, as afirmações de que os CDSS são benéficos para o paciente necessitam de confirmação por ensaios clínicos. Objetivos: Verificar se o uso dos CDSS com base em evidências, está associado com melhores resultados clínicos orientados para o paciente. Métodos: Revisão sistemática da literatura dos ensaios clínicos controlados e randomizados que compararam diretamente o uso de CDSS com práticas clínicas convencionais considerando os desfechos clínicos classificados como orientados para o paciente. Resultados: Nossa estratégia de pesquisa identificou 51283 artigos na base MEDLINE-PubMed, sendo 311 selecionados para leitura de título e resumo após a aplicação do filtro para ensaio clínico randomizado, 45 selecionados para leitura do texto completo, dos quais 19 preencheram o critério de elegibilidade. Outros 9 ensaios foram incluídos através da realização de um overview das revisões sistemáticas anteriores. Os ensaios foram publicados entre os anos de 1995 e 2015 e realizados em cinco contextos assistenciais, com duração máxima de 12 meses. A maioria das fontes de evidências que alimentaram os sistemas foram diretrizes de órgão governamental ou sociedades de especialidades. Doze ensaios avaliaram mortalidade, 14 avaliaram hospitalizações ou atendimento de emergência e 6 avaliaram desfechos relacionados a presença de sintomas. Foram realizadas meta-análises de acordo com o contexto assistencial e o tipo de desfecho. Somente uma meta-análise envolvendo a mortalidade de pacientes tratados em ambulatório por diferentes condições clínicas se mostrou estatisticamente significante, favorável ao grupo CDSS, em 3 ensaios randomizados por aglomerado, com risco de viés considerado moderado, que compromete a qualidade da evidência. Conclusões Apesar do potencial dos CDSS no apoio de intervenções de saúde, não há evidência de boa qualidade de que sejam efetivos para aumentar a sobrevida ou a qualidade de vida dos pacientes. O número de ensaios que avaliam esses desfechos, os períodos de tempo pelos quais os pacientes foram seguidos, o número insuficiente de participantes, bem como a heterogeneidade entre os estudos analisados quanto aos cenários clínicos e as fontes de informação que alimentam os softwares não permitiram resultados mais conclusivos / Background: In spite of the wealth of publications in the field, Evidence-Based Medicine faces challenges in order to improve quality of health care. It takes too long for knowledge produced by its publications to be put into practice. Clinical Decision Support Systems (CDSS) may be a solution for incorporation of evidence into clinical practice. These systems have been associated with improvements in quality of various aspects of health care, including its organization, error minimizations, cost reductions and increases in its efficiency, but patient-oriented outcomes are still rare in research literature. Like any other healthcare intervention, claims that CDSS are beneficial for patients need to be confirmed by clinical trials. Objective: To verify whether the use of evidence-based Clinical Decision Support Systems is associated with improved patient-oriented clinical outcomes. Methods: Systematic literature review of randomized controlled trials that directly compared the use of CDSS with usual practice considering clinical outcomes classified as patient-oriented. Results: Our search strategy has identified 51,283 entries in MEDLINE-PubMed and, after filtering for randomized controlled trials 311 papers were selected for title and abstract reading. Forty-five were selected for full-text reading of which 19 have met eligibility criteria. Another nine trials were included after an overview of previous systematic reviews. Trials were published between 1995 and 2015 and performed in five care settings with a maximum follow-up of 12 months. Most evidence sources feeding systems´ knowledge bases were government agency guidelines or specialty societies. Twelve trials have assessed mortality, 14 have assessed hospital admissions and/or emergency visits and nine have assessed symptom-related outcomes. Meta-analyses were performed according to trials´ care setting and outcome types. Only a meta-analysis of three cluster-randomized trials involving mortality among outpatients with different clinical conditions was statistically significant, favouring CDSS group, but risk of bias was moderate, compromising the quality of evidence. Conclusions: Despite the potential of CDSS to improve healthcare quality there is no reliable evidence that they improve patients´ life extension or quality. The insufficient numbers of trials assessing these outcomes, studies´ subjects and follow-up periods, the heterogeneities of clinical settings across studies and knowledge bases feeding the systems impede achieving results that are more conclusive

