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Privacy as a Factor in Patient Counseling
Privacy as a Factor in Patient Counseling Robert S. Beardsley, C. Anderson Johnson and George Wise The duration of interactions and the quality of communications between pharmacists and patients, patients' later knowledge about drug treatment regimens and special precautions, and patient compliance with prescribed regimens were evaluated in high privacy and low privacy settings and under high education and low education conditions in 106 hospital outpatients. Total conversation times were longest when privacy and educational efforts
were high. Quality of communications, as measured by question asking and the patients' drug knowledge, was also highest when privacy and educational efforts were high. With respect to patients' later knowledge, the only statistically reliable difference was in better recall of special instructions by patients who received the high educational effort. Compliance was highest among patients in the high privacy, high education
group. There was a high degree of consistency among all the measures. The results indicate that communication and patient understanding of and compliance with drug regimens can be enhanced by a well-constructed educational program administered in a setting that offers privacy for pharmacist-patient interaction.
As new clinical roles of the pharmacist expand, pharmacists will become more involved with patient counseling. Currently, pharmacists are being trained at many universities and through continuing education programs to be more effective counselors. To further improve the patient-pharmacist exchange, the environment within which that exchange takes place should be studied and improved. The importance of the environment to human communications has been emphasized 1- 3 but the effects of the pharmacy environment on pharmacist-patient communication have not yet received serious consideration. In many situations, the communication environment in hospital and community pharmacies is less than optimal. More often than not, exchanges occur over a counter in a busy waiting room where there are numerous distractions. Barker 4 and Swenson 5 emphasized the need for an environment which provides the highest quality of consultative services. Dickson and Rodowskas concluded from their study of communication in community pharmacies that changes need to be made in the pharmacy environment to maximize constructive communication. 6 Many authors have related the quality of communication to the degree of patient compliance with prescribed treatment regimens. Linkewich et al. found that verbal communication as well as written instructions were valuable in increasing patient compliance. 7 However, Clinite and Kabat reported that written drug information was "counterproductive" to compliance without the
reinforcement of verbal communication. 8 In separate studies, Blackwell 9 and Becker and Maiman 10 linked compliance with certain patient attitudes toward providers of medical care. Compliance was better in those patients who felt good about their relationships with their physicians and other health professionals. One way to further develop these relationships is to increase the quality of communication petween parties. Although numerous other aspects of the compliance problem have been studied, 11-16 to date no one has considered the effects of the environment in which drug information is transmitted. It seems doubtful, however, that the highly public nature of the typical pharmacy setting could be very conducive to meaningful interpersonal exchange. To establish a relationship between compliance and the environment would be valuable in planning pharmacy facilities. We tested the hypotheses ( 1) that quantity and quality of communications between pharmacists and patients would increase with increasing privacy, (2) that efforts to educate patients in the proper use of prescribed medications would be most successful in privacy and (3) that the impact of educational efforts on patient compliance would be mediated through the degree of privacy in the pharmacist-patient exchange.
etc.) were asked to participate. Drugs selected for inclusion were those for which the pharmacy staff had already developed protocol sheets to facilitate patient education. The sample population of 106 patients included 60 percent adult males and 40 percent adult females of various ages and socioeconomic backgrounds. After signing a voluntary consent form, participants were assigned randomly to either of two levels of privacy and two types of educational effort. To evaluate the effects of privacy, participant responses in both low privacy and high privacy settings were examined. The existing outpatient department became the low privacy setting. The pharmacist-patient interaction occurred through a window separating the crowded patient waiting area from the pharmacy work area. Conversations were within easy listening range of waiting patients and pharmacy personnel. A small office adjacent to the waiting area was used as the high privacy setting. Here, the pharmacist and patient were able to converse without interruption or fear of being overheard. The pharmacist was asked to standardize his approach and the information given to the patient in both settings. The same five pharmacists participated in all four experimental conditions. Education effects were evaluated by measuring participant response to two types 'of educational effort. In the high education condition, pharmacists verbally gave specific information and precautions to patients as called for in the protocol sheets. Patients also took the information sheets home with them. In the low education condition, patients did not receive the prepared information. No concerted effort was made to educate these patients; however, consistent with good practice, an effort was made to answer patients' questions truthfully and accurately. In each condition, social interactions
Robert S. Beardsley, MS, is a PhD candidate in pharmacy administration, and C. Anderson Johnson, PhD, is Assistant Professor, Department of Graduate Studies in Pharmacy Administration, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota 55414. George Wise, BS, is a staff pharmacist at Hennepin County Medical Center, Minneapolis, Minnesota.
