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10.

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

rinciples guiding pharmacy practice have changed radically in a


P short time. In less than 40 years, revealing the therapeutic effect
of a prescription medication to a client evolved from being an unethi-
cal pharmacist behavior (Higby, 1996) to one that is professionally
mandated (College of Pharmacists of British Columbia, 1992; Fern,
1993). Second, pharmaceutical care (Hepler & Strand, 1990)
became widely accepted by most professional pharmacy associations
as the ideal standard of pharmacy practice marking the advent of client
participation or shared decision making in the clinical pharmacy pro-
cess. Finally, the literature acknowledged an underdeveloped poten-
tial and need to extend community pharmacists role in the areas of
health promotion and disease prevention (Anderson, 1995; Burman,
1992; Fincham & Smith, 1988; Gardner & Sennott-Miller, 1987;
Green & Fedder, 1977; Lawrence, 1991; Paluck, Stratton, & Eni,
1994; F. Smith, 1992a, 1992b). Although changes to the profession
have come about quickly, the transition has not been an easy one for all
pharmacists. Central to the successful practice transitions required for
contemporary pharmacy practice is the area of pharmacist-client com-
munication, which has thus stimulated a renewed interest in this area.
The long-term goal of this research was to improve the quality and
frequency of communication occurring between pharmacists and
their clients. Improving communication between pharmacists and cli-
ents will require change with special attention to the personal, social,
environmental, organizational, and legal factors that influence phar-
macy practice (Bennis, Benne, Chin, & Corey, 1976; Chase, 1979;
Orlandi, 1987; Ottoson, 1995, 1997). To accomplish the long-term
research goal, this study identified previously reported facilitators and
barriers to behavioral change in pharmacists and examined their rela-
tionship with observed pharmacist-client communication behaviors.
The studys primary research question addressed the following: What
are the factors that predispose, enable, and reinforce the
communication behaviors of community pharmacists?

THE PRECEDEPROCEED MODEL

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

icy, Regulatory and Organizational Constructs in Educational and


Ecological Development. The PRECEDE component of the model is
a diagnostic or needs assessment phase, whereas the second compo-
nent, PROCEED, forms the developmental stage of planning that ini-
tiates and monitors the implementation and evaluation process. In this
study, only the components of the model pertaining to the PRECEDE
portion were applied.
The PRECEDE framework identifies four categories of factors that
affect the behaviors of individuals and populations. Predisposing fac-
tors are the antecedents to behavior that provide the rationale or moti-
vation for the behavior. Enabling factors are the antecedents to behav-
ior that allow a motivation to be realized. Reinforcing factors are
factors subsequent to a behavior that provide the continuing benefit,
reward, or incentive for the behavior to be repeated and maintained.
Although the three categories are not mutually exclusive, this type of
classification provides a conceptual framework that links behavioral
determinants to the logical interventions to support change. By under-
standing factors contributing to poor pharmacist-client communica-
tion, the most efficient combination of education, training, resource
development, and rewards to influence the factors that predispose,
enable, or reinforce the communication behaviors can be used to inter-
vene. A fourth category, environmental factors, includes determinants
outside the person that can be modified to support the behavior. Being
aware of environmental factors enables planners to be more realistic
about the limitations of programs directed at individual behavioral
change consisting of only education and skills (Green & Kreuter,
1999). The PRECEDE framework suggests a hierarchical approach to
behavioral change by asserting that voluntary behavioral change re-
quires an individual to be sufficiently predisposed to engage in the
behavior and that once the individual has acquired the predispos-
ing factors, the enabling, followed by the reinforcing factors, can be
addressed.

FACTORS INFLUENCING
PHARMACIST-CLIENT COMMUNICATION

The following section discusses the predisposing, enabling, and


reinforcing factors identified through a literature search as being

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 383

associated with pharmacist-client communication. It includes some of


the demographic and contextual variables that are external to the phar-
macists control but would be considered in the planning of future
interventions to improve their communication quality.

