INVOLVEMENT OF BRITISH COLUMBIA COMMUNITY PHARMACISTS IN HEALTH PROMOTION By ELAN CARLA MARIE PALUCK B.S.P., The U n i v e r s i t y o f Saskatchewan, 1988 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES FACULTY OF PHARMACEUTICAL SCIENCES DIVISION OF PHARMACY ADMINISTRATION We a c c e p t t h i s t h e s i s as conforming t o t h e r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1992 © E l a n C a r l a Marie Paluck, 1992 In presenting degree freely at this the University available copying of department publication for this by this in of reference thesis or of thesis for his thesis partial fulfilment British Columbia, and study. scholarly or for her I The University Vancouver, Date DE-6 of gain (2/88) Pharmaceutical Sciences of British Columbia Canada October 15, 1992 further requirements that agree may be It is representatives. financial the 1 agree purposes permission. Department of shall not that the Library an granted by allowed advanced shall permission understood be for the that without for head make extensive of copying my it my or written ABSTRACT Community p h a r m a c i s t s are faced p a r t i c i p a t e i n h e a l t h promotion. determine Columbia the are extent to involved which A causal independent The model pharmacist p u r p o s e o f t h i s s t u d y was to pharmacists practice in activities, l e v e l of developed and to promotion affect this was many o p p o r t u n i t i e s community i n health e x t e r n a l f a c t o r s , i f any, with British and involvement. which proposed variables that would was d i s t r i b u t e d to a systematic 11 influence pharmacists' involvement i n health promotion a c t i v i t i e s . page m a i l q u e s t i o n n a i r e which A five- stratified s a m p l e o f 625 p r a c t i s i n g c o m m u n i t y p h a r m a c i s t s i n B r i t i s h C o l u m b i a . A f i v e - p o i n t L i k e r t - t y p e s c a l e was of pharmacist involvement in used t o examine t h e 33 different frequencies health promotion activities. Three d i f f e r e n t follow-up f i n a l r e s p o n s e r a t e o f 83.6%. pharmacists most frequently p r o c e d u r e s were used t o a t t a i n a Results of the participate in s t u d y show t h a t activities r e l a t e d d i r e c t l y to the dispensing or s e l l i n g of These clients events medications, include querying medical h i s t o r i e s , advising on c l i e n t s on are medications. over-the-counter c l i e n t s on p o s s i b l e a l l e r g i e s , querying that obtaining current medications, suggesting non-drug a l t e r n a t i v e s t o drug t h e r a p y f o r minor ailments. The and a c t i v i t i e s that d i s p l a y e d the lowest p a r t i c i p a t i o n a m o n g s t p h a r m a c i s t s i n c l u d e d s p e a k i n g t o c o m m u n i t y g r o u p s on h e a l t h related matters, participating in disease screening q u e r y i n g c l i e n t s on t h e i r l e v e l o f o c c u p a t i o n a l s t r e s s , programs, counselling c l i e n t s o n AIDS p r e v e n t i o n , a n d q u e r y i n g c l i e n t s on t h e i r status. level of smoking V a r i a b l e s t h a t were f o u n d t o i n f l u e n c e a p h a r m a c i s t ' s participation i n health promotion were a pharmacist's employment s t a t u s ( f u l l - t i m e o r p a r t - t i m e ) , m a r i t a l s t a t u s , t y p e o f practice, personal geographic health location beliefs and of the behaviours, practice, and status of the c l i e n t e l e predominantly served. the pharmacist's socioeconomic ABSTRACT i L I S T OF TABLES L I S T OF FIGURES D E F I N I T I O N OF TERMS ACKNOWLEDGEMENT 1. 2. i v i i X x i XV INTRODUCTION 1 H e a l t h P r o m o t i o n i n Canada Why t h e P h a r m a c i s t a s a Community H e a l t h P r o m o t e r ? . . . Pharmacists' A b i l i t y t o Perform i n t h e Role o f Community H e a l t h A d v i s o r Statement o f Problem Purpose and O b j e c t i v e s Importance o f Study 1 3 6 8 9 11 REVIEW OF THE LITERATURE 12 The P a r t i c i p a t i o n o f Community P h a r m a c i s t s i n Health Promotion Developing the Pharmacist's Role i n Health Promotion Practice Variables i ) Employment p o s i t i o n i i ) P l a c e o f employment i i i ) Socioeconomic s t a t u s o f clientele iv) Geographic l o c a t i o n v) B a r r i e r s Personal Variables i) Pharmacist sex i i ) Pharmacist m a r i t a l status i i i ) P h a r m a c i s t age iv) Pharmacist personal health beliefs v) P h a r m a c i s t p e r s o n a l h e a l t h behaviours 12 16 17 18 19 20 20 21 23 23 24 24 25 26 Page Educational Variables i) Degree-granting i n s t i t u t i o n i i ) Year o f g r a d u a t i o n 3. Development o f a C a u s a l Model o f P h a r m a c i s t Involvement i n Health Promotion 31 METHODOLOGY 36 Q u e s t i o n n a i r e Development Sample S e l e c t i o n Follow-up Procedures S c o r i n g Schemes f o r S u r v e y S t a t i s t i c a l Analyses Undertaken Study L i m i t a t i o n s 4. 29 29 30 RESULTS 36 41 44 44 46 47 48 Response Rate Sample D e s c r i p t i o n Nonresponse B i a s Survey R e s u l t s Pharmacist involvement i n h e a l t h promotion a c t i v i t i e s V a r i a b l e s i n f l u e n c i n g pharmacist involvement i n h e a l t h promotion a c t i v i t i e s Practice Variables i ) Type o f p r a c t i c e i i ) Geographic l o c a t i o n o f p r a c t i c e i i i ) Employment p o s i t i o n iv) Socioeconomic s t a t u s o f c l i e n t e l e v) B a r r i e r s Personal variables i) Pharmacist sex i i ) Pharmacist m a r i t a l status i i i ) Pharmacist personal health beliefs 48 51 57 59 59 66 66 66 69 71 74 74 77 77 78 79 Page 5. i v ) P h a r m a c i s t age v) P h a r m a c i s t p e r s o n a l h e a l t h behaviours 81 Educational variables i ) Year o f g r a d u a t i o n i i ) Degree-granting i n s t i t u t i o n 82 82 82 DISCUSSION AND CONCLUSIONS Pharmacist P a r t i c i p a t i o n i n Health Promotion A c t i v i t i e s V a r i a b l e s I n f l u e n c i n g Pharmacist Involvement i n Health Promotion.... 6. 81 84 84 93 SUMMARY AND RECOMMENDATIONS 104 Summary 104 Areas 106 f o r F u r t h e r Research REFERENCES APPENDIX 1: APPENDIX 2: APPENDIX 3: APPENDIX 4: APPENDIX 5: 110 SURVEY INSTRUMENT COVER LETTER USED I N THE I N I T I A L MAILING OF THE QUESTIONNAIRE REMINDER/THANK-YOU CARD USED I N F I R S T FOLLOW-UP PROCEDURE 117 125 COVER LETTER USED I N SECOND FOLLOW-UP PROCEDURE 126 TELEPHONE DIALOGUE USED I N THE THIRD FOLLOW-UP PROCEDURE 127 124 r LIST OF TABLES 1. 2. 3. 4. 5. 6. 7. Summary o f t h e R e p o r t e d E f f e c t s o f P r a c t i c e V a r i a b l e s o n Community P h a r m a c i s t I n v o l v e m e n t i n Health Promotion 22 Summary o f t h e R e p o r t e d E f f e c t s o f P e r s o n a l V a r i a b l e s o n Community P h a r m a c i s t P a r t i c i p a t i o n i n H e a l t h Promotion A c t i v i t i e s 28 Summary o f t h e R e p o r t e d E f f e c t s o f E d u c a t i o n a l V a r i a b l e s o n Community P h a r m a c i s t I n v o l v e m e n t i n H e a l t h Promotion A c t i v i t i e s 31 O p e r a t i o n a l Hypotheses Surrounding Pharmacist Involvement i n Health Promotion A c t i v i t i e s 34 P i l o t Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Sex 38 P i l o t Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Geographic L o c a t i o n 38 Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Geographic Location 49 8. Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Sex 9. Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Degree-granting I n s t i t u t i o n Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Geographic L o c a t i o n 53 Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t P r a c t i c e Type 53 10. 11. 12. 53 Sample D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Year of Graduation 13. S a m p l e D e s c r i p t i o n A c c o r d i n g t o P h a r m a c i s t Age 14. E m p l o y m e n t P o s i t i o n s o f B r i t i s h C o l u m b i a Community P h a r m a c i s t s A c c o r d i n g t o P h a r m a c i s t Sex E m p l o y m e n t S t a t u s o f B r i t i s h C o l u m b i a Community P h a r m a c i s t s A c c o r d i n g t o P h a r m a c i s t Sex 15. 52 54 55 55 56 LIST OF TABLES—Continued Pacre 16. M a r i t a l S t a t u s o f B r i t i s h Columbia Community P h a r m a c i s t s A c c o r d i n g t o P h a r m a c i s t Sex 17. Non-responding 18. N o n - r e s p o n d i n g Sample A c c o r d i n g t o College D i s t r i c t Non-respondent Sample A c c o r d i n g t o 19. P h a r m a c i s t s A c c o r d i n g t o Sex 59 20. Pharmacist Median H e a l t h Promotion 21. Pharmacist Self-Reported P a r t i c i p a t i o n i n Health Promotion A c t i v i t i e s H e a l t h Promotion A c t i v i t i e s Most F r e q u e n t l y P a r t i c i p a t e d i n by Community P h a r m a c i s t s i n B r i t i s h Columbia 23. 58 58 P r a c t i c e Type 22. 56 Scores Non-dispensing Health Promotion A c t i v i t i e s M o s t F r e q u e n t l y P a r t i c i p a t e d i n by Community P h a r m a c i s t s i n B r i t i s h C o l u m b i a 60 62 64 65 24. H e a l t h P r o m o t i o n E v e n t s B r i t i s h C o l u m b i a Community P h a r m a c i s t s C l a i m They "Never" P a r t i c i p a t e I n 65 25. V a r i a t i o n s i n Health Promotion P a r t i c i p a t i o n A c c o r d i n g t o P h a r m a c i s t P r a c t i c e Type 67 26. V a r i a t i o n s i n Involvement i n I n d i v i d u a l H e a l t h Promotion A c t i v i t i e s According t o Geographic L o c a t i o n s o f B r i t i s h C o l u m b i a Community Pharmacist Practices 70 D i f f e r e n c e s i n D a i l y Time S p e n t i n A d m i n i s t r a t i v e F u n c t i o n s by B r i t i s h C o l u m b i a Community P h a r m a c i s t s A c c o r d i n g t o Employment P o s i t i o n 71 27. L i s t of T a b l e s — c o n t i n u e d 28. 29. V a r i a t i o n s i n H e a l t h P r o m o t i o n P a r t i c i p a t i o n by B r i t i s h C o l u m b i a Community P h a r m a c i s t s A c c o r d i n g t o Employment S t a t u s 73 P a r t i c i p a t i o n i n H e a l t h Promotion A c t i v i t i e s Influenced by B r i t i s h C o l u m b i a Community P h a r m a c i s t E s t i m a t i o n of C l i e n t Socioeconomic S t a t u s 75 30. B r i t i s h C o l u m b i a Community P h a r m a c i s t P e r c e i v e d B a r r i e r s to Expanding T h e i r Involvement i n H e a l t h Promotion Activities 76 31. S i g n i f i c a n t D i f f e r e n c e s Between Male and Female Pharmacist P a r t i c i p a t i o n i n Health Promotion A c t i v i t i e s i n B r i t i s h Columbia 78 P a r t i c i p a t i o n i n H e a l t h Promotion A c t i v i t i e s I n f l u e n c e d b y B r i t i s h C o l u m b i a Community P h a r m a c i s t Marital Status 80 P a r t i c i p a t i o n i n Health Promotion A c t i v i t i e s I n f l u e n c e d b y B r i t i s h C o l u m b i a Community P h a r m a c i s t Degree-granting I n s t i t u t i o n s 83 Summary R e s u l t s o f O p e r a t i o n a l H y p o t h e s e s S u r r o u n d i n g Pharmacist O v e r a l l Involvement i n H e a l t h Promotion Activities 86 A Comparison o f American Versus B r i t i s h Columbian Community P h a r m a c i s t I n v o l v e m e n t i n H e a l t h Promotion A c t i v i t i e s 90 A Comparison o f H e a l t h Promotion A c t i v i t i e s "Never" P a r t i c i p a t e d i n by B r i t i s h Columbia and A m e r i c a n Community P h a r m a c i s t s U s i n g 95% C o n f i d e n c e Intervals 92 V a r i a b l e s I n f l u e n c i n g B r i t i s h C o l u m b i a Community Pharmacist O v e r a l l Involvement i n H e a l t h Promotion... 94 32. 33. 34. 35. 36. 37. LIST OF FIGURES Page F i g u r e 1: F i g u r e 2: C a u s a l M o d e l o f Community P h a r m a c i s t Involvement i n Health Promotion A c t i v i t i e s G e o g r a p h i c L o c a t i o n o f The C o l l e g e o f Pharmacists o f B r i t i s h Columbia Districts .... 33 39 F i g u r e 3: C a l c u l a t i o n F o r Sample S i z e D e t e r m i n a t i o n F i g u r e 4: C u m u l a t i v e Weekly Response Rate 49 F i g u r e 5: Marginal 50 F i g u r e 6: Amended C a u s a l M o d e l D e p i c t i n g Community Pharmacist Involvement i n Health Promotion Activities E f f i c a c y of Follow-up Procedures 41 103 D e f i n i t i o n o f Terms B a r r i e r s t o Involvement i n Health Promotion: In t h i s study, f a c t o r s which l i m i t the frequency of p h a r m a c i s t s ' involvement i n h e a l t h promotion a r e r e f e r r e d t o as b a r r i e r s t o involvement i n h e a l t h promotion. B a r r i e r s examined i n t h i s study i n c l u d e a l a c k of time, l a c k of economic i n c e n t i v e s , l a c k o f c o u n s e l l i n g s k i l l s , l a c k o f pharmacy t e c h n i c i a n s , l a c k o f p a t i e n t demand, l a c k o f a p p r o p r i a t e k n o w l e d g e i n t h e a r e a o f h e a l t h p r o m o t i o n , l a c k o f n e c e s s a r y p a t i e n t i n f o r m a t i o n , and p r o f e s s i o n a l c o n f l i c t s with other health care providers. College Districts: F o r t h e p u r p o s e o f t h e e l e c t i o n o f t h e members o f t h e C o u n c i l of t h e C o l l e g e o f P h a r m a c i s t s o f B r i t i s h Columbia, t h e p r o v i n c e i s d i v i d e d i n t o 10 d i s t r i c t s . Only D i s t r i c t s 1 through 9 are of interest in this s t u d y , as D i s t r i c t 10 represents hospital p h a r m a c i s t s . G e o g r a p h i c a l l y , t h e d i s t r i c t s a r e as f o l l o w s ( C o l l e g e of P h a r m a c i s t s o f B r i t i s h Columbia Bylaws, 1986). District 1: The a r e a c o n t a i n e d w i t h i n t h e C a p i t a l District. Regional District 2 : The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f C o w i c h a n V a l l e y , Nanaimo, A l b e r n i - C l a y o q u o t , ComoxS t r a t h c o n a , Mount W a d d i n g t o n , C e n t r a l C o a s t (Ocean Falls). District 3 : The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f Fraser-Cheam, C e n t r a l F r a s e r V a l l e y , Dewdney-Alouette, and t h e C i t y o f W h i t e R o c k , D i s t r i c t o f S u r r e y and t h a t p a r t of the D i s t r i c t of D e l t a , east of the B u r l i n g t o n Northern Railway. District 4 : The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f Okanagan-Similkameen, N o r t h Okanagan, C e n t a l Okanagan, Thompson-Nicola, from w i t h i n t h e R e g i o n a l D i s t r i c t o f C a r i b o o , t h e town o f L i l l o o e t , and w i t h i n t h e R e g i o n a l D i s t r i c t of S q u a m i s h - L i l l o o e t , t h e town o f L i l l o o e t , and t h e R e g i o n a l D i s t r i c t o f C o l u m b i a - S h u s w a p e x c e p t t h e town o f Golden. D i s t r i c t 5: The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f E a s t K o o t e n a y , C e n t r a l Kootenay, K o o t e n a y Boundary and from w i t h i n the R e g i o n a l D i s t r i c t of Columbia-Shuswap, t h e town o f Golden. District 6 : The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f Skeena-Queen C h a r l o t t e , K i t i m a t - S t i k i n e , B u l k l e y Nechako, F r a s e r - F o r t George, Peace R i v e r - L i a r d , S t i k i n e , and C a r i b o o e x c e p t t h e t o w n o f 100 M i l e H o u s e . D i s t r i c t 7: The a r e a c o n t a i n e d w i t h i n t h e C i t y o f V a n c o u v e r , U n i v e r s i t y Endowment L a n d s . and D i s t r i c t 8: The a r e a c o n t a i n e d w i t h i n t h e C i t i e s o f New W e s t m i n s t e r , P o r t C o q u i t l a m , P o r t Moody, t h e D i s t r i c t s o f Burnaby, C o q u i t l a m , Richmond, and t h a t p a r t o f t h e D i s t r i c t of D e l t a , west of B u r l i n g t o n N o r t h e r n R a i l w a y , and l o c o - B u n t z e n . D i s t r i c t 9 : The a r e a c o n t a i n e d w i t h i n t h e R e g i o n a l D i s t r i c t s o f P o w e l l R i v e r , Sunshine Coast, S q u a m i s h - L i l l o o e t (except t h e t o w n o f L i l l o o e t ) , t h e C i t y o f N o r t h V a n c o u v e r , The V i l l a g e o f L i o n s Bay, t h e D i s t r i c t s o f N o r t h V a n c o u v e r , West V a n c o u v e r , and Bowen I s l a n d . Community Pharmacist: I n t h e p r e s e n t s t u d y , a community p h a r m a c i s t i s a p h a r m a c i s t who p r a c t i s e s p h a r m a c y w i t h i n a r e t a i l , c o m m u n i t y s e t t i n g ( a s opposed t o a h o s p i t a l pharmacy). [See a l s o , " p r a c t i c e t y p e " ] Employment S t a t u s : Employment s t a t u s , i n t h i s s t u d y , i s b a s e d on p h a r m a c i s t s ' h o u r l y w o r k week. F u l l - t i m e employment d e n o t e s a w o r k week o f 22 o r more h o u r s . P a r t - t i m e employment i s a w o r k week o f l e s s t h a n 22 hours. Health Promotion: " . . . a commitment t o d e a l i n g w i t h t h e c h a l l e n g e s o f r e d u c i n g i n e q u i t i e s , e x t e n d i n g t h e s c o p e o f p r e v e n t i o n , and h e l p i n g p e o p l e t o cope w i t h c i r c u m s t a n c e s . . . [ b y ] s t r e n g t h e n i n g community h e a l t h s e r v i c e s . . . [ t o create] environments conducive to health i n which p e o p l e a r e b e t t e r a b l e t o t a k e c a r e o f t h e m s e l v e s . . . " (Epp, 1986) . Intervening Variable: "An i n t e r v e n i n g v a r i a b l e i s a v a r i a b l e t h a t l i n k s an independent v a r i a b l e t o a dependent v a r i a b l e . An intervening v a r i a b l e r e p r e s e n t s an e x p l a n a t i o n o f how t h e i n d e p e n d e n t v a r i a b l e i n f l u e n c e s t h e d e p e n d e n t v a r i a b l e " ( J a c k s o n , 1988, p . 1 1 . ) . Personal Health Behaviour: H e a l t h p r o t e c t i v e b e h a v i o u r : i . e . , "Any b e h a v i o u r p e r f o r m e d by a person r e g a r d l e s s of h i s or her perceived h e a l t h s t a t u s , i n order t o p r o t e c t , promote, or m a i n t a i n h i s or her h e a l t h , whether or not such behaviour i s o b j e c t i v e l y e f f e c t i v e towards t h a t end..." ( H a r r i s and G u t e n , 1 9 7 9 ) . Personal Health Beliefs: " . . . b e l i e f s about the p e r s o n a l v u l n e r a b i l i t y t o i l l c o n d i t i o n s and a b o u t t h e e f f i c a c y o f a c t i o n s t o w a r d o f f threats" ( K i r s c h t , 1974, p . 4 5 7 ) . health health P r a c t i c e Type: In t h i s study, p r a c t i c e type r e f e r s t o f o u r c a t e g o r i e s of community pharmacy p r a c t i c e t y p e s e x i s t i n g i n B r i t i s h Columbia a t the time of t h i s survey; i ) independent s t o r e s , i i ) independent c h a i n s t o r e s (such as Pharmasave), i i i ) f r a n c h i s e s t o r e s (such as S h o p p e r s D r u g M a r t ) , and i v ) c o r p o r a t e c h a i n s t o r e s ( s u c h a s L o n d o n Drugs). Practice Variables: In t h i s study, " p r a c t i c e v a r i a b l e s " r e f e r s to c h a r a c t e r i s t i c s of a pharmacy, as w e l l as t h e p h a r m a c i s t ' s r o l e w i t h i n t h a t pharmacy, t h a t i n f l u e n c e p h a r m a c i s t s ' p a r t i c i p a t i o n i n h e a l t h promotion a c t i v i t i e s . P r a c t i c e v a r i a b l e s of i n t e r e s t i n t h i s study i n c l u d e p h a r m a c i s t s ' employment p o s i t i o n (owner, manager, o r s t a f f ) , employment s t a t u s ( f u l l - t i m e o r p a r t - t i m e ) , p r a c t i c e t y p e (independent, independent chain, f r a n c h i s e , or corporate c h a i n ) , g e o g r a p h i c l o c a t i o n of t h e pharmacy ( C o l l e g e of P h a r m a c i s t s of B r i t i s h C o l u m b i a d i s t r i c t s 1 t o 9) , a n d t h e s o c i o e c o n o m i c s t a t u s o f the c l i e n t e l e predominately served (lower c l a s s t o upper c l a s s ) . Socioeconomic Status: I n t h i s s t u d y , t h e s o c i o e c o n o m i c s t a t u s o f t h e c l i e n t e l e was e s t i m a t e d by p h a r m a c i s t s ' a c c o r d i n g t o t h e f o l l o w i n g income l e v e l descriptions: " L o w e r c l a s s " was d e f i n e d a s u n e m p l o y e d p e r s o n s , o r t h o s e on s o c i a l a s s i s t a n c e ; " L o w e r - m i d d l e c l a s s " was d e f i n e d a s b l u e c o l l a r w o r k e r s , s i n g l e income f a m i l i e s , o r s e n i o r s on a f i x e d income; " M i d d l e c l a s s " was d e s c r i b e d a s i n c l u d i n g w h i t e c o l l a r workers, m i d d l e i n c o m e f a m i l i e s , o r s e n i o r s w i t h some p r i v a t e s a v i n g s ; " U p p e r - m i d d l e c l a s s " i n c l u d e d p r o f e s s i o n a l s a n d h i g h wage earners; w h i l e "Upper c l a s s " c l i e n t s were d e s c r i b e d a s b e i n g landowners, c h i e f executive o f f i c e r s , o r independently wealthy. ACKNOWLEDGEMENT T h i s r e s e a r c h was s u p p o r t e d b y t h e B r i t i s h Columbia H e a l t h Research Foundation and the B r i t i s h Columbia Pharmacy A s s o c i a t i o n . CHAPTER 1 INTRODUCTION Health Interest has P r o m o t i o n i n Canada i nhealth p r o m o t i o n i n Canada a n d a r o u n d t h e w o r l d flourished rapidly. P i v o t a l i n s t i m u l a t i n g t h i s i n t e r e s t were innovative reports Canadians (Lalonde, Promotion (1986). Promotion, defined such a s , A New P e r s p e c t i v e 1974) a n d t h e O t t a w a Epp's 1986 p a p e r , national challenges A Charter Framework f o r Health f o r Health challenges. themes i n t h e s e documents i n c l u d e t h e need t o s t r e n g t h e n community-based participation health i n health services, promotion h e a l t h s e r v i c e s by m o d i f y i n g and of f o r h e a l t h promotion, and p r o p o s e d m e c h a n i s m s a n d s t r a t e g i e s t o meet t h e s e Recurring on t h e H e a l t h a t t i t u d e s o f health care foster activities, greater and t o r e o r i e n t the organization, education, providers. public training To implement Epp's s t r a t e g i e s , a c o o p e r a t i v e , amongst h e a l t h c a r e p r o f e s s i o n a l s w i l l h a v e l i t t l e t i m e and little promoting think of health, a b o u t t h e m and lifestyle they are spend Wilson, not as lack the confidence time physicians 1992). not expensive providers provide (B.C. on a (1971) f o u n d t h a t a d v i s i n g and pharmacists. health counsel effectively Lewis et a l . , e x i s t who to as less can 1991) community-based a l t e r n a t i v e Studies suggest w i l l i n g t o expand Gibson, 1975). L i n n and d i s c u s s i n g h e a l t h problems s e c o n d most t i m e consuming a c t i v i t y o f c i t e d a d v i s i n g p a t i e n t s as t h e able measures, c o s t - e f f e c t i v e choice o p e n and Next t o d i s p e n s i n g in patients promoting Royal Commission, c o m m u n i t y h e a l t h r o l e ( S m i t h and the to important w e r e w i l l i n g and h e a l t h promotion s e r v i c e s . t h a t community p h a r m a c i s t s a r e p a t r o n s was being ( W e s c h l e r , 1983; C o m m u n i t y p h a r m a c i s t s a r e one t h a t can 1992). A l t h o u g h w i t h i n t h e community a l r e a d y d e l i v e r these services. Physicians i n their a b i l i t y to patients represent as prepared Even i f p h y s i c i a n s counselling would (Wilson, factors promote change i n t h e i r p a t i e n t s 1991; necessary. e c o n o m i c i n c e n t i v e t o d e v o t e much t i m e t o c o u n s e l l i n g on h e a l t h p r o m o t i o n physicians be team a p p r o a c h p r e s c r i p t i o n orders, s e c o n d most p r e f e r r e d their Davis with community pharmacists activity. Why the Pharmacist as a Community H e a l t h Promoter? Community p h a r m a c i s t s a r e r e a d i l y a v a i l a b l e a n d a c c e s s i b l e t o the p u b l i c (Smith and G i b s o n , 1975). I n most c o m m u n i t i e s , c o m m u n i t y p h a r m a c y i s t h e most f r e q u e n t l y centre (Nathan, accessibility 1989; Coons, 1990). i s the estimate that already receive counselling v i s i t e d health Coupled care with s i x out of every from t h e i r pharmacist the 10 this patients (Upjohn, 1990; Meade, 1992) w h i c h makes a p h a r m a c i s t ' s p o t e n t i a l i n t h e a r e a o f health promotion quite large. H e a l t h p r o m o t i o n s e r v i c e s o f f e r e d by community p h a r m a c i s t s c a n be e f f i c i e n t a n d c o s t - e f f e c t i v e f o r g o v e r n m e n t ( C o o n s , 1 9 9 0 ; L a u c k a and Hoffman, 1 9 9 2 ) , and a d v a n t a g e o u s , professionally, will f o r the pharmacist both f i n a n c i a l l y (Poirier, 1992). and The public b e n e f i t from t h e a v a i l a b i l i t y o f community s p e c i f i c h e a l t h promotion services i n their local pharmacy. Pharmacy s e r v i c e s r e l a t e d t o t h e d i s t r i b u t i o n o f m e d i c a t i o n c u r r e n t l y o f f e r e d by p h a r m a c i s t s s i m u l t a n e o u s l y improve patient outcome and t h e m e d i c a l c a r e system. both F o r example. Smith (1974) e x a m i n e d 665 c r i t i c a l i n c i d e n t s g a t h e r e d b y a m a i l s u r v e y o f community p h a r m a c i s t s i d e n t i f i e d as p r a c t i s i n g a t a " h i g h l e v e l " o f community pharmacy. These a n e c d o t a l and p a r t i a l l y q u a n t i f i e d c a s e s were examined f o r t h e community p h a r m a c i s t ' s e f f e c t on p a t i e n t end r e s u l t s and t h e m e d i c a l c a r e system p r o c e s s . I n 428 (64%) o f t h e cases, positive results cases, pharmacists use were d e t e c t e d . In one-quarter helped p a t i e n t s avoid, minimize of potentially harmful o r unnecessary of these o r reduce procedures, the tests, or Deady e t a l . ( 1 9 9 1 ) , e x a m i n e d c o m m u n i t y p h a r m a c i s t s ' i m p a c t on surgery. the h e a l t h c a r e system i n a study of p h y s i c i a n s ' acceptance o f drug t h e r a p y r e c o m m e n d a t i o n s by p h a r m a c i s t s . seen by a p h a r m a c i s t T h i r t y - n i n e p a t i e n t s were d u r i n g 49 c l i n i c v i s i t s ; w e r e made t o c h a n g e t h e r a p y . 