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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 University of Saskatchewan, 1988 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES FACULTY OF PHARMACEUTICAL SCIENCES DIVISION OF PHARMACY ADMINISTRATION We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October, 1992 © Elan Carla Marie Paluck, 1992 In present ing this thesis in partial fulf i lment of the requ i rements for an advanced deg ree at the University of British C o l u m b i a , 1 agree that the Library shall make it freely available for re ference and study. I further agree that permiss ion for extensive c o p y i n g of this thesis for scholar ly pu rposes may be granted by the head of my depar tment or by his or her representat ives. It is u n d e r s t o o d that c o p y i n g or publ icat ion of this thesis for financial gain shall not be a l lowed without my written permiss ion . Depar tment of Pharmaceutical Sciences T h e University of British C o l u m b i a Vancouve r , C a n a d a Date October 15, 1992 DE-6 (2/88) ABSTRACT 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 p r o m o t i o n . The purpose o f t h i s s t u d y was t o d e t e r m i n e t h e e x t e n t t o which community p h a r m a c i s t s i n B r i t i s h C olumbia a r e 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 a c t i v i t i e s , and w h i c h e x t e r n a l f a c t o r s , i f any, a f f e c t t h i s l e v e l o f i n v o l v e m e n t . A c a u s a l model was d e v e l o p e d w h i c h p r o p o s e d t h a t 11 i n d e p e n d e n t p h a r m a c i s t and p r a c t i c e v a r i a b l e s would i n f l u e n c e 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 a c t i v i t i e s . A f i v e -page m a i l q u e s t i o n n a i r e was d i s t r i b u t e d t o a s y s t e m a t i c s t r a t i f i e d sample o f 625 p r a c t i s i n g community p h a r m a c i s t s i n B r i t i s h C o lumbia. 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 u sed t o examine t h e f r e q u e n c i e s 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 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 . T hree d i f f e r e n t f o l l o w - u p p r o c e d u r e s were used t o a t t a i n a f i n a l r e s p o n s e r a t e o f 83.6%. R e s u l t s o f t h e s t u d y show t h a t p h a r m a c i s t s most f r e q u e n t l y p a r t i c i p a t e i n a c t i v i t i e s t h a t a r e r e l a t e d d i r e c t l y 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 . These e v e n t s i n c l u d e a d v i s i n g c l i e n t s 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 p o s s i b l e a l l e r g i e s , o b t a i n i n g m e d i c a l h i s t o r i e s , q u e r y i n g c l i e n t s on c u r r e n t m e d i c a t i o n s , and s u g g e s t i n g non-drug a l t e r n a t i v e s t o d r u g t h e r a p y f o r minor a i l m e n t s . The a c t i v i t i e s t h a t d i s p l a y e d t h e l o w e s t p a r t i c i p a t i o n amongst 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 community groups on h e a l t h r e l a t e d m a t t e r s , p a r t i c i p a t i n g i n d i s e a s e s c r e e n i n g programs, 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 , c o u n s e l l i n g c l i e n t s on AIDS p r e v e n t i o n , and q u e r y i n g c l i e n t s on t h e i r smoking s t a t u s . V a r i a b l e s t h a t were found t o i n f l u e n c e a p h a r m a c i s t ' s l e v e l o f 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 were a p h a r m a c i s t ' 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 p r a c t i c e , g e o g r a p h i c l o c a t i o n o f t h e p r a c t i c e , 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 b e h a v i o u r s , and 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 p r e d o m i n a n t l y s e r v e d . ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES X DEFINITION OF TERMS x i ACKNOWLEDGEMENT XV 1. INTRODUCTION 1 H e a l t h P r o m o t i o n i n Canada 1 Why t h e P h a r m a c i s t as a Community H e a l t h Promoter?... 3 P h a r m a c i s t s ' A b i l i t y t o P e r f o r m i n t h e R o l e o f Community H e a l t h A d v i s o r 6 Statement o f Problem 8 Purpose and O b j e c t i v e s 9 Importance o f Study 11 2. 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 H e a l t h P r o m o t i o n 12 D e v e l o p i n g t h e P h a r m a c i s t ' s R o l e i n H e a l t h P r o m o t i o n 16 P r a c t i c e V a r i a b l e s 17 i ) Employment p o s i t i o n 18 i i ) P l a c e o f employment 19 i i i ) S o cioeconomic s t a t u s o f c l i e n t e l e 20 i v ) G e o g r a p h i c l o c a t i o n 2 0 v) B a r r i e r s 21 P e r s o n a l V a r i a b l e s 23 i ) P h a r m a c i s t sex 23 i i ) P h a r m a c i s t m a r i t a l s t a t u s 24 i i i ) P h a r m a c i s t age 24 i 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 b e l i e f s 25 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 b e h a v i o u r s 2 6 Page E d u c a t i o n a l V a r i a b l e s 29 i ) 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 29 i i ) Year o f g r a d u a t i o n 3 0 Development o f a C a u s a l Model 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 31 3. METHODOLOGY 3 6 Q u e s t i o n n a i r e Development 36 Sample S e l e c t i o n 41 F o l l o w - u p P r o c e d u r e s 44 S c o r i n g Schemes f o r Survey 44 S t a t i s t i c a l A n a l y s e s Undertaken 4 6 Study L i m i t a t i o n s 47 4. RESULTS 48 Response Rate 48 Sample D e s c r i p t i o n 51 Nonresponse B i a s 57 Survey R e s u l t s 59 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 59 V a r i a b l e s i n f l u e n c 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 a c t i v i t i e s 66 P r a c t i c e V a r i a b l e s 66 i ) Type o f p r a c t i c e 66 i i ) G e o g r a p h i c l o c a t i o n o f p r a c t i c e 69 i i i ) Employment p o s i t i o n 71 i v ) Socioeconomic s t a t u s o f c l i e n t e l e 74 v) B a r r i e r s 74 P e r s o n a l v a r i a b l e s 77 i ) P h a r m a c i s t sex 77 i i ) P h a r m a c i s t m a r i t a l s t a t u s 78 i i i ) P h a r m a c i s t p e r s o n a l h e a l t h b e l i e f s 79 Page i v ) P h a r m a c i s t age 81 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 b e h a v i o u r s 81 E d u c a t i o n a l v a r i a b l e s 82 i ) Year o f g r a d u a t i o n 82 i i ) 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 82 5. DISCUSSION AND CONCLUSIONS 84 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 84 V a r i a b l e s I n f l u e n c 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 . . . . 93 6. SUMMARY AND RECOMMENDATIONS 104 Summary 104 A r e a s f o r F u r t h e r R e s e a r c h 106 REFERENCES 110 APPENDIX 1: SURVEY INSTRUMENT 117 APPENDIX 2: COVER LETTER USED IN THE I N I T I A L MAILING OF THE QUESTIONNAIRE 124 APPENDIX 3: REMINDER/THANK-YOU CARD USED IN FIRST FOLLOW-UP PROCEDURE 125 APPENDIX 4: COVER LETTER USED IN SECOND FOLLOW-UP PROCEDURE 126 APPENDIX 5: TELEPHONE DIALOGUE USED IN THE THIRD FOLLOW-UP PROCEDURE 127 r LIST OF TABLES 1. Summary o f t h e Re 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 on Community P h a r m a c i s t Involvement i n H e a l t h P r o m o t i o n 22 2. Summary o f t h e Re 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 on 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 P r o m o t i o n A c t i v i t i e s 28 3. Summary o f t h e Re 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 on Community P h a r m a c i s t Involvement 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 31 4. O p e r a t i o n a l Hypotheses S u r r o u n d i n g P h a r m a c i s t Involvement 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 34 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 P h a r m a c i s t Sex 38 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 P h a r m a c i s t G e o g r a p h i c L o c a t i o n 38 7. 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 G e o g r a p h i c L o c a t i o n 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 52 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 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 53 10. 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 G e o g r a p h i c L o c a t i o n 53 11. 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 12. 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 o f G r a d u a t i o n 54 13. 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 Age 55 14. Employment P o s i t i o n 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 55 15. Employment 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 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 56 17. Non-responding P h a r m a c i s t s A c c o r d i n g t o Sex 58 18. Non-responding Sample A c c o r d i n g t o C o l l e g e D i s t r i c t 58 19. Non-respondent Sample A c c o r d i n g t o P r a c t i c e Type 59 20. P h a r m a c i s t Median H e a l t h P r o m o t i o n S c o r e s 60 21. P h a r m a c i s t 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 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 62 22. 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 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 64 23. 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 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 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 Columbia 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 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 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 P r o m o t i o n A c t i v i t i e s A c c o r d i n g t o G e o g r a p h i c L o c a t i o n s o f B r i t i s h Columbia Community P h a r m a c i s t P r a c t i c e s 70 27. D i f f e r e n c e s i n D a i l y Time Spent 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 Columbia 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 L i s t of Tables—continued 28. 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 Columbia 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 29. 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 by B r i t i s h Columbia Community P h a r m a c i s t E s t i m a t i o n o f C l i e n t S o cioeconomic S t a t u s 75 30. B r i t i s h Columbia 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 t o Expanding T h e i r Involvement 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 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 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 n B r i t i s h Columbia 78 32. 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 n f l u e n c e d by B r i t i s h Columbia Community P h a r m a c i s t M a r i t a l S t a t u s 80 33. 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 n f l u e n c e d by B r i t i s h Columbia Community P h a r m a c i s t 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 s 83 34. Summary R e s u l t s o f O p e r a t i o n a l Hypotheses S u r r o u n d i n g P h a r m a c i s t O v e r a l l Involvement 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 86 35. A Comparison o f American V e r s u s B r i t i s h Columbian Community P h a r m a c i s t Involvement 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 90 36. A Comparison o f 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 "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 I n t e r v a l s 92 37. 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 Columbia Community P h a r m a c i s t O v e r a l l Involvement i n H e a l t h P r o m o t i o n . . . 94 LIST OF FIGURES Page F i g u r e 1: C a u s a l Model o f 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 A c t i v i t i e s .... 33 F i g u r e 2: 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 P h a r m a c i s t s o f B r i t i s h Columbia D i s t r i c t s 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 41 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: M a r g i n a l E f f i c a c y o f F o l l o w - u p P r o c e d u r e s 50 F i g u r e 6: Amended C a u s a l Model D e p i c t i n g Community P h a r m a c i s t Involvement 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 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 H e a l t h P r o m o t i o n : I n t h i s s t u d y , f a c t o r s which l i m i t t h e f r e q u e n c y o f 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 a r e r e f e r r e d t o as b a r r i e r s t o 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 . B a r r i e r s examined i n t h i s s t u d y i n c l u d e a l a c k o f t i m e , l a c k o f 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 knowledge 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 w i t h o t h e r h e a l t h c a r e p r o v i d e r s . C o l l e g e D i s t r i c t s : F o r t h e purpose 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 t h r o u g h 9 a r e o f i n t e r e s t i n t h i s s t u d y , as D i s t r i c t 10 r e p r e s e n t s h o s p i t a l 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). D i s t r i c t 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 R e g i o n a l D i s t r i c t . D i s t r i c t 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 Cowichan V a l l e y , Nanaimo, A l b e r n i - C l a y o q u o t , Comox-S t r a t h c o n a , Mount Waddington, C e n t r a l C o a s t (Ocean F a l l s ) . D i s t r i c t 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 White Rock, 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 o f t h e D i s t r i c t o f D e l t a , e a s t o f t h e 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 . D i s t r i c t 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 o f 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 Columbia-Shuswap 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 Kootenay, C e n t r a l Kootenay, Kootenay Boundary and 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 Columbia-Shuswap, t h e town o f Golden. D i s t r i c t 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 town o f 100 M i l e House. 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 Vancouver, and U n i v e r s i t y Endowment Lands. 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 o f D e l t a , west o f 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 C o a s t , S q u a m i s h - L i l l o o e t ( e x c e p t t h e town o f L i l l o o e t ) , t h e C i t y o f N o r t h Vancouver, 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 Vancouver, West Vancouver, and Bowen I s l a n d . Community P h a r m a c i s t : 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 pharmacy w i t h i n a r e t a i l , community s e t t i n g (as 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 based on p h a r m a c i s t s ' h o u r l y work week. F u l l - t i m e employment denotes a work week o f 22 o r more h o u r s . P a r t - t i m e employment i s a work week o f l e s s t h a n 22 h o u r s . H e a l t h P r o m o t i o n : "...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 scope of 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 c r e a t e ] e nvironments c o n d u c i v e t o h e a l t h i n w h i c h 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) . I n t e r v e n i n g V a r i a b l e : "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 i n dependent v a r i a b l e t o a dependent v a r i a b l e . An i n t e r v e n i n g 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 independent v a r i a b l e i n f l u e n c e s t h e dependent v a r i a b l e " ( J a c k s o n , 1988, p . 11.). P e r s o n a l H e a l t h B e h a v i o u r : 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 p e r s o n r e g a r d l e s s o f h i s o r h e r p e r c e i v e d h e a l t h s t a t u s , i n o r d e r t o p r o t e c t , promote, o r m a i n t a i n h i s o r h e r h e a l t h , whether o r n o t such b e h a v i o u r 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 Guten, 1979). P e r s o n a l H e a l t h B e l i e f s : " . . . b e l i e f s about t h e 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 h e a l t h c o n d i t i o n s and about t h e e f f i c a c y o f a c t i o n s t o ward o f f h e a l t h t h r e a t s " ( K i r s c h t , 1974, p.457). P r a c t i c e Type: I n t h i s s t u d y , p r a c t i c e t y p e r e f e r s t o f o u r c a t e g o r i e s o f 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 t h e t i m e o f t h i s s u r v e y ; 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 Shoppers Drug 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 (such as London D r u g s ) . P r a c t i c e V a r i a b l e s : I n t h i s s t u d y , " p r a c t i c e v a r i a b l e s " r e f e r s t o c h a r a c t e r i s t i c s o f 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 p r o m o t i o n 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 o f i n t e r e s t i n t h i s s t u d y 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 ( i n d e p e n d e n t , independent c h a i n , f r a n c h i s e , o r c o r p o r a t e c h a i n ) , g e o g r a p h i c l o c a t i o n o f t h e pharmacy ( C o l l e g e o f P h a r m a c i s t s of B r i t i s h Columbia d i s t r i c t s 1 t o 9) , and 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 p r e d o m i n a t e l y s e r v e d ( l o w e r c l a s s t o upper c l a s s ) . S o c ioeconomic S t a t u s : 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 d e s c r i p t i o n s : "Lower c l a s s " was d e f i n e d as unemployed 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 ; "Lower-middle c l a s s " was d e f i n e d as 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 as i n c l u d i n g w h i t e c o l l a r w o r k e r s , m i d d l e income 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 ; "Upper-middle 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 and h i g h wage e a r n e r s ; 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 as b e i n g landowners, c h i e f e x e c u t i v e o f f i c e r s , o r i n d e p e n d e n t l y w e a l t h y . ACKNOWLEDGEMENT T h i s r e s e a r c h was s u p p o r t e d by t h e B r i t i s h Columbia H e a l t h R e s e a r c h F o u n d a t i o n and t h e B r i t i s h Columbia Pharmacy A s s o c i a t i o n . CHAPTER 1 INTRODUCTION H e a l t h P r o m o t i o n i n Canada I n t e r e s t i n h e a l t h p r o m o t i o n i n Canada and around t h e w o r l d has f l o u r i s h e d r a p i d l y . 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 i n n o v a t i v e r e p o r t s such a s , A New P e r s p e c t i v e on t h e H e a l t h o f Canadians ( L a l o n d e , 1974) and t h e Ottawa C h a r t e r f o r H e a l t h P r o m o t i o n (1986). Epp's 1986 paper, A Framework f o r H e a l t h P r o m o t i o n , d e f i n e d n a t i o n a l c h a l l e n g e s f o r h e a l t h p r o m o t i o n , and pro p o s e d mechanisms and s t r a t e g i e s t o meet t h e s e c h a l l e n g e s . R e c u r r i n g 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 h e a l t h s e r v i c e s , f o s t e r g r e a t e r p u b l i c 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 , and t o r e o r i e n t h e a l t h s e r v i c e s by m o d i f y i n g t h e o r g a n i z a t i o n , e d u c a t i o n , t r a i n i n g and a t t i t u d e s o f h e a l t h c a r e p r o v i d e r s . 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 , team approach 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 be n e c e s s a r y . P h y s i c i a n s have l i t t l e t i m e and l i t t l e economic 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 ( W i l s o n , 1992). A l t h o u g h p h y s i c i a n s t h i n k o f l i f e s t y l e f a c t o r s as b e i n g i m p o r t a n t i n p r o m o t i n g h e a l t h , t h e y a r e n o t as p r e p a r e d t o c o u n s e l p a t i e n t s about them and l a c k t h e c o n f i d e n c e i n t h e i r a b i l i t y t o e f f e c t i v e l y promote change i n t h e i r p a t i e n t s (Weschler, 1983; L e w i s e t a l . , 1991; W i l s o n , 1992). Even i f p h y s i c i a n s were w i l l i n g and a b l e t o spend t i m e c o u n s e l l i n g p a t i e n t s on h e a l t h p r o m o t i n g measures, p h y s i c i a n s would n o t r e p r e s e n t a c o s t - e f f e c t i v e c h o i c e as l e s s e x p e n s i v e p r o v i d e r s w i t h i n t h e community a l r e a d y e x i s t who can d e l i v e r t h e s e s e r v i c e s . (B.C. R o y a l Commission, 1991) Community p h a r m a c i s t s a r e one community-based a l t e r n a t i v e t h a t can p r o v i d e h e a l t h p r o m o t i o n s e r v i c e s . S t u d i e s s u g g e s t t h a t community p h a r m a c i s t s a r e open and w i l l i n g t o expand t h e i r community h e a l t h r o l e (Smith and G i b s o n , 1975). L i n n and D a v i s (1971) f o u n d t h a t a d v i s i n g and d i s c u s s i n g h e a l t h problems w i t h p a t r o n s was t h e second most t i m e consuming a c t i v i t y o f community p h a r m a c i s t s . Next t o d i s p e n s i n g p r e s c r i p t i o n o r d e r s , p h a r m a c i s t s 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 second most p r e f e r r e d a c t i v i t y . Why the Pharmacist as a Community Health 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 and a c c e s s i b l e t o t h e p u b l i c (Smith and G i b s o n , 1975). I n most communities, t h e community pharmacy i s t h e most f r e q u e n t l y v i s i t e d h e a l t h c a r e c e n t r e (Nathan, 1989; Coons, 1990). C o u p l e d w i t h t h i s a c c e s s i b i l i t y i s t h e e s t i m a t e t h a t s i x o u t o f e v e r y 10 p a t i e n t s a l r e a d y r e c e i v e c o u n s e l l i n g from t h e i r p h a r m a c i s t (Upjohn, 1990; Meade, 1992) which 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 h e a l t h p r o m o t i o n q u i t e l a r g e . 