PREDISPOSING FACTORS

Predisposing factors include most cognitive, attitudinal, and per-


ceptual supports or barriers encountered by community pharmacists
attempting to improve communication with their clients (Green &
Kreuter, 1999). An individuals attitude or set of beliefs directed
toward a situation is considered to be the factor that predisposes him
or her to behave a certain way. Among the cognitive variables, factual
knowledge and self-efficacy enable as well as predispose action.
The literature suggests that five primary factors may predispose
pharmacists to engage in quality communication with their clients:
pharmacist attitude toward communicating with clients (Campagna &
Newlin, 1997; Farris & Kirking, 1998; Kirking, 1982; Knapp, Wolf,
Knapp, & Rudy, 1969; Mason & Svarstad, 1984; Ortiz, Walker, &
Thomas, 1992), pharmacist understanding of communication goals
(Odedina, Segal, & Hepler, 1995), pharmacist expectations regarding
client adherence to health advice or client outcomes (Farris &
Kirking, 1998; Sidel et al., 1990), pharmacist job or professional role
expectations (Knapp et al., 1969; Maddux, Stanley, & Manning,
1987; Raisch, 1993a; Schommer & Wiederholt, 1994), and a pharma-
cists perceived knowledge and skill (self-efficacy) in communicating
relevant and accurate information to clients (Coultas, 1991; Farris &
Kirking, 1998; Farris & Schopflocher, 1999; Kuiz et al., 1995; Lewis,
Clancy, Leake, & Schwartz, 1991; Mullen & Holcomb, 1990;
Odedina et al., 1995; Orlandi, 1987; Ortiz et al., 1992; Paluck,
Stratton, & Eni, 1996; Upjohn Company of Canada, 1990; Weschler,
Levine, Idelson, Rohman, & Taylor, 1983; Wilson, 1992).

ENABLING FACTORS

Predisposing factors can account for the motivation and confidence


of pharmacists, but even with motivation, inadequate skills or
resources may impede pharmacists ability to engage effectively in

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384 Evaluation & the Health Professions / December 2003

health-oriented dialogue with clients. An enabling factor is defined as


any characteristic of the environment that will facilitate the provision
of pharmacist-client communication (Green & Kreuter, 1999). The
absence or opposite of an enabling factor, therefore, becomes a barrier
to improving pharmacist-client communication. Some research has
suggested that pharmacists perceived barriers to expanding their role
as health advisors are not correlated with their current participation in
counseling activities. That is, pharmacists who believe that there are
many barriers to furthering their involvement in health promotion
report participating in such activities at the same frequency as phar-
macists who believe that there are few barriers to furthering their
involvement (Paluck et al., 1996). This suggests that a high level of
motivation or predisposition can overcome most barriers. Results
from the Upjohn Survey of 1990 (Upjohn Company of Canada, 1990)
detected a positive relationship between pharmacistsperceived barri-
ers and their participation in pharmacist-client communication. That
is, pharmacists who reported being most actively engaged in advising
clients on medication use also cited the most barriers to furthering
their involvement in this area. A possible explanation for this finding
is that the pharmacists may not discover barriers until they are actively
considering or trying to participate. That is, the enabling factors may
not become salient until the predisposing factors have been acquired
and the behavior attempted. For these reasons, enabling factors need
to be observed more directly or independently. One cannot depend so
completely on perceptions of barriers as disenabling factors.
The literature discusses seven enabling factors related to the occur-
rence of quality communication in community pharmacy practice:
time to communicate (Barnes, Riedlinger, McCloskey, & Montange,
1996; Willison & Muzzin, 1995), financial reimbursement for phar-
macy services (Barnes et al., 1996), adequate staff (Odedina et al.,
1995), adequate space (Odedina et al., 1995; Berger & Grimley,
1997), and appropriate educational materials (Barnes et al., 1996;
Bush, 1983; Morrow & Hargie, 1992; Odedina et al., 1995; Raisch,
1993b). In addition, legal barriers restricting the scope of pharmacy
practice (M. C. Smith & Gibson, 1974) and pharmacistspersonal fear
of legal liability or litigation (Upjohn Company of Canada, 1992) may
act as barriers to quality pharmacist-client communication. Alter-
nately, the legal changes that have shaped pharmacy practice over the