3 6 recommendations Recommendations were a c c e p t e d by p h y s i c i a n s i n 89% o f c a s e s and p a t i e n t outcomes were improved 95% o f c a s e s f o r w h i c h outcome d a t a were a v a i l a b l e . Both t h e s t u d y b y Deady e t a l . a n d b y S m i t h d e m o n s t r a t e p h a r m a c i s t s ' t o improve p a t i e n t outcomes. ability T h i s c a n be t r a n s l a t e d i n t o p o t e n t i a l f i n a n c i a l s a v i n g s f o r t h e h e a l t h care system, unnecessary in as t h e c o s t s of h o s p i t a l i z a t i o n s o r emergency t r e a t m e n t s were likely avoided. A m p l e o p p o r t u n i t i e s t o become i n v o l v e d i n h e a l t h promotion a c t i v i t i e s e x i s t f o r B r i t i s h Columbian community p h a r m a c i s t s , b u t the extent t o which unknown. Currently, involved in t h e y become i n v o l v e d i n s u c h a c t i v i t i e s i s community counselling pharmacists activities d i s t r i b u t i o n and u s e o f m e d i c a t i o n s related thought directly to to be the ( B e a r d s l e y , 1 9 8 3 ) , b u t may n o t be i n v o l v e d i n o t h e r a r e a s o f h e a l t h p r o m o t i o n . increasing i n t e r e s t i n s e l f care are With the p u b l i c ' s ( K i c k b u s c h , 1989) a n d t h e emergence doctors of direct (Anon, billing 1992), an amongst some opportunity of B r i t i s h exists Columbia for community p h a r m a c i s t s t o e x p a n d t h e i r p r o f e s s i o n a l r o l e s t o meet t h e p u b l i c ' s increased demand a n d expectations. E x p a n d i n g p h a r m a c i s t i n v o l v e m e n t i n h e a l t h p r o m o t i o n may p r o v e t o be a d i f f i c u l t task. Smith and G i b s o n (1975) p o i n t t o four major b a r r i e r s t o i n c r e a s i n g t h e pharmacist's r o l e i n preventative medicine i n the United pay f o r advice; States: 2) The 1) The p u b l i c ' s u n w i l l i n g n e s s legal barriers which restrict p h a r m a c i s t ' s scope o f p r a c t i s e ( i . e . , a f e a r o f being charged p r a c t i s i n g medicine without a l i c e n s e ) ; reimbursement f o r pharmacists (i.e., to a with 3) The l a c k o f f i n a n c i a l a lack of government r e c o g n i t i o n f o r s e r v i c e s ; a n d 4) The p u b l i c ' s l a c k o f a c c e p t a n c e o f the pharmacist as a h e a l t h advisor. Many o f t h e s e b a r r i e r s a r i s e f r o m what h a s been i d e n t i f i e d as c o n t r a d i c t i o n s pharmacists' professional 1968; Shaw, 1 9 7 2 ) . professions, relationship with today only i f t h e rapport increased f u l l p r o f e s s i o n a l evolvement i s Shaw c o n c l u d e s , society therefore, can e x i s t in a that a pharmacy between t h e p a t i e n t and t h e p h a r m a c i s t i s t h r o u g h t h e enactment o f laws contemporary w i t h educational (Denzin, t h e p h a r m a c i s t has " b u r e a u c r a t i c a l l y been reduced t o a s p e c i a l i z e d businessman". professional by t h e p u b l i c Shaw n o t e s t h a t b e c a u s e p h a r m a c y i s o n e o f t h e most h i g h l y r e g u l a t e d impinged upon; image p e r c e i v e d i n the standards of the pharmacist. current Pharmacists' A b i l i t y to Perform i n the Role of Community H e a l t h A d v i s o r D e s p i t e an a b u n d a n c e o f l i t e r a t u r e d o c u m e n t i n g t h e impact on t h e h e a l t h c a r e s y s t e m patient counselling from p h a r m a c i s t activities, additional beneficial participation in evidence in the l i t e r a t u r e s u g g e s t s t h a t community p h a r m a c i s t s a r e n o t a c a d e m i c a l l y prepared t o assume t h i s expanded r o l e i n h e a l t h promotion. e x a m p l e , Knapp e t a l . ( 1 9 6 9 ) , f o u n d t h a t 8 3 % o f p h a r m a c i s t s a c o n t r a i n d i c a t e d p r o d u c t t o a p a t i e n t p r e t e n d i n g t o be A r e c e n t s t u d y o f 104 c o m m u n i t y p h a r m a c i e s i n M o n t r e a l t h a t over one-half of the pharmacists performed 'fair' (16%) of performed al., diabetic. demonstrated ' p o o r l y ' (41%) care (Nguyen, 1 9 9 2 ) . i n community A B r i t i s h study measuring pharmacies found that or I n t h i s s t u d y , n o t o n l y was pharmacist the pharmacists most p o o r l y i n t h e a r e a o f h e a l t h e d u c a t i o n 1990). sold i n an a s s e s s m e n t o f p h a r m a c i s t s ' k n o w l e d g e r e g a r d i n g head l i c e treatment quality For (Smith e t participation i n t h i s a r e a c o n s i d e r e d t o be v e r y l o w , b u t o f t h e c o n s u l t a t i o n s t h a t d i d o c c u r , o n l y 14% w e r e r a t e d a s judges. The discuss and d i s e a s e p r e v e n t i o n a s a f o r m a l p a r t o f e d u c a t i o n s o t h a t t h e y may i s s u e s such when g i v i n g the study's authors conclude w i t h a p l e a t o incorporate h e a l t h promotion pharmacists' ' s a t i s f a c t o r y ' by advice. as lifestyle, be able to recognize s m o k i n g and diet with and clients B u r t o n a n d McKay (1990) s u r v e y e d 550 c o m m u n i t y p h a r m a c i s t s i n Maryland (n=139, r e s p o n s e r a t e = 3 8 % ) , a n d f o u n d t h a t o n l y had e v e r c o u n s e l l e d a p a t i e n t on AIDS. 16 (12%) A l t h o u g h p h a r m a c i s t s had been a p p r o a c h e d by c l i e n t s f o r i n f o r m a t i o n and a d v i c e , they were n o t a c t i v e l y p r o v i d i n g t h i s s e r v i c e d e s p i t e t h e f a c t t h a t (42%) 59 of t h e respondent pharmacies stocked zidovudine, a drug u s e d i n t h e t r e a t m e n t o f AIDS. Of t h e 8 6 % o f p h a r m a c i s t s t h a t h a d n e v e r c o u n s e l l e d on AIDS t r e a t m e n t , o v e r o n e - h a l f s t a t e d t h a t t h e y lacked confidence i n t h e i r counselling a b i l i t y Academic preparedness i s not the only i n t h i s area. concern in community p h a r m a c i s t i n v o l v e m e n t i n h e a l t h p r o m o t i o n . d i s c r e p a n c i e s r e l a t e d t o pharmacy's " h e a l t h person" image play an integral role c u r r e n t r o l e i n h e a l t h promotion. expanding Ethical professional/business i n community pharmacists' Brown a n d D i F r a n z a s u r v e y e d 100 c o m m u n i t y p h a r m a c i e s i n M a s s a c h u s e t t s . (1992) Ninety-five s o l d t o b a c c o p r o d u c t s , 50 a d v e r t i s e d t o b a c c o , a n d 23 d i s p l a y e d t h e Camel cartoon targeted advertisement which has s p e c i f i c a l l y at children. i d e n t i f i e d as Eighty-one willing to percent i t to of the s e l l i n g tobacco illegally. The a u t h o r s c o n c l u d e t h a t p h a r m a c i s t s p l a y a n i m p o r t a n t i n t h e p r o m o t i o n o f t o b a c c o u s e among sell being pharmacies role were been minors children. T h e r e f o r e , although expanding t h e pharmacist's r o l e i n h e a l t h p r o m o t i o n may be j u s t i f i a b l e b a s e d upon c o m m u n i t y p h a r m a c i s t s ' a v a i l a b i l i t y and a c c e s s a b i l i t y , r e a s o n a b l e d o u b t e x i s t s as t o t h e p h a r m a c i s t s ' a c a d e m i c and e t h i c a l c a p a b i l i t i e s t o assume t h i s role. Statement of Problem B e f o r e a t t e m p t i n g t o expand community p h a r m a c i s t s ' r o l e i n h e a l t h promotion, i t i s necessary t o determine the current l e v e l of p a r t i c i p a t i o n i n h e a l t h promotion a c t i v i t i e s . Columbia community p h a r m a c i s t s p a r t i c i p a t e activities? pharmacist data i s of system, No quantitative involvement limited Canadian to a o f t e n do i n health data i n h e a l t h promotion u s e f u l n e s s due How British promotion exists regarding activities: American different health care and t e m p o r a l and m e t h o d o l o g i c a l p r o b l e m s i n t h e r e s e a r c h that i s available. Many c o m m u n i t y p h a r m a c i s t s h a v e b e e n s l o w t o a d o p t t h e r o l e o f " c l i n i c a l p h a r m a c i s t " t h a t many h o s p i t a l p h a r m a c i s t s h a v e assumed (Bloom, 1990). I f community p h a r m a c i s t s have been r e l u c t a n t assume a c l i n i c a l r o l e , t h e n i t i s r e a s o n a b l e t o assume t h a t will also be slow to expand their role in health to they promotion. B e c a u s e community and h o s p i t a l p h a r m a c i s t s r e c e i v e u n i f o r m t r a i n i n g i n B r i t i s h Columbia, factors o t h e r than e d u c a t i o n o r knowledge background are important i n d e t e r m i n i n g p h a r m a c i s t s ' involvement i n professional activities. in health promotion What i n f l u e n c e s p h a r m a c i s t s ' i n v o l v e m e n t activities? As covered l i t e r a t u r e r e v i e w , v a r i a b l e s such as gender, i n the following m a r i t a l s t a t u s , age, and a p h a r m a c i s t ' s p e r s o n a l h e a l t h b e l i e f s a n d b e h a v i o u r s may affect the extent promotion t o which activities. pharmacists Other participate variables involvement i n h e a l t h promotion a c t i v i t i e s which in may health influence include a pharmacist's degree-granting i n s t i t u t i o n , years i n p r a c t i c e , l o c a t i o n of practice, and employment p o s i t i o n . I n summary, t w o p r o b l e m s w i l l problem will be to determine be i n v e s t i g a t e d . the current level The of pharmacist involvement i n health promotion a c t i v i t i e s . an a t t e m p t w i l l be made t o d e t e r m i n e w h i c h p h a r m a c i s t first community Secondly, variables i n f l u e n c e p a r t i c i p a t i o n i n h e a l t h p r o m o t i o n a c t i v i t i e s by community pharmacists i n B r i t i s h Columbia. Purpose and O b j e c t i v e s T h i s s t u d y r e p r e s e n t s t h e f i r s t phase o f a l o n g - t e r m project d e s i g n e d t o e n a b l e community p h a r m a c i s t s t o p a r t i c i p a t e i n t h e assessment o f t h e i r community's s p e c i f i c h e a l t h needs and t o expand s e r v i c e s o f f e r e d through pharmacies i d e n t i f i e d needs. w h i c h c a n h e l p t o meet t h e s e In pursuit of t h i s goal, the current level of p h a r m a c i s t p a r t i c i p a t i o n i n h e a l t h p r o m o t i o n a c t i v i t i e s must be first established. Increasing pharmacists' p a r t i c i p a t i o n i n health activities will pharmacists. involve Behavioral (Higginbotham, 1992). behavioural change on promotion the change i s a m u l t i d i m e n s i o n a l That i s , e f f o r t s t o i n c r e a s e part process pharmacists' i n v o l v e m e n t i n h e a l t h p r o m o t i o n a c t i v i t i e s w i l l n o t o c c u r by a change i n p h a r m a c i s t s ' e d u c a t i o n . w i l l e n t a i l addressing personal Changing pharmacist To behaviour s t u d y a l l o f t h e s e f a c t o r s w h i c h may eleven influence T h i s s t u d y w i l l , t h e r e f o r e , be c o n f i n e d t o of the personal, p h a r m a c i s t s t h a t can d e m o g r a p h i c , and S p e c i f i c o b j e c t i v e s of t h i s study 1. of exploring of format. are: To m e a s u r e t h e f r e q u e n c y w i t h w h i c h c o m m u n i t y p h a r m a c i s t s i n B r i t i s h Columbia are promotion a c t i v i t i e s ; 2. scope practice variables be m e a s u r e d i n a q u e s t i o n n a i r e and British p h a r m a c i s t i n v o l v e m e n t i n h e a l t h p r o m o t i o n i s beyond t h e this project. lone the s o c i a l , p r o f e s s i o n a l , environmental, f a c t o r s t h a t i n f l u e n c e pharmacy p r a c t i c e i n Columbia. of To currently involved health and determine i f personal o f p h a r m a c i s t s and in or demographic c h a r a c t e r i s t i c s t h e i r p r a c t i c e s are r e l a t e d to p a r t i c i p a t i o n i n health promotion activities. their Importance o f Study This field study will o f pharmacy make three important administration. First, contributions to the researchers w i l l be provided w i t h b a s e l i n e data r e g a r d i n g t h e frequency w i t h which community p h a r m a c i s t s i n B r i t i s h promotion. Columbia a r e i n v o l v e d i n health Such d a t a w i l l e n a b l e t h e measure o f s u c c e s s o f f u t u r e i n t e r v e n t i o n s aimed a t s t i m u l a t i n g pharmacist involvement i n h e a l t h promotion. Secondly, t h i s necessary, h e r e t o f o r e u n a v a i l a b l e data may e n a b l e p o l i c y m a k e r s t o c o n d u c t more t h o r o u g h e x a m i n a t i o n s o f the contributions of pharmacist a c t i v i t i e s t o the health of the province. Finally, educators will gain insight regarding the e x t e n t t o which c u r r e n t h e a l t h promotion t h e o r y and e d u c a t i o n i s diffusing into the workplace among p h a r m a c i s t s . Specifically, a foundation f o r further study of the incorporation of health promotion into t h e undergraduate pharmacy c u r r i c u l u m and pharmacist continuing education offerings w i l l be p r o v i d e d . into CHAPTER 2 REVIEW OF THE LITERATURE The P a r t i c i p a t i o n o f Community P h a r m a c i s t s i n H e a l t h Promotion L i t t l e r e s e a r c h has been done on community p h a r m a c i s t s ' involvement i n h e a l t h promotion. Much o f w h a t h a s b e e n p u b l i s h e d t o d a t e has been t h e o r e t i c a l i n n a t u r e , and l i t t l e e f f o r t has been made t o s c i e n t i f i c a l l y communities document projects ( E i n a r s o n and P o s t o n , The m o s t c o m p r e h e n s i v e currently u n d e r way i n 1992). work i n t h e a r e a o f p h a r m a c i s t i n v o l v e m e n t i n h e a l t h p r o m o t i o n was d o n e i n t h e e a r l y 1 9 8 0 s b y a r e s e a r c h group d i r e c t e d by P a t r i c i a Bush (1983). project, were 450 c o m m u n i t y p h a r m a c i s t s f r o m surveyed to document across the United States pharmacists' p r e v e n t i o n and h e a l t h p r o m o t i o n As p a r t o f t h i s activities ( B e a r d s l e y , 1983). i n disease The overall r e t u r n r a t e was 4 0 % ( n = 1 8 2 ) . Results of the survey indicated t h a t t h e most f r e q u e n t l y p e r f o r m e d h e a l t h promotion by p h a r m a c i s t s a c t i v i t i e s reported i n c l u d e d h y p e r t e n s i o n s c r e e n i n g and c o u n s e l l i n g , c o u n s e l l i n g about n u t r i t i o n , weight c o n t r o l , a l l e r g i e s , proper use of p r e s c r i p t i o n and o v e r - t h e - c o u n t e r (OTC) m e d i c a t i o n s , referring p a t i e n t s t o o t h e r h e a l t h c a r e p r o v i d e r s , and t a k i n g drug and medical h i s t o r i e s . community Health promotion pharmacist involvement a c t i v i t i e s e n j o y i n g much l e s s included speaking t o community g r o u p s on h e a l t h - r e l a t e d m a t t e r s , r e f e r r i n g p a t i e n t s t o community agencies, and participating in community-based s e x u a l l y - t r a n s m i t t e d d i s e a s e s , mental programs h e a l t h , substance p o i s o n i n g p r e v e n t i o n and cancer s c r e e n i n g . on abuse, Bush c o n c l u d e d that a l t h o u g h p h a r m a c i s t s have a s i g n i f i c a n t impact on t h e h e a l t h s t a t u s of t h e American p o p u l a t i o n , h e a l t h promotion and d i s e a s e p r e v e n t i o n a c t i v i t i e s which lack a d i r e c t l i n k t o t h e d i s p e n s i n g o r s e l l i n g o f m e d i c a t i o n w e r e n o t d a i l y , a n d i n some c a s e s n e v e r , a c t i v i t i e s o f most community p h a r m a c i s t s . pharmacist She s t a t e s t h a t p h a r m a c y e d u c a t i o n a n d i n c e n t i v e s must increase their a c t i v i t i e s Although be changed i n t h e area of h e a l t h health are t o promotion. Bush's work remains t h e o n l y comprehensive s t u d y i n t h i s area, Beardsley's r e s u l t s which not u s e f u l i f pharmacists as i n d i c a t o r s promotion form p a r t o f t h a t paper a r e o f Canadian pharmacists' f o r a number o f r e a s o n s . s t u d y was u n d e r t a k e n First, involvement i n t h e American i n 1981 when C a n a d i a n e m p h a s i s o n h e a l t h promotion a c t i v i t i e s j u s t g a i n i n g momentum ( L a s t , 1 9 8 9 ) . As d i f f u s i o n o f h e a l t h p r o m o t i o n t r a i n i n g i n t o t h e w o r k p l a c e had not y e t had was time to occur, pharmacist, currently might Beardsley's results, i f applied to underestimate the level of promotion undertaken. Secondly, d i f f e r e n c e s i n the h e a l t h care the health today's United States and Canada may give p u b l i c ' s a t t i t u d e s toward u t i l i z a t i o n rise d e l i v e r y systems i n to differences i n of the the community p h a r m a c i s t as a s o u r c e o f h e a l t h i n f o r m a t i o n . Because A m e r i c a n p a t i e n t s must generally visit pay out-of-pocket to physicians p r a c t i t i o n e r s f o r health counselling or advice, or nurse- the pharmacist i s s e e n as a l e s s e x p e n s i v e , competent a l t e r n a t i v e . Many U.S. pharmacies o f f e r a wide array of h e a l t h promotion a c t i v i t i e s , for r e d u c e d o r no (Hampton et. weigh-ins, charge, i n c l u d i n g blood al.,1990), uric acid hypercholesterolemia however, visits diabetes to the counselling, testing, screening monitoring (Martin, glucose (Martin, physician person's p r o v i n c i a l health plan. pressure are generally In paid C a n a d i a n s i n c u r no an including economic incentive pharmacists, for to seek health out reason a (Crichton, for Canadians caregivers, services. Canadian s t u d i e s , consumers e x p r e s s e d a p r e f e r e n c e by out-of-pocket alternative promotion and Canada, for e t a l . , 1990), i n c l u d i n g h e a l t h c o u n s e l l i n g ; t h e r e f o r e , lack 1990), testing, 1990a). e x p e n s e s f o r v i s i t i n g a p h y s i c i a n f o r a l m o s t any often In the four physician over information the pharmacist as a source ( S t a c h i w , 1989; S t r a t t o n Marstellar, 1991; S t r a t t o n , consumers mentioned 1993). of prescription and S t e w a r t , drug 1991; Burson- I n one o f t h e s t u d i e s , t h e pharmacist l e s s than seven p e r c e n t o f t h e t i m e when a s k e d a b o u t information sources f o r general health concerns ( S t r a t t o n and S t e w a r t , 1991). T h e r e f o r e , because Canadian p h a r m a c i s t s may be u n d e r u t i l i z e d when c o m p a r e d t o A m e r i c a n pharmacists, Beardsley's results may overestimate pharmacists' involvement i n h e a l t h promotion Finally, activities. B e a r d s l e y ' s s m a l l sample s i z e and low r e t u r n weaken t h e s t u d y ' s e x t e r n a l pharmacists Canadian validity. (91% of a l l respondents) An o v e r - r e s p o n s e and a lack rate o f male of follow-up p r o c e d u r e s may h a v e i n t r o d u c e d r e s p o n d e n t b i a s , a s i t i s p o s s i b l e t h a t o n l y p h a r m a c i s t s w i t h e i t h e r a keen i n t e r e s t o r above average participation t o the i n health promotion activities responded survey. While l i t t l e in i n f o r m a t i o n e x i s t s about p h a r m a c i s t health promotion, Einarson exhaustive literature review and of Poston conducted an the preventive strategies in community h e a l t h u n d e r t a k e n by p h a r m a c i s t s . (1992) involvement The o b j e c t i v e s o f t h e i r r e v i e w were t o i d e n t i f y and d e s c r i b e t h e range o f a c t i v i t i e s r e l a t i n g t o h e a l t h p r o m o t i o n i n which p h a r m a c i s t s have been involved, critically a s s e s s t h e c o n t e n t o f pharmacy-based health p r o m o t i o n a c t i v i t i e s w i t h r e s p e c t t o h e a l t h p r o m o t i o n mechanisms and implementation s t r a t e g i e s o u t l i n e d i n A c h i e v i n g Heath f o r A l l (Epp, 1 9 7 6 ) , a n d c r i t i c a l l y a s s e s s t h e e x t e n t and q u a l i t y e v a l u a t i o n s of pharmacy-based h e a l t h promotion of activities. E i n a r s o n and P o s t o n c o n c l u d e d t h a t t h e p h a r m a c i s t ' s r o l e i n p r e v e