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 can be e f f i c i e n t and c o s t - e f f e c t i v e f o r government (Coons, 1990; Laucka and Hoffman, 1992), and advantageous, b o t h f i n a n c i a l l y and p r o f e s s i o n a l l y , f o r t h e p h a r m a c i s t ( P o i r i e r , 1992). The p u b l i c w i l l 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 p r o m o t i o n s e r v i c e s i n t h e i r l o c a l 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 b o t h p a t i e n t outcome and t h e m e d i c a l c a r e system. F o r example. Smith (1974) examined 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 by 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 c a s e s , p o s i t i v e r e s u l t s were d e t e c t e d . I n o n e - q u a r t e r o f t h e s e c a s e s , p h a r m a c i s t s h e l p e d p a t i e n t s a v o i d , m i n i m i z e o r reduce t h e use o f p o t e n t i a l l y h a r m f u l o r unn e c e s s a r y p r o c e d u r e s , t e s t s , o r s u r g e r y . Deady e t a l . ( 1 9 9 1 ) , examined community p h a r m a c i s t s ' impact on t h e h e a l t h c a r e system i n a s t u d y o f p h y s i c i a n s ' a c c e p t a n c e o f d r u g t h e r a p y recommendations by p h a r m a c i s t s . T h i r t y - n i n e p a t i e n t s were seen by a p h a r m a c i s t d u r i n g 49 c l i n i c v i s i t s ; 3 6 recommendations were made t o change t h e r a p y . 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 i n 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 . B o t h t h e s t u d y by Deady e t a l . and by Smith demonstrate p h a r m a c i s t s ' a b i l i t y t o improve p a t i e n t outcomes. T h i s can 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 c a r e system, as t h e c o s t s o f u n n e c e s s a r y 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 l i k e l y a v o i d e d . Ample 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 p r o m o t i o n 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 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 s u c h a c t i v i t i e s i s unknown. C u r r e n t l y , community p h a r m a c i s t s a r e t h o u g h t t o be i n v o l v e d i n c o u n s e l l i n g a c t i v i t i e s r e l a t e d d i r e c t l y t o t h e d i s t r i b u t i o n and use o f m e d i c a t i o n s ( B e a r d s l e y , 1 9 8 3 ) , but 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 . W i t h t h e p u b l i c ' s i n c r e a s i n g i n t e r e s t i n s e l f c a r e ( K i c k b u s c h , 1989) and t h e emergence o f d i r e c t b i l l i n g amongst some o f B r i t i s h Columbia d o c t o r s (Anon, 1992), an o p p o r t u n i t y e x i s t s f o r community p h a r m a c i s t s t o expand 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 i n c r e a s e d demand and e x p e c t a t i o n s . E x panding 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 prove t o be a d i f f i c u l t t a s k . Smith and G i b s o n (1975) p o i n t t o f o u r m ajor b a r r i e r s t o i n c r e a s i n g 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 a t i v e m e d i c i n e i n t h e U n i t e d S t a t e s : 1) The p u b l i c ' s u n w i l l i n g n e s s t o pay f o r a d v i c e ; 2) The l e g a l b a r r i e r s w h i c h r e s t r i c t a 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 b e i n g c h a r g e d w i t h p r a c t i s i n g m e d i c i n e w i t h o u t a l i c e n s e ) ; 3) The l a c k o f f i n a n c i a l r eimbursement f o r p h a r m a c i s t s ( i . e . , a l a c k o f government r e c o g n i t i o n f o r s e r v i c e s ; and 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 t h e p h a r m a c i s t as a h e a l t h a d v i s o r . Many o f t h e s e b a r r i e r s a r i s e from what has 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 i n t h e p h a r m a c i s t s ' p r o f e s s i o n a l image p e r c e i v e d by t h e p u b l i c ( D e n z i n , 1968; Shaw, 1972). Shaw n o t e s t h a t because pharmacy i s one o f t h e most h i g h l y r e g u l a t e d p r o f e s s i o n s , f u l l p r o f e s s i o n a l evolvement i s im p i n g e d upon; 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". Shaw c o n c l u d e s , t h e r e f o r e , t h a t a p r o f e s s i o n a l r e l a t i o n s h i p w i t h s o c i e t y can e x i s t i n a pharmacy t o d a y o n l y i f t h e r a p p o r t 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 i n c r e a s e d t h r o u g h t h e enactment o f laws contemporary w i t h c u r r e n t e d u c a t i o n a l s t a n d a r d s o f t h e p h a r m a c i s t . P h a r m a c i s t s ' A b i l i t y t o P e r f o r m i n t h e R o l e o f Community H e a l t h A d v i s o r D e s p i t e an abundance o f l i t e r a t u r e documenting t h e b e n e f i c i a l i mpact on t h e h e a l t h c a r e system from 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 p a t i e n t c o u n s e l l i n g a c t i v i t i e s , a d d i t i o n a l e v i d e n c e i n t h e 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 p r e p a r e d t o assume t h i s expanded r o l e i n h e a l t h p r o m o t i o n . For example, Knapp e t a l . (1969), found t h a t 83% o f p h a r m a c i s t s s o l d 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 d i a b e t i c . A r e c e n t s t u d y o f 104 community pharmacies i n M o n t r e a l demonstrated t h a t o v e r o n e - h a l f o f t h e p h a r m a c i s t s p e r f o r m e d ' p o o r l y ' (41%) o r ' f a i r ' (16%) i n an assessment of p h a r m a c i s t s ' knowledge r e g a r d i n g head l i c e t r e a t m e n t (Nguyen, 1992). A B r i t i s h s t u d y m e a s u r i n g t h e q u a l i t y o f c a r e i n community pharmacies found t h a t p h a r m a c i s t s p e r f o r m e d 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 ( S m i t h e t a l . , 1990). I n t h i s s t u d y , n o t o n l y was 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 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 low, 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% were r a t e d as ' s a t i s f a c t o r y ' by t h e j u d g e s . The s t u d y ' s a u t h o r s c o n c l u d e w i t h a p l e a t o i n c o r p o r a t e h e a l t h p r o m o t i o n and d i s e a s e p r e v e n t i o n as a f o r m a l p a r t o f p h a r m a c i s t s ' e d u c a t i o n so t h a t t h e y may be a b l e t o r e c o g n i z e and d i s c u s s i s s u e s such as l i f e s t y l e , smoking and d i e t w i t h c l i e n t s when g i v i n g a d v i c e . B u r t o n and McKay (1990) s u r v e y e d 550 community p h a r m a c i s t s i n M a r y l a n d (n=139, r e s p o n s e r a t e = 3 8 % ) , and found t h a t o n l y 16 (12%) 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. A l t h o u g h p h a r m a c i s t s had been approached 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 , t h e y 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 59 (42%) o f t h e r e s p o n d e n t pharmacies s t o c k e d z i d o v u d i n e , a d r u g used i n t h e t r e a t m e n t o f AIDS. Of t h e 86% o f p h a r m a c i s t s t h a t had ne 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 l a c k e d c o n f i d e n c e i n t h e i r c o u n s e l l i n g a b i l i t y i n t h i s a r e a . Academic p r e p a r e d n e s s i s not t h e o n l y c o n c e r n i n ex p a n d i n g 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 . E t h i c a l 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 p r o f e s s i o n a l / b u s i n e s s p e r s o n " image p l a y an i n t e g r a l r o l e i n community p h a r m a c i s t s ' c u r r e n t r o l e i n h e a l t h p r o m o t i o n . Brown and D i F r a n z a (1992) s u r v e y e d 100 community pharmacies i n M a s s a c h u s e t t s . N i n e t y - f i v e 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 , and 23 d i s p l a y e d t h e Camel c a r t o o n a d v e r t i s e m e n t which has been i d e n t i f i e d as b e i n g t a r g e t e d s p e c i f i c a l l y a t c h i l d r e n . E i g h t y - o n e p e r c e n t o f t h e p h a r m a c i e s s e l l i n g t o b a c c o were w i l l i n g t o s e l l i t t o minors i l l e g a l l y . 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 an i m p o r t a n t r o l e i n t h e p r o m o t i o n o f t o b a c c o use among c h i l d r e n . T h e r e f o r e , a l t h o u g h expanding t h e p h a r m a c i s t ' 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 based upon community 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 doubt e x i s t s as t o t h e p h a r m a c i s t s ' academic 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 r o l e . 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 p r o m o t i o n , i t i s n e c e s s a r y t o d e t e r m i n e t h e c u r r e n t l e v e l o f 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 . How o f t e n do B r i t i s h C olumbia 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 a c t i v i t i e s ? No q u a n t i t a t i v e Canadian d a t a e x i s t s r e g a r 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 a c t i v i t i e s : American d a t a i s o f l i m i t e d u s e f u l n e s s due t o a d i f f e r e n t h e a l t h c a r e system, and t e m p o r a l and m e t h o d o l o g i c a l problems i n t h e r e s e a r c h t h a t i s a v a i l a b l e . Many community p h a r m a c i s t s have been s l o w t o adopt 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 have 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 t o 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 t h e y w i l l a l s o be s l o w t o expand t h e i r r o l e i n h e a l t h p r o m o t i o n . Because 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, f a c t o r s o t h e r t h a n e d u c a t i o n o r knowledge background a r e i m p o r t a n t i n d e t e r m i n i n g p h a r m a c i s t s ' i n v o l v e m e n t i n p r o f e s s i o n a l a c t i v i t i e s . 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 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 c o v e r e d i n t h e f o l l o w i n g 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, 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 and b e h a v i o u r s may a f f e c t t h e e x t e n t t o wh i c h 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 a c t i v i t i e s . Other v a r i a b l e s w h i c h may i n f l u e n c e 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 i n c l u d e a 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 , y e a r s i n p r a c t i c e , l o c a t i o n o f p r a c t i c e , and employment p o s i t i o n . I n summary, two problems w i l l be i n v e s t i g a t e d . The f i r s t p r o b l em w i l l be t o de t e r m i n e t h e c u r r e n t l e v e l o f 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 a c t i v i t i e s . S e c o n d l y , 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 v a r i a b l e s 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 p h a r m a c i s t s i n B r i t i s h Columbia. Purpose and Objectives 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 p r o j e c t 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 t h r o u g h pharmacies w h i c h can h e l p t o meet t h e s e i d e n t i f i e d needs. I n p u r s u i t o f t h i s g o a l , t h e c u r r e n t l e v e l o f 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 f i r s t be e s t a b l i s h e d . I n c r e a s i n g 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 p r o m o t i o n a c t i v i t i e s w i l l i n v o l v e b e h a v i o u r a l change on t h e p a r t o f p h a r m a c i s t s . B e h a v i o r a l change i s a m u l t i d i m e n s i o n a l p r o c e s s (Higginbotham, 1992). That i s , e f f o r t s t o i n c r e a s e 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 a c t i v i t i e s w i l l n o t o c c u r by a l o n e change i n p h a r m a c i s t s ' e d u c a t i o n . Changing p h a r m a c i s t b e h a v i o u r w i l l e n t a i l a d d r e s s i n g t h e s o c i a l , p r o f e s s i o n a l , e n v i r o n m e n t a l , and p e r s o n a l 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 B r i t i s h C olumbia. To 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 i n f l u e n c e 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 scope o f t h i s p r o j e c t . 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 e x p l o r i n g e l e v e n o f t h e p e r s o n a l , demographic, and p r a c t i c e v a r i a b l e s o f p h a r m a c i s t s t h a t can be measured i n a q u e s t i o n n a i r e f o r m a t . S p e c i f i c o b j e c t i v e s o f t h i s s t u d y a r e : 1. To measure 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 Columbia a r e c u r r e n t 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 a c t i v i t i e s ; and 2. To d e t e r m i n e i f p e r s o n a l o r demographic c h a r a c t e r i s t i c s o f p h a r m a c i s t s and t h e i r p r a c t i c e s a r e r e l a t e d t o 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 p r o m o t i o n a c t i v i t i e s . Importance o f Study T h i s s t u d y w i l l make t h r e e i m p o r t a n t c o n t r i b u t i o n s t o t h e f i e l d o f pharmacy a d m i n i s t r a t i o n . F i r s t , r e s e a r c h e r s w i l l be p r o v i d e d w i t h b a s e l i n e d a t a r e g a r d i n g t h e f r e q u e n c y 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 Columbia a r e 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 . 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 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 . S e c o n d l y , t h i s n e c e s s a r y , h e r e t o f o r e u n a v a i l a b l e d a t a may e n a b l e p o l i c y makers t o conduct more t h o r o u g h e x a m i n a t i o n s o f t h e c o n t r i b u 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 t o t h e h e a l t h o f t h e p r o v i n c e . F i n a l l y , e d u c a t o r s w i l l g a i n i n s i g h t r e g a r d i n g t h e e x t e n t t o wh i c h c u r r e n t h e a l t h p r o m o t i o n t h e o r y and e d u c a t i o n i s d i f f u s i n g i n t o t h e w o r k p l a c e among p h a r m a c i s t s . S p e c i f i c a l l y , a f o u n d a t i o n f o r f u r t h e r s t u d y o f t h e i n c o r p o r a t i o n o f h e a l t h p r o m o t i o n i n t o t h e u n d e r g r a d u a t e pharmacy c u r r i c u l u m and i n t o p h a r m a c i s t c o n t i n u i n g e d u c a t i o n o f f e r i n g s w i l l be p r o v i d e d . 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 P r o m o t i o n 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 ' 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 . Much o f what has been 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 document p r o j e c t s c u r r e n t l y under way i n communities ( E i n a r s o n and P o s t o n , 1992). The most comprehensive 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 done i n t h e e a r l y 1980s by 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). As p a r t o f t h i s p r o j e c t , 450 community p h a r m a c i s t s from a c r o s s t h e U n i t e d S t a t e s were s u r v e y e d t o document p h a r m a c i s t s ' a c t i v i t i e s i n d i s e a s e 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 ( B e a r d s l e y , 1983). The o v e r a l l r e t u r n r a t e was 40% (n=182). R e s u l t s o f t h e s u r v e y i n d i c a t e d t h a t t h e most f r e q u e n t l y performed 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 r e p o r t e d by p h a r m a c i s t s 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 , w e i g h t c o n t r o l , a l l e r g i e s , p r o p e r use o f 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 , r e f e r r i n g 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 d r u g and m e d i c a l h i s t o r i e s . 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 e n j o y i n g much l e s s community p h a r m a c i s t i n v o l v e m e n t i n c l u d e d s p e a k i n g t o community groups 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 a g e n c i e s , and p a r t i c i p a t i n g i n community-based programs 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 , mental h e a l t h , s u b s t a n c e abuse, p o i s o n i n g p r e v e n t i o n and c a n c e r s c r e e n i n g . Bush c o n c l u d e d t h a t 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 o f t h e A m e r i c a n p o p u l a t i o n , h e a l t h p r o m o t i o n 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 w h i c h l a c k 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 were n o t d a i l y , and 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 . She s t a t e s t h a t pharmacy e d u c a t i o n and p h a r m a c i s t i n c e n t i v e s must be changed i f p h a r m a c i s t s a r e t o i n c r e a s e t h e i r a c t i v i t i e s 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 . A l t h o u g h Bush's work remains t h e o n l y comprehensive s t u d y i n t h i s a r e a , B e a r d s l e y ' s r e s u l t s which form p a r t o f t h a t paper a r e no t u s e f u l as i n d i c a t o r s o f Canadian 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 f o r a number o f r e a s o n s . F i r s t , t h e American s t u d y was u n d e r t a k e n i n 1981 when Canadian emphasis on 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 j u s t g a i n i n g momentum ( L a s t , 1989). 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 n o t y e t had t i m e t o o c c u r , B e a r d s l e y ' s r e s u l t s , i f a p p l i e d t o t o d a y ' s p h a r m a c i s t , might u n d e r e s t i m a t e t h e l e v e l o f h e a l t h p r o m o t i o n c u r r e n t l y u n d e r t a k e n . S e c o n d l y , d i f f e r e n c e s i n t h e h e a l t h c a r e d e l i v e r y systems i n t h e U n i t e d S t a t e s and Canada may g i v e r i s e t o d i f f e r e n c e s i n t h e p u b l i c ' s a t t i t u d e s t oward u t i l i z a t i o n o f t h e 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 American p a t i e n t s must g e n e r a l l y pay o u t - o f - p o c k e t t o v i s i t p h y s i c i a n s o r n u r s e -p r a c t i t i o n e r s f o r h e a l t h c o u n s e l l i n g o r a d v i c e , t h e p h a r m a c i s t i s seen 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. p harmacies o f f e r a wide a r r a y o f 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 f t e n f o r r e d u c e d o r no c h a r g e , i n c l u d i n g b l o o d p r e s s u r e m o n i t o r i n g (Hampton e t . a l . , 1 9 9 0 ) , d i a b e t e s c o u n s e l l i n g , ( M a r t i n , 1990), w e i g h - i n s , u r i c a c i d t e s t i n g , g l u c o s e t e s t i n g , and h y p e r c h o l e s t e r o l e m i a s c r e e n i n g ( M a r t i n , 1990a). I n Canada, however, v i s i t s t o t h e p h y s i c i a n a r e g e n e r a l l y p a i d f o r by a p e r s o n ' s p r o v i n c i a l h e a l t h p l a n . Canadians i n c u r no o u t - o f - p o c k e t expenses 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 r e a s o n ( C r i c h t o n , 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 , Canadians l a c k an economic i n c e n t i v e t o seek out a l t e r n a t i v e c a r e g i v e r s , i n c l u d i n g p h a r m a c i s t s , f o r h e a l t h p r o m o t i o n s e r v i c e s . I n f o u r C anadian 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 f o r t h e p h y s i c i a n o v e r t h e p h a r m a c i s t as a s o u r c e o f p r e s c r i p t i o n d r u g i n f o r m a t i o n ( S t a c h i w , 1989; S t r a t t o n and S t e w a r t , 1991; B u r s o n -M a r s t e l l a r , 1991; S t r a t t o n , 1993). I n one o f t h e s t u d i e s , consumers mentioned t h e p h a r m a c i s t l e s s t h a n seven p e r c e n t o f t h e t i m e when asked about i n f o r m a t i o n s o u r c e s f o r g e n e r a l h e a l t h c o n c e r n s ( 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 compared t o American p h a r m a c i s t s , B e a r d s l e y ' s r e s u l t s may o v e r e s t i m a t e Canadian 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 a c t i v i t i e s . F i n a l l y , 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 r a t e weaken t h e s t u d y ' s e x t e r n a l v a l i d i t y . An o v e r - r e s p o n s e o f male p h a r m a c i s t s ( 91% o f a l l re s p o n d e n t s ) and a l a c k o f f o l l o w - u p p r o c e d u r e s may have i n t r o d u c e d respondent b i a s , as 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 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 responded t o t h e s u r v e y . W h i l e l i t t l e 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 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 , E i n a r s o n and P o s t o n (1992) c o n d u c t e d an e x h a u s t i v e l i t e r a t u r e r e v i e w o f t h e p r e v e n t i v e s t r a t e g i e s i n 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 . 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 wh i c h p h a r m a c i s t s have been i n v o l v e d , c r i t i c a l l y a s s e s s t h e c o n t e n t o f pharmacy-based 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 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 i m p l e m e n t a t i o n 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, 1976), and 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 o f e v a l u a t i o n s o f pharmacy-based 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 . 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 has been d e v e l o p e d and promoted i n t h e U n i t e d S t a t e s and B r i t a i n , b u t Canada has been much l e s s a c t i v e . They found t h a t t h e r e had been 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 programs f o r p h a r m a c i s t s i n Canada but few d e m o n s t r a t i o n p r o j e c t s o r p i l o t s t u d i e s . Canadian p r o j e c t s t h a t a r e r e p o r t e d t e n d 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 s uch as a l a c k o f f i n a n c i a l 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 o f s p e c i f i c t r a i n i n g 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 , a 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 s p o n s o r s h i p i n t h i s a r e a . 