national survey evaluates community pharmacy as health education center*

Chet Huntley reporting ••• national survey evaluates community pharmacy as

health education center* T

his is Chet Huntley. It is my good fortune to reveal to you for the first time the results of a most significant experimental study which should take its proper place in the progress of your profession. The AMERICAN PHARMACEUTICAL ASSOCIATION~in cooperation with the United States Public Health Service, National Analysts of Philadelphia and 26 of the nation's For an excellent job of reporting, APhA's then president, Robert J. Gillespie (right), thanks Chet Huntley at the conclusion of his presentation before the General Session at APhA 's annual m eeting in New York.

A top com m entator in American broadcasting, Chet Huntley is familiar to millions of Americans as half of the team on the "H untleyBrinkley Report," which originated in 1956. His "Chet Huntley Reporting" program has also added to his fame and reputation . Huntley began his higher education as a premedical student. After winning a national oratory tournament in 1932, he switched his talents to the study of speech and drama. Following graduation from Washington University in 1934, Huntley went to work first for a Seattle newspaper and later for several radio stations in the Washington-Oregon area before joining CBS in 1951. He joined NBC News in 1955.

major voluntary health associations and national professional health societies-has just completed an experimental study which not only firmly establishes the concept of the community pharmacy as a health education center but also reveals just how important the practicing pharmacist can be as a source of family health information. This survey, for example, points the road to a new level of professional attainment which has, up to now, been an aspiration more than an achievement. The pharmacist has been shown definitely to be second only to the physician as a source of health information. The study further reveals that the public does see the pharmacist in a new light after exposure to family health literature even for a short, six-month period. The patrons of the survey pharmacies now are definitely more likely to ask the pharmacist about health matters than they were before the study was initiated and the people receiving such help have considerably more confidence in the pharmacist as a resource person. But first things first. We must place the importance of this survey into proper perspective. The first pharmacy survey ever conducted in this country was undertaken by the AMERICAN PHARMACEUTICAL ASSOCIATION back in 1853 to obtain statistical data about pharmacy throughout the country. But it was not until the 1920's that an attempt was made to obtain a comprehensive picture of the profession and its future needs. In 1923 Professor W.W. Charters of the University of Pittsburgh and two professors at the University of Buffalo school of pharmacy launched a study to determine

*

Presented at the ll1th annual meeting of the AMERICAN PHARMACEUTICAL ASSOCIATION, August 3 , 1964, in New York City.

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Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

why the "profession is undergoing a heavy barrage of criticism." They pointed out at the conclusion of their study in 1927 that some feltIn the effort to commercialize the occupation, the ancient professional morale has been lost with the result that the occupation has ceased to be a profession and has now become a trade.

Not satisfied with this fate for what they termed "an ancient and honorable profession," these researchers, using a $34,000 grant from the Commonwealth Fund, launched a study to determine "what the pharmacist does, what place he fills or may fill in society, how much he needs to know, and what sort of training should be given him in order that he may properly and intelligently fulfill his functions." Among the various responsibilities and duties of the pharmacist assigned by Dr. Charters in 1927 is the followingThe pharmacists are more strategically situated than any other group of individuals to give personal advice upon matters of public health on which they are informed. The information is given free of charge and can be secured within easy walking distance of the home. 'The materials necessary for controlling the health problem are in stock and can be obtained promptly. Queries about health facts are casually asked by interested customers. Odds and ends of information not easily accessible in the health literature can be gained in such conversations with a pharmacist. A well informed pharmacist is the best single individual to disseminate information about public health.

Dr. Charters then proceeded to review tuberculosis, venereal disease, smallpox, typhoid fever and diphtheria, pointing to the fact that it was important for the pharmacist to have information on these diseases so that his advice may be of benefit to the community. Charters' proposal was re-emphasized by Surgeon General Hugh S. Cumming of the Public Health Service in 1928 but too many members of the pharmaceutical complex were apparently more interested in seeking data on the "commercial aspects of pharmacy," which barely were touched upon in Charters' survey, than they were in pursuing the recommendations for permitting the pharmacist to serve as a medication expert and health communicator. This was due to a variety of circumstances, not the least of which were the pressures of the manufacturers of the so-called "drug sundries" and the economic crises of the 1930's. It was not until 1940 that the first co-operative program was launched through the joint efforts of the U.S. Public Health Service, the American Social Hygiene Association and APHA to use the pharmacist to help motivate those suffering from venereal disease to undergo proper medical treatment. These efforts were limited during the war years but shortly after World War II a more ambitious program of cancer detection was launched by your national professional association and the American Cancer Society. The chief of the Office of Health Information at the Public Health Service coined the term "health education center" for those nearly 18,000 pharmacies which were participating in the cancer detection drive in 1948 and APHA expressed the hope that "in planning new pharmacies and in the renovation of existing establishments, a section will be set aside for permanent use in storing and distributing authoritative health information." The President of the United States, Harry S. Truman, stated in 1948It is particularly gratifying to note that pharmacists are endeavoring to use their close contact with the community to help control major diseases through public education and co-operation with private and governmental health agencies.