n t i v e h e a l t h h a s b e e n d e v e l o p e d and p r o m o t e d i n t h e U n i t e d States and Britain, but Canada h a s b e e n much l e s s active. They f o u n d t h a t t h e r e h a d b e e n a g r e a t many c o n t i n u i n g e d u c a t i o n p r o g r a m s f o r p h a r m a c i s t s i n C a n a d a b u t few d e m o n s t r a t i o n or p i l o t studies. projects Canadian p r o j e c t s t h a t are r e p o r t e d tend t o be a n e c d o t a l i n n a t u r e , o r l a c k an a p p r o p r i a t e r e s e a r c h d e s i g n . The l a c k o f p r o g r e s s i n p h a r m a c i s t i n v o l v e m e n t i n p r e v e n t i v e h e a l t h was a t t r i b u t e d t o i m p l e m e n t a t i o n b a r r i e r s such as a l a c k financial i n c e n t i v e s and m o t i v a t i o n , a l a c k of s p e c i f i c of training programs f o r p r e v e n t i v e h e a l t h i n pharmacy s c h o o l s , and f i n a l l y , l a c k o f f e d e r a l r e c o g n i t i o n f o r r e s e a r c h and a sponsorship i n t h i s area. O v e r a l l , a s i t u a t i o n e x i s t s where v e r y l i t t l e i s known a b o u t community p h a r m a c i s t s ' i n v o l v e m e n t i n h e a l t h p r o m o t i o n ; i s known a b o u t C a n a d i a n p h a r m a c i s t s ' i n v o l v e m e n t i n t h i s Developing the Pharmacist's Role i n Health area. Promotion Knowing t h a t a change i n e d u c a t i o n a l o n e w i l l pharmacists' involvement i n h e a l t h promotion even l e s s not i n c r e a s e ( H i c k s , 1988), i t i s n e c e s s a r y t o a l s o d e t e r m i n e w h i c h v a r i a b l e s , i f any, a r e r e l a t e d t o pharmacist involvement i n health promotion a c t i v i t i e s . Previous r e s e a r c h h a s i d e n t i f i e d t h r e e m a i n v a r i a b l e s t h a t may b e associated with pharmacists' h e a l t h promotion involvement: p r a c t i c e v a r i a b l e s , educational v a r i a b l e s , and p e r s o n a l v a r i a b l e s . Practice Variables A v a r i e t y o f p r a c t i c e v a r i a b l e s may opportunities Practice to participate variables found in to be a f f e c t pharmacists' health promotion associated p a r t i c i p a t i o n i n other professional a c t i v i t i e s activities. with pharmacist include a p h a r m a c i s t ' s employment p o s i t i o n , t h e t y p e o f pharmacy i n which t h e p h a r m a c i s t i s employed (independent, independent chain, franchise, or corporate chain), the geographic l o c a t i o n of the pharmacy, and predominantly the served socioeconomic by the status pharmacy. The of the following clientele section r e v i e w s l i t e r a t u r e p e r t a i n i n g t o p r a c t i c e v a r i a b l e s and concludes with variables a summary o f p r o p o s e d h y p o t h e s e s ' ( T a b l e 1 on p a g e 2 2 ) . concerning these i) Employment p o s i t i o n ; C o n f l i c t i n g evidence e x i s t s regarding the e f f e c t o f a p h a r m a c i s t ' s employment p o s i t i o n e m p l o y e e ) on w o r k p e r f o r m a n c e . that pharmacy owners and B e l a s c o and A r b e i t employees p e r c e p t i o n s as p h a r m a c i s t s . (owner, differed (19 69) in or found their role I f a p h a r m a c i s t does n o t p e r c e i v e h i s / h e r r o l e as i n c l u d i n g t h e p r o v i s i o n o f community promoting s e r v i c e s , he/she would activities (Knapp e t a l , 1 9 6 9 ) . Beardsley manager, health n o t be a c t i v e l y e n g a g e d i n s u c h (1983) f o u n d t h a t p h a r m a c y o w n e r s w e r e more likely t h a n m a n a g e r s o r s t a f f p h a r m a c i s t s t o be i n v o l v e d i n c e r t a i n h e a l t h promotion a c t i v i t i e s . to T h i s r e l a t i o n s h i p , h o w e v e r , was p o s t u l a t e d be due t o t h e t y p e o f p r a c t i c e ( i . e . , many p h a r m a c y o w n e r s w e r e owners o f s m a l l , independent practices) rather than t o the employment p o s i t i o n a l o n e . Owners o f p h a r m a c i e s h a v e b e e n a c c u s e d o f b e i n g more economically, or business-oriented than s t a f f pharmacists (Belasco and Arbeit, 1969). In 1963, v i o l a t i o n s w e r e more l i k e l y pharmacists and occur Quinney found that t o o c c u r among b u s i n e s s - o r i e n t e d least among the professionally p h a r m a c i s t s , who t e n d e d t o be s t a f f p h a r m a c i s t s . o r i e n t e d p h a r m a c i s t s may, h e a l t h promotion a c t i v i t i e s prescription oriented Professionally- t h e r e f o r e , be more a c t i v e l y involved i n t h a n b u s i n e s s - o r i e n t e d p h a r m a c i s t s , who w o u l d b e more i n c l i n e d t o s e l l a n o v e r - t h e - c o u n t e r (OTC) m e d i c a t i o n ( L i n n a n d D a v i s , 1973) t h a n t o s p e n d t i m e c o u n s e l l i n g t h e p a t i e n t . R e f u t i n g b o t h o f t h e a b o v e t h e o r i e s , an e a r l i e r s t u d y by L i n n and D a v i s (1971) f o u n d t h a t o w n e r s h i p of e i t h e r activity or o r i e n t a t i o n s t a t u s was not a determinant (professional versus business) among p h a r m a c i s t s . ii) P l a c e of employment; The b u s i n e s s environment o f a pharmacy s i g n i f i c a n t l y a f f e c t s b o t h t h e a c t i v i t y and o r i e n t a t i o n o f p h a r m a c i s t i t e m p l o y s ( L i n n and D a v i s , 1 9 7 1 ) . t h a t e c o n o m i c a l l y s u c c e s s f u l pharmacies the L i n n and D a v i s found a r e more l i k e l y t o h a v e i n t h e i r employ p h a r m a c i s t s w i t h a g r e a t e r i n t e r e s t and i n v o l v e m e n t i n professional activities. The r e l a t i o n s h i p , however, i s u n c l e a r . pharmacists make a causal Do community pharmacy direction this professionally-oriented successful, s u c c e s s o f a pharmacy t h a t e n a b l e s i t t o r e t a i n motivated s t a f f through s u p e r i o r f i n a n c i a l Inadequate of or i s i t the professionally reimbursement? r e i m b u r s e m e n t schemes f r o m t h i r d p a r t y p a y e r s h a v e resulted i n declining profits c l o s u r e o f many i n d e p e n d e n t (Carroll, pharmacies. 1991) and inevitable Larger chain stores, s e l l i n g a v a s t a r r a y o f non-pharmacy m e r c h a n d i s e , f l o u r i s h during t h i s time. the h a v e managed t o Larger chain stores could, therefore, be s e e n a s b e i n g more e c o n o m i c a l l y s u c c e s s f u l , a n d t h u s , may pharmacists w i t h a greater i n t e r e s t i n h e a l t h promotion employ activities. iii) Socioeconomic s t a t u s o f c l i e n t e l e ; Very l i t t l e r e s e a r c h has examined t h e e f f e c t o f a c l i e n t ' s s o c i o e c o n o m i c s t a t u s on t h e l e v e l o f s e r v i c e p r o v i d e d by community p h a r m a c i s t s . (1971) found neighbourhoods that tended pharmacies study, professional dispensing whose p r e d o m i n a t e more constituted p r e s c r i p t i o n orders, with clients. and involved in health promotion and opportunities to participate i n health i n remote than clientele. suggests promotion towns o r remote s e t t i n g s a r e g r e a t e r Whether t h i s activities Anecdotal evidence, though n o t through f i n d i n g s i n the l i t e r a t u r e , caregivers advising Therefore, pharmacists substantiated areas. medical c l i e n t e l e c o u l d be c l a s s i f i e d a s " l o w e r c l a s s " Geographic l o c a t i o n ; small were In this making pharmacists serving predominantly "upper-class" iv) group i n p r o f e s s i o n a l a c t i v i t i e s than d i d activities d i s c u s s i n g h e a l t h problems be minority l o c a t e d i n p r i m a r i l y Caucasian neighbourhoods. preparations, may in t o h a v e a s e m p l o y e e s p h a r m a c i s t s who more i n t e r e s t e d a n d i n v o l v e d pharmacies located L i n n and D a v i s than areas activities i n larger, s i t u a t i o n i s due t o a l a c k that in urban of alternative o r t o i s o l a t e d pharmacies having a c o n s i s t e n t and f a m i l i a r c l i e n t e l e , p h a r m a c i s t s i n remote areas a r e hypothesized t o be more i n v o l v e d i n health than pharmacists i n l a r g e r urban centres. r e f u t e t h i s h y p o t h e s i s were found i n t h e V) Barriers; promotion activities No d a t a t o s u p p o r t o r literature. H e a l t h p r o f e s s i o n a l s t e n d t o c i t e two m a j o r b a r r i e r s to f u r t h e r i n g p r o f e s s i o n a l involvement. These b a r r i e r s i n c l u d e lack incentives of Weschler time and e t a l . , 1983; the Upjohn Survey expanding a lack of economic S o b a l , 1985; o f 1990, Schwartz " k n o w l e d g e " was (Bush, a 1983, e t a l . , 1991). In c i t e d as a b a r r i e r t o pharmacist involvement i n p a t i e n t c o u n s e l l i n g . Another b a r r i e r commonly s t a t e d by p h a r m a c i s t s i s a l a c k o f p a t i e n t demand ( Z e l n i o e t a l . , 1984). I t i s h y p o t h e s i z e d t h a t p h a r m a c i s t s who believe that there are many b a r r i e r s t o f u r t h e r i n g t h e i r i n v o l v e m e n t i n h e a l t h w i l l n o t be h i g h l y i n v o l v e d i n h e a l t h p r o m o t i o n . between " p h a r m a c i s t s ' p e r c e i v e d b a r r i e r s " and h e a l t h promotion i s refuted, a p o s i t i v e r e l a t i o n s h i p may Upjohn's study of patient This relationship involvement i n h o w e v e r , by d a t a w h i c h a c t u a l l y e x i s t (Upjohn, counselling, promotion suggests 1990). p h a r m a c i s t s who area. In were most a c t i v e l y engaged i n p a t i e n t c o u n s e l l i n g c i t e d t h e most b a r r i e r s t o f u r t h e r i n g t h e i r involvement i n t h i s that the TABLE 1 SUMMARY OF THE REPORTED EFFECTS OF PRACTICE VARIABLES ON COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION Practice Variable Hypothesized E f f e c t ( s ) on H e a l t h Promotion Involvement 1. Employment Position S t a f f > M a n a g e r s > Owners Owners > M a n a g e r s o r S t a f f No E f f e c t 2. P l a c e o f Employment C o r p o r a t e Chain > Independent No E f f e c t 3. Socioeconomic Status of Clientele 4. Geographic Location 5. B a r r i e r s Lower C l a s s > Upper C l a s s North > South R u r a l > Urban Supporting Literature Quinney (1963) L i n n & D a v i s (1973) Beardsley (1983) Linn & Davis (1971) Linn & Davis (1973) Linn & Davis (1971) Linn & Davis (1971) None available Many B a r r i e r s = L o w I n v o l v e m e n t None available Many B a r r i e r s = H i g h I n v o l v e m e n t Upjohn (1990) Personal V a r i a b l e s The following section discusses hypothesized e f f e c t s of p h a r m a c i s t s ' s e x , m a r i t a l s t a t u s , age, and p e r s o n a l h e a l t h a n d b e h a v i o u r s on h e a l t h p r o m o t i o n i n v o l v e m e n t . beliefs T a b l e 2 ( p a g e 28) , summarizes t h e l i t e r a t u r e p e r t a i n i n g t o p e r s o n a l v a r i a b l e s . i) Pharmacist sex; Canadian A s t u d y o f p a t i e n t c o u n s e l l i n g p r a c t i c e s among community p h a r m a c i s t s i n 1990 (Upjohn, 1990) suggested t h a t f e m a l e p h a r m a c i s t s w e r e more i n v o l v e d i n p a t i e n t counselling t h a n were male p h a r m a c i s t s . differences Among A m e r i c a n i n t e r n i s t s , i n h e a l t h promotion c o u n s e l l i n g p r a c t i c e s were a l s o found t o f a v o u r females (Schwartz e t a l . , 1991). Females have a l s o been f o u n d t o have h e a l t h b e l i e f s and behaviours that are (Lau e t a l . , 1990). health promotion significantly different from those of health males The c a u s a l m o d e l o f p h a r m a c i s t i n v o l v e m e n t i n ( F i g u r e 1) p r o p o s e s t h a t p h a r m a c i s t s ' i n v o l v e m e n t i n h e a l t h p r o m o t i o n i s i n f l u e n c e d by a p h a r m a c i s t ' s p e r s o n a l h e a l t h beliefs and health behaviours. Therefore, a difference in p h a r m a c i s t i n v o l v e m e n t i n h e a l t h p r o m o t i o n a c t i v i t i e s based upon a p h a r m a c i s t ' s s e x may also exist. ii) Pharmacist m a r i t a l status: M a r r i e d p e r s o n s a r e more a c t i v e l y engaged i n p r o t e c t i n g t h e i r h e a l t h t h a n a r e s i n g l e persons 1986). (Sobal, H e a l t h b e h a v i o u r i s an i n t e r v e n i n g v a r i a b l e i n t h e model o f pharmacist involvement i n health promotion (Figure 1). Therefore, one h y p o t h e s i s b e i n g t e s t e d i s t h a t m a r r i e d p h a r m a c i s t s a r e more actively involved i n h e a l t h promotion a c t i v i t i e s than are s i n g l e pharmacists. If health divorce, L i t e r a t u r e , however, i s n o t a v a i l a b l e on t h i s i s s u e . b e h a v i o u r s and h e a l t h than divorced b e l i e f s remain constant a f t e r a p h a r m a c i s t s may show l e v e l s o f i n v o l v e m e n t s i m i l a r t o married pharmacists. A f t e r a d i v o r c e , however, t h e p e r s o n a l h e a l t h b e l i e f s and h e a l t h b e h a v i o u r s o f a p h a r m a c i s t may b e g i n t o " d r i f t " , r e f l e c t i n g t h e p h a r m a c i s t ' s new s o c i a l p e e r g r o u p w h i c h t h e o r e t i c a l l y w o u l d c o n t a i n more s i n g l e p e r s o n s t h a n b e f o r e the divorce. Perhaps divorced pharmacists p a r t i c i p a t i o n l e v e l s i n h e a l t h promotion two iii) will intermediate exhibit between t h e extremes o f m a r r i e d and s i n g l e . P h a r m a c i s t age: Schwartz e t a l . , (1991) f o u n d t h a t a g e was a f a c t o r i n i n t e r n i s t s ' p e r s o n a l h e a l t h b e h a v i o u r s and i n t h e extent t o which they o f f e r e d h e a l t h promotion clients. activities As p h a r m a c i s t s age, t h e i r tends t o decrease (Linn services to their involvement and Davis, i n professional 1971). Older p h a r m a c i s t s a r e , t h e r e f o r e , e x p e c t e d t o be l e s s i n v o l v e d i n h e a l t h promotion a c t i v i t i e s than younger p h a r m a c i s t s . iv) Pharmacist personal perceptions p e r t a i n i n g t o health help b e h a v i o u r s (Olsen, 1992). the health beliefs; Attitudes or shape p e r s o n a l health P o s i t i v e or o p t i m i s t i c b e l i e f s regarding e f f i c a c y of a p a r t i c u l a r health behaviour w i l l increase the l i k e l i h o o d o f p e r f o r m i n g t h a t behaviour (Olsen, 1992), b u t evidence regarding and the strength o f t h e r e l a t i o n s h i p between h e a l t h b e l i e f s h e a l t h behaviours i s f a r from c o n c l u s i v e (Hicks e t a l . , 1988). Based upon t h e s e f i n d i n g s , t h e p r o p o s e d c a u s a l model o f p h a r m a c i s t involvement i n health promotion ( F i g u r e 1) s u g g e s t s , f o r e x a m p l e , t h a t p h a r m a c i s t s who b e l i e v e t h a t e x e r c i s i n g t h r e e t i m e s a week i s i m p o r t a n t i n p r o m o t i n g t h e h e a l t h o f t h e a v e r a g e i n d i v i d u a l w i l l be more likely to become necessity of regular engaged i n counselling clients on t h e exercise. A l t h o u g h s t u d i e s have examined t h e h e a l t h b e l i e f s o f h e a l t h professionals (Sobal e t a l . , 1985; Fincham and S m i t h , 1988; J a n e s e t a l . , 1992), few have s t u d i e d t h e r e l a t i o n s h i p between health care p r o f e s s i o n a l s ' p e r s o n a l h e a l t h b e l i e f s and t h e i r p a r t i c i p a t i o n in health promotion activities a t work. Only one study has examined t h e r e l a t i o n s h i p between h e a l t h c a r e p r o f e s s i o n a l s ' h e a l t h b e l i e f s , h e a l t h b e h a v i o u r s , and t h e i r p a r t i c i p a t i o n i n h e a l t h promotion activities a t work (Merlino and Price, 1992). a u t h o r s i n t h i s s t u d y c o n c l u d e d t h a t o n l y a weak c o n n e c t i o n between h e a l t h c a r e professionals' personal t h e i r p a r t i c i p a t i o n i n h e a l t h promotion The exists h e a l t h b e l i e f s and activities. v) Pharmacist personal health behaviours: S t u d i e s have examined t h e h e a l t h b e h a v i o u r s o f A m e r i c a n p h y s i c i a n s a n d n u r s e s , (Wyshak e t al., 1980;; Henry e t a l . , 1992), as w e l l students as t h e h e a l t h (Coe e t a l . , Benson and W i l l i a m s , health care 1987; Kahn e t a l . , behaviours 1988; Janes of medical et a l . , and n u r s i n g 1982; S o b a l , 1986; R i c h t e r e t a l . , 1987; 1988). practitioners I n a l l o f t h e s e s t u d i e s among b o t h and health care students, health p r o m o t i n g b e h a v i o u r s were b e i n g p r a c t i s e d a t no g r e a t e r a r a t e t h a n among t h e g e n e r a l p u b l i c . Many s t u d i e s refute t h e e x i s t e n c e o f an a s s o c i a t i o n between h e a l t h b e h a v i o u r and an i n d i v i d u a l ' s b e l i e f s about t h e outcomes o f each behaviour (Norman, 1986; H i c k s , e t a l . , 1988). Evidence s u p p o r t s o n l y a modest r e l a t i o n s h i p between b e h a v i o u r s and b e l i e f s , ( P i l l and S t o t t , 1984; B r i z i a r e l l i , 1988) a n d s u g g e s t s t h a t demographic v a r i a b l e s such as age, gender, background may (Calnan, 1989). 384 d i e t i c i a n s and health a c t t o support and e d u c a t i o n a l or antagonize M e r l i n o and P r i c e this relationship (1992), f o r example, surveyed (70 p e r c e n t r e s p o n s e ) t o e x a m i n e t h e h e a l t h practices of dieticians reduction through n u t r i t i o n . socio- i n relation beliefs t o cancer risk Although the d i e t i c i a n s reported a s t r o n g p r e v e n t a t i v e h e a l t h o r i e n t a t i o n , many o f t h e i r b e l i e f s w e r e not t r a n s f o r m e d i n t o p r a c t i c e , and d i e t i c i a n s d i d n o t s t r o n g l y b e l i e v e t h a t many o f t h e U.S. n a t i o n a l n u t r i t i o n recommendations w h i c h t h e y p e r s o n a l l y p r a c t i s e d were e f f e c t i v e i n r e d u c i n g c a n c e r risk. Schwartz et al., exists between degree t o which The (1991) c l a i m t h a t a s t r o n g r e l a t i o n s h i p internists' personal health behaviours and t h e t h e y o f f e r e d t h e same s e r v i c e s t o t h e i r clients. " s t r e n g t h " o f t h e r e l a t i o n s h i p between i n t e r n i s t s ' p e r s o n a l h e a l t h b e h a v i o u r s and t h e i r involvement i n h e a l t h promotion counselling however, and c o l l e a g u e s i s n o t known, as Schwartz r e p o r t o n l y t h e p r o b a b i l i t y l e v e l , and n o t t h e n a t u r e and v a l u e o f the t e s t s t a t i s t i c obtained. I t has been s u g g e s t e d t h a t f o r b e h a v i o u r s w h i c h a r e inconsistent with personal beliefs, a set of situational s t r u c t u r a l v a r i a b l e s such as demographic d i f f e r e n c e s , status, o r peer or family pressure exists e n t i r e " b e l i e f : behaviour" r e l a t i o n s h i p which socioeconomic may (Norman 1 9 8 6 ) . or govern t h e Confirming t h e e x i s t e n c e o f t h e s e m e d i a t i n g v a r i a b l e s i s beyond t h e scope o f the present study. Table 2 SUMMARY OF THE REPORTED EFFECTS OF PERSONAL VARI7ŒLES ON COMMUNITY PHARMACIST PARTICIPATION IN HEALTH PROMOTION ACTIVITIES Personal Variable Hypothesized Effect Supporting Literature 1. S e x Female > Male U p j o h n , 1990 Schwartz e t al.,1991 2. A g e Younger > O l d e r Schwartz e t al.,1991 Linn & Davis,1971 3. M a r i t a l Status 4. H e a l t h B e l i e f s & Health Behaviours Married > Single S o b a l , 1986 Health Beliefs = Health Behaviours L a u , 1990 H e a l t h B e l i e f s do n o t = Health Behaviours M e r l i n o & P r i c e 1990 P i l l & S t o t t 1984 B r i z i a r e l l i 1988 (+) H e a l t h B e h a v i o u r s = High involvement i n Health Promotion i n the workplace (+) H e a l t h B e l i e f s = (+) H e a l t h B e h a v i o u r s = High involvement i n Health Promotion i n the workplace Schwartz e t al.,1991 None available Educational Variables In this section the literature knowledge of h e a l t h promotion pertaining to i s r e v i e w e d , as measured pharmacist by p h a r m a c i s t s ' d e g r e e - g r a n t i n g i n s t i t u t i o n and y e a r o f g r a d u a t i o n . A summary o f p r o p o s e d hypotheses related to the e f f e c t e d u c a t i o n a l v a r i a b l e s on p h a r m a c i s t i n v o l v e m e n t i n h e a l t h activities ( T a b l e 3, p a g e 31) educational i) of promotion concludes the l i t e r a t u r e review variables. Degree-granting i n s t i t u t i o n ; P r o f e s s i o n a l e x p e c t a t i o n s h e l d by the e d u c a t i o n a l i n s t i t u t i o n from which a pharmacist graduates one on are o f many f a c t o r s t h a t m o u l d a s t u d e n t ' s p e r c e p t i o n o f a pharmacist's r o l e w i t h i n the h e a l t h c a r e system Arbeit, health 1969). Universities promotion coursework with pharmacy should produce ( B e l a s c o and programs pharmacists h e a l t h p r o m o t i o n a c t i v i t i e s a s a component o f t h e i r role. containing who view professional No d a t a e x i s t s o n c u r r i c u l u m v a r i a t i o n s i n p h a r m a c y undergraduate programs i n Canada; therefore, an a n a l y s i s of the d i f f e r e n c e s i n h e a l t h p r o m o t i o n c o n t e n t between d i f f e r e n t pharmacy programs i s not e a s i l y undertaken. I n Canada, a l l l i c e n s e d pharmacists graduation wishing to are required practise t o pass Canada Q u a l i f y i n g E x a m i n a t i o n . uniform competency Furthermore, among outside their province t h e Pharmacy E x a m i n i n g of Board of T h i s exam i s d e s i g n e d t o e n s u r e pharmacists practising in Canada. a l lpharmacists wishing t o practice i n B r i t i s h C o l u m b i a m u s t p a s s a s e t o f p r o v i n c i a l p a n e l exams f o c u s i n g o n pharmaceutical knowledge, r e g u l a t o r y knowledge. patient counselling skills, Even w i t h s t r i n g e n t l i c e n s i n g and requirements such as these, d i f f e r e n c e s i n pharmacist involvement i n h e a l t h promotion w i l l a minimum dispensing l i k e l y a r i s e as l i c e n s i n g requirements ensure level or of competency selling assessing pharmacist of medication. the stage where p h a r m a c i s t ii) (Bush, Neither of to the the Health promotion c o u n s e l l i n g participation r e q u i r e m e n t , b u t i s n o t an e s s e n t i a l , practice related exams c o m p e t e n c y i n c l u d e a minimum p r o f i c i e n c y i n h e a l t h promotion c o u n s e l l i n g . at for activities only i s a remains "should have" "must h a v e " s k i l l f o r 1983). Year of g r a d u a t i o n ; L o g i c a l l y , pharmacists graduating i n r e c e n t y e a r s s h o u l d h a v e more u p - t o - d a t e k n o w l e d g e i n h e a l t h p r o m o t i o n a n d be more a c t i v e l y activities than their involved i n health promotion c o l l e a g u e s g r