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 about 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 ; even l e s s i s known about Canadian 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 a r e a . D e v e l o p i n g t h e P h a r m a c i s t ' s R o l e i n H e a l t h P r o m o t i o n 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 n o t i n c r e a s e 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 ( 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 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 . P r e v i o u s r e s e a r c h has i d e n t i f i e d t h r e e main v a r i a b l e s t h a t may 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 ' 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 : p r a c t i c e v a r i a b l e s , e d u c a t i o n a l 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 a f f e c t p h a r m a c i s t s ' 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 p r o m o t i o n 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 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 o t h e r p r o f e s s i o n a l a c t i v i t i e s i n c l u d e 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 w h i c h t h e p h a r m a c i s t i s employed (ind e p e n d e n t , i n d e p e n d e n t c h a i n , f r a n c h i s e , o r c o r p o r a t e c h a i n ) , t h e g e o g r a p h i c l o c a t i o n o f t h e pharmacy, and 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 p r e d o m i n a n t l y s e r v e d by t h e pharmacy. The f o l l o w i n g s e c t i o n 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 c o n c l u d e s w i t h a summary o f p r o p o s e d h y p o t h e s e s ' c o n c e r n i n g t h e s e v a r i a b l e s ( T a b l e 1 on page 2 2 ) . i ) Employment position; C o n f l i c t i n g e v i d e n c e e x i s t s r e g a r d i n g t h e 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 (owner, manager, o r employee) on work performance. B e l a s c o and A r b e i t (19 69) found t h a t pharmacy owners and employees d i f f e r e d i n t h e i r r o l e p e r c e p t i o n s as p h a r m a c i s t s . I f a p h a r m a c i s t does not 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 h e a l t h p r o m o t i n g s e r v i c e s , he/she would not be a c t i v e l y engaged i n such a c t i v i t i e s (Knapp e t a l , 1969). B e a r d s l e y (1983) found t h a t pharmacy owners were more l i k e l y t h a n managers 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 p r o m o t i o n a c t i v i t i e s . T h i s r e l a t i o n s h i p , however, was p o s t u l a t e d t o be due t o t h e t y p e o f p r a c t i c e ( i . e . , many pharmacy owners were owners o f s m a l l , independent p r a c t i c e s ) r a t h e r t h a n t o t h e employment p o s i t i o n a l o n e . Owners o f pharmacies have been a c c u s e d o f b e i n g more e c o n o m i c a l l y , o r b u s i n e s s - o r i e n t e d t h a n s t a f f p h a r m a c i s t s ( B e l a s c o and A r b e i t , 1969). I n 1963, Quinney f o u n d t h a t p r e s c r i p t i o n v i o l a t i o n s were more l i k e l y t o o c c u r among 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 and o c c u r l e a s t among t h e p r o f e s s i o n a l l y o r i e n t e d p h a r m a c i s t s , who tended t o be s t a f f p h a r m a c i s t s . P r o f e s s i o n a l l y -o r i e n t e d p h a r m a c i s t s may, t h e r e f o r e , be more a c t i v e 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 a c t i v i t i e s 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 would be more i n c l i n e d t o s e l l an 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 and D a v i s , 1973) t h a n t o spend 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 above 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) found t h a t ownership s t a t u s was n o t a d e t e r m i n a n t o f e i t h e r a c t i v i t y o r o r i e n t a t i o n ( p r o f e s s i o n a l v e r s u s b u s i n e s s ) among p h a r m a c i s t s . i i ) Place 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 t h e p h a r m a c i s t i t employs ( L i n n and D a v i s , 1971). L i n n and D a v i s found 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 a r e more l i k e l y t o have 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 p r o f e s s i o n a l a c t i v i t i e s . The c a u s a l d i r e c t i o n o f t h i s r e l a t i o n s h i p , however, i s u n c l e a r . Do p r o f e s s i o n a l l y - o r i e n t e d p h a r m a c i s t s make a community pharmacy s u c c e s s f u l , o r i s i t t h e 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 p r o f e s s i o n a l l y m o t i v a t e d s t a f f t h r o u g h s u p e r i o r f i n a n c i a l reimbursement? Inadequate reimbursement schemes from t h i r d p a r t y p a y e r s have r e s u l t e d i n d e c l i n i n g p r o f i t s ( C a r r o l l , 1991) and t h e i n e v i t a b l e c l o s u r e o f many independent p h a r m a c i e s . L a r g e r c h a i n s t o r e s , s e l l i n g a v a s t a r r a y o f non-pharmacy merchandise, have managed t o f l o u r i s h d u r i n g t h i s t i m e . L a r g e r c h a i n s t o r e s c o u l d , t h e r e f o r e , be seen as 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 , and t h u s , may 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 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 i i ) Socioeconomic status of c l i e n t e l e ; V e r y 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 . L i n n and D a v i s (1971) found t h a t pharmacies l o c a t e d i n m i n o r i t y group neighbourhoods t e n d e d t o have as employees p h a r m a c i s t s who were more i n t e r e s t e d and i n v o l v e d i n p r o f e s s i o n a l a c t i v i t i e s t h a n d i d pharmacies l o c a t e d i n p r i m a r i l y C a u c a s i a n neighbourhoods. I n t h i s s t u d y , p r o f e s s i o n a l a c t i v i t i e s c o n s t i t u t e d making m e d i c a l p r e p a r a t i o n s , d i s p e n s i n g p r e s c r i p t i o n o r d e r s , and a d v i s i n g and d i s c u s s i n g h e a l t h problems w i t h c l i e n t s . T h e r e f o r e , p h a r m a c i s t s whose pr e d o m i n a t e 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 as " l o w e r c l a s s " may be 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 a c t i v i t i e s t h a n p h a r m a c i s t s s e r v i n g p r e d o m i n a n t l y " u p p e r - c l a s s " c l i e n t e l e . iv) Geographic location; A n e c d o t a l e v i d e n c e , though n o t s u b s t a n t i a t e d t h r o u g h f i n d i n g s i n t h e l i t e r a t u r e , s u g g e s t s t h a t 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 p r o m o t i o n a c t i v i t i e s i n s m a l l towns o r remote s e t t i n g s a r e g r e a t e r t h a n i n l a r g e r , urban a r e a s . Whether t h i s s i t u a t i o n i s due t o a l a c k o f a l t e r n a t i v e c a r e g i v e r s i n remote a r e a s o r t o i s o l a t e d p h a r m a c i e s h a v i n g 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 a r e a s a r e h y p o t h e s i z e d t o be 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 a c t i v i t i e s t h a n p h a r m a c i s t s i n l a r g e r urban c e n t r e s . No d a t a t o s u p p o r t o r 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 l i t e r a t u r e . V) B a r r i e r s ; 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 major b a r r i e r s t o f u r t h e r i n g p r o f e s s i o n a l i n v o l v e m e n t . These b a r r i e r s i n c l u d e a l a c k o f t i m e and a l a c k o f economic i n c e n t i v e s (Bush, 1983, W e s c h l e r e t a l . , 1983; S o b a l , 1985; Schwartz e t a l . , 1991). I n t h e Upjohn Survey o f 1990, "knowledge" was c i t e d as a b a r r i e r t o 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 p a t i e n t c o u n s e l l i n g . A n o t h e r 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 b e l i e v e t h a t t h e r e a r e 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 p r o m o t i o n 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 . T h i s r e l a t i o n s h i p 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 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 r e f u t e d , however, by d a t a w h i c h s u g g e s t s t h a t a p o s i t i v e r e l a t i o n s h i p may a c t u a l l y e x i s t (Upjohn, 1990). I n Upjohn's 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 h a r m a c i s t s who were t h e 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 i n v o l v e m e n t i n t h i s a r e a . TABLE 1 SUMMARY OF THE REPORTED EFFECTS OF PRACTICE VARIABLES ON COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION Practice Variable Hypothesized Effect(s) on Health Promotion Involvement Supporting Li t e r a t u r e 1. Employment Po s i t i o n S t a f f > Managers > Owners Owners > Managers o r S t a f f No E f f e c t Quinney (1963) L i n n & D a v i s (1973) B e a r d s l e y (1983) L i n n & D a v i s (1971) 2. Place of C o r p o r a t e C h a i n > Independent L i n n & D a v i s (1973) Employment No E f f e c t L i n n & D a v i s (1971) 3. Socioeconomic Lower C l a s s > Upper C l a s s L i n n & D a v i s (1971) Status of C l i e n t e l e 4. Geographic Location N o r t h > South R u r a l > Urban None a v a i l a b l e 5. Ba r r i e r s Many B a r r i e r s = L o w Involvement None a v a i l a b l e Many B a r r i e r s = H i g h Involvement Upjohn (1990) Personal Variables The f o l l o w i n g s e c t i o n d i s c u s s e s h y p o t h e s i z e d e f f e c t s o f 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 b e l i e f s and 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 . T a b l e 2 (page 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; 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 Canadian community p h a r m a c i s t s i n 1990 (Upjohn, 1990) s u g g e s t e d t h a t f e m a l e p h a r m a c i s t s were more i n v o l v e d i n p a t i e n t c o u n s e l l i n g t h a n were male p h a r m a c i s t s . Among American i n t e r n i s t s , 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 u n s e l l i n g p r a c t i c e s were a l s o f o u n d t o f a v o u r f e m a l e s (Schwartz e t a l . , 1991). Females have a l s o been found t o have 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 t h a t a r e s i g n i f i c a n t l y d i f f e r e n t f r om t h o s e o f males (Lau e t a l . , 1990). The c a u s a l model 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 ( 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 b e l i e f s and h e a l t h b e h a v i o u r s . T h e r e f o r e , a d i f f e r e n c e 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 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 sex may a l s o e x i s t . i i ) P h a r m a c i s t m a r i t a l s t a t u s : 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 p e r s o n s ( S o b a l , 1986). 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 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 ( F i g u r e 1 ) . T h e r e f o r e , 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 a c t i v e 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 a c t i v i t i e s t h a n a r e s i n g l e p h a r m a c i s t s . L i t e r a t u r e , however, i s not a v a i l a b l e on t h i s i s s u e . I f h e a l t h b e h a v i o u r s and h e a l t h b e l i e f s r e m a i n c o n s t a n t a f t e r a d i v o r c e , t h a n d i v o r c e d 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 m a r r i e d p h a r m a c i s t s . 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 eer group w h i c h t h e o r e t i c a l l y would 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 t h e d i v o r c e . Perhaps d i v o r c e d p h a r m a c i s t s w i l l e x h i b i t 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 p r o m o t i o n i n t e r m e d i a t e between t h e two extremes o f m a r r i e d and s i n g l e . i i i ) P h a r m a c i s t age: Schwartz e t a l . , (1991) found t h a t age 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 e x t e n t t o w h i c h t h e y o f f e r e d h e a l t h p r o m o t i o n s e r v i c e s t o t h e i r c l i e n t s . As p h a r m a c i s t s age, t h e i r i n v o l v e m e n t i n p r o f e s s i o n a l a c t i v i t i e s t e n d s t o d e c r e a s e ( L i n n and D a v i s , 1971). O l d e r 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 p r o m o t i o n a c t i v i t i e s t h a n younger p h a r m a c i s t s . i 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 b e l i e f s ; A t t i t u d e s o r p e r c e p t i o n s p e r t a i n i n g t o h e a l t h h e l p shape p e r s o n a l h e a l t h b e h a v i o u r s ( O l s e n , 1992). P o s i t i v e o r o p t i m i s t i c b e l i e f s r e g a r d i n g t h e e f f i c a c y o f a p a r t i c u l a r h e a l t h b e h a v i o u r w i l l i n c r e a s e t h e 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 b e h a v i o u r ( O l s e n , 1992), b u t e v i d e n c e r e g a r d i n g t h e 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 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 i s f a r from c o n c l u s i v e ( H i c k s e t a l . , 1988). Based upon t h e s e f i n d i n g s , t h e proposed c a u s a l model 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 ( F i g u r e 1) s u g g e s t s , f o r example, 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 average i n d i v i d u a l w i l l be more l i k e l y t o become engaged i n c o u n s e l l i n g c l i e n t s on t h e n e c e s s i t y o f r e g u l a r e x e r c i s e . 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 p r o f e s s i o n a l s ( S o b a l e t a l . , 1985; Fincham and S m i t h , 1988; Janes 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 h e a l t h c a r e 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 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 a t work. On l y one s t u d y 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 p r o m o t i o n a c t i v i t i e s a t work ( M e r l i n o and P r i c e , 1992). The 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 e x i s t s between h e a l t h c a r e 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 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 . 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 b e h a v i o u r s : 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 American p h y s i c i a n s and n u r s e s , (Wyshak e t a l . , 1980;; Henry e t a l . , 1987; Kahn e t a l . , 1988; Janes e t a l . , 1992), as w e l l as t h e h e a l t h b e h a v i o u r s o f m e d i c a l and n u r s i n g s t u d e n t s (Coe e t a l . , 1982; S o b a l , 1986; R i c h t e r e t a l . , 1987; Benson and W i l l i a m s , 1988). I n a l l o f t h e s e s t u d i e s among b o t h h e a l t h c a r e p r a c t i t i o n e r s and h e a l t h c a r e s t u d e n t s , 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 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 r e f u t e 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 b e h a v i o u r (Norman, 1986; H i c k s , e t a l . , 1988). E v i d e n c e 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) and s u g g e s t s t h a t s o c i o -demographic v a r i a b l e s such as age, gender, and e d u c a t i o n a l background may a c t t o s u p p o r t o r a n t a g o n i z e t h i s r e l a t i o n s h i p ( C a l n a n , 1989). M e r l i n o and P r i c e (1992), f o r example, s u r v e y e d 384 d i e t i c i a n s (70 p e r c e n t response) t o examine t h e h e a l t h b e l i e f s and h e a l t h p r a c t i c e s o f d i e t i c i a n s i n r e l a t i o n t o c a n c e r r i s k r e d u c t i o n t h r o u g h n u t r i t i o n . A l t h o u g h t h e d i e t i c i a n s r e p o r t e d 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 were n o t 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 wh 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 r i s k . Schwartz e t a l . , (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 e x i s t s 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 degree t o whi c h 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 c l i e n t s . The " 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 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 c o u n s e l l i n g i s not known, however, as Schwartz and c o l l e a g u e s 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 t h e t e s t s t a t i s t i c o b t a i n e d . 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 i n c o n s i s t e n t w i t h p e r s o n a l b e l i e f s , a s e t o f s i t u a t i o n a l o r s t r u c t u r a l v a r i a b l e s s uch as demographic d i f f e r e n c e s , s o c i o e c o n o m i c s t a t u s , o r peer o r f a m i l y p r e s s u r e e x i s t s w h i c h may go v e r n t h e e n t i r e " b e l i e f : b e h a v i o u r " r e l a t i o n s h i p (Norman 1986). C o n f i r m i n g 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 t h e p r e s e n t s t u d y . Table 2 SUMMARY OF THE REPORTED EFFECTS OF PERSONAL VARI7ŒLES ON COMMUNITY PHARMACIST PARTICIPATION IN HEALTH PROMOTION ACTIVITIES Personal Variable Hypothesized E f f e c t Supporting L i t e r a t u r e 1. Sex Female > Male Upjohn, 1990 Schwartz e t al.,1991 2. Age 3. M a r i t a l S t a t u s Younger > O l d e r M a r r i e d > S i n g l e Schwartz e t a l . , 1 9 9 1 L i n n & Davis,1971 S o b a l , 1986 4. 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 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 Lau, 1990 H e a l t h B e l i e f s do not = H e a l t h B e h a v i o u r s 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 = H i g h 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 n t h e w o r k p l a c e Schwartz e t a l . , 1 9 9 1 (+) 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 = Hi g h 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 n t h e w o r k p l a c e None a v a i l a b l e Educational Variables I n t h i s s e c t i o n 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 h a r m a c i s t knowledge o f h e a l t h p r o m o t i o n i s r e v i e w e d , as measured 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 proposed h y p o t h e s e s r e l a t e d t o t h e e f f e c t o f 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 p r o m o t i o n a c t i v i t i e s ( T a b l e 3, page 31) c o n c l u d e s t h e l i t e r a t u r e r e v i e w on e d u c a t i o n a l v a r i a b l e s . i) 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 t h e e d u c a t i o n a l i n s t i t u t i o n from w h i c h a p h a r m a c i s t g r a d u a t e s a r e one o f many f a c t o r s t h a t mould a s t u d e n t ' s p e r c e p t i o n o f a p h a r m a c i s t ' s r o l e w i t h i n t h e h e a l t h c a r e system ( B e l a s c o and A r b e i t , 1969). U n i v e r s i t i e s w i t h pharmacy programs c o n t a i n i n g h e a l t h p r o m o t i o n coursework s h o u l d produce p h a r m a c i s t s who v i e w 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 a component o f t h e i r p r o f e s s i o n a l r o l e . No d a t a e x i s t s on c u r r i c u l u m v a r i a t i o n s i n pharmacy u n d e r g r a d u a t e programs i n Canada; t h e r e f o r e , an a n a l y s i s o f t h e 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 u n d e r t a k e n . I n Canada, a l l l i c e n s e d p h a r m a c i s t s w i s h i n g t o p r a c t i s e o u t s i d e t h e i r p r o v i n c e o f g r a d u a t i o n a r e r e q u i r e d t o pass t h e Pharmacy Examining Board o f Canada Q u a l i f y i n g E x a m i n a t i o n . T h i s exam i s d e s i g n e d t o ensure u n i f o r m competency among p h a r m a c i s t s p r a c t i s i n g i n Canada. F u r t h e r m o r e , a l l p h a r m a c i s t s w i s h i n g t o p r a c t i c e i n B r i t i s h C olumbia must pass 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 on p h a r m a c e u t i c a l knowledge, p a t i e n t c o u n s e l l i n g s k i l l s , and r e g u l a t o r y knowledge. Even w i t h s t r i n g e n t l i c e n s i n g r e q u i r e m e n t s such as t h e s e , d i f f e r e n c e 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 h e a l t h p r o m o t i o n w i l l l i k e l y a r i s e as l i c e n s i n g r e q u i r e m e n t s e n s u r e o n l y a minimum l e v e l o f competency f o r a c t i v i t i e s 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 . N e i t h e r o f t h e exams a s s e s s i n g p h a r m a c i s t competency 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 p r o m o t i o n c o u n s e l l i n g . 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 remains a t t h e s t a g e where p h a r m a c i s t p a r t i c i p a t i o n i s a " s h o u l d have" 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 , "must have" s k i l l f o r p r a c t i c e (Bush, 1983). i i ) Year of graduation; L o g i c a l l y , p h a r m a c i s t s g r a d u a t i n g i n r e c e n t y e a r s s h o u l d have more u p - t o - d a t e knowledge i n h e a l t h p r o m o t i o n and be more a c t i v e 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 a c t i v i t i e s t h a n t h e i r 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 t i m e . 