Consumer acceptance of pharmacist prescribing

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Consumer acceptance of pharmacist prescribing
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xiv, 259 leaves : ill. ; 29 cm.
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Pennock, Albert Stanton
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Prescriptions, Drug   ( mesh )
Pharmacists   ( mesh )
Pharmaceutical Services   ( mesh )
Consumer Satisfaction   ( mesh )
Pharmacy thesis Ph.D   ( mesh )
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Thesis:
Thesis (Ph.D.)--University of Florida, 1987.
Bibliography:
Bibliography: leaves 254-258.
Statement of Responsibility:
by Albert Stanton Pennock.
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Typescript.
General Note:
Vita.

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University of Florida
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CONSUMER ACCEPTANCE OF PHARMACIST PRESCRIBING


BY






ALBERT STANTON PENNOCK


















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


1987

























Copyright 1987

by

Albert Stanton Pennock























To the citizens of Florida whose cooperation
made this study possible
and to "J,Y" my special friend
whose very presence gave me the impetus
to continue this work.
















ACKNOWLEDGMENTS


I am very grateful for having had the opportunity to

study here, to have been associated with so many fine and

wonderful people, and to have learned many new and exciting

things. I will always consider Dr. William McCormick, Dr.

Richard Angorn, Dr. Carole Kimberlin, Dr. Donna Berardo,

Dr. Howard Eng, and Dr. Wes Hutchinson to be a part of my

family, as each person has had a definite influence on me

during the formative years of my educational development.

I am also very grateful to Ned Phillips for his patient

assistance in guiding my use of the University computing

facilities.

I owe a great deal to my close friends, parents, and

other relatives for their continuous support and constant

interest in my work. This includes the sharing of my

educational program and of my research findings that I

report here.

I would like to thank all the many cooperative

consumers in the state of Florida who gave me their time so

that I was able to collect the data necessary for this

research project. These people probably will never know

who I am or how much they were able to help me. My heart

goes out to the many people who used me as a listening ear











and told me of the difficult personal situations in which

they were involved.

Lastly I would like to acknowledge two of my former

professors from the University of Texas, Dr. Robert G.

Brown, Associate Professor of Pharmacology, and Dr. Ester

Jane Hall, Associate Professor of Pharmacy

Administration. Undoubtedly these two people also have had

a definite influence on the direction of my life.















TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS .......................................... iv

LIST OF TABLES ........................................... ix

ABSTRACT ............................................... xiii

CHAPTERS

I THE PROBLEM..................................... 1

Introduction.................................... 1
Problem Statement............................... 4
Significance of Problem......................... 4

II BACKGROUND CONCERNING THE FLORIDA PHARMACIST
PRESCRIBING LAW....... .......................... 8

Early Legislation............................ 8
The OTC Drug Pipeline..................... .... 11
The "Third Class" of Drugs .....................13
The Florida Pharmacist Prescribing Law.........17

III REVIEW OF THE LITERATURE .......................21

OTC Drugs--General Discussuion .................21
Definitions of OTC Drugs ..................21
Consumer Expenditures on Self-
Medication .............................. 22
Extent of OTC Drug Availability...........23
The American Pharmacy Consumer................. 24
The Trend Toward Mass Merchandise
Retailers............................... 24
The Dichter Study......................... 25
Pharmacy Consumer Behavior .....................27
Consumer Attitude Toward the Pharmacist...27
The Pharmacist's Role in Patient
Counseling .............................. 29
Consumer Sources of Help and Information
for Self-Medication.....................32
The Importance of Pharmacist
Recommendations......................... 34










Consumer Willingness to Pay for Pharmacy
Services ................................ 36
Prescribed and Nonprescribed Drug Use..........38
Physician Availability ....................39
Health Status....................... 39
Demographic Characteristics................40
Summary........................................ 40

IV METHODOLOGY ................................... 43

Research Design............................... .43
Independent and Dependent Variables....... 44
Hypothesized Relationships ................ 47
Instrumentation ........................... 50
Pilot Study............................... 51
Data Collection................................ 52
Interviewing Process ......................52
Instrument Reliability ....................54

V RESULTS ........................................ 58

Location of Respondents........................ 58
Description of Respondents .....................59
Descriptive Statistics......................... 64
Pharmacy Patronage ........................ 64
Physician Use............................. 67
Attitudes... ............................. 70
Physician Availability....................71
Physician Access.......................... 73
Monetary Cost............................. 73
Time Cost................................. 75
Consumer Satisfaction with Physicians.....78
Pharmacist Availability ...................80
Pharmacist Helpfulness .................... 80
Trust in Pharmacist Competence............ 83
Pharmacist Bond........................... 83
Views of Pharmacist Prescribing...........85
Health Status............................ 101
Other Findings........................... 101
Hypothesized Relationships.................... 106
Physician Availability................... 108
Physician Access......................... 109
Monetary Cost............................ 111
Pharmacist Availability .................. 113
Pharmacist Helpfulness ................... 115
Pharmacist Competence .................... 117
Pharmacist Bond.......................... 119
Demographic Characteristics.............. 121
Investigated Relationships....................128
Cost of Time in Visiting a Physician..... 128
Satisfaction with Physicians............. 129


vii










Consumer Health Status...................131
Demographic Characteristics.............. 135
Consumer Willingness to Pay a
Consultation Fee ....................... 139
Consumers First Consulting a Pharmacist
for Specific Health Ailments........... 147
Respondent Comments........................... 161

VI SUMMARY AND CONCLUSIONS ....................... 170

Summary of Results ............................ 170
Conclusions......... ..........................179
Public Policy Implications.................... 184
Limitations................................... 186
Suggestions for Future Research............... 187

APPENDICES

A PILOT QUESTIONNAIRE........................... 190

B SURVEY QUESTIONNAIRE (ENGLISH VERSION)........ 209

C SURVEY QUESTIONNAIRE (SPANISH VERSION)........ 230

D STATISTICAL TABLES FOR ADDITIONAL ANALYSES.... 250

REFERENCES .............................................. 254

BIOGRAPHICAL SKETCH..................................... 259


viii















LIST OF TABLES


Table Page

4-1 Results of the Sampling Frame ....................55

4-2 Item Analysis for the Attitude Dimensions
of the Survey .................................... 57

5-1 Counties Surveyed ................................ 60

5-2 Demographic Characteristics of the Respondents...62

5-3 Survey Results Concerning General Pharmacy
Patronage ...................................... 65

5-4 Survey Results Concerning Physician
Utilization ...................................... 68

5-5 Consumer Reactions to Physician Availability.....72

5-6 Consumer Reactions to Physician Access........... 74

5-7 Consumer Reactions to Monetary Cost.............. 76

5-8 Consumer Reactions to Time Cost ..................77

5-9 Consumer Reactions to Satisfaction with
Physicians....................................... 79

5-10 Consumer Reactions to Pharmacist Availability....81

5-11 Consumer Reactions to Pharmacist Helpfulness.....82

5-12 Consumer Reactions to Trust in Pharmacist
Competence....................................... 84

5-13 Consumer Reactions to the Presence of a
Pharmacist Bond .................................. 86

5-14 Consumer Awareness of the Law ....................87

5-15 Consumer Knowledge of the Law .................... 90










5-16 The Conditions for Which Consumers Would
First Consult a Pharmacist .......................93

5-17 Consumers' Views of the Law....................... 95

5-18 Consumer Sentiment Concerning Other Health
Professionals and Their Prescribing Privileges...97

5-19 Consumer Willingness to Pay a Consultation Fee...98

5-20 Consumer Health Status .......................... 102

5-21 Other Findings.................................. 104

5-22 Statistical Summary for Physician Availability
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 110

5-23 Statistical Summary for Physician Access
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 112

5-24 Statistical Summary for Monetary Cost
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 114

5-25 Statistical Summary for Pharmacist Availability
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 116

5-26 Statistical Summary for Pharmacist Helpfulness
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 118

5-27 Statistical Summary for Trust in Pharmacist
Competence and Consumer Approval of the Law
and Consumer Intent to Allow a Pharmacist to
Prescribe....................................... 120

5-28 Statistical Summary for Pharmacist Bond
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe.......122

5-29 Statistical Summary for Hypothesized
Demographic Characteristics and Consumer
Approval of the Law and Consumer Intent
to Allow a Pharmacist to Prescribe.............. 123

5-30 Statistical Summary for Time Cost and
Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 130












5-31 Statistical Summary for Physician Satisfaction
and Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 132

5-32 Statistical Summary for Health Status and
Consumer Approval of the Law and Consumer
Intent to Allow a Pharmacist to Prescribe....... 134

5-33 Statistical Summary for Investigated
Demographic Characteristics and Consumer
Approval of the Law and Consumer Intent
to Allow a Pharmacist to Prescribe.............. 136

5-34 Statistical Summary for Consumer Demographic
Characteristics and Willingness to Pay a Fee
for a Consultation Resulting in a Prescribed
Drug............................................ 140

5-35 Statistical Summary for Consumer Demographic
Characteristics and Willingness to Pay a Fee
for a Consultation Resulting in the
Recommendation of an OTC Drug................... 143

5-36 Statistical Summary for Consumer Demographic
Characteristics and Willingness to Pay a Fee
for a Consultation Resulting in the
Recommendation to See a Physician............... 145

5-37 Statistical Summary for Consumer Demographic
Characteristics and Willingness to Allow a
Pharmacist to Prescribe If A Third Party
Would Pay the Costs............................. 148

5-38 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Head Lice.............. 151

5-39 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Corns and Warts........ 154

5-40 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Fluoride Vitamins...... 157

5-41 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Pinworms............... 159











5-42 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Nausea and Vomiting.... 162

5-43 Statistical Summary for Consumer Demographic
Characteristics and Willingness to First
Consult a Pharmacist for Burning Urination...... 164

D-1 Point Biserial Correlations Between Specific
Consumer Conditions and Their Approval of the
Law ............................................. 250

D-2 Point Biserial Correlations Between Specific
Consumer Conditions and Their Intent to
Allow a Pharmacist to Prescribe................. 251

D-3 Product Moment Correlations of Selected
Variables....................................... 252

D-4 Point Biserial Correlations Between Consumer
Bond with a Pharmacist and Acceptance of
Pharmacist Prescribing ..........................253


xii
















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

CONSUMER ACCEPTANCE OF PHARMACIST PRESCRIBING

BY

ALBERT STANTON PENNOCK

May, 1987

Chairman: William C. McCormick
Major Department: Pharmacy

Florida is the first state to enact legislation that

allows its licensed pharmacists to independently prescribe

legend drugs (drugs required to be sold only a prescription

of a practitioner licensed by law). Although, initially,

pharmacists may only prescribe such drugs from a limited

formulary, the act may later be expanded to encompass a much

larger formulary of these drugs. The drugs presently

included are used to treat minor and/or self-limiting

conditions, for which the patient otherwise might be forced

to purchase a less effective over-the-counter drug or visit

a physician in order to obtain a prescription.

Pharmacist prescribing is one way in which the

profession of plermacy can better serve the health needs of

the public. This study points out (1) the consumers the law

will benefit most and (2) what pharmacists can learn from

consumers in order to more effectively practice their

profession.


xiii










The methodology employed to obtain the necessary

information was a telephone survey of consumers representing

the entire state of Florida. The interviews were performed

by random digit dialing. A total of 402 consumers was

interviewed for a response rate of 53%.

