An Interpersonal perception approach to understanding communication between pharmacists and patients

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An Interpersonal perception approach to understanding communication between pharmacists and patients
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Patients   ( mesh )
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Interpersonal Relations   ( mesh )
Professional-Patient Relations   ( mesh )
Patient Education   ( mesh )
Attitude   ( mesh )
Health Care Surveys   ( mesh )
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Thesis:
Thesis (Ph.D.)--University of Florida, 1997.
Bibliography:
Bibliography: leaves 156-164.
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by Michelle Tal Assa.
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Typescript.
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Vita.

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Full Text









AN INTERPERSONAL PERCEPTION APPROACH TO UNDERSTANDING
COMMUNICATION BETWEEN PHARMACISTS AND PATIENTS




















By

MICHELLE TAL ASSA


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1997































Copyright 1997

by

Michelle Tal Assa





























This manuscript is dedicated to my parents, whose constant love and support have

given me the opportunity to realize this goal; to my grandmother and extended family,

who have always been there to encourage me; and to my friends, who have made these

years in Gainesville much more enjoyable.













ACKNOWLEDGMENTS


My sincere gratitude goes to Dr. Carole Kimberlin, my major advisor, for her

tireless efforts throughout this project. I would also like to thank Drs. Donna Berardo,

Doug Ried and Rebecca Cline for their guidance and contributions to this research.

Many thanks to the Pharmacy Health Care Administration faculty for their

direction over the years. I would also like to thank my fellow graduate students who

were always there to commiserate and joke. My appreciation goes to DeLayne, Debbie,

Ned and the office staff for their flexibility and assistance which has made my work

easier in so many ways.

Finally, I would like to extend my love and appreciation to my family and friends

who have encouraged me throughout my graduate school experience.













TABLE OF CONTENTS



ACKNOWLEDGMENT ...................................... iv

ABSTRACT ............................................. vii

CHAPTERS

1 INTRODUCTION ..................................... 1
Problem Statement ................................. 1
Significance ..................................... 2
Background ..................................... 4

2 THEORETICAL FRAMEWORK AND SUPPORTING LITERATURE .... 8
Background ..................................... 8
Models of Interpersonal Perception ..................... 13
Interpersonal Perception Literature ..................... 16
Research Questions ............................... 20

3 REVIEW OF LITERATURE .............................. 23
Introduction and Background ......................... 23
Effect of Pharmacist-Patient Communication ............... 25
Extent of Patient Counseling ......................... 30
Pharmacist Views of Patient Counseling .................. 35
Pharmacist Variables Associated with Counseling ............ 39
Patients' Views of Pharmacist Counseling ................. 40
Changing Patients' Views of Pharmacy ................... 42
Summary ...................................... 44
Research Hypotheses .............................. 48

4 METHODOLOGY .................................... 50
Overview ..................................... 50
Instrument Development and Validation .................. 51
Study Variables .................................. 61
Analyses ...................................... 69














5 RESULTS .................
Characteristics of the Sample
Instrumentation .........
Descriptive Analysis ......
Testing the Hypotheses ....


6 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
Interpersonal Perception Method ................
Perceptions and Pharmaceutical Care .............
Implications .............................
Limitations .............................
Future Study ............................

APPENDICES

A QUESTIONNAIRES ............................
Pharmacist Survey .........................
Patient Survey ...........................


B REVISED QUESTIONNAIRES .
Pharmacist Survey .......
Patient Survey .........

REFERENCES ..................

BIOGRAPHICAL SKETCH ..........


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Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

AN INTERPERSONAL PERCEPTION APPROACH TO UNDERSTANDING THE
COMMUNICATION BETWEEN PHARMACISTS AND PATIENTS

By

MICHELLE TAL ASSA

August 1997

Chairperson: Professor Carole Kimberlin
Major Department: Pharmacy Health Care Administration

The purpose of this study was to examine the relationships between pharmacists'

and patients' perceptions of pharmaceutical care type services and the extent to which

these perceptions are associated with the types of services offered to patients. Using an

interpersonal perception approach to understanding the perceptions that pharmacists and

patients have, this study examined i) pharmacists' agreement with patients, ii)

pharmacists' understanding of patients, iii) patients' understanding of pharmacists, iv)

pharmacists' realization about patients' understanding of them, v) patients' realization

about pharmacists' understanding of them, vi) pharmacists' feeling understood and vii)

patients' feeling understood. Further, this study analyzed the extent to which pharmacists'

agreement, pharmacists' understanding, pharmacists' realization and pharmacists' feeling

understood predicted pharmacists' reported provision of pharmaceutical care. Data were








collected via telephone interviews with 147 pharmacists practicing in the community

setting, and 151 adult patients who had a prescription filled during the previous six

months.

Findings revealed that, according to the interpersonal perception method,

pharmacists and patients disagree on the pharmaceutical care services they believe would

be beneficial for patients. Overall, pharmacists perceived the services to be more

beneficial for patients than patients did. Further, pharmacists were found to

misunderstand patients' perceptions regarding pharmacy services. Likewise, patients

misunderstood pharmacists' perceptions. Results also indicate that pharmacists failed to

realize that patients misunderstood pharmacists' perceptions of the services. Patients, on

the other hand, realized that pharmacists misunderstood patients' perceptions of pharmacy

services. Despite this realization, patients did not feel misunderstood by pharmacists.

Finally, pharmacists felt erroneously understood by patients with regard to

pharmaceutical care services.

Pharmacists' understanding of patients' perceptions and pharmacists' agreement

with patients regarding the benefits of pharmaceutical care type services were found to be

significant predictors of pharmacists' provision of those services. However, only a small

percentage of the variability in pharmacists' behavior was explained by the model.

Based on these results, the study suggests that interventions designed to improve

communication between pharmacists and patients should focus on helping pharmacists to

realize their misunderstanding of patients and improving their understanding of each

others' perceptions of the benefits of pharmaceutical care type services.

viii













CHAPTER 1
INTRODUCTION


Problem Statement

Pharmacists, administrators, legislators and academics are calling for the

profession of pharmacy to move forward toward a more clinical, patient-oriented focus

in an attempt to provide better patient care and to improve patient outcomes from drug

therapy. One approach is the promotion of the concept of pharmaceutical care. Under

this philosophy, pharmacists work directly with patients and physicians in order to

design, implement and monitor patient medication regimens (Hepler and Strand 1990).

Pharmacists actively participate in decision making; monitoring and evaluating a

patient's use of medication. Despite noted benefits from this process, such as improved

compliance (Edwards and Pathy, 1984; Gotsch and Liguori, 1982; Sharpe and Mikeal,

1974; McKenney et al., 1973) and reduced cost of care (Knowlton and Knapp, 1994;

Forstrom et al., 1990), pharmacists in the community setting have been slow to adopt

this practice. Legal measures also have been aimed at expanding the type of services

provided by community pharmacists, yet few changes have occurred (Rumore, Feifer

and Rumore, 1995; Raisch, 1993; Alkhawajah and Eferakeya, 1992; Campbell et al.,

1989). In the community setting, pharmacists continue to dispense medications and

provide medication information sheets to patients in order to comply with regulations










established by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) (U.S.

Government Printing Office, 1990). But many pharmacists have yet to begin collecting

specific patient information or designing, implementing and monitoring patient-specific

therapeutic plans.

In order for the profession of pharmacy to move toward these expanded roles,

barriers in the pharmacy environment (including pharmacist-related, patient-related,

informational/philosophical as well as other) must be overcome. These barriers will be

discussed in further detail in Chapter Two. Pharmacists often cite lack of patient

demand for these services as a primary rationale for not providing them (Nelson,

Zelnio and Beno, 1984; Raisch, 1993; Herrier and Boyce, 1994). Despite pharmacists'

perceptions, patients report wanting additional information as well as additional

services by pharmacists (Erstad et al., 1994; Enlund et al., 1991; Hirsch et al., 1990).

It is precisely this incongruence which is at the heart of this study. Of further interest

is a related issue regarding the provision of pharmaceutical care type services. Because

pharmacists cite lack of patient demand as a barrier to providing pharmaceutical care

services, it stands to reason that if pharmacists understand patient demand, they may

indeed be more likely to provide those services. To better understand this issue, one

must understand the relationships between pharmacists' and patients' perceptions.



Significance

As the profession of pharmacy begins to shift toward more patient centered

activities, communication with patients becomes more important. Although dispensing








3
the right drug in the right dose to the right patient remains paramount to the profession

of pharmacy, it no longer is sufficient to define the role of the professional pharmacist.

The implementation of pharmaceutical care is a step toward a more active, patient

centered role for pharmacists. Such a practice model depends upon a pharmacist's

ability to interact with patients, as well as other health care professionals.

In addition, pharmacists are faced with changes in health care financing.

Pharmacists are increasingly being asked to justify their role in health care. As noted

by Knowlton and Knapp (1994), pharmacist involvement in therapeutic decision making

can save a payor money. For the pharmacy itself, however, providing patient services

can be a way of satisfying patients' needs and desires while at the same time saving the

health care system money.

By understanding patients' desires for services such as the provision of

information about medications and monitoring of medication effects, pharmacists can

more accurately direct the types of services they provide for their patients. This study

will attempt to characterize the level of understanding between pharmacists and patients

in terms of what types of services would be beneficial for patients.

Researchers have shown that often pharmacists do not fully understand what

their patients would like from them (Herrier and Boyce, 1994; Hirsch, 1990; Carroll

and Gagnon, 1984a). Similarly, because patients have not had experience with

expanded pharmacy services such as pharmacist development, implementation and

monitoring of therapeutic plans, patients may not fully understand what pharmacists are

capable of providing or what services pharmacists would like to provide for them










(Chewning and Schommer, 1996; Gagnon, 1978). This difference in expectations and

understandings can lead to a pharmacist being frustrated by a patient's lack of patience

when picking up a prescription; or, a patient being frustrated by his or her pharmacist's

lack of attention when dispensing a prescription. This study will attempt to illustrate

the extent to which pharmacists and patients agree or disagree on the types of pharmacy

services they perceive to be valuable. Further, it stands to reason that if a pharmacist

understood patients' desires for expanded services, that he or she would indeed provide

those services. This study will also attempt to test that hypothesis. If pharmacists

understand patients' desires for pharmacy services, are they more likely to provide

those services or do pharmacists merely understand patients' desires but not incorporate

them into practice?



Background

Pharmacists are in a unique position to provide patients with medication

information. Not only are they the last health care professionals to come in contact

with the patient prior to medication consumption, but they maintain a distinct

knowledge base of drug information which can provide patients with essential

information to prevent adverse drug effects and potential drug interactions. Policy

makers have recognized this potential and mandated through OBRA '90 that

pharmacists counsel all Medicaid patients receiving prescription medications beginning

January 1, 1993. Mandatory counseling laws are now widespread. The most recent

National Association of Boards of Pharmacy Survey of Pharmacy Law (1997) reported










that 45 states, including the District of Columbia, have required counseling for

Medicaid patients. One state had legislation pending to institute mandatory counseling,

and the remaining five states required an offer to counsel Medicaid patients. In

addition, 36 states required counseling for all other patients. Michigan and the District

of Columbia had legislation pending, while only seven states had no requirements for

counseling all other patients.

Pharmacists themselves, along with patients, recognize the need for patient

counseling. For example, Ortiz et al. (1984) asked pharmacists to complete a

questionnaire assessing their level of agreement with statements about the role of

community pharmacists. In response to the survey, 96 percent of pharmacists agreed

that community pharmacists should counsel patients about prescription and

nonprescription medications. They also agreed that pharmacists should keep up with

current drug information, should regularly attend continuing education programs and

have good working relationships with other health care professionals. Schommer and

Wiederholt (1994) found that pharmacists believe it is important to provide both oral

and written information to patients in order to avoid potential problems and

misunderstandings. Further, pharmacists have been shown to customize patient

counseling activities by identifying different elements of importance in patient

counseling based on various situations (Schommer and Wiederholt, 1994). However,

contrary to this view of pharmacist involvement, Hirsch et al. (1990) found that patients

want more drug information but reported that pharmacists do not always provide such

information. Alkhawajah and Eferakeya (1992) support this notion with their findings










that although pharmacists provided more information about medications than

physicians, patients still did not receive crucial information. None of the patients

involved in the study was told about potential adverse drug reactions and only 9 percent

of study patients were warned of important precautions.

Although pharmacists are in a position to counsel patients, and both pharmacists

and patients recognize the importance of patient counseling, many pharmacists still do

not counsel patients. To explain this phenomenon, pharmacists cite excessive

workload, lack of privacy, patient attitudes and store layout as barriers to providing

patient specific counseling services (Raisch, 1993; Herrier and Boyce, 1994). Carroll

and Gagnon (1984) noted that pharmacists' perceptions of patient demand is as

important as the actual patient demand in determining the provision of "patient-oriented

pharmacy services". The study explored pharmacists' perceptions of consumers'

demand for patient oriented pharmacy services. Researchers collected information

from both pharmacists and consumers and upon comparison of the two perspectives,

concluded that "pharmacists underestimate [patients'] demand for patient medication

records but not for voluntary provision of advisory services" (p.640). Herrier and

Boyce (1994) offer further support that, "one barrier regularly listed was low patient

expectations. Pharmacists felt that patients were not open to counseling because they

did not expect it" (p.23).

The extent to which pharmacists' perceptions serve as a barrier to counseling is

yet unknown. Examining pharmacists' perceptions of patients' expectations relative to

patients' actual expectations may provide a better understanding of any potential








7
barriers to counseling. This study will attempt to characterize pharmacists' perceptions

of patients' beliefs, patients' perceptions of pharmacists' beliefs as well as the extent to

which the congruency of these perceptions affects the communication that occurs

between them.













CHAPTER 2
THEORETICAL FRAMEWORK AND SUPPORTING LITERATURE



Background

The relationships between pharmacists' and patients' perceptions of the

communication that occurs, or can occur, between them is the primary focus of this

study. Communication between pharmacists and patients is an interpersonal process

that will be examined from an interpersonal communication approach to better

understand patient and pharmacist perceptions and the relationship between them. The

finding that pharmacists often perceive patients to be uninterested in learning more

about their medications despite patients' expressed desire for additional information,

may indicate that pharmacists hold inaccurate perceptions of patients' expectations.

Likewise, the fact that some patients may perceive their pharmacist as uninterested in

helping them may also be inaccurate. The congruency of pharmacists' and patients'

perceptions may determine if there is communication between the two and if so, the

nature of that communication. Thus, both pharmacist and patient perceptions must be

examined in order to understand and characterize the potential gap between them.

Individuals' perceptions help form the basis for the communication in which they

engage. For example, if patients perceive pharmacists to be too busy, then perhaps

they will not ask questions they have about medications. This perception can facilitate

8










the pharmacists' inaccurate perceptions of uninterested patients. Thus, each party's

perceptions not only shape the way they communicate (or not communicate) but in this

case may also further define the role of the pharmacist as merely a dispenser of

medications. This chapter will explore perception of self and others, the development

of models to explain interpersonal perception and finally will review interpersonal

perception literature.