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 . W a t k i n s and Norwood (1978) s t u d i e d t h e e f f e c t o f knowledge on p h a r m a c i s t s ' p h y s i c i a n and p a t i e n t c o n s u l t a t i o n b e h a v i o u r , and found t h a t 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 had no e f f e c t on c o n s u l t a t i o n r a t e s . 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 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 a c t i v i t i e s . *ie************************ie**************************ie* Table 3 SUMMARY OP THE REPORTED EFFECTS OF EDUCATIONAL VARIABLES ON COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Educational Hypothesized E f f e c t on Supporting Variables Pharmacist Involvement Lit e r a t u r e 1. D e g r e e - G r a n t i n g No E f f e c t None A v a i l a b l e I n s t i t u t i o n 2. Y e a r o f G r a d u a t i o n No E f f e c t W a t kins & 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 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 ( F i g u r e 1 ) . 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 , e d u c a t i o n a l , and p r a c t i c e - t y p e v a r i a b l e s . The i n f l u e n c e o f t h e s e independent v a r i a b l e s on 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 a c t i v i t i e s i s e x p l a i n e d by t h r e e main v a r i a b l e s ; 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 , t h e i r knowledge o f h e a l t h and h e a l t h -r e l a t e d m a t t e r s , and t h e o p p o r t u n i t y t o 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 a c t i v i t i e s . O t her v a r i a b l e s such as t h e p u b l i c ' 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 b e h a v i o u r s , and t h e n a t u r e o f t h e o p e r a t i n g h e a l t h c a r e system ( u n i v e r s a l o r p r i v a t e - i n s u r a n c e ) f o r example, may a l s o a f f e c 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 a c t i v i t i e s , b u t a r e beyond t h e scope o f t h e p r e s e n t s t u d y t o measure. I n c o n c l u d i n g t h e l i t e r a t u r e r e v i e w , i t must be s t r e s s e d t h a t t h e c u r r e n t s t u d y i s i n t e n d e d t o be d e s c r i p t i v e and e x p l o r a t o r y . The main o b j e c t i v e o f t h e s t u d y i s t o o b t a i n 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 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 p r o m o t i o n 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 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 p r o m o t i o n a c t i v i t i e s p r o v i d 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 t e s t i n g . As t h e number o f h y p o t h e s e s b e i n g 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 s p e c i f i c h y p o t h e s e s b e i n g t e s t e d i n t h i s s t u d y . FIGURE 1 CAUSAL MODEL OF COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Independent variables Intervening Variables Dependent Variable Pharmacist sex Marital status Personal health bel iefs Age Year of graduation Degree-granting inst i tut ion * Type of Pract ice * Geograph ic location of pract ice Employment posi t ion Soc ioeconomic status of c l ientele Perceived barr iers to part ic ipat ion in health promotion act iv i t ies Health Behaviours Knowledge Pharmacist Involvement in Health Promotion Opportuni ty TABLE 4 OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES HI: Community 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 p r o m o t i o n s c o r e s 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 t h a n f o r n o n - d i s p e n s i n g r e l a t e d 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 . 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 p r o m o t i o n s c o r e s t h a n male p h a r m a c i s t s . 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 p r o m o t i o n s c o r e s t h a n s i n g l e p h a r m a c i s t s . 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 p r o m o t i o n 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 p r o m o t i o n s c o r e . 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 p r o m o t i o n s c o r e s 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 b e h a v i o u r s c o r e s . H7: No 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 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 C o l umbia, 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 u n i v e r s i t i e s . H9: P h a r m a c i s t s employed i n "in d e p e n d e n t " pharmacies w i l l have l o w e 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 s t h a n p h a r m a c i s t s employed i n " c o r p o r a t e c h a i n " p h a r m a c i e s . HIO: P h a r m a c i s t s employed i n C o l l e g e d i s t r i c t 6 w i l l 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 s c o r e s t h a n p h a r m a c i s t s 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, and 7-9. H l l : 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 p r o m o t i o n s c o r e s t h a n p h a r m a c i s t s p r a c t i s i n g i n u r b a n communities. H12: S t a f f 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 p r o m o t i o n s c o r e s t h a n owners. TABLE 4 —continued OPERATIONAL HYPOTHESIS SURROUNDING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES 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 from 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 p r o m o t i o n s c o r e s t h a n p h a r m a c i s t s s e r v i n g a p r e d o m i n a t e l y upper c l a s s c l i e n t e l e . 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 p r o m o t i o n s c o r e s t h a n p a r t - t i m e p h a r m a c i s t s . H15: 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 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 p r o m o t i o n s c o r e . CHAPTER 3 METHODOLOGY Q u e s t i o n n a i r e Development A s u r v e y i n s t r u m e n t used t o examine 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 i s a v a i l a b l e ( B e a r d s l e y , 1983) , and was used as 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 an a d d i t i o n a l 15 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 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 s t u d y . A second 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 t h e i n d i c e s e v a l u a t i n g p h a r m a c i s t s ' f r e q u e n c y o f 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 . B e a r d s l e y ' s q u e s t i o n n a i r e u t i l i z e d a s i x - 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 "never" t o "more t h a n once d a i l y " . 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 "once d a i l y " and "more t h a n once d a i l y " i n t o a s i n g l e "once o r more d a i l y " c a t e g o r y , 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 e v o l v e d f o r t h i s s t u d y . T h i s a c t i o n 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 and was b e l i e v e d t o l e s s e n t h e t i m e r e q u i r e d by p h a r m a c i s t s t o complete t h e q u e s t i o n n a i r e . F u r t h e r m o r e , 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 p erformed "once a day" o r "more t h a n once a day" was i n c o n s e q u e n t i a l , as b o t h c a t e g o r i e s would be i n t e r p r e t e d as b e i n g " r e g u l a r " o r f r e q u e n t e v e n t s o f p h a r m a c i s t s . B e a r d s l e y does not mention t h e means o r methods o f p r e - t e s t i n g t h e s u r v e y i n s t r u m e n t used i n h i s s t u d y . T h e r e f o r e , measures t o ensu r e 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 . To ensu r e f a c e v a l i d i t y , 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 l e t t e r (Appendices 1 and 2) were r e v i e w e d by 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 , and by f a c u l t y members from t h e Department o f H e a l t h Care and E p i d e m i o l o g y , F a c u l t y o f M e d i c i n e a t t h e U n i v e r s i t y o f B r i t i s h C o lumbia. Based 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 were 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 random sample o f 30 community 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 p r o v i n c e o f B r i t i s h Columbia. Not knowing t h e p h a r m a c i s t p o p u l a t i o n demographics a t t h a t t i m e , t h e p i l o t s t u d y 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 ut t o a sample c o n s i s t i n g o f 14 male p h a r m a c i s t s ( 4 7 % ) , and 16 female p h a r m a c i s t s (53%) ( T a b l e 5 ) , l o c a t e d i n 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 d i s t r i c t s as 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 D i s t r i c t s 4 and 8 ( F i g u r e 2) were o v e r - r e p r e s e n t e d , and D i s t r i c t s 3 and 6 were u n d e r - r e p r e s e n t e d . T h i s d i s p r o p o r t i o n a t e r e p r e s e n t a t i o n o f t h e C o l l e g e d i s t r i c t s i s n o t s u r p r i s i n g , as a n o n - m o d i f i e d random s e l e c t i o n p r o c e s s was used, and 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 Description According to Pharmacist Sex Pharmacist Sex n % Male 14 47% Female 16 53% Table 6 P i l o t Sample Description According to Pharmacist Geographic Location DISTRICTS 1 2 3 4 5 6 7 8 9 Tot n 3 0 3 8 0 1 6 7 2 30 n% 10 0 10 27 0 3 20 23 7 100 N%* 9.3 7.5 15.5 11.2 3.3 6.1 22 .1 17.3 7.6 100 *N= p o p u l a t i o n o f community 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 c o u n t . May,1992. D i s t r i c t s * D i s t r i c t 1 = G r e a t e r V i c t o r i a / G u l f I s l a n d s D i s t r i c t 2 = Vancouver I s l a n d D i s t r i c t 3 = F r a s e r V a l l e y D i s t r i c t 4 = Thompson Okanagan D i s t r i c t 5 = Kootenay 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 = F r a s e r R i v e r N o r t h (*See d e f i n i t i o n s o r F i g u r e 2) A c o v e r i n g l e t t e r and a stamped, a d d r e s s e d r e t u r n envelope were i n c l u d e d i n t h e package. Three f o l l o w - u p p r o c e d u r e s were u t i l i z e d : a r e m i n d e r / t h a n k - y o u c a r d m a i l e d two weeks a f t e r t h e 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-r e s p o n d e n t s a t one week a f t e r t h e d e a d l i n e s t a t e d i n t h e c o v e r l e t t e r ; and f i n a l l y , a r e m i n d e r t e l e p h o n e c a l l t o r e m a i n i n g non-r e s p o n d e n t s . A f i n a l r e s p o n s e r a t e o f 83% was a t t a i n e d (25/30). The t e l e p h o n e f o l l o w - u p o f non-respondents r e v e a l e d t h a t 10% (3/30) o f t h e t o t a l p i l o t sample f a i l e d t o meet t h e s t u d y ' s i n c l u s i o n c r i t e r i a ; t h e s e r e s p o n d e n t s were e i t h e r on m a t e r n i t y l e a v e , r e t i r e d , o r were no l o n g e r p r a c t i s i n g i n a community s e t t i n g . Completed q u e s t i o n n a i r e s were a n a l y z e d f o r r e s p o n d e n t s ' comments and f o r q u e s t i o n s 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 o f t h e community i n w h i c h t h e p h a r m a c i s t p r a c t i s e d had a h i g h degree of non-response ( 8 / 2 5 ) ; t h e r e f o r e , t h i s q u e s t i o n was o m i t t e d from t h e f i n a l s u r v e y i n s t r u m e n t as i t c o u l d be o b t a i n e d from o t h e r s o u r c e s . 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 were made. A f t e r t h e s e r e v i s i o n s , s t a t i s t i c a l c o n s u l t a t i o n was sought from t h e U n i v e r s i t y o f B r i t i s h Columbia's Department o f S t a t i s t i c s . V e r y few changes were 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 , making i t p o s s i b l e t o p o o l t h e s e r e s p o n s e s w i t h t h o s e o b t a i n e d i n t h e f u l l - s c a l e s t u d y . Sample S e l e c t i o n To c a l c u l a t e t h e sample s i z e n e c e s s a r y f o r e x t e r n a l v a l i d i t y , t h e s t a n d a r d d e v i a t i o n o f p h a r m a c i s t s ' 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 from t h e p i l o t s t u d y was used 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 below (Walpole, 1983). Figure 3 CALCULATION FOR SAMPLE SIZE DETERMINATION n= ( c o n f i d e n c e l i m i t ) ( s t a n d a r d d e v i a t i o n ) ( a l l o w a b l e e r r o r ) n= (1.96)(0.561) (0.05) To e nsure t h a t a t l e a s t 484 p h a r m a c i s t s i n t h e s t u d y r e t u r n e d c o m p l e t e d q u e s t i o n n a i r e s , t h e r e t u r n r a t e o f c o mpleted s u r v e y s was o f paramount i m p o r t a n c e . L i t e r a t u r e r e g a r d i n g a n t i c i p a t e d r e t u r n r a t e s i s i n c o n c l u s i v e . An i n i t i a l r e t u r n r a t e o f 30%, w i t h an o v e r a l l r e t u r n r a t e o f 60% as a r e s u l t o f f o l l o w - u p s i s p r o p o s e d by B e r d i e and Anderson (1974). A l t e r n a t i v e l y , H e b e r l e i n and Baumgartner (1978) s u g g e s t a t e n v a r i a b l e model t o p r e d i c t f i n a l r e s p o n s e r a t e s . 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 109% f o r t h e p r e s e n t s t u d y ' s c o m b i n a t i o n o f f o l l o w - u p p r o c e d u r e s . 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 Canada a r e about 7% l o w e r t h a n r e s u l t s o b t a i n e d i n t h e U n i t e d S t a t e s . B e l i e v i n g b o t h B e r d i e and A n derson's, and H e b e r l a i n and Baumgartner's p r e d i c t e d r e t u r n r a t e s t o r e p r e s e n t t h e extremes, t h e p i l o t s t u d y ' s r e t u r n r a t e (83%) was g i v e n p r i o r i t y when c a l c u l a t i n g t h e s i z e o f t h e f i n a l sample r e q u i r e d f o r e x t e r n a l v a l i d i t y . The sample r e q u i r e d t o a t t a i n a l e v e l o f a t l e a s t 484 r e s p o n d e n t p h a r m a c i s t s was c a l c u l a t e d by m u l t i p l y i n g 484 community p h a r m a c i s t s by t h e p i l o t s t u d y ' s p r e d i c t e d non-response r a t e o f 17%, w h i c h i s 566 p h a r m a c i s t s . An a d d i t i o n a l 10% (57) was added t o t h e sample 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 s t u d y ' s i n c l u s i o n c r i t e r i a . T h e r e f o r e , t h e f u l l - s c a l e sample i n c l u d e d 566 + 57 ( 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 pondent) = 623, 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 were p r o v i d e d from t h e p i l o t s t u d y . The f u l l - s c a l e s t u d y sample was chosen t h r o u g h a s y s t e m a t i c s a m p l i n g t e c h n i q u e ( J a c k s o n , 1988). A l i s t o f p h a r m a c i s t s r e g i s t e r e d w i t h 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 was o b t a i n e d . R e g i s t r a t i o n w i t h t h e C o l l e g e o f P h a r m a c i s t s i s mandatory f o r p r a c t i c e , so t h e l i s t was c o n s i d e r e d c o m p l e t e . The C o l l e g e D i r e c t o r y l i s t s p h a r m a c i s t s a l p h a b e t i c a l l y a c c o r d i n g t o each C o l l e g e d i s t r i c t . T h e r e f o r e , knowing t h a t t h e r e a r e 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 C o lumbia, t h e f i n a l sample o f 625 (which 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 p a r e n t p o p u l a t i o n ) was 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 s e l e c t i n g e v e r y t h i r d p h a r m a c i s t l i s t e d i n t h e D i r e c t o r y . U s i n g a random number t a b l e , t h e second 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 D i r e c t o r y was chosen t o b e g i n t h e s e l e c t i o n o f e v e r y t h i r d p h a r m a c i s t . P h a r m a c i s t s f o r whom a work a d d r e s s was n o t l i s t e d were assumed unemployed and were e x c l u d e d , as t h e s t u d y was o n l y i n t e r e s t e d i n p r a c t i s i n g p h a r m a c i s t s . T h i s a s s u m p t i o n was v e r i f i e d w i t h 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 as b e i n g c o r r e c t . F o l l o w - u p P r o c e d u r e s The f i v e page 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 s t u d y s u b j e c t s a t Week 1. To maximize t h e r e s p o n s e r a t e , c e r t a i n measures were u n d e r t a k e n ( J a c k s o n , 1988): B u s i n e s s r e p l y r e t u r n e n v e l o p e s were 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 ; A l l s u b j e c t s were 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 / thank-you c a r d (see Appendix 3) ; Two weeks a f t e r t h e d e a d l i n e had pa s s e d f o r s u r v e y s t o be r e c e i v e d , non-r e s p o n d e n t s were m a i l e d 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 c o v e r l e t t e r (see Appendix 4 ) ; F i n a l l y , a r e m i n d e r t e l e p h o n e c a l l (see Appendix 5 f o r a copy o f t h e d i a l o g u e ) was made t o a l l r e m a i n i n g n o n-respondents a t a p p r o x i m a t e l y n i n e weeks a f t e r t h e i n i t i a l m a i l i n g . I f r e q u e s t e d by t h e r e s p o n d e n t , 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 o u t a t t h i s t i m e . S c o r i n g Schemes f o r Survey P h a r m a c i s t s were asked t o e s t i m a t e t h e f r e q u e n c y o f t h e i r 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 on 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" r e p r e s e n t i n g "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 were t h e n summed, p r o v i d i n g an 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 f o r each p h a r m a c i s t which s e r v e d as t h e dependent v a r i a b l e . The H e a l t h P r o m o t i o n S c o r e was t e s t e d a g a i n s t p h a r m a c i s t s ' p e r s o n a l v a r i a b l e s , p r a c t i c e v a r i a b l e s , and e d u c a t i o n a l v a r i a b l e s . Each o f 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 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 p r o m o t i o n a c t i v i t i e s . 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 were a s s e s s e d t h r o u g h f o u r q u e s t i o n s u s i n g a f o u r - p o i n t f o r c e d - c h o i c e r a t i n g s c a l e . 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 imp o r t a n c e o f each a c t i v i t y 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 average p e r s o n . The s c o r e s were 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 . The t o t a l H e a l t h B e l i e f S c o r e s e r v e d as an independent v a r i a b l e t o be t e s t e d a g a i n s t 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 S c o r e s . 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 q u e s t i o n s t h a t r e q u i r e d p h a r m a c i s t s t o e s t i m a t e t h e f r e q u e n c y w i t h w h i c h t h e y p a r t i c i p a t e d i n p a r t i c u l a r a c t i v i t i e s . The s c a l e s ' a n c h o r s f o r s e l f - a s s e s s m e n t v a r i e d a c c o r d i n g t o t h e h e a l t h -p r o m o t i n g a c t i v i t y , b ut 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 p a r t i c i p a t i o n . S c o r e s were summed t o a t t a i n a t o t a l H e a l t h B e h a v i o u r S c o r e , 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 ' H e a l t h P r o m o t i o n S c o r e s . E i g h t b a r r i e r s t o expanding 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 were examined i n t h i s s t u d y . On a s c a l e o f one ( 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 t h e e x t e n t t o w h i c h 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 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 . S c o r e s were 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 H e a l t h P r o m o t i o n S c o r e s . Space was p r o v i d e d f o r r e s p o n d e n t s t o i n c l u d e b a r r i e r s n o t p r o v i d e d i n t h e l i s t . S t a t i s t i c a l A n a l y s e s U ndertaken Data was a n a l y z e d u s i n g K r u s k a l l - W a l l i s one way A n a l y s i s o f V a r i a n c e (ANOVA), one way ANOVA, Mann-Whitney U- W i l c o x o n Rank Sum W T e s t , and P e a r s o n - p r o d u c t c o r r e l a t i o n s . The Tukey-b h o n e s t l y -s i g n i f i c a n t - d i f f e r e n c e t e s t was used t o s e t t h e ra n g e s where t h e ANOVA t e s t s were s i g n i f i c a n t . A l l r e q u i r e d t e s t s were u n d e r t a k e n u s i n g t h e S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s ( P e r s o n a l Computer) program (SPSS/PC+). 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 t o be t a k e n i n t o c o n s i d e r a t i o n ( I s a a c and M i c h a e l , 1981). L i n n (1973), i n a s t u d y o f p h a r m a c i s t s ' i n d i c a t e d and a c t u a l b e h a v i o u r s , f o u n d t h a t t h e m a j o r i t y o f p h a r m a c i s t s p e rformed 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%) o r d e v i a t e d from t h e i r r e p o r t e d a c t i v i t y on t h e s i d e o f c a u t i o n ( 1 2 % ) . T h e r e f o r e , assuming t h a t t h e r e p o r t i n g b e h a v i o u r of p h a r m a c i s t s i n B r i t i s h Columbia i s s i m i l a r t o t h e r e p o r t i n g b e h a v i o u r o f American p h a r m a c i s t s , i t i s e x p e c t e d t h a t B r i t i s h Columbia p h a r m a c i s t s w i l l p e r f o r m 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 s , o r d e v i a t e on t h e s i d e o f c a u t i o n ( i . e . , u n d e r - r e p o r t t h e i r l e v e l o f a c t i v i t y ) . T h e r e f o r e , a l t h o u g h s e l f - r e p o r t i n g i s a b i a s , t h e a c t u a l impact o f o v e r - r e p o r t i n g i s e x p e c t e d t o be o f minor consequence. To c o n t r o l f o r t h i s b i a s , t h e c o n f i d e n t i a l n a t u r e o f t h e s u r v e y r e s u l t s was emphasized t o t h e p h a r m a c i s t . The u l t i m a t e 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 " out t o r a n d o m l y - s e l e c t e d community pharmacies w i t h problems w h i c h would b e n e f i t from some p h a r m a c i s t h e a l t h p r o m o t i o n a c t i v i t y . I t i s beyond t h e scope o f t h i s s t u d y , however, t o a t t e m p t t h i s l e v e l o f c o n f i r m a t i o n . 