Overall, respondents reported favorable attitudes and

opinions regarding their health care. Concerning their

acceptance of pharmacist prescribing, the variable

"consumer's relationship with physicians" was not

significant. However, "consumer's relationship with

pharmacists" was significant. When consumer demographic

characteristics were related to their acceptance of

pharmacist prescribing, only three characteristics showed

evidence of significance. These were age, marital status,

and the presence of dependent children in the household.

The consumers the law will help most are those who

reported that they frequently seek the advice of a

pharmacist. Many of these consumers also have bonds

(defined as close, personal working relationships) with

their pharmacists. Essentially, these consumers appear to

be practicing self-care.

In order for pharmacists to more effectively practice

their profession, they should be viewed by the public as

being available by telephone, easily approachable, and able

to dispense competent advice. The consumers who expressed

such feelings about pharmacists were those who were found to

be the most likely to accept pharmacist prescribing.


xiv















CHAPTER I
THE PROBLEM


Introduction

According to data published by the Health Care

Financing Administration, the 1985 aggregate health care

expenditure in the United States amounted to $425 billion,

10.7% of the gross national product (Waldo, Levit, &

Lazenby, 1986). This translates to a per capital

expenditure of $1,721. Although hospital services

accounted for 390 of each dollar spent, fees for

physicians' services, which was included in "other personal

expenditures," was in second place at 200.

The Review of Over the Counter Drugs (Review) by the

Federal Food and Drug Administration (FDA) represents an

attempt by the government to reduce health care costs by

reclassifying many prescription drugs to over-the-counter

(OTC) status if they are shown to be safe and effective for

self-administration (Gerald, 1979). Today, about 75% of

all health complaints are self-treated at a cost of 20 or

30 of each health dollar ("OTC therapy cost effective,"

1982). One result of the Review is that new OTC product

introductions in the U.S. jumped to 300 in the first four

months of 1984 compared with 253 one year earlier ("OTC's

on the rise," 1984).










The American Pharmaceutical Association (APhA) has

expressed concern that some of the newer OTC drugs are not

totally safe for self-administration and are subject to

improper use or abuse. It takes the position that the

public would be more effectively served if a new "third

class" of drugs were to be created that could be sold only

by a pharmacist after a brief consultation with the patient

(Kesselman, 1983).

The Proprietary Association (PA), a trade association

representing manufacturers of over-the-counter drugs,

opposes the establishment of a "third class" of drugs. It

rejects APhA's claim of more effective service to the

patient and takes the position that such drugs would be of

limited availability and sold at higher prices due to a

decrease in retail competition (Ugoretz, 1983).

Regardless of the public debates among several special

interest groups, the FDA claims it currently lacks

regulatory authority to create a "third class" of drugs.

According to the FDA, this could only be accomplished by

amending the Food, Drug, and Cosmetic Act which would

require special action by Congress. However, in the case

of legend drugs (drugs required to be sold only on

prescription of a practitioner licensed by law), the law's

requirement for dispensing "only on the prescription of a

licensed practitioner" does not specify who a licensed










practitioner is. This is left to the individual states to

determine.

One way of helping to reduce the burden of health care

costs on consumers within the existing legal framework

would be to allow pharmacists to prescribe legend drugs.

The state legislature of Florida enacted such a law.

Covington (1983) describes other pharmacist prescribing

laws in the states of California, Oregon, and Washington.

Yet, in these states, pharmacists have only "dependent

authority" in that their prescribing powers are delegated

by a practitioner who is authorized to prescribe. The

Florida law allows pharmacists to have "independent

authority" and creates a special committee with authority

to establish a formulary of enumerated drugs which can be

prescribed by pharmacists in accordance with established

guidelines.

While this law was enacted for the purpose of

financially benefiting consumers, not all consumers will

choose to avail themselves of the law's provisions, because

they feel that the existing system, which entails visiting

a physician for an evaluation and visiting a pharmacy for a

prescription or an over-the-counter drug, is sufficient.

This investigation is of particular importance for the

continuation and possible expansion of the law. Although

the law went into effect October 1, 1985, it is slated to

be repealed automatically October 1, 1996. At that time,










the state legislature of Florida will choose either to

eliminate it or to renew it in its reenactment of the

Pharmacy Practice Act.



Problem Statement

The basic question to be answered is "to what extent

will pharmacist prescribing be accepted by consumers?"

There are six components to be addressed.

1. How do consumers' views regarding physicians affect

attitudes toward pharmacist prescribing?

2. How do consumers' views regarding pharmacists

affect attitudes toward pharmacist prescribing?

3. To what extent, if any, do attitudes toward

pharmacist prescribing differ by demographics?

4. How does consumer health status affect attitudes

toward pharmacist prescribing?

5. Would consumers be willing to pay a small fee for a

private and uninterrupted consultation with a

pharmacist regarding drug product selection?

6. Would consumers be willing to accept pharmacist

prescribing if a third-party assumed responsibility

for payment?



Significance of Problem

When the pharmacist prescribing issue was restricted

to the creation of a "third class" of drugs, some





5



authorities described it as a fight for sales dollars

between pharmacies and mass merchandisers ("Drugstores

facing wider competition," 1984). A study by Drug Topics

showed that consumers who look for value and convenience

make most of their OTC purchases in general merchandise

stores (Laverty, 1984c). A separate study by Charles H.

Kline and Co. showed that food stores alone had increased

their share of the OTC market by approximately 6% each year

from 1979 through 1983 ("Keeping up with your OTC rivals,"

1984). The Proprietary Association conducted a survey of

its own and concluded that consumers are taking more

responsibility for their own treatment and that they find

OTC medications to be both safe and reliable ("Health care

practices and perceptions," 1984).

In contrast, health care professionals pointed to

examples of OTC drugs that had been misused. The

metaproternol inhaler was reclassified from prescription to

OTC status. In the absence of professional advice, a large

number of consumers misused the product. This resulted in

the inhaler being returned to prescription status (Caputo,

1984). Pharmacy groups preferred to see such products

classified into a new limited OTC category which could be

sold only by pharmacists. Now, instead of recommending and

selling drugs from a "third class," Florida pharmacists are

able to prescribe prescription drugs from a limited









formulary in accordance with approved dispensing

procedures.

The results of this study will be useful to policy

makers in making knowledgeable decisions concerning

pharmacists' prescribing. Pharmacists realize that

improved patient contact will lead to enhanced professional

standing ("Communicating the value of comprehensive

pharmaceutical services," 1973; "What is the Dichter

Institute saying about you?" 1973). It also brings

customers into their stores (Gagnon, 1976; Galloway & Eby,

1977; Kabat, 1969; McGhan, Hurd, Johnson, & McKennell,

1980; Nickel & Wertheimer, 1979). Yet many pharmacists are

perceived by the public as being "too busy" to be available

(Knapp, Knapp, & Engel, 1966).

Pharmacist prescribing provides a way in which the

profession of pharmacy can expand its health services to

the public. If pharmacist prescribing is to gain public

acceptance, then pharmacists will have to practice their

profession differently than commonly perceived. That is,

they must be more patient oriented and less dispensing

oriented. This study points out (1) the categories of

consumers the law will benefit most and (2) what

pharmacists can learn from consumers in order to more

effectively practice their profession.

Since the law is relatively new, there is the

possibility that many consumers will not be aware of the










services now available. In addition, many consumers who

are aware of the law may not have availed themselves of its

intended benefits. Therefore, this study provides

"baseline" information concerning consumer intent to use

the service and not actual consumer utilization.

At times, pharmacists have been characterized as

"over-educated" and "under-utilized." In addition,

pharmacists have been characterized as "the most available

members of the health care profession" (Covington, 1983,

p. 166). The Florida Pharmacist Prescribing Law opens

another avenue to the public in obtaining increased access

to medical care.















CHAPTER II
BACKGROUND CONCERNING THE FLORIDA
PHARMACIST PRESCRIBING LAW



Early Legislation

A chronological outline of Federal legislation as

compiled by Wilkerson and Pietrangelo (1983) follows. The

Pure Food and Drug Act, 34 Stat. 768(1906), was the first

federal enactment to regulate the manufacture of

pharmaceuticals. It required that all drugs must meet the

standards of strength and purity claimed by the

manufacturer. The Act formally recognized the United

States Pharmacopeia and the National Formulary as official

compendia to set legal standards for drugs. It prohibited

false and misleading claims but did not specifically

prohibit false therapeutic claims.

The Sherley Amendment, 37 Stat. 416(1912), prohibited

manufacturers from making false and fraudulent therapeutic

claims about a product. This was difficult to enforce

because the burden of proving fraud was placed on the

government. The amendment seemed to correct many of the

Act's perceived deficiencies in regulating the production

and distribution of pharmaceuticals. However, it still did










not require evidence of safety prior to marketing; nor did

it regulate the advertising of drugs.

Probably the most precipitating event in drug

legislation history was the "Sulfanilamide Elixir." Over

100 people died from a new product that had not been tested

for safety. This occurrence so aroused public pressure

that Congress, as a result, passed the Food, Drug, and

Cosmetic Act (FDCA), 52 Stat. 1040(1938), which for the

first time required that drugs be proven to be safe prior

to marketing. The Act also established the Food and Drug

Administration (FDA).

Internecine squabbling regarding which agency had

enforcement jurisdiction over false advertising gave cause

for considerable concern. The Federal Trade Commission

(FTC) lobbied against sharing jurisdiction with the FDA.

The Proprietary Association and other trade organizations

of OTC manufacturers supported the FTC. The central

objection stemmed from the holding in Federal Trade

Commission v. Raladam, 51 SCt 86, 52 SCt 14. Here, a

Supreme Court decision limited FTC authority only to false

advertising in which an injury to competition could be

shown. Pharmacist legislators Wheeler and Lea sought to

give the FTC full responsibility for advertising by

congressional enactment. The Wheeler-Lea Act,

15 USC Secs. 12-15(1938), prohibited the dissemination of

any false advertising for the sale of food, drugs, devices,










or cosmetics. Included also was the omission of any

material fact that may result in a misleading

advertisement. Such actions constitute unfair or deceptive

practices under the FTC Act. In summary, the FTC gained

jurisdiction over drug advertising while the FDA retained

jurisdiction over labels and labeling.

The Durham-Humphrey Amendment, 21 USC Sec. 353(6)(1)

(1951), to the Food, Drug, and Cosmetic Act officially

divided drugs into two categories, prescription and non-

prescription. The amendment required that prescription

drugs in the manufacturers' package now contain the legend

"Caution: Federal law prohibits dispensing without a

prescription." These "legend drugs" are restricted to sale

only upon a prescription order and may not be refilled by a

pharmacist without the authorization of the prescriber.

The Kefauver-Harris Amendment, 76 Stat. 780(1962),

required manufacturers to establish the safety and efficacy

of all new prescription drug products prior to marketing.

In addition, drugs approved for marketing by the FDA

between 1938 and 1962 were required to undergo an efficacy

review. Since more than 3000 drugs were involved, the FDA

contracted with the National Academy of Sciences and its

research division, the National Research Council to

evaluate the drugs. This program was termed the Drug

Efficacy Study Implementation (DESI) whereby each product










reviewed was classified as effective, probably effective,

possibly effective, or not effective.

