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1177/0163278703258104
Evaluation & the Health Professions / December 2003
Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS
ARTICLE
This study identified previously reported facil-
itators and barriers to pharmacistclient
communication and then evaluated their
impact on the observed communication ASSESSMENT OF
behaviors of pharmacists. Pharmacists (n = COMMUNICATION
100) completed a seven-page questionnaire BARRIERS IN
collecting information on 11 variables that
had been organized according to the Policy, COMMUNITY
Regulatory and Organizational Constructs in PHARMACIES
Educational and Ecological Development
(PROCEDE) model as predisposing, enabl-
ing, or reinforcing of pharmacist communica- ELAN C. PALUCK
tion with their clients. Demographic variables Regina QuAppelle Health Region,
also were included. Communication qual- Saskatchewan, Canada
ity served as the studys dependent variable, LAWRENCE W. GREEN
whereas pharmacist responses served as the Centers for Disease Control and Prevention,
independent variables. Communication qual- U.S. Department of Health and
Human Services
ity scores for each pharmacist were obtained
from the analysis of 765 audiorecordings of C. JAMES FRANKISH
verbal exchanges occurring between the study Michael Smith Foundation for
Health Promotion Research
pharmacists and their consenting clients dur-
ing 4-hour, on-site observation periods. Four DAVID W. FIELDING
of the variables examined in the study were BETH HAVERKAMP
found to share a unique relationship with com- University of British Columbia
munication quality (pharmacists attitude,
year of graduation, adherence expectations,
and outcome expectations). Hierarchical mul-
tiple regression analysis revealed that the
variables measured in the questionnaire
accounted for 23% of the variance in commu-
nication quality scores. Plausible explana-
tions for why the study was unable to capture
more of the variance in its proposed relation-
ships and future areas for research are
provided.
AUTHORS NOTE: This article was funded
Keywords: patient-provider communication; by grants from B.C. Health Research Founda-
pharmacist services; PRECEDE-PROCEED tion Operating Grant and National Health &
model Research Development Program Doctoral
Fellowship.
EVALUATION & THE HEALTH PROFESSIONS, Vol. 26 No. 4, December 2003 380-403
DOI: 10.1177/0163278703258104
2003 Sage Publications
380
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 381
Green and Kreuter (1999) used the acronym PRECEDE to stand for
Predisposing, Reinforcing, and Enabling Constructs in Educational/
Environmental Diagnosis and Evaluation; PROCEED stands for Pol-
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382 Evaluation & the Health Professions / December 2003
FACTORS INFLUENCING
PHARMACIST-CLIENT COMMUNICATION
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 383
PREDISPOSING FACTORS
ENABLING FACTORS
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384 Evaluation & the Health Professions / December 2003
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 385
last 40 years (e.g., the right to inform clients of their medication com-
position, use of pharmacy technicians, etc.) are believed to have
served as enabling factors for quality pharmacist-client communica-
tion (Brushwood, 1995; Campagna & Newlin, 1997; Fink, 1995).
REINFORCING FACTORS
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386 Evaluation & the Health Professions / December 2003
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 387
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388 Evaluation & the Health Professions / December 2003
MEASURES
Two research instruments were developed for use in this study. The
Pharmacists Questionnaire collected self-reported data on factors
that predispose, enable, and reinforce pharmacist-client communi-
cation. The expert panel to evaluate the verbal exchanges recorded
between pharmacists and clients during the study period used the
Quality of Communication Scale.