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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

Reinforcing factors provide reward or incentive for the behavior


and contribute to its repetition. Positive reinforcement increases the
likelihood that the behavior will be repeated. A failure to reinforce
does not always decrease the likelihood the behavior will be per-
formed. That is, it only reduces the likelihood the behavior will be per-
formed in situations where the person expects to receive a form of
punishment (Perry, Baranowski, & Parcel, 1990). Reinforcing factors
can be described as being intrinsic (such as a personal sense of a job
well done) or extrinsic (such as financial benefits). Internal reinforc-
ing factors account for why some people behave in a manner that is not
reinforced externally.
In this study, factors believed to reinforce the occurrence of quality
pharmacist-client communication include the pharmacys policies on
pharmacist-client communication or customer service, the availabil-
ity of peer and managerial support for participating in pharmacist-
client communication, and the rewards offered by pharmacy man-
agement or peers for establishing quality pharmacist-client communi-
cation and maintaining competency.
Very little information in the pharmacy literature is available in the
pharmacy literature on the impact of reinforcing factors on pharmacist-
client communication. Reduced third-party reimbursements for phar-
macists dispensing fees, increased competition from large discount
pharmacies and from the presence of mail-order pharmacies have
resulted in pharmacies lowering their dispensing fees and the market-
ing of pharmacies as a loss leader within larger mega-pharmacies.
Although it is common for pharmacists to claim that these current
financial pressures have resulted in a profession that rewards quantity
and not quality (Munroe & Rosenthal, 1994), the published literature
does not address whether communication quantity or quality have
been affected.
In addition to the economic forces shaping community pharmacy
practice, a number of factors within each pharmacy serve to reinforce

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386 Evaluation & the Health Professions / December 2003

the provision of quality communicationtwo of which such factors


are peer and managerial support. If pharmacists do not feel support
from their coworkers or pharmacy management to communicate with
their clients, then they will likely be hesitant to expand their role in this
area. In support of this hypothesis, Raisch (1993a) found that peer
pressure to not counsel was correlated with patient counseling.
In general, legal changes in the pharmacistsscope of responsibility
have paved the way for the professional development of pharmacy
practice (Brushwood, 1995; Fink, 1995) and thus may be viewed as an
enabling force. Legal factors, however, may also adversely reinforce
pharmacist-client communication by creating a form of punishment,
with fear being the motivator (Green & Kreuter, 1999). Like many
American states, British Columbia has a mandatory dialogue law that
has been legally imposed on pharmacists. There exists no agreement,
however, on the effectiveness of the mandatory consultation laws on
improving pharmacist-patient communication and ultimately on cli-
ent outcomes (Campbell, Baker, Jinks, & Evenson-St. Amand, 1989;
Nichol & Michael, 1992; Scott & Wessels, 1997).

DEMOGRAPHIC AND CONTEXTUAL INFLUENCES


ON PHARMACIST-CLIENT COMMUNICATION

A number of contextual and demographic variables may not lend


themselves to direct intervention or change but may also influence the
quality of pharmacist-client communication. For example, client
characteristics such as age (Fisher, Corrigan, & Henman, 1991;
Sleath, 1996; F. Smith, 1992b; Wiederholt, Clarridge, & Svarstad,
1992), social class (Paluck et al., 1996; Raisch, 1993b), client need for
cognition or factual information (Schommer, Sullivan, & Haugtvedt,
1995), and client attitudes/expectations (Barnes et al., 1996;
Campagna & Newlin, 1997; Odedina et al., 1995) have all been
demonstrated to have some influence on pharmacist-client com-
munication. Similarly, pharmacist characteristics such as age
(Barnett, Nykamp, & Hopkins, 1992; Laurier, Archambault, &
Contandriopoulos, 1989; Wiederholt et al., 1992), gender, training
(Laurier & Poston, 1992), and pharmacy type (Campagna & Newlin,
1997; Kirking, 1984; Laurier, Archambault, & Contandriopoulos,
1989; Laurier & Poston, 1992; Paluck et al., 1996; Sisson & Israel,
1996;) have also been shown to have a relationship with pharmacist