Interpersonal Perception

People have the ability to explore the concept of self and as such develop

generalized views of themselves, or self-concepts. Self-concepts are derived not only

through rumination, but more significantly from interactions with others. Laing,

Phillipson and Lee (1966) call attention to the fact that many philosophical,

psychological and sociological theories have developed primarily from an "I"

orientation. Such theories lack an acknowledgment of the fact that "others" also play

an important role in the definition of self. However, Cooley (1902), with the concept

of the "looking glass self," began to explore the interplay between self and others and

how this in turn affects the "self". Cooley (1902) proposed that one's understanding of

self develops from one's perceptions of others' reactions to oneself. That is to say, one

learns about self mainly through experiences with others. The idea of the looking glass

self suggests that one's impressions of self are seen as a mirror of other's reactions. In

Laing's (Laing et al., 1966) terms, a person's experience is made up of not only a

direct view of the self and of a direct view of the other, but also includes an abstraction








10
of self. This includes others' views of the self as well as the self's view of their views,

which coalesce to form abstractions, labeled metaperspectives. For example, consider

that although I am unable to see myself as others see me, I am able to perceive them

seeing me in particular ways. These perceptions, combined with my view of self, form

my self-identity. In summary, the theoretical constructs of self-identity (my view of

myself) and meta-identity (my view of your view of me) are formulated not only by

looking at ourselves but also by looking at others looking at us and our perceptions of

the views of others' toward us, called metaperspectives.

The term phantasyy" has been used to denote a "primary way of experiencing

self and others which contributes to, and sustains, our relations with others throughout

life" (Laing, 1961, p.9). Isaacs (1952) suggests that the notion of phantasy helps a

person to identify and relate to others, and is a creation of a mode of experience which

is private, or internal, and only accessible by the self. One element of phantasy is that

knowledge of another person is based solely upon inference. Because a person's

experience is private, and unknown to others, one must attempt to interpret perceptions

of another person's behavior and oral communication in order to understand the other

person's experience. Further, this inference presupposes that the other person's actions

are in some way a function of the other's experiences. It is through perception that we

are able to experience and comprehend our environment as well as interact with people

in our environment (Heider, 1959). One can influence another's experience through

modification of one's behavior or alteration of the other's perceptions.










A person's behavior can be seen as a function of the person's experience with

another person's behavior in a common situation. More specifically, Person A's

behavior influences Person B's experience of the situation. This, in turn, influences

Person B's behavior which again influences Person A's experience (see Figure 1). In

essence, it is a circle of experience and influence. That is to say, the "behavior of each

towards the other is mediated by the experience by each of the other, just as the

experience of each is

mediated by the behavior of

each" (Laing et al., 1966;
A's Behavior B's Experience
p. 10). However, the
A Common situation B
behavior does not directly

lead to experience. It must A's Experience B's Behavior

first be perceived and

interpreted by the individual.
Figure 1. Interpersonal Perception and Behavior
As perception occurs, Laing, Phillipson and Lee (1966), p.9

interpretations are made. Further, because the criteria by which behaviors are

interpreted vary among individuals, one action may be perceived quite differently by

two people. For example, "to feel loved is to perceive and interpret, that is, to

experience the actions of the other as loving" (p. 11). Further, although the behavior

may be agreed upon, the meaning conveyed by the behavior may be disagreed upon.

For example, to one person, actions demonstrating love may be perceived by another as

controlling. Thus, experience entails the perception of an act as well as the










interpretation of it. Interpretations are based on past learning and can also vary

according to context. When two people do not agree on the meaning of a particular

behavior, questions arise as to their understanding of the difference of the

interpretations. This situation arises when peoples' perceptions of one another are

inaccurate. Further, one must question whether they realize that their understandings

differ. At the same time, two individuals can misunderstand each other and can realize

or fail to realize their misunderstanding.

For example, misunderstanding and misinterpretations of communication can

lead to spirals between two people which have dramatic implications for their

relationship. What one person thinks of the other, affects the second person's view of

self. This, in turn, affects the second's actions in response to the first. This example

illustrates the potential effect perceptions have on behavior. In order to discern the

nature of these spirals, one can view them as having multiple levels of analysis based

on multiple levels of perception. "Through my behavior I can act upon three areas of

the other: on his experience of me; on his experience of himself; and upon his

behaviors. In addition, I cannot act on the other himself directly, but I can act on my

own experience of him" (p.22). Three levels of perception that help us perceive

relationships with others, called metaperspectives, will be discussed. These include the

direct perspective, the metaperspective and the meta-metaperspective (Laing et al.,

1966).

As Laing et al. describe (1966), the direct perspective is a direct experience, or

perception. It is one person's view of another, or a person's view of self. For










example, one can perceive oneself as trustworthy while at the same time perceive

another to be untrustworthy. Second, the metaperspective is one person's view of

another's view of their relationship. Continuing with the example of trustworthiness, a

statement from the metaperspective may be "I imagine you would say I am

trustworthy." In other words, the metaperspective is each person's view of the other

person's direct perspective. Third, the meta-metaperspective is what I think you think

about what I think about you. For example, a statement from the meta-metaperspective

may be "I think that you imagine that I would say 'you are trustworthy'." In other

words, it is each person's view of the other person's metaperspective.



Models of Interpersonal Perception

Newcomb's Coorientation Model (1953) serves as the foundation for approaches

to interpersonal perception and thus offers

the groundwork for viewing how

interpersonal perceptions shape A B-- B

communication. As depicted in Figure 2,

the model assumes that two persons, A and X

B, are attracted to each other either

positively or negatively. Further, they Figure 2. Newcomb's Coorientation
Model; Wilmot (1975), p.84
simultaneously maintain an orientation or

attitude toward an object of communication, X. Newcomb (1953) suggests that

symmetry must be maintained in the triangular relationship. Under conditions of








14

discrepancy, such as if A dislikes X while B likes X, a state of psychological tension is

produced. This psychological tension must be reduced in some way. Symmetry can be

restored if A's attitude

toward B, or toward X,

changes. Other ways to A'A-B anderstming or
about X aboutX
restore symmetry include A t B

trying to change B's Accuracy

evaluation of X, A A N
Perceptions of Peelpions of
discontinuing communication B's co5nitions A' coapitions
Figure 3 Expanded Coorientation Model
with B, A seeking support McLeod and Chaffee (1973), p.484

from other persons, or A cognitively distorting perception of the realities of the

situation.

An expanded Coorientation Model was proposed by Taguiri et al. (1958) and

further elaborated by Chaffee and McLeod (1968). The expanded model facilitates the

measurement of the conceptual model detailed by Newcomb and employs the use of the

terms agreement, congruency and accuracy to describe perceptual differences between

two people. Congruency refers to the degree of similarity between A's own cognitions

and A's perception of B's cognitions. Communication can affect congruency by either

increasing or decreasing it depending on its initial level and accuracy. Agreement

refers to the degree of similarity between A and B's perceptions. This can also be

referred to as understanding in the context of a person-to-person orientation. Finally,

accuracy refers to the extent to which A's estimate of B's perceptions reflect the true










nature of his perceptions. Figure 3 provides a representation of the expanded

Coorientation Model.

Although Taguiri et al. (1958) are concerned with person-to-person relations,

rather than person to object orientations, this model can be applied to both. McLeod

and Chaffee (1973) propose that the Coorientation Model can be used in understanding

dyadic communication because it provides the groundwork for a relational analysis. In

order to understand a relationship between two people, one must examine the nature of

the relationship itself rather than merely observing the two as individuals. In other

words, the dyad is the unit of analysis rather than the individual. Therefore, McLeod

and Chaffee (1973) propose that any index of a dyadic relationship should include a

measure of what each person's attitudes or orientation toward the other person or object

are, as well as what each person perceives the other's attitude or orientation to be. This

type of approach yields the relational data regarding congruence and accuracy.

Newcomb's and Taguiri's models of communication are the beginnings of

relational models. Relational perspectives on communication began to develop in the

1950s and 1960s when researchers in Palo Alto, led by Bateson, brought into focus

relationships as systems (Reardon, 1987). They proposed that within relationships,

"patterns of interaction emerge and dysfunctional patterns, or problems, can often be

identified and altered" (Reardon, 1987; p. 43). Relational communication suggests that

not only does communication between two people serve to transmit content, it also

serves to define and maintain their relationship. Through metaperspectives individuals

gauge the relational communication that occurs between them. As Wilmot (1975)








16
explains, in transactions, each person 1) assumes a role for herself, 2) imputes a role to

the other and 3) estimates what role the other thinks she is assuming. These ideas are

analogous to Laing's terms, of direct, meta- and meta-metaperspectives in that each

person has a view of his and the other's role. In any given transaction, both

participants attempt to define themselves, the other and the relationship by interpreting

the relational cues from their communication. In a relationship, each participant has his

or her own definition of the situation and also an awareness of and ability to adjust to

how he or she thinks the other person defines the relationship. This leads to a mutual

definition of a relationship.

Based on the ideas of the looking glass self and relational communication,

people define themselves based on the others' reaction to their projected identity.

Further, they tend to seek support for the identities they project (McCall, 1970).

Through the meta-metaperspective, a measure of the degree of support for the projected

identity is possible.



Interpersonal Perception Literature

The IPM evolved from a psychological orientation and has been used

predominantly in the study of interactions between married couples (Drewery and Rae,

1969; Kottas, 1969; Sillars and Scott, 1983) or between friends (Sullins, 1992).

Further, studies have focused on accuracy of interpersonal perception, perceived

understanding (Sillars et al., 1994), resolution of marital conflict (Knudson et al.,

1980), and relationship control (Wichstrom and Holte, 1993).








17

In order to measure and analyze these perspectives and the relationships among

them, an Interpersonal Perception Method (IPM) was developed by Laing et al. (1966).

For this method, two people, A and B, can be asked to respond to a series of statements

from each perspective. Comparisons are then made between the two direct perspectives

to assess the pair's agreement or disagreement on that statement. A comparison of A's

metaperspective with the B's direct perspective yields a measure of A's understanding

or misunderstanding of B. A comparison of A's meta-metaperspective with the B's

metaperspective yields a measure of A's realization or failure to realize whether B has

understood or misunderstood A. Finally, a comparison between one's own direct and

meta-metaperspectives yields a measure of feeling understood or feeling misunderstood.

This will be discussed in further detail in Chapter Four.

Drewery (1969) further expanded Laing et al.'s (1966) Interpersonal Perception

Method (IPM), and distinguished his Interpersonal Perception Technique in three ways.

First, the technique uses the Edwards Personal Preference Schedule (EPPS), a

personality questionnaire designed to measure 15 personality traits. Second, the

technique limits the perceptual analysis, using a married couple as an example, to the

level of "husband's view of wife's view of a topic" which is labeled as Laing's

metaperspective. Laing extends his analysis to the meta-metaperspective which would

be the husband's view of the wife's view of the husband's view. Drewery believed that

the meta-metaperspective introduced a degree of conceptual difficulty into the task

which would seriously limit its usefulness. Third, a difference lies in the method of

comparison between dyads. Laing compares dyads by comparing the amount and










nature of the agreements or disagreements. Drewery's techniques, on the other hand,

compare dyads in terms of agreements and disagreements on established personality

traits (the EPPS).

As Sillars and Scott (1983) detail, numerous studies have shown a positive

relationship between understanding and adjustment in a relationship (Dymond, 1954;

Christensen and Wallace, 1976; Newmark et al., 1977; Laing et al., 1966; Murstein

and Beck, 1972; Sillars et al., 1994; Knudson et al., 1980). In a few of these studies,

the association has been found only when the wife responds in predicting the husband's

perceptions (Murstein and Beck, 1972; Stuckert, 1963). Subsequent studies (Sullins

1992; Alperson and Friedman 1983; Schullo and Alperson 1984) have corroborated the

finding that females tend to be more accurate in their perceptions of their partner or

friend than males. Researchers have also found perceived similarity, expectations of

agreement and feeling understood to be associated with higher levels of marital

satisfaction (Corsini 1956; Laing et al. 1966; Dymond 1954). However, Sillars et al.

(1983) suggest that the relationship between perception and marital satisfaction depends

on the couple's assumptions about marriage. For example, as Fitzpatrick (1982)

identifies, couples may engage in different type of relationships: traditional, in which

husbands and wifes function in traditional male and female roles; independent, in which

husbands and wives complement each other and work together but not in traditional

roles; and separate, in which husbands and wives function almost independently of one

another. If a "traditional" couple values sharing, their understanding may be very

important to marital satisfaction. On the other hand, if a "separate" couple values








19
emotional distance or autonomy, perceived understanding may not be related to marital

satisfaction. Research among disturbed couples (those who were seeking therapy or a

divorce) in comparison to nondisturbed couples has shown that using the IPM, there are

fewer disjunctions in the interactions of nondisturbed couples and that the nondisturbed

couples report a higher degree of harmony (Laing et al., 1966). Another study using

the Interpersonal Perception Technique (Drewery and Rae, 1969) showed differences

between alcoholic and non-alcoholic marriages. In non-alcoholic marriages, wives'

understanding of their husbands increased with duration of marriage. Conversely, in

alcoholic marriages, wives' understanding of their husbands decreased with length of

marriage.

Finally, Wichstrom and Holte (1993) used a shortened, modified version of the

IPM, the DYADE, to study the relationship between perception and relationship

control. This study improved upon earlier studies, which relied solely on the self-

report of behaviors, by observing couples on three occasions. Results indicated that

couples who communicated in dysfunctional ways reported less satisfaction in the

marriage. They also were less accurate in their perceptions of the other's feelings.

In summary, studies have shown agreement and understanding between partners

to be positively associated with adjustment and relationship control among married

couples. It would also seem that females are better able to perceive their partner

(Sullins, 1992; Alperson and Friedman, 1983; Schullo and Alperson, 1984). Laing,

Phillipson and Lee's (1966) Interpersonal Perception Method "is designed to measure

and provide understanding .. [of] the conjunctions and disjunctions, of two








20

individuals in respect of a range of key issues with which they may be concerned in the

context of their dyadic relationship" (p.38). Although traditionally used in the analysis

of personal relationships, this model of dyadic relationship seems to reach the essence

of the potential misperceptions between pharmacist and patient. A key issue in the

pharmacist-patient relationship is how pharmacists' and patients' perceptions influence

their communication. As will be detailed in the following chapter, pharmacists report

that they attempt to provide patients with the type of services they perceive patients

want, while at the same time patients perceive pharmacists' to be too busy to answer

questions and as such leave the pharmacy with unanswered questions. An adapted

version of the Interpersonal Perception Method may be helpful in providing a better

understanding of this discrepancy.



Research Questions

In parallel to intimate relationships, the extent to which pharmacists and patients

agree upon the potential benefits of pharmaceutical care, understand each other's

perceptions, realize their understanding and feel understood, may have a dramatic effect

upon their relationship. The incongruence that appears to exist between pharmacists

and patients is explored through the application of the interpersonal perception model.

Based upon the type information that can be gleaned from collecting data from the three

levels of perception; the direct, metaperspective and meta-metaperspective,

comparisons are made between pharmacists' and patients' perceptions to answer the

following questions:










1. Do pharmacists and patients agree on the type of pharmacy services

which they perceive would be beneficial to patients if provided by

pharmacists?

2a. Do pharmacists understand patients' perceptions of pharmaceutical care

type services?

2b. Do patients understand pharmacists' perceptions of pharmaceutical care

type services?

3a. Do pharmacists realize or fail to realize that patients understand (or

misunderstand) pharmacists' perceptions of pharmaceutical care type

services?

3b. Do patients realize or fail to realize that pharmacists understand (or

misunderstand) patients' view of pharmaceutical care type services?

4a. Do pharmacists feel understood by patients with regard to

pharmaceutical care type services?

4b. Do patients feel understood by pharmacists with regard to

pharmaceutical care type services?