Due to the large number of OTC drugs involved, the FDA

ruled in 1972 that a separate review for OTC drugs would be

required. To accomplish this, the FDA appointed 17

advisory panels of physicians, pharmacologists,

toxicologists, and pharmacists. The Review involved

approximately 350,000 products containing approximately

1100 ingredients that were assigned to 70 categories

according to pharmacologic groupings (Mercill, 1983). The

advisory panels studied ingredients, concentrations, dosage

schedules, formulations, and labeling. Uniform standards

were established for the safety, efficacy, and labeling of

nonprescription products. Each OTC ingredient was assigned

to a monograph that contained a description of the

ingredients, indications for use, directions for use, and

other conditions that related to safety and efficacy. The

monographs were classified as follows:

Category I: generally recognized as safe and
effective

Category II: unsafe, ineffective, or improperly
labeled

Category III: insufficient data for a classification
in either Category I or II.


The OTC Drug Pipeline

Under Federal law, habit forming and potentially

harmful drugs are restricted to prescription sale, but drug









products for use in self-medication are generally available

if they can be adequately labeled for use by the general

public (Mercill, 1983). The underlying rationale is that

if a drug is safe for lay use on the basis of its labeling

alone, then it must be made available for OTC sale.

From 1938 until the beginning of the OTC Review in

1972, FDA decisions on drug status were erratic; many of

these decisions were made at the urging of the drug

manufacturers (Murphy, 1984). Nevertheless, between 1951

and 1983, only slightly more than 50 such products were

reclassified by the FDA from prescription status to OTC

status (Becker, 1984).

By 1983, the OTC Review had been ongoing for 11

years. An FDA report estimated that the review would cost

industry as much as $91.5 million in relabeling,

reformulation, and testing expenses ("OTC drug review could

cost $92 million," 1983). This translates into a cost of

.2% to .4% of the OTC drug industry's sales.

In 1980, FDA Commissioner Goyan proposed to members of

an agency panel that the FDA should create a special

committee to consider additional candidates for OTC status

once the review is completed (Mercill, 1983). Peter Hutt,

former counsel for the FDA and sometimes called the

"father" of the OTC review, remarked, "There is virtually

no limit to the number of prescription drugs that are










potential candidates for transfer to non-prescription

status" (Murphy, 1984, p. 14).

Other than the OTC review, there are two other

pathways for creating new OTC drugs: (1) a manufacturer

may submit a New Drug Application (NDA) to the FDA in a

format similar to that required for prescription drugs; and

(2) existing OTC monographs may be expanded by the FDA as

to usage after hearing evidence from a manufacturer, an FDA

advisory committee, or any member of the general public

(Murphy, 1984). Hutt claims that there is still a major

backlog of items to be considered.



The "Third Class" of Drugs

James Dolusio (1983), Dean of the College of Pharmacy

at the University of Texas at Austin, has pointed out that

pharmacists are in a unique position to assist and advise

patients who choose self-medication. Although higher

standards of safety have been established for OTC drugs

than for prescription drugs since they are intended to be

used in the absence of medical supervision, there are no

practical provisions available for monitoring their safe

usage (Gerald, 1979). According to Dean Dolusio, the

public does not fully comprehend its limitations in self-

diagnosing and utilizing medication and the risks of

exceeding those limitations. Gerald (1979) points out that

potential risks might be due to (1) an adverse drug










reaction even when the OTC drug is taken as directed, (2)

an acute toxicity from overdose, (3) a drug-drug

interaction, or (4) an inappropriate therapeutic use

resulting from a misdiagnosis.

Gerald (1979) claims that it is the FDA's

responsibility to determine the safety and efficacy of OTC

drugs and that pharmacists have a professional

responsibility to help patients assess the promotional

claims made by manufacturers. It has been estimated that a

physician is involved in only about 5% of all instances in

which a patient perceives and treats a health problem

(Dolusio, 1983). Self-medication is used as a treatment

mode in 75% of these instances.

The American Pharmaceutical Association (APhA) has

long sought to classify drugs into four classes: (1)

prescription, (2) over-the-counter, (3) drugs which may

be dispensed on the order of a pharmacist, and (4)

prescription drugs that are renewable at the pharmacist's

discretion (Kesselman, 1983; Ugoretz, 1983). The proposed

"third class" of drugs would be composed of drugs that are

not sufficiently dangerous to require a physician's

supervision, but nevertheless might require some degree of

counseling and screening by a pharmacist (Mercill, 1983).

According to Sol Kesselman (1983), Chairman of the

Illinois Association of Community Pharmacists executive

board, the FDA's shifting of many drugs from prescription










to OTC status illustrates the need for a "third class" of

drugs. He states that the public would receive better

service and greater protection at a lower cost than is

usually associated with obtaining prescription drugs. The

pharmacist would act as a safety net in forestalling drug

misuse among patients. Kesselman added,


Competition would keep prices down, as has
happened with prescription drugs, the most
restricted class
a third class of drugs would only involve a
small percentage of drugs
a third class of drugs would allow the FDA more
leeway in releasing drugs for public sale and
would therefore lower medical costs. (1983,
p. 12)


The FDA does not recognize a "third class" of drugs

(Mercill, 1983). Mercill notes that in 1974, the

Department of Justice stated in a letter to the FDA that a

"third class" of drugs would result in less competition,

less convenience, and higher prices. The FDA commissioner

agreed and replied that a "third class" of drugs would

decrease the number of outlets where OTC drugs could be

sold, cause prices to rise, and result in no public

benefit.

J.D. Ugoretz (1983), Assistant General Counsel of the

Proprietary Association, said that a "third class" of drugs

would not result in greater consumer protection, but in

less consumer choice, less convenience, and higher

prices. Ugoretz continues,











The philosophy behind our present system of drug
regulation is that if a drug can be used safely
by a consumer on the basis of labeling directions
without professional supervision, then it shall
be generally available to consumers over the
counter. On the other hand, a drug that
cannot be used safely without the supervision of
a physician shall be restricted to sale and
use only by prescription. (1983, p. 11)


A public hearing was held in Newark, New Jersey, in

May, 1984, to gather information pertaining to a New Jersey

Pharmaceutical Association backed proposal for a "third

class" of drugs ("Third class of drugs runs into stiff

opposition," 1984). William Halsey, Director of Government

Relations for the New Jersey Chamber of Commerce, claimed

that such a proposal would create a "druggists monopoly"

that would result in a severe reduction in sales for the

pharmaceutical industry as the number of retail outlets is

decreased. Charles Marcinate, President of the New Jersey

AFL-CIO stated that,


there is no need for it it
understates the intelligence of the consumer
it would increase the already unaffordable
prices of medicines due to more pharmacist time
required the third class proposal was
generated by pharmacists not consumers. ("Third
class of drugs runs into stiff opposition," 1984,
p. 15)


James Barry, Director of the New Jersey Division of

Consumer Affairs, asserted that the "third class" of drugs

would be ". anticonsumer limit availability .










not allow the consumer to compare labels ." ("Third

class of drugs runs into stiff opposition," 1984, p. 15).

Ugoretz concluded his statement by saying,


If a consumer has a question about ingredients or
actions of an OTC drug or its labeling,
pharmacists are a knowledgeable source of
information. But if a consumer has no questions,
then he should not be compelled by law to buy it
in a drugstore. (1983, p. 12)


Kesselman countered, "Congress may not care if the

corner drugstore survives, but it can't ignore the growing

evidence of damage to the elderly and other sectors of the

population caused by the misuse and abuse of some OTC

drugs" (1983, p. 12).



The Florida Pharmacist Prescribing Law

One way of circumventing the "third class" of drugs

issue is to change the current restrictive state statutes

so that they encompass new types of prescribers, such as

pharmacists. Although such action might result in a slow-

down in the reclassification of many prescription drugs to

OTC status or provide the states with a reason to restrict

certain OTC drugs to sale only by prescription, the public

is most likely to benefit. Pharmacists will be in a

position to advise and counsel patients regarding drugs,

hitherto unavailable without prescriptions from traditional

practitioners, that might be considered unsafe for ordinary










self-medication yet which may be adequate for treatment of

minor disease states.

The state of Florida now includes pharmacists among

those authorized by law to prescribe medicinal drugs. The

term "prescription" in the Florida statutes now includes an

order by a pharmacist for a drug product selected from a

special formulary. More specifically, the Pharmacist

Prescribing Law, 465.186 Fla. Stat. (1985), includes the

following features:

1. A committee is created which has the responsibility

of establishing a formulary of drugs which can be

made available to the public upon the order of a

pharmacist.

2. The composition of the committee consists of two

M.D. members of the Board of Medical Examiners, one

D.O. member of the Board of Osteopathic Medical

Examiners, three pharmacist members of the Board of

Pharmacy, and one additional member with training

in pharmacology or health care appointed by the

other members of the committee.

3. The law specifies the categories of drugs

permissible for inclusion and charges the committee

with establishing the formulary and any necessary

dispensing instructions. The categories are

a. Any medicinal drug of single or multiple active

ingredients in any strengths when such active










ingredients have been approved individually or

in combination for OTC sale by the FDA.

b. Any medicinal drug recommended by the FDA

Advisory Panel for transfer to OTC status,

pending approval by the FDA.

c. Any medicinal drug containing any antihistamine

or decongestant as a single active ingredient

or in combination.

d. Any medicinal drug containing fluoride in any

strength.

e. Any medicinal drug containing lindane in any

strength.

f. The formulary may not include any OTC drugs.

4. The formulary of medicinal drugs and dispensing

procedures established by the committee must be

adopted as a rule under the Florida Administrative

Procedure Act in order to become effective.

5. Any drug product ordered by a pharmacist must be

selected and dispensed only by that pharmacist and

the order is not refillable. In addition, no other

drug may be ordered for the same condition unless

such act is consistent with the dispensing

procedures established by the committee. The

pharmacist must create and maintain a prescription

record in the form required by law.










6. The pharmacist must affix to the container, a label

with the following information:

a. The name of the pharmacist.

b. The name and address of the pharmacy.

c. The date of dispensing.

d. The prescription order number.

e. The name of the patient.

f. The directions for use.

g. A clear and concise statement that the order

may not be refilled.

7. The pharmacist is eligible for reimbursement by

third party prescription programs when so provided

by contract or when otherwise provided by such

program.

8. There are penalties for violations of the

provisions of the law.

9. The law took effect October 1, 1985, and will be

automatically repealed under Florida's Regulatory

Sunset Law on October 1, 1996, unless reenacted by

the state legislature prior to that date.















CHAPTER III
REVIEW OF THE LITERATURE


A summary of the literature is presented and appears

under four general headings. A "general discussion"

distinguishes OTC drugs from prescription drugs, presents

consumer expenditures on self-medication, and describes the

extent of OTC drug availability. The "American pharmacy

consumer" is profiled and his reasons for choosing a

particular pharmacy are identified. "Pharmacy consumer

behavior" outlines the interactions between pharmacists and

patients. "Prescribed and nonprescribed drug use" examines

the correlates of health care consumers and their health

seeking behavior.



OTC Drugs--General Discussion

As indicated, this section is composed of three

subsections. First, OTC drugs are distinguished from

prescription drugs; second, consumer expenditures on self-

medication are presented; and third, the extent of OTC drug

availability is explored.