Methodology
Participants in the study were selected from the patient population of an outpatient pharmacy department in a large Minneapolis hospital. * Patients receiving certain categories of drugs (antihistamines, analgesics,
* We are gratefUl to John Goldner, Director of Pharmacy Services at Hennepin County Medical Center, Minneapolis, Minnesota, and to Jan Thies, William Diers, Norman Wikel ius and David Chinnock for providing immeasurable assistance in this study's execution.
366
Journal of the American Pharmaceutical Association
between pharmacists and patients were audio-taped. Tapes were scored independently by two observers for the duration of interactions and the quality of communications. Duration measures were the total time that the patient talked, the total time that the pharmacist talked and the combined total of the two. Quality measures included the number of questions asked by the pharmacist and the number asked by the patient. Quality also was assessed in terms of the patient's immediate recall and understanding of the information protocols. Long-term recall and understanding were measured seven to ten days later to assess whether difference in privacy and education influenced understanding and retention over time. The effects of privacy and education on patient compliance to drug regimens was measured as well. Patients were interviewed either in their home (those with new prescriptions) or by phone (those with renewal prescriptions). Degree of compliance was determined by asking participants to recall the schedule by which they had taken the drug and the extent of deviation from that schedule and / or by counting the actual number or volume of medication remaining. Medications were counted only for those patients with new prescriptions since patients with renewal prescriptions might have had
additional medication supplies in their home, thus interfering with the count. Results Results are presented in three parts: (1) duration of interactions and the quality of communications between pharmacists and patients, (2) patients' later knowledge about treatment regimens and special precautions and (3) patient compliance with prescribed regimens. Duration of interactions and quality of communications between pharmacists and patients. Separate two-way analyses of variance were performed correcting for unequal cell sizes (Winer, pp. 402-403).17 Table 1 (below) reveals main effects both for privacy and for educational effort. Total conversation times were longer when privacy was high (F = 24.92, P <.001) and when systematic efforts were undertaken to educate patients (F = 39.38, P <.001) . A significant interaction between privacy and education (F = 4.50, P <.05) took statistical precedence over both main effects. Conversation time was longest when both privacy and education were high, and was shortest when both privacy and education were low (t comparisons ranged from 3.01 to 6.95, and all were significant at p <.001) . Both pharmacists and patients talked more
Table 1. Mean durations of conversations between pharmacists and patients and the contribution made by each Pharmacist Speaking
Patient Speaking
Asked by Pharmacist
Mean durations are expressed in seconds. Standard deviations are in parentheses. Cell sizes are 16, 34, 19 and 37 for the high privacy-high education (HP-HE), low privacy-high education (LP-HE) , HP-LE and LP-LE condit ions, respectively.
Table 3. Percentage of patients accurately recalling instructions immediately after medication delivery
High 100a 96
Low 73 a 90
Special Instructions
How Long To Take
High 95 b 92
High 62 c 88 cd
Low 80 b 86
Low 65 51 d
Cell sizes are the same as in Table 1. Values sharing one or more letter subscripts are different at p < .05.
Vol. NS 17, No.6, June 1977
Asked by Patient
Privacy High Low 1.69ab 1.15c Educa} High (.9) (1.5) tional Effort Low 1.0b .5 abc (.6) (0.8)
Total
High Low 1.89 de .85 d ( 1.2) (.8) 1.47f (1.7)
. 1def (.3)
High 3.6g h (1.5) 2.4 h (1.8)
Low 2.0g (2.9) .6g h (.5)
Standard deviations are in parentheses. Cell sizes are the same as in Table 1. Values sharing one or more letter subscripts are different at p <.05.
Mean values sharing one or more letter subscripts are different at p <.001.