5. What is the relationship between pharmacists' agreement with patients,

pharmacists' understanding of patients, pharmacists' realization of

understanding and pharmacists' feeling understood and the extent to

which pharmacists provide pharmaceutical care type services?

Research questions 3a and 3b were shaped by the results of research questions

2a and 2b. According to the theory, once understanding or misunderstanding has








22
occurred, the questions of realization can be addressed. If, in fact, patients were found

to understand pharmacists, results from research question number 3a would indicate

whether pharmacists realize or fail to realize that understanding had occurred.

Alternatively, if patients were found to misunderstand pharmacists, the question would

address whether pharmacists realize or fail to realize that misunderstanding had

occurred. Likewise, results from question 2b shaped question 3b for patients. The

following chapter will address what is known from the literature about communication

between pharmacists and patients which may help answer these research questions.













CHAPTER 3
REVIEW OF LITERATURE


Introduction and Background

In 1967, American Pharmaceutical Association President Bill Apple (Apple,

1967) called for pharmacists to communicate with other health professionals and

patients about the proper use of medications and to avoid becoming preoccupied with

the potential liabilities. After nearly thirty years and several legislative efforts,

pharmacists have yet to fully embrace their potential role as drug advisors. Pharmacists

have not yet assumed the role of drug educator, and patients continue to leave

physician's offices and pharmacies uninformed or misinformed about their medications.

Not only can pharmacists provide patients with information, they can assess patients'

response to treatment, provide ongoing monitoring of patients' response to treatment

and make recommendations to optimize patients' therapy. This expanded role for

pharmacists has recently become a focus within the profession of pharmacy. Hepler

and Strand (1990) outline this role for pharmacists as the provision of pharmaceutical

care that involves pharmacists working with patients and physicians to design,

implement and monitor patients' drug therapy. More than legislative requirements for

the provision of information, this type of involvement in patients' therapy relies on the

pharmacist's ability to communicate effectively with both patients and physicians.










Pharmacists must first initiate the communication with patients and then must collect

patient-specific information and utilize it to develop patient specific therapeutic plans.

In 1993, in order to assist pharmacists with the transition toward greater patient

involvement, the American Journal of Hospital Pharmacy printed guidelines on

pharmacist-conducted patient counseling. Fourteen points applicable to both

prescription and nonprescription drugs were listed as pertinent information. These

criteria are consistent with legislation (OBRA '90) mandating such patient counseling.

Through both legal and professional authorities, pharmacists are being urged to provide

patients with information. Historically, however, pharmacists have not provided much

information to patients. Despite the noted absence of counseling, patients recognize its

importance (Gagnon, 1994; Carroll and Gagnon, 1984b; Hirsch et al., 1990; Gotsch

and Liguori, 1992; Norwood et al., 1976).

The issue of patient counseling is of obvious significance to patients as well as

pharmacists and the profession of pharmacy. In order to better understand patient

counseling, researchers have observed the interactions between pharmacists and

patients. However, as discussed by Chaffee and McLeod (1973), it is not sufficient to

merely observe two individuals to understand their interaction, rather one must also

include a measure of each person's attitudes toward the other or object. The

Interpersonal Perception Method (IPM) is designed for this purpose--to measure and

provide an understanding of the "conjunctions and disjunctions of two individuals in

respect of a range of key issues with which they may be concerned in the context of

their dyadic relationship," (Laing et al., 1966; p. 38). In this case, it is not sufficient to








25

observe pharmacists' interaction with patients to judge the benefit of the services they

provide. Rather, one must ask both pharmacists and patients about their perceptions of

patient counseling from a pharmaceutical care perspective. Extensive research has

addressed patient counseling; some has included pharmacists' and patients' perceptions.

This chapter reviews the literature detailing the benefits of patient counseling in order

to demonstrate salience of this issue. Second, literature describing the extent to which

pharmacists engage in counseling behavior is reviewed to demonstrate what has been

learned through study of the issues. Finally, literature addressing pharmacists' and

patients' perceptions of counseling is reviewed to illuminate any gaps in our

understanding of pharmacists' and patients' perceptions as well as the congruency or

incongruence between their perceptions.



Effect of Pharmacist-Patient Communication

Researchers have used numerous terms in their description of pharmacist-patient

interactions. "Patient education", "patient counseling" and "pharmacist-patient

communication" have often been used interchangeably (DeYoung, 1996). As DeYoung

(1996) explains, researchers have been vague in defining "counseling." Some have

focused on pharmacists' provision of information specific to the medication (Gotsch and

Liguori, 1982; McBean and Blackburn, 1982; Slama and Gurwich, 1978; Madden,

1973), while more recently, others have studied more extensive pharmacist-patient

interactions in which pharmacists addressed patient concerns and questions in addition

to providing information (Borgsdorf et al., 1994; Opdycke et al., 1992; Kimberlin and








26
Berardo, 1987). Overall, benefits have been linked to pharmacists' involvement with

patients through the provision of written and oral information. These benefits include i)

an improvement in patients' knowledge about their therapy (Rantucci and Segal, 1986;

Jonston et al., 1986; Ascione and Shimp, 1984; McBean and Blackburn, 1982;

Madden, 1973; McKenney et al., 1973), ii) improved compliance (Lipton and Bird,

1994; Kimberlin and Berardo, 1987; Edwards and Pathy, 1984; Gotsch and Liguori,

1984; Slama and Gurwich, 1978; Clinite and Kabat, 1974; Sharpe and Mikeal, 1974),

iii) reduction in medication related problems (Hammarlund et al., 1985) and iv) cost

savings (Forstrom et al., 1990; Knowlton and Knapp, 1994). In keeping with the

interpersonal focus of this study, this section focuses on improved patient knowledge

and compliance because of the direct impact the pharmacist-patient relationship can

have on these variables.

Patient Knowledge

Numerous studies have demonstrated that provision of information can improve

patients' knowledge about their own therapy. Madden (1973) found a significant

difference in patients' knowledge about drug treatment in a group of 120 patients

studied in an experimental education group, as compared to an equal size control group

which received traditional pharmacy services. In another 1973 study, McKenney et al.

found that patients in the experimental group showed a significant improvement in their

knowledge of hypertension and its treatment compared to control group patients. Both

of these studies utilized patient recall as the measure of improved knowledge and found

that experimental group patients were able to provide significantly more correct










answers than controls. Later studies confirmed that patients' knowledge can be

improved through pharmacist intervention (Johnston et al., 1986; Rantucci and Segal,

1986; Ascione and Shimp, 1984; McBean and Blackburn, 1982). McBean and

Blackburn (1982) found that patients who had received both written and oral

information had significantly higher knowledge scores than patients who received no

information from the pharmacist. Further, in their study of over-the-counter

medications, Rantucci and Segal (1986) found that oral counseling did increase the

patients' knowledge of potential side effects, precautions and contraindications of the

medication. DeTullio and Corson (1987) showed that "instruction with demonstration

and practice resulted in better patient understanding and performance of the correct

steps for inhaler use, with improved bronchodilation as measured by ...[pulmonary

function tests]" (p. 1802). Contrary to these findings, when Slama and Gurwich (1978)

studied the effect of pharmacist consultation, they found that patients who were

counseled were more knowledgeable about their disease state and appropriate

medication use. Yet, patients who were not counseled were more knowledgeable about

medication names and renewal information.

Overall, pharmacist intervention generally has been shown to have a positive

effect on patient knowledge. Patients can benefit from pharmacists' knowledge and

accessibility, which allows pharmacists to answer questions and provide information

about medications and disease states. However, as DeYoung (1996) explains, the

relationship between improved patient knowledge and other patient outcomes is

unknown. For example, Kimberlin and Berardo (1987) found no significant










relationship between total knowledge and compliance, raising questions about the

usefulness of patient knowledge as an outcome of pharmacist counseling. Rantucci and

Segal (1986) also suggest that pharmacists' provision of information may not be

sufficient to affect change in patients' behavior. They suggest that it is a relationship

between pharmacists and patients that can prove most beneficial in improving patient

outcomes. Ascione and Shimp (1984) suggest that the pharmacist-patient relationship

can be developed by pharmacists tailoring their communication to the patient's specific

needs.

Compliance

Research in the area of compliance has shown conflicting results. Some

researchers have found no effect resulting from patient counseling on compliance. Yet,

others have found counseling promotes significant improvements in compliance. Early

research showed a short term improvement in compliance but little effect on long-term

compliance. McKenney et al. (1973) found that when taken on a long-term basis,

patients may become noncompliant even after initial compliance with the medication

regimen. During the five month period of counseling, patients randomly assigned to

the treatment group were significantly more compliant than non-counseled patients.

However, after the study period, the patients in the experimental group returned to their

baseline level of compliance. One study, Slama and Gurwich (1978), found that

consultation with a pharmacist had no effect on compliance. Kimberlin and Berardo

(1987) found a significant difference in patients' compliance between the pre-










intervention period and the intervention period where patients received medication

information from the pharmacist.

Pharmacist counseling can be particularly important in helping elderly patients

manage their complex medication regimens. Although studies by Wandless and

Whitmore (1981) and Roden et al. (1985) each found no significant improvement in

elderly patients' compliance despite pharmacist counseling, many studies of patient

compliance in the elderly have found that pharmacist involvement does improve

compliance (Lipton and Bird, 1994; Edwards and Pathy, 1984; Gotsch and Liguori,

1982; Sharpe and Mikeal, 1974). Specifically, Lipton and Bird (1994) studied the

effect of pharmacist intervention with elderly patients discharged from the hospital.

They found that at initial follow-up the experimental group patients were not more

compliant; however, at subsequent follow up they did have better overall compliance.

This supports the view that ongoing pharmacist contact may provided beneficial results

in compliance. Edwards and Pathy (1984) found that a counseled group of patients had

better compliance after six days. Further, Kimberlin and Berardo (1987) found a

significant relationship between knowledge about medications and compliance among

patients over the age of 60.

Results are mixed on whether written information alone is sufficient to improve

compliance. Sharpe and Mikeal (1974) studied the effect of providing written

information to patients receiving prescriptions for antibiotics. In a comparison of two

groups of patients (those who had received no additional information beyond the

prescription label and those who had received an information sheet), those who









received additional information were more compliant with their medication regimen.

Gotsch and Liguori (1982) also found higher rates of compliance among patients who

received patient package inserts for their antibiotic therapy compared to patients who

received no information. Clinite and Kabat (1974) suggest that "written drug

information without oral reinforcement was 'counterproductive' to compliance" (p. 85).

This statement was based on the fact that patients who received only written

information made the most 'errors' (30%) in dosing, while those who received verbal

review of the written information made the fewest 'errors' (14%). This suggests that

pharmacist involvement in providing written and oral information on an ongoing basis

is beneficial for patients. Kimberlin and Berardo (1987) found that patients responded

favorably to both written and oral information, as well as the combination of the two.

Pharmacists in the study preferred the combination of written and oral information and

believed that it was most effective in educating patients.

In summary, while some researchers found no significant improvement in

patients' compliance despite pharmacist counseling, the majority of research supports

pharmacists' ability to enhance compliance, via education and monitoring, particularly

in the short run. This suggests that ongoing pharmacist involvement may be the key to

improving patients' compliance with medication regimens.



Extent of Patient Counseling

Until the late 1960s few studies of pharmacists' communication with patients

were conducted. Knapp et al. (1969) suggest that while many articles may be found on










the philosophy of the pharmacist's role as a drug advisor, relatively few studies have

attempted to measure the quantity or quality of the pharmacist's performance. Knapp et

al. conducted one such a study, wherein a researcher posing as a diabetic patient

purchased a medication that is contraindicated in patients with diabetes. Of 36

pharmacists, only six refused to sell the medication to the patient. In another scenario,

a patient presented a prescription for a monoamine oxidase inhibitor used to treat severe

depression, and one week later returned with a prescription for Tofranil, another

medication for depression. Only one pharmacist out of 12 refused to dispense the

second prescription. This study helped identify the problem of the lack of pharmacists'

counseling in situations where a potential drug related problem exists.

A body of literature has emerged as researchers have attempted to quantify the

percent of patients who receive information from pharmacists. Early researchers

consistently found that approximately 70 per cent of patients do not receive oral

counseling from the pharmacist when they receive a prescription. Using pharmacy

students as mock patients, Rowles et al. (1974) found that 73 percent received no oral

counseling from the pharmacist when they picked up their prescriptions. Similarly,

Morris (1980) found that 72 percent of women received no oral counseling when

picking up a prescription for estrogen, while Ross et al. (1981) found that 69 percent

of patients received no oral counseling. Mason and Svarstad (1984) and Carroll and

Gagnon (1984) each found pharmacists to be providing counseling to more patients than

earlier studies. In these studies, 62 percent, 30 percent and 50 percent of patients did








32
not receive counseling, respectively. Mason and Svarstad (1984) used a mock patient,

whereas Carroll and Gagnon (1984b) conducted a mail survey of households.

Berardo, Kimberlin and Barnett (1989) conducted direct observation of

community pharmacists' interactions with patients. Prior to an educational intervention

with pharmacists, they found that in 381 encounters between pharmacists and patients,

between zero and 48 percent of patients received counseling from the eight different

pharmacists observed. Raisch (1993) also conducted an observational study in

conjunction with a self-report of pharmacists' patient counseling activities to compare

counseling based on different payment methods and practice settings. The percentage

of patients that were counseled ranged from only 7.9 to 12.9, with those in capitation

programs receiving significantly less.

Other national estimates are much higher. Meade (1994) reports that

pharmacists initiate conversations with patients 48 percent of the time, up from 39

percent in 1988. An earlier survey, reported by Meade (1992), found that 72 percent

of pharmacists offer advice to patients before they ask for it and that six out of ten

patients are counseled.

Some research has focused on the patient as a source of information regarding

pharmacists' counseling activities rather than relying on mock patients or pharmacist

self-report. Boyd et al. (1974) conducted interviews with patients, and found that 87

percent reported receiving no oral counseling from the pharmacist. Morris (1982)

conducted a telephone survey of 1,223 individuals to assess the level of counseling

provided to them by their pharmacist. Only 11 percent said that they had been










informed about potential side effects from their medication. Most (72 percent),

reported that nothing had been said to them at the pharmacy. Rather, they had received

written information in the form of auxiliary labels or leaflets. Some 19 percent

reported receiving no information at all from the pharmacist. Enlund et al. (1991)

surveyed 623 hypertensive patients, only 31 percent of whom were satisfied with the

amount of information they received on potential adverse effects. Finally, Wiederholt,

Clarridge and Svarstad (1992) report on an unpublished study in which Svarstad et al.

conducted direct observations of patients receiving prescriptions. Of the 558 patients

observed, 50 percent did not receive counseling. These studies suggest that only a

small fraction of patients are actually receiving counseling from pharmacists. Further,

the patients were not satisfied with the amount of drug information they received.

The National Pharmacy Consumer Survey, conducted in 1996, asked patients

about the information they received from their pharmacists. As Stover (1996) reports,

89 percent of patients report that they receive written drug information either "always"

or "often" for new prescriptions, and 70 percent of patients reported receiving written

drug information for refill prescriptions. Further, approximately half of patients

reported that they "always" or "often" speak with the pharmacist directly about their

medications. Despite these results, the patients also reported wanting more

information. This is consistent with an earlier study by Hirsch et al. (1990). Their

findings also suggested that patients were pleased with pharmacy services, but thought

pharmacists should supply more drug information.