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 387

communication behaviors. The year of graduation variable is seen as


central to this study because of its proxy for time since pharmacy
training and all of the issues associated with that as noted in the
introductory paragraph.

STUDY METHODS, MEASURES, & PARTICIPANTS

A prospective direct observational study design was chosen to meet


the studys research objectives. All Lower Mainland community phar-
macists in British Columbia (N = 836) were mailed an invitational let-
ter requesting their participation in a study examining verbal commu-
nication between pharmacists and clients. A comprehensive follow-
up protocol (letter, phone call, and an on-site visit to the pharmacy
manager) recruited 100 pharmacists to the study (14% participation
rate). Participating pharmacists were provided with a $50
honorarium.
Pharmacists completed a written questionnaire examining per-
sonal, workplace, and social factors that predisposed, enabled, and
reinforced the occurrence of pharmacist-client communication. A
stamped, addressed envelope was included with the questionnaire. No
follow-up of nonresponders was required, as all of the pharmacists
returned their questionnaires as requested.
To obtain data on observed pharmacist-client communication
behaviors (the studys dependant variable), on-site observation peri-
ods were scheduled with the study pharmacists over a 6-week period.
During the 4-hour site visit, verbal exchanges occurring between the
pharmacist and consenting clients were audiotaped with a wireless
microphone worn by the pharmacist. Research assistants who used a
standardized script recruited pharmacy clients. All clients were
informed that their conversation with the pharmacist would be
audiotaped and that they were free to withdraw from the study at
any time. English-speaking pharmacy clients over the age of 18 years
who were visiting a participating pharmacy to have a prescription dis-
pensed during the study period were considered eligible for the study.
To minimize the potential bias imposed by the audiotaping process,
pharmacists and clients were encouraged to not modify the duration,
style, or location of their communication and every effort was made to

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388 Evaluation & the Health Professions / December 2003

not interrupt the normal flow of pharmacy events. On completion of


their visit with the pharmacist, patients were provided with a $1.00
coupon for their participation.
An eight-member expert panel listened to the audiotapes and
worked in pairs to rate the quality of the consultations (the studys
dependent variable) that were collected (n = 765). The expert panel
consisted of the four faculty members assuming primary teaching and
evaluation of pharmacy undergraduate training in patient communi-
cation, and four pharmacy practitioners trained by the provinces reg-
ulatory body to serve as licensing examiners for the province. Prior to
the evaluation period, the 765 audiorecordings were systematically
randomized onto four master tapes to ensure that more than one pair of
raters evaluated each pharmacist. Each pair rated approximately 176
consultations in total.
All study methods and data collection instruments used in this
study were approved by the University of British Columbias Behav-
ioral Sciences Ethical Review Committee and endorsed by the Col-
lege of Pharmacists of British Columbia and the British Columbia
Pharmacy Association.

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

A number of previously developed instruments provided a majority


of the final questionnaire items. Many of the items measuring the pre-
disposing attitudinal factors were obtained from an instrument
designed by Ortiz and his colleagues (1992). Remaining items in the
Pharmacist Questionnaire were adapted from previously developed
instrumentssome for use with pharmacists (Raisch, 1993a; F. J.