Privacy Educational ~ High Effort Low
Mean number of questions between pharmacists and
Total
Low High Low Privacy High High Low 140.9a 74.5a 66.8 bc 19.2c 207.8 ef 91.2e Educa-} High (93.7) (55.0) (107 .5) (27.9) (145.7) (69.4) tional Effort Low 70.3 f 45.0 a 14.8a 25.0 bd 8.5 cd 23.4 ef (67.2) (48.0) (37.2) (10.2) (35.6) (39.7)
How To Take
Table 2. patients
in the high education conditions than in the low education conditions, and more in the high privacy conditions than in the low privacy conditions. The main effect for education was highly significant among pharmacists (F = 55.28, P <.001) and among patients (F = 5.83, P <.025) as was the main effect for privacy (F = 21.40, P <.001 for pharmacists and F = 8.86, P <.005 for patients) . Neither interaction was significant (F = 2.99 and F = 2.04, respectively) . There were three measures of communication quality: (1) the number of drug-related questions asked by the pharmacist (about allergies, medication histories, etc.) , (2) the number of drug-related questions asked by the patient (about treatment schedule, precautions, side effects, etc.) and (3) the patient's level of knowledge about the drug (s) in question immediately following the interview (assessed by a short self-administered questionnaire before the patient left the pharmacy) . Numbers of questions asked were taken as measures of the pharmacist's and patient's concern about adequately communicating essential information. Pharmacists and patients both asked more questions of the other when privacy was high than when it was low (F = 9.4, P <.005 for pharmacists and F = 9.5, P <.005 for pa-
Table 4. Percentage of patients accurately recalling instructions 7-10 days later How To Take Privacy Educational~ High Effort Low
High 100 84
Low 87 92
Special Instructions
How Long To Take
High 9.5a 68 a
High
Low 87 82
67 44
Low 62 41
Cell sizes are same as in Table 1. Values sharing the same letter subscripts are different at p <.02.
367
tients). Pharmacists also asked more questions when educational efforts were high (F = 15.39, P <.001) , but patients did not (F = 2.29, n.s.) . Neither statistical interaction was significant (F = 1.37 for pharma. cists and F = 0.02 for patients) . Question asking both by pharmacists and patients was greatest when privacy was high and educational efforts were high and was least when privacy was low and educational efforts were low (Table 2, PC!ge 367) . In terms of knowledge, patients benefited more from education in private than in public with 100 percent of those privately educated recalling accurately how to take their medications, compared to only 73 percent of those publicly educated (Fisher'$ exact probability, p <.01 , see Table 3, page 367) . Patients also had better recall for special instructions when educated in private (Fisher's exact probability, p <.01, see Table 3) . The effects of privacy on recall of how long to take occurred among patients in the low education conditions (Fisher's exact probability, · p <.01), but not among those in the high education conditions. Unexplicably, recall among privately educated patients of how long to take medications was better in the low education than in the high education condition (Fisher's exact probability, p <.03) . Patients' later knowledge. Time appears to have leveled many of the effects of privacy and eduoation on patient knowledge 'of their medications. In personal and t~lephone interviews conducted seven to ten days after intera9tions with pharmacists, there still was a trend for patients who had received the high education communication in private to exhibit the best recall (Table 4, page 367) . However, the only statistically reliable difference was in recall for special instructions. A difference occurred between patients who had received the high educational effort and . the low educational effort in private (Fisher's ~xact probability, p <.02) . Compliance. Probably the most important of all the measures ·in terms of patients' well-being was the degree to which patients Qomplied with prescribed treatment regimens. Compliance was highest among patients who had been educated in private (Table 5, above) . Fisher'S exact probability comparisons of the high education-high privacy condition with the high education-low privacy conditions, with the low educationlow privacy conditions, and with the low education-high privacy conditions were all significant at p <.05 or better. Not only were communications and understanding maximized by education in private, so too was patient compliance. Discussion
Perhaps the most striking feature of these findi!1gs was the high degree of consistency among all the measures. Attempts to edu ~ cate were optimized by privacy; in fact, in some cases they were effective only when
Table 5. Percent of noncompliers as a function of privacy and education Privacy
Educationalt Effort ~
High Low
Cell sizes are same as in Table 1. Values sharing one or more letter subscripts are different at p < .05.