Definitions of OTC Drugs

According to a definition by Mercill,


Nonprescription drugs are those that are lawfully
sold over the counter for the public to use in
self-medication without professional supervision


21










on the basis of labeling that provides adequate
directions for proper use. (1983, p. 207)


He differentiates them from prescription drugs by stating,


Prescription drugs are those that, because of
their potentially harmful effects, their method
of use, or their collateral measures required,
are not safe for self-medication and accordingly
must be dispensed only under the supervision of a
prescribing physician or dentist. (p. 207)


For the most part, OTC drug use is unsupervised by any

member of the health care team. Patients diagnose their

own symptoms, select an OTC drug product for themselves,

and then monitor and evaluate their own therapeutic

response to the medication (Smith, Czaplich, Sohocki,

Kamikowski, & McKercher, 1978). Self-medication with OTC

products is a common and important mode of therapy for

treating mild, self-limiting symptoms and medical

conditions (Becker, 1984). Over-the-counter drugs are a

first line of defense in health care. They are inexpensive

and convenient (Mercill, 1983). In a study of a national

sampling of 2000 families, 7 of every 10 consumers were

found to self-medicate "frequently" with OTC products

(Inhorn, 1981).

Consumer Expenditures on Self-Medication

The high frequency of use of OTC drug products has

been attributed to the rising education level of the

general public (Knapp, Knapp, & Engel, 1966). That is, the










public has an increased self-confidence in its ability to

treat itself. In 1980, American consumers spent about $5.4

billion for OTC drugs which accounted for 2.3% of the

nation's total health expenditures (Health Care Financing

Administration, 1983). According to this study, the 1980

expenditures per person by category were found to be

for OTC drugs $20 per person per year

for Rx drugs $37 per person per year

for dentists $46 per person per year

for physicians $146 per person per year

for hospital services $300 per person per year

Later data show that American consumers are now spending an

aggregate amount of $9 billion yearly for OTC drugs

(Becker, 1984).

Extent of OTC Drug Availability

Consumers have many OTC drug products to consider, as

more than 350,000 such items were available in 1984

(Becker, 1984). Becker notes that consumers purchase

approximately 60% of their aggregate OTC drug needs in

pharmacy outlets. Slater (1979) adds that a typical

pharmacy stocks 10,000 to 20,000 different OTC items.

According to Slater,


a full 90% are sold off the shelf without
requiring any of the pharmacist's time in
selection
the consumer is inside the store for only a few
minutes and has an average eye contact time per
item of about 0.1 second










over 40% of all buying decisions are made
inside the store while the consumer is
shopping. (1979, p. 315)


Some authorities claim that most people are limited in

their ability to self-diagnose and that they may not be

aware of the many potential problems associated with OTC

products (Becker, 1984). According to Becker, the

pharmacist is in a unique position to assess, educate, and

advise patients in selecting the right drugs, in the right

amounts, for the right reasons, and at the right times.



The American Pharmacy Consumer

This section describes the American pharmacy consumer

in his search for medication advice. First, the trend

toward purchasing OTC drugs from mass merchandise retailers

is explored; and second, the Dichter Study is presented as

a possible explanation of why consumers are relying less on

the pharmacist as a source of help and information.

The Trend Toward Mass Merchandise Retailers

A study by Louis Harris in 1983 sponsored by the APhA

showed that 6 of every 10 consumers purchase OTC drugs in a

different outlet from where they have their prescriptions

filled (Laverty, 1984c). Most consumers in the Harris

study favored mass merchandise stores because of

convenience, variety, and low prices. Another study by

Charles H. Kline in 1984 indicated that OTC drug purchases










are split between food stores, mass merchandisers, and

drugstores ("Keeping up with your OTC rivals," 1984).

Although drugstores are losing their share to the other

outlets, the size of the market is expanding overall. Yet

drugstores must compete with nonpharmacy retailers as more

and more OTC drugs are sold in supermarkets and mass

merchandise stores (Laverty, 1984a).

A 1982 study of the shopping habits of 2,000 consumers

by Family Opinion, a market research company, pointed out

that 53% are not loyal to a single drugstore but tend to

shop in a variety of stores (Rosendahl, 1982). The most

important factors in choosing a store were price and a

pleasant shopping environment. A 1984 study of the

shopping habits of 1,400 families by People Panel, another

market research organization, disclosed that young

couples/parents favored supermarkets, middle aged/parents

favored mass merchandise stores, and older/retired persons

favored drugstores (Laverty, 1984a). The Family Opinion

study showed that most respondents buy more than one item

at a time and that 25% of the respondents compare items in

the store before purchase. Eighty-eight percent shop in

stores that regularly advertise (Rosendahl, 1982).

The Dichter Study

Perhaps part of the trend toward purchasing OTC drugs

and traditional drug store items from food stores and mass

merchandise retailers can be explained by the findings of










the Dichter Institute for Motivational Research. The

study, commissioned by the APhA, sought to determine the

public's attitude toward the pharmacist and his services

("Communicating the value of comprehensive pharmaceutical

services to the consumer," 1973). Pharmacy has an unusual

mix of professional service and commercialism that results

in confusion in the minds of the public. That is, the

study found that the public finds it difficult to perceive

the pharmacist as a professional on the same plane as a

physician or attorney. The public tends to think of the

pharmacist as being closely aligned with the manufacturer

or as a businessman with primarily commercial

motivations. The key finding of the study was that the

pharmacist has lost contact with his patients. As

described by Smith,


one of the most prevalent perceptions is
that the pharmacist hides behind a specialized
counter in a corner of the establishment, makes a
little bit of noise, and comes up with a small
bottle and a large bill. (1980, p. 264)


The Dichter Study showed that patients expect and

desire personal contact, attention, and professional

service from their pharmacist. Patients desire an "ideal

pharmacist" that is friendly, approachable, and concerned

about his patients, one who maintains personal contact, and

calls them by name ("What is the Dichter Institute saying

about you?" 1973).










Instead, patients feel a sense of isolation and

alienation. They feel that they are being "pushed away"

from the pharmacist rather than being "pulled in" by the

lower prices of the discount stores ("Communicating the

value of comprehensive pharmacy services to the consumer,"

1973). Without the opportunity to confer directly with the

pharmacist, the public is likely to make its drug purchases

at discount stores where prices are usually lower.

Therefore, pharmacists are losing patrons because their

customers feel that price is the only factor that needs to

be considered ("What is the Dichter Institute saying about

you?" 1973).



Pharmacy Consumer Behavior

This section presents findings from studies relative

to interactions between pharmacists and patients. It

includes consumer attitudes toward pharmacists, the

pharmacist's role in patient counseling, the consumer's

sources of help and information, the importance of

pharmacist recommendations, and consumer willingness to pay

for a pharmacist's services.

Consumer Attitude Toward the Pharmacist

A few years before the Dichter Study, Kabat (1969)

found that most people visit a pharmacy in excess of their

visits to any other health care outlet. Ninety percent of

those people surveyed visited a pharmacy at least monthly










while 60% visited a pharmacy at least weekly. Kabat

studied consumer perceptions of different types of

pharmacies and concluded that the independent community

pharmacists were the only ones that had been able to

maintain their personal identity to any significant

degree. He termed pharmacists from chain and discount

stores as "phantom pharmacists" and "generic

pharmacists." He noted that in these stores, both the

drugs and the services are standardized at an acceptable

quality level so that the public's personal choice of

pharmacist is unimportant from a quality point of view.

Many studies have found that the pharmacist is very

important for the overall consumer perception of the

pharmacy. Consumers want personalized professional contact

with the pharmacist (Gagnon, 1976). They are concerned

about having access to a competent pharmacist (McGhan,

Hurd, Johnson, & McKennell, 1980) and that he be available

when they need him (Gagnon, 1976). Heavy users of

medications consider the pharmacist to be the most

important factor in choosing a pharmacy (Nickel &

Wertheimer, 1979). Some consumers say that liking their

pharmacist is very important (Kabat, 1969). Low income

consumers tend to view pharmacists more favorably than

higher income consumers (Galloway & Eby, 1977).

Interestingly, the response to an item that the

pharmacist "aids in the selection of OTC drugs" was rated










as "unimportant" in one study (Stewart, Kabat, & Purohit,

1977). The authors hypothesized that this particular

service was not generally being performed and that

consumers had not learned to expect it.

When the pharmacist is not a factor in a consumer's

choice of a pharmacy, then other services and conveniences

are. For community pharmacies, location has been found to

be most important (Kabat, 1969; Stewart, Kabat, & Purohit,

1977). For chain and discount pharmacies, price has been

found to be most important (Nickel & Wertheimer, 1979;

Stewart, Kabat, & Purohit, 1977).

Although no literature support is available, this

study considered the possibility that consumers will be

more likely to trust their pharmacist's judgment and advice

if they have developed a personal "bond" with him. That

is, many consumers who rely upon one particular pharmacist

will also have a close personal working relationship with

him. Therefore, this study employed the independent

variable of "pharmacist bond" in order to explore this

interpersonal relationship in determining if these

consumers are more likely to accept pharmacist prescribing.

The Pharmacist's Role in Patient Counseling

Patient counseling has been defined as "the provision

of information that will help patients to use their

medications correctly" (Kirking, 1982, p. 230). Dickson










and Rodowskas (1975a) found that their sample of

pharmacists devoted a total of 11% of their time

communicating. The vast majority of their communication

was verbal and with patients. However, only one half of

this time was spent on professional communications.

Kirking (1982) found that pharmacists favor counseling

although the sessions are usually brief and

unidirectional. That is, Kirking noted an absence of

dialogue, where the pharmacists did the talking and the

patients did the listening. Dickson and Rodowskas (1975b)

found that pharmacists in prescription-oriented pharmacies

devoted more time to patient communication than pharmacists

in chain store pharmacies.

The People Panel Study (Laverty, 1984c) found that

over 50% of consumers do not receive voluntary information

from their pharmacists. In the group of patients who did

not receive a voluntary consultation from their

pharmacists, some (20%) asked questions while most of them

(30%) did not and, hence, received no information.

Regulations by the Washington State Board of Pharmacy

require that pharmacists meet with patients and that they

provide information to assist in a better understanding of

the medications prescribed. However, Campbell and Grisafe

(1975) found that this does not always occur. The

investigators used pharmacy students acting undercover who










presented a prescription in each of 212 pharmacies. The

study found that 81% of the pharmacists met with the

patients, but only 47% of the pharmacists explained the

directions to the patient. The Schering Study

("Pharmacists exert big influence on buyers of OTC's,"

1980) found that 60% of the respondents said that they

would not hesitate to discuss any ailment with their

pharmacists. That is, the public seems to be eager to

receive medication advice and information, but pharmacists

are not providing help on a routine basis.

Dickson and Rodowskas (1975c) performed a detailed

study of pharmacist communications which controlled for the

variables of year of graduation, day of week, time of day,

job title, prescription volume, and prescription department

staffing. The most significant variable was staffing, in

that it varied inversely with total communication time.

That is, additional personnel decreased communication

time. The authors hypothesized that pharmacists do not

efficiently delegate tasks that can be performed by other

employees. Therefore, a higher volume pharmacy will have

increased staffing, but the pharmacists will be doing more

work by themselves. According to the authors, "the

pharmacist is envisioned as a prescription producing

factory rather than as a health professional providing

patient services" (Dickson & Rodowskas, 1975c, p. 497).










Consumer Sources of Help and Information for
Self-Medication

An early study by Knapp, Knapp, and Engel (1966)

involved in-depth interviews of consumers. The study found

that friends and family members were the most relied upon

sources of information concerning OTC drugs. Because of

their utilization of nonprofessionals for sources of

information, many consumers used home remedies. Physicians

were frequently questioned but were not contacted for the

sole purpose of obtaining information on OTC drugs. This

was because of the expense of seeing a physician and

because physicians were perceived as being "too

authoritarian." Pharmacists were likewise not approached

since they were perceived as being "too busy." Pharmacists

rarely volunteered information; rather, the patients had to

request information from them. Supermarkets were

patronized for OTC drugs used for treating "low risk"

health problems. Consumers were more influenced by

negative stories in the press regarding health care than

positive stories. The most important factors influencing

their decision-making were brand name and price. The

authors concluded that consumers are reasonably

sophisticated about drugs but often lack specific

information. Consumers' awareness of their deficiencies

might explain their reliance on informal communications and

their interest in reading health related articles.