34
One early study revealed differences in counseling based on practice setting. In

1978, Puckett et al., surveyed counseling practices in 95 pharmacies. They found that

practitioners in pharmacies where only prescription and nonprescription medications as

well as health care accessories were sold had the highest incidence of volunteering

information to patients when compared to practitioners in traditional pharmacies and

chain or discount pharmacies. Additionally, they found that when information was

given, it was most frequently related to warnings about the drug's action, the frequency

of administration and the need to avoid certain foods or activities. Although this

information was given, pharmacists generally failed to be specific with regard to the

timing of doses and many were not complete in the information provided. The

frequency of counseling varied by practice setting; in the traditional practice site, 36

percent of pharmacies provided voluntary counseling; in professional settings, 54

percent volunteered information; and in the chain or discount setting, 29 percent

provided voluntary counseling.

In summary, researchers have attempted to quantify the amount of patient

counseling that occurs in community pharmacies. Over time, there seems to have been

improvement. Recent results (Stover, 1996; Meade, 1994) have indicated that more

patients are receiving written and oral counseling from pharmacists than in the past

(Ross et al., 1981; Boyd et al., 1974). As described in numerous studies, many

factors may account for the observed variation, including practice setting, practice

environment and pharmacist characteristics. However, despite the benefits associated










with counseling and the wide range of estimates, it appears that pharmacists are not

providing consistent counseling to their patients.



Pharmacist Views of Patient Counseling

When exploring the apparent lack of patient counseling, one must consider the

views of pharmacists themselves, or pharmacists' direct perspectives of involvement

with patients. Many studies have attempted to understand the lack of pharmacist

counseling from the pharmacists' perspective. Zelnio, Nelson and Beno (1984) began

to explore potential barriers to pharmacists' involvement with patients. Community

pharmacists were sent mail questionnaires asking them to rate their willingness and

perceived level of competency for five potential levels of counseling ranging from

minimal to maximal interaction. Results indicated that both competency and

willingness may serve as barriers to pharmacists' provision of counseling services in

the community setting.

In further analysis of the responses to the mail questionnaire, Nelson, Zelnio

and Beno (1984) identified the following as barriers pharmacists perceived to their

provision of counseling services: lack of revenue from services, pharmacists' attitudes,

lack of time, physicians' attitudes, legal barriers, patients' attitudes, lack of patient

contact, pharmacist incompetence, lack of demand, services being too costly, lack of

facilities, inadequate pricing methods and pharmacists' characteristics such as type of

entry level degree. These barriers are echoed in more recent studies of barriers to








36

counseling (Raisch, 1993). In addition, lack of privacy and store layout were identified

by the 73 pharmacists who completed the survey.

The most comprehensive evidence is offered by Herrier and Boyce (1994) with

the results from workshops with nearly 30,000 pharmacists. Participating pharmacists

were asked to identify barriers to patient counseling at their practice sites. Once again,

common themes emerged in the discussions. Pharmacy environment, as well as

barriers that were pharmacist-related, patient-related, informational/philosophical and

miscellaneous were addressed. Barriers in the pharmacy environment included

excessive workload and lack of time or staff. The physical layout of the pharmacy and

lack of privacy were also mentioned as potential barriers. Pharmacist-related barriers

included lack of formal education or lack of knowledge about the prescribed drug, or

poor counseling skills.

Patient related barriers were most frequently identified as the patient being in a

hurry or uninterested in receiving information about the medication. The perceptions of

patients being uninterested in the information would be considered as coming from

pharmacists' metaperspective. Philosophical or information barriers were related to

pharmacists' questioning of their abilities to affect patient outcomes through counseling

activities. Finally, miscellaneous barriers include concerns over liability and lack of

reimbursement as barriers to providing counseling services. Consistent with previous

findings, Schommer (1994) also identified "lack of time" as the primary barrier to

counseling. Rumore, Feifer and Rumore (1995) in a study designed to explore

pharmacist' implementation of OBRA '90 regulations found that pharmacists listed time










constraints, lack of reimbursement and patient indifference as problems in

implementing OBRA '90 requirements. Finally, in one on one interviews pharmacists

identified the external barriers of time, practice setting, patient expectations and

personality as most salient (Assa, 1995).

Kirking (1982) offered a different, more positive view of pharmacists'

perception by looking at pharmacists' direct perspective of benefits of patient

counseling. In the study of pharmacists' perceptions of their patient counseling

activities as well the extent to which they engage in counseling activities, the

pharmacists reported that counseling would likely be beneficial for both patients

pharmacists. The pharmacists agreed that auxiliary labels and patient package inserts

cannot replace oral counseling. Further, they believed they were qualified to counsel

without additional training. Interestingly, they did not believe that the pharmacy layout

had an inhibitory effect on their counseling. Pharmacists' metaperspective of pharmacy

services was also included in the study. Pharmacists seemed to believe that although

patients may want counseling, they are unwilling to pay for those services.

Oliver and Barnes (1983) conducted an anonymous survey of 50 pharmacists

who identified communicating information about medications, gathering information

and responding to patients' anxieties as most important in patient counseling. They also

believed that pharmacists should initiate patient counseling rather than wait for the

patient to initiate it. Nelson, Zelnio and Beno (1984) found that pharmacists saw a

great need for their provision of clinical services, yet only a small demand for them.

Miller and Ortmeir (1995) also found that pharmacists believed they could provide










beneficial services that would meet the needs of patients. The pharmacists surveyed

ranked the services of providing a computerized patient profile, drug allergy screening

and drug interaction screening along with oral patient counseling and over the counter

medication counseling as the most important services they could provide for patients.

Consistent with the theoretical premise of interpersonal perception, pharmacists

rely on their perceptions of patients to define their role as pharmacists. Schommer and

Wiederholt (1994b) identified patient motivation, patient abilities and time available as

the most frequently cited determinants of the amount and type of counseling. The

situational elements were also identified as playing a role in pharmacists' decision to

counsel. Specifically, patients' familiarity with the medication and the pharmacists'

perceptions of seriousness of potential consequences with a particular medication were

important determinants of pharmacists' counseling. Schommer (1994b) found similar

results in a study of Ohio pharmacists. He, too, reports that pharmacists use "patient

desire for counseling and the type of medication to determine the amount and content of

counseling they give their patients" (p.765).

In summary, pharmacists recognize the importance of counseling yet find it

difficult to provide patients with the information they need due to many perceived

barriers. Pharmacists question their own knowledge and competency, yet also cite

external barriers such as lack of revenue, lack of time or lack of patient interest as key

issues. These barriers must be overcome if pharmacists are to proceed with what they

recognize as beneficial services. Pharmacists report that they perceive they are








39
behaving in accordance with what they think patients want from them. However, the

accuracy of pharmacists' perceptions is unknown.



Pharmacist Variables Associated with Counseling

The barriers identified by pharmacists suggest situational as well as personal

reasons patients may not be receiving as much counseling as they might desire or find

helpful. Differences between pharmacists may also be important when looking at the

provision of counseling services. Factors such as practicing independent pharmacy

settings, holding advanced pharmacy degrees, having completed more hours of

continuing education, working more hours per week and being more willing to

participate in continuing education programs have been found to be associated with a

higher level of provision of counseling services (Zelnio, Nelson and Beno, 1984).

Watkins and Norwood (1976) studied the relationship of practice environment and

pharmacist age to the quality of counseling pharmacists provide. They hypothesized

that there would be a difference in attitude, knowledge and behavior of pharmacists

based on the length of time since graduation and that there would be differences in

attitude, knowledge and behavior among pharmacists in different practice sites. They

found that there were no differences in the pharmacists attitudes or knowledge across

environment, yet there was a significant difference in behavior. Those pharmacists in

discount pharmacies had the lowest levels of counseling behavior, whereas those in

independent pharmacies had the highest. There was also a significant difference

between groups based on year of graduation on knowledge and attitude with those out










longer having less positive attitudes. No significant differences were found in

behavior.

Researchers generally agree that practice setting does affect the behavior of

pharmacists, with those in independent type pharmacies exhibiting the most counseling

behavior. This difference may be due to the amount of time available to pharmacists

for counseling or a difference in emphasis placed on these services by managers. Some

research evidence suggests that barriers such as pharmacy environment and lack of time

in certain practice settings noted by pharmacists are indeed barriers to counseling

(Zelnio et al., 1984; Watkins and Norwood, 1976).



Patients' Views of Pharmacist Counseling

In contrast to the studies of pharmacists, many researchers have studied

pharmacist-patient interaction from the patient's perspective. For example, Hirsch,

Gagnon and Camp (1990) attempted to understand patients' direct perceptions of

pharmacy through consumer focus groups. Overall, the patients in the study were

pleased with their pharmacists, but believed that the pharmacists should supply more

drug information. In fact, some patients believed that pharmacists were deliberately

withholding information from them. Further, while some patients complained about

having to wait for their prescriptions, others merely wondered why a waiting room was

not available. Chewning and Schommer (1996) assessed patients' perceptions and

knowledge of pharmacists' roles. They found that patients perceived pharmacists to be

too busy to interact with them. Some patients also felt that pharmacists were rude.








41
As Gagnon (1994) details, patients rated talking with the pharmacist about issues

such as dosage directions, side effects, interactions and allergies as either important or

very important. This underscores earlier work by Carroll and Gagnon (1984), who

gathered consumer self-reports of importance of pharmacy services in an effort to

characterize the accuracy of pharmacists' perceptions of consumer demands.

Consumers rated the voluntary provision of advisory services as the most

important service that could be provided. Also noted as important by consumers were,

successively, the friendliness of pharmacists, availability of advisory services on

request, nominal increase in prescription price (for additional time spent with the

pharmacists) and maintenance of patient medication records were rated as important by

consumers. Finally, Perri et al. (1995) conducted a survey to assess the impact of

OBRA '90 on pharmacists and patients. They found that patients felt pharmacists

provided useful information. They also reported that patients were willing to give the

pharmacist personal information to help the pharmacist improve their care.

Patients can receive information about their medications from a variety of

sources: while they still look primarily to their physician, they do value the pharmacist

as an advisor. Stratton and Stewart (1990) found that the public ranked "physicians

more highly than the pharmacist as a source of drug information only 19 of 95

respondents (20 percent) ranked the pharmacist as the first person from whom they

would seek information about a prescription drug" (p.21). Nonetheless, pharmacists

were ranked second among consumers as a source for drug information and as sources

of assistance in monitoring compliance as well as prevention of drug interactions.








42
Interestingly, almost two thirds (65 percent) of the consumers ranked the pharmacist as

the primary source of information about nonprescription drugs. In an earlier study of

rural consumers, Norwood et al. (1976) found that pharmacists were thought to be

extremely important as advisors concerning drugs, poisons and sickroom supplies.

In the National Pharmacy Consumer Survey (Stover, 1996) patients were asked

whether they would be interested in pharmaceutical care type services. Specifically,

they were asked if they would be interested in a service where a pharmacist would 1)

review the patient's medical history and develop a plan for taking the medication

properly, 2) meet with the patient to discuss the medication plans and answer questions,

3) recommend changes in the treatment plan to physicians and 4) contact the patient

occasionally to discuss how well the medication is working and any side effects the

patient may be experiencing. The majority of patients (69 percent) had a favorable

attitude toward those services.



Changing Patients' Views of Pharmacy

Early research by Norwood (1975) suggests that by improving patient

communication about drug therapy, consumers' attitudes toward pharmacy can be

improved. Consumer attitudes were measured using a scale that included items such as

patient reports about whether or not the pharmacist had a good knowledge of health

problems and of medications. In a study designed to determine the effect of written

information on compliance, Gotsch and Liguori (1982) found that patients in the

experimental group, who received written information, reported interest in receiving








43
patient package inserts routinely with new prescriptions. Berardo and Kimberlin (1987)

showed that when pharmacists are trained to provide medication information, they can

change patients' attitudes toward pharmacists. Most patients (91 percent) interacting

with pharmacists who provided them with written and oral information reported that the

pharmacists showed personal concern. Erstad et al. (1994) conducted a study in which

a randomized experimental group received increased contact with the pharmacist.

Patients in the experimental group reported being more satisfied with the increased

levels of pharmacy service as well as appreciating the greater contact. Patients also

reported desiring more contact with the pharmacist.

Patients may be uncertain of appropriate behavior for their role in the pharmacy.

Chewning and Schommer (1996) studied the effect of providing patients with a

pamphlet which described potential pharmacy services to patients on patients'

knowledge of pharmacists' roles. Patients who received the pamphlet demonstrated

significantly more knowledge about pharmacists' abilities than those who did not.

Patients cite embarrassment and ignorance that it was appropriate to seek information

from pharmacists as reasons they did not do so more often (Chewning and Schommer,

1996). This suggests that patients, too, use cues from pharmacists to define their

relationship.

In summary, research suggests patients value contact with the pharmacist and

feel the interactions can be helpful. In other words, from the patients' direct

perspective, pharmacy services are quite beneficial. Even when patients have not had

interaction with a pharmacist in the past, it appears that direct perspectives can be









altered by experience. If patients are given more opportunity to interact with

pharmacists, they appreciate it and come to prefer it. As pharmacists attempt to gauge

the type of services the patient would like to receive, they undertake a risk of

misunderstanding patients' desires. In order to more accurately direct services to

patients' wishes, pharmacists must first understand what those wishes are. Further,

pharmacists must understand that patients may not expect a high level of interaction

from the pharmacist based on past experiences, but that when additional interaction

with the pharmacist and additional information about medications are provided, patients

respond favorably.



Summary

Both pharmacists and patients rely on perceptions of one another to define their

relationships. Patients report feeling embarrassed or being unaware that it was

appropriate to seek information from pharmacists and that pharmacists are too busy or

were rude. They also suggested that pharmacists "give direct clues that they expect and

want to take an active patient consultation role" (Chewning and Schommer, 1996;

p. 1303). Yet, when patient expectations are met or exceeded, higher levels of patient

satisfaction are found (Schommer, 1995). Pharmacists report utilizing their perceptions

of patient attitudes to determine the extent of counseling they provide (Schommer,

1994b; Schommer and Wiederholt, 1994a).

From the literature detailing pharmacists' and patients' perceptions about their

interaction, inferences can be made about the relationships between their perceptions.










According to the comparisons made in using the Interpersonal Perception Method

(IPM), of interest is whether pharmacists and patients agree on the issue of patient

counseling from a pharmaceutical care perspective; whether each group understands or

misunderstands the other, whether each group realizes or fails to realize that they are

understood or misunderstood; and finally, whether each group feels understood.

Research suggests that pharmacists recognize the benefits of offering their expertise to

patients (Schommer and Wiederholt, 1994b; Ortiz et al., 1984; Oliver and Barnes

1983; Kirking, 1982) and patients recognize the benefit of that information as well

(Stover, 1996; Erstad et al., 1994; Carroll and Gagnon, 1984; Gotsch and Liguori,

1982; Norwood et al,. 1976). For example, McGhan et al. (1980) found a high

correlation (0.89) between pharmacists' and consumers' rankings of pharmacy services.

Pharmacists' and patients' direct perspectives seem to be similar, which implies that

they may agree on the types of pharmaceutical care services they perceive as beneficial

for patients.

