Aim: To develop two versions of the Communication Assessment Tool (CAT) skilled for the setting of community pharmacy and to pilot test it on a selected sample.

Materials: Development of two versions of CAT-tool for community pharmacists. Validity and reliability assessments were required to determine the psychometric properties of developed tool versions. To investigate the construct validity of each adapted tool item, confirmatory factor analysis was performed. Reliability was assessed with the Cronbach’s Alpha evaluation, internal validity by submitting tool versions to patients of eleven pharmacies from North, Center, and South of Italy for pilot testing.

Results: Two CAT versions were developed and tested: CAT-Pharm-community Adherence to therapy and Minor Disease Management versions. First to evaluate pharmacist-patient communication following the dispensing of a prescription drug, second a consultation for minor disease management.

Conclusion: Communication tools are useful to implement optimal management of chronic diseases to minimize non-adherence and patients’ negative health outcomes.

communication assessment tool, community pharmacy, patient empowerment, patient-pharmacist relationship

Patient communication is a key strategy for achieving better health outcomes and reducing the failure of physician-prescribed therapies. Information regarding the appropriate medication use together with other recommendations are an essential part of the pharmacist’s profession at the time of prescription dispensing (Kerr et al 2021). Patients’ understanding concerning prescribed pharmacological treatment is crucial to ensure a proper adherence to the therapy and/or an adequate management of their minor disease (Náfrádi et al 2017; De Geest et al 2018; Steininger et al 2020; Duffy et al 2021). Clearing up misunderstandings and confusion on this aspect should be a key task for the community pharmacist (Menditto et al 2015; Scala et al 2016; Scala et al 2018). Pharmacist recommendations could be better understood if they are conveyed effectively and appropriately to the patient’s specific problem (Ferranti et al 2010; Carter et al 2015).

In this scenario, a psychometrically instrument, the Communication Assessment Tool (CAT), was already developed and validated for patient assessment of physician communication skills by Makoul et al in 2007 (Mercer et al 2008; Makoul et al 2017).

Albeit the community pharmacist play a fundamental role in the prescribing-pharmacist-patient chain, to date, no specific assessment tools to detect the quality of communication between community pharmacist and patient during the dispensing of a prescription drug are available. Indeed, the community pharmacist can greatly contribute to the improvement of the patient’s disease management. The pharmacist holds a key role in the relationship with the patient by providing useful information, acting as a facilitator, advising the patient on the use of medications and devices, with the ultimate goal of supporting patients and caregivers in the optimal management of the disease. There is now a worldwide recognition that the role of the community pharmacist should be directed towards the provision of advanced, high value-added services. The community pharmacist is an assurer of pharmaceutical care, which involves the active management of minor diseases, chronic conditions, verifying adherence, and monitoring drug therapies.

In this view, we recently developed a CAT tool skilled for the Pharmacist role: CAT-Pharm (Scala et al 2022). As a result, goals of this study were: i) to develop two versions of a Communication Assessment Tool skilled for the setting of community pharmacy: CAT-Pharm-community Adherence to Therapy version and Minor Disease Management version; ii) to pilot testing a preliminary assessment of the communication between the clinical pharmacist and the patient following the dispensing of a prescription drug (Adherence to Therapy version) or a consultation for the management of a minor disease (Minor Disease Management version).

A pilot study was carried out in Italy from July to August 2019. Eleven pharmacies from North, Center and South of Italy were involved in the study by convenience sampling. Ethics approval was obtained by the Ethics Committee of Cardarelli Hospital in Naples, Italy (424/2017).

Both CAT-Pharm-community versions consisted of 16 items and explored several areas of communication at the time of drug dispensing. For each of the 16 items, the patient completing the test could assign a score from 1 (poor) to 5 (excellent).