A nationwide study was conducted by the Harry Heller

Research Corporation for the Proprietary Association in

order to determine consumer attitudes, beliefs, and

behaviors concerning OTC drugs ("Health care practices and

perceptions," 1984). This 1984 nationwide sample of 2000

consumers showed that people have an average of 4.5 health

problems per 2 week period and purchase an average of 1.09

products per health problem. Self-treatment is limited to

a short duration with only 40% of the consumers continuing

treatment beyond one day. Today it seems that people seem

to know which problems require professional attention

(stomach ulcers and migraine headaches), which problems can

be self-treated (athlete's foot and minor headache), and

which problems are to be left alone (minor fatigue and

bruises). In order to obtain their information, 86% of the

consumers in this study read the information on the

package, 79% asked the pharmacist, and 72% relied on

advertising. Overall, 92% of the consumers surveyed were

"satisfied" with the information obtained concerning

products they used.

Cohen (1977) has argued that a possible lack of

consumer information from health professionals concerning

the use of OTC drugs should require that advertising be

more strictly regulated. Consumers who rely on advertising

for information could be affected by improper advertising

that could lead to mistakes in self-medication. She states










that OTC drugs are not like other consumer goods where all

that a person can lose is money, since if a person

incorrectly chooses an OTC drug, he has less money for

another OTC drug or for a trip to a physician and a

resulting prescription. At present, advertisements fail to

disclose risks. Cohen advocates that OTC advertisements be

required to state (1) each symptom or condition when a

consumer should not use the product; (2) each symptom or

condition indicating when a consumer should decrease usage,

discontinue the product, or consult a physician; and (3)

each ingredient that is habit forming or will result in

dependency or continued use.

The Importance of Pharmacist Recommendations

An early study found that patients from lower

socioeconomic backgrounds had less tendency to form

opinions about OTC drugs and relied more on the pharmacist

to recommend a product and provide instructions (Smith,

Czaplich, Sohocki, Kamikowski, & McKercher, 1978). The

authors observed that patients are more likely to accept

advice when they know the pharmacist. One other

investigation showed a distinct relationship between

confidence in the pharmacist and acceptance of his advice

(Riley & Baldwin, 1980). The researchers interviewed 200

people in 13 pharmacies concerning a pharmacist's advice

about a toothache remedy. It was concluded that confidence

in the pharmacist results from both recognition of










professional capability and personal trust. The Schering

Study surveyed 1650 consumers and found that 95% purchase

the product recommended by the pharmacist, 92% are

satisfied with the product, and 87% would purchase it

again.

Each year American Druggist conducts an "open call"

survey to determine which specific OTC products pharmacists

are recommending. Although not statistically valid, the

1983 results, nevertheless, showed that the public is

becoming increasingly aware that OTC products differ in

degree, and not in kind, from prescription drugs. In

addition, the public believes that getting professional

advice when purchasing OTC drugs is beneficial to them.

The study found that there was a significant increase in

consumer requests for information in 1983 over 1982 ("Big

rise found in requests by OTC customers for pharmacist

recommendations," 1983).

A classic study by Knapp, Wolf, Knapp, and Rudy (1969)

indicated that under certain conditions a pharmacist's

advice might not be accurate. The authors conducted an

undercover survey of 36 pharmacists. The "customer" asked

the pharmacist for advice on insulin storage while

purchasing an OTC product contraindicated for diabetics.

Only 6 out of 36 pharmacists noticed the problem. Thirty

out of 36 pharmacists either sold the contraindicated










product or else recommended that the "customer" purchase

another product that was also contraindicated.

A later study by Wertheimer, Shefter, and Cooper

(1973) presented similar findings. Participant observers

approached different pharmacists for advice concerning

three health conditions. These were a lingering cough for

the patient, an unchecked diarrhea for a baby, and a

request for quinine capsules as an abortifacient. All 86

pharmacists recommended a specific OTC product for the

cough without considering that such a cough may have

indicated a serious condition. Not one pharmacist out of

50 inquired as to the baby's weight, duration of symptoms,

or the presence of fever. Only 4 out of 31 pharmacists

refused to sell the quinine, 22 of the 26 who did sell the

quinine failed to label the capsules with directions, and

only three pharmacists questioned the use of the quinine

but after learning its intended use, nevertheless,

dispensed the quinine. The authors concluded that many

pharmacists have a casual attitude toward OTC medication

and patient care.

Consumer Willingness to Pay for Pharmacy Services

It has been suggested that pharmacists might be more

available for patient consultations if patients would be

willing to pay for the service. The People Panel Survey

("Payment for services: Don't hold your breath", 1984)

contacted 1400 households and asked consumers if they would










be willing to pay for the maintenance of patient profiles

by pharmacies. Thirty-seven percent said they would. The

survey also asked consumers if they would be willing to pay

for counseling. Twenty-six percent of the consumers

sampled said they would.

Schondelmeyer and Trinca (1983) conducted an

experimental study of 218 consumers on their willingness to

pay for a prescription consultation. Four groups of

consumers were offered the service at four different price

levels. Eighty-eight percent of the consumers in the first

group used the service at no charge. Twenty-four percent

of the consumers in the second group used the service at a

$1.00 charge. Thirty-six percent of the consumers in the

third group used the service at a $2.00 charge. And, 16.7%

of the consumers in the fourth group used the service at a

$3.00 charge. It was interesting that more consumers from

the $2.00 group were willing to pay than from the $1.00

group.

Kirking (1982) arranged a series of semantic

differential scales for his analysis of consumer

perceptions of pharmacy services. Where a score of +3

indicated a willingness to pay and -3 indicated an

unwillingness to pay, consumers reported an average score

of -2.16.

The People Panel Survey ("Payment for services: Don't

hold your breath," 1984) found that those consumers who










were willing to pay for counseling were better educated and

had a greater interest and knowledge regarding health

care. Schondelmeyer and Trinca (1983) studied consumers in

terms of income, education, age, sex, and race. They found

that age was the only significant variable related to

willingness to pay. The age group of those most willing to

pay was 36-45 while the age group of those least willing to

pay was 66-75. The reasons given for willingness were

curiosity and a desire for more information.

The above studies were concerned with payments for

prescription counseling and the maintenance of patient

medication profiles. No studies have been performed

concerning the willingness to pay for a pharmacist's

consultation when there is a possibility that the

pharmacist might recommend an OTC drug or refer the patient

to a physician.



Prescribed and Nonprescribed Drug Use

The literature contains studies describing correlates

of physician-prescribed drug use; however, there are no

studies concerning pharmacist-prescribed drug use. At this

time, it is not known if consumers will regard the drugs

that pharmacists prescribe as a class of prescription drugs

or as a class of OTC drugs. This section examines the

correlates of health seeking behavior as they might

describe consumers who would utilize a pharmacist's










prescribing services. These are physician availability,

health status, and demographic characteristics.

Physician Availability

Bush and Osterweis (1978) reasoned that the more

people perceive medical care as convenient and available,

the more likely they are to use a prescribed drug and less

likely to use an OTC drug. These authors found that travel

time is not a factor, while cost is. They noted that the

use of prescription and nonprescription drugs are two

distinct activities. Rabin (1977) and Rabin and Bush

(1974) also found the use of nonprescribed drugs to be

substitutes for physician visits and for the prescribed

medicines associated with the formal health care system.

However, it is not known if a health care consumer who

perceives that his physician is less available will be more

likely to utilize the services of another type of health

care professional who is more available.

Health Status

Bush and Osterweis (1978) developed a model of

medication use. They showed that low health status (fair

to poor health) has a positive effect on both prescribed

and nonprescribed drug use. They hypothesized that low

health status may necessitate more physician visits, thus

resulting in more prescribed drugs. Rabin (1972) also

showed that low health status is highly correlated with

prescription and nonprescription drug use. Yet it is not










known whether persons of low health status will first

approach a pharmacist or their regular physician concerning

a restricted drug.

Demographic Characteristics

Rabin (1972) found that both OTC and prescription

drugs are more likely to be purchased by whites, higher

educated individuals, individuals of higher social status,

individuals of both high and low incomes, and older

individuals. He also found that single member households

spend more dollars on OTC drugs and that this value

declines with increasing family size. Rabin and Bush

(1975a, 1975b) found that whites use more OTC and

prescription drugs than nonwhites and that race has an

effect on prescribed drug use that is independent of social

or ethnic class. Again, it is not known whether persons of

such demographic characteristics will first approach a

pharmacist or their regular physician concerning a

restricted drug.



Summary

Early studies have shown that consumers lack specific

information concerning OTC drugs (Knapp, Knapp, & Engel,

1966) while other studies have shown that consumers feel

they know all that is necessary in order to make a purchase

(Kabat, 1969). Another study showed that only 30% of

consumers ever discussed OTC drugs with the pharmacist and










7% did not because they perceived him as being "too busy"

(Kabat, 1969). Physicians were likewise not approached

because they were perceived as being "too authoritarian"

(Knapp, Knapp, & Engel, 1966). Advertising and labeling

may not disclose all relevant information (Cohen, 1977).

Today, consumers look for a pharmacist who makes

himself available for consultation, will recommend OTC

drugs, and discuss how to use them ("Pharmacists exert big

influence on buyers of OTC's," 1980). Many consumers

mention the presence of a knowledgeable and helpful

pharmacist as the main reason for selecting a pharmacy

(Laverty, 1984c). In one study, 76% of consumers surveyed

indicated that the pharmacist has some influence on their

purchase of an OTC product (Laverty, 1984a).

Consumers apparently favor the reclassification of

prescription drugs to OTC status. The survey by People

Panel indicated that 57% favor reclassification. Younger

and better educated consumers are more in favor of

reclassification while older and less educated consumers

are less in favor (Laverty, 1984a).

Pharmacist prescribing will not be successful unless

it has public support. If pharmacists are allowed to

prescribe, then, possibly, fewer prescription drugs will be

reclassified by the FDA to OTC status. In addition,

individual states might elect to restrict the sale of










certain OTC drugs to the order of a prescription of a

licensed practitioner, including the pharmacist.

The Dichter Study originally focused on pharmacists

from independently owned pharmacies. The study attempted

to account for the success of chain store and discount

pharmacies. Today, it might be expected that a similar

effect is taking place with regard to the purchase of OTC

drugs. Smith (1983) reasons that today's pharmacists are

cool, aloof, and lacking in knowledge regarding the

socioeconomic and behavioral aspects of the health

professions. That is, pharmacists may not understand the

complexities of patient behavior. It might be concluded

that if patients do not feel comfortable approaching the

pharmacist for advice, then there is no reason for them to

request a pharmacist to prescribe. Price and convenience

become the important factors. If this is the true state of

the pharmacist-patient relationship, then pharmacist

prescribing might not be well received.

Research has focused on the correlates of physician-

prescribed drug use and the correlates of self-

medication. However, it is not known if consumers will

regard the drugs that pharmacists prescribe as a class of

prescription drugs or as a class of OTC drugs.