But these post-war programs were limited in scope, generally of a week or month duration, and a long-range, year-round

Figure I-Forerunner to APhA's experimental study was a 1948 cooperative program which distributed this poster to community pharmacies.

program in co-operation with all major voluntary health associations was still needed. Furthermore, neither the 1943 Bernays national survey to determine the "relationship between the pharmaceutical profession and the public" nor the 1948 Pharmaceutical Survey evaluating pharmaceutical education offered any direction for fully equipping the pharmacist so that he could serve as a health communicator. So it was not until the fifties that any real attempts were made to explore ways to utilize the pharmacist better in health education campaigns. A series of local pilot studies was launched in Philadelphia, in New Jersey and in New York to set the pattern while stories were reaching our shores from France of a program launched in 1959 by French pharmacists to serve their communities as health educators. Dr. Joseph B. Sprowls, chairman of APHA's public health committee, summed up the trend by acknowledgingThese programs are but manifestations of a revival of interest among pharmacists in an area of service which has been part of the traditional role of the pharmacist. They are coming about in part as the result of a new spirit which is alive in pharmacy-a resurgence of professionalism-a re-examination of pharmacy's objectives.

It is a unique situation to be presenting the first report on a study which is already in the history books ... but this is the case. The latest edition of Kremers and Urdang's History of Pharmacy, edited by Dr. Glenn Sonnedecker, statesAn opportunity to develop the foundation for such service on a more systematic basis came to the American Pharmaceutical Association in 1963 through a grant ($100,800) from the U.S. Public Health Service "to evaluate the scope of the community pharmacy as a community health education center and formulate a procedure ... "

In review then- the present experimental study had as a precursor earlier programs. One poster, jointly developed by the U.S. Public Health Service, the American Cancer Society and APHA, was requested by and distributed to nearly 18,000 Vol. NS4, No. 10, October 1964

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community pharmacies in the country during National Pharmacy Week in 1948 (see Figure 1). The present study has had its counterparts in other countries- like the program in France initiated by the French pharmacist's committee for health and social education in 1959. The committee distributes educational posters promoting various health education campaigns to 15,000 dispensing pharmacists. Perhaps the most signific~nt part of the French program is the distribution of health hterature corresponding to the posters on display at any given time. As the French cartoon caption indicates (see Figure 2), these are truly' 'public relations brochures." But let us turn our attention to the APHA experimental study. To start the program National Analysts of Philadelphia randomly selected for study 360 participating pharmacies from 53 areas based on a National Probability Sample (see Figure 3). The APHA Board of Literature Review screened well over 100 different health brochures-85 of which were accepted for inclusion in the program (see Figure 4). Four million, three hundred thousand copies of the pamphlets were contributed by 26 national voluntary health agencies and national professional health associations for distribution to the publ!c through the 360 participating pharmacies. Therefore, m addition to the $100,800 grant from the U.S. Public Health Service, there were material contributions from these he~lth organizations, as well as supporting grants from E.R. SqUlbb and Sons and from Smith Kline and French Laboratories. National Analysts interviewed 1,200 patrons of the pharmacies before the program began to establish a basis for comparison. In the meanwhile, APHA distributed a specially designed display rack (see Figure 5) to each of the pharmacies and during the course of the six months from November 1963 to April 1964, provided the pharmacies with approximately 100 copies each of from 15 to 18 different health brochures each month. Recognizing that differences of acceptability may exist between the different types, the pharmacies were divided evenly into three classes (see Figure 6) for the purpose of evaluation. The first group was called Exclusive Service Pharmacies in which prescription practice and all related health items accounted for 70 percent or more of the income of the pharmacy. The second group was called General Pharmacies and they were those in which prescription practice and all related health items accounted for not more than 69 percent or less. than 31 percent of the total dollar income. The third class was designated Retail Complex Pharmacies and were identified by the fact that not more than 30 percent

Figure 2-Cartoons are used to advise French pharmacists of the value of their health information program.