PHARMACISTS QUESTIONNAIRE
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 389
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390 Evaluation & the Health Professions / December 2003
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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 391
TABLE 1
Sample Description of Participating Pharmacist (N = 100)
Variable Percent
Pharmacist gender
Men 54.0
Women 46.0
Employment position
Owner 2.9
Owner or manager 8.8
Manager 37.3
Staff pharmacist 51.0
Year of graduation
1990-1995 21.0
1980-1989 34.0
1970-1979 34.0
1950-1969 11.0
Type of pharmacy
Independent 20.6
a
Small chain 7.9
Large chain 33.3
Franchise 38.2
Number of full-time pharmacists employed
<2 20.0
2-3 61.0
4-5 17.0
5+ 2.0
Private consultation area available
Yes 22.0
No 78.0
PARTICIPANTS
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392 Evaluation & the Health Professions / December 2003
ANALYSES
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RESULTS
DESCRIPTIVE ANALYSIS
OF THE PHARMACIST QUESTIONNAIRE ITEMS
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394 Evaluation & the Health Professions / December 2003
TABLE 2
Descriptive Summary of Pharmacists Questionnaire Items
(N = 100)
Factor Variables M SD
A. Predisposing
A.1 Adherence expectations
Importance of medication counseling in promoting health 4.48 0.63
Certainty that the average person follows through with advice 3.42 0.97
Importance of health advice in promoting health 4.33 0.61
A.2 Attitude
Counseling increases job satisfaction 4.62 0.51
a
Dont like talking to customers 4.53 0.80
It increases professional responsibility 4.37 0.84
a
Counseling may not be necessary 4.30 0.91
a
People do not respect the advice of the pharmacist 4.18 0.87
a
Customers do not perceive the benefits of counseling 3.74 0.85
a
Worry about contradicting doctors 3.68 0.95
a
Not prepared to accept the professional responsibility 3.56 1.37
A.3 Job/role expectations
Counseling is not my responsibility and should be performed
a
by a doctor 4.43 0.88
Counseling enables me to become part of the health care team 4.38 0.75
Supervisor expects that my full scope of training is applied 4.34 0.69
Respected community member and advice is expected from me 4.17 0.85
A.4 Outcome expectations (compliance)
With counseling, meds are more likely to be taken properly 4.52 0.54
Counseling improves patient compliance 4.47 0.52
Counseling does not lead to significant improvements in
a
health care 4.35 0.70
Counseling may prevent adverse drug effects 4.10 0.87
Counseling reduces drug wastage 4.04 0.83
A.5 Outcome expectations (patronage)
Counseling improves patient-pharmacist relationships 4.59 0.59
Customers appreciate the extra care 4.49 0.54
Counseling brings more people into the pharmacy 3.85 0.78
Counseling increases sales 3.73 0.72
Counseling improves doctor-pharmacist relationships 3.69 0.90
B. Enabling
B.1 Self-efficacy
a
I do not know how to approach people 4.33 0.65
I know enough about regular customers to counsel effectively 4.29 0.82
Certainty that you can provide patients with appropriate drug info 4.25 0.48
a
I lack confidence in my knowledge 4.16 0.71
a
I do not know enough about drugs and their effects 4.13 0.77
Certainty that you can provide appropriate health info 4.02 0.70
B.2 Resources and space
Workplace library meets counseling needs 3.91 0.64
(continued)
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TABLE 2 (continued)
only 12% believed that there were consequences in their pharmacy for
poor performance as a pharmacist.
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396 Evaluation & the Health Professions / December 2003
TABLE 3
Hierarchical Regression Analysis of Factors
Influencing the Quality of Pharmacist-Client Communication
(n = 98)
Demographic factors
Year of graduation .23 .26* .07 3.38 0.038*
Predisposing factors
Adherence expectations .21 .21*
Outcome expectations .14 .27* .20 .13 3.63 0.003*
Attitude .15 .29*
Job or role expectations .03 .04
Enabling factors
Resources .11 .12
Time .10 .07 .22 .02 2.35 0.017*
Space .001 .01
Self-efficacy .05 .06
Reinforcing
Rewards .001 .10
Organizational structure .06 .11 .23 .01 1.89 0.043*
Support .12 .03
DISCUSSION
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The study model and analyses undertaken assumed that the rela-
tionships between the variables were linear. Although the literature
review suggested that some of the variables studied have had a curvi-
linear or u-shaped relationship with communication quality (in partic-
ular, pharmacist workload and perceived barriers), there exists little
evidence in this study of this type of a relationship. Scatter plots of
the predisposing, enabling, and reinforcing construct values plotted
against Communication Quality scores seemed to suggest neither a
linear nor a curvilinear relationship.
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398 Evaluation & the Health Professions / December 2003
DIRECTIONALITY OF CAUSATION
CONCLUSIONS
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400 Evaluation & the Health Professions / December 2003
general reported being less confident that their advice would be fol-
lowed by clients and worried that their advice may contradict the
advice provided by physicians.
A second-line intervention might focus on enabling pharmacists to
provide quality communication. Many pharmacists reported that their
workplace library often failed to meet their daily communication
requirements, and thus an examination of the current library contents
of community pharmacies may be warranted. An intervention that
increases the amount of available time a pharmacist has to communi-
cate with clients may be difficult to design; however, pharmacistsatti-
tude toward the time required to provide a good consultation may be a
place to begin. Pharmacists could also be trained to recognize more
sharply which clients, drugs, or medical conditions (or combinations
of these three) warrant more or less time.
A final intervention that may improve the quality or frequency of
pharmacist-client communication could address the reinforcing fac-
tors of quality communication. This study documented the relative
absence of reinforcing factors (financial or emotional) in most phar-
macies. This type of intervention may be best targeted at the upper
management of pharmacies, by outlining the potential short- and
long-term benefits of providing financial incentives, recognition, and
feedback for pharmacist performance.
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