CHAPTER IV
METHODOLOGY



Research Design

The research design used for this study was a cross

sectional survey method. Consumers were surveyed via

telephone in order to assess their attitudes concerning the

prescribing law. A telephone survey was chosen over a mail

survey for two reasons. First, it was expected that many

households would be reached that contained elderly or less

literate individuals who might not respond to a mail

survey. Second, many individuals from households might be

reached in which Spanish, rather than English, is the

spoken language.

A computer generated list of 1,600 random telephone

numbers was purchased from a marketing information agency,

Survey Sampling, Inc., of Westport, Connecticut. The firm

has supplied references which support the claim that it has

provided such sampling services for many research

organizations nationwide. Its samples are fully

projectable.

The statistical characteristics of these samples are

described by five criteria:










1. The method produces samples in which all telephone

households in the geographic sampling frame are

given equal probability of selection.

2. The method produces element samples rather than

clustered samples.

3. The samples are stratified to all counties such

that the number of telephone households drawn from

a county is proportional to that county's share of

telephone households.

4. Samples are drawn systematically from an array of

counties and an array of working telephone blocks

within each county.

5. The method employs double sampling with the final

sample drawn from the county-stratified first phase

sample.

The interviews were conducted over an 8-week period.

The study resulted in 402 usable responses.

This section describes the independent and dependent

variables, hypothesized relationships, instrumentation, and

pilot study with instrument reliability.

Independent and Dependent Variables

The survey measured the following independent

variables.

1. Consumer attitude toward physicians.

Attitude toward physicians was operationalized as

follows:










a. The perceived availability of a physician at

the time of need.

b. The perceived access to a physician at the time

of need.

c. The perceived burden of cost of time in

visiting a physician.

d. The perceived burden of monetary cost in

visiting a physician.

2. Consumer attitude toward pharmacists.

Attitude toward pharmacists was operationalized as

follows:

a. The perceived availability of a pharmacist at

the time of need.

b. The perceived helpfulness of pharmacists.

c. The perceived competence of pharmacists.

d. The presence of a "pharmacist bond."

3. The health status of the consumer.

Health status was operationalized as follows:

A subjective rating from the consumer's personal

evaluation on a scale of excellent, good, fair, or

poor.

4. Consumer demographic characteristics.

Consumer demographic characteristics were

operationalized as follows:

a. Sex: male and female.










b. Age (actual age of individual, later grouped

for analysis into the four categories used by

the National Health Care Expenditure Survey):

18-24 years, 25-54 years, 55-64 years, and 65

years and above.

c. Race (five categories used by the U.S.

Department of Census): White, Black, Hispanic,

American Indian, and Asian.

d. Marital status (five categories used by the

U.S. Department of Census): single, married,

separated, divorced, and widowed.

e. Household income (five categories that were

selected before the data collection began):

below $10,000, $10,001-$30,000, $30,001-

$50,000, $50,001-$75,000, and over $75,000.

f. Education (12 categories, later grouped for

analysis into the five categories used by the

U.S. Department of Census): no formal

schooling, elementary school, high school, some

college, college, and beyond college.

g. Single or multiple member household.

h. If a parent, whether or not dependent children

live in the household.

The survey measured the following dependent variables,

which describe consumer acceptance of pharmacist

prescribing:










1. Consumer approval of the law.

2. Consumer intent to have a pharmacist prescribe for

them.

In addition, the study measured two other dependent

variables which are related to consumer acceptance of

pharmacist prescribing:

3. Consumer choice whether to first consult a

pharmacist or a physician for an initial

consultation concerning specific health conditions.

4. Consumer willingness to pay a fee for a

consultation with a pharmacist concerning drug

product selection.

a. When the pharmacist prescribes an allowable

drug.

b. When the pharmacist recommends an OTC drug.

c. When the pharmacist recommends that the patient

consult a physician.

d. Consumer willingess to accept pharmacist

prescribing if a third party assumes the cost.

The dependent variables were operationalized as

follows: simple answers of "yes," "no," or "uncertain"

obtained by self-reports of the respondents.

Hypothesized Relationships

The following relationships have support from the

literature and were hypothesized:










1. There will be a negative relationship between the

perceived availability of a physician at the time

of need and consumer acceptance of pharmacist

prescribing.

2. There will be a negative relationship between the

perceived access to a physician at the time of need

and consumer acceptance of pharmacist prescribing.

3. There will be a positive relationship between the

perceived burden of monetary cost in visiting a

physician and consumer acceptance of pharmacist

prescribing.

4. There will be a positive relationship between the

perceived availability of a pharmacist at the time

of need and consumer acceptance of prescribing.

5. There will be a positive relationship between the

perceived helpfulness of pharmacists and consumer

acceptance of pharmacist prescribing.

6. There will be a positive relationship between the

perceived competence of pharmacists and consumer

acceptance of pharmacist prescribing.

7. There will be a positive relationship between the

presence of a pharmacist bond and consumer

acceptance of pharmacist prescribing.

8. Older consumers will be more likely to accept

pharmacist prescribing.










9. White consumers will be more likely to accept

pharmacist prescribing.

10. Higher educated consumers will be more likely to

accept pharmacist prescribing.

11. Both low and high income consumers rather than

middle income consumers will be more likely to

accept pharmacist prescribing.

12. Consumers from single member households will be

more likely to accept pharmacist prescribing.

The following questions were investigated even though

there were no hypotheses as to the nature of the

relationship among variables.

1. What is the relationship between the perceived

burden of cost of time in visiting a physician and

consumer acceptance of pharmacist prescribing?

2. What is the relationship between satisfaction with

their physician care and consumer acceptance of

pharmacist prescribing?

3. What is the relationship between perceived health

status and consumer acceptance of pharmacist

prescribing?

4. What is the relationship between sex and consumer

acceptance of pharmacist prescribing?

5. What is the relationship between marital status and

consumer acceptance of pharmacist prescribing?










6. What is the relationship between the presence or

absence of dependent children in the household and

consumer acceptance of pharmacist prescribing?

7. Which consumers would be willing to pay a

consultation fee for a pharmacist's prescribing

service?

8. Which consumers would be willing to take advantage

of a pharmacist's prescribing services if a third

party would pay for the costs?

9. Which consumers would first consult a pharmacist

for specific health conditions?

Instrumentation

Items for the questionnaire were developed with the

aid of the theoretical frameworks pertaining to the

correlates of prescribed and nonprescribed drug use and

with the assistance of pharmacy and marketing professors

who are familiar with consumer behavior, health care

marketing, and research design. A list containing all

possible items was reviewed by the expert judges who then

critiqued the wordings, eliminated some statements, and

suggested others. The items for the attitude scales were

created according to the Likert scaling technique.

The measures of the attitudinal independent variables

were determined by scores on a series of 3-point scales.

The anchors were (1) agree, (2) no opinion, and (3)

disagree. It was decided that a 3-point scale would be










relatively simple to administer over the telephone and to a

wide variety of respondents. Scores close to "1" were to

indicate positive attitudes. Statements worded in the

negative were recorded for the item analysis. It was

assumed that the response "no opinion" would be equivalent

to "neutral" for the purpose of measurement. Therefore,

this would create ordinal data that would lend itself to

tests of item analysis and Cronbach's alpha.

Pilot Study

The questionnaire was pretested using a sample of 90

telephone numbers in the Gainesville area. The pretest

sample was selected from the Gainesville telephone

directory. Several listings under each letter of the

alphabet were chosen at random.

A total of 50 households answered when called. Of

these individuals, 36 agreed to be interviewed, resulting

in a response rate of 72%. The overall completion rate is

defined here as the total number of completed calls as a

percentage of the sampling frame. Here, 36 interviews were

obtained from 90 calls, resulting in a completion rate of

4o%.

Few changes in the questionnaire were needed. The

rate of response was acceptable and no subject showed signs

of difficulty in responding to the items. However, the

revisions that were made resulted in the addition of items

and, therefore, an increase in the length of the survey

instrument. The pretest questionnaire appears as










Appendix A. The revised questionnaire appears as

Appendix B. The questionnaire also was translated into

conversational Spanish so that the study sample would be

fully representative of the State of Florida. The Spanish

version appears as Appendix C.



Data Collection

This section describes the interviewing process with

response rates and final instrument reliability. The unit

of analysis is "the consumer over the age of 18 and living

in the state of Florida."

Interviewing Process

The respondents were selected from a random sample of

residential telephone numbers. The sample size of 400 was

calculated for a 95% level of confidence as follows

(Kinnear & Taylor, 1983):



precision 2/(p.q/n)



where the precision was chosen to be 5% and both and q

were chosen to be .5 and .5, reflecting the largest

proportions of the sample accepting and not accepting

pharmacist prescribing, respectively. The letter n

represents the sample size.

The completion rate was defined as the number of

completed calls as a percentage of the sampling frame. The










balance of the sampling frame is composed of the refusals,

terminations, no answers, business listings, nonworking

numbers, and continually busy signals. Survey Sampling,

Inc. estimated that the completion rate would be

approximately 25%. Therefore, a sampling frame of 1,600

telephone numbers was considered to be necessary.

Subjects were telephoned in the manner suggested by

Dillman (1978). He mentions that the "socially desirable"

times for calling are first, weekday evenings; second,

weekend afternoons; third, weekday afternoons; and fourth,

weekday mornings. If telephoned in this manner, the number

of "not at homes" and callbackss" can be minimized.

For the purpose of this study, calls were made (1)

Monday through Thursdays, 7:00 PM to 9:00 PM; (2) Mondays

through Thursdays, 2:00 PM to 4:00 PM; and (3) Weekends,

2:00 PM to 4:00 PM. Three attempts were made to reach each

household. The person answering the telephone was

interviewed, if it was determined that the individual was

over 18 years of age.

All of the English speaking interviews were performed

by the researcher. All of the Spanish speaking interviews

were performed by a single paid assistant. When a Spanish

speaking household was reached, the researcher made a

notation to have the assistant call back in Spanish. No

formal measures of inter-rater reliability were performed.









The English interviews were completed over an 8-week

period, from September 2, 1986, through October 25, 1986.

Approximately 50 interviews were completed each week. The

Spanish interviews were completed during the 1-week period

of November 9, 1986, through November 15, 1986. They

numbered 12 out of a possible 27.

As shown in Table 4-1, of the 1,600 attempts at

contacting the various households, there were 756

answers. Four hundred two individuals agreed to be

interviewed, resulting in a response rate of 53%. The

refusals included the people who refused to be interviewed

(327), the terminations by respondents (18), and the

hearing impaired (9). The balance of the 1,600 calls

resulted in no answers (320), continuously busy (29),

disconnected service (360), and business listings (135).

The overall completion rate was defined as the number of

completed calls as a percentage of the sampling frame.

Here, 402 interviews were obtained from 1,600 original

telephone numbers, resulting in a completion rate of 25%.

Instrument Reliability

In order to assess the internal consistency of the

attitudinal portion of the instrument, an item analysis was

performed. This was done even though summated scores were

not initially considered for the data analysis. For the

purpose of the item analysis, the score for each item was














Table 4-1 Results of the Sampling Frame


Result Number of Calls Percent of Total


Completed Calls 402 25.1
No Answer 320 20.0
Busy 29 1.8
Disconnected 360 22.5
Business/Government 135 8.5
Hearing Impaired 9 0.6
Terminations 18 1.1
Refusals 327 20.4
Total 1600 100.0









expected to correlate with the total score on the attitude

scale. A minimum value of 0.35 was expected. In addition,

a test of Cronbach's alpha was performed. A minimum value

of 0.60 was expected. Both types of correlations were

observed for a 95% level of confidence.