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 389

Smith, Salkind, & Jolly, 1990)but others with physicians and/or


other health care providers (McDonald, 1991; Moos, 1988; Mullen &
Holcomb, 1990; Sanazaro, 1983). A draft version of the questionnaire
was circulated among peers to ensure face and content validity. The
questionnaire was then pretested on a small sample of pharmacists
(n = 3) to correct problems associated with ambiguity or wording.
The final questionnaire was seven pages long and contained 63
items measuring 11 independent variables assigned a priori to one of
the three PRECEDE categories of factors hypothesized to be associ-
ated with pharmacist-client communication. A mixture of positively
and negatively worded questions pertaining to pharmacist-client com-
munication were included in the questionnaire, with most items being
scored on a 5-point strongly agree to strongly disagree continuum.
Negatively worded items were reverse scored in the coding of data.
Cronbachs alpha was used to assess the internal consistency of
items in the questionnaires three constructs (r < .30). To ensure the
scales homogeneity, items that substantially lowered the constructs
internal consistency and/or failed to correlate with the scale construct
greater than or equal to .20 were removed. Self-efficacy, a cognitive
variable that predisposes as well as enables, was assigned a priori to
the predisposing factors construct. However, a decision to include
self-efficacy as an enabling variable was guided by the finding that
including efficacy items with the enabling factor items considerably
improved the alpha coefficient for the revised enabling factors con-
struct (.81), with minimal influence on the predisposing factors con-
struct ( = .87). In the reinforcing factors construct, four items dem-
onstrated weak item-total correlations and were removed, leaving
seven items with an alpha coefficient of .73.

QUALITY OF COMMUNICATION SCALE

The Quality of Communication Scale was used by the expert panel


to rate the quality of pharmacist-client interactions collected and rep-
resented the studys dependent variable to which the predisposing,
enabling, and reinforcing variables would be analyzed. The following
section briefly discusses the development of the instrument. A more
detailed description of the instrument is the content of a separate
manuscript being submitted elsewhere for publication.

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390 Evaluation & the Health Professions / December 2003

The Quality of Communication Rating Scale developed for this


study was facilitated by existing resources that included the evalua-
tion form used for students clinical rotation in the Doctor of Phar-
macy program at the University of British Columbia, as well as pre-
scription and nonprescription product (OTC) counseling guidelines
for pharmacists outlined by McBean-Cochrane (1992), Thompson
(1993), and Farris and Kirking (1993). Two slightly different rating
instruments were developed: one for prescription medications and
one for OTC and general health advice consultations, as they differ in
their technical content requirements. Both scales contained nine items
and allowed the verbal interactions to be rated on a 7-point scale rang-
ing from 1 (poor) to 7 (very good).
The eight-member expert panel was offered an honorarium of $750
(Cnd) for their 3-1/2 day commitment. A training session was pro-
vided for the panel to establish the criteria required to obtain a rating
of satisfactory for each of the scale items. After that, panel members
worked in assigned pairs for the duration of the 3-day period and
assumed responsibility for evaluating approximately 176 recorded
pharmacist-client interactions.
Cronbachs alpha, a measure of the Quality of Communication
Scales internal consistency, was found to be adequate for the pur-
poses of the study (.85). A modified, weighted kappa approach, as
suggested by Perreault and Leigh (1989), indicated a high frequency
of agreement for the interrater, intrarater, and test/retest ratings (range
0.91 to 1.00).
The 786 pharmacist-client exchanges recorded for the study,
involved a total of 924 drug- or health-related topics as more than one
topic was sometimes discussed during the consultations. Approxi-
mately 55% of the pharmacist-client exchanges involved a new pre-
scription, 13% were for a refill prescription, and 19% pertained to
OTC medications. In just under 10% of the consultations, it could not
be determined whether the consultation was pertaining to a new or
refill prescription.
The Quality of Communication ratings were normally distributed
with 58.5% of the consultations rated as being satisfactory or
better. Approximately 15% of the consultations did not meet the mini-
mum communication requirements and would be classified as poor
(receiving a score lower than 3.0), whereas almost 18% of the

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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

a. Defined as three or fewer pharmacies

consultations were rated as being very good (receiving a score


higher than 5.0). The mean quality score for the audiorecordings eval-
uated was 3.45 0.74.