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 were e x c l u d e d from t h e s t u d y 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 . I n t h e 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 on s i c k l e a v e , b u t had m a i n t a i n e d r e g i s t r a t i o n w i t h t h e C o l l e g e o f P h a r m a c i s t s . T h e r e f o r e , t h e u s e a b l e sample was r e d u c e d t o 581 p h a r m a c i s t s . Four hundred and e i g h t y - s i x (486) p h a r m a c i s t s r e t u r n e d completed q u e s t i o n n a i r e s f o r a r e s p o n s e r a t e o f 83.6% (486/581). 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. F i g u r e 4 d i s p l a y s t h e r e t u r n r a t e o f t h e q u e s t i o n n a i r e s i n r e l a t i o n t o t h e f o l l o w - u p p r o c e d u r e s u n d e r t a k e n . 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 p r o c e d u r e i n i l l i c i t i n g a r e s p o n s e . R e t u r n r a t e s exceeded B e r d i e and Anderson's p r e d i c t i o n s , but c l o s e l y mimicked t h e p i l o t s t u d y ' s r e t u r n r a t e . 100 80 60 40 20 0 FIGURE 4 CUMULATIVE WEEKLY RESPONSE RATE PERCENT RETURNED PHONE STAF CALLS TED , 2N0 M AILING THAN CARDS (-YOU vlAILED 1 1 1 1 1 1 1 6 7 8 9 10 11 12 13 14 15 16 17 18 WEEK OF STUDY RESPONSE RATE FIGURE 5 MARGINAL EFFICACY OF FOLLOW-UP PROCEDURES PERCENT RETURNED 100 I INITIAL MAILING THANK-YOU CARDS SECOND MAILING PHONE CALLS FOLLOW-UP PROCEDURE MARGINAL RESPONSE ^ CUMULATIVE RESPONSE Sample D e s c r i p t i o n Because t h e s t u d y ' s sample c l o s e l y r e p r e s e n t e d t h e 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 p h a r m a c i s t s (see T a b l e 7) , t h e r e i s no r e a s o n t o b e l i e v e t h a t t h e s t u d y ' s sample 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 olumbia's community p h a r m a c i s t p o p u l a t i o n w i t h r e s p e c t t o o t h e r d e s c r i p t i v e v a r i a b l e s s u c h as t y p e o f p r a c t i c e , age, sex, and p l a c e o f employment (See T a b l e s 8 t o 1 3 ) . Demographic 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 and 15 and 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 l i k e l y t h a n male 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 p a r t - t i m e ( X' =94.236; df=2 ; p<0.001). T a b l e 16 d i s p l a y s t h e m a r i t a l 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 , and w i l l be examined 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 C o l l e g e D i s t r i c t 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 T o t a l 485 100.0 Table 8 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST SEX n % Male 288 59.4 Female 193 39.8 M i s s i n g Data 4 0.8 T o t a l 485 100.0 Table 9 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST DEGREE-GRANTING INSTITUTION 1 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 n % U n i v e r s i t y o f B r i t i s h Columbia 374 77.1 Other Canadian u n i v e r s i t y 49 10.1 F o r e i g n u n i v e r s i t y 22 4.5 M i s s i n g d a t a 40 8.2 1 T o t a l 485 100. 0 Table 10 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST EMPLOYMENT STATUS Employment S t a t u s n % F u l l - t i m e 372 76.7 P a r t - t i m e 113 23.3 M i s s i n g d a t a 0.0 0.0 T o t a l 485 100.0 Table 11 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST PRACTICE TYPE Type o f P r a c t i c e n % Independent 156 32.2 Independent C h a i n 119 24.5 F r a n c h i s e 88 18.1 C o r p o r a t e C h a i n 121 24.9 M i s s i n g d a t a 1 0.2 T o t a l 485 100 Table 12 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST YEAR OF GRADUATION Year o f G r a d u a t i o n 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 M i s s i n g d a t a 4 0.8 T o t a l 485 100.0 Table 13 SAMPLE DESCRIPTION ACCORDING TO PHARMACIST AGE Age ( y e a r s ) 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 > 70 4 0.82 M i s s i n g 17 3.51 T o t a l 485 100.00 TABLE 14 EMPLOYMENT POSITIONS OP BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PHARMACIST SEX* Male Female T o t a l S t a f f 30.7% 72.7% 230 47.5% Manager 34.8% 20.1% 140 28.9% Owner 34.5% 7.2% 114 23.6% T o t a l 290 59.9% 194 40.1% 484 100% [*X^ = 94.236; d] f = 2; p <0.001] Table 15 EMPLOYMENT STATUS OF BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PHARMACIST SEX* 1 Male Female M i s s i n g Row T o t a l P a r t - t i m e 43 70 0 113 (23.3%) F u l l - t i m e 245 123 4 372 (76.7%) Column T o t a l 288 (59.4%) 193 (39.8%) 4 (0.8%) 485 (100.0%) I*.^2 = 28.907; d f = l ; p<0.0 01] TABLE 16 MARITAL STATUS OF BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO PH2^RMACIST SEX* Male Female T o t a l M a r r i e d 76.8% 67.0% 348 72.8% D i v o r c e d 6.0% 4.6% 26 5.4% S i n g l e 17.3% 28.4% 104 21.8% T o t a l 284 59.4% 194 40.6% 478 100% II [* X^=8.30; d f =2; p<0.001] 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 non-respondent sample. The non-respondent sample was examined a c c o r d i n g t o p h a r m a c i s t sex ( T a b l e 16) , C o l l e g e d i s t r i c t ( T a b l e 17) , and t y p e o f p r a c t i c e ( T a b l e 18) . A p p r o x i m a t e l y 56% o f non-respondents were male and 44% were f e m a l e ; t h e s e numbers c l o s e l y r e s e m b le t h e a c t u a l p h a r m a c i s t d i s t r i b u t i o n a c c o r d i n g t o sex i n B r i t i s h Columbia. D i s t r i c t 3 had a lower number o f non-respondents t h a n most o t h e r d i s t r i c t s . D i s t r i c t 9 had a h i g h e r p e r c e n t a g e o f non-respondents t h a n i t s a c t u a l p h a r m a c i s t d i s t r i b u t i o n i n t h e p a r e n t p o p u l a t i o n . The h i g h e s t p e r c e n t a g e o f non-responders worked i n an indepe n d e n t pharmacy ( 3 8 % ) , f o l l o w e d by 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 indepen d e n t c h a i n (24%) s t o r e s . P h a r m a c i s t s w o r k i n g i n f r a n c h i s e p harmacies 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 sample c o n s t i t u t e d p h a r m a c i s t s w o r k i n g i n f r a n c h i s e p h a r m a c i e s . P h a r m a c i s t s w o r k i n g i n independent pharmacies were l e a s t 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 , a c c o u n t i n g f o r 38% o f a l l non-respondents. Table 17 NON-RESPONDING PHARMACISTS ACCORDING TO SEX P h a r m a c i s t Sex n P e r c e n t a g e o f non-res p o n d e n t sample Male 53 56% Female 42 44% 1 T o t a l 95 100% Table 18 NON-RESPONDENT SAMPLE ACCORDING TO COLLEGE DISTRICT D i s t r i c t n P e r c e n t a g e o f non-respondent sample A c t u a l Pop. D i s t r i b u t i o n * 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 T o t a l 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 as o f May, 1992. Table 19 NON-RESPONDENT SAMPLE ACCORDING TO PRACTICE TYPE P r a c t i c e Type n % o f nonrespondents Independent 36 38 Independent C h a i n 23 24 F r a n c h i s e 12 13 C o r p o r a t e C h a i n 24 25 T o t a l 95 100 1 Survey Results 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 ' median 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 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 . Of a p o s s i b l e s c o r e o f 165, p h a r m a c i s t s ' median H e a l t h P r o m o t i o n S c o r e was 105. The median 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 as non-d i s p e n s i n g h e a l t h promotion) was 79 out o f a p o s s i b l e s c o r e o f 135. P h a r m a c i s t s ' median H e a l t h P r o m o t i o n S c o r e on e v e n t s r e l a t e d d i r e c t l y t o t h e s e l l i n g o r d i s p e n s 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 as d i s p e n s i n g h e a l t h promotion) was 2 6 out o f a p o s s i b l e 30 p o i n t s . TABLE 2 0 PHARMACIST MEDIAN HEALTH PROMOTION SCORES O v e r a l l HP Score (n=485) N o n - d i s p e n s i n g HP S c o r e (n=485) D i s p e n s i n g HP Score (n=479) Median 105 79 26 Minimum 39.0 29.0 6.0 Maximum 158.0 128.0 30.0 S t d . Dev. 18.9 16.4 3.6 P e r c e n t a g e S c o r e 64 % 58 % 87 % 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 . The f i v e 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 e n j o y i n g t h e h i g h e s t p a r t i c i p a t i o n r a t e s by community p h a r m a c i s t s ( T a b l e 22) were 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 p r o m o t i o n a c t i v i t i e s . A l t h o u g h t h e f o u r a c t i v i t i e s w i t h t h e h i g h e s t p a r t i c i p a t i o n r a t e i n t h i s c a t e g o r y 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 olumbia, 1989), t h e d a t a show t h a t t h e r e i s l e s s t h a n p e r f e c t p a r t i c i p a t i o n i n t h e s e a c t i v i t i e s . 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 b e f o r e 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 p r o m o t i o n 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 p h a r m a c i s t s on a d a i l y b a s i s . These e v e n t s 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 f o r minor a i l m e n t s (such as d i e t a r y changes f o r c o n s t i p a t i o n ) , r e f e r r i n g 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 , s u g g e s t i n g non-d r u g a d j u n c t s t o d r u g t h e r a p y (such as i c e packs as an a d j u n c t t o i b u p r o f e n 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 a d v i c e 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 d r u g o r h e a l t h i n f o r m a t i o 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 t h t h e l o w e s t l e v e l s of p h a r m a c i s t p a r t i c i p a t i o n a r e d i s p l a y e d i n T a b l e 24. These a r e a c t i v i t i e s t h a t p h a r m a c i s t s r e p o r t e d " never" p a r t i c i p a t i n g i n , and 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, p a r t i c i p a t i n g i n d i s e a s e s c r e e n i n g programs, o b t a i n i n g a c l i e n t ' s 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 m e d i c a l h i s t o r y , c o u n s e l l i n g on AIDS p r e v e n t i o n , and o b t a i n i n g a p a t i e n t ' s smoking 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 h i s t o r y . Table 21 PHARMACIST SELF-REPORTED PARTICIPATION IN HEALTH PROMOTION ACTIVITIES (n=485) Percentage of Pharmacists Reporting Never Once Once Once More t h a n A c t i v i t y a Year a Month a Day Once a Day Co u n s e l c l i e n t s on: STDs 31. 3% 36. ,5% 24. 4% 7. 5% 0.: 2% Smoking c e s s a t i o n 5 .0% 16 .7% 40 .0% 31 .9% 6 .3% A l c o h o l abuse 34 . 0% 37 .9% 18 .1% 7 .9% 1 .9% I l l i c i t d r u g abuse 36 .7% 33 .5% 19 .8% 6 .0% 3 .8% Rx d r u g abuse 2 .7% 9 .2% 30 .8% 33 .1% 24 .0% OTC d r u g abuse 3 .3% 7 .3% 25 .8% 34 . 0% 29, .4% P o i s o n p r e v e n t i o n 9, .8% 39 .2% 36, .9% 11 .0% 2, .9% H y p e r t e n s i o n 6, .9% 10 .4% 31, .0% 33 .8% 17, .7% Cancer s i g n a l s 35, . 0% 35 .4% 24. . 0% 4 .2% 1. .3% N u t r i t i o n 4, .8% 9 .2% 30, .2% 33 .3% 22. .3% M e n t a l h e a l t h 24. .4% 23 .8% 32, .1% 13 .5% 6. .0% D i a b e t e s 7. .5% 14 .6% 34, .8% 29 .2% 13. .8% Weight c o n t r o l 7. .9% 11 .5% 42. ,3% 28 .8% 9, .2% F i r s t a i d 6. . 0% 7 .3% 25. ,6% 32 .9% 27, .9% I n f a n t c a r e 7. ,3% 9 .6% 29. , 0% 30 .2% 23, ,8% AIDS 41. .3% 34 .0% 17. ,3% 6 .7% 0, ,6% D e n t a l h y g i e n e 11. 0% 21 .9% 38. ,3% 23 .5% 5. , 0% C h o l e s t e r o l 7. 7% 14 .8% 37. ,9% 30 . 6% 8. ,8% Table 21—continued Percentage of Pharmacists Reporting Once Once a Once a Once or A c t i v i t y Never Yearly Month Week More Daily Speak t o community groups 63.1% 31.7% 4.6% 0.4% 0.2% P r o v i d e w r i t t e n d r u g o r h e a l t h i n f o r m a t i o n 2.9% 6.0% 32.1% 29.6% 29.2% A d v i s e c l i e n t s on OTC m e d i c a t i o n s 0.8% 0.2% 1.0% 3.8% 94.0% 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 c a r e p r o v i d e r s 1.7% 2.5% 11.3% 39.0% 45.4% P r o v i d e a d v i c e 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 2.1% 4.6% 24.6% 35.8% 32.7% 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 56.9% 29.2% 9.6% 2.5% 1.7% O b t a i n from c l i e n t s , i n f o r m a t i o n r e g a r d i n g : A l l e r g i e s 0, .8% 1, .3% 1 .3% 1. 7% 94, .8% M e d i c a l h i s t o r y 6. .9% 2, .7% 10 .0% 15. 0% 65, .2% C u r r e n t d r u g s 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% A l c o h o l 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% Table 21—continued Percentage of Pharmacists Reporting Once Once a Once a Once or A c t i v i t y Never Yearly Month Week More Daily 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 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 dr u g s t h e r a p y 1.7% 1.9% 13.3% 36.9% 46.0% Suggest non-drug a d j u n c t s t o d r u g t h e r a p y 2.9% 3.1% 18.3% 35.8% 39.6% ******************************************************************* ******************************************************************* Table 22 HEALTH PROMOTION ACTIVITIES MOST FREQUENTLY PARTICIPATED IN BY COMMUNITY PHARMACISTS IN BRITISH COLUMBIA (n=485) Percent Reporting A c t i v i t y Daily P a r t i c i p a t i o n 1. A d v i s i n g c l i e n t s on 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 on 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 on c u r r e n t d rugs 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 from c l i e n t s 64.9% 5. S u g g e s t i n g non-drug a l t e r n a t i v e s f o r minor 46.4% a i l m e n t s Table 23 NON-DISPENSING HEALTH PROMOTION ACTIVITIES MOST FREQUENTLY PARTICIPATED IN BY COMMUNITY PHARMACISTS IN BRITISH COLUMBIA (N=485) Percent Reporting A c t i v i t y Daily P a r t i c i p a t i o n 1. Suggest non-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 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 c a r e p r o v i d e r s 45.4% 3. Suggest non-drug a d j u n c t s t o dr u g t h e r a p y 39.8% 4. P r o v i d e a d v i c e t o o t h e r h e a l t h c a r e p r o f e s s i o n a l s 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 o r h e a l t h i n f o r m a t i o n 29.5% ***********ieie***ie*ie****ie*****ie*************************** Table 2 4 HEALTH PROMOTION EVENTS BRITISH COLUMBIA COMMUNITY PHARMACISTS CLAIM THEY "NEVER" PARTICIPATE IN (n=485) Percentage of A c t i v i t y Pharmacists Reporting 1. Speak t o community groups 63.1% 2. 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 56.7% 3. Query 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 s t r e s s 44.5% 4. 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. Query c l i e n t s on t h e i r smoking s t a t u s 40.0% VARIABLES INFLUENCING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Practice Variables i) Type of Practice P h a r m a c i s t s employed i n "independent c h a i n " d r u g s t o r e s had s i g n i f i c a n t l y 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 S c o r e s t h a n d i d p h a r m a c i s t s employed 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 o r "in d e p e n d e n t " d r u g s t o r e s { 9C^=14.6564 ; df=3,481; p=0.002). T h i s r e l a t i o n s h i p h e l d f o r b o t h 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 (X"^  =13 . 7673 ; df=3,481; p=0.003), and 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 ( 9("=8.5702; df=3,481; p=0.036)-N i n e t e e n i n d i v i d u a l 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 s p l a y e d d i f f e r e n c e s i n p a r t i c i p a t i o n l e v e l s between d i f f e r e n t p r a c t i c e s e t t i n g s ( T a b l e 25) . G e n e r a l l y , p h a r m a c i s t s w o r k i n g i n "ind e p e n d e n t c h a i n " d r u g s t o r e s o r " f r a n c h i s e " d r u g s t o r e s showed a g r e a t e r p a r t i c i p a t i o n l e v e l t h a n d i d p h a r m a c i s t s w o r k i n g i n "i n d e p e n d e n t " o r " c o r p o r a t e c h a i n " d r u g s t o r e s i n many h e a l t h 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 c e s s a t i o n , o v e r -t h e - c o u n t e r m e d i c a t i o n abuse, n u t r i t i o n , and w e i g h t c o n t r o l . Table 2 5 VARIATIONS IN HEALTH PROMOTION PARTICIPATION ACCORDING TO PHARMACIST PRACTICE TYPE* A c t i v i t y Outcome T e s t S t a t i s t i c * * P 1. C o u n s e l l i n g on smoking c e s s a t i o n 2 > 1 12 .222 0. .007 2. C o u n s e l l i n g on a l c o h o l abuse 2 1 > > 3 3 /4 ,4 21 .446 0. 000 3. C o u n s e l l i n g 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 misuse 3 > 1 10 .494 0. 015 4. C o u n s e l l i n g on n u t r i t i o n 2 ,3, 4 > 1 19 .274 0. 000 5. C o u n s e l l i n g on we i g h t c o n t r o l 2, 3 > 1 21 .155 0. 007 6. C o u n s e l l i n g on f i r s t a i d 2, 3 3 > > 1 4 21 .294 0. 000 7. C o u n s e l l i n g on i n f a n t c a r e 2 ,3, 4 > 1 38 .014 0. 000 8. C o u n s e l l i n g on d e n t a l h y g i e n e 3 > 1 12 .933 0. 005 9. Speak t o community groups on h e a l t h - r e l a t e d m a t t e r s 1 ,2, 3 > 4 25 .640 0. 000 10. P r o v i d e a d v i c e 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 2 ,3, 4 > 1 16 .483 0. 001 11. 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 c a r e p r o v i d e r s 3, 4 > 1 15 .215 0. 002 12. 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 on c u r r e n t m e d i c a t i o n s 2 > 4 13 .854 0. 003 14. Q u e r y i n g c l i e n t s on smoking s t a t u s 1, 2 2 > > 3 4 26, .828 0. 000 Table 25—continued A c t i v i t y Outcome Test S t a t i s t i c * * 16. 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 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 2 > 4 12.379 0.006 18. P a r t i c i p a t e i n coitununity h e a l t h e v e n t s 2 > 4 13.087 0.004 19. S u g g e s t i n g non-drug a d j u n c t s t o d r u g t h e r a p y 2,3,4 > 1 15.906 0.001 20. P r o v i d e a d v i c e 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 1 > 3 11.929 0.008 * 1= Independent s t o r e 2= Independent c h a i n ( e . g . , Pharmasave, P e o p l e ' s Drug Mart) 3= F r a n c h i s e ( e . g . , Shoppers Drug Mart) 4= C o r p o r a t e C h a i n (e.g. London Drugs, Safeway) ** df=3,480 ********************************************************* 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 l i k e l y t h a n p h a r m a c i s t s w o r k i n g i n "independent c h a i n " s t o r e s t o 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 o f a l c o h o l , o 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 . i i ) Geographic Location of Practice P h a r m a c i s t s 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 s t a t i s t i c a l l y s i g n i f i c a n t 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 s c o r e t h a n d i d p h a r m a c i s t s i n D i s t r i c t s 1, 3, 7, and 8 (X^=26.257; 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 p r o m o t i o n a c t i v i t i e s (X^=10.537; df=8,476). 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 p r o m o t i o n p a r t i c i p a t i o n a c c o r d i n g t o t h e g e o g r a p h i c l o c a t i o n s o f p h a r m a c i s t s ' p r a c t i c e s 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 p r o m o t i o n a c t i v i t i e s (see T a b l e 2 6) . 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 p h a r m a c i s t s i n o t h e r g e o g r a p h i c d i s t r i c t s , e x c e p t i n t h e c a s e o f s p e a k i n g t o community groups about h e a l t h - r e l a t e d m a t t e r s , where 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 s i g n i f i c a n t l y more i n v o l v e d t h a n urban D i s t r i c t 7 (7^"^ =48.167; df=8,476; p=0.000). Table 2 6 VARIATIONS IN INVOLVEMENT IN INDIVIDUAL HEALTH PROMOTION ACTIVITIES ACCORDING TO GEOGRAPHIC LOCATIONS* OF BRITISH COLUMBIA COMMUNITY PHARMACIST PRACTICES A c t i v i t y Outcome Test S t a t i s t i c * * P 1. C o u n s e l l i n g on 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 on 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 on 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 on w e i g h t c o n t r o l 6 > 1,3,7,8 28.132 0. 000 5. C o u n s e l l i n g i n f i r s t a i d 6 > 3,7,8 20.436 0. 009 6. C o u n s e l l i n g on i n f a n t c a r e 6 > 1,3,7 34.869 0. 000 7. Speak t o community groups on h e a l t h - r e l a t e d m a t t e r s 6 > 1,2,3,4, 7,8,9 4 > 7,8 48.167 0. 000 8. Query c l i e n t s on a l c o h o l use 7 > 3,8 19.900 0. O i l 9. 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 6 > 1,2,3,7, 8,9 19.331 0. 013 * 1= G r e a t e r V i c t o r i a / G u l f I s l a n d s 6= N o r t h e r n B r i t i s h Columbia 2= Vancouver I s l a n d 7= C i t y o f Vancouver 3= F r a s e r V a l l e y 8= Richmond/Delta/Bby 4= Thompson Okanagan 9= F r a s e r R i v e r N o r t h 5= Kootenay (see d e f i n i t i o n s o r F i g u r e 2) ** df=8,476 i i i ) Employment Posit i o n P h a r m a c i s t s ' employment p o s i t i o n had 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 ( 9 6^=1.103; df=2,482). A l t h o u g h t h e t i m e p h a r m a c i s t s s p e n t d o i n g 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, and owners (F=287.0818; df=2,482; p=.05) (see T a b l e 2 7 ) , a l l t h r e e groups p a r t i c i p a t e d 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 a t f a i r l y s i m i l a r l e v e l s . * * * * * * * * * * * * * * * i e * * * * * * * * * * * * * * * * * * * i e * * * * i s * i s * * * * * * * i e i e * * * * i s Table 27 DIFFERENCES IN DAILY TIME SPENT IN ADMINISTRATIVE FUNCTIONS BY BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO EMPLOYMENT POSITION P o s i t i o n Mean Hrs/Day* S t a f f 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=287.0818;df=2,482;p=.05] ***************************************************************** I n i n d i v i d u a l 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 a f f p h a r m a c i s t s were more i n v o l v e d t h a n owners i n c o u n s e l l i n g c l i e n t s on n u t r i t i o n (7^ '^  =12.735; df=2,482; p=0.002) and i n f a n t c a r e (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 c a r e p r o v i d e r s (']tl^^=10.986; df=2,482; p=0.004), and s u g g e s t i n g non-d r u g a l t e r n a t i v e s (X"^  =12.016; df=2,482; p=0.002) and a d j u n c t s ( } 6 =10.116; df=2,482; p=0.006) f o r minor a i l m e n t s . Owners and managers were 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 speak t o community groups {'Y^'^=A2.119 ; df=2,482; p<0.001) and 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; df=2,482; p<0.001). 