Table 4-2 shows that 23 of the 34 statements could be

grouped into six sets. These were assigned the labels of

(1) physician availability (items 16, 17, 18, and 19; alpha

= 0.60), (2) physician access (items 32, 33, and 34; alpha

= 0.67), (3) monetary cost (items 30, 37, and 38; alpha =

0.65), (4) physician satisfaction (items 23, 24, 25, 26,

28, and 29; alpha = 0.80), (5) pharmacist helpfulness

(items 39, 42, and 43; alpha = .63), and (6) pharmacist

bond (items 46, 47, 48, and 49; alpha 0.91).

Eleven of the attitudinal statements could not be

grouped with any others, either logically, or because of a

loss in the correlations. These were items intended to

measure (1) physician availability (item 21), (2) physician

access (item 20), (3) monetary cost (items 31 and 36), (4)

physician satisfaction (item 27), (5) time cost (items 22

and 35), (6) pharmacist availability (items 40 and 41), and

(7) pharmacist competence (items 44 and 45).
For the most part, the items appeared to be internally

consistent and relatively homogeneous. However, only six

scales could be formed with two-thirds of the items.












Table 4-2 Item Analysis for the Attitude
Survey


Dimensions of the


Alpha
Item Item Total if Item Number of
Scale # Correlation Deleted Cases Alpha


Physician
Availability



Physician
Access


Monetary
Cost


Physician
Satisfaction





Pharmacist
Helpfulness


Pharmacist
Bond


.35
.41
.43
.36

.35
.60
.53

.32
.52
.56

.62
.65
.57
.57
.48
.45

.42
.47
.43

.82
.84
.76
.79


.57
.51
.49
.54

.72
.40
.51

.74
.46
.43

.75
.74
.76
.76
.78
.79

.55
.48
.54

.88
.87
.90
.89


401 *




401 *



315*



401 *






321 *



300*


.60




.67



.65



.80






.63



.91


* Number of cases responding
specific area of interest.


to all questions relating to a















CHAPTER V
RESULTS


This section presents the descriptive and statistical

analyses of the survey findings under five general

headings. First, the geographical distribution of the

respondents was compared with that of the state

population. Second, the demographic characteristics of the

respondents are presented; they were likewise compared with

the population estimates. Third, the responses for each

item of the questionnaire were analyzed descriptively with

frequencies and percentages. Fourth, the hypotheses were

tested for statistical support. Fifth, the investigated

relationships were analyzed for statistical support.



Location of Respondents

The survey sample includes respondents from 50 of

Florida's 67 counties. Dade County has the highest

percentage of representation (47 or 11.8%), followed by

Broward County (38 or 9.5%). Seventeen counties were not

represented in the survey. This may be because these

counties have such small populations, that the "no answers"

when added to the nonresponsess" eliminated them completely










from the study. Table 5-1 shows a breakdown of the

respondents in terms of county location. The table

includes the 17 nonrepresented counties. Table 5-1 also

compares the distribution of the respondents with the

distribution of the general population as provided by the

University of Florida Bureau of Economic Research (Florida

Estimates of Population, 1986) and with the data provided

by Survey Sampling, Inc. The survey sample is reasonably

consistent with the 1985 estimates of population and with

the original frame supplied by Survey Sampling, Inc.


Description of Respondents

In summary, the respondents were primarily female (266

or 66.3%), were mainly white (353 or 87.8%), mainly married

(244 or 60.8%), and had annual household incomes between

$10,000 and $30,000 (172 or 45.6%). The respondents ranged

in age from 18 to 90 (mean of 47.4) and the highest

percentage of educational attainment appeared in the high

school category (151 or 38.0%). The majority did not have

dependent children in the household (282 or 70.5%).

Table 5-2 shows the demographic characteristics of the

respondents. The table also shows a comparison with

demographic estimates for 1987 provided by the Florida

State Data Center. However, the Center was only able to

provide estimates for three demographic characteristics,










Table 5-1 Counties Surveyed


Survey Population
County Frequency Sample % Estimate %* Estimate %**


Alachua 9 2.3 1.4 1.5
Baker 0 0.0 0.1 0.1
Bay 5 1.3 0.9 1.0
Bradford 1 0.3 0.1 0.2
Brevard 14 3.5 3.1 3.0
Broward 38 9.5 11.3 9.9
Calhoun 1 0.3 0.1 0.1
Charlotte 4 1.0 0.8 0.7
Citrus 1 0.3 0.7 0.6
Clay 4 1.0 0.6 0.7
Collier 1 0.3 1.0 1.0
Columbia 1 0.3 0.3 0.3
Dade 47 11.8 14.9 15.6
Dixie 0 0.0 0.1 0.1
De Soto 0 0.0 0.1 0.2
Duval 28 7.0 5.1 5.5
Escambia 15 3.8 2.1 2.3
Flagler 0 0.0 0.1 0.1
Franklin 0 0.0 0.1 0.1
Gadsden 3 0.8 0.3 0.4
Gilchrist 1 0.3 0.1 0.1
Glades 0 0.0 0.1 0.1
Gulf 1 0.3 0.1 0.1
Hamilton 0 0.0 0.1 0.1
Hardee 0 0.0 0.1 0.1
Hendry 2 0.5 0.1 0.2
Hernando 2 0.5 0.6 0.6
Highlands 0 0.0 0.5 0.5
Hillsborough 23 5.8 6.1 6.7
Holmes 1 0.3 0.1 0.1
Indian River 4 1.0 0.7 0.7
Jackson 2 0.5 0.3 0.4
Jefferson 0 0.0 0.1 0.1
Lafayette 0 0.0 0.1 0.1
Lake 6 1.5 1.1 1.1
Lee 6 1.5 2.4 2.3
Leon 6 1.5 1.4 1.5
Levy 1 0.3 0.2 0.2
Liberty 0 0.0 0.0 0.1
Madison 0 0.0 0.1 0.1
Manatee 5 1.3 1.7 1.5
Marion 8 2.0 1.3 1.4










Table 5-1--continued.


Survey Population
County Frequency Sample % Estimate %* Estimate %**


Martin
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumpter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
Total


2
2
1
2
1
17
4
19
7
37
17
1
2
12
10
1
4
2
0
0
0
15
0
1
1
PT*


0.5
0.5
0.3
0.5
0.3
4.3
1 .0
4.8
1.8
9.3
4.3
0.3
0.5
3.0
2.5
0.3
1.0
0.5
0.0
0.0
0.0
3.8
0.0
0.3
0.3
100.0


0.8
0.6
0.3
1.0
0.2
4.6
0.6
7.0
2.4
8.4
2.9
0.5
0.6
2.6
1.9
0.5
0.9
0.3
0.2
0.1
0.1
2.6
0.1
0.2
0.1
100.0


0.7
0.6
0.3
1.2
0.2
4.9
0.7
6.3
2.1
7.1
3.2
0.5
0.6
2.1
2.0
0.6
1.0
0.2
0.2
0.1
0.1
3.4
0.1
0.2
0.1
100.0


* Data provided by Survey Sampling, Inc.

** Data provided by "Florida Estimates of
1986," Bureau of Business and Economic
University of Florida.


Population
Research,


*** The codes for four counties were incorrectly recorded.












Table 5-2 Demographic Characteristics of the Respondents


Survey Population
Sample Estimate*
Characteristic # % %


Sex




Age


Male
Female



18-24
25-54
55-64
Over 64


Race
White
Black
Hispanic


Marital Status
Single
Married
Divorced
Widowed


Income
Under $10,000
$10,001-$30,000
$30,001-$50,000
$50,001-$75,000
Over $75,000


135
266
-1 **


54
191
58
97
04-T**


353
32
17
o402


90
244
20
47
T401**


91
172
91
13
10
- T**


33.7
66.3
100.0


13.5
47.8
14.5
24.2
100.0


87.8
8.0
4.2
100.0


22.4
60.8
5.0
11.7
100.0


24.1
45.6
24.1
3.4
2.7
T1.T0


Nonblack
Black


47.3
52.7
100.0


12.9
48.4
14.1
24.6
100.0


88.6
11 .4


100.0










Table 5-2--continued.


Survey Population
Sample Estimate*
Characteristic # % %


Education
None 2 0.5
Some Elementary 7 1.8
Elementary 9 2.3
Some High School 26 6.5
High School 151 38.0
Some College 111 28.0
College 65 16.4
Some Graduate Work 8 2.0
Master Degree 13 3.3
Doctoral Degree 5 1.2
Medical Degree 0 -
Law Degree 0 -
797T** 10-.

Children at Home
Yes 118 29.5
No 282 70.5
T4Q** 100.0


* Population Estimate for 1987 provided by Florida State
Data Center, Office of Planning and Budgeting, Executive
Office of the Governor, The Capitol, Tallahassee, FL.
The center was able to supply estimates of only three
demographic characteristics. As presented here, they
describe individuals aged 18 years and over.

** Does not indicate the expected total of 402 due to item
nonresponse.










sex, age, and race. The consumers interviewed for this

study provided demographic characteristics that were

reasonably consistent with the estimates for the state for

1987.



Descriptive Statistics

This section presents a description of the survey

results. Frequencies and percentages are reported. Not

all individuals responded to all items. Such item

nonresponse occurred when the item did not pertain to a

certain individual or when an individual refused to respond

or could not respond to the item.

Pharmacy Patronage

As seen in Table 5-3, 317 (78.9%) of all respondents

reported having one particular pharmacy where they trade

most of the time. For most of these people, it was a chain

type store (212 or 66.8%). Their length of time trading at

the same pharmacy ranged from 1 year to 20 or more years

with a mean of 7.3 years. The largest category was 2 years

(45 or 14.2%), followed by 10 years (42 or 13.2%), then 5

years (41 or 12.9%). Interestingly, most respondents did

not know the name of the pharmacist who usually assists

them (226 or 71.5%). A total of 324 (80.6%) of the

respondents reported that they pay for their own

prescriptions. Of this group, 126 (39.0%) reported that










Table 5-3 Survey Results
Patronage


Concerning General Pharmacy


Response Frequency Percent


Consumers Indicating a
Regular Pharmacy


Pharmacy Type





Number of Years
Trading with that
Pharmacy


Consumers Who Know the
Name of Their
Pharmacist


Yes
No
Total


Chain
Independent
HMP PPO
Clinic
Total

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 or more
Total


Yes
No
Total


317
85
70T2

212
83
6
16
317

34
45
31
13
41
22
13
13
6
42
1
6
3
3
18
1
5
2
1
19
T37

90
226
TTY*


78.9
21 .1


66.8
26.2
1.9
5.0
100.0

10.7
14.2
9.8
4.1
12.9
6.9
4.1
4.1
1.9
13.2
0.3
1.9
0.9
0.9
5.7
0.0
1.6
0.6
0.0
5.8
100.0

28.5
71.5
100.0












Table 5-3--continued.


Response Frequency Percent


How Consumers Pay for Self 324 80.6
Prescriptions Private Third
Party 59 14.7
Federal or
State Aid 18 4.5
Other 1 0.2
Total T4 100.0

If Reimbursed Yes 126 39.0
No 197 61.0
Total 3-3** 100.0

If a Copay Yes 116 92.1
No 10 7.9
Total T12 100.0


* Does not indicate the
nonresponse.