Figure 3-Across the nation from 53 areas pharmacies were selected to participate in the pilot study.

of the total income of the pharmacy was derived from the practice of pharmacy. And there were differences between the three classes of pharmacies (see Figure 7) . For example, in the overall distribution pattern, General Pharmacies distributed the most literature, Exclusive Service Pharmacies were next and Retail Complex Pharmacies - despite their larger volume of traffic- were the poorest media of total distribution. However, the Retail Complex Pharmacies did distribute the largest number of brochures in a couple of categories such as venereal disease and narcotic addiction. There also were regional differences (see Figure 8). The northeast and the central regions provided the best areas for distribution; the south was third and the West was poorest of all. This pattern of regional differences is similar to that found on both patron and pharmacist interviews - except that the central region usually was the best of all. National Analysts interviewed a second 1,200 patrons of the participating pharmacies at the conclusion of the experimental program and then tabulated the differences in an effort to determine changes in opinion and behavior. An indication of the popularity of the subjects covered in the pamphlets is shown by patron responses to the question "Which of the pamphlets on this list did you look at or take home?" As the bar graph of pre-program and post-program results shows (see Figure 9), pamphlets on cancer, heart, childhood diseases, arthritis and respiratory diseases were taken most frequently. The first objective that had to be accomplished was for the patron to see the display rack in the pharmacy. It was found that 42 percent of the clientele saw the rack and, of those who saw the rack, two out of every three took literature. The display rack was seen and used most often in the Exclusive Service Pharmacy and in the General Pharmacy but least often was seen and used in the Retail Complex Pharmacy- presumably due to the higher degree of competiti.on from other stimuli (see Figure 10). If we can charactenze the patrons who reported having seen the rack, we find that1. 2. 3. 4.

MET A VOTRE

DISPOSITION LES CAHIERS Of l'OffiCIN UNE BROCHURE DE REL~TfON5 PUBLIQUES TRAITANT DES MEMES SUJETS ... 478

Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

More are in the central region than from any other region They are younger than patrons who didn't see the rack They are more likely to be female than male Their chances of seeing the rack and taking Werature increased with the more education they had.

There can be no question about it. The rack served its purpose. It caught the attention 9f the patrons and made them aware that health information was available at the pharmacy. Whether this awareness led to any changes in attitudes, opinions or behaviors must be examined now. People have developed their own ideas about the best resources available to them for information on all subjects-

managerial personnel, younger people and those patronizing Exclusive Service Pharmacies (see Figure 13). The participating pharmacists were also interviewed to determine their reaction to the program. Pharmacists estimated that four out of every ten patrons made some comments to them about the rack or the materials and a majority reported that other members of the health profession had come into contact with the program. The largest percentage of such contacts were in the Exclusive Service Pharmacies, the second in General Pharmacies and the least contacts in Retail Complex Pharmacies. Out of the 148 pharmacists who reported comments from physicians, all but five indicated that they were highly complimentary (see Figure 14). Such conunents included "it's about time we had a program like this" or "long overdue." Of the five non-complimentary comments, four were from the west and only one was hostile. Several pharmacists indicated subsequent acceptance after an initial criticism. For example, one pharmacist statedAt first people would ask the doctor questions about the pamphlets and he wasn't in favor of them, but as time went on he thought they were very good.

r"7 At the conclusion of the interview

National Analysts asked the pharmacists if their participation in the project had any

Figure 4-Pamphlets and brochures by the millions were dis· tributed in the health education program.

the repair of automobiles, guidance on financial matters or information about health. It isn't surprising, therefore, that the physician was selected by 98 percent of the respondents as the person they would be most likely to turn to for information about health. It was a pleasant surprise, however, to find that the pharmacist was selected by 82 percent as the second most likely source of health information. As the bar graph shows, the nurse was third with 56 percent; relatives-as mother or father-were fourth with 50 percent; the dentist fifth with 35 percent and the neighbor sixth with 31 percent. The policeman, clergyman, fireman and teacher, in that order, completed the listing (see Figure 11). In the response to the question, "What kind of health matters do you think you might discuss with the pharmacist?" by far the most frequently mentioned subject was respiratory diseases. This included colds, sinus and nasal conditions, sore throats, influenza and asthma. Other main categories were skin care, prescription medication, first aid, minor ailments, headache and non-prescription drugs (see Figure 12). Perhaps the most significant finding of the entire study was the fact that for those who saw the literature rack and took literature from it, the likelihood of their discussing health matters with the pharmacist almost doubled. Female patrons in general were more likely to discuss health matters with the pharmacist than were male patrons. But the program appears to have made the greatest impressions on the higher educated, those with higher incomes, professional and

FigureS-The rack, distributed by APhA, was designed especially for use in the study.

Figure 6-Three classes of pharmacies were designated-general, exclusive and retail complex.

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effect on their pharmacy. Thirty-three percent claimed that the program had aroused a great deal of interest in their patrons and stimulated them to ask more questions. Others felt that it had created a better image of the pharmacy, establishing it as a true health education center. A small percent even felt that it enlarged their practice.