a d u a t i n g a t an e a r l i e r L i t e r a t u r e , however, does n o t s u p p o r t t h i s t h e o r y . time. W a t k i n s and Norwood (1978) physician studied the effect and p a t i e n t o f knowledge consultation behaviour, on p h a r m a c i s t s ' and found that a p h a r m a c i s t ' s y e a r o f g r a d u a t i o n h a d no e f f e c t on c o n s u l t a t i o n rates. T h e r e f o r e , y e a r o f g r a d u a t i o n s h o u l d have no e f f e c t on pharmacists' involvement i n h e a l t h promotion activities. *ie************************ie**************************ie* Table 3 SUMMARY OP THE REPORTED EFFECTS OF EDUCATIONAL VARIABLES ON COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Educational Variables 1. D e g r e e - G r a n t i n g Institution 2. Y e a r o f G r a d u a t i o n Hypothesized E f f e c t on Pharmacist Involvement No E f f e c t No E f f e c t Supporting Literature None A v a i l a b l e Watkins & Norwood, 1978 ***************************************************************** DEVELOPMENT OF A CAUSAL MODEL OF PHARMACIST INVOLVEMENT IN HEALTH PROMOTION P e r s o n a l p r a c t i c e e x p e r i e n c e and i n f o r m a t i o n o b t a i n e d from t h e p r e c e d i n g l i t e r a t u r e r e v i e w were used t o d e v e l o p a c a u s a l model o f pharmacist involvement i n h e a l t h promotion a c t i v i t i e s (Figure1). The model proposes t h a t p h a r m a c i s t p a r t i c i p a t i o n i n h e a l t h p r o m o t i o n a c t i v i t i e s i s i n f l u e n c e d by e l e v e n p e r s o n a l , educational, and independent practice-type variables. variables on activities i s explained personal pharmacists' i n f l u e n c e of these involvement in health promotion by t h r e e m a i n v a r i a b l e s ; p h a r m a c i s t s ' h e a l t h b e h a v i o u r s , t h e i r k n o w l e d g e o f h e a l t h and r e l a t e d m a t t e r s , and the promotion a c t i v i t i e s . personal The opportunity the operating for e x a m p l e , may to participate i n health O t h e r v a r i a b l e s s u c h as t h e h e a l t h b e l i e f s and health care h e a l t h b e h a v i o u r s , and system health- (universal or public's the nature of private-insurance) a l s o a f f e c t pharmacists' involvement i n health p r o m o t i o n a c t i v i t i e s , but a r e beyond the scope of the p r e s e n t s t u d y t o measure. In concluding the The current main information t h e l i t e r a t u r e r e v i e w , i t m u s t be s t r e s s e d study i s intended objective of the t o be d e s c r i p t i v e and study is to obtain that exploratory. descriptive pertaining to pharmacists p a r t i c i p a t i o n i n health promotion a c t i v i t i e s . However, e x a m i n i n g v a r i a b l e s r e l a t e d t o pharmacists' p a r t i c i p a t i o n i n h e a l t h promotion a c t i v i t i e s an o p p o r t u n i t y t o engage i n h y p o t h e s i s testing. As t h e number o f hypotheses being examined i s l a r g e . T a b l e 4 d i s p l a y s t h e hypotheses being tested i n this study. provides specific FIGURE 1 C A U S A L M O D E L OF C O M M U N I T Y PHARMACIST I N V O L V E M E N T HEALTH PROMOTION ACTIVITIES Independent variables Intervening Variables Pharmacist sex Marital status Personal health beliefs Age Health Behaviours Year of g r a d u a t i o n Degree-granting institution Knowledge * T y p e of P r a c t i c e * Geographic location of p r a c t i c e Employment position S o c i o e c o n o m i c status of c l i e n t e l e P e r c e i v e d b a r r i e r s to p a r t i c i p a t i o n in health promotion activities Opportunity IN Dependent Variable Pharmacist Involvement in Health Promotion TABLE 4 OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST IN HEALTH PROMOTION ACTIVITIES INVOLVEMENT HI: Community p h a r m a c i s t s w i l l h a v e h i g h e r o v e r a l l h e a l t h promotion scores f o r d i s p e n s i n g - r e l a t e d a c t i v i t i e s than f o r non-dispensing r e l a t e d h e a l t h promotion a c t i v i t i e s . H2: Female p h a r m a c i s t s w i l l have h i g h e r o v e r a l l h e a l t h s c o r e s t h a n male p h a r m a c i s t s . promotion H3 : M a r r i e d p h a r m a c i s t s w i l l have h i g h e r o v e r a l l h e a l t h scores than s i n g l e pharmacists. promotion H4: A p o s i t i v e c o r r e l a t i o n e x i s t s between o v e r a l l h e a l t h promotion s c o r e s and t o t a l h e a l t h b e l i e f s c o r e s . H5: An i n v e r s e c o r r e l a t i o n e x i s t s between p h a r m a c i s t age and o v e r a l l h e a l t h promotion score. H6: A p o s i t i v e c o r r e l a t i o n e x i s t s between p h a r m a c i s t s ' o v e r a l l h e a l t h promotion scores and t h e i r t o t a l p e r s o n a l h e a l t h behaviour scores. H7: No c o r r e l a t i o n e x i s t s b e t w e e n p h a r m a c i s t s ' g r a d u a t i n g y e a r and t h e i r o v e r a l l h e a l t h p r o m o t i o n s c o r e . H8: No d i f f e r e n c e i n o v e r a l l h e a l t h p r o m o t i o n s c o r e s e x i s t s amongst pharmacy g r a d u a t e s from t h e U n i v e r s i t y o f B r i t i s h Columbia, o t h e r Canadian u n i v e r s i t i e s , and f o r e i g n universities. H9: P h a r m a c i s t s employed i n "independent" pharmacies w i l l have lower o v e r a l l h e a l t h promotion scores than pharmacists employed i n " c o r p o r a t e c h a i n " pharmacies. HIO: P h a r m a c i s t s e m p l o y e d i n C o l l e g e d i s t r i c t 6 w i l l h a v e h i g h e r o v e r a l l h e a l t h promotion scores than pharmacists p r a c t i s i n g i n i n D i s t r i c t s 1-5, a n d 7-9. Hll: P h a r m a c i s t s p r a c t i s i n g i n r u r a l communities w i l l have h i g h e r o v e r a l l h e a l t h promotion scores than pharmacists p r a c t i s i n g i n urban communities. H12: Staff pharmacists w i l l s c o r e s t h a n owners. have h i g h e r o v e r a l l h e a l t h promotion TABLE 4 — c o n t i n u e d OPERATIONAL HYPOTHESIS SURROUNDING PHARMACIST IN HEALTH PROMOTION ACTIVITIES INVOLVEMENT H13: P h a r m a c i s t s s e r v i n g c l i e n t e l e f r o m a p r e d o m i n a t e l y l o w e r s o c i o e c o n o m i c s t a t u s w i l l have h i g h e r o v e r a l l h e a l t h promotion scores than pharmacists s e r v i n g a predominately upper c l a s s clientele. H14: F u l l - t i m e p h a r m a c i s t s w i l l have h i g h e r o v e r a l l promotion scores than part-time pharmacists. health H15: A n i n v e r s e c o r r e l a t i o n e x i s t s b e t w e e n p h a r m a c i s t s t o t a l b a r r i e r s c o r e and t h e i r o v e r a l l h e a l t h promotion s c o r e . CHAPTER 3 METHODOLOGY Q u e s t i o n n a i r e Development A survey i n s t r u m e n t used t o examine community involvement i n h e a l t h promotion pharmacist i s a v a i l a b l e ( B e a r d s l e y , 1983) , a n d was u s e d a s a s t a r t i n g p o i n t f o r t h e p r e s e n t s t u d y ' s q u e s t i o n n a i r e . B e a r d s l e y ' s s u r v e y i n s t r u m e n t was m o d i f i e d , a d d i n g a n a d d i t i o n a l 15 h e a l t h promotion a c t i v i t i e s t o r e f l e c t changes i n p u b l i c h e a l t h c o n c e r n s and p h a r m a c i s t r o l e s t h a t have o c c u r r e d s i n c e B e a r d s l e y ' s study. A s e c o n d m o d i f i c a t i o n t o B e a r d s l e y ' s i n s t r u m e n t was r e l a t e d t o the i n d i c e s e v a l u a t i n g pharmacists' frequency h e a l t h promotion. ofparticipation i n Beardsley's questionnaire u t i l i z e d a six-point, L i k e r t - t y p e s c a l e r a n g i n g from "never" t o "more t h a n o n c e By c o l l a p s i n g t h e L i k e r t s c a l e h e a d i n g s o f " o n c e d a i l y " than once d a i l y " into a single daily". a n d "more " o n c e o r more d a i l y " category, a f i v e - p o i n t , L i k e r t - t y p e scale evolved f o r t h i s study. This action s t r e a m l i n e d t h e q u e s t i o n n a i r e a n d was b e l i e v e d t o l e s s e n t h e t i m e required by Furthermore, pharmacists to complete the questionnaire. i t was b e l i e v e d t h a t f o r t h i s s t u d y , t h e d i s t i n c t i o n between a c t i v i t i e s performed " o n c e a d a y " o r "more t h a n o n c e a d a y " was i n c o n s e q u e n t i a l , a s b o t h c a t e g o r i e s w o u l d be i n t e r p r e t e d a s being " r e g u l a r " o r frequent events of pharmacists. B e a r d s l e y d o e s n o t m e n t i o n t h e means o r m e t h o d s o f p r e - t e s t i n g the survey instrument used i n h i s study. ensure t h e v a l i d i t y o f t h i s s t u d y ' s q u e s t i o n n a i r e were t a k e n . ensure face v a l i d i t y , letter (Appendices T h e r e f o r e , measures t o To t h e r e s u l t i n g f i v e page s u r v e y and c o v e r i n g 1 a n d 2) w e r e r e v i e w e d b y f a c u l t y members from t h e D i v i s i o n o f Pharmacy A d m i n i s t r a t i o n , F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s , a n d b y f a c u l t y members f r o m t h e D e p a r t m e n t o f H e a l t h C a r e and E p i d e m i o l o g y , Columbia. Based Faculty of Medicine a t the U n i v e r s i t y of B r i t i s h upon t h e s e r e v i e w s , r e v i s i o n s t o w o r d i n g and c o n t e n t w e r e made, a f t e r w h i c h t h e q u e s t i o n n a i r e was p i l o t - t e s t e d on a r a n d o m s a m p l e o f 30 c o m m u n i t y p h a r m a c i s t s p r a c t i s i n g i n t h e province of British p o p u l a t i o n demographics Columbia. Not knowing the pharmacist a t that time, the p i l o t study i n t e n t i o n a l l y t a r g e t e d a sample c o n t a i n i n g e q u a l p r o p o r t i o n s o f male and female p h a r m a c i s t s , p r a c t i s i n g i n community pharmacy i n B r i t i s h Columbia. The p i l o t q u e s t i o n n a i r e was m a i l e d o u t t o a s a m p l e c o n s i s t i n g of 14 m a l e p h a r m a c i s t s ( 4 7 % ) , a n d 16 f e m a l e p h a r m a c i s t s ( 5 3 % ) (Table 5 ) , located i n the College of Pharmacists o f B r i t i s h C o l u m b i a d i s t r i c t s a s d i s p l a y e d i n T a b l e 6. D i s t r i c t s 2 and 5 were n o t r e p r e s e n t e d t h r o u g h random s e l e c t i o n o f r e s p o n d e n t s , w h i l e Districts 3 4 a n d 8 ( F i g u r e 2) w e r e o v e r - r e p r e s e n t e d , a n d D i s t r i c t s and 6 were representation non-modified under-represented. This of the College d i s t r i c t s random selection disproportionate i s not surprising, process was used, and as a most p h a r m a c i s t s p r a c t i c e i n t h e Lower M a i n l a n d a r e a o f t h e p r o v i n c e . Table 5 P i l o t Sample D e s c r i p t i o n A c c o r d i n g t o Pharmacist Pharmacist Sex Sex n % Male 14 47% Female 16 53% Table 6 P i l o t Sample D e s c r i p t i o n A c c o r d i n g t o Pharmacist Geographic L o c a t i o n DISTRICTS n n% N%* 1 2 3 4 5 6 7 8 9 Tot 3 0 3 8 0 1 6 7 2 30 10 0 10 27 0 3 20 23 7 100 7.5 15.5 11.2 6.1 22 .1 17.3 7.6 100 9.3 3.3 *N= p o p u l a t i o n o f c o m m u n i t y p h a r m a c i s t s p r a c t i s i n g i n B r i t i s h Columbia based on t h e C o l l e g e o f P h a r m a c i s t s ' o f f i c i a l count. May,1992. Districts* District 1 = Greater District 2 = District 3 = District 4 = District 5 = Victoria/ Gulf Islands Vancouver I s l a n d Fraser Valley Thompson O k a n a g a n Kootenay (*See d e f i n i t i o n s D i s t r i c t 6 = N o r t h e r n B.C. D i s t r i c t 7 = Vancouver D i s t r i c t 8 = Richmond/Delta D i s t r i c t 9 = Fraser River North or Figure 2) A covering letter and a stamped, addressed were i n c l u d e d i n t h e package. utilized: a return envelope Three f o l l o w - u p procedures reminder/thank-you after the i n i t i a l m a i l i n g ; an a d d i t i o n a l m a i l i n g o f t h e q u e s t i o n n a i r e t o non- respondents at letter; f i n a l l y , a reminder and respondents. The one card week a f t e r A f i n a l response telephone leave, criteria; retired, two deadline telephone weeks stated i n the cover c a l l to remaining r a t e o f 8 3 % was attained or pilot s a m p l e f a i l e d t o meet t h e these were respondents no longer 10% study's were e i t h e r practising non- (25/30). follow-up of non-respondents r e v e a l e d t h a t (3/30) o f t h e t o t a l inclusion the mailed were in on maternity a community setting. Completed comments and questionnaires were analyzed for respondents' f o r questions w i t h a h i g h non-response r a t e . A demographic q u e s t i o n s e e k i n g i n f o r m a t i o n r e g a r d i n g t h e p o p u l a t i o n of the degree community of i n which non-response the (8/25); omitted from the f i n a l survey from o t h e r sources. pharmacist p r a c t i s e d had therefore, this a high question i n s t r u m e n t a s i t c o u l d be was obtained A l l o t h e r q u e s t i o n s were answered and no n e g a t i v e comments r e g a r d i n g t h e i n s t r u m e n t w e r e made. After these revisions, s t a t i s t i c a l c o n s u l t a t i o n was from the U n i v e r s i t y of B r i t i s h Columbia's Department o f sought Statistics. V e r y few c h a n g e s w e r e made t o t h e p i l o t s t u d y q u e s t i o n n a i r e , m a k i n g i t p o s s i b l e t o pool these responses full-scale with those obtained i n t h e study. Sample To calculate Selection t h e sample size necessary f o rexternal validity, t h e standard d e v i a t i o n o f pharmacists' o v e r a l l health promotion s c o r e s from t h e p i l o t s t u d y was u s e d i n t h e c a l c u l a t i o n shown i n F i g u r e 3 b e l o w ( W a l p o l e , 1983). Figure 3 CALCULATION FOR SAMPLE SIZE DETERMINATION (confidence limit)(standard deviation) n= (allowable error) (1.96)(0.561) n= (0.05) To e n s u r e t h a t a t l e a s t 484 pharmacists i n the study returned completed questionnaires, the r e t u r n r a t e of completed surveys of paramount importance. Literature regarding rates i s inconclusive. An initial anticipated return r e t u r n r a t e o f 30%, o v e r a l l r e t u r n r a t e o f 60% a s a r e s u l t o f f o l l o w - u p s Berdie and Anderson Baumgartner the with an i s proposed A l t e r n a t i v e l y , Heberlein final However, t h i s model p r e d i c t s a r e t u r n r a t e o f present study's combination of by and (1978) s u g g e s t a t e n v a r i a b l e m o d e l t o p r e d i c t response rates. for (1974). was follow-up 109% procedures. R e g a r d l e s s o f t h e method u t i l i z e d t o p r e d i c t r e s p o n s e r a t e , Goyder (1985) n o t e s t h a t r e s p o n s e r a t e s i n C a n a d a a r e a b o u t 7% r e s u l t s obtained i n the United A n d e r s o n ' s , and H e b e r l a i n to represent given The Baumgartner's p r e d i c t e d r e t u r n when c a l c u l a t i n g t h e for external s i z e of the sample r e q u i r e d t o a t t a i n a l e v e l p h a r m a c i s t s by t h e p i l o t w h i c h i s 566 final was sample of at l e a s t 484 community study's p r e d i c t e d non-response r a t e An a d d i t i o n a l 10% (57) was t h e s a m p l e t o a l l o w f o r p h a r m a c i s t s t h a t f a i l e d t o meet t h e + 57 rates (83%) c a l c u l a t e d by m u l t i p l y i n g 484 pharmacists. inclusion criteria. and validity. r e s p o n d e n t p h a r m a c i s t s was 17%, B e l i e v i n g both Berdie the extremes, the p i l o t study's r e t u r n r a t e priority required and States. lower than Therefore, the f u l l - s c a l e added t o study's sample i n c l u d e d ( p r e d i c t e d number o f i n e l i g i b l e r e s p o n d e n t ) = 623, of 566 rounded t o 625 p h a r m a c i s t s f o r c o n v e n i e n c e , 3 0 o f w h i c h w e r e p r o v i d e d f r o m t h e pilot study. The full-scale sampling technique s t u d y s a m p l e was (Jackson, chosen through a s y s t e m a t i c 1988). A list of pharmacists r e g i s t e r e d w i t h the C o l l e g e of Pharmacists of B r i t i s h Columbia obtained. was R e g i s t r a t i o n with the College of Pharmacists i s mandatory f o r p r a c t i c e , s o t h e l i s t was considered complete. The College Directory l i s t s pharmacists a l p h a b e t i c a l l y according to each C o l l e g e d i s t r i c t . a p p r o x i m a t e l y 1900 community p h a r m a c i s t s i n B r i t i s h t h e f i n a l s a m p l e o f 625 p a r e n t p o p u l a t i o n ) was every third Therefore, knowing t h a t t h e r e are pharmacist Columbia, ( w h i c h r e p r e s e n t s a p p r o x i m a t e l y 3 0% o f t h e e a s i l y o b t a i n e d by s y s t e m a t i c a l l y listed i n the Directory. Using selecting a random number t a b l e , t h e s e c o n d p h a r m a c i s t l i s t e d a t t h e b e g i n n i n g o f t h e Directory was pharmacist. chosen to Pharmacists begin the selection f o r whom a w o r k a d d r e s s of every was not third listed w e r e a s s u m e d u n e m p l o y e d and w e r e e x c l u d e d , a s t h e s t u d y was interested i n p r a c t i s i n g pharmacists. with the correct. T h i s a s s u m p t i o n was College of Pharmacists of B r i t i s h Columbia as only verified being Follow-up Procedures The f i v e p a g e q u e s t i o n n a i r e was m a i l e d a t Week 1. undertaken (Jackson, 1988): Business r e p l y r e t u r n e n v e l o p e s were A l l s u b j e c t s w e r e f o l l o w e d up a t Week 3 w i t h a r e m i n d e r / t h a n k - y o u c a r d the deadline respondents letter were had passed mailed (see Appendix 4 ) ; ( s e e A p p e n d i x 3) ; f o r surveys Finally, non-respondents a t approximately I f requested Two weeks t o be r e c e i v e d , n o n - an a d d i t i o n a l q u e s t i o n n a i r e and a reminder telephone Appendix 5 f o r a copy o f t h e d i a l o g u e ) mailing. subjects To m a x i m i z e t h e r e s p o n s e r a t e , c e r t a i n m e a s u r e s w e r e i n c l u d e d w i t h each q u e s t i o n n a i r e ; after out t o study cover c a l l (see was made t o a l l r e m a i n i n g n i n e weeks a f t e r t h e i n i t i a l by t h e respondent, a f i n a l copy o f t h e q u e s t i o n n a i r e was m a i l e d out a t t h i s time. S c o r i n g Schemes f o r S u r v e y Pharmacists were a s k e d t o e s t i m a t e t h e frequency of their p a r t i c i p a t i o n i n 33 d i f f e r e n t h e a l t h p r o m o t i o n a c t i v i t i e s o n a f i v e - p o i n t L i k e r t - t y p e s c a l e , w i t h " 1 " r e p r e s e n t i n g "Never" and "5" representing "Once o r more d a i l y " . The s c o r e s f o r each h e a l t h p r o m o t i o n a c t i v i t y w e r e t h e n summed, p r o v i d i n g a n o v e r a l l Health Promotion Score variable. f o r each pharmacist which The pharmacists' Health personal Promotion Score variables, educational variables. served as t h e dependent was practice tested against variables, E a c h o f t h e 33 h e a l t h p r o m o t i o n and activities were c a t e g o r i z e d as b e i n g e i t h e r " d i s p e n s i n g " o r " n o n - d i s p e n s i n g " h e a l t h promotion activities. Pharmacists' four questions personal using a health beliefs were four-point forced-choice P h a r m a c i s t s were r e q u i r e d t o r a t e t h e importance i n promoting assessed t h e h e a l t h o f t h e average person. summed t o p r o v i d e a t o t a l H e a l t h B e l i e f S c o r e . B e l i e f Score s e r v e d as an independent pharmacists' H e a l t h Promotion through rating o f each scale. activity The s c o r e s w e r e The t o t a l Health v a r i a b l e t o be t e s t e d a g a i n s t Scores. P h a r m a c i s t s ' p e r s o n a l h e a l t h b e h a v i o u r s were a s s e s s e d by f i v e questions that required pharmacists t o estimate the frequency with which they anchors participated i n particular activities. The scales' f o r self-assessment varied according t o the h e a l t h - promoting a c t i v i t y , b u t a l l a c t i v i t i e s were a s s e s s e d u s i n g a f i v e - p o i n t s c a l e w i t h " 5 " r e p r e s e n t i n g t h e most f r e q u e n t l e v e l o f participation. S c o r e s w e r e summed t o a t t a i n a t o t a l Behaviour Score, and t h e n t e s t e d a g a i n s t p h a r m a c i s t s ' Promotion Scores. Health Health E i g h t b a r r i e r s t o expanding pharmacists' involvement i n h e a l t h promotion were examined i n t h i s s t u d y . On a s c a l e o f o n e ( s t r o n g l y d i s a g r e e ) t o 5 ( s t r o n g l y a g r e e ) , p h a r m a c i s t s were asked t o i n d i c a t e the extent t o which each b a r r i e r l i m i t e d o r c o n s t r a i n e d t h e i r involvement i n h e a l t h promotion. S c o r e s w e r e summed t o r e c e i v e a t o t a l B a r r i e r S c o r e , w h i c h was t h e n t e s t e d a g a i n s t t h e p h a r m a c i s t s ' t o t a l Health Promotion to Scores. S p a c e was p r o v i d e d f o r r e s p o n d e n t s include barriers not provided i n the l i s t . S t a t i s t i c a l Analyses D a t a was a n a l y z e d Variance W Test, using Kruskall-Wallis o n e way A n a l y s i s o f (ANOVA), o n e way ANOVA, M a n n - W h i t n e y U- W i l c o x o n and Pearson-product significant-difference correlations. the Statistical Rank Sum The Tukey-b h o n e s t l y - t e s t was u s e d t o s e t t h e r a n g e s w h e r e t h e ANOVA t e s t s w e r e s i g n i f i c a n t . using Undertaken A l l r e q u i r e d t e s t s were Package f o r t h e S o c i a l Computer) p r o g r a m (SPSS/PC+). Sciences undertaken (Personal An a l p h a l e v e l o f s i g n i f i c a n c e o f 0.05 was s e l e c t e d p r i o r t o commencement o f t h e s t u d y . Study L i m i t a t i o n s S e l f - r e p o r t i n g o f any a c t i v i t y i s a p o s s i b l e b i a s t h a t had be taken (1973), into consideration (Isaac i n a study of pharmacists' and Michael, 1981). i n d i c a t e d and a c t u a l to Linn behaviours, found t h a t the m a j o r i t y of pharmacists performed c o n s i s t e n t l y w i t h t h e i r s e l f - r e p o r t e d b e h a v i o u r (58%) activity the on the reporting similar s i d e of caution behaviour of or d e v i a t e d from t h e i r (12%). Therefore, pharmacists in British that British Columbia pharmacists c o n s i s t e n t l y with t h e i r s e l f - r e p o r t e d behaviours, of caution Therefore, (i.e., although over-reporting To assuming under-report their that Columbia to the r e p o r t i n g behaviour of American pharmacists, expected side reported will i t is perform o r d e v i a t e on level of activity). s e l f - r e p o r t i n g i s a b i a s , the a c t u a l impact of c o n t r o l f o r t h i s b i a s , the c o n f i d e n t i a l nature emphasized t o the pharmacist. The of the ultimate method t o check f o r o v e r - r e p o r t i n g i s t o send " p a t i e n t a c t o r s " to randomly-selected from some out community p h a r m a c i e s w i t h p r o b l e m s w h i c h w o u l d pharmacist beyond t h e scope of t h i s study, l e v e l of the i s e x p e c t e d t o be o f m i n o r c o n s e q u e n c e . s u r v e y r e s u l t s was benefit is confirmation. health promotion activity. however, t o a t t e m p t this It is Chapter 4 RESULTS Response Rate F o r t y - f o u r o f t h e s t u d y ' s 625 p h a r m a c i s t s w e r e e x c l u d e d the study f o r f a i l i n g t o meet t h e i n c l u s i o n c r i t e r i a . from In the m a j o r i t y o f t h e s e c a s e s , t h e p h a r m a c i s t was r e t i r e d o r o n s i c k leave, but had Pharmacists. pharmacists. returned maintained Therefore, Four completed (486/581). registration the useable hundred and with the s a m p l e was eighty-six reduced (486) q u e s t i o n n a i r e s f o r a response College of t o 581 pharmacists rate o f 83.6% One r e t u r n e d s u r v e y was u n u s a b l e , l e a v i n g t h e number o f u s e a b l e s u r v e y s a t 485. Figure 4 displays the return rate of the questionnaires i n r e l a t i o n t o the follow-up procedures undertaken. F i g u r e 5 d i s p l a y s t h e m a r g i n a l e f f i c a c y o f each f o l l o w - u p procedure in illiciting Anderson's return a response. predictions, rate. R e t u r n r a t e s exceeded B e r d i e and but c l o s e l y mimicked the p i l o t study's FIGURE 4 CUMULATIVE WEEKLY RESPONSE RATE 100 PERCENT RETURNED PHONE CALLS STAF T E D 80 60 , 2 N 0 M AILING T H A N (-YOU CARDS vlAILED 40 20 0 1 1 1 1 1 1 1 6 7 8 9 10 11 12 WEEK OF STUDY RESPONSE RATE 13 14 15 16 17 18 FIGURE 5 MARGINAL EFFICACY OF FOLLOW-UP PROCEDURES 100 PERCENT RETURNED I INITIAL MAILING THANK-YOU CARDS SECOND MAILING PHONE CALLS FOLLOW-UP PROCEDURE MARGINAL RESPONSE ^ CUMULATIVE RESPONSE Sample Because the study's Description sample closely represented p o p u l a t i o n ' s t r u e g e o g r a p h i c d i s t r i b u t i o n o f community (see Table 7) , t h e r e i s no reason to believe the pharmacists that the study's s a m p l e was n o t r e p r e s e n t a t i v e o f B r i t i s h C o l u m b i a ' s c o m m u n i t y pharmacist population with respect t o other d e s c r i p t i v e variables s u c h a s t y p e o f p r a c t i c e , age, s e x , and p l a c e o f employment (See Tables 8 t o 13). D e m o g r a p h i c i n f o r m a t i o n o b t a i n e d i s shown i n T a b l e s 14 a n d 15 a n d r e v e a l s t h a t women p h a r m a c i s t s a r e s i g n i f i c a n t l y more likely t h a n m a l e p h a r m a c i s t s t o occupy s t a f f p h a r m a c i s t p o s i t i o n s , and t o be employed displays part-time the marital ( X' =94.236; status of df=2 ; p < 0 . 