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Involvement of British Columbia community pharmacists in health promotion Paluck, Elan Carla Marie 1992

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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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V e r s i o n number 4.0. S t a c h i w PM. They t r u s t us, b u t . . . Journal. 1 9 8 9 ( M a y ) ; 1 2 2 : 261-62.  Social  Sciences  Canadian  (Personal  Pharmaceutical  S t r a t t o n TP. L o n g - t e r m i m p a c t o f t h e B r i t i s h C o l u m b i a Brown Bag C l i n i c s on c l i e n t a w a r e n e s s o f t h e p h a r m a c i s t a s a p r o v i d e r o f c o n s u m e r d r u g and h e a l t h i n f o r m a t i o n . J o u r n a l o f P h a r m a c e u t i c a l M a r k e t i n g and Management. 1993; ( S p r i n g ) ; 7 ( 3 ) : I n p r e s s . S t r a t t o n TP and S t e w a r t EE. The r o l e o f t h e c o m m u n i t y p h a r m a c i s t i n p r o v i d i n g d r u g and h e a l t h i n f o r m a t i o n : A p i l o t s u r v e y among t h e p u b l i c , p h y s i c i a n s and p h a r m a c i s t s . Journal of Pharmaceutical M a r k e t i n g and Management. 1991;5(4): 3-26. U p j o h n Company o f C a n a d a . C a n a d i a n P h a r m a c y S e r v i c e s S t u d y P a t i e n t C o u n s e l l i n g : A S u r v e y Among Community P h a r m a c i s t s .  1990.  V a n d e l JH. A b o a r d member's v i e w p o i n t s on t h e t e c h n i c i a n i s s u e . I n : T e c h n i c a l P e r s o n n e l i n Pharmacy: D i r e c t i o n s f o r t h e P r o f e s s i o n i n S o c i e t y . P r o c e e d i n g s o f an i n v i t a t i o n a l c o n f e r e n c e c o n d u c t e d by t h e U n i v e r s i t y o f M a r y l a n d C e n t r e on D r u g s and P u b l i c P o l i c y , O c t o b e r 29 t o November 1, 1988. American J o u r n a l of H o s p i t a l Pharmacy. 1989;46:545-547. W a l p o l e RE. E l e m e n t a r y S t a t i s t i c a l C o n c e p t s . P u b l i s h i n g Company L t d . , 1983.  New  York:  MacMillan  W a t k i n s RL a n d Norwood G J . P h a r m a c i s t d r u g c o n s u l t a t i o n b e h a v i o u r . S o c i a l S c i e n c e and M e d i c i n e . 1978;12:235-239. W e c h s l e r H, L e v i n e S, I d e l s o n R, Rohman M a n d T a y l o r JO. physician's r o l e i n h e a l t h promotion- a survey of primary practitioners. New E n g l a n d J o u r n a l o f M e d i c i n e . 1 9 8 3 ; 308(2):97-100.  The care  Whalen F J . S u p p o r t i v e p e r s o n n e l a n d t r a i n i n g management, i n : McLeod DC, M i l l e r WA, e d s . The P r a c t i c e o f P h a r m a c y . Cincinnati, Ohio. Harvey Whitney Books;1981:338-51. Wilson R. Physician.  H e a l t h p r o m o t i o n : Whose j o b i s i t ? 1 9 9 2 ; 3 8 ( F e b ) : 336-339.  Canadian  Family  Wyshak G, Lamb GA, L a w r e n c e RS a n d C u r r a n WJ. A profile of the h e a l t h - p r o m o t i n g b e h a v i o u r s o f p h y s i c i a n s a n d l a w y e r s . New E n g l a n d Journal of Medicine. 1 9 8 0 ; 3 0 3 ( 2 ) : 104-107. Z e l n i o RN, N e l s o n AA J r . , a n d Beno CE. 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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