HEALTH LITERATURE OF MOST INTEREST TO PATRONS

summary In summary, the principal objective of this study was to assess the feasibility of changing opinions and behaviors of the public with respect to use of the pharmacy as a community health information center by the introduction of a display rack with free health information materials. For the rack to have any effect it had to be seen-42 percent reported having seen it, which means that the basic objective was accomplished. Given the fact that the program had a "share of attention" of the patrons, did it have a "share of the mind?" In other words, did it affect attitudes, opinions, perceptions or behaviors? There were significant changes in several areas even though a high level of regard for the pharmacist generally was noted at the beginning of the program. While one can't be absolutely certain of the pattern of events, the data suggest that it went something like thiswhen the patrons saw the rack with free health materials on a wide variety of health problems, they perceived the pharmacist as a source of health information and developed new

Figure 9-Literature on cancer, heart and arthritis proved most popular and interesting to patrons.

WHO SAW DISPLAY RACK AND WHERE 58/0

Figure 7-The overall distribution pattern from the publications varied according to class of pharmacy.

PUBLICATION DISTRIBUTION BY CLASS OF PHARMACY 39.0%

Figure ID-Two out of every three patrons who saw the rack took some of the literature.

General

Pharmac'y

Exclusive Service Pharma9'

Retail

Complex Ph8l macy 1

Figure 8-Regional differences were also evident in the distribution pattern.

PERCENTAGE OF PUBLICATION DISTRIBUTION BY REGION

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Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

confidence in him as a resource person. This led them to address questions more frequently to the pharmacist. Patron responses also indicated that they were satisfied with the help provided by the pharmacist. This too may lead to greater confidence and usage in the future. The survey reveals that pharmacists were more likely to call the rack to the attention of people who have had no more than a high school education rather than to those who have had some college training. This is important because it was found that the college-trained people reacted more favorably to the program than did those who weren't college-educated. As a result of the program, more of the higher educated felt that they would be inclined to talk with a pharmacist about health care and minor illnesses; a smaller percentage of the higher educated would talk about "no" health matter. There was an increase from 53 to 82 percent among college graduates who said they would have a great deal of confidence in what a pharmacist told them; the chances of a person seeing a display rack increased with the more education he had. The chances of a person going to look at the titles and the pamphlets once having seen the rack increased as the amount of education increased; the percentage of people who read the pamphlets in the pharmacy as well as at home increased with education.

Not only did the responses of the college-trained increase more than others, their responses were to different things. The college-educated appeared to be more cognizant of and influenced by the training of the pharmacist while others referred more often to the helpfulness and friendliness of the pharmacists. If it is true that a program based upon reading matter will have its greatest effect on people with greater reading skills, then it is clear that the pharmacist should devote more effort than he does now to guiding his higher educated patrons to the display rack. The younger people (under 45) responded in many respects more favorably than did the older groups but, like the collegetrained, they were somewhat neglected by the pharmacist. Females in general not only represent the largest bulk of the patrons, they also represent a public that responds to this type of program slightly better than do male patrons. Besides the one of directing patrons to the display, other roles the pharmacist might fill include being attentive to the human needs of their patrons, being knowledgeable of the subjects discussed in the pamphlets and being aware of the resources available in the community, including special clinics, nursing care, homes for the aged and medical specialists. The pharmacy can also serve as an information and referral service. The program did produce some change in this respect which was noted in particular by people with less education.

THOSE WHO SAW RACK AND TOOK LITERATURE INCREASED THEIR LIKELIHOOD OF DISCUSSINGHEALTH MATTERS WITH PHARMACIST BY 80% Figure 13-Literature rack served its purpose as this graph, depicting the most significant finding of the survey, indicates.

PHARMACIES REPORTING FAVORABLE COMMENTS BY OTHER' HEALTH PROFESSIONS

Figure ll-Patrons rank pharmacists second as source for health information.

WHERE PATRONS OBTAIN HEALTH INFORMATION

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Figure 14-Physicians approved the program and the distribution of health information by the pharmacist.

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Figure 12-Respiratory diseases, including coughs and colds, were the subjects patrons most often discussed with pharmacists.

TOPICS MOST DISCUSSED WITH PHARMACIST

Exclusive Service Pharmac:Y

The active role of the pharmacist in this program and in future programs has not been considered but cannot be neglected. The ultimate objective is to increase the frequency with which patrons rely on the pharmacist for information about health matters; the display rack is only one part of the effort to modify the image of the pharmacy; the pharmacist himself is the other part. Patrons must find that pharmacists are knowledgeable and competent to answer their questions or to direct them to competent sources for the answers. If they are disappointed at this juncture, the entire program will fail. Education and training of the pharmacist must be as much a part of such a program as are the printed materials on display. If I may, I think I can safely make one broad conclusion out of my some 30 years in my profession of journalism and it is this-revolutions are in progress in our country; old ways, old trends, old habits, old methods are being turned out. And I know that most of you know that your profession is no exception to this state of change. I would hope, therefore, that you might deal with your revolution as all revolutions must be dealt with- with restraint, with an open mind and with a willingness to listen and perhaps even a willingness to consider that change in some respects is inevitable. • Vol. NS4, No. 10, October 1964

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