PARTICIPANTS

Table 1 presents the demographic characteristics of the 100 partici-


pating community pharmacists. Demographic data provided by the
College of Pharmacists of British Columbia suggest that participating
pharmacists were representative of the population area. The nature
of the research methods used and this study topic, however, likely

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392 Evaluation & the Health Professions / December 2003

attracted pharmacists more confident and motivated in client com-


munication than the population norm.

ANALYSES

Mean responses on the Pharmacist Questionnaire served as the


independent variables. The studys dependent variable, referred to as
Communication Quality, represented the mean of all interactions
recorded for each pharmacist. An average of 7 consultations per phar-
macist were obtained during the site visits (range of 0 to 15). The
two site visits that resulted in zero audiorecordings necessitated the
removal of these pharmacists from the regression analyses.
Simple descriptive statistics to initially explore questionnaire
responses were followed by hierarchical multiple linear regression to
answer the studys research question. Order of entry for the regression
analysis was reflective of the PRECEDE model: Demographic factors
were entered in Block 1, predisposing variables in Block 2, enabling
factors in Block 3, and the reinforcing factors in Block 4.
The studys conceptual model required that, ideally, the majority of
variability in Communication Quality scores would be found between
pharmacists. However, results from a one-way analysis of variance
test revealed that the studys large client-to-pharmacist ratio (765:98)
resulted in a situation where the within-pharmacist variability
exceeded the between-pharmacist variability. Although the average
between-pharmacist variability was actually greater than the within-
pharmacist variability (M sum of squares = 1.63 vs. 0.38 for within),
the pool of variance was greater within pharmacists. To overcome
this situation, a new variable was created by removing the within-
pharmacist variability. In practical terms, this estimated and removed
the variation in communication resulted from client variables such as
age, need for cognition, or familiarity with the prescription, for exam-
ple, that might dictate the pharmacists communication style and con-
tent. The adjusted Communication Quality score retained the
between- pharmacist variability and was used as the dependent vari-
able in the subsequent regression analyses undertaken with the SPSS
for Windows (release version 10.0) software package. An a priori
alpha level of .05 was chosen.

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 393

RESULTS

DESCRIPTIVE ANALYSIS
OF THE PHARMACIST QUESTIONNAIRE ITEMS

Predisposing factor item means ranged from 3.3 to 4.6 (maximum


score 5) (Table 2). Items with the highest mean scores (indicating
pharmacists strongest support for the statement) included that phar-
macists enjoy speaking with clients (4.59 0.80) and that pharmacist-
client communication increases job satisfaction (4.62 0.51).
The overall item means for the enabling factor items appear to be
slightly lower than those of the predisposing factor items. The most
highly supported enabling factor items pertained to pharmacists per-
ceived self-efficacy. Pharmacists reported being confident in their
ability to approach people (4.33 0.65), in their ability to provide
drug information (4.25 0.48), and in their knowledge (4.16 0.71).
Items rated the lowest pertained to the frequency of using the private
consultation area (3.09 3.09) and the adequacy of the workplace
library to meet their professional requirements (3.91 0.64).
The majority of pharmacists (86%) believed that time was not a
barrier to the occurrence of pharmacist-client communication and
reported that the number of pharmacists employed at their pharmacy
was about right. Most pharmacists (72%) indicated that the number
of technicians employed at their pharmacy was also adequate. Only
21% of participating pharmacists had access to a semiprivate area for
communicating with clients.
Reinforcing factor items were generally scored lower than the pre-
disposing or enabling factor items, although items measuring pharma-
cists perceived support from their peers were rated high. Pharmacists
strongly agreed with the statements that they believed there was
coworker support for counseling (4.38 0.79) and that their work-
place relations with coworkers were favorable (4.52 0.58). Receiv-
ing comments or rewards from supervisors for good performance
(2.87 0.97) and a lack of feedback from clients (3.36 0.95) were the
two lowest rated items in the reinforcing factors construct. Almost
30% of the sample reported that their supervisor never or rarely com-
mented on or rewarded their good performance, and 70% reported
receiving no tangible incentives for good performance. In addition,