0 0 1 ) . British Columbia Table 16 community p h a r m a c i s t s , a n d w i l l be e x a m i n e d c l o s e r i n t h e d i s c u s s i o n s e c t i o n . Table 7 SAMPLE DESCRIPTION ACCORDING PHARMACIST GEOGRAPHIC LOCATION College District n % 1 51 10.5 2 42 8.7 3 66 13.6 4 62 12.8 5 19 3.9 6 26 5.4 7 101 20.8 8 78 16.1 9 40 8.2 485 100.0 Total Table 8 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST SEX % n Male 288 59.4 Female 193 39.8 4 0.8 485 100.0 Missing Total Data Table 9 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST DEGREE-GRANTING INSTITUTION 1 Degree-Granting Institution University of B r i t i s h Columbia 374 77.1 49 10.1 Foreign university 22 4.5 Missing 40 8.2 Other Canadian university 1 % n data Total 485 100. 0 Table 10 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST EMPLOYMENT STATUS Employment Status n % Full-time 372 76.7 Part-time 113 23.3 0.0 0.0 485 100.0 Missing data Total T a b l e 11 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST PRACTICE TYPE Type o f Practice n % Independent 156 32.2 Independent Chain 119 24.5 Franchise 88 18.1 Corporate Chain 121 24.9 1 0.2 485 100 Missing data Total Table 12 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST YEAR OF GRADUATION Year o f Graduation % n 1990 - 1992 35 7.2 1980 - 1989 152 31.3 1970 - 1979 167 34.4 1960 - 1969 69 14.2 1950 - 1959 50 10.3 1940 - 1949 8 1.6 Missing 4 0.8 485 100.0 Total data Table 13 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST AGE n % 20 - 29 103 21.24 30 - 39 189 38.97 40 - 49 71 14.64 50 - 59 62 12.78 60 - 69 39 8.04 4 0.82 17 3.51 485 100.00 Age (years) > 70 Missing Total TABLE 14 EMPLOYMENT POSITIONS OP BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PHARMACIST SEX* Male Female Total Staff 30.7% 72.7% 230 47.5% Manager 34.8% 20.1% 140 28.9% Owner 34.5% Total 290 59.9% [*X^ = 9 4 . 2 3 6 ; d]f = 2; p <0.001] 7.2% 194 40.1% 114 23.6% 484 100% 1 Table 15 EMPLOYMENT STATUS OF BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PHARMACIST SEX* Male Female Missing Row Total Part-time 43 70 0 113 (23.3%) Full-time 245 123 4 372 (76.7%) Column 288 193 Total (59.4%) (39.8%) I*.^2 = 2 8 . 9 0 7 ; d f = l ; p<0.0 01] 4 (0.8%) 485 (100.0%) TABLE 16 MARITAL STATUS OF BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PH2^RMACIST SEX* Male Female Total 76.8% 67.0% 348 72.8% Divorced 6.0% 4.6% 26 5.4% Single 17.3% 28.4% 104 21.8% 284 59.4% [* X^=8.30; d f =2; p<0.001] 194 40.6% 478 100% Married Total II Non-response B i a s N i n e t y - f i v e p h a r m a c i s t s f a i l e d t o r e t u r n q u e s t i o n n a i r e s (16%) , and t h u s c o m p r i s e d t h e n o n - r e s p o n d e n t sample. The non-respondent s a m p l e was e x a m i n e d a c c o r d i n g t o p h a r m a c i s t s e x ( T a b l e 16) , C o l l e g e district (Table 17) , and type A p p r o x i m a t e l y 56% o f n o n - r e s p o n d e n t s t h e s e numbers c l o s e l y resemble of had a higher the actual pharmacist percentage of non-respondents distribution worked i n an District 9 than i n the parent population. o f non-responders 18) . D i s t r i c t 3 had a lower t h a n most o t h e r d i s t r i c t s . percentage pharmacist d i s t r i b u t i o n (Table were male and 44% were f e m a l e ; a c c o r d i n g t o sex i n B r i t i s h Columbia. number o f n o n - r e s p o n d e n t s practice i t s actual The h i g h e s t independent pharmacy ( 3 8 % ) , f o l l o w e d b y p h a r m a c i s t s w o r k i n g i n c o r p o r a t e c h a i n (25%) o r independent pharmacies c h a i n (24%) s t o r e s . were most l i k e l y t o r e t u r n t h e i r q u e s t i o n n a i r e , as o n l y 13% o f t h e non-respondent working Pharmacists working i n franchise in independent franchise pharmacies sample c o n s t i t u t e d pharmacies. were least pharmacists Pharmacists likely to working return q u e s t i o n n a i r e , a c c o u n t i n g f o r 38% o f a l l n o n - r e s p o n d e n t s . in their T a b l e 17 NON-RESPONDING PHARMACISTS ACCORDING TO SEX Pharmacist Sex 1 n Percentage o f nonr e s p o n d e56% nt sample Male 53 Female 42 44% Total 95 100% T a b l e 18 NON-RESPONDENT SAMPLE ACCORDING TO COLLEGE DISTRICT District n Percentage o f non-respondent sample A c t u a l Pop. Distribution* 1 11 11.6 9.3 2 8 8.4 7.5 3 8 8.4 15.5 4 8 8.4 11.2 5 2 2.1 3.3 8 8.4 6.1 7 23 24.2 22.1 8 16 16.8 17.3 9 11 11. 6 7.6 Total 95 100 100 * C o l l e g e o f P h a r m a c i s t s o f B.C.'s o f f i c i a l c o u n t a s o f May, 1 9 9 2 . T a b l e 19 NON-RESPONDENT SAMPLE ACCORDING TO PRACTICE TYPE P r a c t i c e Type n Independent 36 38 Independent Chain 23 24 Franchise 12 13 24 25 95 100 Corporate Chain Total % o f nonrespondents 1 Survey R e s u l t s PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES T a b l e 19 d i s p l a y s p h a r m a c i s t s ' m e d i a n s c o r e s f o r o v e r a l l p a r t i c i p a t i o n i n health promotion a c t i v i t i e s . Of a p o s s i b l e s c o r e o f 1 6 5 , p h a r m a c i s t s ' m e d i a n H e a l t h P r o m o t i o n S c o r e was 1 0 5 . The m e d i a n H e a l t h P r o m o t i o n S c o r e f o r a c t i v i t i e s n o t r e l a t e d t o t h e d i s p e n s i n g o r s e l l i n g o f m e d i c a t i o n s ( h e r e a f t e r r e f e r r e d t o a s nond i s p e n s i n g h e a l t h p r o m o t i o n ) was 79 o u t o f a p o s s i b l e s c o r e o f 1 3 5 . P h a r m a c i s t s ' median H e a l t h Promotion Score on events directly t o the selling referred t o as dispensing health p o s s i b l e 30 p o i n t s . related o r dispensing of medications promotion) was 2 6 (hereafter out of a TABLE 2 0 PHARMACIST MEDIAN HEALTH PROMOTION SCORES O v e r a l l HP Score (n=485) Non-dispensing HP S c o r e (n=485) Dispensing HP S c o r e (n=479) Median 105 79 26 Minimum 39.0 29.0 6.0 Maximum 158.0 128.0 30.0 18.9 16.4 3.6 58 % 87 % S t d . Dev. Percentage Score 64 % T a b l e 21 d i s p l a y s p h a r m a c i s t s ' s e l f - r e p o r t e d p a r t i c i p a t i o n i n t h e 33 h e a l t h p r o m o t i o n a c t i v i t i e s s t u d i e d . promotion activities community p h a r m a c i s t s promotion highest activities. participation The f i v e health enjoying thehighest participation r a t e s by ( T a b l e 22) w e r e p r i m a r i l y d i s p e n s i n g h e a l t h Although the four a c t i v i t i e s w i t h t h e rate i nthis category a r e " e s s e n t i a l " , o r r e q u i r e d s e r v i c e s o f a community p h a r m a c i s t ( C o l l e g e o f P h a r m a c i s t s o f B r i t i s h C o l u m b i a , 1 9 8 9 ) , t h e d a t a show t h a t t h e r e i s l e s s perfect p a r t i c i p a t i o n i n these a c t i v i t i e s . than F o r example, 94.6% o f p h a r m a c i s t s r e p o r t q u e r y i n g c l i e n t s on p o s s i b l e a l l e r g i e s before d i s p e n s i n g o r s e l l i n g a m e d i c a t i o n t o them. T a b l e 23 d i s p l a y s t h e f i v e n o n - d i s p e n s i n g h e a l t h activities daily basis. most frequently participated promotion i n by p h a r m a c i s t s on a These events i n c l u d e s u g g e s t i n g non-drug a l t e r n a t i v e s for minor ailments (such as d i e t a r y changes f o r constipation), r e f e r r i n g p a t i e n t s t o other health care p r o v i d e r s , suggesting drug adjuncts ibuprofen t o drug therapy (such non- as i c e packs as an a d j u n c t f o r s t r a i n s and s p r a i n s ) , p r o v i d i n g p r o f e s s i o n a l to advice t o o t h e r h e a l t h c a r e p r o v i d e r s , and p r o v i d i n g c l i e n t s w i t h w r i t t e n drug o r health Health information. promotion a c t i v i t i e s with t h e lowest l e v e l s of pharmacist p a r t i c i p a t i o n are displayed a c t i v i t i e s that pharmacists reported and i n T a b l e 24. These a r e "never" p a r t i c i p a t i n g i n , i n c l u d e a c t i v i t i e s such as s p e a k i n g t o community groups, participating level of i n disease occupational screening stress c o u n s e l l i n g o n AIDS p r e v e n t i o n , programs, o b t a i n i n g a c l i e n t ' s when taking a medical and o b t a i n i n g a p a t i e n t ' s s t a t u s when t a k i n g t h e p a t i e n t ' s m e d i c a l history. history, smoking Table 21 PHARMACIST SELF-REPORTED PARTICIPATION IN HEALTH PROMOTION ACTIVITIES (n=485) Percentage o f Pharmacists R e p o r t i n g Never Activity Once a Year Once a Month Once a Day More t h a n Once a Day Counsel c l i e n t s on: STDs 3 1 . 3% 36.,5% 5 .0% 16 .7% 40 .0% 31 .9% 6 .3% 34 . 0% 37 .9% 18 . 1 % 7 .9% 1 .9% a b u s e 36 .7% 33 .5% 19 .8% 6 .0% 3 .8% 2 .7% 9 .2% 30 .8% 33 . 1 % 24 .0% 3 .3% 7 .3% 25 .8% 34 . 0% 29,.4% Poison prevention 9,.8% 39 .2% 36,.9% 11 .0% 2,.9% Hypertension 6,.9% 10 .4% 31,.0% 33 .8% 17,.7% 35,. 0% 35 .4% 24.. 0% 4 .2% 1..3% Smoking cessation Alcohol abuse Illicit drug Rx d r u g abuse OTC d r u g Cancer abuse signals Nutrition 24. 4% 7. 5% 0.:2% 4,.8% 9 .2% 30,.2% 33 . 3 % 22..3% 24..4% 23 .8% 32,.1% 13 . 5 % 6..0% Diabetes 7..5% 14 .6% 34,.8% 29 .2% 13..8% Weight 7..9% 11 .5% 42.,3% 28 .8% 9,.2% Mental health control First aid 6.. 0% 7 .3% 25.,6% 32 .9% 27,.9% Infant 7.,3% 9 .6% 29., 0% 30 .2% 23,,8% 41..3% 34 .0% 17.,3% 6 .7% 0,,6% 11. 0% 21 .9% 38.,3% 23 . 5 % 5., 0% 7. 7% 14 .8% 37.,9% 30 . 6% 8.,8% care AIDS Dental hygiene Cholesterol Table 21—continued Percentage o f Pharmacists Activity Never Speak t o c o m m u n i t y groups 63.1% Once Yearly Once a Month Reporting Once a Once o r Week More D a i l y 31.7% 4.6% 0.4% 6.0% 32.1% 29.6% 29.2% 0.8% 0.2% 1.0% 3.8% 94.0% Refer c l i e n t s t o other health care providers 1.7% 2.5% 11.3% 39.0% 45.4% Provide advice t o other health care providers 2.1% 4.6% 24.6% 35.8% 32.7% Participate i n disease s c r e e n i n g programs 56.9% 29.2% 9.6% 2.5% 1.7% Provide w r i t t e n drug or health information 2.9% A d v i s e c l i e n t s o n OTC medications 0.2% Obtain from c l i e n t s , information regarding: Allergies 0,.8% 1,.3% 1 .3% 1. 7% 94,.8% Medical 6..9% 2,.7% 10 .0% 15. 0% 65,.2% 5.,0% 1,.5% 8. 3% 17 .5% 67..1% Smoking s t a t u s 39..8% 15..8% 20. 6% 17 .5% 6..0% Alcohol use 38.,1% 16.,5% 18. 1% 18 . 1 % 0.,0% O c c u p a t i o n a l s t r e s s 44.,4% 15. ,2% 23. 3% 11 .9% 5.. 0% history Current drugs Table 2 1 — c o n t i n u e d Percentage o f Pharmacists R e p o r t i n g Activity Never Once Yearly Once a Month Once a Once o r Week More D a i l y P a r t i c i p a t e i n community health events 12.9% 22.7% 32.9% 20.8% 10.4% Suggest non-drug a l t e r n a t i v e s t o drugs therapy 1.7% 1.9% 13.3% 36.9% 46.0% 3.1% 18.3% 35.8% 39.6% Suggest non-drug to drug therapy adjuncts 2.9% ******************************************************************* ******************************************************************* Table 22 HEALTH PROMOTION ACTIVITIES MOST FREQUENTLY PARTICIPATED IN BY COMMUNITY PHARMACISTS IN BRITISH COLUMBIA (n=485) Percent R e p o r t i n g Daily Participation Activity 1. A d v i s i n g c l i e n t s o n OTC m e d i c a t i o n s 94.0% 2. Q u e r y i n g c l i e n t s o n p o s s i b l e a l l e r g i e s 94.6% 3. Q u e r y i n g c l i e n t s o n c u r r e n t d r u g s 66.6% 4. O b t a i n i n g a m e d i c a l h i s t o r y f r o m c l i e n t s 64.9% 5. S u g g e s t i n g n o n - d r u g ailments a l t e r n a t i v e s f o r minor 46.4% T a b l e 23 NON-DISPENSING HEALTH PROMOTION ACTIVITIES MOST FREQUENTLY PARTICIPATED IN BY COMMUNITY PHARMACISTS IN BRITISH COLUMBIA (N=485) Percent R e p o r t i n g Daily Participation Activity 1. S u g g e s t n o n - d r u g a l t e r n a t i v e s f o r minor a i l m e n t s 46.4% 2. R e f e r c l i e n t s t o o t h e r h e a l t h care providers 45.4% 3. Suggest non-drug a d j u n c t s t o drug therapy 39.8% Provide advice t o other health care professionals 32.8% 5. P r o v i d e c l i e n t s w i t h w r i t t e n d r u g or health information 29.5% 4. ***********ieie***ie*ie****ie*****ie*************************** Table 2 4 HEALTH PROMOTION EVENTS BRITISH COLUMBIA COMMUNITY PHARMACISTS CLAIM THEY "NEVER" PARTICIPATE IN (n=485) Percentage o f Activity Pharmacists R e p o r t i n g 1. S p e a k t o c o m m u n i t y g r o u p s 63.1% 2. 56.7% P a r t i c i p a t e i n d i s e a s e s c r e e n i n g programs 3. Q u e r y c l i e n t s r e g a r d i n g l e v e l o f o c c u p a t i o n a l 4. stress 44.5% C o u n s e l c l i e n t s on AIDS p r e v e n t i o n 41.4% 5. Q u e r y c l i e n t s o n t h e i r smoking s t a t u s 40.0% VARIABLES INFLUENCING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Practice i) Variables Type o f P r a c t i c e P h a r m a c i s t s employed i n "independent had chain" drug s i g n i f i c a n t l y higher o v e r a l l Health Promotion Scores than d i d pharmacists employed in "independent" drug stores relationship held activities "corporate chain" drug stores { 9C^=14.6564 ; d f = 3 , 4 8 1 ; p = 0 . 0 0 2 ) . f o r both non-dispensing health (9("=8.5702; This promotion d f = 3 , 4 8 1 ; p=0.036)- Nineteen i n d i v i d u a l h e a l t h promotion a c t i v i t i e s differences i nparticipation settings or (X"^ =13 . 7673 ; d f = 3 , 4 8 1 ; p = 0 . 0 0 3 ) , a n d d i s p e n s i n g h e a l t h promotion a c t i v i t i e s (Table "independent a stores 25) . l e v e l s between d i f f e r e n t Generally, pharmacists practice working chain" drug stores o r " f r a n c h i s e " drug s t o r e s greater participation "independent" displayed level than or "corporate chain" d i d pharmacists drug stores p r o m o t i o n a r e a s , i n c l u d i n g c o u n s e l l i n g on smoking t h e - c o u n t e r m e d i c a t i o n abuse, nutrition, showed working i n i n many health cessation, and weight in control. over- Table 2 5 VARIATIONS IN HEALTH PROMOTION PARTICIPATION ACCORDING TO PHARMACIST PRACTICE TYPE* Activity Outcome Test Statistic** P 1. C o u n s e l l i n g o n s m o k i n g cessation 2 > 1 12 .222 0..007 2. C o u n s e l l i n g o n a l c o h o l abuse 2 > 3 /4 1 > 3 ,4 21 .446 0. 000 3 > 1 10 .494 0. 015 2 ,3, 4 > 1 19 .274 0. 000 2, 3 > 1 21 .155 0. 007 2, 3 > 1 3 > 4 21 .294 0. 000 2 ,3, 4 > 1 38 .014 0. 000 12 .933 0. 005 1 ,2, 3 > 4 25 .640 0. 000 2 ,3, 4 > 1 16 .483 0. 001 3, 4 > 1 15 .215 0. 002 Become i n v o l v e d i n d i s e a s e s c r e e n i n g programs 2 > 1 20 .985 0. 000 13 . Q u e r y i n g c l i e n t s o n c u r r e n t medications 2 > 4 13 .854 0. 003 2 > 3 1, 2 > 4 26, .828 0. 000 3. C o u n s e l l i n g o n o v e r - t h e counter medication misuse 4. C o u n s e l l i n g o n n u t r i t i o n 5. C o u n s e l l i n g o n w e i g h t control 6. C o u n s e l l i n g o n f i r s t a i d 7. C o u n s e l l i n g o n i n f a n t care 8. C o u n s e l l i n g o n d e n t a l hygiene 9. S p e a k t o c o m m u n i t y g r o u p s o n health-related matters 10. 11. 12. 14. Provide counter a d v i c e on o v e r - t h e medications Refer c l i e n t s t o other care providers 3 > 1 health Q u e r y i n g c l i e n t s on smoking status Table 2 5 — c o n t i n u e d Activity 16. Outcome Test S t a t i s t i c * * Q u e r y i n g c l i e n t s on t h e i r a l c o h o l use 2 > 4 18.478 0.000 17. Q u e r y i n g c l i e n t s o n t h e i r level of occupational stress 2 > 4 12.379 0.006 P a r t i c i p a t e i n coitununity h e a l t h events 2 > 4 13.087 0.004 Suggesting non-drug to drug therapy 2,3,4 > 1 15.906 0.001 1 > 3 11.929 0.008 18. 19. 20. adjuncts Provide advice t o other health care providers * 1= 2= 3= 4= Independent s t o r e Independent c h a i n (e.g., Pharmasave, P e o p l e ' s F r a n c h i s e (e.g., Shoppers Drug Mart) C o r p o r a t e C h a i n (e.g. London Drugs, Safeway) Drug Mart) ** d f = 3 , 4 8 0 ********************************************************* P h a r m a c i s t s w o r k i n g i n " c o r p o r a t e c h a i n " d r u g s t o r e s were l e s s likely than pharmacists working i n "independent chain" stores to o b t a i n a p a t i e n t ' s c u r r e n t m e d i c a t i o n s t a t u s , smoking s t a t u s , use of alcohol, or level of occupational stress. ii) Geographic L o c a t i o n o f Practice Pharmacists p r a c t i s i n g i n C o l l e g e d i s t r i c t 6 had a statistically s i g n i f i c a n t higher o v e r a l l h e a l t h promotion than d i dpharmacists i n Districts score (X^=26.257; 1, 3, 7, a n d 8 df=8,476;p=0.001). T h i s r e l a t i o n s h i p d i d n o t e x i s t f o r d i s p e n s i n g h e a l t h promotion activities (X^=10.537; d f = 8 , 4 7 6 ) . S t a t i s t i c a l d i f f e r e n c e s i n h e a l t h promotion according t o t h e geographic locations participation of pharmacists' were d e t e c t e d i n n i n e i n d i v i d u a l h e a l t h promotion T a b l e 2 6) . practices a c t i v i t i e s (see F o r t h e most p a r t . D i s t r i c t 6 p h a r m a c i s t s exceeded t h e p a r t i c i p a t i o n o f pharmacists i n other geographic d i s t r i c t s , except i n t h e c a s e o f s p e a k i n g t o community groups a b o u t m a t t e r s , w h e r e a l o n g w i t h D i s t r i c t 6, D i s t r i c t 4 was more involved p=0.000). than urban District 7 health-related significantly ( 7 ^ " ^ =48.167; df=8,476; Table 2 6 VARIATIONS IN INVOLVEMENT IN INDIVIDUAL HEALTH PROMOTION ACTIVITIES ACCORDING TO GEOGRAPHIC LOCATIONS* OF BRITISH COLUMBIA COMMUNITY PHARMACIST PRACTICES Activity Outcome Test Statistic** P 1. C o u n s e l l i n g o n a l c o h o l abuse 6 > 3,8 15.655 0. 047 2. C o u n s e l l i n g o n h y p e r t e n s i o n p r e v e n t i o n +/or c o n t r o l 6 > 3,8 22.065 0. 005 3. C o u n s e l l i n g o n d i a b e t e s p r e v e n t i o n +/or c o n t r o l 6 > 1,3,7,8 20.332 0. 009 4. C o u n s e l l i n g o n w e i g h t control 6 > 1,3,7,8 28.132 0. 000 6 > 3,7,8 20.436 0. 009 6 > 1,3,7 34.869 0. 000 6 > 1,2,3,4, 7,8,9 4 > 7,8 48.167 0. 000 19.900 0. O i l 19.331 0. 013 5. C o u n s e l l i n g i n first aid 6. C o u n s e l l i n g o n i n f a n t care 7. S p e a k t o c o m m u n i t y g r o u p s on h e a l t h - r e l a t e d m a t t e r s 8. Q u e r y c l i e n t s o n a l c o h o l use 9. P a r t i c i p a t e i n c o m m u n i t y health events * 1= 2= 3= 4= 5= 7 > 3,8 6 > 1,2,3,7, 8,9 Greater V i c t o r i a / G u l f Islands 6= N o r t h e r n B r i t i s h C o l u m b i a Vancouver I s l a n d 7= C i t y o f V a n c o u v e r Fraser Valley 8= R i c h m o n d / D e l t a / B b y Thompson Okanagan 9= F r a s e r R i v e r N o r t h Kootenay ( s e e d e f i n i t i o n s o r F i g u r e 2) ** d f = 8 , 4 7 6 iii) Employment P o s i t i o n P h a r m a c i s t s ' e m p l o y m e n t p o s i t i o n h a d no s i g n i f i c a n t i n f l u e n c e on o v e r a l l H e a l t h P r o m o t i o n S c o r e s Although t h e time pharmacists (96^=1.103; spent doing df=2,482). a d m i n i s t r a t i v e , non- p r o f e s s i o n a l l y r e l a t e d t a s k s was s i g n i f i c a n t l y d i f f e r e n t f o r s t a f f p h a r m a c i s t s , managers, a n d owners (F=287.0818; df=2,482; (see Table 2 7 ) , a l l t h r e e groups p a r t i c i p a t e d activities at fairly i nhealth p=.05) promotion similar levels. * * * * * * * * * * * * * * * i e * * * * * * * * * * * * * * * * * * * i e * * * * i s * i s * * * * * * * i e i e * * * * i s T a b l e 27 DIFFERENCES IN DAILY TIME SPENT IN ADMINISTRATIVE FUNCTIONS BY BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO EMPLOYMENT POSITION Position Mean H r s / D a y * Staff 0.0779 Manager 1.9714 Owner 3.1491 [* a l l means s i g n i f i c a n t l y d i f f e r e n t ; F = 2 8 7 . 0 8 1 8 ; d f = 2 , 4 8 2 ; p = . 0 5 ] ***************************************************************** In i n d i v i d u a l h e a l t h promotion activities, staff pharmacists w e r e more i n v o l v e d t h a n o w n e r s i n c o u n s e l l i n g c l i e n t s o n n u t r i t i o n (7^'^ =12.735; d f = 2 , 4 8 2 ; p=0.002) a n d i n f a n t care (X'^=8.558; df=2,482;p=0.014), r e f e r r i n g c l i e n t s t o o t h e r h e a l t h providers (']tl^^=10.986; d f = 2 , 4 8 2 ; p = 0 . 0 0 4 ) , a n d s u g g e s t i n g n o n - drug a l t e r n a t i v e s (}6 care (X"^ =12.016; d f = 2 , 4 8 2 ; p=0.002) a n d a d j u n c t s =10.116; d f = 2 , 4 8 2 ; p=0.006) f o r m i n o r ailments. Owners a n d m a n a g e r s w e r e more l i k e l y t h a n s t a f f p h a r m a c i s t s t o s p e a k t o community groups {'Y^'^=A2.119 ; d f = 2 , 4 8 2 ; p<0.001) a n d t o p a r t i c i p a t e i n community h e a l t h e v e n t s (X^^=72.896; d f = 2 , 4 8 2 ; p < 0 . 