Recent surveys of pharmacists (Herrier and Boyce, 1994; Schommer and

Wiederholt, 1994; Rumore et al., 1995) have shown that pharmacists identify patient-

related factors as barriers to counseling. Pharmacists in these studies perceived patients

to be in a hurry or uninterested in receiving additional information about their

medications. To the contrary, patients report wanting more information (Erstad et al.,

1994; Hirsch et al., 1990) and valuing the information provided by pharmacists

(Gagnon, 1994; Carroll and Gagnon, 1984; Norwood et al., 1976). This suggests that

pharmacists metaperspectives are not congruent with patients' direct perspectives,










which would indicate that pharmacists misunderstand patients' perceptions of

counseling. Patients, too, may misunderstand pharmacists' perceptions of counseling

behavior (Gagnon, 1978; Chewning and Schommer, 1996). One study found that some

patients believe that pharmacists were deliberately withholding information from them

(Hirsch et al., 1990). Based on the experiences patients have traditionally had in

pharmacies, they may not understand what pharmacists are capable of providing for

them (Chewning and Schommer, 1996; Erstad et al., 1994). Because patients are

unaccustomed to the additional attention of a pharmacist, they may believe that

pharmacists perceive it to be unnecessary. Patients' metaperspectives do not seem

congruent with pharmacists' direct perspectives, which indicates that patients may

misunderstand pharmacists' perceptions of the benefits of pharmaceutical care type

services. Thus, both pharmacists and patients may misunderstand the other's

perceptions of the benefits of counseling and fail to recognize their misunderstanding of

each other.

Little research exists as a basis for hypotheses about pharmacists' and patients'

realization of their misunderstanding because no research has examined pharmacists'

and patients' meta-metaperspectives directly. Pharmacists cite many barriers (e.g.

pharmacist-related or financial barriers) to counseling in the community setting

including patient demand. Logically, however, if pharmacists realized patients' desire

for counseling, patient demand would not be one of the perceived barriers they cite. It

seems that pharmacists may fail to realize that patients misunderstand them. It also

seems that patients fail to realize that pharmacists misunderstand their perceptions.








47
Researchers (Herrier and Boyce, 1994; Schommer and Wiederholt, 1994b; Schommer

1994a) have found that pharmacists consider patient desire for counseling as a factor in

deciding when to provide counseling. Patients report desiring more information, yet

pharmacists report perceiving them as uninterested. Perhaps if patients were to realize

that pharmacists perceived them to be in a hurry or uninterested, they would make their

views about counseling known.

Because of the suggestions that pharmacists and patients misunderstand each

other and each group fails to realize that the other group misunderstands them, as

described above, both groups feel misunderstood by the other with regard to patient

counseling activities. Further, because of the external barriers reported by pharmacists,

perhaps pharmacists feel that patients would not understand their perceptions of the

benefits of pharmaceutical care services. Finally, patients might expect that if the

pharmacist was aware of their desires for additional information, the pharmacist would

indeed provide counseling.

In order to predict pharmacists' behavior, it is logical to consider pharmacists'

perceptions of that behavior. Because pharmacists claim to consider patient demand

when providing counseling services (Herrier and Boyce, 1994; Schommer and

Wiederholt, 1994b; Schommer 1994a), it is reasonable to expect pharmacists'

understanding of patient perceptions to predict their behavior. Also, their agreement

with patients as to the benefits of that behavior is likely to be a strong predictor of that

behavior. Other data from the IPM, such as pharmacists' realization that patients

understand (or misunderstand) them and pharmacists' feelings of being understood (or










misunderstood), are likely to be weaker predictors of their behavior but will be

included in the analysis because they represent pharmacists' perceptions.



Research Hypotheses

Based on the literature and theory of interpersonal perception and literature

regarding pharmacists' and patients' perceptions of pharmaceutical care, the following

hypotheses were proposed.

H1 Pharmacists and patients agree on the types of pharmaceutical care

services they perceive as beneficial for patients if provided by

pharmacists.

H2, Pharmacists misunderstand patients perceptions of the benefits of

pharmaceutical care type services.

H2b Patients misunderstand pharmacists' perceptions of the benefits of

pharmaceutical care type services.

H3, Pharmacists fail to realize that patients misunderstand their perceptions

of the benefits of pharmaceutical care type services.

H3b Patients fail to realize that pharmacists misunderstand their perceptions

of pharmaceutical care type services.

H4, Pharmacists feel misunderstood by patients with regard to

pharmaceutical care type services.

H4b Patients feel misunderstood by pharmacists with regard to

pharmaceutical care type services.








49
H5 The level of pharmaceutical care type services reported by pharmacists is

predictable from the level of pharmacists' agreement, level of

pharmacists' understanding, level of pharmacists' realizations and level

of pharmacists' feeling understood.













CHAPTER 4
METHODOLOGY


Overview

This study investigated the relationships between pharmacists' and patients'

perceptions of the benefits of pharmaceutical care type services and the extent to which

those services are provided by pharmacists. By implementing an adapted version of the

Interpersonal Perception Method, pharmacists' and patients' perceptions were

compared to determine the extent to which i) pharmacists and patients agree on the

types of services they perceive would be beneficial for patients if provided by

pharmacists, ii) pharmacists understand patients' perceptions of these services, iii)

patients understand pharmacists' perceptions of these services, iv) pharmacists realize

that patients understand their perceptions of these services, v) patients realize that

pharmacists understand their perceptions of these services, vi) pharmacists feel

understood by patients with regard to the provision of pharmacy services, vii) patients

feel understood by pharmacists with regard to the provision of pharmacy services and

viii) the preceding factors predict pharmacists' reported provision of pharmaceutical

care type services. Data were collected via telephone interviews from both pharmacists

and patients throughout the state of Florida to characterize and compare their

perceptions. The remainder of this chapter describes instrument development and

validation, data collection procedures, study variables and data analysis.

50










Instrument Development and Validation

Interpersonal Method--Pharmaceutical Care Questionnaire

The interpersonal perception method was applied to aid in understanding

pharmacists' and patients' perceptions of beneficial pharmaceutical care type services.

The instrument included modified items from the Pharmaceutical Care Questionnaire

(PCQ) developed by Badejogbin (1994) as well as questions about the types of activities

pharmacists would perform if they were practicing according to the pharmaceutical care

practice model. These activities represented the domains of patient assessment, patient

consultation, patient record screening, implementation of therapeutic objectives,

documentation of patients' medical information and verification of patient

understanding. PCQ questions were chosen based on the visibility of the tasks to

patients and were modified to lay language. Some pharmaceutical care activities such

as documenting information may not be visible to patients. Because the visibility of

these services may be low and patients unaware of their benefit, these items were not

used. In addition to the relevant PCQ questions chosen, questions specific to the

communication that occurs between pharmacist and patient were developed through a

review of relevant literature to enhance the domain of patient consultation.

Once the items were generated, questions were worded to reflect the

interpersonal perception method. This involved phrasing the questions as statements

from each of the perspectives. For example, items on the patient questionnaire were

phrased from the patient's perspective, what the patient believes the pharmacist thinks

and finally what the patient thinks the pharmacist thinks of the patient's beliefs.








52
Consider the item "discuss the patient's drug therapy with him or her." On the patient

questionnaire this item appeared in the following forms: 1) the patient's direct

perspective "I think it would be beneficial if my pharmacist were to discuss my drug

therapy with me," 2) the patient's metaperspective "My pharmacist would say 'I think it

would be beneficial for my patients if I were to discuss the patient's drug therapy with

him or her,'" and 3) the patient's meta-metaperspective "My pharmacist thinks I would

say 'I think it would be beneficial if my pharmacist were to discuss my drug therapy

with me.'"

The pharmacists' questionnaire included identical items although they were

originally phrased from the pharmacist's perspective and led to the pharmacist's

perception of the patient's perspective and finally to what the pharmacist thinks the

patients think about the pharmacists' beliefs. Continuing with the same example, items

appeared in the following forms: 1) the pharmacist's direct perspective "I think it

would be beneficial for my patients if I were to discuss the patient's drug therapy with

him or her," 2) the pharmacist's metaperspective "My patients would say 'I think it

would be beneficial if my pharmacist were to discuss my drug therapy with me,'" and

3) the pharmacist's meta-metaperspective "My patients think I would say 'I think it

would be beneficial for my patients if I were to discuss the patient's drug therapy with

him or her.'"

Fourteen items were included in the original version of the Interpersonal

Perception Method-Pharmaceutical Care (IPM-PC) questionnaire for patients and

pharmacists (see Appendix A). The items were scaled on a 7-point scale with the










anchors of 'strongly agree' and 'strongly disagree'. A 7-point rather than a 5-point

scale was chosen to elicit greater variability in response to the items.

Pretest of Instrument

A small number of patients and pharmacists (five each) were asked to complete

the instrument and were interviewed after completing the instrument to discuss any

problems they had in understanding the questions and to comment on the ease of

completing the instrument. Of particular concern were the statements from the meta-

metaperspective. As Drewery (1969) suggests, respondents may be confused by the

phrasing of meta-metaperspective items and have difficulty completing them. If that

was found to be the case, items would have been converted to direct questions of

feeling understood, or eliminated if necessary. This was not the case, however,

because the pharmacists and patients who completed the survey reported being able to

understand the questionnaire. When asked to explain their understanding of the three

perspectives, all of the pharmacists and four of the five patients gave accurate

descriptions of the perspectives. This suggested that it was reasonable to include the

meta-metaperspectives statements in the pilot study. Few editorial revisions were made

to the instrument prior to a larger pilot study of approximately 30 pharmacists and 30

patients.

Sampling Procedure. Pharmacists were selected randomly from the current

listing of active pharmacists in the state of Florida. The database received from the

Board of Professional Regulations included pharmacists' home address. Only

pharmacists residing in the state of Florida were included. Because the database did not










include home telephone numbers, once names were randomly selected, pharmacists'

home phone numbers were looked up in the most recent telephone directories for their

cities. A world wide web site (Database America) was also used to attempt to identify

phone numbers that were unlisted in the city directories.

In order to identify patients, a random sample of telephone numbers throughout

the state of Florida was purchased, from Genesys, Inc., by the survey research firm

assisting with the interviews. The sample purchased was a random digit dial sample

from which certain exchanges known to be primarily business numbers had been

eliminated.

Interview procedure. Data collection was via telephone interview by the Florida

Survey Research Center at the University of Florida. This methodology was chosen for

data collection because of the ease of obtaining the data and the increased response rates

over mail questionnaires (Dillman, 1978). Both pharmacist and patient interviews were

completed between March 10 and March 14, 1997. Individuals were contacted by

telephone by trained interviewers between the hours of five pm and nine pm.

Interviewers recorded the results of each telephone call (e.g. if there was no answer,

busy signal, answering machine etc.) and attempted to contact each individual three

times.

All interviews began with identification of the interviewer, and an explanation

that the interviewer was calling from the University of Florida. This was followed with

a brief description of the survey. Respondents were informed that their participation in

the study was voluntary and verbal consent was obtained from each participant prior to








55
establishing eligibility. At that point, respondents were screened to determine if they

were eligible to participate in the survey. Pharmacists were asked in what type of

setting they practiced. Only those pharmacists who practiced in the community setting

were eligible to complete the survey. Patients were asked if there was someone in the

household who had a prescription dispensed during the previous six months and if that

person was over the age of 18. If that person was available, he or she was asked for

consent to be interviewed. When respondents did not meet those criteria, they were

thanked for their willingness to participate and the telephone call was terminated.

Pharmacists and patients were called until 30 of each had completed the interview.

Patient questionnaires included the interpersonal perception method

questionnaire (IPM-PC) assessing how beneficial they perceived the pharmacy services

would be to them if they were provided by their pharmacist. Information about the

patient such as the number of prescription medications currently being taken, number of

pharmacies visited on a regular basis and number of times in the past six months they

have had a prescription dispensed was also collected. Questions were asked about

patients' experience with pharmacists including; "Do you know the name of the

pharmacist who usually fills your prescriptions?," "Does your pharmacist usually

volunteer information about your medicine when you get a new prescription filled?,"

"Does your pharmacist usually ask if you are having any problems when you get a

refill?," and "What type of pharmacy do you go to?." Demographic information

including age, gender, level of education and income was also collected. The mean

length of patients' interviews was 12.3 minutes (s.d. =3.6).










Pharmacist questionnaires included the interpersonal perception method

questionnaire (IPM-PC) related to the types of pharmacy services they believed should be

provided and the self-report measure of the pharmaceutical care type services they

actually provided to patients (PCQ). Information about the pharmacist's education (e.g.

type of degree held and number of years in practice) and information about the pharmacy

(e.g. type of pharmacy and number of prescriptions dispensed per day) as well as

demographic information about the pharmacist (age and gender) were collected. The

mean length of pharmacists' interviews was 17.8 (s.d. =2.8) minutes.

Data was entered to a SAS file by the Florida Survey Research Center and was

checked for errors via examination of the frequencies of the variables. Cases were also

spot checked for accuracy of data entry after the file was obtained from the Research

Center.

Results of Instrument Pretest

Sample. Twenty eight pharmacists completed the questionnaire. Of those, 35

percent (N= 10) were female. Half of the pharmacists (N= 14) reported holding

Bachelor of Science degrees, while 46 percent (N= 13) reported holding Doctor of

Pharmacy degrees. One pharmacist held both a Bachelor of Science and a Doctor of

Pharmacy degree. Ten (36 percent) of the pharmacists had been in practice for over 20

years, eight (29 percent) reported being in practice between 11 and 20 years, and 10

(36 percent) had been in practice less than ten years. When asked to describe their

practice, six (21 percent) pharmacists reported practicing in independent pharmacies,

12 (42 percent) reported practicing in drug chain store such as Eckerd's and 10 (36








57
percent) reported practicing in discount chain pharmacies such as WalMart. More than

half of the pharmacists (54 percent, N= 15) described their position as an employee

pharmacist, 39 percent (N= 11) described their position as a pharmacy manager, and 7

percent (N=2) described their position as pharmacy owner.

Thirty one respondents completed the patient version of the questionnaire. Of

those, 68 percent (N=21) were female. Twenty-six percent (N=8) of the patients were

over the age of 60 years, 36 percent (N= 11) were between the ages of 40 and 60 years,

and 48 percent (N= 12) were between the ages of 18 and 39. Thirty-six percent

(N= 11) of patients reported patronizing a discount chain pharmacy such as WalMart,

36 percent (N= 11) reported patronizing a drug chain such as Eckerd's, 10 percent

(N=3) reported patronizing an independent pharmacy, 13 percent (N=4) reported

patronizing a grocery store pharmacy, and 13 percent (N=4) reported using another

type of pharmacy. Nine patients (29 percent) reported having an approximate

household income of less that $20,000, fifteen (49 percent) reported having an income

between $20,000-$59,999, and four patients (13 percent) reported a household income

greater than $60,000.

Instrument. Responses to the pretest from pharmacists and patients indicated

some problems with the instrument. Respondents indicated that the questions were

sometimes confusing and that the questionnaire was too long. They also had difficulty

with the 7-point range of responses. Based on the comments from the pretest, it was

decided to reduce the number of items in an effort to shorten the questionnaire. This

was intended to reduce the amount of time people were kept on the telephone and









58

increase response rate, but also to ensure that respondents would not be fatigued upon

making the final transition to thinking from the meta-metaperspective. Also, it was

decided that the range from one to seven may be too confusing. It is possible that it

was more difficult for people to use the seven point response range over the telephone

when compared to a written format of the questionnaire. The range was increased to

one through ten in order to maximize variability while at the same time offering

familiar response categories. Additionally, a ten point scale eliminates a true midpoint

which elicits either positive or negative reactions from respondents.