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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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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 395

TABLE 2 (continued)

Use of private area for counseling (n = 21) 3.09 0.83


Number of pharmacy journals subscribed by your pharmacy 1.56 2.14
B.3 Time
a
I am too busy to counsel 4.04 0.69
FTE pharmacists employed 2.59 1.18
FTE pharmacy technicians employed 1.62 1.96
C. Reinforcing
C.1 Organizational structure
Approachability of supervisor 4.20 0.93
Approachability of head office 3.81 1.04
C.2 Rewards or incentives
a
There is lack of feedback from people 3.36 0.95
How often does your supervisor comment or reward you
when you have previously attempted to use your pharmacy
training? 2.87 0.97
Number of incentives or rewards available at workplace for
pharmacists participating in continuing education activities? 1.08 2.46
C.3 Support
Workplace relationship among pharmacists 4.52 0.58
Support of coworkers for patient counseling 4.38 0.79
Support of supervisor for patient counseling 4.23 0.90

a. Items that were reversed coded.

only 12% believed that there were consequences in their pharmacy for
poor performance as a pharmacist.

REGRESSION ANALYSES OF PREDISPOSING,


ENABLING, AND REINFORCING FACTORS

The 11 variables measuring the predisposing, enabling, and rein-


forcing factors accounted for 16% of the variance in pharmacists
Communication Quality scores (Table 3). Overall, the predisposing
variables accounted for 13% of the variance, the enabling factors
accounted for 2% of the variance, and the reinforcing factors
accounted for 1%. The demographic variable pharmacist year of
graduation explained an additional 7% of the variance.
Pharmacists who had graduated more recently and who had a posi-
tive attitude toward communicating with clients were more likely to
provide a quality consultation. Two additional variables, adherence
expectations and outcome expectations, also were predictive of qual-
ity pharmacist-client communication, but in a negative direction.

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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)

Simple Multiple Increment Signif.


2 2
Variable r Beta R in R F F

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

NOTE: Multiple R, .48; R-squared, .23; *p < .05; df = 12, 82.

DISCUSSION

Mean scores of the three PRECEDE model constructs suggest that


although pharmacists report being highly predisposed to participating
in quality pharmacist-client communication (4.35 0.40), they to
some degree lack the enabling factors (4.02 0.40) and reinforcing
factors (3.91 0.74) proposed to support the occurrence and continu-
ance of quality pharmacist-client communication.
This study proposed that a combination of predisposing, enabling,
and reinforcing factors would be related to the quality of pharmacist-
client communication. In support of this assertion, a hierarchical
multiple regression revealed that these three constructs account for
16% of the variance in pharmacists Communication Quality scores.
The inclusion of the key demographic variable, year of graduation,
raises the variance accounted for by the model to 23%. In this study,
the relative amounts of variance accounted for by the constructs (7%
for environmental, 13% for predisposing, 2% for enabling, and 1% for
reinforcing) support the PRECEDEs proposition that quality com-

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 397

munication is influenced by a combination of these variable catego-


ries and that an initial segmentation on a key demographic or environ-
mental variable improves the fit.
Four of the variables examined in this study were associated with
quality communication between pharmacists and clients. Pharma-
cists attitude toward communicating with clients was positively re-
lated to communication quality, whereas year of graduation, adher-
ence expectations, and outcome expectations demonstrated inverse
relationships with communication quality. The inverse relationships
found between communication quality and the outcome and adher-
ence expectations variables would suggest that pharmacists who
believe that their consultation will demonstrate little or no benefit are
more likely to provide a quality consultation. The significance and
interpretation of this finding remains obscure, but it is possible that
pharmacists may have been applying a triage system to their commu-
nication practices. That is, given the time constraints of community
pharmacy practice, pharmacists may be targeting their efforts toward
clients who are at greatest riski.e., those clients whom pharmacists
believed were least likely to adhere to their regimen and potentially
experience a negative outcome.
There are three plausible explanations for why the proposed rela-
tionships in this study (particularly the enabling and reinforcing fac-
tors) failed to explain a greater portion of the variance in the Commu-
nication Quality scores. These include (a) linearity assumption in the
relationships; (b) directionality of causation; and (c) operationaliza-
tion of the constructs.