Regarding the CAT Pharm-community Test - Adherence to Therapy version, items’ construct validity was assessed. Pearson’s correlation test showed significant positive correlations between CAT-Pharm items. The correlation coefficients ranged from -0.142 to 0.797 (Suppl. material 4: 1). The results of the Bartlett’s test of sphericity showed a KMO of 0.818 and χ2 = 583.141 (df = 120, p < 0.01), indicating that the correlation matrix was suitable for factor analysis. A four-factor solution was found identifying four questionnaires macro-areas (Suppl. material 4: 2). Factors 1 (items 1–5) was focused on the understanding of patient clinical needs; Factor 2 (items 6–10) was focused on communication about therapy to the patient; Factor 3 (items 11–13) was focused on the evaluation of patient understanding; Factor 4 (items 14–16) was focused on the building of a trust relation between pharmacist and patient. Results of confirmatory factor analysis are showed in the Suppl. material 4. Moreover, reliability results indicated very high overall scale reliability for the 16 items of the Adherence to therapy version (Cronbach’s Alpha = 0.88).

To assess the tool’s internal validity, the CAT Pharm-community Adherence to Therapy version was tested on 67 patients, 70% of these were women. Overall, mean age recorded was 59 years (standard deviation: ±14.9). Characteristics of these patients is showed in Table 1. Overall, Majority of patients considered as excellent the respectful attitude of the pharmacist (92%, item 2) and the pharmacist’s welcome (85%, item 1). A minor percentage of patients (42%) considered excellent the manner in which the pharmacist discussed future interventions, including any examinations and follow-up visits. (item 14) (Table 2). In addition, approximately 80% of patients considered as very important the attitude and communication methods adopted by the pharmacist, whereas 20.9% didn’t find very useful the information received about future interventions such as examinations and follow-up visits (Table 3).

Regarding the CAT Pharm-community Test - Minor Diseases Management version, item’s construct validity was assessed. Pearson’s correlation test showed significant positive correlations between CAT-Pharm items. The correlation coefficients ranged from 0.115 to 0.761 (Suppl. material 4: 3). The results of the Bartlett’s test of sphericity recorded a KMO of 0.750 and χ2 = 581.129 (df = 120, p < 0.01), indicating that the correlation matrix was suitable for factor analysis. A four-factor solution was found in this tool’s version identifying the same four macro-areas (Suppl. material 4: 4 and 5). Moreover, reliability results indicated very high overall scale reliability for the 16 items of the Adherence to therapy version (Cronbach’s Alpha = 0.87).

To assess the tool’s internal validity, the CAT Pharm-community Minor Diseases Management version was tested in 65 patients, of which 73.8% were women. Overall, mean age was 57.5 years (standard deviation: ± 13.9) (Table 1). Majority of patients (93.8%) rated as excellent the pharmacist’s respectful attitude (item 2), and 90.8% of patients also considered excellent the pharmacist’s welcome (item 1). Only 47.7% of patients adequately received encouragement from the pharmacist to ask questions (item 13) (Table 4). In addition, about 80% of patients rated very important the communication attitude adopted by the pharmacist, while 15% consider not very useful to receive information about possible interactions of the prescribed therapy with other drugs and foods (Table 5).

Ineffective communication between health professionals and patients is recognized to be one of the main causes of medical errors and damage to patients’ health. To overcome this gap, implementation strategies for better communication in healthcare have been investigated for more than a decade (Haley et al 2021,) . In this scenario, the main strength of this study lies in the introduction of two specific tools that patients can use to assess communication with community pharmacists in relation to prescribed medication. The two CAT-Pharm-community tools available in Italian language, have proven their potential to be implemented in all community pharmacies. The two tools, compared to the original Italian CAT (Scala et al 2016) and CAT-Pharm (Scala et al 2022), are more specific for the patients’ needs. Indeed, the Adherence to Therapy version is exclusively aimed at investigating the level of communication between the community pharmacist and the patient with a specific treatment plan to be followed, while, the Minor Disease Management version investigates the level of communication with the patient following counselling for the management of a minor disease. Several differences can be detected in the two versions, especially in 3 items: “Showed interest in my ideas about the prescribed therapy” for the Adherence to therapy version instead “Asked if I had consulted the doctor about this problem or taken some medication before the consultation” for the Minor Disease Management version; the same for the item “Explained how to correctly follow the prescribed therapy” instead “Gave me right therapy and advice for my problem” and for “Asked about my ability to follow the prescribed therapy” instead “Explained how to correctly follow the prescribed therapy”.