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 P r o m o t i o n S c o r e s t h a n d i d p a r t - t i m e p h a r m a c i s t s (z=-2.519;df=483;p=0.012). T h i s r e l a t i o n s h i p d i d n o t h o l d t r u e f o r d i s p e n s i n g - r e l a t e d 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 (z=-1.239; df=483). D i f f e r e n c e s i n t h e l e v e l s o f p a r t i c i p a t i o n o f i n d i v i d u a l 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 c c o r d i n g t o p h a r m a c i s t s ' employment s t a t u s do e x i s t . 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 v o l v e d i n seven i n d i v i d u a l h e a l t h p r o m o t i o n p r a c t i c e s (See T a b l e 2 8 ) . Table 28 VARIATIONS IN HEALTH PROMOTION PARTICIPATION BY BRITISH COLUMBIA COMMUNITY PHARMACISTS ACCORDING TO EMPLOYMENT STATUS* A c t i v i t y Outcome Test S t a t i s t i c * * 1. 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 F > P z= -2.605 (p=0.009) 2. C o u n s e l l i n g on smoking c e s s a t i o n F > P z= -3.854 (p<0.001) 3. C o u n s e l l i n g on AIDS p r e v e n t i o n F > P z= -3.024 (p=0.002) 4. S p e a k i n g t o community groups on h e a l t h m a t t e r s 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 c a r e p r o v i d e r s F > P z= -2.422 (p=0.015) 6. 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 F > P z= -3.892 (p<0.001) 7. A d v i s e on OTC p r o d u c t s F > P z= -2.377 (p=0.017) * F= f u l l - t i m e employment, P= p a r t - t i m e employment ** df=4 ***********ie******************************************** i v ) S o cioeconomic S t a t u s o f C l i e n t e l e The 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 r v e d by t h e p h a r m a c i s t e f f e c t s p h a r m a c i s t s ' o v e r a l l 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 ('X^=11.748; df=4,421; p=0.019); p h a r m a c i s t s s e r v i n g l o w e r - c l a s s c l i e n t s were more i n v o l v e d t h a n p h a r m a c i s t s s e r v i n g u p p e r - c l a s s c l i e n t s . D i f f e r e n c e s i n 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 s p e c i f i c 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 c c o r d i n g t o 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 s e r v e d a l s o e x i s t e d . P h a r m a c i s t s s e r v i n g l o w e r - c l a s s c l i e n t s 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 on i l l i c i t and p r e s c r i p t i o n d r u g abuse (see T a b l e 2 9 ) . v) Barriers The median T o t a l B a r r i e r S c o re f o r p h a r m a c i s t s was 23 out o f a p o s s i b l e 40 p o i n t s (range 8.0 t o 40.0). 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 . No r e l a t i o n s h i p was d e t e c t e d between a 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 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 (r=-0.0752). B a r r i e r s t h a t 50% o r more o f p h a r m a c i s t s a g r e e d as b e i n g 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 p r o m o t i o n i n v o l v e m e n t i n c l u d e d " l a c k o f t i m e " and a " l a c k o f economic i n c e n t i v e s " . Table 29 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA PHARMACIST ESTIMATION OF CLIENT SOCIOECONOMIC STATUS* A c t i v i t y Outcome T e s t S t a t i s t i c * * 1. 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 2. C o u n s e l l i n g c l i e n t s on p r e s c r i p t i o n d r u g abuse 1 > 2,3 14.441 0.006 3. 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 c a r e 2 > 3 12.511 0.014 4. S u g g e s t i n g non-drug a l t e r n -a t i v e s t o d r u g t h e r a p y 4 > 1 13.027 0.011 * 1= Lower C l a s s 2= Lower-middle C l a s s 3= M i d d l e C l a s s 4= Upper-middle C l a s s 5= Upper C l a s s ** df=4,421 **ie****ie*ie*ie****ie***ie*******************ie*************isie* Table 30 BRITISH COLUMBIA COMMUNITY PHARMACIST PERCEIVED BARRIERS TO EXPANDING THEIR INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES (n=485) Percentage of Pharmacists Reporting Strongly Disagree Not Agree Strongly Ba r r i e r Disagree Sure Agree Time 3.1% 11. 8% 3.5% 50.5% 31.1% No economic i n c e n t i v e 9.5 25 .4 12.2 35.5 17.5 Sh o r t a g e 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 t h e a r e a 10.9 47 .4 19.4 21.0 1.2 Lack o f p a t i e n t demand 9.9 34 .2 26.2 25.6 4.1 Lack 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 6.0 40 .2 16.9 32.2 4.7 Lack c o u n s e l l i n g s k i l l s 19.8 55 .3 10.1 13.6 1.2 S t a f f p h a r m a c i s t s b e l i e v e d t h a t t h e r e were 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 (F=3.5188;df=2,482;p=.05). S t a f f p h a r m a c i s t s were a l s o more l i k e l y t h a n owners t o c i t e t h a t l a c k o f t i m e (F=6.5359; df=2,482; p=0.05), l a c k o f demand f o r h e a l t h p r o m o t i o n s e r v i c e s (F=4.5245; df=2,482; p=0.05), and a s h o r t a g e o f pharmacy t e c h n i c i a n s (F=11.9481; df=2,482; p=0.05) were 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 . P e r s o n a l V a r i a b l e s i) Pharmacist Sex A p h a r m a c i s t ' s sex had no s i g n i f i c a n t e f f e c t on 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 Score (^^=0.0612; df=482) . Nor was sex 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 e r s o n a l h e a l t h b e l i e f s (z=-0.2498; df=482), p e r s o n a l h e a l t h b e h a v i o u r s (z=-1.4052; df=482), nor i n t h e i r p e r c e p t i o n o f b a r r i e r s l i m i t 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 a c t i v i t i e s (z=-0.4227; df=482). 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 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 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 s e x e s (see T a b l e 3 1 ) . Male p h a r m a c i s t s were more a c t i v e l y i n v o l v e d i n s p e a k i n g t o community gr o u p s , p a r t i c i p a t i n g i n community h e a l t h e v e n t s , and c o u n s e l l i n g on smoking c e s s a t i o n . Female p h a r m a c i s t s 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 c a r 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 t o d r u g t h e r a p y , and s u g g e s t i n g non-drug a d j u n c t s t o d r u g t h e r a p y . TABLE 31 SIGNIFICANT DIFFERENCES BETWEEN MALE (M) AND FEM2U:.E (F) PHARMACIST PARTICIPATION IN HEALTH PROMOTION ACTIVITIES IN BRITISH COLUMBIA T e s t A c t i v i t y Outcome S t a t i s t i c * 1. P a r t i c i p a t i n g i n community community h e a l t h e v e n t s M > F z=-3.786; p<0.001 2. S u g g e s t i n g non-drug a l t e r n -a t i v e s t o dr u g t h e r a p y F > M z=-3.552; p<0.001 3. S u g g e s t i n g non-drug a d j u n c t s t o d r u g t h e r a p y F > M z=-3.731; p<0.001 4. C o u n s e l l i n g on smoking c e s s a t i o n M > F z=-2.339; p=0.019 5. C o u n s e l l i n g on i n f a n t c a r e F > M z=-3.083; p=0.002 6. Speak t o community groups on h e a l t h - r e l a t e d m a t t e r s M > F z-3.807; p<0.001 * df=479 i n a l l c a s e s *********** **ic*ieie**********************is*************ie** i i ) Pharmacist M a r i t a l Status S i n g l e and d i v o r c e d 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 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 more f r e q u e n t l y t h a n m a r r i e d p h a r m a c i s t s 7.5345; df=2,475; p=0.023), p e r s o n a l h e a l t h b e l i e f s (7^^=0.6621; df=2,475), 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). D i f f e r e n c e s a c c o r d i n g t o p h a r m a c i s t s ' m a r i t a l s t a t u s were d e t e c t e d i n i n d i v i d u a l 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 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 c o n t r o l , AIDS p r e v e n t i o n , as w e l l as 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 c a r e p r o v i d e r s , and 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 when t a k i n g a c l i e n t ' s h i s t o r y . D i v o r c e d p h a r m a c i s t s were 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 become i n v o l v e d 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 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 c o n t r o l , AIDS p r e v e n t i o n , and 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 c a r e p r o v i d e r s (see T a b l e 32) . S i n g l e p h a r m a c i s t s were 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 p a r t i c i p a t e i n c o u n s e l l i n g on AIDS p r e v e n t i o n , and t h e p r e v e n t i o n o f 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 . i i i ) Pharmacist Personal Health B e l i e f s A m i l d , b u t 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 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 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 S c o r e s ( r = 0 . 1 l 0 5 , p=0.01). The s t r o n g e r 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 average 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 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 . T h i s 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 r d i s p e n s i n g - r e l a t e d 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 . Table 32 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA COMMUNITY PHARMACIST MARITAL STATUS (n=485) A c t i v i t y Outcome* T e s t S t a t i s t i c * * 1. 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 D,S > M 19.240 0.000 2. C o u n s e l l i n g on m e n t a l h e a l t h D > M 7.673 0.022 3. C o u n s e l l i n g on w e i g h t c o n t r o l D > M 10.914 0.004 4. C o u n s e l l i n g on AIDS p r e v e n t i o n 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 h e a l t h c a r e p r o v i d e r s S > M,D 11.090 0.004 6. Query c l i e n t s on 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 D > M 9.373 0.009 7. Suggest non-drug a l t e r n -a t i v e s t o dr u g t h e r a p y S > M 7.400 0.025 8. Suggest non-drug a d j u n c t s t o d r u g t h e r a p y S > M 8.166 0.017 * 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************************ iv) Pharmacist Age No a s s o c i a t i o n was d e t e c t e d between age and a p h a r m a c i s t ' s 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 (r=-0.0887). Age was weakl y c o r r e l a t e d t o 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 (r=0.1295, p=0.01), meaning t h a t as a p h a r m a c i s t g e t s o l d e r , h i s o r h e r p e r s o n a l h e a l t h p r a c t i c e s improve. No l i n k between 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 was d e t e c t e d (r=0.0304). V) Pharmacist Personal Health Behaviours A m i l d , b u t 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 (r=0.2189, p=0.001) e x i s t e d 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 S c o r e s . P h a r m a c i s t s 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 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 such as w e a r i n g s e a t b e l t s o r e x e r c i s i n g r e g u l a r l y were more l i k e l y t o p r o v i d e h e a l t h p r o m o t i o n 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. T h i s r e l a t i o n s h i p h e l d t r u e f o r 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 (r=0.1326, p=0.01), as w e l l as 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 (r=0.2237, p=0.001). Educational Variables i) Year of Graduation A s i g n i f i c a n t r e l a t i o n s h i p was d e t e c t e d between 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 and o v e r a l l 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 (r=0.1411; p=0.001). 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 , however, i s t o o weak t o be o f p r a c t i c a l meaning. i i ) Degree-Granting I n s t i t u t i o n No s i g n i f i c a n t d i f f e r e n c e s i n o v e r a l l 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 were d e t e c t e d between U n i v e r s i t y o f 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 from o t h e r Canadian o r f o r e i g n u n i v e r s i t i e s ('X'^  =0.723 ; df=2,442). I n d i v i d u a l 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 , however, showed v a r i a t i o n between t h e d i f f e r e n t g r a d u a t e s (see T a b l e 3 3 ) . U n i v e r s i t y o f B r i t i s h Columbia g r a d u a t e s were 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 s u g g e s t non-drug a d j u n c t s t o d r u g t h e r a p y t h a n g r a d u a t e s from o t h e r Canadian p r o v i n c e s o r o t h e r c o u n t r i e s . TABLE 33 PARTICIPATION IN HEALTH PROMOTION ACTIVITIES INFLUENCED BY BRITISH COLUMBIA COMMUNITY PHARMACIST DEGREE-GRANTING INSTITUTIONS (n=485) A c t i v i t y Outcome* T e s t S t a t i s t i c * * 1. C o u n s e l l i n g on i n f a n t c a r e 1 > 2,3 10.282 0.006 2. S u g g e s t i n g non-drug a d j u n c t s t o d r u g t h e r a p y 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 Columbia g r a d u a t e s 2= Ot h e r Canadian 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 Health 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 olumbia were t o r e c e i v e a p e r c e n t a g e grade f o r 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 e y would r e c e i v e a mark o f 64% (105/165). No benchmarks e x i s t t o de t e r m i n e i f t h i s 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 i s "good", "average", o r "bad". A s c o r e o f 58% (79/135) was o b t a i n e d by p h a r m a c i s t s f o r t h e i r p a r t i c i p a t i o n i n 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 . 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 d i s p e n s i n g - r e l a t e d h e a l t h p r o m o t i o n a t 87% (26/30) o f t h e maximum l e v e l t o be o b t a i n e d i n t h i s s t u d y . 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 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), a l l o w i n g h y p o t h e s i s one (HI) t o be r e t a i n e d (see T a b l e 34) . T h e r e f o r e , community 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 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 t h a n i n non-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 . Four o f t h e f i v e 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 showing t h e 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 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 a r e d i r e c t l y l i n k 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 of m e d i c a t i o n s . These e v e n t s i n c l u d e a d v i s i n g c l i e n t s on OTC 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 p o s s i b l e a l l e r g i e s , q u e r y i n g 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 , and o b t a i n i n g a c l i e n t ' 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 " t o c o m p e t e n t l y f i l l a p r e s c r i p t i o n o r s e l l an o v e r - t h e - c o u n t e r m e d i c a t i o n ( 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 lumbia, 1989). D e s p i t e t h e n e c e s s i t y o f t h e s e a c t i v i t i e s , o n e - t h i r d o f 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 b a s i s . 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 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 c o n f i r m s t h a t p h a r m a c i s t s a c t i v e l y c o u n s e l and 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 c a r e p r o v i d e r s , p r o v i d e a d v i c e t o o t h e r 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 , but c l i n i c a l l y s u i t a b l e a l t e r n a t i v e s t o d r u g t h e r a p y f o r minor a i l m e n t s . There i s ample room f o r i n c r e a s e d p h a r m a c i s t i n v o l v e m e n t i n t h e s e a r e a s o f h e a l t h p r o m o t i o n , as about o n e - t h i r d o f 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 d a i l y b a s i s . TABLE 34 SUMMARY RESULTS OF OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST OVERALL INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES H y p o t h e s i s S t a t u s 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 s c o r e s 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 t h a n f o r non-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 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 p r o m o t i o n s c o r e s t h a n male p h a r m a c i s t s 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 p r o m o t i o n s c o r e s t h a n s i n g l e p h a r m a c i s t s 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 s c o r e 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 s c o r e s 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 p r o m o t i o n s c o r e s 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 ' t o t a l p e r s o n a l h e a l t h b e h a v i o u r s c o r e s and 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 ACCEPTED 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 y e a r and 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 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 from t h e U n i v e r s i t y o f B r i t i s h C olumbia, 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 u n i v e r s i t i e s ACCEPTED H9: P h a r m a c i s t s employed i n "ind e p e n d e n t " p h a r m a c i e s w i l l have lo w e 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 s t h a n p h a r m a c i s t s employed i n " c o r p o r a t e c h a i n " pharmacies REJECTED HIO: P h a r m a c i s t s employed i n C o l l e g e d i s t r i c t 6 w i l l 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 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 and 7-9 ACCEPTED TABLE 34—continued SUMMARY RESULTS OF OPERATIONAL HYPOTHESES SURROUNDING PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES H y p o t h e s i s S t a t u s H l l : 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 p r o m o t i o n s c o r e s t h a n p h a r m a c i s t s p r a c t i s i n g i n u r b a n a r e a s ACCEPTED H12: S t a f f 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 p r o m o t i o n s c o r e s t h a n owners 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 from 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 p r o m o t i o n s c o r e s t h a n p h a r m a c i s t s s e r v i n g a p r e d o m i n a t e l y " u p p e r - c l a s s " c l i e n t e l e 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 p r o m o t i o n s c o r e s t h a n p a r t - t i m e p h a r m a c i s t s ACCEPTED H15: 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 s t o t a l b a r r i e r s c o r e and 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 REJECTED 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 a c t i v i t i e s e n j o y i n g t h e h i g h e s t r a t e o f p a r t i c i p a t i o n a r e d i r e c t l y 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 i s s i m i l a r t o B e a r d s l e y ' 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 t h e c u r r e n t s t u d y ' s r e s u l t s can be i n t e r p r e t e d i n t h r e e d i f f e r e n t ways: 1) No change has o c c u r r e d o v e r t h e l a s t decade i n t h e l e v e l o f 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 a c t i v i t i e s ; 2) B e a r d s l e y ' s sample, w h i c h was s m a l l and non-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 were e x t r e m e l y a c t i v e 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 and t h u s caused an o v e r -e s t i m a t i o n o f p h a r m a c i s t i n v o l v e m e n t f o r t h a t t i m e p e r i o d ; o r 3) A m e r i c a n p h a r m a c i s t s have a more e x t e n s i v e community h e a l t h r o l e t h a n Canadian p h a r m a c i s t s . T h i s l a t t e r p o s s i b i l i t y may o r may n o t 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 p h a r m a c i s t a r i s i n g from t h e d i f f e r i n g h e a l t h c a r e systems. T a b l e 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 American p h a r m a c i s t s as compared t o t h e c u r r e n t r e s u l t s from B r i t i s h C o lumbia p h a r m a c i s t s . D i f f e r e n c e s i n s t u d y samples and s t u d y 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 s t u d y 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 compare d a t a o b t a i n e d i n B e a r d s l e y ' s s t u d y w i t h d a t a o b t a i n e d i n t h e p r e s e n t s t u d y . However, some t r e n d s a r e w o r t h n o t i n g . F o r 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 common t o b o t h s t u d i e s , 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 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 (Walpole, 1983) . The p r o p o r t i o n o f p h a r m a c i s t s r e p o r t i n g a p a r t i c i p a t i o n f r e q u e n c y o f "never" was used f o r comparison because B e a r d s l e y ' s s t u d y used a 6 - p o i n t L i k e r t s c a l e , whereas t h i s s t u d y used a f i v e -p o i n t s c a l e , w h i c h may a f f e c t p h a r m a c i s t s ' e s t i m a t i o n o f t h e i r p a r t i c i p a t i o n l e v e l . "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 , means "never", and p r o v i d e d t h e most u n e q u i v o c a l c a t e g o r y f o r c o m p a r i s o n . Based 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 ican p h a r m a c i s t s t e n d e d t o be more i n v o l v e d i n c o u n s e l l i n g on a l c o h o l abuse, h y p e r t e n s i o n , c a n c e r s i g n a l s , d i a b e t e s , and w e i g h t c o n t r o l ( T a b l e 3 6 ) . B r i t i s h Columbia p h a r m a c i s t s , i n c o n t r a s t , r e p o r t e d 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 i n t e r v i e w i n g c l i e n t s f o r p o s s i b l e a l l e r g i e s , m e d i c a l h i s t o r y , o r c u r r e n t d r u g s . TABLE 3 5 A COMPARISON OF AMERICAN VS. BRITISH COLUMBIAN COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES* R e p o r t e d Frequency [%U.S.