0 0 1 ) . F u l l - t i m e p h a r m a c i s t s had h i g h e r o v e r a l l H e a l t h Scores than d i d part-time pharmacists This relationship promotion (z=-2.519;df=483;p=0.012). d i d not hold true f o r dispensing-related activities (z=-1.239; s t a t u s do e x i s t . i n seven health df=483). Differences i n the levels of participation h e a l t h promotion Promotion of individual a c t i v i t i e s according t o pharmacists' employment F u l l - t i m e p h a r m a c i s t s a r e more a c t i v e l y i n d i v i d u a l h e a l t h promotion p r a c t i c e s involved (See T a b l e 2 8 ) . Table 28 VARIATIONS IN HEALTH PROMOTION PARTICIPATION BY BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO EMPLOYMENT STATUS* Activity Outcome Test Statistic** 1. C o u n s e l l i n g o n s e x u a l l y transmitted diseases F > P z= -2.605 (p=0.009) 2. C o u n s e l l i n g o n s m o k i n g cessation F > P z= -3.854 (p<0.001) 3. C o u n s e l l i n g o n AIDS prevention F > P z= -3.024 (p=0.002) 4. S p e a k i n g t o c o m m u n i t y groups on h e a l t h matters F > P z= -3.978 (p<0.001) 5. P r o v i d i n g a d v i c e t o o t h e r h e a l t h care providers F > P z= -2.422 (p=0.015) 6. P a r t i c i p a t e i n c o m m u n i t y h e a l t h events F > P z= -3.892 (p<0.001) 7. A d v i s e F > P z= -2.377 (p=0.017) o n OTC p r o d u c t s * F= f u l l - t i m e e m p l o y m e n t , P= p a r t - t i m e ** d f = 4 ***********ie******************************************** employment iv) Socioeconomic The Status of Clientele socioeconomic status of the c l i e n t e l e served pharmacist e f f e c t s pharmacists' o v e r a l l p a r t i c i p a t i o n promotion ('X^=11.748; d f = 4 , 4 2 1 ; p = 0 . 0 1 9 ) ; by t h e i n health pharmacists serving l o w e r - c l a s s c l i e n t s w e r e more i n v o l v e d t h a n p h a r m a c i s t s serving upper-class clients. Differences i n pharmacist p a r t i c i p a t i o n i n s p e c i f i c promotion a c t i v i t i e s according t o the socioeconomic c l i e n t e l e served also existed. health status of the Pharmacists serving lower-class c l i e n t s w e r e s i g n i f i c a n t l y more i n v o l v e d i n c o u n s e l l i n g on illicit and p r e s c r i p t i o n d r u g abuse ( s e e T a b l e 2 9 ) . v) Barriers The m e d i a n T o t a l B a r r i e r S c o r e f o r p h a r m a c i s t s was 23 o u t o f a p o s s i b l e 40 p o i n t s ( r a n g e 8.0 t o 4 0 . 0 ) . T a b l e 30 d i s p l a y s p h a r m a c i s t s ' r e p o r t e d f r e q u e n c i e s f o r each o f t h e b a r r i e r s . r e l a t i o n s h i p was d e t e c t e d b e t w e e n a p h a r m a c i s t s ' T o t a l Score and activities their overall (r=-0.0752). participation in Barrier health incentives". included promotion B a r r i e r s t h a t 5 0 % o r more o f p h a r m a c i s t s agreed as being p r o h i b i t i v e i n f u r t h e r i n g t h e i r h e a l t h involvement No "lack of time" and a "lack of promotion economic T a b l e 29 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA PHARMACIST ESTIMATION OF CLIENT SOCIOECONOMIC STATUS* 1. Activity Outcome Test C o u n s e l l i n g c l i e n t s on i l l i c i t d r u g abuse 1 > 2,5 15.744 0.003 1 > 2,3 14.441 0.006 2. C o u n s e l l i n g c l i e n t s o n p r e s c r i p t i o n drug abuse Statistic** 3. C o u n s e l l i n g c l i e n t s o n infant care 2 > 3 12.511 0.014 4. S u g g e s t i n g n o n - d r u g a l t e r n a t i v e s t o drug therapy 4 > 1 13.027 0.011 * 1= L o w e r C l a s s 2= L o w e r - m i d d l e C l a s s 3= M i d d l e C l a s s ** d f = 4 , 4 2 1 **ie****ie*ie*ie****ie***ie*******************ie*************isie* 4= U p p e r - m i d d l e 5= U p p e r C l a s s Class Table 30 BRITISH COLUMBIA COMMUNITY PHARMACIST PERCEIVED BARRIERS TO EXPANDING THEIR INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES (n=485) Percentage o f Pharmacists Reporting Strongly Disagree Disagree 3.1% 11. 8% 3.5% 50.5% 31.1% 9.5 25 .4 12.2 35.5 17.5 Shortage o f t e c h n i c i a n s 13.0 43 .9 20.0 18.8 4.3 Lack o f knowledge i n the area 10.9 47 .4 19.4 21.0 1.2 9.9 34 .2 26.2 25.6 4.1 6.0 40 .2 16.9 32.2 4.7 19.8 55 .3 10.1 13.6 1.2 Barrier Time No e c o n o m i c i n c e n t i v e Lack o f p a t i e n t Lack necessary information demand patient Lack c o u n s e l l i n g skills Staff pharmacists believed Not Agree Sure Strongly Agree t h a t t h e r e w e r e more b a r r i e r s t o f u r t h e r i n g t h e i r i n v o l v e m e n t i n h e a l t h p r o m o t i o n t h a n d i d pharmacy managers more (F=3.5188;df=2,482;p=.05). likely than df=2,482; p=0.05), (F=4.5245; technicians owners to cite lack o f demand df=2,482; p=0.05), (F=11.9481; furthering their S t a f f p h a r m a c i s t s were that lack f o r health and df=2,482; a promotion shortage p=0.05) involvement i n health o f time were promotion. of also (F=6.5359; services pharmacy barriers to Personal i) Pharmacist Variables Sex A p h a r m a c i s t ' s s e x h a d no s i g n i f i c a n t e f f e c t H e a l t h Promotion Score (^^=0.0612; df=482) . on t h e i r N o r was associated with pharmacists' personal health b e l i e f s df=482), personal health behaviours t h e i r p e r c e p t i o n of b a r r i e r s promotion a c t i v i t i e s (z=-0.4227; Participation in individual on smoking nor i n df=482). health promotion M a l e p h a r m a c i s t s w e r e more a c t i v e l y counselling (z=-0.2498; involvement i n health d i s p l a y e d s p e c i f i c d i f f e r e n c e s between t h e sexes community g r o u p s , p a r t i c i p a t i n g sex (z=-1.4052; df=482), limiting their overall activities (see T a b l e 31). involved i n speaking t o i n community h e a l t h e v e n t s , cessation. pharmacists were s i g n i f i c a n t l y more i n v o l v e d i n c o u n s e l l i n g c l i e n t s on i n f a n t care, s u g g e s t i n g non-drug a l t e r n a t i v e s Female and t o d r u g t h e r a p y , and non-drug a d j u n c t s t o drug therapy. suggesting TABLE 31 SIGNIFICANT DIFFERENCES BETWEEN MALE (M) AND FEM2U:.E (F) PHARMACIST PARTICIPATION IN HEALTH PROMOTION ACTIVITIES IN BRITISH COLUMBIA Activity Test Statistic* Outcome 1. P a r t i c i p a t i n g i n c o m m u n i t y community h e a l t h e v e n t s M > F z=-3.786; p<0.001 2. Suggesting non-drug a l t e r n a t i v e s t o drug therapy F > M z=-3.552; p<0.001 3. Suggesting non-drug to drug therapy F > M z = - 3 . 7 3 1 ; p<0.001 M > F z = - 2 . 3 3 9 ; p=0.019 F > M z = - 3 . 0 8 3 ; p=0.002 M > F z - 3 . 8 0 7 ; p<0.001 adjuncts 4. C o u n s e l l i n g o n s m o k i n g cessation 5. C o u n s e l l i n g on i n f a n t care 6. S p e a k t o c o m m u n i t y g r o u p s on h e a l t h - r e l a t e d m a t t e r s * df=479 i n a l l c a s e s *********** ii) **ic*ieie**********************is*************ie** Pharmacist M a r i t a l S t a t u s S i n g l e and d i v o r c e d pharmacists p a r t i c i p a t e d p r o m o t i o n a c t i v i t i e s more f r e q u e n t l y t h a n m a r r i e d 7.5345; d f = 2 , 4 7 5 ; p = 0 . 0 2 3 ) , p e r s o n a l health i n health pharmacists beliefs (7^^=0.6621; d f = 2 , 4 7 5 ) , o r p e r s o n a l h e a l t h b e h a v i o u r s {jf^= 1.4785; df=2,475). Differences detected according t o pharmacists' m a r i t a l s t a t u s were i n i n d i v i d u a l health promotion a c t i v i t i e s such as c o u n s e l l i n g on s e x u a l l y t r a n s m i t t e d d i s e a s e s , m e n t a l h e a l t h , w e i g h t control, AIDS p r e v e n t i o n , health care providers, occupational stress as r e f e r r i n g c l i e n t s and q u e r y i n g when p h a r m a c i s t s w e r e more involved as w e l l taking likely a c l i e n t s on t h e i r client's were more care likely providers than than married pharmacists t o become (see Table married counselling o n AIDS p r e v e n t i o n , transmitted diseases. iii) l e v e l of Divorced i n c o u n s e l l i n g on s e x u a l l y - t r a n s m i t t e d health other history. h e a l t h , w e i g h t c o n t r o l , AIDS p r e v e n t i o n , other to diseases, mental and r e f e r r i n g c l i e n t s t o 32) . Single pharmacists to pharmacists participate i n and t h e p r e v e n t i o n of sexually- Pharmacist P e r s o n a l H e a l t h B e l i e f s A mild, but s t a t i s t i c a l l y between p h a r m a c i s t s ' p e r s o n a l Health Promotion Scores significant correlation exists h e a l t h b e l i e f s and t h e i r o v e r a l l (r=0.1l05, p=0.01). The stronger a p h a r m a c i s t b e l i e v e d t h a t c e r t a i n h e a l t h p r a c t i c e s would promote t h e h e a l t h o f t h e a v e r a g e p e r s o n , t h e more f r e q u e n t l y t h e p h a r m a c i s t p a r t i c i p a t e d i n health promotion a c t i v i t i e s . This r e l a t i o n s h i p d i d not h o l d t r u e f o rd i s p e n s i n g - r e l a t e d h e a l t h promotion activities. Table 32 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA COMMUNITY PHARMACIST MARITAL STATUS (n=485) Activity Outcome* Test D,S > M 19.240 0.000 2. C o u n s e l l i n g o n m e n t a l health D > M 7.673 0.022 3. C o u n s e l l i n g o n w e i g h t control D > M 10.914 0.004 4. C o u n s e l l i n g o n A I D S prevention S > M 15.071 0.001 5. R e f e r c l i e n t s t o o t h e r health care providers S > M,D 11.090 0.004 6. Q u e r y c l i e n t s o n l e v e l of o c c u p a t i o n a l s t r e s s D > M 9.373 0.009 7. S u g g e s t n o n - d r u g a l t e r n a t i v e s t o drug therapy S > M 7.400 0.025 8. S u g g e s t n o n - d r u g a d j u n c t s to drug therapy S > M 8.166 0.017 1. C o u n s e l l i n g o n s e x u a l l y transmitted diseases * M= m a r r i e d o r e q u i v a l e n t D= d i v o r c e d S= s i n g l e **df=2,474 ****ie***************************ie************************ Statistic** iv) Pharmacist Age No a s s o c i a t i o n was d e t e c t e d b e t w e e n age a n d a p h a r m a c i s t ' s o v e r a l l Health Promotion Score (r=-0.0887). Age was weakly correlated t o pharmacists' personal h e a l t h behaviours p=0.01), meaning that as personal health practices a pharmacist improve. No gets link older, Pharmacist Personal Health h i s or between p h a r m a c i s t ' s p e r s o n a l h e a l t h b e l i e f s was d e t e c t e d V) (r=0.1295, and a (r=0.0304). Behaviours A mild, but s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n p=0.001) e x i s t e d age her (r=0.2189, between p h a r m a c i s t s ' p e r s o n a l h e a l t h b e h a v i o u r s and t h e i r o v e r a l l H e a l t h P r o m o t i o n Scores. Pharmacists who f r e q u e n t l y p r a c t i s e d p e r s o n a l health-promoting behaviours such as wearing to seatbelts or exercising provide h e a l t h promotion regularly were more likely s e r v i c e s f o r t h e i r c l i e n t s a t work. r e l a t i o n s h i p h e l d t r u e f o r dispensing h e a l t h promotion (r=0.1326, p=0.01), as w e l l as activities (r=0.2237, p=0.001). non-dispensing health This activities promotion Educational Variables i) Year o f Graduation A significant relationship y e a r o f g r a d u a t i o n and (r=0.1411; too ii) p=0.001). was d e t e c t e d between p h a r m a c i s t s ' overall participation i n health promotion The s t r e n g t h o f t h e c o r r e l a t i o n , h o w e v e r , i s weak t o be o f p r a c t i c a l m e a n i n g . Degree-Granting I n s t i t u t i o n No significant differences in overall p a r t i c i p a t i o n were d e t e c t e d between U n i v e r s i t y health promotion of B r i t i s h Columbia g r a d u a t e p h a r m a c i s t s , and t h o s e g r a d u a t i n g f r o m o t h e r C a n a d i a n foreign universities promotion activities, ('X'^ =0.723 ; d f = 2 , 4 4 2 ) . however, d i f f e r e n t graduates (see Table 33). showed Individual variation University health between of B r i t i s h Canadian adjuncts to drug therapy than provinces or other countries. graduates the Columbia g r a d u a t e s w e r e more l i k e l y t o c o u n s e l on i n f a n t c a r e o r t o non-drug or from suggest other TABLE 33 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA COMMUNITY PHARMACIST DEGREE-GRANTING INSTITUTIONS (n=485) Activity 1. C o u n s e l l i n g o n i n f a n t Outcome* care 2. S u g g e s t i n g n o n - d r u g a d j u n c t s to drug therapy Test Statistic** 1 > 2,3 10.282 0.006 1 > 3 8.423 0.015 * 1= U n i v e r s i t y o f B r i t i s h C o l u m b i a g r a d u a t e s 2= O t h e r C a n a d i a n u n i v e r s i t y g r a d u a t e s 3= F o r e i g n u n i v e r s i t y g r a d u a t e s **df=2,442 ******************************************************************* CHAPTER 5 DISCUSSION AND CONCLUSIONS Pharmacist P a r t i c i p a t i o n i n H e a l t h Promotion A c t i v i t i e s I f community p h a r m a c i s t s i n B r i t i s h C o l u m b i a were t o r e c e i v e a percentage grade f o r t h e i r involvement i n h e a l t h promotion, they w o u l d r e c e i v e a mark o f 6 4 % ( 1 0 5 / 1 6 5 ) . determine i f t h i s o v e r a l l No b e n c h m a r k s e x i s t t o h e a l t h p r o m o t i o n s c o r e i s "good", " a v e r a g e " , o r "bad". A s c o r e o f 5 8 % (79/135) was o b t a i n e d b y p h a r m a c i s t s f o r t h e i r participation i nnon-dispensing health promotion activities. Pharmacists p a r t i c i p a t e d i n d i s p e n s i n g - r e l a t e d h e a l t h promotion a t 87% (26/30) o f t h e maximum l e v e l t o b e o b t a i n e d i n t h i s The d i f f e r e n c e i n p h a r m a c i s t s ' p a r t i c i p a t i o n study. between d i s p e n s i n g and n o n - d i s p e n s i n g h e a l t h p r o m o t i o n a c t i v i t i e s was s i g n i f i c a n t (t=61.76, df=481; p<0.001), allowing h y p o t h e s i s one (HI) t o be r e t a i n e d ( s e e T a b l e 34) . T h e r e f o r e , c o m m u n i t y p h a r m a c i s t s a r e more involved i n dispensing health d i s p e n s i n g h e a l t h promotion Four of the five promotion activities than in non- showing the activities. health promotion activities g r e a t e s t d a i l y p a r t i c i p a t i o n by c o m m u n i t y p h a r m a c i s t s i n B r i t i s h Columbia are d i r e c t l y medications. linked t o the dispensing or s e l l i n g These medications, events querying include clients on advising possible of clients allergies, c l i e n t s on t h e i r c u r r e n t m e d i c a t i o n s , a n d o b t a i n i n g a on OTC querying client's m e d i c a l h i s t o r y , and a r e c o n s i d e r e d n e c e s s a r y o r " e s s e n t i a l " competently fill medication Despite a (College the prescription of necessity or Pharmacists of these sell of an British activities, to over-the-counter Columbia, one-third 1989). of a l l r e s p o n d i n g p h a r m a c i s t s i n d i c a t e d t h a t t h e y do n o t p a r t i c i p a t e i n t h e l a t t e r two a c t i v i t i e s on a d a i l y basis. Pharmacists' p a r t i c i p a t i o n i n non-dispensing health activities confirms that pharmacists actively promotion c o u n s e l and refer c l i e n t s to other health care providers, provide advice to other h e a l t h c a r e p r o f e s s i o n a l s , and promote l e s s e x p e n s i v e , clinically s u i t a b l e a l t e r n a t i v e s t o drug therapy f o r minor ailments. T h e r e i s a m p l e room f o r i n c r e a s e d p h a r m a c i s t in areas these but of health promotion, as about involvement one-third r e s p o n d i n g p h a r m a c i s t s p a r t i c i p a t e i n t h e s e e v e n t s on a basis. daily of TABLE 34 SUMMARY RESULTS OF OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST OVERALL INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Hypothesis Status HI: Community p h a r m a c i s t s w i l l have h i g h e r h e a l t h p r o m o t i o n scores f o r d i s p e n s i n g - r e l a t e d a c t i v i t i e s than f o r nondispensing related a c t i v i t i e s ACCEPTED H2: Female p h a r m a c i s t s w i l l have h i g h e r o v e r a l l h e a l t h s c o r e s t h a n male p h a r m a c i s t s promotion REJECTED H3: M a r r i e d p h a r m a c i s t s w i l l have h i g h e r o v e r a l l h e a l t h scores than single pharmacists promotion REJECTED H4: A p o s i t i v e c o r r e l a t i o n e x i s t s between p h a r m a c i s t s ' p e r s o n a l h e a l t h b e l i e f scores and t h e i r o v e r a l l h e a l t h promotionscores ACCEPTED H5: An i n v e r s e c o r r e l a t i o n e x i s t s between p h a r m a c i s t age and o v e r a l l h e a l t h promotion scores REJECTED H6: A p o s i t i v e c o r r e l a t i o n e x i s t s between p h a r m a c i s t s ' p e r s o n a l h e a l t h behaviour s c o r e s and o v e r a l l h e a l t h scores H7: A p o s i t i v e c o r r e l a t i o n e x i s t s between p h a r m a c i s t s ' g r a d u a t i n g year and o v e r a l l h e a l t h promotion scores REJECTED H8: No d i f f e r e n c e i n o v e r a l l h e a l t h p r o m o t i o n s c o r e s e x i s t s amongst pharmacy g r a d u a t e s f r o m t h e U n i v e r s i t y o f B r i t i s h Columbia, o t h e r Canadian u n i v e r s i t i e s , and f o r e i g n universities ACCEPTED H9: P h a r m a c i s t s employed i n "independent" pharmacies w i l l have lower o v e r a l l h e a l t h promotion scores than pharmacists employed i n " c o r p o r a t e c h a i n " pharmacies REJECTED total promotion ACCEPTED HIO: P h a r m a c i s t s e m p l o y e d i n C o l l e g e d i s t r i c t 6 w i l l h a v e h i g h e r o v e r a l l h e a l t h promotion s c o r e s t h a n p h a r m a c i s t s employed i n D i s t r i c t 1-5 a n d 7-9 ACCEPTED TABLE 3 4 — c o n t i n u e d SUMMARY RESULTS OF OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Hypothesis Status Hll: P h a r m a c i s t s p r a c t i s i n g i n r u r a l communities w i l l have h i g h e r o v e r a l l h e a l t h promotion scores than pharmacists p r a c t i s i n g i n urbanareas ACCEPTED H12: Staff pharmacists w i l l s c o r e s t h a n owners have h i g h e r o v e r a l l h e a l t h p r o m o t i o n REJECTED H13: P h a r m a c i s t s s e r v i n g c l i e n t e l e f r o m a p r e d o m i n a t e l y lower socioeconomic s t a t u s w i l l have h i g h e r o v e r a l l h e a l t h promotion scores than pharmacists s e r v i n g a predominately "upper-class"clientele ACCEPTED H14: F u l l - t i m e p h a r m a c i s t s w i l l have h i g h e r o v e r a l l h e a l t h promotion scores than part-time pharmacists ACCEPTED H15: A n i n v e r s e c o r r e l a t i o n e x i s t s b e t w e e n p h a r m a c i s t s b a r r i e r score and o v e r a l l h e a l t h promotion score The c o n c l u s i o n t h a t h e a l t h p r o m o t i o n highest rate of participation total REJECTED a c t i v i t i e s enjoyingthe are directly related to the dispensing o r s e l l i n g o f medications i s s i m i l a r t o Beardsley's c o n c l u s i o n i n 1981. The s i m i l a r i t y i n r e s u l t s between B e a r d s l e y ' s and the current d i f f e r e n t ways: study's results c a n be interpreted i n three 1) No c h a n g e h a s o c c u r r e d o v e r t h e l a s t d e c a d e i n t h e l e v e l o f community p h a r m a c i s t involvement i n health promotion activities; 2) Beardsley's sample, which was small r e p r e s e n t a t i v e , c o n t a i n e d p r i m a r i l y p h a r m a c i s t s who active i n h e a l t h promotion e s t i m a t i o n of pharmacist American pharmacists activities involvement and thus were e x t r e m e l y caused T h i s l a t t e r p o s s i b i l i t y may a r i s i n g from the d i f f e r i n g h e a l t h c a r e over3) o r may not pharmacist systems. 35 d i s p l a y s B e a r d s l e y ' s 1981 r e s u l t s from as compared t o t h e c u r r e n t r e s u l t s from Columbia pharmacists. an f o r t h a t time p e r i o d ; or be due t o d i f f e r e n t p a t i e n t i n c e n t i v e s t o c o n s u l t w i t h a pharmacists non- h a v e a more e x t e n s i v e c o m m u n i t y h e a l t h r o l e than Canadian pharmacists. Table and American British D i f f e r e n c e s i n s t u d y samples and study d e s i g n , as w e l l as t h e t e n y e a r t i m e span between B e a r d s l e y ' s and t h e p r e s e n t one make i t i n a p p r o p r i a t e t o s t a t i s t i c a l l y study compare data obtained i n Beardsley's study w i t h data obtained i n the present study. promotion H o w e v e r , some t r e n d s a r e w o r t h n o t i n g . activities common to both studies, For h e a l t h 95% confidence i n t e r v a l s were c o n s t r u c t e d u s i n g t h e c u r r e n t s t u d y ' s d a t a 1983) . The frequency p r o p o r t i o n of pharmacists of "never" was reporting a used f o r comparison (Walpole, participation because Beardsley's s t u d y used a 6-point L i k e r t s c a l e , whereas t h i s s t u d y used a p o i n t s c a l e , w h i c h may participation means " n e v e r " , comparison. level. a f f e c t pharmacists' e s t i m a t i o n of five- their "Never", r e g a r d l e s s o f t h e s c a l e u t i l i z e d , and p r o v i d e d t h e m o s t u n e q u i v o c a l c a t e g o r y f o r B a s e d on t h e s e c o n f i d e n c e i n t e r v a l s , A m e r i c a n p h a r m a c i s t s tended to be hypertension, 36). more involved i n counselling cancer s i g n a l s , diabetes, on alcohol and w e i g h t c o n t r o l B r i t i s h Columbia pharmacists, i n c o n t r a s t , reported abuse, (Table more a c t i v e i n v o l v e m e n t i n c o u n s e l l i n g c l i e n t s on smoking c e s s a t i o n and n u t r i t i o n , p r o v i d i n g w r i t t e n i n f o r m a t i o n on h e a l t h r e l a t e d m a t t e r s , and interviewing c l i e n t s f o rpossible a l l e r g i e s , medical history, or current drugs. TABLE 3 5 A COMPARISON OF AMERICAN VS. B R I T I S H COLUMBIAN COMMUNITY PHARMACIST INVOLVEMENT I N HEALTH PROMOTION A C T I V I T I E S * Reported Frequency [%U.S.(n=182) / % B.C. r e s p o n d e n t s ( n = 5 8 1 ) ] Never Activity Once Yearlv Once Once Monthly Weekly Once o r More D a i Counsel c l i e n t s on: STD prevention 28/31 39/37 26/24 5/8 2/0 Smoking cessation 14/5 18/17 29/40 23/32 Alcohol abuse 21/34 25/38 32/18 16/8 6/2 Illicit drug abuse 10/37 13/34 37/20 25/6 15/4 Poison prevention 11/10 34/39 34/37 15/11 5/3 2/10 12/31 34/34 49/18 28/35 33/24 13/4 12/9 25/30 27/33 29/22 21/24 30/32 15/14 10/6 Hypertension prevention or control Cancer s i g n a l s 22/35 7/5 Nutrition Mental 4/7 health 25/24 16/6 4/1 Diabetes prevention or c o n t r o l 5/8 7/15 35/35 33/29 21/14 Weight c o n t r o l 5/8 5/12 22/42 35/29 33/9 0/0 0/0 Speak t o community g r p s 65/63 28/32 Provide written information 39/3 21/6 A d v i s e o n OTCs 1/1 1/0 3/1 Refer patient t o other health care providers 2/2 1/3 16/11 health 7/5 21/32 8/30 12/30 3/4 93/94 27/39 54/45 Table 35—continued Reported Frequency [% U.S.(n=182) / % B.C. r e s p o n d e n t s ( n = 5 8 1 ) ] Activity Once Yearlv Once a Month 16/29 13/10 7/3 a b o u t : 8/1 4/1 11/1 19/2 95/95 16/7 8/3 10/10 19/15 47/65 9/5 3/2 8/8 17/18 63/67 Never Once a Once o r Week More D a i l y Participate i n disease screening I n t De rr uv gi e wa lplaetrigeinetss Medical history Current drugs 55/57 ********************************************************* * U.S. d a t a f r o m B e a r d s l e y , 1 9 8 3 . B.C. d a t a f r o m p r e s e n t 9/2 study. Table 3 6 A COMPARISON OF HEALTH PROMOTION ACTIVITIES "NEVER" PARTICIPATED IN BY BRITISH COLUMBIA AND AMERICAN COMMUNITY PHARMACISTS USING 95% CONFIDENCE INTERVALS (CI) 95% C . I . f a ) Activity Counsel American Percent R e p o r t i n g That They "Never" P a r t i c i p a t e C l i e n t s on: Sexually-transmitted diseases Smoking C e s s a t i o n A l c o h o l Abuse Poisoning Prevention Hypertens i o n Cancer S i g n a l s Nutrition Mental Health Diabetes Weight C o n t r o l S p e a k t o Community G r o u p s 27.4? 