** Does not indicate the
nonresponse.


expected total of 317 due to item


expected total of 324 due to item










they are reimbursed by an insurance company for all or part

of their prescription expenses.

Physician Use

Questions were asked concerning physician use which

were similar to those regarding pharmacist use. As seen in

Table 5-4, of all respondents, 352 (87.8%) reported having

a regular physician available when they are ill. For most

of these people (206 or 58.7%), this physician was a solo

practitioner in private practice. The time period of the

relationship with their current physician ranged from 1

year to 10 or more years with a mean of 8.1 years. They

were not asked if they knew the name of their physician. A

total of 315 (78.4%) respondents reported that they pay for

their own physician visits and 202 (64.3%) of these

respondents reported that they are reimbursed for all or

part of their physician expenses. The respondents were

asked to report the number of times they visited a

physician in the last year. Their answers ranged from 0

visit to 20 or more visits with a mean of 4.4 visits. The

most frequent response was one visit (19.9%) followed by

none (16.2%) and, then, two visits (14.9%). Most (314 or

78.1%) indicated they had made five or less visits while a

sizeable number of respondents (39 or 9.7%) indicated 10-12

visits. In the former case, the respondents mentioned that

they consulted a physician only in time of need or for a











Table 5-4 Survey Results Concerning Physician Utilization


Response Frequency Percent


Consumers Indicating a
Regular Physician


Physician Practice






Number of Years
Seeing Physician


How Consumers Pay for
Physician Visits


Yes
No
Total


Private Solo
HMO PPO
Group
Clinic
Doc in the Box
Not Sure
Total

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 or more
Total

Self
Private
Third Party
Federal or
State
Other
Total


352
49
401T*

206
17
70
46
7
5
351**

38
39
37
25
38
18
17
13
2
42
1
10
4
3
19
3
2
4
0
35
357*


315

50

29
8
o402


87.8
12.2
100.0

58.7
4.8
19.9
13.1
2.0
1 .4
100.0

10.9
11 .1
10.6
7.1
10.9
5.1
4.9
3.7
0.6
12.0
0.3
2.9
1.1
0.9
5.4
0.9
0.6
1.1
0
10.1
100.0


7.2
2.0
100.0










Table 5-4--continued.


Response Frequency Percent


If Reimbursed


If a Copay


Yes
No
Total

Yes
No
Total


Physician Visits in
Last Year


5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 or more
Total


202
112
31 T***

196
5
201T****

65
80
60
53
41
15
24
2
3
1
10
0
29
0
0
3
1
0
0
0
15
T402


64.3
35.7
100.0

97.5
2.5
100.0

16.2
19.9
14.9
13.2
10.2
3.7
6.0
0.5
0.7
0.2
2.5
0.0
7.2
0.0
0.0
0.7
0.2
0.0
0.0
0.0
3.5
100.0


* Does not indicate
item nonresponse.

** Does not indicate
item nonresponse.


the expected total of 402 due to


the expected total of 352 due to


Does not indicate the expected total of 315 due to
item nonresponse.


**** Does not indicate
item nonresponse.


the expected total of 202 due to










yearly check-up. In the latter case, the respondents

mentioned that they have specific conditions which

necessitate a visit to a physician at least once a month.

Some of these people were either hospitalized and/or

maternity patients.

Attitudes

As previously discussed, several statements were

presented and the respondents were asked to report whether

they agree, disagree, or have no opinion. These statements

were constructed to elicit the various attitudes the

respondents may have in regard to pharmacists and

physicians. Responses to these attitudinal statements were

used for hypothesis testing. In addition, the descriptive

statistics presented here provide an interesting overview

of consumer attitudes in general.

The statements were constructed so that the respondent

could be interviewed whether or not he had a "regular

doctor." This term was presented to the respondents

earlier in the survey in such a manner that it was self-

defining as "a customary or established physician." If the

respondent earlier reported that he, indeed, had a "regular

doctor," then the statement was phrased in the particular

case, ". my doctor. ." Otherwise, if the

respondent had reported that he did not have a "regular

doctor," then the statement was phrased in the general

sense, ". .most doctors ." or ". .a










doctor. ." The same technique was employed for the

statements measuring attitudes toward pharmacists. It was

recognized in advance that many respondents would not have

"regular doctors" or "regular pharmacists." In this

manner, the global attitudes for all health care consumers

could be recorded.

Physician Availability

There were five statements measuring consumers'

perceptions of physician availability, items 16, 17, 18,

19, and 21. These were presented to all respondents.

However, the test of Cronbach's alpha indicated that one

statement, item 21, did not group with the others regarding

physician availability and that it might have been

measuring a slightly different construct.

As seen in Table 5-5, consumers generally consider

their physicians to be available when needed. A majority

of the respondents (352 or 87.8%) reported that they can

get an appointment with a physician in 2 or 3 days, while a

smaller number (207 or 51.6%) reported that they can see a

physician without an appointment. Most respondents (277 or

69.1%) reported that their physician will talk to them over

the telephone, while fewer (189 or 47.1%) reported that

their physician is available after office hours, if

needed. Only 58 respondents (14.5%) reported that their

physician does not like to be troubled unless it is really

necessary.




















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Physician Access

There were four statements measuring consumers'

perceptions of access to a physician, items 20, 32, 33, and

34. These were presented to all respondents. However, the

test of Cronbach's alpha indicated that one statement, item

20, did not group with the others regarding consumer access

to a physician and that it might have been measuring a

slightly different construct.

As seen in Table 5-6, access to a physician does not

seem to be a problem for most consumers. A total of 348

(86.8%) respondents reported that their physician's office

is conveniently located for them, while only 61 (15.2%)

reported that they have to travel over 30 minutes each way

in order to see him. A majority (362 or 90.3%) reported

that getting transportation to the office is no problem,

while only 25 (6.2%) reported that transportation is too

expensive for them.

Monetary Cost

There were five statements measuring consumers'

monetary cost of visiting a physician, items 30, 31,36, 37,

and 38. These statements were presented only to those

respondents indicating that they pay for their own

physician visits and/or prescription costs. The test of

Cronbach's alpha indicated that two statements, items 31

and 36, did not group with the others regarding monetary



















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cost and that they might have been measuring slightly

different constructs.

As noted in Table 5-7, the monetary cost of visiting a

physician does not seem to be a problem with most

consumers. Only 90 (28.6%) of the 315 respondents who pay

for their own physicians' visits feel that these costs are

too expensive for them, but 237 (75.2%) reported that their

physicians' fees are reasonable. Most (250 or 79.3%) of

these respondents reported that they do not have to pay

their physician a separate fee for each time they contact

him. Furthermore, 222 (69.2) of the 321 respondents who

pay for their own prescriptions are not in fear of

receiving a costly prescription. A majority (319 or 79.6%)

of all respondents reported that they do not have to lose

pay from work in order to visit a physician.

Time Cost

There were two statements measuring consumers' cost of

time in visiting a physician, items 22 and 35. These were

presented to each respondent. However, the test of

Cronbach's alpha indicated that they did not group together

and that they might have been measuring slightly different

constructs.

As shown in Table 5-8, most consumers do not seem to

be too inconvenienced concerning the time required to visit

a physician. Only 135 (33.7%) respondents reported that

they have to wait too long in the office, while 272 (68.0%)



















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respondents reported that they do not mind waiting up to 30

minutes in order to see a physician.

Consumer Satisfaction with Physicians

There were seven statements measuring consumers'

satisfaction with their physicians, items 23, 24, 25, 26,

27, 28, and 29. These were presented to all respondents.

However, the test of Cronbach's alpha indicated that one

statement, item 27, did not group with the others regarding

consumers' satisfaction with physicians and that it might

have been measuring a slightly different construct.

As shown in Table 5-9, most consumers seem to be

reasonably satisfied with their present level of physician

care. A majority (350 or 87.3%) of the respondents

reported that they are satisfied with the amount of time

their physician spends with them. A majority (333 or

83.1%) also reported that their physician will spend extra

time with them when they need it. The largest number of

respondents (365 or 91.0%) reported that their physician

always lets them finish telling him about their problem and

339 (84.5%) disagreed that their physician seems to be

rushing them. Another 362 (90.3%) respondents reported

that their physician always explains their condition while

fewer (293 or 73.1%) respondents reported that their

physician will tell them frankly if he does not know what

their trouble is. Interestingly, 115 (28.7%) respondents




























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reported that their physician uses terms they do not

understand.

Pharmacist Availability

There were two statements intended to measure

consumers' perceptions of pharmacist availability, items 40

and 41. These were presented to all respondents. Yet, the

test of Cronbach's alpha indicated that they did not group

with each other and that they might have been measuring

slightly different constructs.

As revealed in Table 5-10, most consumers are of the

opinion that pharmacists are generally available and

approachable. A majority (244 or 60.7%) of all respondents

reported that they usually can converse directly with the

pharmacist as opposed to communicating with him through a

drug clerk. Another 256 (63.7%) reported that pharmacists

will readily talk to them over the telephone if needed.

Pharmacist Helpfulness

There were three statements measuring consumers'

perceptions of pharmacist helpfulness, items 39, 42, and

43. The first two statements were presented to all

respondents. The third was presented only to those

respondents indicating that they pay for their own

prescriptions.

As seen in Table 5-11, respondents generally feel that

pharmacists are helpful. A majority (321 or 79.9%) of all

respondents reported that they feel comfortable in asking a







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pharmacist for advice or information. A smaller number

(263 or 65.4%) reported that they feel pharmacists show a

personal concern for their health, and 239 (74.5%) of the

321 respondents who pay for their own prescriptions believe

that pharmacists try to save them money on their

prescriptions.

Trust in Pharmacist Competence

There were two statements intended to measure

consumers' perceptions of pharmacist competence, items 44

and 45. These were presented to all respondents. However,

the test of Cronbach's alpha indicated that they did not

group with each other and that they might have been

measuring slightly different constructs.

Table 5-12 shows that consumers generally consider

pharmacists to be competent. Most (330 or 82.1%)

respondents reported that they trust the recommendations

and advice they receive from pharmacists while less than

one-third (126 or 31.5%) of the respondents indicated that

they would like to get a second opinion.

Pharmacist Bond

There were four statements measuring a patient-

pharmacist bond, items 46, 47, 48, and 49. These

statements were presented only to those respondents

answering "yes" to the screening question, "Do you have one

pharmacy in particular where you trade most of the time?".







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As indicated in Table 5-13, almost half (148 or 49.0%)

of respondents reported that their pharmacist knows them by

name. However, the same number (148 or 49.3%) of

respondents reported that their pharmacist does not usually

call them by name. Almost as many (144 or 48.0%)

respondents reported that their pharmacist will not usually

stop work in order to talk to them; yet, many (138 or

46.0%) respondents feel that they can confide in their

pharmacist.

Of the approximately 300 respondents who answered each

of the above statements, about half indicated agreement

with each statement. This indicates that about as many

consumers have a "pharmacist bond" as those who do not.

Views of Pharmacist Prescribing

As seen in Table 5-14, a majority of the respondents

feel that pharmacists are qualified to prescribe drugs (234

or 58.5%). The same number of respondents had already

heard about the new law (234 or 58.2%). Most had learned

about it through a local newspaper report (104 or 45%) or a

local television report (72 or 31.2%). In contrast, only 4

(1.7%) of the respondents who had heard about the new law
reported that they had learned about it from a

pharmacist. Two (0.9%) respondents had learned about the

law from physicians, while 11 (4.8%) had learned about it

from some other health care professional.















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