The results of the present study prove that, regardless of the type of consultation required by the patient, information regarding a treatment plan to be followed or a minor disease to manage, the most important aspect for the patient seems to be the confidentiality assured by the pharmacist. To prove it, items considered most important in a patient perspective were: “Greeted me in a way that made me feel comfortable”, “Treated me with respect” and “Understood my main health concerns”. These same items were also rated as excellent in both CAT-Pharm-community versions, hence, generally the patients seem satisfied from the interaction with the community pharmacist. This may be explained by the circumstance that the majority of patients who received the Adherence to Therapy and Minor Disease Management versions (91% and 98%, respectively) had had a consultation with the community pharmacist more than once.

Notably, in the Adherence to therapy version, less than half of patients rated excellent the item “Discussed next steps, including any follow-up plans”. Therefore, in the Italian context, enhancing the pharmacist’s role as a driver of proper medication adherence seems to be a key aspect. The pharmacist is a pivotal figure in the prescriber-pharmacist-patient chain to ensure adherence to the prescribed treatment and the achievement of favorable health outcomes. In this sense, several recent studies have investigated and confirmed the positive impact of the pharmacist services on patient medication adherence (Bunchuailua et al 2021; Bruggmann et al 2021; Gautier et al 2021).

This role is crucial to encourage adherence to a specific prescribed treatment plan, but also, as demonstrated by the use of the Minor Disease Management version tool, to improve clinical outcomes and promote health status of patients following a minor disease consultation. Corroborating to our evidences, a recent systematic review underlined the role of the clinical pharmacist services in improving patient outcomes and medication therapy management. Clinical pharmacist interventions showed a positive impact on therapeutic, humanistic, and safety outcomes (Ahmed et al 2021).

Another recent systematic review (Falch and Alves 2021) investigated on impact of pharmacists as health professionals with the opportunity to act on medication regimen complexity reduction, particularly for older patients. Moreover, results of this review confirmed that pharmacists’ active role in this sense has not been studied in depth so far.

Finally, our results indicated that patients need to be actively involved in decisions about their care, regardless of the type of minor or major health problem. This is also confirmed by the finding that few patients felt encouraged to ask questions (item 13) and this issue was also previously revealed by the pilot study conducted for the development and validation of the CAT-Pharm. The pharmacist-patient relationship seems to be crucial to obtain information from the patient about their needs, their ability to follow the prescribed treatment, and to support them so that they understand their minor disorder or the prescribed treatment plan (Osuna et al 2018; Ilardo and Speciale 2020).

Communication Assessment Tool (CAT) adapted to the community pharmacy setting (CAT-Pharm-community) could be a useful aid for the pharmacist in evaluating the patient’s perception of the approach to the problem they reported. Feedback obtained from the questionnaire may be useful in taking corrective action to improve the quality of pharmacy service during counseling for management of a minor disorder. Moreover, the communication tool could be useful for the implementation of an optimal management of chronic diseases to minimize non-adherence treatment and consequently patient’s negative health outcomes.

The author(s) declare that there are no conflicts of interest.

The study was supported by grants from the Italian Medicine Agency (AIFA), funding on ‘’Progetto per la valutazione e l’analisi della prescrizione farmaceutica in Regione Campania” – ‘Fondi Farmacovigilanza 2012–2014’.

• Stefano Miggos, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Assunta Pistone, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Valentina Gianotti, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Alberto Lepore, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Michele Modugno, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Paolo Levantino, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Paolo Dolcetti, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Giulio Poletti, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Teo Preza, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy
• Vittorio Ruiu, Società Italiana Farmacia Clinica (SIFAC), Cagliari, Italy