some measure of privacy was provided.·The fact that patient understanding was maximized by privacy makes the finding of greater communication more than trivial. That patient compliance was improved uniquely by education in private has important implications. Heretofore, evidence for meaningful effects of patient education on compliance has been meager indeed. This study's findings assume their greatest importance in the promise they hold for effecting greater participation by patients in their prescribed treatment regimens. A question of theoretical interest is whether the effects of privacy and education on patients were the direct result of these factors or whether these effects resulted indirectly as the consequence of greater pharmacist counseling in the high privacy and high education conditions. In other words, would privacy and education have affected patient measures if the amount of pharmacist talking had been controlled? An analysis of covariance reveals the answer to be an unqualified yes. When pharmacist talking is controlled statistically as a covariate, privacy and education still caused greater patient talking (F = 62.48, P <.001 for privacy and F = 11 . 13, P < .001 for education) . By the same token , an analysis of covariance reveals pharmacist talking to have been greater in the high privacy condition (F = 50.1, P <.001) and in the high education condition (F = 84.5, P < .001) when patient talking is controlled as the covariate. The percentage of noncompliance reported in this study is somewhat lower than figures previously reported in the literature. Thirty-five percent noncompliance is not uncommon 18 and noncompliance among hypertensives may be as high as 85 percent. 19 The lower figures reported in this study are due, at least partially, to our relatively liberal definition of compliance. Noncompliers.in this study were defined in terms of the fit between a count of untaken medication and the appropriate number called for by the treatment regimen. Roth et al. 20 have pointed out that the problems with this measure of compliance relate primarily to assumptions about the fate of missing medications. Presumably, they could have been given away or dropped in the sink. Nevertheless, there is no reason that one group of patients would be more prone than another to such deceptions. Therefore, we assume the comparisons between groups to
368
be valid as measures of relative compliance. These find ings point to several factors which should be considered when planning a patient counseling program . Communication , patient understanding and compliance can be enhanced by a well-constructed educational program administered in a setting that offers some measure of privacy for personal interaction. When considering ways to improve rapport with patients, pharmacists should be .mindful of the environment which they offer to the pubiic. Privacy allows both pharmacist and patient to express doubts and deeply felt personal concerns, to ask questions, to listen more effectively, to evaluate more judiciously and to express enlightened and honest opinions. Several patients commented to th~ follow-up interviewers that they were very grateful to the pharmacists for supplying Informati on about their medications in a private room away from the interference of the crowded waiting room. The advantages of counseling patients in private (better rapport, understanding and compliance) can be bought at a very small price, the average pharmaCist-patient exchang~ having lasted only three-and-a-half minutes even in the high privacy-high education condition. The cost-benefit ratio of implementing a high privacy pharmacy setting would appear to be quite low. • References 1. Barker, R : Ecological psychology, Stanford University Press, Palo Alto, California, 1968. 2. Maas, R : Evaluating treatment environment , John Wiley and Sons, New York , 1974. 3. Esser, A , editor: Behavior and environment, Plenum Press, New York , 1971 . 4. Barker, K. N.: Planning a hospital pharmacy facility, Am. J. Hosp. Pharm. 28: 422-446 (June) 197 1. 5. Swenson, E. S.: An innovative deSign in hospital pharmacy fac ilities, Am. J. HO$p. Pharm. 28: 422-446 (June)
197 1. 6. Dickson, W. M., and Rodowskas, C. A : Verbal communication of community pharmacists, Me.d. Care 13: 486-498 (June) 1975. 7. Linkewich , S. A.: The effect of packaging and instruction on outpatient compliance with medication regimens, Drug Intel!. Clin. Pharm. 8: 10- 15 (Jan.) 1974. 8. Clinite, J. C., and Kabat, H. F.: Improving patient compliance, J. Am. Pharm. Assoc. NS 16: 75- 85 (Feb.) 1976. 9. Blackwell, B.: The drug defaulter, Clin. Pharmacol. Ther. 13: 84 1-848 (Nov.- Dec.) 1972. . 10. Becker, M. H., and Mai man, L. A : Sociobehavioral determin ants of compliance with health and medical care recommendation, Med. Care 8: 10-24 (Jan .) 1975. 11 . Sharpe, T., and Mikeal, R : Patients compliance with anti biotic regimens, Am. J. Hosp. Pharm. 31: 479-484 (May) 1974. 12. Arnhold, R G. et al.: Comprehension and compliance with medical instructions in a su burban pediatric practice, Clin. Pediatr. 9: 648 (Nov.) 1970. 13. Anon.: Problems of aged persons taking meds at home, Nurs. Res. 12: 52 (Jan.- Feb.) 1968. 14. Stewart, R B.: A study of outpatients' use of medications, Hosp. Pharm. 7: 108-1 17 (Apr.) 1972. 15. David, M. S.: Physiological, psychological, and demographic factors in patient compliance with MD orders, Med. Care 6: 115 (Mar.-Apr.) 1968. 16. Sackett, D. D. et al.: Randomized clinical trial of strategies for improving medication compliance in primary hypertension, Lancet 1: 1206 (May 31) 1975. 17. Winer, B. J.: Statistical principles in experimental design, McGraw-Hili, New York, 197 1. 18. Marston, M. V.: Compliance with medical regimens: a review of the literatu re, Nurs. Res. 19: 312, 1970. 19. Wood, E. et al. : Guidelines for the detection, diagnosis, and management of hypertenSion population, Circula tion 44:
4623, 197 1. 20. Roth, et al.: Measuring intake of prescribed medication, a bottle count and tracer technique compared , Clin. Pharmacol. Ther. 11: 228 (Apr.) 1970.