Reliability. Statistical procedures were used to assess the reliability of each

instrument and to determine which items would be eliminated. Internal consistency

reliability is designed to measure the extent to which the items in an instrument are

homogeneous. Cronbach's alpha was used to establish the internal consistency of the

subscales IPM-PC (direct, metaperspective and meta-metaperspective scales for

pharmacists and patients). These reliabilities can be found in Table 4-1.

Table 4-1. Reliabilities of Pretest Scales
Scale Original Alpha Revised Alpha
Fourteen Items Seven Items
Pharmacists
Direct 0.87 0.82
Meta 0.90 0.82
Meta-Meta 0.96 0.91
Patients
Direct 0.90 0.83
Meta 0.97 0.92
Meta-Meta 0.98 0.95








59
In addition, the inter-item correlation matrices and corrected item to total correlations

were analyzed to determine whether any item did not meet criteria for inclusion in a

summated scale. Table 4-2 (page 75) lists the corrected item to total correlations and

alpha coefficients for pharmacists' scales while Table 4-3 (page 76) provides the same

information for the patients' scales. Some suggest that acceptable correlations should

be 0.50 or greater (Bearden et al., 1989); however, Nunnally (1978) suggests that

corrected correlations of greater than 0.30 are sufficient. For this study, corrected item

to total correlations greater that 0.30 were considered acceptable.

Modifications. In making decisions regarding the modifications of the

instrument, results from both pharmacists' and patients' questionnaires were reviewed.

The consensus of pretest subjects was that the instrument needed to be shortened. One

way of accomplishing this was to eliminate items from domains represented by more

than one item. Also, the relative visibility of each behavior to patients was

reconsidered in determining which items would be included in the questionnaire. Table

4-4 (page 77) details the Interpersonal Perception Method-Pharmaceutical Care items

and pharmaceutical care domains they represent. In revising the instrument, items A

("Explain to patients how to use their medicationss)) and B ("Tell patients about other

drugs which may cause problems with their medicationss)) were selected to represent

the domain of consultation (provision of information). Items F ("Ask patients questions

to find out if they might be having any problems with their medications") and J ("Ask

patients questions to figure out if their goals) for their medications) are being

reached") were selected to represent the domain of assessment. Items K and L were










merged to form one item ("Design and carry out follow-up plans to measure my

progress toward my goals) for my medicationss).) which represented implementation

of therapeutic plans. Item H ("Carry out plans to solve (or prevent) problems with

patients' medications") was also included in the domain of implementation. Finally,

item N ("Make sure that patients understand the information given to them") was

included for the domain of verification of patient understanding.

Content validity of the revised IPM-PC was assessed via a panel of experts who

matched items to the performance domains to ensure that the scale represented the

intended behavior domain.



Procedure

Pharmacist and patient interviews were conducted according to the procedure

followed for the pretest, described earlier in this chapter. Patient data were collected

over a period of four days from March 24 through March 28, 1997. Pharmacist data

were collected over a period of four days from April 8 through April 11, 1997.

The necessary sample size was determined based the standard deviation and

means for the scale variables from the pretest data using ST-plan (Brown et al., 1993)

software. In order to detect differences between the group means using T-tests and based

on achieving a statistical power of 0.80 and a Type I error rate of 0.05, sample size

estimates were calculated for each of the comparisons to be made with the interpersonal

perception method. The largest sample size was needed to detect differences between

pharmacists' metaperspective and patients' direct perspective. For this comparison, the










sample size estimate was 150 respondents. Estimates made based on the other IPM

comparisons resulted in fewer respondents needed. Thus, 150 was chosen as the desired

sample size for pharmacist and patient groups.



Study Variables

According to the interpersonal perception method, by comparing the three

perspectives (direct, metaperspective and meta-metaperspective), agreement,

understanding, realization of understanding and feeling understood can be calculated for

pharmacists and patients. Using the IPM-PC questionnaire, data were collected from

patients and pharmacists for all three of the perspectives. The questionnaire addressed

the perceived benefits of pharmacists engaging in behavior that is consistent with a

pharmaceutical care approach to patient counseling. Specific examples include whether

or not it would be beneficial to patients if the pharmacist were to discuss potential side

effects of medications with patients; ask if patients have any questions to ask of the

pharmacist; and, address questions or concerns patients have. See Appendix B for the

final version of the questionnaire. The operational definitions of the variables appear

below.

Direct Perspective (Pharmacist and Patient)

The "direct perspective" is the pharmacist's or patient's perceptions of the

benefits of pharmaceutical care type services derived from the responses to the IPM-PC

from the first level of perception--one's own. "Patient Direct Perspective" is a summed

score of the patients' responses to the items from the direct perspective (items la-lg on










patient questionnaire). These items addressed perceived benefits to patients of

pharmacist activities of patient assessment, patient consultation, record screening,

implementation of therapeutic plans and patient understanding verification. The parallel

variable, "Pharmacists' Direct Perspective", is calculated based on the pharmacists'

direct perspective statements (items la-Ig on pharmacist questionnaire). Each item was

measured on a 10 point scale anchored by "strongly disagree" (1) and "strongly agree"

(10). Because the questionnaire included 7 items, the potential range of scores for the

overall direct perspective variables is from 7 to 70.

Metaperspective (Pharmacist and Patient)

The "metaperspective" represents the pharmacist's or patient's responses to the

IPM-PC items from the second level of perception--the other person's. This is a

measure of pharmacists' and patients' perceptions of each other's perceptions of the

benefits of the pharmaceutical care type services. Specifically, pharmacists' responded

based on how they thought their patients would answer. Likewise, patients responded

based on how they thought their pharmacist would answer. A summated score of

patients' metaperspective scores responses (items 2a-2g on patient questionnaire)

yielded "Patients' Metaperspective", and a summed score of pharmacists'

metaperspective responses (items 2a-2g on pharmacist questionnaire) yielded

"Pharmacists' Metaperspective". An overall metaperspective score for the IPM-PC

questionnaire was calculated like the direct perspective score described above. It was

measured on a 10 point scale anchored by "strongly disagree" (1) and "strongly agree"








63
(10). The potential range of scores for the overall metaperspective variable is the same

as the direct perspective score range (7 to 70).

Meta-Metaperspective (Pharmacist and Patient)

The "meta-metaperspective" represents responses to the IPM-PC questionnaire

from the third level of perception--one's perception of another's perception of one's

own perception of the benefits to the patient of pharmaceutical care type services.

Pharmacists' responses to the meta-metaperspective versions of the items (3a-3g on the

pharmacist questionnaire) were summed to calculate the variable "Pharmacists' Meta-

metaperspective". Likewise, patients' responses to the meta-metaperspective versions

of the items (items 3a-3g on patient questionnaire) were summed to create the variable

"Patients' Meta-metaperspective". Responses were measured on a 10 point scale

anchored by "strongly disagree" (1) and "strongly agree" (10). The potential range of

scores for the overall instrument on the meta-metaperspective variables is the same as

described under the direct perspective.

Level of Pharmaceutical Care: The Pharmaceutical Care Questionnaire (PCQ)

The dependent variable in this study is the extent to which pharmacists engage

in pharmaceutical care type activities when interacting with their patients. Using the

Pharmaceutical Care Questionnaire (PCQ) (Badejogbin, 1994), pharmacists' self-report

of behavior was used as the measure of the types of services which they actually offer

to their patients. The PCQ asks the pharmacist to recall the last five patients who

presented a new or refill prescription for a medication used to treat a chronic condition

and to indicate with how many of these patients the pharmacist pursued patient specific










information sharing and discussion. Examples of pharmacist behavior include asking

what the patient would like to achieve from therapy, discussing the patient's drug

therapy and documenting all medication currently being taken by the patient. Further,

the PCQ asks what action was taken, if any, if a drug-related problem was detected.

The activities measured by the PCQ can be divided into six domains including 1)

documentation activities, 2) patient assessment activities, 3) therapeutic objective

implementation activities, 4) patient consultation, 5) patient understanding verification

and 6) record screening activity (Badejogbin, 1994). Pharmacist response scores were

summed based on the number of patients they indicate for each question (0-5). There

are eighteen questions over the six domains in the PCQ, thus, the total potential score is

90 for the overall instrument. Each of the six domains is described below.

Documentation. The domain of documentation included six items. They

include whether the pharmacist documented information about a) the patients' medical

condition, b) all medications currently being taken, c) the therapeutic objective, d) any

drug-related problems, and e) the therapeutic objective for each of the drug-related

problems identified and any interventions made. The range of scores is from zero to

thirty for this subscale.

Assessment. The domain of patient assessment was also comprised of six items.

These included, a) asking the patient to describe his/her medical condition, b) asking

what he/she wants to achieve from drug therapy, c) assessing patterns of actual

medication use, d) assessing whether the patient is experiencing any drug-related

problems, and e) assessing the patients' perceptions of the effectiveness of medications








65

and assessing whether the therapeutic objectives are being reached. Again, the range of

scores for this subscale was from zero to thirty.

Implementation. Implementation of therapeutic objectives was a domain

measured using three items. The range of scores possible for this subscale is from zero

to fifteen. The items include whether the pharmacist a) implemented a strategy to

resolve any drug-related problems, b) established follow-up plans to evaluate progress

toward therapeutic objectives, and c) carried out the established follow up plans.

Screening. Patient record screening was a domain measured using one item to

assess the frequency of pharmacists checking patient records for potential drug related

problems. Since this subscale was measured using one item, the range of scores was

from zero to five.

Consultation. The domain of consultation most directly addresses the

communication between pharmacists and patients. It was measured by the item

assessing the frequency of pharmacists discussing the patient's drug therapy with the

patient. The range of scores for this subscale was from zero to five.

Verification. Verification of patient understanding was a domain measured

using an item asking pharmacists the frequency with which they verified patient

understanding of the information which was presented. In the factor analysis conducted

by Badejogbin (1994), this item was found to be a separate domain. The range of

scores for this subscale was from zero to five.

In a survey of 793 community pharmacists, the overall reliability of the PCQ

was found to be 0.88 (Badejogbin, 1994). The reliabilities of the six domains were








66
found to be as follows: 0.72 for documentation, 0.90 for patient assessment and 0.74

for therapeutic objective implementation. The reliabilities for the other three domains

(patient record screening, patient consultation and patient understanding verification)

were not calculated because they were measured by a single item.

Pharmaceutical Care Score II

Pharmaceutical care score II was a variable which measured the extent to which

pharmacists engaged in the pharmaceutical care activities described above that were

included in the IPM-PC questionnaire. Thus, it measures the extent to which

pharmacists engage in the behaviors, visible to patients, that they were asked to respond

to about how beneficial they are for patients. The PCQ items included in this variable

are as follows i) "verify that the patient understands the information I present to him or

her," ii) "discuss the patient's drug therapy with him or her," iii) "ask the patient

questions to find out if he/she is experiencing drug-related problems," iv) "ask the

patient questions to ascertain whether the therapeutic objectives) is (are) being

reached," v) "implement a strategy to resolve (or prevent) the drug related problems,"

vi) "establish follow-up plans to evaluate the patient's progress toward his/her drug

therapy objectives" and vii) "carried out the follow up plans established for the patient's

progress toward his/her drug therapy." PC-2 was calculated as a summated score of

the PCQ items listed above.

Pharmacists' Agreement

Pharmacists' agreement is the extent to which a pharmacist is in agreement with

patients' on the responses to the IPM-PC scale. It was calculated for each pharmacist








67
as a difference score between the pharmacist's total score for the overall instrument and

the mean of all patients' responses on the scale. As a difference score, the scores for

this variable can range from the negative value of the largest difference (-63) to the

positive value of the largest difference possible (+63). The largest difference possible

is calculated based on the minimum and maximum potential scores for the scale, which

are seven and 70 respectively for the seven-item instrument. The difference between

them, 63, represents the largest potential difference score. Thus, the potential range of

scores for this variable is -63 to +63. According to the Interpersonal Perception

Method, a comparison from the pharmacists' perspective is made by entering the

pharmacists' perspective first. Thus, a positive value would imply that pharmacists

rated the items higher than patients. In other words, a positive difference suggests that

pharmacists believed the pharmacy services would be more beneficial than patients did.

On the other hand, a negative value would suggest that pharmacists believed the

pharmacy services would be less beneficial than patients did.

Pharmacists' Understanding

Pharmacists' understanding is the extent to which pharmacists understand

patients with regard to pharmaceutical care activities. It was calculated according to the

interpersonal perception method by comparing the pharmacists' metaperspective to the

patients' direct perspective. This comparison was made for each pharmacist based on

their overall metaperspective score compared to patients' mean overall direct

perspective score. This difference score was used in the multiple regression. As

discussed above, the potential range of scores for the seven-item instrument on this








68
variable is -63 to 63. For this variable, a positive value would suggest that pharmacists

rated patients' perceptions of the services higher than the patients actually did. A

negative value would suggest that pharmacists rated patients' perceptions of the

pharmacy services lower than the patients actually did, or in other words, that patients

perceived the services as more beneficial than pharmacists thought they would.

Pharmacists' Realization

Pharmacist realization is the extent to which pharmacists realize that patients

understand them. It was derived by comparing pharmacists' meta-metaperspective to

patients' metaperspective. Pharmacists' individual responses were compared to mean

patient responses on the overall scale to calculate the difference score. Accordingly,

the potential range of scores is from -63 to +63. A positive value would suggest that

the pharmacist rated patients' perceptions of pharmacists' perceptions of the services

higher than the patients actually did, while a negative value would suggest that

pharmacists rated patients' beliefs about pharmacists' perceptions of the pharmacy

services lower than the patients actually did, or in other words, that patients perceived

that pharmacists would rate the services as more beneficial than pharmacists thought

they would.

Pharmacists' Feeling Understood

Pharmacists' feeling understood is derived by comparing pharmacists' meta-

metaperspective with pharmacists' own direct perspective and was calculated as a

difference score on the overall scale between these two perspectives for each

pharmacist. The potential range of scores for this variable is from -63 to +63. A










positive value would suggest that the pharmacist believed patients' perceptions of

pharmacists' opinion higher than the pharmacist actually did. On the other hand, a

negative value would suggest that the pharmacist believed patients perceived

pharmacists' answers lower than the pharmacists themselves actually did.



Analyses

Descriptive information about the sample and the variables was examined.

Associations between the IPM-PC and PCQ questionnaires were examined. In

addition, associations between patients' perceptions of the benefits of pharmaceutical

care type services and their pharmacy patronage were explored. The following

analyses were carried out to test the hypotheses.

Hi: Pharmacists and patients agree on the types of pharmaceutical care type services

they perceive would be beneficial for patients.

A sum of the item scores for both the pharmacists' direct perspective ("I think it

would be beneficial for my patients if I were to discuss the patient's drug therapy with

him or her") and patients' direct perspective ("I think it would be beneficial if my

pharmacist were to discuss my drug therapy with me") on the IPM-PC questionnaire

was calculated. A T-test between means of the summated scale scores was conducted to

determine if pharmacists and patients disagree on the type of pharmacy services they

believe would be beneficial. Significant difference between the means would indicate

that pharmacists and patients disagree on the overall scale. According to the

Interpersonal Perception Method, a nonsignificant difference would mean that










pharmacists and patients do agree on the types of services they believe would be

beneficial. Alpha was set at 0.10 in order to reduce the risk of committing a Type II

error.

H2,: Pharmacists misunderstand patients' perceptions of the benefits of pharmaceutical

care type services.