(n=182) / % B.C. respondents(n=581)] A c t i v i t y Never Once Y e a r l v Once Once M o n t h l y Weekly Once o r More D a i C o u n s e l c l i e n t s on: STD p r e v e n t i o n 28/31 39/37 26/24 5/8 2/0 Smoking c e s s a t i o n 14/5 18/17 29/40 23/32 16/6 A l c o h o l abuse 21/34 25/38 32/18 16/8 6/2 I l l i c i t d r u g abuse 10/37 13/34 37/20 25/6 15/4 P o i s o n p r e v e n t i o n 11/10 34/39 34/37 15/11 5/3 H y p e r t e n s i o n p r e v e n -t i o n o r c o n t r o l 4/7 2/10 12/31 34/34 49/18 Cancer s i g n a l s 22/35 28/35 33/24 13/4 4/1 N u t r i t i o n 7/5 12/9 25/30 27/33 29/22 M e n t a l h e a l t h 25/24 21/24 30/32 15/14 10/6 D i a b e t e s p r e v e n t i o n o r 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 Speak t o community g r p s 65/63 28/32 7/5 0/0 0/0 P r o v i d e w r i t t e n h e a l t h i n f o r m a t i o n 39/3 21/6 21/32 8/30 12/30 A d v i s e on OTCs 1/1 1/0 3/1 3/4 93/94 R e f e r p a t i e n t 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 2/2 1/3 16/11 27/39 54/45 T a b l e 3 5 — c o n t i n u e d R e p o r t e d Frequency [% U.S.(n=182) / % B.C. respondents(n=581)] Once Once a Once a Once o r A c t i v i t y Never Y e a r l v Month Week More D a i l y 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 55/57 16/29 13/10 7/3 9/2 I n t e r v i e w p a t i e n t s about: Drug a l l e r g i e s 8/1 4/1 11/1 19/2 95/95 M e d i c a l h i s t o r y 16/7 8/3 10/10 19/15 47/65 C u r r e n t drugs 9/5 3/2 8/8 17/18 63/67 ********************************************************* * U.S. d a t a from B e a r d s l e y , 1983. B.C. d a t a from p r e s e n t s t u d y . Table 3 6 A COMPARISON OF HEALTH PROMOTION ACTIVITIES "NEVER" PARTICIPATED IN BY BRITISH COLUMBIA AND AMERICAN COMMUNITY PHARMACISTS USING 95% CONFIDENCE INTERVALS (CI) A c t i v i t y 95% C . I . f a ) American Datafb) C o u n s e l C l i e n t s 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 Smoking C e s s a t i o n A l c o h o l Abuse P o i s o n i n g P r e v e n t i o n H y p e r t e n s i o n Cancer S i g n a l s N u t r i t i o n M e n t a l H e a l t h D i a b e t e s Weight C o n t r o l Speak t o Community Groups P r o v i d e w r i t t e n i n f o r m a t i o n A d v i s e on OTC p r o d u c t s R e f e r c l i e n t s t o o t h e r p r o v i d e r s 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 I n t e r v i e w c l i e n t s f o r : A l l e r g i e s M e d i c a l H i s t o r y C u r r e n t Drugs Percent Reporting That They "Never" P a r t i c i p a t e 27.4? 3.0 30.0 8.5 4.6 31.1 2.8 20.5 5.1 5.4 1.4 0.0 0.5 52.3 0.0 4.7 0.0 35.6% 6.8 38.4 11.3 9.0 39.6 6.6 28.1 9.7 10.2 58.8 - 67.4 - 4.4 - 1.6 2.7 61.1 1.6 9.3 0.6 28% 14(c) 21(d) 11 4(d) 22(d) 7(c) 25 5(d) 5(d) 65 39(C) 1 2 55 8(c) 16(c) 9(c) (a) based upon B r i t i s h Columbia d a t a from p r e s e n t s t u d y . (b) B e a r d s l e y , 1983. (c) F a l l s o u t s i d e t h e 95% c o n f i d e n c e i n t e r v a l , showing a low 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 95% c o n f i d e n c e i n t e r v a l , showing 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 Seven (64%) o f t h e 11 v a r i a b l e s examined 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 p r o m o t i o n a c t i v i t i e s . V a r i a b l e s found t o be r e l a t e d t o community p h a r m a c i s t s ' o v e r a l l 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 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 b e h a v i o u r s , t y p e o f p r a c t i c e , g e o g r a p h i c l o c a t i o n and 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 (see T a b l e 37) . T h e r e f o r e , Hypotheses 4, 6, 10, 11 and 14 r e g a r d i n g t h e s e r e l a t i o n s h i p s a r e a c c e p t e d , w h i l e h y p o t h e s e s 9 (which proposed t h a t 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 pharmacies would be 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 i ndependent pharmacies) and 3 (which proposed t h a t m a r r i e d p h a r m a c i s t s would be 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 r e j e c t e d . C o r r e l a t i o n c o e f f i c i e n t s f o r t h e r e l a t i o n s h i p 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 p r o m o t i o n s c o r e s and t h e i r t o t a l h e a l t h b e l i e f and h e a l t h b e h a v i o u r s c o r e s a r e t o o weak t o have any p r a c t i c a l i m p l i c a t i o n s (see T a b l e 37) . They were r e t a i n e d as v a r i a b l e s a s s o c i a t e d w i t h 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 because t h e q u e s t i o n s e x a m i n i n g t h i s r e l a t i o n s h i p were e x p l o r a t o r y and more r e s e a r c h i n t h i s a r e a i s w a r r a n t e d . TABLE 37 VARIABLES INFLUENCING BRITISH COLUMBIA COMMUNITY PHARMACIST OVERALL INVOLVEMENT IN HEALTH PROMOTION Variable Test S t a t i s t i c df p Employment s t a t u s Y^=6.341 483 0.012 P e r s o n a l h e a l t h b e l i e f s r=0.110 — 0.010 Type o f p r a c t i c e s e t t i n g l^:;. =14.656 3,481 0.002 G e o g r a p h i c l o c a t i o n 'X=26.257 8,476 0.001 P e r s o n a l h e a l t h b e h a v i o u r r=0.219 — 0.001 Soc i o e c o n o m i c s t a t u s o f t c l i e n t e l e 'X=11.748 4,421 0.019 M a r i t a l s t a t u s ")^=7.534 2,485 0.023 ***************************************************** F o r many y e a r s , t h e independent d r u g s t o r e has h e l d a r e p u t a t i o n f o r p r o v i d i n g p e r s o n a l i z e d s e r v i c e and b e i n g more p r o f e s s i o n a l l y - o r i e n t e d t h a n l a r g e , c h a i n d r u g s t o r e s (Berube, 1992) . Data from t h e p r e s e n t s t u d y r e f i n e t h a t b e l i e f ; i n d e p e n d e n t s t o r e s w h i c h belonged t o a v o l u n t a r y c h a i n employed p h a r m a c i s t s w i t h s t a t i s t i c a l l y s i g n i f i c a n t 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 S c o r e s t h a n d i d t r a d i t i o n a l , i n d e p e n d e n t " c o r n e r d r u g s t o r e s " . Many d i f f e r e n c e s i n i n d i v i d u a l 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 were a l s o p r e s e n t (see T a b l e 25) . O n l y i n a few i n s t a n c e s d i d t h e p h a r m a c i s t employed i n an indepe n d e n t s t o r e 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 employed i n any o t h e r p r a c t i c e s e t t i n g . A l t h o u g h e a r l i e r s t u d i e s (see T a b l e 2) have s u g g e s t e d t h a t sex and age would 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 p r o m o t i o n , t h e p r e s e n t s t u d y f a i l e d t o f i n d t h e s e 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 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 . A l l e l e v e n o f t h e v a r i a b l e s examined d i d 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 i n d i v i d u a l 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 . 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 e x t e n t t h a n f e m a l e p h a r m a c i s t s . T h i s f i n d i n g may be due t o t h e d i s p r o p o r t i o n a t e number o f males i n t h e m a n a g e r i a l o r owner p o s i t i o n ( 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 a c t i v i t i e s . 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 were 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 c a r e . Female p h a r m a c i s t s were 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 non-drug 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 due t o a weaker economic i n c e n t i v e amongst female p h a r m a c i s t s t o make a s a l e , as t h e y occupy owner o r manager p o s i t i o n s l e s s o f t e n t h a n 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 t h a n male 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 economic 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 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 (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 were 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 que 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 have s p e n t more t i m e w o r k i n g on 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 o f d o i n g so and f e e l c o m f o r t a b l e c o u n s e l l i n g c l i e n t s a c c o r d i n g l y . 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 female p h a r m a c i s t s (6.0% v e r s u s 4.7%) ( T a b l e 1 6 ) ; t h e f a c t t h a t more male p h a r m a c i s t s a r e d i v o r c e d may be an a r e a f o r f u t u r e r e s e a r c h . S i n g l e p h a r m a c i s t s c o u n s e l l e d c l i e n t s on AIDS and 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 p r e v e n t i o n more o f t e n t h a n m a r r i e d p h a r m a c i s t s . 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 age; 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 younger, and 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 'embarrassed' t o c o u n s e l c l i e n t s on AIDS and 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 p h a r m a c i s t s . However, no r e l a t i o n s h i p between age and AIDS (r= 0.0386) o r STD (r=-0.0335) c o u n s e l l i n g e x i s t e d . Perhaps t h e n e c e s s i t y o f " s a f e r - s e x " p r a c t i c e s i s more r e l e v a n t t o s i n g l e 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 r e l a t i o n s h i p , and so may have more o p p o r t u n i t y t o p e r s o n a l l y p r a c t i s e t h e s e b e h a v i o u r s . 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 l i k e l y t h a n p h a r m a c i s t s w o r k i n g i n "independent c h a i n " s t o r e s t o t a k e an adequate 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 e x p l a i n t h e l a c k o f a t t e n t i o n g i v e n t o t h e s e a c t i v i t i e s . More r e s e a r c h i s needed i n t h i s a r e a , as t o c o m p e t e n t l y p e r f o r m d i s p e n s i n g f u n c t i o n s p h a r m a c i s t s must 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 , i n c l u d i n g i n f o r m a t i o n r e g a r d i n g c l i e n t s ' a l l e r g i e s and c u r r e n t m e d i c a t i o n s from each p a t i e n 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 lumbia, 1989). P h a r m a c i s t s employed i n " c o r p o r a t e c h a i n " s t o r e s showed l o w e r p a r t i c i p a t i o n r a t e s t h a n p h a r m a c i s t s employed i n "independent c h a i n s " i n two o f t h e s e a c t i v i t i e s . 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 p r o m o t i o n a c t i v i t i e s t h a n p a r t - t i m e p h a r m a c i s t s . D u r i n g d a t a a n a l y s i s , i t was f e a r e d t h a t p a r t - t i m e and f u l l - t i m e p h a r m a c i s t s c o m p r i s e d two s e p a r a t e p o p u l a t i o n s . I f t r u e , c o m b i n i n g f u l l - t i m e and p a r t - t i m e p h a r m a c i s t s t o g e t h e r f o r d a t a a n a l y s i s would be i n c o r r e c t . The c a t e g o r i c a l n a t u r e o f t h e d a t a c o l l e c t e d p r e v e n t e d P e a r s o n - p r o d u c t c o r r e l a t i o n s from b e i n g used. T h e r e f o r e , t o e n s u r e t h a t p a r t - t i m e and f u l l - t i m e p h a r m a c i s t s were o f t h e same p o p u l a t i o n , 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 r e s u l t a n t i n t e r v a l i n c l u d e d z e r o and t h u s . p e r m i t t e d t h e assu m p t i o n t h a t p a r t - t i m e and f u l l - t i m e p h a r m a c i s t s were from 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 p a r t i c i p a t i n g i n community h e a l t h e v e n t s o r d i s e a s e s c r e e n i n g programs, 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 have 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 ; however, t h i s was n o t t h e s i t u a t i o n . S i x t y - t h r e e p e r c e n t (63%) o f p a r t - t i m e p h a r m a c i s t s were femal e (see T a b l e 14) , and may have 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 . Thus, t h e y may n o t have t h e a d d i t i o n a l t i m e t h a t would be e x p e c t e d o f a p a r t - t i m e p h a r m a c i s t . P a r t - t i m e p h a r m a c i s t s were a l s o more l i k e l y 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 i n d i c a t e 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 n e c e s s a r y f o r 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 a c t i v i t i e s (z=-2.377; 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 not have 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 t h o s e 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 t h a t d e v i a t e from t r a d i t i o n a l p h a r m a c i s t f u n c t i o n s . An unexpected f i n d i n g was t h a t p h a r m a c i s t s were more l i k e l y t o s u g g e s t non-drug a l t e r n a t i v e s t o d r u g t h e r a p y f o r minor a i l m e n t s t o u p p e r - m i d d l e 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 background who c o u l d b e n e f i t g r e a t l y from a " n o - c o s t " a l t e r n a t i v e t o d r u g t h e r a p y . However, c l i e n t s from t h e l o w e s t s o c i o e c o n o m i c c l a s s e s r e c e i v e f r e e m e d i c a l c o v e r a g e , i n c l u d i n g p r e s c r i p t i o n m e d i c a t i o n s ; t h e r e f o r e , t h e i n c e n t i v e f o r t h e s e p e r s o n s t o not p u r c h a s e a p r o d u c t may be l e s s t h a n i t would be f o r a c l i e n t w i t h o u t t h i s t y p e o f p u b l i c a s s i s t a n c e . The number o f p e r c e i v e d b a r r i e r s t o f u r t h e r 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 a c t i v i t i e s was not f o u nd 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 ' o v e r a l l 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 . The o p e r a t i o n a l h y p o t h e s i s (H2) i s 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 . The o n l y 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 l a c k o f t i m e t o 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 a c t i v i t i e s . A l t h o u g h t h e r o l e o f t h e pharmacy t e c h n i c i a n i n f r e e i n g up a p h a r m a c i s t ' s t i m e i s w e l l known (Whalen, 1981), i t was i n t e r e s t i n g t h a t o n l y 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 " l a c k o f t i m e " was a b a r r i e r a l s o b e l i e v e d t h a t a " s h o r t a g e o f t e c h n i c i a n s " was a b a r r i e r . A l a c k o f economic i n c e n t i v e s i s one o f t h e most commonly c i t e d b a r r i e r s f o r p h a r m a c i s t s ( B e a r d s l e y , 1983). O n l y 53% o f B r i t i s h Columbian p h a r m a c i s t s a g r e e d w i t h t h i s s t a t e m e n t ; 47% o f 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 were n o t s u r e i f t h i s was a b a r r i e r 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 a c t i v i t i e s . Owners, whom l i t e r a t u r e have d e s c r i b e d as b e i n g e c o n o m i c a l l y m o t i v a t e d , d i d not r e p o r t " l a c k o f economic i n c e n t i v e s " as a b a r r i e r any 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 managers ( %''^ =4 . 7483 ; df=2,482). A l t h o u g h owners were more l i k e l y t h a n 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 n e c e s s a r y f o r 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 ( =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 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 a c t i v i t i e s , as owners p a r t i c i p a t e d a t l e v e l s t h a t d i d n o t 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 o f a r e l a t i o n s h i p between 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 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 p r o m o t i o n i s i n t e r e s t i n g . Recent g r a d u a t e s who have been a b l e t o t a k e advantage o f a c u r r i c u l u m w h i c h i n c l u d e s h e a l t h p r o m o t i o n i d e o l o g y a r e not showing p a r t i c i p a t i o n l e v e l s s i g n i f i c a n t l y d i f f e r e n t from o l d e r g r a d u a t e s , who r e c e i v e d t r a i n i n g w h i c h f o c u s e d p r i m a r i l y on a " p r o d u c t - o r i e n t e d " , r a t h e r t h a n " p a t i e n t - o r i e n t e d " , c u r r i c u l u m ( S c h u l z and Brushwood, 1991; A p p l e b y , 1992). L o g i c a l l y , 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 t h e u n d e r g r a d u a t e c u r r i c u l u m i s n o t d i f f u s i n g i n t o t h e w o r k p l a c e . A l t e r n a t e l y , o n - t h e - j o b e x p e r i e n c e may p l a y a r o l e i n b r i n g i n g o l d e r p h a r m a c i s t s up t o t h e same l e v e l o f r e c e n t pharmacy g r a d u a t e s . More t h a n o n e - h a l f o f p h a r m a c i s t s a r e c o m f o r t a b l e w i t h t h e knowledge t h e y p o s s e s s t o 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 a c t i v i t i e s ; t h e r e f o r e t h e e f f e c t o f any changes t o u n d e r g r a d u a t e o r c o n t i n u i n g e d u c a t i o n programs i s u n c l e a r . A l t h o u g h t h i s s t u d y was e x p l o r a t o r y i n n a t u r e , and more r e s e a r c h 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 , a t t e m p t s t o i n c r e a s e 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 were found 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 p r o m o t i o n a c t i v i t i e s . F o r example, p a r t - t i m e p h a r m a c i s t s , p h a r m a c i s t s employed i n "independent" pharmacies o r " c o r p o r a t e c h a i n " p h a r m a c i e s , 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, and 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 e d u c a t i o n programs. Fu r t h e r m o r e , t h r o u g h pharmacy s t o r e s ' p o l i c i e s , as w e l l as 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 b o a r d s ' 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 and b e h a v i o u r s amongst 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, 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 a c t i o n s range from d e c l a r i n g a l l pharmacy b o a r d meetings as "non-smoking" o r i m p l e m e n t i n g " d e s i g n a t e d d r i v e r " programs a t a l l pharmacy 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 an a d d i t i o n a l 15 minutes t o s t a f f l u n c h b r e a k s f o r t h o s e p a r t i c i p a t i n g i n a p h y s i c a l a c t i v i t y . 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 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 second model, based on t h e p r e s e n t s t u d y ' s r e s u l t 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 independent c h a i n d r u g s t o r e , and work i n a remote 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 p r o m o t i o n a c t i v i t i e s . H a ving a c q u i r e d b a s e l i n e d a t a on 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 p r o m o t i o n a c t i v i t i e s o b v i a t e s 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 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 . F u t u r e i n t e r v e n t i o n s can now be 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 i n t h o s e i n d i v i d u a l 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 showing low p a r t i c i p a t i o n l e v e l s . From t h e p r e s e n t s t u d y , p h a r m a c i s t s ' 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 i n s t i t u t i o n , and 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 p r e d o m i n a t e l y s e r v e d have emerged as i m p o r t a n t v a r i a b l e s t o be 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 groups f o r f u t u r e i n t e r v e n t i o n s d e s i g n e d t o i n c r e a s e 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 p r o m o t i o n a c t i v i t i e s . F IGURE 6 A M E N D E D CAUSAL MODEL DEPICTING COMMUNITY PHARMACIST INVOLVEMENT IN HEALTH PROMOTION ACTIVITIES Personal Health Bel iefs Personal Health Behaviors Employment Posit ion Employment Status Marital Status Type of Pract ice Geographic Location Pharmacist Overall Involvement in Health Promotion Soc ioeconomic Status of Cl ientele 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 p r o m o t i o n . The purpose o f t h i s s t u d y was t o de t e r m i n e t h e e x t e n t t o whic h community p h a r m a c i s t s i n B r i t i s h C o lumbia a r e 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 a c t i v i t i e s and wh i c h e x t e r n a l f a c t o r s , i f any, a r e a s s o c i a t e d w i t h t h i s r a t e o f in v o l v e m e n t . 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 , s t r a t i f i e d sample o f 625 p r a c t i s i n g community 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 "once o r more d a i l y " was used t o examine t h e f r e q u e n c i e s o f 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 a c t i v i t i e s . 