3.0 30.0 8.5 4.6 31.1 2.8 20.5 5.1 5.4 58.8 35.6% 6.8 38.4 11.3 9.0 39.6 6.6 28.1 9.7 10.2 28% 14(c) 21(d) 11 4(d) 22(d) 7(c) 25 5(d) 5(d) - 67.4 65 39(C) Provide written information 1.4 - 4.4 A d v i s e o n OTC p r o d u c t s 0.0 - 1.6 1 Refer c l i e n t s 0.5 2.7 2 Participate t o other providers i n Disease Datafb) Screening 52.3 61.1 55 Interview clients for: Allergies Medical History C u r r e n t Drugs 0.0 4.7 0.0 1.6 9.3 0.6 8(c) 16(c) 9(c) (a) b a s e d u p o n B r i t i s h C o l u m b i a d a t a f r o m p r e s e n t s t u d y . (b) B e a r d s l e y , 1 9 8 3 . (c) F a l l s o u t s i d e t h e 9 5 % c o n f i d e n c e i n t e r v a l , s h o w i n g a l o w e r p a r t i c i p a t i o n l e v e l by American p h a r m a c i s t s . (d) F a l l s o u t s i d e t h e 9 5 % c o n f i d e n c e i n t e r v a l , s h o w i n g a g r e a t e r p a r t i c i p a t i o n by American p h a r m a c i s t s . VARIABLES INFLUENCING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION S e v e n ( 6 4 % ) o f t h e 11 v a r i a b l e s e x a m i n e d i n t h i s s t u d y appear t o be a s s o c i a t e d w i t h p h a r m a c i s t s ' i n v o l v e m e n t i n h e a l t h promotion activities. community Variables found to be related to pharmacists' o v e r a l l involvement i n h e a l t h promotion were p h a r m a c i s t m a r i t a l s t a t u s , employment s t a t u s , p e r s o n a l h e a l t h b e l i e f s and h e a l t h behaviours, type o f p r a c t i c e , geographic l o c a t i o n a n d s o c i o e c o n o m i c s t a t u s o f t h e c l i e n t e l e ( s e e T a b l e 37) . Therefore, Hypotheses 4, 6, 10, 11 and 14 regarding these r e l a t i o n s h i p s a r e accepted, w h i l e hypotheses 9 (which proposed pharmacists working i n c o r p o r a t e c h a i n pharmacies would that b e more i n v o l v e d i n h e a l t h p r o m o t i o n c o u n s e l l i n g t h a n p h a r m a c i s t s employed i n independent pharmacies) p h a r m a c i s t s would rejected. and 3 (which proposed that married b e more a c t i v e t h a n s i n g l e p h a r m a c i s t s ) , a r e Correlation coefficients f o rtherelationships between p h a r m a c i s t s ' o v e r a l l h e a l t h promotion s c o r e s and t h e i r t o t a l h e a l t h belief and h e a l t h behaviour scores practical implications (see Table variables associated with promotion activities because a r e t o o weak 37) . pharmacist the They were involvement questions t o have any retained i n examining as health this r e l a t i o n s h i p w e r e e x p l o r a t o r y a n d more r e s e a r c h i n t h i s a r e a i s warranted. TABLE 37 VARIABLES INFLUENCING B R I T I S H COLUMBIA COMMUNITY PHARMACIST OVERALL INVOLVEMENT I N HEALTH PROMOTION Variable Test S t a t i s t i c Employment s t a t u s df Y^=6.341 Personal health beliefs r=0.110 Type o f p r a c t i c e s e t t i n g l ^ : ; . =14.656 Geographic l o c a t i o n 'X=26.257 Personal health behaviour 0.012 — 0.010 8,476 0.002 0.001 — t Marital status 483 3,481 r=0.219 Socioeconomic s t a t u s o f clientele p 0.001 'X=11.748 4,421 0.019 ")^=7.534 2,485 0.023 ***************************************************** For many reputation years, the f o r providing professionally-oriented 1992) . independent personalized than large, drug store service chain drug Data from t h e p r e s e n t study r e f i n e t h a t has and held being stores a more (Berube, belief; independent stores which belonged t o a v o l u n t a r y chain employed pharmacists with s t a t i s t i c a l l y s i g n i f i c a n t higher o v e r a l l Health Promotion Scores drugstores". activities instances than Many were did traditional, differences also present d i d t h e pharmacist independent i n individual (see Table employed 25) . i n an health Only "corner promotion in a independent few store p a r t i c i p a t e more f r e q u e n t l y t h a n a p h a r m a c i s t e m p l o y e d i n a n y o t h e r practice setting. A l t h o u g h e a r l i e r s t u d i e s ( s e e T a b l e 2) h a v e s u g g e s t e d that sex and age w o u l d be a s s o c i a t e d w i t h p h a r m a c i s t s ' p a r t i c i p a t i o n i n h e a l t h promotion, t h e present study f a i l e d t o f i n d these f a c t o r s t o be s t a t i s t i c a l l y r e l a t e d t o p h a r m a c i s t s ' o v e r a l l h e a l t h promotion a c t i v i t i e s . involvement i n A l l e l e v e n o f t h e v a r i a b l e s examined did influence pharmacists' p a r t i c i p a t i o n i n i n d i v i d u a l health promotion activities. Male p h a r m a c i s t s p a r t i c i p a t e d i n s p e a k i n g t o community groups and p a r t i c i p a t e d i n community h e a l t h e v e n t s t o a g r e a t e r extent than female pharmacists. T h i s f i n d i n g may b e d u e t o t h e d i s p r o p o r t i o n a t e number o f m a l e s i n t h e m a n a g e r i a l o r owner position ( T a b l e 14) - a p o s i t i o n w h i c h t y p i c a l l y a l l o w s more freedom t o p h y s i c a l l y l e a v e t h e d i s p e n s a r y and t a k e p a r t i n such activities. W i t h women t r a d i t i o n a l l y b e i n g t h e p r i m a r y c a r e g i v e r f o r i n f a n t s a t home, i t i s n o t s u r p r i s i n g t h a t f e m a l e p h a r m a c i s t s w e r e more involved i n counselling clients on infant care. Female p h a r m a c i s t s w e r e a l s o more i n v o l v e d i n s u g g e s t i n g n o n - d r u g a l t e r n a t i v e s and a d j u n c t s f o r minor a i l m e n t s . T h i s may be d u e t o a w e a k e r e c o n o m i c i n c e n t i v e a m o n g s t f e m a l e p h a r m a c i s t s t o make a s a l e , a s t h e y o c c u p y owner o r manager p o s i t i o n s l e s s o f t e n than male p h a r m a c i s t s . Female p h a r m a c i s t s a r e l e s s l i k e l y than m a l e p h a r m a c i s t s t o s t a t e t h a t a l a c k o f e c o n o m i c i n c e n t i v e s was p r o h i b i t i n g t h e i r involvement i n h e a l t h promotion activities (z= -2.507; df=482; p=0.012). D i v o r c e d p h a r m a c i s t s w e r e more l i k e l y t h a n m a r r i e d p h a r m a c i s t s t o c o u n s e l c l i e n t s on m e n t a l h e a l t h and t o q u e r y c l i e n t s on t h e i r l e v e l o f o c c u p a t i o n a l s t r e s s when t a k i n g a c l i e n t ' s h i s t o r y . One p o s s i b l e e x p l a n a t i o n f o r t h i s f i n d i n g may be t h a t d i v o r c e d p h a r m a c i s t s h a v e s p e n t more t i m e w o r k i n g o n t h e i r own m e n t a l h e a l t h d u r i n g t h e i r d i v o r c e , and t h u s r e a l i z e t h e i m p o r t a n c e and feel comfortable counselling clients o f doing so accordingly. I n t e r e s t i n g l y , male p h a r m a c i s t s i n t h e s t u d y were d i v o r c e d a l m o s t 30% more o f t e n t h a n f e m a l e p h a r m a c i s t s 16); ( 6 . 0 % v e r s u s 4.7%) (Table t h e f a c t t h a t more m a l e p h a r m a c i s t s a r e d i v o r c e d may be a n area f o r future research. Single pharmacists counselled clients prevention more o n AIDS a n d often sexually- transmitted diseases than married pharmacists. One p o s s i b l e t h e o r y f o r t h i s r e l a t i o n s h i p was a g e ; s i n g l e p h a r m a c i s t s a r e l i k e l y t o be y o u n g e r , a n d t h e r e f o r e may be l e s s i n h i b i t e d o r ' e m b a r r a s s e d ' t o c o u n s e l c l i e n t s o n A I D S a n d s e x u a l l y - t r a n s m i t t e d d i s e a s e s (STD) p r e v e n t i o n t h a n o l d e r pharmacists. 0.0386) o r STD necessity of H o w e v e r , no r e l a t i o n s h i p b e t w e e n a g e a n d AIDS ( r = (r=-0.0335) c o u n s e l l i n g e x i s t e d . "safer-sex" practices i s more Perhaps t h e relevant to single p h a r m a c i s t s who a r e l e s s l i k e l y t o be i n v o l v e d i n a monogamous relationship, and p r a c t i s e these so may have more opportunity to personally behaviours. P h a r m a c i s t s w o r k i n g i n " c o r p o r a t e c h a i n " drug s t o r e s were l e s s likely than pharmacists working i n "independent t a k e an a d e q u a t e p a t i e n t h i s t o r y . P r e s c r i p t i o n volume i s t y p i c a l l y l a r g e r i n c o r p o r a t e c h a i n d r u g s t o r e s w h i c h may attention given to these a c t i v i t i e s . this area, as to competently chain" stores to e x p l a i n the lack of More r e s e a r c h i s needed i n perform dispensing p h a r m a c i s t s m u s t o b t a i n an u p - t o - d a t e m e d i c a l h i s t o r y , information regarding clients' from each p a t i e n t 1989). allergies and including current medications (College of Pharmacists of B r i t i s h Columbia, P h a r m a c i s t s e m p l o y e d i n " c o r p o r a t e c h a i n " s t o r e s showed lower p a r t i c i p a t i o n r a t e s than p h a r m a c i s t s employed i n c h a i n s " i n two of these "independent activities. F u l l - t i m e p h a r m a c i s t s a r e more i n v o l v e d i n h e a l t h a c t i v i t i e s than part-time pharmacists. was f e a r e d t h a t p a r t - t i m e and separate populations. pharmacists f u l l - t i m e pharmacists comprised I f t r u e , combining together f o r data c o r r e l a t i o n s from b e i n g used. full-time pharmacists promotion During data analysis, i t two f u l l - t i m e and p a r t - t i m e a n a l y s i s would be c a t e g o r i c a l nature of the data c o l l e c t e d prevented and functions incorrect. The Pearson-product Therefore, t o ensure t h a t p a r t - t i m e were of the same population, 95% c o n f i d e n c e i n t e r v a l s were c o n s t r u c t e d t o examine t h e d i f f e r e n c e s i n t h e two means. The resultant interval i n c l u d e d z e r o and thus. p e r m i t t e d t h e assumption t h a t p a r t - t i m e and f u l l - t i m e pharmacists w e r e f r o m t h e same p o p u l a t i o n . F o r e v e n t s such as s p e a k i n g t o community g r o u p s , and participating i n community health events or disease screening p r o g r a m s , p a r t - t i m e p h a r m a c i s t s s h o u l d t h e o r e t i c a l l y h a v e more t i m e t h a n f u l l - t i m e p h a r m a c i s t s t o become i n v o l v e d i n t h e s e a r e a s ; h o w e v e r , t h i s was n o t t h e s i t u a t i o n . part-time pharmacists were female S i x t y - t h r e e p e r c e n t (63%) o f (see Table 14) , a n d may d e c r e a s e d t h e i r w o r k l o a d due t o c h i l d - r e a r i n g o b l i g a t i o n s . have Thus, t h e y may n o t h a v e t h e a d d i t i o n a l t i m e t h a t w o u l d be e x p e c t e d o f a part-time pharmacist. than full-time P a r t - t i m e p h a r m a c i s t s w e r e a l s o more pharmacists to indicate that they c o u n s e l l i n g s k i l l s necessary f o r f u r t h e r i n g t h e i r health promotion activities (z=-2.377; likely lacked the involvement i n df=483; p=0.018). T h e r e f o r e , p a r t - t i m e p h a r m a c i s t s may n o t h a v e t h e c o n f i d e n c e t o p a r t i c i p a t e i n those h e a l t h promotion a c t i v i t i e s t h a t d e v i a t e from t r a d i t i o n a l pharmacist functions. A n u n e x p e c t e d f i n d i n g was t h a t p h a r m a c i s t s w e r e more l i k e l y t o suggest non-drug a l t e r n a t i v e s t o drug therapy f o r minor a i l m e n t s t o upper-middle c l a s s c l i e n t s as opposed t o c l i e n t s from a l o w e r - c l a s s b a c k g r o u n d who c o u l d b e n e f i t g r e a t l y f r o m a " n o - c o s t " t o drug therapy. classes receive medications; However, c l i e n t s f r o m t h e l o w e s t free medical coverage, including alternative socioeconomic prescription therefore, the i n c e n t i v e f o r these persons t o not purchase a p r o d u c t may be l e s s t h a n i t w o u l d without t h i s type of p u b l i c The number involvement associated promotion of with barriers to promotion pharmacists' activities. client assistance. perceived i n health be f o r a The furthering activities overall was not pharmacist found participation in operational hypothesis to health (H2) t h e r e f o r e , r e j e c t e d , and t h e n u l l h y p o t h e s i s i s r e t a i n e d . be is The only b a r r i e r t h a t a c l e a r m a j o r i t y o f r e s p o n d e n t p h a r m a c i s t s a g r e e d upon was a lack of time t o p a r t i c i p a t e i n h e a l t h promotion Although the role of the pharmacy technician p h a r m a c i s t ' s t i m e i s w e l l known ( W h a l e n , in activities. freeing up a 1 9 8 1 ) , i t was i n t e r e s t i n g that only 58% o f p h a r m a c i s t s t h a t s t r o n g l y a g r e e d t h a t t i m e " was a b a r r i e r also believed that a "shortage of technicians" was "lack of a barrier. A l a c k o f e c o n o m i c i n c e n t i v e s i s one c i t e d b a r r i e r s f o r pharmacists B r i t i s h Columbian o f t h e m o s t commonly (Beardsley, 1983). O n l y 53% pharmacists agreed w i t h t h i s statement; of 47% of p h a r m a c i s t s e i t h e r d i s a g r e e d o r w e r e n o t s u r e i f t h i s was a b a r r i e r to furthering their involvement i n h e a l t h promotion O w n e r s , whom l i t e r a t u r e h a v e d e s c r i b e d motivated, did not report "lack of activities. as b e i n g e c o n o m i c a l l y economic incentives" as a b a r r i e r a n y more f r e q u e n t l y t h a n d i d s t a f f p h a r m a c i s t s o r m a n a g e r s ( %''^=4 . 7483 ; d f = 2 , 4 8 2 ) . A l t h o u g h o w n e r s w e r e more l i k e l y than managers t o f e e l t h a t t h e y l a c k e d t h e c o u n s e l l i n g s k i l l s for participation in health promotion activities necessary ( =7.4240; df=2,482; p=0.024), t h i s b e l i e f d i d not i n f l u e n c e t h e i r d e c i s i o n t o participate i n h e a l t h p r o m o t i o n a c t i v i t i e s , as owners participated a t l e v e l s t h a t d i d not d i f f e r from s t a f f p h a r m a c i s t s o r managers. The l a c k of a r e l a t i o n s h i p graduation and interesting. their between p h a r m a c i s t s ' participation R e c e n t g r a d u a t e s who in year health of promotion have been a b l e t o t a k e advantage of a c u r r i c u l u m which includes h e a l t h promotion ideology showing p a r t i c i p a t i o n g r a d u a t e s , who received t r a i n i n g which focused "product-oriented", (Schulz and levels significantly different B r u s h w o o d , 1991; Appleby, 1992). are from not older primarily rather than " p a t i e n t - o r i e n t e d " , is on a curriculum Logically, i t would be f a i r t o c o n c l u d e t h a t h e a l t h p r o m o t i o n e d u c a t i o n r e c e i v e d i n the undergraduate the Alternately, curriculum is not on-the-job experience o l d e r p h a r m a c i s t s up diffusing may play a role t o t h e same l e v e l o f r e c e n t g r a d u a t e s . More t h a n o n e - h a l f t h e r e f o r e t h e e f f e c t o f any or continuing education i n bringing pharmacy i n health changes t o with promotion undergraduate programs i s u n c l e a r . Although t h i s study research workplace. of pharmacists are comfortable the knowledge they possess t o p a r t i c i p a t e activities; into was exploratory i s needed t o c o n f i r m t h e s e f i n d i n g s , i n nature, attempts to and more increase t h e p a r t i c i p a t i o n i n h e a l t h p r o m o t i o n a c t i v i t i e s amongst community p h a r m a c i s t s may c o n s i d e r t a r g e t i n g t h e v a r i a b l e s t h a t w e r e f o u n d t o be a s s o c i a t e d w i t h p h a r m a c i s t p a r t i c i p a t i o n i n h e a l t h promotion activities. pharmacists employed For in pharmacies, example, "independent" part-time pharmacists, pharmacies or "corporate chain" and p h a r m a c i s t s employed i n t h e d e n s e l y p o p u l a t e d C o l l e g e d i s t r i c t s 7, 8, a n d 9 c o u l d be t a r g e t e d w i t h c o n t i n u i n g education programs. Furthermore, through pharmacy stores' p o l i c i e s , as w e l l a s r e g u l a t o r y and v o l u n t a r y pharmacy o r g a n i z a t i o n boards' p o l i c i e s , t h e development and s u s t a i n m e n t o f h e a l t h y p e r s o n a l b e l i e f s a n d b e h a v i o u r s a m o n g s t a l l p h a r m a c i s t s s h o u l d be a c t i v e l y encouraged, a c t i o n s range smoking" or c u l t i v a t e d , and s u p p o r t e d . Examples o f t h e s e from d e c l a r i n g a l l pharmacy board meetings implementing "designated driver" a s "non- programs at a l l p h a r m a c y s o c i a l f u n c t i o n s , t o p r o v i d i n g a n a d d i t i o n a l 15 m i n u t e s t o s t a f f lunch breaks f o r those p a r t i c i p a t i n g i n a p h y s i c a l The c a u s a l model proposed i n F i g u r e 1 i s r e j e c t e d as i t does n o t a c c u r a t e l y p r e d i c t community p h a r m a c i s t s ' o v e r a l l i n h e a l t h promotion. results, activity. involvement A s e c o n d m o d e l , b a s e d on t h e p r e s e n t s t u d y ' s i s d e p i c t e d i n F i g u r e 6. Based on t h i s m o d i f i e d model, p h a r m a c i s t s who b e l i e v e i n t h e i m p o r t a n c e o f h e a l t h y l i f e s t y l e s t o m a i n t a i n h e a l t h , p r a c t i c e h e a l t h y l i f e s t y l e c h o i c e s , a r e employed f u l l - t i m e , work i n an i n d e p e n d e n t c h a i n d r u g s t o r e , and work i n a r e m o t e l o c a t i o n , a r e more l i k e l y t o be more i n v o l v e d i n h e a l t h promotion activities. H a v i n g a c q u i r e d b a s e l i n e d a t a on pharmacists' p a r t i c i p a t i o n i n h e a l t h promotion a c t i v i t i e s obviates t h e need t o s p e c u l a t e as t o p h a r m a c i s t s ' o v e r a l l i n h e a l t h promotion activities. F u t u r e i n t e r v e n t i o n s c a n now aimed a t s t i m u l a t i n g p a r t i c i p a t i o n promotion activities participation i n those i n d i v i d u a l showing low p a r t i c i p a t i o n be health levels. From the p r e s e n t study, pharmacists' gender, m a r i t a l s t a t u s , d e g r e e - g r a n t i n g institution, and predominately served socioeconomic have emerged status as of important the clientele variables c o n s i d e r e d i n d e v e l o p i n g and t a r g e t i n g t h e p h a r m a c i s t to be groups f o r future i n t e r v e n t i o n s designed t o increase p a r t i c i p a t i o n i n s p e c i f i c h e a l t h promotion activities. FIGURE 6 A M E N D E D CAUSAL MODEL DEPICTING COMMUNITY PHARMACIST I N V O L V E M E N T IN H E A L T H P R O M O T I O N A C T I V I T I E S Personal Health Beliefs Personal Health Behaviors T y p e of Practice Geographic Location Employment Position Employment Status Marital Status Socioeconomic Status of Clientele Pharmacist Overall Involvement in Health Promotion CHAPTER 6 SUMMARY AND RECOMMENDATIONS SUMMARY Community p h a r m a c i s t s a r e f a c e d w i t h many o p p o r t u n i t i e s t o p a r t i c i p a t e i n h e a l t h promotion. determine Columbia t h e extent t o which are involved external factors, T h e p u r p o s e o f t h i s s t u d y was t o community i n health i f any, pharmacists promotion i n British activities and which are associated with t h i s r a t e o f involvement. A f i v e - p a g e m a i l q u e s t i o n n a i r e was m a i l e d o u t t o a s y s t e m a t i c , stratified s a m p l e o f 625 p r a c t i s i n g c o m m u n i t y p h a r m a c i s t s i n B r i t i s h Columbia. A f i v e - p o i n t L i k e r t - t y p e s c a l e r a n g i n g from " n e v e r " t o " o n c e o r more d a i l y " was u s e d t o e x a m i n e t h e f r e q u e n c i e s of i n v o l v e m e n t i n 33 d i f f e r e n t h e a l t h p r o m o t i o n activities. D e s c r i p t i v e i n f o r m a t i o n p e r t a i n i n g t o t h e p h a r m a c i s t s i n t h e sample was also used, collected. Three different r e s u l t i n g i n a response follow-up procedures were r a t e o f 84%. R e s u l t s o f t h e s t u d y showed t h a t p h a r m a c i s t s m o s t f r e q u e n t l y p a r t i c i p a t e i n h e a l t h promotion events which a r e d i r e c t l y l i n k e d t o the dispensing or s e l l i n g of medications. These events i n c l u d e q u e r y i n g c l i e n t s on p o s s i b l e d r u g a l l e r g i e s , advising clients on o v e r - t h e - c o u n t e r m e d i c a t i o n s , q u e r y i n g c l i e n t s on c u r r e n t drugs they are taking, obtaining medical h i s t o r i e s , drug a l t e r n a t i v e s f o r minor a i l m e n t s . pharmacists community questioning counselling smoking The a c t i v i t i e s t h a t showed t h e l o w e s t p a r t i c i p a t i o n groups, participating clients on AIDS on their i n disease level prevention, and and s u g g e s t i n g non- of i n were s p e a k i n g t o screening programs, occupational querying clients stress, on their status. Seven variables were found pharmacists' o v e r a l l involvement to be related to i n h e a l t h promotion community activities. These v a r i a b l e s i n c l u d e a p h a r m a c i s t ' s p e r s o n a l h e a l t h b e l i e f s and health behaviours, marital p o s i t i o n , geographic status, type of practice, l o c a t i o n , and s o c i o e c o n o m i c c l i e n t e l e predominately employment status of the served. This study provides researchers w i t h b a s e l i n e data regarding t h e f r e q u e n c y w i t h w h i c h community p h a r m a c i s t s i n B r i t i s h are i n v o l v e d i n h e a l t h promotion a c t i v i t i e s . Columbia The d a t a m i g h t s e r v e as a benchmark a g a i n s t w h i c h t h e s u c c e s s o f f u t u r e aimed at m i g h t be s t i m u l a t i n g pharmacist measured. The involvement r e s u l t s a l s o may interventions i n health promotion e n a b l e p o l i c y makers to c o n d u c t more t h o r o u g h e x a m i n a t i o n s o f p h a r m a c i s t a c t i v i t i e s on the contributions the province. of community pharmacists F i n a l l y , the data provide the health insight regarding to which current health promotion theory d i f f u s e d i n t o t h e w o r k p l a c e by h e a l t h to and the education is of extent being professionals. Areas f o r Future Research Pharmacists' personal h e a l t h b e l i e f s and b e h a v i o u r s w e r e f o u n d t o be involvement study i n health measuring exploratory, two further research care p r o f e s s i o n a l s ' personal b e h a v i o u r s , and only m i l d l y c o r r e l a t e d to promotion. these personal Because variables the were health pharmacist questions in the intended to be i n t o the r e l a t i o n s h i p between h e a l t h health b e l i e f s , t h e i r personal health t h e e x t e n t t o w h i c h t h e y become i n v o l v e d i n h e a l t h p r o m o t i o n c o u n s e l l i n g a t w o r k i s w a r r a n t e d by t h e s e preliminary results. P e r c e i v e d k n o w l e d g e , and n o t a c t u a l k n o w l e d g e , was t h i s study. Therefore, measured i n i t