ASSUMED LINEARITY OF THE RELATIONSHIPS

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

The PRECEDE model provides for feedback from behavior as an


influence on reinforcing, on perceived enabling, and ultimately on
predisposing factors. The analysis treated these as independent vari-
ables. The negative relationships found here could indicate that more
and better quality communication with clients lowers pharmacists
expectations of the clients probability of adherence and positive out-
comes as they come to appreciate the barriers faced by their clients.
This shift in perception is negative, but also probably to a more realis-
tic level of expectation, and one that motivates them to try harder in
their communications with clients. Related to this enhanced predispo-
sition is the likelihood that sufficient motivation can overcome the
variability in enabling and reinforcing factors to accomplish the
behavior change.

OPERATIONALIZATION OF THE CONSTRUCTS

The research problems examined in this study required that a num-


ber of constructs be operationalized and measured. The construct
validity of the instruments used may have been another reason for fail-
ing to capture more of the variance in the study relationships.
Although many of the scale items were extracted from previously
tested instruments, not all had been tested on pharmacists and few
had been used to evaluate pharmacist-client communication. Second,
this study restricted itself to evaluating the impact of variable on
pharmacist-client communication that was (or at least partially)
within the pharmacists control. Characteristics such as the clients
age, social class, need for cognition or factual information, and atti-
tudes/expectations were all revealed in the literature review to have
some influence on pharmacist-client communication but not exam-
ined in this study.

CONCLUSIONS

With the long-term goal of improving the quality, frequency, and


content of communication occurring between pharmacists and
clients, this study used the PRECEDE model to assess facilitators

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Paluck et al. / ASSESSMENT OF COMMUNICATION BARRIERS 399

and barriers that were identified in the literature as being related to


pharmacistclient communication and then examined their impact on
the observed communication behaviors of pharmacists.
The study found that a combination of predisposing, enabling,
reinforcing, and environmental factors accounted for 23% of the vari-
ance in the pharmacists Communication Quality scores. Four of the
variables examined appear to share a unique relationship with the
overall quality of communication. Pharmacists general attitude
toward communicating with their clients was positively associated
with quality communication. The remaining variables, year of gradu-
ation, adherence expectations, and outcome expectations, were asso-
ciated with communication quality but in a direction opposite to what
may have been anticipated.

IMPLICATIONS FOR RESEARCH

The relationships revealed between the studys predisposing,


enabling, and reinforcing factors and communication quality must be
addressed. The literature, and a unidirectional interpretation of the
PRECEDE model, had suggested that these relationships would be
positive, yet this study revealed inverse relationships between phar-
macists available resources, adherence expectations, and outcome
expectations. Focus groups and other qualitative methods would be
helpful in examining these issues more closely and determining how
these and other feedback or compensatory mechanisms are involved.

IMPLICATIONS FOR PRACTICE

The Pharmacists Questionnaire provides valuable information


about the factors predisposing, enabling, and reinforcing pharmacist-
client communication. This information can be used to design future
programs or interventions that improve the quality and frequency of
pharmacist-client communication. For example, an early initiative
aimed at improving the quality, frequency, or duration of pharmacist-
client communication may involve the production of educational/
promotional literature that refines pharmacist-held attitudes and ex-
pectations surrounding pharmacist-client communication. Although
most of the participating pharmacists could be described as being
highly predisposed to communicate with clients, pharmacists in

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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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