Journal of the American Pharmaceutical Association
were high. Quality of communications, as measured by question asking and the patients' drug knowledge, was also highest when privacy and educational efforts were high. With respect to patients' later knowledge, the only statistically reliable difference was in better recall of special instructions by patients who received the high educational effort. Compliance was highest among patients in the high privacy, high education
group. There was a high degree of consistency among all the measures. The results indicate that communication and patient understanding of and compliance with drug regimens can be enhanced by a well-constructed educational program administered in a setting that offers privacy for pharmacist-patient interaction.
As new clinical roles of the pharmacist expand, pharmacists will become more involved with patient counseling. Currently, pharmacists are being trained at many universities and through continuing education programs to be more effective counselors. To further improve the patient-pharmacist exchange, the environment within which that exchange takes place should be studied and improved. The importance of the environment to human communications has been emphasized 1- 3 but the effects of the pharmacy environment on pharmacist-patient communication have not yet received serious consideration. In many situations, the communication environment in hospital and community pharmacies is less than optimal. More often than not, exchanges occur over a counter in a busy waiting room where there are numerous distractions. Barker 4 and Swenson 5 emphasized the need for an environment which provides the highest quality of consultative services. Dickson and Rodowskas concluded from their study of communication in community pharmacies that changes need to be made in the pharmacy environment to maximize constructive communication. 6 Many authors have related the quality of communication to the degree of patient compliance with prescribed treatment regimens. Linkewich et al. found that verbal communication as well as written instructions were valuable in increasing patient compliance. 7 However, Clinite and Kabat reported that written drug information was "counterproductive" to compliance without the
reinforcement of verbal communication. 8 In separate studies, Blackwell 9 and Becker and Maiman 10 linked compliance with certain patient attitudes toward providers of medical care. Compliance was better in those patients who felt good about their relationships with their physicians and other health professionals. One way to further develop these relationships is to increase the quality of communication petween parties. Although numerous other aspects of the compliance problem have been studied, 11-16 to date no one has considered the effects of the environment in which drug information is transmitted. It seems doubtful, however, that the highly public nature of the typical pharmacy setting could be very conducive to meaningful interpersonal exchange. To establish a relationship between compliance and the environment would be valuable in planning pharmacy facilities. We tested the hypotheses ( 1) that quantity and quality of communications between pharmacists and patients would increase with increasing privacy, (2) that efforts to educate patients in the proper use of prescribed medications would be most successful in privacy and (3) that the impact of educational efforts on patient compliance would be mediated through the degree of privacy in the pharmacist-patient exchange.