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 a l s o c o l l e c t e d . Three d i f f e r e n t f o l l o w - u p p r o c e d u r e s were used, r e s u l t i n g i n a r e s p o n s e 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 most 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 p r o m o t i o n e v e n t s w h i c h a r e d i r e c t l y l i n k 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 . These e v e n t s 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 , a d v i s i n g c l i e n t s 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 t h e y a r e t a k i n g , o b t a i n i n g m e d i c a l h i s t o r i e s , and s u g g e s t i n g non-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 . The a c t i v i t i e s t h a t p h a r m a c i s t s showed t h e l o w e s t p a r t i c i p a t i o n i n were s p e a k i n g t o community groups, p a r t i c i p a t i n g i n d i s e a s e s c r e e n i n g programs, q u e s t i o n 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 , c o u n s e l l i n g on AIDS p r e v e n t i o n , and q u e r y i n g c l i e n t s on t h e i r smoking s t a t u s . Seven v a r i a b l e s were found t o be r e l a t e d t o community p h a r m a c i s t s ' o v e r a l l 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 . 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 h e a l t h b e h a v i o u r s , m a r i t a l s t a t u s , t y p e o f p r a c t i c e , employment p o s i t i o n , g e o g r a p h i c l o c a t i o n , and 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 p r e d o m i n a t e l y s e r v e d . T h i s s t u d y p r o v i d e s r e s e a r c h e r s w i t h b a s e l i n e d a t a r e g a r d i n g 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 Columbia a r e 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 a c t i v i t i e s . The d a t a might 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 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 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 might be measured. The r e s u l t s a l s o may e n a b l e p o l i c y makers t o c o nduct 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 t h e c o n t r i b u t i o n s o f community p h a r m a c i s t s t o t h e h e a l t h o f t h e p r o v i n c e . F i n a l l y , t h e d a t a p r o v i d e i n s i g h t r e g a r d i n g t h e e x t e n t t o w h i c h c u r r e n t h e a l t h p r o m o t i o n t h e o r y and e d u c a t i o n i s b e i n g 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 p r o f e s s i o n a l s . Areas for Future Research 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 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 found t o be o n l y m i l d l y c o r r e l a t e d t o 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 . Because t h e q u e s t i o n s i n t h e s t u d y m e a s u r i n g t h e s e two v a r i a b l e s were i n t e n d e d t o be e x p l o r a t o r y , f u r t h e r r e s e a r c h i n t o 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 ' p e r s o n a l h e a l t h b e l i e f s , t h e i 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 , and 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 work i s w a r r a n t e d by t h e s e p r e l i m i n a r y r e s u l t s . P e r c e i v e d knowledge, and n o t a c t u a l knowledge, was measured i n t h i s s t u d y . T h e r e f o r e , i t i s n e c e s s a r y t o d e t e r m i n e i f p h a r m a c i s t s ' p e r c e p t i o n s o f 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 knowledge base, and 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 t h e w o r k p l a c e . 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 knowledge assessment t e s t on t h e v a r i o u s 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 . F o r example, an exam based upon h e a l t h p r o m o t i o n c ase 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 q u a l i t y 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 knowledge l e v e l . The r e l a t i o n s h i p between a p h a r m a c i s t ' s a c t u a l knowledge i n h e a l t h p r o m o t i o n and h i s o r h e r s e l f - r e p o r t e d l e v e l o f 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 c o u l d be examined. S i m i l a r l y , a d e t e r m i n a t i o n c o u l d be made whether p h a r m a c i s t s who s t a t e d t h a t a " l a c k o f knowledge" was not a b a r r i e r s c o r e d h i g h e r t h a n d i d p h a r m a c i s t s who f e l t t h a t " l a c k o f knowledge" was a b a r r i e r f o r them. A s u r p r i s i n g f i n d i n g was t h a t t h e o v e r a l l l e v e l o f 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 i n t e r e s t i n g 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 S c o r e 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 owners o r managers (depending on t h e t y p e o f p r a c t i c e ) shape t h e i r s t o r e ' 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 p h a r m a c i s t s i n h e a l t h p r o m o t i o n ? As mentioned 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 measuring 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 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 . I d e a l l y , t h e d a t a 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 used i n t h i s manner. The a c c u r a c y 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 must be d e t e r m i n e d , 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 t h e c l i e n t s r e c e i v i n g t h e h e a l t h p r o m o t i o n s e r v i c e . 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 . One v a l i d a t i o n method i n v o l v e s t r a i n i n g a group o f a c t o r c l i e n t s w i t h p a r t i c u l a r 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 p r o m o t i o n s e r v i c e from a p h a r m a c i s t , and s e n d i n g them i n t o a random sample o f community pharmacies. T h i s method i s more c o s t l y and l a b o u r i n t e n s i v e t h a n o t h e r methods, b u t would 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 s e r v i c e i s a c t u a l l y r e c e i v e d i n community pharmacies i n B r i t i s h C o lumbia. T h i s method would n o t , however, be a b l e t o v e r i f y 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 . The o n l y way t o t r u l y v a l i d a t e t h e f r e q u e n c i e s 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 a c t i v i t i e s , would be t o have 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 day f o r one y e a r ( i . e . , t o i n s u r e t h a t t h o s e e v e n t s p a r t i c i p a t e d i n by p h a r m a c i s t s o n l y once a y e a r a r e n o t m i s s e d ! ) . A n o t h e r method t h a t c o u l d be used t o v a l i d a t e t h e a c c u r a c y and 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 would 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 case 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 p h a r m a c i s t would do i f p r e s e n t e d w i t h a p a r t i c u l a r s i t u a t i o n . The 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 t e l e p h o n e i n t e r v i e w has been used s u c c e s s f u l l y on M o n t r e a l community p h a r m a c i s t s (Nguyen, 1992) , and would perhaps 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 c t i v i t i e s were b e i n g examined. A l t h o u g h good r e s p o n s e r a t e s and low c o s t s a r e bonuses t o b o t h t h e w r i t t e n and t e l e p h o n e assessments o f q u a l i t y , a drawback t o b o t h i s t h a t t h e i n f o r m a t i o n i s s e l f - r e p o r t e d and may v e r y l i k e l y d i f f e r 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 p r a c t i c e . The advantages and s h o r t c o m i n g s o f a l l o f t h e s e methods w i l l have t o be c o n s i d e r e d i n expanding r e s e a r c h i n t h e 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 f community p h a r m a c i s t s . References Anon. MDs c l o s i n g d o o r s i n B.C. b i l l i n g row. T o r o n t o S t a r . 1992; J u l y 9 ; page A9. A p p l e b y J . K e e p i n g up w i t h t h e p r o f e s s i o n , ( e d i t o r i a l ) American Pharmacy. 1992;NS32(3): 188. B e a r d s l e y RS. 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O c c u p a t i o n a l o r i e n t a t i o n and o v e r t b e h a v i o u r - t h e p h a r m a c i s t as d r u g a d v i s o r t o p a t i e n t s . American J o u r n a l o f P u b l i c H e a l t h . 1973 ; 6 3 ( 6 ) : 502-508. M a r t i n S. Making c h o l e s t e r o l s c r e e n i n g work i n s m a l l - t o w n A m e r i c a . A m e rican Pharmacy. 1990; NS30(8): 42-43. M a r t i n S. T r a d i t i o n a l v a l u e s , i n n o v a t i v e p r a c t i c e s : P h a r m a c i s t s who p r o v i d e c o g n i t i v e s e r v i c e s . American Pharmacy. 1990a; NS30(4):22-27. Meade V. APhA s u r v e y l o o k s a t p a t i e n t c o u n s e l l i n g . American Pharmacy. 1992;NS32(4): 307-309. M e r l i n o NS and P r i c e JH. D i e t i t i a n s ' p e r c e p t i o n s about and p e r s o n a l n u t r i t i o n p r a c t i c e s f o r c a n c e r r e d u c t i o n . J o u r n a l o f Community H e a l t h . 1992 ; 1 7 ( 2 ) : 117-130. Nathan A. 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S m i t h F J , S a l k i n d MR and J o l l y BC. Community pharmacy: a method o f a s s e s s i n g q u a l i t y o f c a r e . S o c i a l S c i e n c e and M e d i c i n e . 1990; 31(5):603-607. Smi t h MC. P a t i e n t end r e s u l t s o f community pharmacy s e r v i c e . J o u r n a l o f t h e American P h a r m a c e u t i c a l A s s o c i a t i o n . 1974;NS14(3): 131-135. S m i t h MC and G i b s o n JT. The p h a r m a c i s t and p r e v e n t i v e m e d i c i n e . J o u r n a l o f t h e American P h a r m a c e u t i c a l A s s o c i a t i o n . 1975;NS15(2):79-83. S o b a l J , V a l e n t e CM, Muncie HL J r , L e v i n e DM and Deforge BR. P h y s i c i a n s ' b e l i e f s about t h e importance o f 25 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 . American J o u r n a l o f P u b l i c H e a l t h . 1985(Dec); 75(12):1427-28. S o b a l J . 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 s i n f i r s t y e a r m e d i c a l s t u d e n t s . 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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. 1991;5(4): 3-26. Upjohn Company of Canada. Canadian Pharmacy S e r v i c e s Study 1990. P a t i e n t C o u n s e l l i n g : A Survey Among Community P h a r m a c i s t s . V a n d e l JH. A board 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 Drugs 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 o f 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 Concepts. New York: M a c M i l l a n P u b l i s h i n g Company L t d . , 1983. Watkins RL and Norwood GJ. 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. Wechsler H, L e v i n e S, I d e l s o n R, Rohman M and T a y l o r JO. The p h y s i c i a n ' s r o l e i n h e a l t h p r o m o t i o n - a s u r v e y o f p r i m a r y c a r e p r a c t i t i o n e r s . New England J o u r n a l o f M e d i c i n e . 1983; 308(2):97-100. Whalen F J . S u p p o r t i v e p e r s o n n e l and t r a i n i n g management, i n : McLeod DC, M i l l e r WA, eds. The P r a c t i c e o f Pharmacy. C i n c i n n a t i , Ohio. Harvey Whitney Books;1981:338-51. W i l s o n R. H e a l t h p r o m o t i o n : Whose j o b i s i t ? Canadian F a m i l y P h y s i c i a n . 1992;38(Feb): 336-339. Wyshak G, Lamb GA, Lawrence RS and Cur r a n WJ. A p r o f i l e o f t h e 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 and l a w y e r s . New England J o u r n a l o f M e d i c i n e . 1980; 3 0 3 ( 2 ) : 104-107. Z e l n i o RN, N e l s o n AA J r . , and Beno CE. C l i n i c a l p h a r m a c e u t i c a l s e r v i c e s i n r e t a i l p r a c t i c e : P h a r m a c i s t s ' w i l l i n g n e s s and a b i l i t i e s t o p r o v i d e s e r v i c e s . 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 I N HKALTH [ > t ? 0 1 V f O T f O N 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 ONCE ONCE ONCE OR YEARLY MONTHLY WEEKLY MORE DAILY a) Control of sexually-transmitted 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) OTC 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 J) Nutrition ^ 2 3 4 -> k) Mental health ^ 2 3 4 5 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 5 q) Dental hygiene ^ 2 3 4 0 Hypercholesterolemia prevention and/or control i 2 3 4 5 How often do you speak to commuaily groups? ONCE YEARLY ONCE HONTKCr ONCE WEEKLY ONCE OR MORE DAILY How often do you provide clicats with written drug or health information materials? NEVER ONCE ONCE ONCE ONCE OR MORE DAÏI.V YEARLY MONTULÏ WEEKLY 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 ONCE ONCE YEARLY MONTHLÏ MEEKLY ONCE OR MORE DAILY How often are you involved in disease screening programs (e.g., blood pressure clinics)? NEVER ONCE ONCE ONCE ONCE OR YEARLY MONTHLY WEEKLY 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? 3^ 21 Never R^ircly Sometimes Almost Gvcrytimc Every time Ofrcrcd 1 2 3 < S 10. How frequently do you suggest non-drug alternatives for minor ailments (e.g., dietary changes for constipation)? Never Once Once Once Once or Yearly Monthly Weekly More Daily 1 2 3 4 5 11. 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 Once Once Once Once or Yearly Monthly Ueclcly More Daily 1 Z 3 4 5 12. 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 3 4 b. Participating in exercise activity three times a week 1 2 3 - 4 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 13. Please estimate how often you participate in each of the activities listed below by placing an "X" in the space that best estimates the frequency of your participatioiL a. When did you last have your cholesterol checked? Never >2 years ^ l-Z years 41Z months b. How often do you participate in exercise activity? fJever jSometicnes 2^-4 times/week OnUy c How often do you use seatbelts when riding in a car? ^Never Sometimes Almost Always Always d. How often do you watch your: (a) weight? Never ^Sometimes ^Almost Daily ^Daily ( b ) diet? 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. a_ Lack of time b. Lack of economic incentives c. Shortage of pharmacy technicians d. Lack of appropriate knowledge in those areas e. Lack of patient demand f. Professional conflicts with other health care providers g. Lack of necessary patient information h. Lack of cotmselling skills i. Others? Please comment: strongly Disagree I 1 1 1 .1 1 1 •1 ^Disagree Z Z Z Z Z 2 2 2 Not Sure 3 3 3 3 3 3 3 Agree 4 4 4 4 4 4 4 122 s t r o n g l y Agree 5 5 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) Staff (b) Manager (c) 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 o f G r a d u a t i o n : Year o f G r a d u a t i o n : Age: Sex: ^Male M a r i t a l S t a t u s : ^Married o r e q [ u i v a l e n t Female D i v o r c e d S i n g l e From t h e l i s t below, p l e a s e check o f f a c a t e g o r y t h a t b e s t 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 income 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 ) Upper C l a s s (landowners, . CEO's, i n d e p e n d e n t l y w e a l t h y ) Space i s p r o v i d e d below f o r any comments you would l i k e t o make 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 you w i s h t o make. We g r e a t l y a p p r e c i a t e y o u r t a k i n g t h e t i m e t o complete t h i s s u r v e y - Thank 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 : A l m o st a l l p h a r m a c i s t s a r e 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 a c t i v i t i e s t o v a r y i n g d e g r e e s . 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 an e f f o r t t o det e r m i n e t h e e x t e n t t o whi c h B r i t i s h Columbia p h a r m a c i s t a r e 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 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 m i n u t e s 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 by Ms. E l a n P a l u c k and Dr.Timothy 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 has 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 be used 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 Dr. S t r a t t o n i f n e c e s s a r y . Data w i l l be k e p t l o c k e d i n Dr. S t r a t t o n ' s o f f i c e , and o n l y Ms. P a l u c k and Dr. S t r a t t o n w i l l see 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 form o n l y ; your r e s p o n s e s cannot be t r a c e d back t o you. 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 p r o j e c t . 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 you g i v e y o u r c o n s e n t t o t a k e 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 s t u d y i s v o l u n t a r y ; no i l l w i l l towards you w i l l be h e l d by 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 nor by 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 i f you choose n ot t o t a k e p a r t . Your a s s i s t a n c e , however, w i l l h e l p us t o document t h e e x t e n t t o whi c h p h a r m a c i s t s a r e i n v o l v e d i n n o n - d i s p e n s i n g p r o f e s s i o n a l a c t i v i t i e s . We ask t h a t t h e completed 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 e n v e l o p e by . Reminders w i l l be s e n t o u t a f t e r t h a t d a t e . I f you have any q u e s t i o n s o r c o n c e r n s 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 M a i n l a n d . Thank you f o r your s u p p o r t ! S i n c e r e l y , E l a n P a l u c k , B.S.P. Graduate S t u d e n t Timothy S t r a t t o n , Ph.D., R.Ph. A s s i s t a n t P r o f e s s o r Appendix 3 Reminder/Thank-you Card Used i n F i r s t Follow-up Procedure 5 m T)ear Coffeayue, Uwo weeÂs ayo, a survey cuas maifecf foyou reyarxfinyp/iarmacist inuofuemenl in £ealt£promofion. S7fyou Aaue afreacfy returned your coinpfe/e<f survey, we woufifIi£e h tAan£youforyourparlicipajion / SJfyou £ave notyet returned your survey, pfease ta£e a fern minutes to camp fete 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'/iarmaceuticaf Sciences at622-2031. Ofian^-you foryour lime! Faculty of Pharmaceutical Sciences 2146 East Mall Vancouver, B.C. Canada V6T 1Z3 Tel: (604) 822-3183 Fax: (604) 822-3035 Appendix 4 Cover Letter Used i n Second Follow-up Procedure Dear C o l l e a g u e : About a month ago, we m a i l e d t o your work a d d r e s s an i n v i t a t i o n t o t a k e p a r t i n a p r o j e c t t o d e t e r m i n e t h e e x t e n t t h a t B r i t i s h C olumbia 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 a c t i v i t i e s . 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 Pharmacy A d m i n i s t r a t i o n , and Dr. Tim S t r a t t o n , a f a c u l t y member i n 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 . 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 Canadian 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 i m p o r t a n t i n d e e d . 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 t h e c a s e , we have i n c l u d e d a second s u r v e y f o r y o u r use. 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 urge you t o complete i t as soon as 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 twenty 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 completed 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 p r o v i d e d . As mentioned above, you w i l l be h e l p i n g t o break new ground f o r pharmacy w i t h t h i s p r o j e c t . Pharmacy groups w h i c h a t t e m p t e d t o document 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 Commission on H e a l t h Care 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 numbers 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 r e q u e s t e d . 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 use by our p r o f e s s i o n . A g a i n , y o u r r e s p o n s e i s v e r y i m p o r t a n t t o us and t o y o u r p r o f e s s i o n . P l e a s e t a k e t h e t i m e t o complete 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 o f our r e q u e s t i s g r e a t l y a p p r e c i a t e d ! I f you have 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 822-2051. 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 M a i n l a n d . S i n c e r e l y , E l a n P a l u c k , B.S.P. Graduate s t u d e n t Timothy P. S t r a t t o n , Ph.D., R.Ph. A s s i s t a n t P r o f e s s o r Appendix 5 Telephone 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 P r o c e d u r e H e l l o , may 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 , ask 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 you? 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 you a t home/work, but 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 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 . 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 , but 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 , so we a r e unsure as t o whether 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 wondering i f you c o u l d t e l l me i f you have m a i l e d i n your c o m p l e t e d q u e s t i o n n a i r e y e t ? I F RESPONSE IS "YES": When e x a c t l y was i t m a i l e d ? (make note o f i t ) . G r e a t ! A t l e a s t we 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 and 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 IS "NO"; May I ask you 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 you have chosen n o t t o p a r t i c i p a t e ? " L o s t s u r v e y " : 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 q u e s t i o n n a i r e " ? ( c o n f i r m t h e i r a d d r e s s ) "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 you c o u l d m a i l them o u t a n o t h e r copy o f t h e q u e s t i o n n a i r e . "Don't Have Time" o r "Don't Want To": The q u e s t i o n n a i r e does 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 about 15 t o 2 0 m i n u t e s t o complete. T h i s i s a g r a d u a t e s t u d e n t ' 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 would be g r e a t l y a p p r e c i a t e d . CLOSING: W e l l , t h a n k s a g a i n f o r y o u r t i m e . Bye f o r now. 

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