In order to test this hypothesis, the scores from the pharmacists'

metaperspectives ("My patients would say 'I think it would be beneficial if my

pharmacist were to discuss my drug therapy with me'") were compared to the patients'

direct perspectives ("I think it would be beneficial if my pharmacist were to discuss my

drug therapy with me"). An independent samples T-test was conducted between

pharmacists' and patients' mean scores. Alpha was set at 0.05 for this and the

remaining analyses. A significant difference would indicate that pharmacists

misunderstand patients' perceptions about the type of pharmacy services which patients

believe would be beneficial. According to the Interpersonal Perception Method, a

nonsignificant difference would indicate that pharmacists understand patients'

perceptions of the benefits of pharmaceutical care type services.

H2b. Patients misunderstand pharmacists' perceptions of the benefits of pharmaceutical

care type services.

In this case, patients' metaperspectives ("My pharmacist would say 'I think it

would be beneficial for my patients if I were to discuss the patient's drug therapy with

him or her'") were compared to pharmacists' direct perspectives ("I think it would be

beneficial for my patients if I were to discuss the patient's drug therapy with him or








71
her"). An independent samples T-test was used to compare patients' and pharmacists'

mean scores. A significant difference between the means would indicate that patients

misunderstand pharmacists' attitudes toward the types of services pharmacists believe

would be beneficial. According to the IPM, a nonsignificant difference would indicate

that patients understand pharmacists' perceptions of the benefits of pharmaceutical care

type services.

H3,: Pharmacists fail to realize that patients misunderstand their perceptions of the

benefits of pharmaceutical care type services.

To test this hypothesis comparisons between pharmacists' meta-metaperspectives

("My patients think I would say 'I think it would be beneficial for my patients if I were

to discuss the patient's drug therapy with him or her'") and patients' metaperspectives

("My pharmacist would say 'I think it would be beneficial for my patients if I were to

discuss the patient's drug therapy with him or her'") must be made. An independent

samples T-test was conducted to compare the means of the pharmacists' meta-

metaperspective to the patients' metaperspective score. A significant difference would

indicate that pharmacists fail to realize that patients understand (or misunderstand)

pharmacists' perceptions of the types of pharmacy services they believe to be

beneficial. A nonsignificant difference would indicate that, according to the IPM,

pharmacists realize that patients understand (or misunderstand) their perceptions of the

benefits of pharmaceutical care type services.










H3b: Patients fail to realize that pharmacists misunderstand their perceptions of the

benefits of pharmaceutical care type services.

In order to determine if patients realize or fail to realize that the pharmacist

understands (or fails to understand) their perceptions, a comparison between the

patients' meta-metaperspectives ("My pharmacist thinks I would say 'I think it would

be beneficial if my pharmacist were to discuss my drug therapy with me'") and the

pharmacists' metaperspectives ("My patients would say 'I think it would be beneficial if

my pharmacist were to discuss my drug therapy with me'") was made. Again, this

comparison was made using an independent samples T-test between patients' mean

meta-metaperspective score and pharmacists' mean metaperspective score. A

significant difference would indicate that patients fail to realize that pharmacists

understand (misunderstand) patients' perceptions. A nonsignificant difference would

indicate, according to the IPM, that patients realize that pharmacists understand (or

misunderstand) their perceptions of the benefits of pharmaceutical care type services.

H4,: Pharmacists feel misunderstood by patients with regard to pharmaceutical care

type services.

By comparing the pharmacists' meta-metaperspectives ("My patients think I

would say 'I think it would be beneficial for my patients if I were to discuss the

patient's drug therapy with him or her'") with the pharmacists' own direct perspectives

("I think it would be beneficial for my patients if I were to discuss the patient's drug

therapy with him or her"), the pharmacists' feeling of being understood was analyzed.

Pharmacists' mean direct perspective score was compared with pharmacists' mean










meta-metaperspective score using a paired samples T-test. A significant difference

would indicate that pharmacists feel misunderstood by patients in regard to

pharmaceutical care type services. Based on the IPM, a nonsignificant difference

would mean that pharmacists feel understood by patients with regard to pharmaceutical

care type services.

H4b: Patients feel misunderstood by pharmacists with regard to pharmaceutical care

type services.

Likewise, in order to analyze patients' feelings of being understood, patients'

meta-metaperspectives ("My pharmacist thinks I would say 'I think it would be

beneficial if my pharmacist were to discuss my drug therapy with me'") was compared

to patients' own direct perspective ("I think it would be beneficial if my pharmacist

were to discuss my drug therapy with me"). Patients' mean meta-metaperspective score

were compared with patients' mean direct perspective score by a paired samples T-test

and a significant difference would indicate that patients feel misunderstood by

pharmacists with regard to patient care services. Based on the IPM, a nonsignificant

difference would mean patients feel understood by pharmacists with regard to

pharmaceutical care type services.

H5: The level of pharmaceutical care type services reported by pharmacists will be

predicted by the level of pharmacists' agreement, level of pharmacists' understanding,

level of pharmacists' realization and level of pharmacists' feeling understood.

Pharmacists' self-report of pharmaceutical care type services was measured

using the PCQ. Scores were summed to yield an overall pharmaceutical care score that








74
served as the dependent variable. Multiple regression analysis was conducted utilizing

the difference scores of pharmacist agreement, pharmacist understanding, pharmacist

realization and pharmacist feeling understood as the independent variables used to

predict pharmacists self report of pharmaceutical care activities performed.

Subsequent analysis repeated the multiple regression utilizing PC-II as the

dependent variable. This dependent variable represents the pharmaceutical care

behaviors which are represented on the IPM-PC questionnaire. As in the previous

analysis, the regression was conducted utilizing the independent variables of pharmacist

agreement, pharmacist understanding, pharmacist realization and pharmacist feeling

understood.











Table 4-2. Item to Total Correlations and Coefficient Alpha of Pharmacist Pretest
Scales
Scale Item-Total Correlation Alpha if Item Deleted

Pharmacist: Direct
A 0.57 0.87
B 0.69 0.86
C 0.54 0.87
D 0.11 0.87
E 0.60 0.86
F 0.35 0.87
G 0.46 0.87
H 0.74 0.85
I 0.45 0.87
J 0.79 0.85
K 0.53 0.87
L 0.70 0.86
M 0.62 0.86
N 0.47 0.87

Pharmacist: Meta
A 0.65 0.89
B 0.68 0.89
C 0.71 0.89
D 0.07 0.91
E 0.71 0.89
F 0.72 0.89
G 0.33 0.90
H 0.53 0.89
I 0.85 0.88
J 0.87 0.88
K 0.85 0.88
L 0.65 0.89
M 0.51 0.90
N 0.41 0.90

Pharmacist: Meta-Meta
A 0.81 0.96
B 0.87 0.96
C 0.85 0.96
D 0.83 0.96
E 0.87 0.96
F 0.80 0.96
G 0.69 0.96
H 0.81 0.96
I 0.84 0.96
J 0.79 0.96
K 0.76 0.96
L 0.74 0.96
M 0.77 0.96
N 0.77 0.96











Table 4-3. Item to Total Correlations and Coefficient Alpha of Patient Pretest Scales

Scale Item-Total Correlation Alpha if Item Deleted

Patient: Direct
A 0.52 0.90
B 0.45 0.90
C 0.47 0.90
D 0.22 0.91
E 0.62 0.89
F 0.48 0.90
G 0.71 0.89
H 0.79 0.89
I 0.66 0.89
J 0.74 0.89
K 0.70 0.89
L 0.73 0.89
M 0.57 0.89
N 0.60 0.90

Patient: Meta
A 0.61 0.97
B 0.69 0.96
C 0.82 0.96
D 0.71 0.96
E 0.83 0.96
F 0.89 0.96
G 0.80 0.96
H 0.86 0.96
I 0.80 0.96
J 0.86 0.96
K 0.85 0.96
L 0.86 0.96
M 0.82 0.96
N 0.80 0.96

Patient: Meta-Meta
A 0.79 0.98
B 0.89 0.98
C 0.89 0.98
D 0.86 0.98
E 0.88 0.98
F 0.86 0.98
G 0.90 0.98
H 0.88 0.98
I 0.89 0.98
J 0.89 0.98
K 0.86 0.98
L 0.87 0.98
M 0.88 0.98
N 0.84 0.98











Table 4-4. Interpersonal Perception Method-Pharmaceutical Care Items and
Pharmaceutical Care Domains
Interpersonal Perception Method-Pharmaceutical Care Pharmaceutical
Item Care Domain
A. Explain to patients how to use their Consultation
medicationss.
B. Tell patients about other drugs which may cause
problems with their medicationss.
C. Tell patients about possible side effects of their
medicationss.
D. Ask patients if they have any questions to ask.
M. Answer any questions or concerns patients may
have.

E. Ask patients questions to find out how well they Assessment
think the medications) they are taking is/are
working.
F. Ask patients questions to find out if they might be
having any problems with their medications.
I. Ask patients what they want to achieve by taking
their medicationss.
J. Ask patients questions to figure out if their
goals) for their medications) are being reached.

G. Check patients' records for potential problems Screening
with their medicationss.

H. Carry out plans to solve (or prevent) problems Implementation
with patients' medications.
K. Design follow-up plans to measure patients'
progress toward their goals) for their
medicationss.
L. Carry out the follow-up plans to measure
patients' progress toward their goals) for their
medicationss.

N. Make sure that patients understand the Patient
information given to them. Understanding
Verification














CHAPTER 5
RESULTS


Characteristics of the Sample

Pharmacists

The final sample was comprised of 147 pharmacists practicing in the state of

Florida in the community setting. Table 5-1 (page 102) describes the pharmacist sample

and compares the sample with national estimates. When asked to describe their positions,

52 percent identified themselves as employee pharmacists, 39 percent as pharmacy

managers, 5 percent as pharmacy owners and 3 percent described their position as

"other." None of the pharmacists who indicated a different type of position indicated

what position they held. Most of the pharmacists surveyed held Bachelor of Science

degrees (85 percent), while several held both B.S. and Doctor of Pharmacy degrees (11.6

percent). Only 5.4 percent reported holding a Doctor of Pharmacy degree as the sole

professional degree. Pharmacists were also asked to indicate how long they had been in

practice. Twenty percent of the pharmacists had been in practice 1-5 years, 18 percent

between 6-10 years, 12 percent 11-15 years, 14 percent 16-20 years and 37 percent

reported practicing pharmacy for over 20 years. Males accounted for 65 percent of the

sample.








79

Pharmacists also were asked to characterize the number of prescriptions that were

dispensed in their pharmacies on an average day. Seventeen percent of pharmacists

reported that under 100 prescriptions were dispensed, 27 percent reported that an average

of between 100 and 299 prescriptions were dispensed daily, 27 percent reported that

between 200 and 299 prescriptions were dispensed, 15 percent between 300 and 399, 8

percent between 400 and 499, and 7 percent 500 and over. The pharmacists' practice

settings were also recorded. Thirty eight percent of pharmacists practiced in chain

pharmacies such as Eckerd's, 31 percent in independent pharmacies and 31 percent in

discount chain stores (such as WalMart). One pharmacist reported working at a health

maintenance organization (HMO) outpatient pharmacy. Information regarding the

distribution of pharmacists in the state of Florida was unavailable, so comparisons

between the sample and national figures were made. By comparison, national figures

show that 33 percent of pharmacists practice in independent community pharmacies and

33 percent practice in chain pharmacies (Martin, 1993). According to the study reported

by Martin (1993) 86 percent of pharmacists hold a Bachelor of Science degree in

pharmacy and the remaining 14 percent held either a Doctor of Pharmacy degree or both

degrees. The sample seems to reflect the national distribution of pharmacists with respect

to practice site, degree held, age and gender as found in the Pharmacy Manpower Project

described by Martin (1993).

Pharmacist Nonresponse

The most recent list of registered pharmacists in Florida included 18,798 names,

of which 12,239 listed addresses in Florida. From those residing in Florida, 1,700








80
pharmacists were randomly selected for identification of their telephone numbers. A total

of 1,105 (65 percent) of the telephone numbers were identified from the most recent city

directories available and Database America, a national online database including home

address and telephone numbers. Only 947 of the 1,105 numbers were called when the

sample size of 150 was reached. Of those, 150 were nonworking numbers, 35 were non-

household numbers (business, cellular phone, fax number) and 64 were wrong numbers.

Due to language barriers between the interviewer and the person who answered the

telephone, 35 of the pharmacists were not reached. Twenty calls were not completed

because the individual was deceased. Thus, 643 pharmacists were asked to complete the

questionnaire. There were 205 (31.9 percent of calls) refusals, 291 (45.2 percent of calls)

pharmacists were ineligible because they worked in hospital or mail order pharmacies or

were no longer in practice and 150 pharmacists completed the questionnaire. Three of the

pharmacists who completed the interview did not meet eligibility criteria. Because they

practiced in the hospital setting, they were eliminated from the sample. Thus, 147

eligible pharmacists completed the questionnaire. The response rate of eligible

pharmacists, assuming that all refusals came from eligible pharmacists, was 41 percent.

This is the worst case estimate for the response rate since it is unknown what percentage

of the pharmacists who refused to complete the questionnaire were, in fact, eligible for

the study. The mean length of pharmacist interviews was 9.5 minutes (s.d.=2.7).

Patient Sample Characteristics

The final sample of patients included 151 consumers throughout Florida who had

filled at least one prescription during the previous six months. Table 5-2 (page 103)










summarizes the characteristics of the patient sample in comparison to the 1990 census

report (U.S. Department of Commerce Bureau of the Census, 1990).

Females accounted for two-thirds of the respondents (67 percent). According to

the 1990 census, 52 percent of the population of Florida is female. The higher percentage

of female respondents may be accounted for by the fact that women tend to complete

questionnaires more often than men. Women also utilize health care, including

prescriptions, more often than men (Cockerham, 1992). Most of the patients were under

50 years of age (66.3 percent). Approximately one-fourth of all patients (23 percent)

were between the ages of 18 and 29 years, one-fifth were between 30 and 39 years (22

percent), one-fifth between 40 and 49 years (21 percent). Of those over the age of 50, 10

percent were between the ages of 50 and 59, 13 percent were between 60 and 69, and 11

percent were 70 years of age and older. This is consistent with the age distribution

throughout the state of Florida. In Florida, approximately 23 percent of people are

between the ages of 18 and 29, 20 percent between 30 and 39 years, 15 percent between

40 and 49 years, 12 percent between 50 and 59 years, and 30 percent over the age of 60

years (U.S. Census Report, 1990).

When asked to describe their education level, 34 percent reported having

completed some college, 36 percent reported being college graduates (including post-

baccalaureate degrees), 19 percent reported being high school graduates and 9 percent

reported less than a high school education. By comparison, in the state of Florida, 25

percent have less than a high school degree, 30 percent have completed high school, 27

percent have completed some college, 10 percent have completed college and 9 percent










have a professional degree or have completed at least some graduate school. Seventeen

percent of the patients reported annual household income below $20,000.

Twenty five percent reported income between $20,000 and $39,999, 20 percent

reported income between $40,000 and $59,999, 11 percent between $60,000 and $79,999

and 8.6 percent reported income in excess of $80,000. Many patients declined to answer

this question (19 percent). The categories used in this study to measure income are not

consistent with the categories used in the U.S. census, however, for comparison, the

census figures are included here. In the state of Florida, 15 percent of the population

reports earning less than $10,000 annually; 30 percent report incomes of between $10,000

and $24,999; 34 percent report household incomes between $25,000 and $49,999; and 21

percent report annual household incomes over $50,000. Comparison figures for the

population are shown in Table 5-2 (page 103). The sample seems to reflect a higher level

of education than the overall population in Florida, although based on age this sample

seems to reflect Florida's population.