etc.) were asked to participate. Drugs selected for inclusion were those for which the pharmacy staff had already developed protocol sheets to facilitate patient education. The sample population of 106 patients included 60 percent adult males and 40 percent adult females of various ages and socioeconomic backgrounds. After signing a voluntary consent form, participants were assigned randomly to either of two levels of privacy and two types of educational effort. To evaluate the effects of privacy, participant responses in both low privacy and high privacy settings were examined. The existing outpatient department became the low privacy setting. The pharmacist-patient interaction occurred through a window separating the crowded patient waiting area from the pharmacy work area. Conversations were within easy listening range of waiting patients and pharmacy personnel. A small office adjacent to the waiting area was used as the high privacy setting. Here, the pharmacist and patient were able to converse without interruption or fear of being overheard. The pharmacist was asked to standardize his approach and the information given to the patient in both settings. The same five pharmacists participated in all four experimental conditions. Education effects were evaluated by measuring participant response to two types 'of educational effort. In the high education condition, pharmacists verbally gave specific information and precautions to patients as called for in the protocol sheets. Patients also took the information sheets home with them. In the low education condition, patients did not receive the prepared information. No concerted effort was made to educate these patients; however, consistent with good practice, an effort was made to answer patients' questions truthfully and accurately. In each condition, social interactions
Robert S. Beardsley, MS, is a PhD candidate in pharmacy administration, and C. Anderson Johnson, PhD, is Assistant Professor, Department of Graduate Studies in Pharmacy Administration, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota 55414. George Wise, BS, is a staff pharmacist at Hennepin County Medical Center, Minneapolis, Minnesota.
Methodology
Participants in the study were selected from the patient population of an outpatient pharmacy department in a large Minneapolis hospital. * Patients receiving certain categories of drugs (antihistamines, analgesics,
* We are gratefUl to John Goldner, Director of Pharmacy Services at Hennepin County Medical Center, Minneapolis, Minnesota, and to Jan Thies, William Diers, Norman Wikel ius and David Chinnock for providing immeasurable assistance in this study's execution.
366
Journal of the American Pharmaceutical Association
between pharmacists and patients were audio-taped. Tapes were scored independently by two observers for the duration of interactions and the quality of communications. Duration measures were the total time that the patient talked, the total time that the pharmacist talked and the combined total of the two. Quality measures included the number of questions asked by the pharmacist and the number asked by the patient. Quality also was assessed in terms of the patient's immediate recall and understanding of the information protocols. Long-term recall and understanding were measured seven to ten days later to assess whether difference in privacy and education influenced understanding and retention over time. The effects of privacy and education on patient compliance to drug regimens was measured as well. Patients were interviewed either in their home (those with new prescriptions) or by phone (those with renewal prescriptions). Degree of compliance was determined by asking participants to recall the schedule by which they had taken the drug and the extent of deviation from that schedule and / or by counting the actual number or volume of medication remaining. Medications were counted only for those patients with new prescriptions since patients with renewal prescriptions might have had
additional medication supplies in their home, thus interfering with the count. Results Results are presented in three parts: (1) duration of interactions and the quality of communications between pharmacists and patients, (2) patients' later knowledge about treatment regimens and special precautions and (3) patient compliance with prescribed regimens. Duration of interactions and quality of communications between pharmacists and patients. Separate two-way analyses of variance were performed correcting for unequal cell sizes (Winer, pp. 402-403).17 Table 1 (below) reveals main effects both for privacy and for educational effort. Total conversation times were longer when privacy was high (F = 24.92, P <.001) and when systematic efforts were undertaken to educate patients (F = 39.38, P <.001) . A significant interaction between privacy and education (F = 4.50, P <.05) took statistical precedence over both main effects. Conversation time was longest when both privacy and education were high, and was shortest when both privacy and education were low (t comparisons ranged from 3.01 to 6.95, and all were significant at p <.001) . Both pharmacists and patients talked more
Table 1. Mean durations of conversations between pharmacists and patients and the contribution made by each Pharmacist Speaking
Patient Speaking
Asked by Pharmacist
Mean durations are expressed in seconds. Standard deviations are in parentheses. Cell sizes are 16, 34, 19 and 37 for the high privacy-high education (HP-HE), low privacy-high education (LP-HE) , HP-LE and LP-LE condit ions, respectively.
Table 3. Percentage of patients accurately recalling instructions immediately after medication delivery
High 100a 96
Low 73 a 90
Special Instructions
How Long To Take
High 95 b 92
High 62 c 88 cd
Low 80 b 86
Low 65 51 d
Cell sizes are the same as in Table 1. Values sharing one or more letter subscripts are different at p < .05.