Introdução: A Medicina Baseada em Evidências, apesar da grande profusão de publicações da área, enfrenta desafios no intuito de melhorar a qualidade da assistência à saúde. O conhecimento gerado por suas publicações demora a ser posta em prática. Os softwares CDSS de apoio à decisão clínica, podem ser a solução de incorporação das evidências na prática clínica. Esses sistemas já foram associados a melhorias na qualidade de diversos aspectos da assistência à saúde, como a organização, minimização de erros, redução de custos, aumento da eficiência dos cuidados, mas pesquisas com desfechos centrados no paciente ainda são raras. Como outra qualquer intervenção em saúde, as afirmações de que os CDSS são benéficos para o paciente necessitam de confirmação por ensaios clínicos. Objetivos: Verificar se o uso dos CDSS com base em evidências, está associado com melhores resultados clínicos orientados para o paciente. Métodos: Revisão sistemática da literatura dos ensaios clínicos controlados e randomizados que compararam diretamente o uso de CDSS com práticas clínicas convencionais considerando os desfechos clínicos classificados como orientados para o paciente. Resultados: Nossa estratégia de pesquisa identificou 51283 artigos na base MEDLINE-PubMed, sendo 311 selecionados para leitura de título e resumo após a aplicação do filtro para ensaio clínico randomizado, 45 selecionados para leitura do texto completo, dos quais 19 preencheram o critério de elegibilidade. Outros 9 ensaios foram incluídos através da realização de um overview das revisões sistemáticas anteriores. Os ensaios foram publicados entre os anos de 1995 e 2015 e realizados em cinco contextos assistenciais, com duração máxima de 12 meses. A maioria das fontes de evidências que alimentaram os sistemas foram diretrizes de órgão governamental ou sociedades de especialidades. Doze ensaios avaliaram mortalidade, 14 avaliaram hospitalizações ou atendimento de emergência e 6 avaliaram desfechos relacionados a presença de sintomas. Foram realizadas meta-análises de acordo com o contexto assistencial e o tipo de desfecho. Somente uma meta-análise envolvendo a mortalidade de pacientes tratados em ambulatório por diferentes condições clínicas se mostrou estatisticamente significante, favorável ao grupo CDSS, em 3 ensaios randomizados por aglomerado, com risco de viés considerado moderado, que compromete a qualidade da evidência. Conclusões Apesar do potencial dos CDSS no apoio de intervenções de saúde, não há evidência de boa qualidade de que sejam efetivos para aumentar a sobrevida ou a qualidade de vida dos pacientes. O número de ensaios que avaliam esses desfechos, os períodos de tempo pelos quais os pacientes foram seguidos, o número insuficiente de participantes, bem como a heterogeneidade entre os estudos analisados quanto aos cenários clínicos e as fontes de informação que alimentam os softwares não permitiram resultados mais conclusivos / Background: In spite of the wealth of publications in the field, Evidence-Based Medicine faces challenges in order to improve quality of health care. It takes too long for knowledge produced by its publications to be put into practice. Clinical Decision Support Systems (CDSS) may be a solution for incorporation of evidence into clinical practice. These systems have been associated with improvements in quality of various aspects of health care, including its organization, error minimizations, cost reductions and increases in its efficiency, but patient-oriented outcomes are still rare in research literature. Like any other healthcare intervention, claims that CDSS are beneficial for patients need to be confirmed by clinical trials. Objective: To verify whether the use of evidence-based Clinical Decision Support Systems is associated with improved patient-oriented clinical outcomes. Methods: Systematic literature review of randomized controlled trials that directly compared the use of CDSS with usual practice considering clinical outcomes classified as patient-oriented. Results: Our search strategy has identified 51,283 entries in MEDLINE-PubMed and, after filtering for randomized controlled trials 311 papers were selected for title and abstract reading. Forty-five were selected for full-text reading of which 19 have met eligibility criteria. Another nine trials were included after an overview of previous systematic reviews. Trials were published between 1995 and 2015 and performed in five care settings with a maximum follow-up of 12 months. Most evidence sources feeding systems´ knowledge bases were government agency guidelines or specialty societies. Twelve trials have assessed mortality, 14 have assessed hospital admissions and/or emergency visits and nine have assessed symptom-related outcomes. Meta-analyses were performed according to trials´ care setting and outcome types. Only a meta-analysis of three cluster-randomized trials involving mortality among outpatients with different clinical conditions was statistically significant, favouring CDSS group, but risk of bias was moderate, compromising the quality of evidence. Conclusions: Despite the potential of CDSS to improve healthcare quality there is no reliable evidence that they improve patients´ life extension or quality. The insufficient numbers of trials assessing these outcomes, studies´ subjects and follow-up periods, the heterogeneities of clinical settings across studies and knowledge bases feeding the systems impede achieving results that are more conclusive