Pharmacy Patronage

In describing their pharmacy patronage, almost half of patients reported

patronizing a large discount chain store, such as WalMart, for their prescriptions (47

percent). Another third reported patronizing smaller pharmacy chains such as Eckerd's

(33 percent). Nine percent reported using an independent store, 6 percent used a grocery

store and 5 percent reported using other types of pharmacies (such as an HMO

pharmacy). This distribution of pharmacy patronage is comparable to national figures

from the 1993 National Prescription Buyers Survey described by Meade (1994). Most










patients reported patronizing only one pharmacy on a regular basis (72 percent), 17

percent reported using two pharmacies, and 3 percent reported using three pharmacies on

a regular basis. This, too, is consistent with other findings. According to Meade (1994),

75 percent of patients go to only one pharmacy to have their prescriptions dispensed.

Most patients did not know the name of the pharmacist who usually fills their

prescriptions (82 percent).

Finally, patients were asked to list what factors they considered when choosing a

pharmacy. The most frequent response included insurance requirements (17 percent),

location or convenience (38 percent) and price (17 percent). Customer services including

friendliness (10 percent), hours (4 percent), knowledgeable pharmacists (3 percent) and

efficiency (3 percent) were also named. One patient reported that the doctor had

recommended a particular pharmacy. These figures vary slightly from those described by

Meade (1994). By comparison, only 15 percent of those patients mentioned using a

designated pharmacy, 28 percent reported location, 22 percent mentioned price and 20

percent named characteristics of pharmacists or staff. See Table 5-3 (page 104) for a

description of the sample's pharmacy patronage.

Patients were also asked questions concerning their medication use including how

many prescription medications were taken on a regular basis and how many new and

refill prescriptions they had dispensed in the previous six months. In response to the

number of prescription medications taken on a regular basis, answers ranged from zero to

nine. Approximately one-third of the respondents used one prescription medication on a

regular basis (34 percent). Twenty-seven percent reported not regularly using any










prescription medications. Fifteen percent reported using two prescriptions on a regular

basis while 24 percent use three or more prescriptions on a regular basis.

When asked about number of new prescriptions in the previous six months, the

range of responses was from zero to 12 with a mean of 1.7 (s.d. = 2.0). Patients reported

a range of zero to 48 refill prescriptions dispensed over the previous six months (mean

4.1 6.6). Twenty-five percent of respondents had no refill prescriptions dispensed

over the past six months, 19 percent had one, 17 percent had 2. Twelve percent of

patients had between 3 and 5 prescriptions dispensed while 15 percent had 6 refills.

Thirteen percent of patients had over six prescriptions refilled in the previous six

months.

When asked to describe their interaction with their pharmacist, 43 percent of

patients reported that their pharmacist usually volunteers information when they have a

prescription dispensed. This is consistent with the national figure (43 percent) reported

by Meade (1994). Twenty-two percent of patients reported that their pharmacist

usually asks if they are having any problems when they receive refill prescriptions.

This is higher than the percentage reported (10 percent) for the control group of a study

on the effects of an education program for pharmacists to help them detect drug-related

problems in elderly patients (Kimberlin et al., 1993).

Patient Nonresponse

A total of 744 telephone numbers were called. Of those, 251 were either

nonworking numbers or were businesses rather than households and 35 calls were not

completed due to a language barrier. Thus, 485 households were contacted for consent








85
to participate in the interview. There were 250 refusals (51.5 percent of calls) and 57

households (11.7 percent of calls) were ineligible, meaning there was no one in the

household over the age of 18 who had a prescription dispensed in the previous six

months. Although it is unknown what percent of patients who refused to complete the

questionnaire were eligible, 151 patient interviews were completed yielding a response

rate of 35 percent in the worst case assumption that all refusals were eligible. The

mean length of patient interviews was 7.2 minutes (s.d. =3.0).



Instrumentation

Factor analysis was used to establish the construct validity of the pharmacist and

patient scales. The factor loadings for pharmacist and patient scales are presented in

Table 5-4 (page 104) and Table 5-5 (page 105) respectively. Separate analyses of

pharmacists' direct, metaperspective and meta-metaperspective responses (Table 5-4,

p. 105) indicated that at each level of perception, all the items were representative of

one factor. This is inconsistent with the theoretical development of the questionnaire

and will be discussed further in the final chapter.

Results from analysis of patients' direct and metaperspective responses (Table

5-5, p. 106) showed that the items loaded on two factors. Based on direct perspective

results, only one item seems to be representative of Factor 2, while the other six items

loaded on Factor 1. Item G ("Tells me about other drugs which may cause problems

with my medicationss)) loaded more highly on Factor 2--"Discuss problems" than on

Factor 1--"Counseling." This suggested that the item represented a unique factor and










should not be included in the summated scores with the other items. Analysis of the

metaperspective showed that item G loaded on both factors, but more highly on Factor

2--"Discuss problems." Item D ("Make sure I understand the information given to

me") also loaded on Factor 2--"Discuss problems," but loaded more highly on Factor

1--"Counseling." Factor analysis of patients' meta-metaperspective revealed only one

factor for all seven items. Crocker and Algina (1986) suggest that factor loadings less

then 0.30 are usually considered unimportant, thus a loading of 0.30 was considered the

criteria for inclusion in the scale score. All of the loadings for the items in Factor 1

were found to be greater than 0.30 in each of the perspectives, so all items were thus

kept in the scale.

Internal consistency reliability of the summed scales was calculated using

Cronbach's coefficient alpha. The overall reliability estimates for the pharmacists' and

patients' direct perspective scales were 0.87 and 0.79 respectively (see Table 5-6, page

107 and Table 5-7, page 108). Corrected item-total correlations on the pharmacists'

scale ranged from 0.54 to 0.81, while patients' ranged from 0.22 to 0.73. Item G

("Tell me about other drugs which may cause problems with my medicationss))

showed the lowest item to total correlation on the patients' scale (0.22), which is

consistent with the results of the factor analysis. The overall reliability of the scale was

at least 0.80 and was considered high .

Coefficient alpha estimates for the metaperspective and meta-metaperspectives

scales are also presented in Tables 5-6 (p. 107) and 5-7 (p. 108). Coefficient alpha for

pharmacists' metaperspective and meta-metaperspective scales were 0.90 and 0.93










respectively. Coefficient alpha for patients' scales were 0.86 and 0.91 respectively.

All of the item to total correlations were greater than 0.50 with the exception of item G

on patients' metaperspective scale. This was consistent with results from the direct

perspective scale. Thus, item G was eliminated from all summated scales and was

analyzed as an independent item. Coefficient alpha for the revised scales are also

presented in Tables 5-6 (p. 107) and 5-7 (p. 108). There was little change in the

coefficients after the deletion of item G. Coefficient alpha for patients' direct

perspective scales increased from 0.79 to 0.80, metaperspective increased from 0.86 to

0.87, and for the meta-metaperspective coefficient alpha remained the same (0.91).

Coefficient alpha for pharmacists' direct and metaperspective scales decreased slightly

from 0.87 and 0.90 to 0.86 and 0.89 respectively. Pharmacists' meta-metaperspective

scale showed no change in coefficient alpha (0.93).



Descriptive Analysis

Distributions of items in the IPM and PCQ were examined. Scores covered the

full range and indicated variability in response to items. Overall, pharmacists rated the

provision of the pharmaceutical care type services as potentially more beneficial than

patients. Means of pharmacists' and patients' responses to each item are presented in

Table 5-8. Their direct perspective responses provide an indication of how potentially

beneficial each group perceives the services to be. On the scale from one to ten, where

ten represented strong agreement with the potential benefit of the service described,

pharmacists consistently rated the items toward strong agreement. The range of mean










pharmacists responses on different items was from 7.7 (s.d. =2.4) to 9.4 (s.d.= 1.3).

This suggests that pharmacists perceive that the services would be of benefit to patients.

Pharmacists believed that the most beneficial services would be to explain to patients

how to use their medications (9.4 1.3), to make sure patients understand the

information given to them (9.2 1.5) and to tell patients about other drugs which may

cause problems with their medications (9.1 1.5). Asking patients questions to find out

if they might be having any problems with their medications (8.6 1.9), carrying out

plans to solve or prevent problems with patients' medications (8.2 2.1) and asking

patients questions to figure out if their goals for the medications are being reached (8.1

2.3) were also seen as very beneficial. Designing and carrying out follow up plans to

measure patients' progress toward their goals for their medications was seen as the least

beneficial service which could be offered to patients (7.7 2.4).

Results from pharmacists' report of their pharmaceutical care activities indicated

that pharmacists provided a wide range of services. Summed scores for the level of

services provided ranged from 0 to 90, covering the entire range of potential scores. The

mean score was 40.0 (s.d.=22.9). Table 5-9 (page 110-111) displays the means and

standard deviations for each service. Compared to Badejogbin's (1994) study, it seems

that pharmacists are providing pharmaceutical care services to more patients. The overall

mean score was reported by Badejogbin (1994) to be 32.9 (s.d.=23.2). The mean score

for the documentation domain (range 0 to 30) was 13.8 (s.d.=12.2), slightly higher than

Badejogbin's finding (1994) of 10.6 (s.d.=7.2). Therapeutic objective implementation

and patient assessment were provided to fewer patients. The mean for the domain of










patient assessment (range 0 to 30) services was 9.2 (s.d.=10.0). Pharmacists reported

providing therapeutic objective implementation (range 0 to 15) for 5.7 (s.d.=6.0) patients.

Badejogbin's findings (1994) showed pharmacists' mean scores in these domains to be 6.9

(s.d.=7.0) and 4.6 (s.d.=4.2), respectively. Pharmacists reported providing screening of

patients' record often, providing it to an average of 3.9 (s.d.=1.8) patients of the last five.

Verification of patient understanding and patient consultation were also provided to more

than half of patients. Pharmacists reported consulting with an average of 3.0 (s.d.=1.9)

patients of the last five, and reported verifying the understanding of an average of 3.2

(s.d.=1 .9) patients which is consistent with the level reported by Badejogbin (1994).

These means are comparable with earlier findings, which reported means of 4.4

(s.d.=1.4), 3.1 (s.d.=1.7) and 3.3 (s.d.=1.8) respectively. It seems that pharmacists report

providing more pharmaceutical care services than in 1994. However, the types of

services being reported seem to be consistent with those reported by the pharmacists

surveyed in 1994 (Badejogbin).

Association Between IPM and PCQ

Each of the items on the IPM-PC had a corresponding item on the PCQ.

Associations between pharmacists' perceptions of the benefits of the services and the

number of patients for whom they provided that service was calculated to examine the

extent to which pharmacists engaged in behaviors they believed would be beneficial for

patients. Table 5-10 (page 112) shows the correlations between these items. Of the seven

items, three were found to be significantly correlated with their corresponding behavior

measure. A significant positive correlation was found between the items "it would be










beneficial for my patients if I were to make sure that they understand the information

given to them" and the number of patients for whom pharmacists reported that they

verified that the patient understands the information presented to him or her (r=0.41,

p<0.001). The item "it would be beneficial for my patients if I were to carry out plans to

solve (or prevent) problems with their medications," was found to be positively

associated with the number of patients for whom pharmacists reported that they

implemented a strategy to resolve (or prevent) the drug related problem (r=0.24, p<0.01).

Finally, a significant positive correlation was found between the item "it would be

beneficial for my patients if I were to tell them about other drugs which may cause

problems with their medications," and the number of patients for whom pharmacists

reported that they discussed the patient's drug therapy with him or her (r = 0.27, p<0.001).

Although none of the correlations was large, they were in the direction expected, in that

pharmacists who rated the item as more beneficial for patients did in fact report that they

provided the service to more patients. The remaining four items were not found to be

significantly associated with pharmacists' reported behavior.

The three measures of behavior found to be associated with the corresponding

PCQ item were also found to be associated with other IPM-PC items (see Table 5-10).

The item "discuss the patient's drug therapy with him or her" was found to be

significantly correlated with five of the items (items C (r=0.22, p<0.01), D (r=0.33,

p<0.001) E (r=0.22, p<0.01), F (r=0.21, p<0.01), G (r=0.27, p<0.001)) representing the

domains of assessment, verification of understanding and one of two items representing

consultation and implementation of therapeutic plans. The item "verify that the patient








91
understands the information presented to him or her" was found to be associated with its

PCQ counterpart (r-=.41, p<0.001) and also the item "tell me about other drugs which may

cause problems with my medicationss" (r=0.21, p<0.01) from the domain of

consultation. Finally, the item "implementing a strategy to resolve (or prevent) the drug

related problems" was found to be correlated with the items representing the domain of

consultation (items A (r=0.25, p<0.01) and G (r=0.27, p<0.01)), the one item representing

verification of understanding (item D, r=-0.25, p<0.01) in addition to its corresponding

PCQ item. The summated score of pharmacists' direct perspective scores were found to

be positively associated with overall score on the PCQ (r=0.22, p<0.01).

Correlations between pharmacists' metaperspective scores for individual items on

the IPM-PC and reported behavior on the PCQ were calculated. As can be seen in Table

5-10, none of these correlation was found to be significant. Additionally, correlations

between pharmacists' meta-metaperspective scores and reported behavior were calculated

(Table 5-10, p. 112). The item in which pharmacists responded to the extent that their

patients would say "my pharmacist would say 'I think it would be beneficial for my

patients if I were to make sure that they understand the information given to them'" was

found to be correlated with the number of patients for whom pharmacists reported

performing this service (r=0.24, p<0.01).

Summary of Difference Scores

Difference scores for each pharmacist were calculated to determine the

pharmacists' agreement with patients, pharmacists' understanding of patients, pharmacists'

realization that patients misunderstand them and pharmacists' feeling understood. The










mean difference score for pharmacists' agreement with patients was 5.2 (s.d.=8.9)

Approximately 20 percent (N=30) of pharmacists had negative difference scores, while

80 percent had positive difference scores (N=l 17). This suggests that most pharmacists

perceived the pharmaceutical care services to be more beneficial than patients did. The

difference scores for pharmacists' understanding of patients showed that 30 percent

(N=44) of pharmacists thought patients would perceive the services as less beneficial than

they did. On the other hand, 70 percent (N=103) believed that patients rated the services

as more beneficial than they actually did. The mean understanding difference score was

3.0 (s.d.= 10.7). The results of pharmacists' realization that patients misunderstand them

were similar to those of pharmacists' understanding. Negative difference scores, which

indicated that pharmacists' meta-metaperspective scores were lower than patients'

metaperspective scores were found for 29 percent of pharmacists (N=43). Positive scores

were found for the remaining 71 percent (N= 104), which indicated that most pharmacists

believed patients rated pharmacists' perceptions higher than patients did. Overall, the

mean difference score for pharmacists' realization was 3.2 (s.d.=10.2). Finally, the mean

difference score for pharmacists' feeling understood was -1.0 (s. d.=9.1). Negative scores

accounted for 42 percent (N=62) of the scores and 58 percent (N=85) were positive.

Thus, more than half of pharmacists thought patients would rate pharmacists' perceptions

higher than pharmacists' actual perceptions.

Patients' direct perspective responses on the potential benefits to them of

pharmaceutical care services were consistently lower than pharmacists'. Means ranged

from 6.1 (s.d.=2.4) to 9.4 (s.d.=1.6). Patients believed that being told about other drugs