i s necessary to determine i f p h a r m a c i s t s ' p e r c e p t i o n s of t h e i r knowledge c o r r e l a t e w i t h t h e i r a c t u a l k n o w l e d g e b a s e , a n d how t h i s r e l a t e s t o p h a r m a c i s t b e h a v i o u r i n the workplace. knowledge T h i s c o u l d be t e s t e d by a d m i n i s t e r i n g a w r i t t e n assessment activities. test on the various health promotion F o r e x a m p l e , an exam b a s e d u p o n h e a l t h p r o m o t i o n case s t u d i e s r e q u i r i n g p h a r m a c i s t i n t e r v e n t i o n c o u l d be a d m i n i s t e r e d . The quality and a c c u r a c y o f p h a r m a c i s t a d v i c e c o u l d be measured, and t h e n compared t o h i s o r h e r s e l f - a s s e s s e d k n o w l e d g e l e v e l . relationship promotion health between and a h i s or promotion pharmacist's her actual self-reported activities could be knowledge level of p h a r m a c i s t s who felt health involvement examined. d e t e r m i n a t i o n c o u l d be made w h e t h e r p h a r m a c i s t s who " l a c k o f k n o w l e d g e " was in The in Similarly, a stated that a not a b a r r i e r scored h i g h e r than d i d that "lack o f k n o w l e d g e " was a barrier for them. A s u r p r i s i n g f i n d i n g was that the o v e r a l l l e v e l of p a r t i c i p a t i o n i n h e a l t h p r o m o t i o n a c t i v i t i e s d i d n o t d i f f e r amongst owners, managers, and s t a f f p h a r m a c i s t s . I t would be interesting t o d e t e r m i n e i f a s t a f f p h a r m a c i s t ' s H e a l t h P r o m o t i o n Score matched t h e i r manager's o r s t o r e owner's H e a l t h P r o m o t i o n S c o r e . Do o w n e r s o r m a n a g e r s ( d e p e n d i n g on t h e t y p e o f p r a c t i c e ) s h a p e t h e i r store's h e a l t h p r o m o t i o n i d e o l o g y and d e t e r m i n e t h e p a r t i c i p a t i o n l e v e l o f s t a f f pharmacists i n health promotion? A s m e n t i o n e d p r e v i o u s l y , t h i s d a t a w i l l be u s e f u l i n m e a s u r i n g t h e s u c c e s s o f i n t e r v e n t i o n s aimed a t s t i m u l a t i n g involvement i n health promotion activities. pharmacist Ideally, s h o u l d be v a l i d a t e d b e f o r e b e i n g u s e d i n t h i s manner. o f t h e p h a r m a c i s t s ' s e l f - r e p o r t e d f r e q u e n c i e s m u s t be the data The a c c u r a c y determined, as w e l l as t h e q u a l i t y o r a p p r o p r i a t e n e s s o f a d v i c e t h a t i s b e i n g o f f e r e d t o the c l i e n t s r e c e i v i n g the h e a l t h promotion D i f f e r e n t methods t o a c h i e v e t h i s end e x i s t . involves training a group of actor service. One v a l i d a t i o n m e t h o d clients with particular s i t u a t i o n s r e q u i r i n g a h e a l t h promotion s e r v i c e from a pharmacist, and sending them into a random sample o f community pharmacies. T h i s m e t h o d i s more c o s t l y a n d l a b o u r i n t e n s i v e t h a n o t h e r m e t h o d s , but would service g i v e t h e most a c c u r a t e d e s c r i p t i o n o f what q u a l i t y o f i s actually Columbia. r e c e i v e d i n community pharmacies i n British T h i s m e t h o d w o u l d n o t , h o w e v e r , be a b l e t o v e r i f y t h e pharmacists' self-reported frequencies. The o n l y way to truly v a l i d a t e the frequencies of pharmacist involvement i n health promotion a c t i v i t i e s , would be t o h a v e r e s e a r c h e r s s i t i n a d i s p e n s a r y e v e r y d a y f o r one y e a r events participated (i.e., i n by p h a r m a c i s t s to insure that o n l y once a y e a r those are not missed!). A n o t h e r m e t h o d t h a t c o u l d be u s e d t o v a l i d a t e t h e a c c u r a c y a n d q u a l i t y o f h e a l t h p r o m o t i o n s e r v i c e s b e i n g o f f e r e d w o u l d be t o a d m i n i s t e r a w r i t t e n exam u s i n g c a s e s t u d i e s , s e e k i n g t o d e t e r m i n e what a pharmacist situation. The would do i f presented with c a s e s t u d y method i n c o r p o r a t e d i n t o a i n t e r v i e w h a s b e e n u s e d s u c c e s s f u l l y on M o n t r e a l pharmacists a particular telephone community (Nguyen, 1992) , and w o u l d p e r h a p s be a p p r o p r i a t e i f o n l y one o r two o f t h e h e a l t h p r o m o t i o n A l t h o u g h good response a c t i v i t i e s were b e i n g examined. r a t e s and l o w c o s t s a r e b o n u s e s t o b o t h the w r i t t e n and t e l e p h o n e a s s e s s m e n t s o f q u a l i t y , a d r a w b a c k t o b o t h i s that the information i s self-reported and may very likely from what a d v i c e i s b e i n g p r o v i d e d t o c l i e n t s i n a c t u a l The a d v a n t a g e s and shortcomings t o be c o n s i d e r e d i n e x p a n d i n g differ practice. o f a l l o f t h e s e methods w i l l research i n the h e a l t h a c t i v i t i e s o f community p h a r m a c i s t s . have promotion References A n o n . 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C l i n i c a l pharmaceutical services i n retail practice: Pharmacists' w i l l i n g n e s s and a b i l i t i e s t o provide services. Drug I n t e l l i g e n c e i n C l i n i c a l Pharmacy. 1984(Nov)18 : 917-22. Appendix l Survey Instrument A Study By Elan Paluck, B.Sc. (Pharm) Tim Stratton, Ph.D., R.Ph. UBC Faculty of Pharmaceutical Sciences PHARMACIST INVOLVEMENT IN HEALTH PROMOTION I'f f A R I v r A C l S T r N V O L V E M K N T IN HKALTH [>t?01VfOTfON lliaak you for taking the time to participate in this survey. Your input wil[ Iielp to strengthen our profession. For your current practice, please estimate Iiow frequently you arc involved in each of the activities listed below. Circle the numbered column that best corresponds with your estimate. L How often do you counsel individuals in the following areas: NEVER ONCE YEARLY ONCE MONTHLY ONCE WEEKLY ONCE OR MORE D A I L Y a) Control of sexuallytransmitted diseases ^ 2 3 4 S b) Smoking cessation ^ 2 3 4 5 c) Alcohol abuse i 2 3 4 5 d) Illicit drug abuse ^ 2 3 4 5 e) Rx drug misuse ^ 2 3 4 5 f) O T C drug misuse i 2 3 4 5 g) Poisoning prevention ^ 2 3 4 5 h) Hypertension prevention and/or control i 2 3 4 5 i) Cancer signals ^ 2 3 4 5 ^ 2 3 4 -> J) Nutrition Mental health ^ 2 3 4 5 k) 1) Diabetes prevention and/or control ^ 2 3-. 4 5 m) Weight control ^ 2 3 4 5 n) First aid i 2 3 4 5 o) Infant care ^ 2 3 4 5 P) AIDS prevention ^ 2 3 4 5 q) Dental hygiene ^ 2 3 4 0 Hypercholesterolemia prevention and/or control i 2 3 4 5 5 How often do you speak to commuaily groups? ONCE YEARLY How often do you provide materials? NEVER ONCE YEARLY ONCE HONTKCr ONCE WEEKLY ONCE OR MORE D A I L Y clicats with written drug or health information ONCE MONTULÏ ONCE WEEKLY ONCE OR MORE DAÏI.V How frequently do you advise consumers on non-prescription medications? NEVER ONCE YEARLY ONCE MONTHLY ONCE WEEKLY ONCE OR MORE DAILY .5 How often do you. refer patients to other health care providers? NEVER ONCE YEARLY ONCE MO(ma.r ONCE WEEKLY ONCE OR MORE DAILY Estimate how frequently you provide professional advice to other health care providers. ^^^^^ ONCE OR ONCE ONCE ONCE YEARLY MONTHLÏ MEEKLY MORE DAILY How often are you involved in disease screening programs (e.g., blood pressure clinics)? NEVER ONCE YEARLY ONCE MONTHLY ONCE WEEKLY ONCE OR MORE DAILY How frequently do you seek the following information from your clients: NEVER a) Drug allergies b) Medical history c) Current drugs d) Smoking status e) Alcohol use f) Level of occupational stress ONCE YEARLY ONCE MONTHLY ONCE WEEKLY ONCE OR MORE DAILY 9. When community health events (such as Poison Prevention Week or a community health fair, for example) occur, how^ often do you participate? Never 1 10. R^ircly 2 Almost Every time < 3 3^21 Gvcrytimc Ofrcrcd S How frequently do you suggest non-drug alternatives for minor ailments (e.g., dietary changes for constipation)? Never 1 11. Once Yearly 2 Once Monthly Once Weekly 3 4 Once or More Daily 5 How frequently do you suggest non-drug adjuncts to drug therapy (e.g., ice packs as an adjimct to ibuprofen for strains and sprain)? Never 1 12. 13. Sometimes Once Yearly Z Once Once Monthly Ueclcly 3 4 Once or More Daily 5 By circling the appropriate column, please rate the following health practices as being very unimportant (VIS), unimportant (U), important (I), or very important (VI), in promoting the health of the average persoru VU U I VI a. Eating breakfast daily 1 2 4 b. Participating in exercise activity three times a week 1 2 c. Having a first aid kit in the home 1 2 3 4 d. Getting 7-8 hours of sleep each night 1 2 3 4 3 3 - 4 Please estimate how often you participate in each of the activities listed below by placing an "X" in the space that best estimates thefrequencyof your participatioiL a. When did you last have your cholesterol checked? Never b. l-Z years 41Z months jSometicnes ^2-4 times/week OnUy How often do you use seatbelts when riding in a car? ^Never d. ^ How often do you participate in exercise activity? fJever c >2 years Sometimes Almost Always Always How often do you watch your: (a) weight? diet? (b) Never ^Sometimes ^Almost Daily ^Daily Never ^Sometimes ^Almost Daily Daily 14. Below is a list of possible barriers to cxpaiidiug pharmacist iuvolveuicnt in health promotion activities. By circling the appropriate column, please indicate tlic extent to which each barrier limits or constrains involvement in your practice. strongly Disagree ^Disagree Not Sure Agree 122 strongly Agree a_ Lack of time I Z 3 4 b. Lack of economic incentives 1 Z 3 4 c. Shortage of pharmacy technicians 1 Z 3 4 d. Lack of appropriate knowledge in those areas 1 Z 3 4 e. Lack of patient demand .1 Z 3 4 f. Professional conflicts with other health care providers 1 2 g. Lack of necessary patient information 1 2 3 4 5 h. Lack of cotmselling skills 2 3 4 5 i. Others? Please comment: •1 GENERAL INFORMATION: Employment status: Part-time (< 32 hrs/wk) FuU-time(>32 hrs/wk) Type of pharmacy in which you spend the majority of your time: Independent Independent chain (e.g.Phannasave, People's Drug Mart) Franchise (e.g.. Shoppers Drug Mart) Corporate Chain (e.g. London Drugs, Safeway, Over-waitea) Employment Position: (a) (b) (c) Staff Manager Owner If you checked off cither option (b) or (c) above, please estimate how many hours per day you spend in administrative, non-dispensary related work (e.g., 6 out of 8 hours)? U n i v e r s i t y of Graduation: Year of Graduation: Sex: ^Male Female Age: Marital Status: ^Married o r e q [ u i v a l e n t Divorced Single From t h e l i s t b e l o w , p l e a s e c h e c k o f f a c a t e g o r y t h a t best d e s c r i b e s t h e c l i e n t e l e p r e d o m i n a t e l y s e r v i c e d by y o u r c u r r e n t p l a c e o f employment. Lower C l a s s (unemployed, s o c i a l a s s i s t a n c e , e t c . ) "Lpwe/- - M i d d l e C l a s s ( b l u e c o l l a r , s i n g l e i n c o m e f a m i l i e s , s e n i o r s on a f i x e d p e n s i o n , e t c . ) M i d d l e C l a s s (white c o l l a r , m i d d l e income f a m i l i e s , s e n i o r s w i t h some p r i v a t e s a v i n g s ) U p p e r - M i d d l e C l a s s ( p r o f e s s i o n a l s , h i g h wage e a r n e r s ) U p p e r C l a s s ( l a n d o w n e r s , . CEO's, i n d e p e n d e n t l y wealthy) S p a c e i s p r o v i d e d b e l o w f o r a n y comments y o u w o u l d l i k e t o m a k e r e g a r d i n g t h e t o p i c s c o v e r e d i n t h e s u r v e y , t h e sur-vey i t s e l f , o r any o t h e r g e n e r a l comments y o u w i s h t o make. We greatly a p p r e c i a t e your t a k i n g the time t o complete t h i s surveyThank you a g a i n f o r y o u r v e r y i m p o r t a n t c o n t r i b u t i o n t o t h i s s t u d y i Comments: Faculty of Pharmaceutical Sciences 2146 East Mall Vancouver, B.C. Canada V6T 1Z3 Tel: (604) 822-3183 Fax: (604) 822-3035 Appendix 2 Cover L e t t e r i n t h e I n i t i a l M a i l i n g o f t h e Q u e s t i o n n a i r e Dear C o l l e a g u e : Almost a l l pharmacists a r ei n v o l v e d i n h e a l t h promotion a c t i v i t i e s to v a r y i n g degrees. You a r e i n v i t e d t o p a r t i c i p a t e i n a n e f f o r t t o determine t h e extent t o which B r i t i s h Columbia pharmacist a r e involved i n h e a l t h promotion a c t i v i t i e s . The s u r v e y s h o u l d t a k e about twenty minutes t o complete. T h i s p r o j e c t i s b e i n g u n d e r t a k e n b y Ms. E l a n P a l u c k a n d D r . T i m o t h y S t r a t t o n from t h e D i v i s i o n o f Pharmacy A d m i n i s t r a t i o n . Your s u r v e y h a s a r a n d o m l y - a s s i g n e d number t h a t w i l l b e u s e d o n l y f o r f o l l o w - u p by Ms. P a l u c k o r D r . S t r a t t o n i f n e c e s s a r y . D a t a w i l l be k e p t l o c k e d i n D r . S t r a t t o n ' s o f f i c e , a n d o n l y Ms. P a l u c k a n d D r . S t r a t t o n w i l l s e e t h e s u r v e y forms, so p l e a s e attempt t o answer t h e q u e s t i o n s as o b j e c t i v e l y as p o s s i b l e . Data w i l l be r e p o r t e d i n summary f o r m o n l y ; y o u r r e s p o n s e s c a n n o t be t r a c e d b a c k t o y o u . A l l r e t u r n e d s u r v e y s w i l l be d e s t r o y e d a f t e r c o m p l e t i o n o f t h i s project. By c o m p l e t i n g t h e s u r v e y , i t i s assumed t h a t y o u g i v e y o u r c o n s e n t to take p a r t i n t h i s p r o j e c t . P a r t i c i p a t i o n i n t h i s study i s v o l u n t a r y ; no i l l w i l l t o w a r d s y o u w i l l be h e l d b y t h e F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s n o r by t h e C o l l e g e o f Pharmacists o f B r i t i s h Columbia i f you choose n o t t o t a k e p a r t . Your a s s i s t a n c e , h o w e v e r , w i l l h e l p u s t o document t h e e x t e n t t o w h i c h p h a r m a c i s t s are i n v o l v e d i n non-dispensing p r o f e s s i o n a l a c t i v i t i e s . We a s k t h a t t h e c o m p l e t e d s u r v e y be r e t u r n e d i n t h e e n c l o s e d envelope by . Reminders w i l l be s e n t o u t a f t e r that date. I f y o u have any q u e s t i o n s o r concerns r e g a r d i n g t h i s p r o j e c t , p l e a s e c o n t a c t D r . S t r a t t o n o r E l a n P a l u c k a t 822-2051. F e e l f r e e t o c a l l c o l l e c t i f d i a l l i n g from o u t s i d e o f t h e Lower Mainland. Thank y o u f o r y o u r support! Sincerely, E l a n P a l u c k , B.S.P. Graduate Student T i m o t h y S t r a t t o n , Ph.D., R.Ph. Assistant Professor Appendix 3 Reminder/Thank-you Card Used i n F i r s t Follow-up Procedure m 5 T)ear Coffeayue, Uwo weeÂs ayo, a survey cuas maifecffoyou reyarxfinyp/iarmacist inuofuemenl in £ealt£promofion. S7fyou Aaue afreacfy returned your coinpfe/e<fsurvey, we woufifIi£e h tAan£youforyourparlicipajion / SJfyou £ave notyet returned your survey, pfease ta£e afern minutes to campfete it now; we are eayerfy awaitiny its return. 3fyou Aave any /questionspfease calf OICs. Ctfan U^afuci or 'X>r. Uimot^y Stratton at tAe Q/jBC C?acufty of T'/iarmaceuticafSciences Ofian^-youforyour lime! at622-2031. Faculty of Pharmaceutical Sciences 2146 East Mall Vancouver, B.C. Canada V6T 1Z3 Tel: (604) 822-3183 Fax: (604) 822-3035 Appendix 4 Cover L e t t e r Used i n Second Follow-up Procedure Dear C o l l e a g u e : A b o u t a month ago, we m a i l e d t o y o u r w o r k a d d r e s s an i n v i t a t i o n t o take p a r t i n a p r o j e c t t o determine the extent t h a t B r i t i s h Columbia community p h a r m a c i s t s p a r t i c i p a t e i n h e a l t h p r o m o t i o n activities. The p r o j e c t i s b e i n g u n d e r t a k e n by p h a r m a c i s t s E l a n P a l u c k , a g r a d u a t e s t u d e n t i n P h a r m a c y A d m i n i s t r a t i o n , and D r . T i m Stratton, a faculty member in the Division of Pharmacy Administration. T h i s t y p e o f p r o j e c t has never been u n d e r t a k e n w i t h C a n a d i a n p h a r m a c i s t s b e f o r e , so y o u r a s s i s t a n c e i s v e r y important indeed. P o s s i b l y you d i d not r e c e i v e our f i r s t m a i l i n g . I f t h i s i s the c a s e , we h a v e i n c l u d e d a s e c o n d s u r v e y f o r y o u r u s e . I f you have a l r e a d y r e c e i v e d a s u r v e y , we u r g e y o u t o c o m p l e t e i t a s s o o n a s p o s s i b l e ; i t s h o u l d t a k e no more t h a n t w e n t y m i n u t e s o f y o u r t i m e . P l e a s e m a i l t h e c o m p l e t e d s u r v e y t o us i n t h e r e t u r n e n v e l o p e provided. As m e n t i o n e d a b o v e , y o u w i l l be h e l p i n g t o b r e a k new g r o u n d f o r pharmacy w i t h t h i s p r o j e c t . Pharmacy g r o u p s w h i c h a t t e m p t e d t o d o c u m e n t t h e v a l u e o f t h e p h a r m a c i s t i n t h e i r s u b m i s s i o n s t o B.C.'s R o y a l C o m m i s s i o n on H e a l t h C a r e and C o s t s many t i m e s l a c k e d t h e h a r d n u m b e r s on p h a r m a c i s t a c t i v i t i e s t h a t t h e Commissioners requested. T h i s s t u d y r e p r e s e n t s an i m p o r t a n t o p p o r t u n i t y t o c o l l e c t some o f t h i s v e r y i m p o r t a n t d a t a f o r f u t u r e u s e by o u r profession. Again, your response i s very important t o us and to your profession. P l e a s e t a k e t h e t i m e t o c o m p l e t e t h e s u r v e y and m a i l i t back t o us. Your c o n s i d e r a t i o n of our r e q u e s t i s g r e a t l y appreciated! I f y o u h a v e any q u e s t i o n s , p l e a s e c o n t a c t e i t h e r o f us a t 8 2 2 - 2 0 5 1 . C a l l c o l l e c t i f d i a l l i n g f r o m o u t s i d e o f t h e L o w e r Mainland. Sincerely, E l a n P a l u c k , B.S.P. Graduate student T i m o t h y P. S t r a t t o n , Ph.D., Assistant Professor R.Ph. Appendix Telephone H e l l o , may 5 D i a l o g u e Used i n t h e T h i r d F o l l o w - u p Procedure I p l e a s e speak w i t h . [ I f p e r s o n i s n o t i n , a s k when t h e y a r e e x p e c t e d back.] H i Mr./Ms./Mrs. . How a r e y o u ? My name i s and I am a s t u d e n t i n t h e F a c u l t y o f P h a r m a c e u t i c a l S c i e n c e s a t UBC. I a p o l o g i z e f o r c o n t a c t i n g y o u a t home/work, b u t I am w o r k i n g on Dr. S t r a t t o n ' s and E l a n P a l u c k ' s s t u d y o f community p h a r m a c i s t involvement i n h e a l t h promotion. C u r r e n t l y , we a r e a t t e m p t i n g t o b e g i n t h e d a t a a n a l y s i s f o r t h i s p r o j e c t , b u t due t o t h e s t r i k e on campus, we a r e e x p e r i e n c i n g a few s e t b a c k s . Campus m a i l d e l i v e r y i s e x t r e m e l y b a c k l o g g e d , s o we a r e u n s u r e a s t o w h e t h e r y o u r q u e s t i o n n a i r e i s s i t t i n g somewhere i n a p i l e o f u n d e l i v e r e d m a i l o r n o t . I was w o n d e r i n g i f y o u c o u l d t e l l me i f y o u h a v e m a i l e d i n your completed q u e s t i o n n a i r e yet? I F RESPONSE I S "YES": When e x a c t l y was i t m a i l e d ? (make n o t e o f i t ) . Great! At l e a s t know t h a t t h e q u e s t i o n n a i r e i s on i t s way, and t h a t i t w i l l j u s t be a m a t t e r o f t i m e b e f o r e t h e b a c k l o g o f m a i l on campus b e g i n s f l o w i n g a g a i n a n d we r e c e i v e i t . Thanks a g a i n f o r y o u r t i m e and p a r t i c i p a t i o n ! Bye f o r now. I F RESPONSE I S we "NO"; May I a s k y o u i f t h e r e i s a s p e c i f i c r e a s o n why to participate? "Lost survey": you have chosen not C o u l d I m a i l you out a n o t h e r copy o f t h e questionnaire"? (confirm t h e i r address) "Never R e c e i v e d i t " : C o n f i r m t h e i r a d d r e s s and t h e n ask i f y o u c o u l d m a i l them o u t a n o t h e r c o p y o f the questionnaire. "Don't Have T i m e " o r "Don't Want T o " : The q u e s t i o n n a i r e d o e s l o o k l o n g , b u t i t s h o u l d o n l y t a k e a b o u t 15 t o 2 0 m i n u t e s t o complete. This i s a graduate student's t h e s i s , so y o u r p a r t i c i p a t i o n and s u p p o r t f o r t h e p r o j e c t w o u l d be g r e a t l y appreciated. CLOSING: W e l l , t h a n k s a g a i n f o r your time. Bye f o r now.
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Involvement of British Columbia community pharmacists in health promotion Paluck, Elan Carla Marie 1992
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Title | Involvement of British Columbia community pharmacists in health promotion |
Creator |
Paluck, Elan Carla Marie |
Date Issued | 1992 |
Description | Community pharmacists are faced with many opportunities to participate in health promotion. The purpose of this study was to determine the extent to which community pharmacists in British Columbia are involved in health promotion activities, and which external factors, if any, affect this level of involvement. A causal model was developed which proposed that independent pharmacist and practice variables would influence pharmacists' involvement in health promotion activities. A five- page mail questionnaire was distributed to a systematic stratified sample of 625 practising community pharmacists in British Columbia. A five-point Likert-type scale was used to examine the frequencies of pharmacist involvement in 33 different health promotion activities. Three different follow-up procedures were used to attain a final response rate of 83.6%. Results of the study show that pharmacists most frequently participate in activities that are related directly to the dispensing or selling of medications. These events include advising clients on over-the-counter medications, querying clients on possible allergies, obtaining medical histories, querying clients on current medications, and suggesting non-drug alternatives to drug therapy for minor ailments. The activities that displayed the lowest participation amongst pharmacists included speaking to community groups on health related matters, participating in disease screening programs, querying clients on their level of occupational stress, counselling clients on AIDS prevention, and querying clients on their smoking status. Variables that were found to influence a pharmacist's level of participation in health promotion were a pharmacist's employment status (full-time or part-time), marital status, type of practice, geographic location of the practice, pharmacist's personal health beliefs and behaviours, and the socioeconomic status of the clientele predominantly served. |
Extent | 4799843 bytes |
Genre |
Thesis/Dissertation |
Type |
Text |
File Format | application/pdf |
Language | eng |
Date Available | 2009-01-09 |
Provider | Vancouver : University of British Columbia Library |
Rights | For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use. |
DOI | 10.14288/1.0086902 |
URI | http://hdl.handle.net/2429/3476 |
Degree |
Master of Science - MSc |
Program |
Pharmaceutical Sciences |
Affiliation |
Pharmaceutical Sciences, Faculty of |
Degree Grantor | University of British Columbia |
Graduation Date | 1992-11 |
Campus |
UBCV |
Scholarly Level | Graduate |
Aggregated Source Repository | DSpace |
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