Vol. NS 17, No.6, June 1977
Asked by Patient
Privacy High Low 1.69ab 1.15c Educa} High (.9) (1.5) tional Effort Low 1.0b .5 abc (.6) (0.8)
Total
High Low 1.89 de .85 d ( 1.2) (.8) 1.47f (1.7)
. 1def (.3)
High 3.6g h (1.5) 2.4 h (1.8)
Low 2.0g (2.9) .6g h (.5)
Standard deviations are in parentheses. Cell sizes are the same as in Table 1. Values sharing one or more letter subscripts are different at p <.05.
Mean values sharing one or more letter subscripts are different at p <.001.
Privacy Educational ~ High Effort Low
Mean number of questions between pharmacists and
Total
Low High Low Privacy High High Low 140.9a 74.5a 66.8 bc 19.2c 207.8 ef 91.2e Educa-} High (93.7) (55.0) (107 .5) (27.9) (145.7) (69.4) tional Effort Low 70.3 f 45.0 a 14.8a 25.0 bd 8.5 cd 23.4 ef (67.2) (48.0) (37.2) (10.2) (35.6) (39.7)
How To Take
Table 2. patients
in the high education conditions than in the low education conditions, and more in the high privacy conditions than in the low privacy conditions. The main effect for education was highly significant among pharmacists (F = 55.28, P <.001) and among patients (F = 5.83, P <.025) as was the main effect for privacy (F = 21.40, P <.001 for pharmacists and F = 8.86, P <.005 for patients) . Neither interaction was significant (F = 2.99 and F = 2.04, respectively) . There were three measures of communication quality: (1) the number of drug-related questions asked by the pharmacist (about allergies, medication histories, etc.) , (2) the number of drug-related questions asked by the patient (about treatment schedule, precautions, side effects, etc.) and (3) the patient's level of knowledge about the drug (s) in question immediately following the interview (assessed by a short self-administered questionnaire before the patient left the pharmacy) . Numbers of questions asked were taken as measures of the pharmacist's and patient's concern about adequately communicating essential information. Pharmacists and patients both asked more questions of the other when privacy was high than when it was low (F = 9.4, P <.005 for pharmacists and F = 9.5, P <.005 for pa-
Table 4. Percentage of patients accurately recalling instructions 7-10 days later How To Take Privacy Educational~ High Effort Low
High 100 84
Low 87 92
Special Instructions
How Long To Take
High 9.5a 68 a
High
Low 87 82
67 44
Low 62 41
Cell sizes are same as in Table 1. Values sharing the same letter subscripts are different at p <.02.
367
tients). Pharmacists also asked more questions when educational efforts were high (F = 15.39, P <.001) , but patients did not (F = 2.29, n.s.) . Neither statistical interaction was significant (F = 1.37 for pharma. cists and F = 0.02 for patients) . Question asking both by pharmacists and patients was greatest when privacy was high and educational efforts were high and was least when privacy was low and educational efforts were low (Table 2, PC!ge 367) . In terms of knowledge, patients benefited more from education in private than in public with 100 percent of those privately educated recalling accurately how to take their medications, compared to only 73 percent of those publicly educated (Fisher'$ exact probability, p <.01 , see Table 3, page 367) . Patients also had better recall for special instructions when educated in private (Fisher's exact probability, p <.01, see Table 3) . The effects of privacy on recall of how long to take occurred among patients in the low education conditions (Fisher's exact probability, · p <.01), but not among those in the high education conditions. Unexplicably, recall among privately educated patients of how long to take medications was better in the low education than in the high education condition (Fisher's exact probability, p <.03) . Patients' later knowledge. Time appears to have leveled many of the effects of privacy and eduoation on patient knowledge 'of their medications. In personal and t~lephone interviews conducted seven to ten days after intera9tions with pharmacists, there still was a trend for patients who had received the high education communication in private to exhibit the best recall (Table 4, page 367) . However, the only statistically reliable difference was in recall for special instructions. A difference occurred between patients who had received the high educational effort and . the low educational effort in private (Fisher's ~xact probability, p <.02) . Compliance. Probably the most important of all the measures ·in terms of patients' well-being was the degree to which patients Qomplied with prescribed treatment regimens. Compliance was highest among patients who had been educated in private (Table 5, above) . Fisher'S exact probability comparisons of the high education-high privacy condition with the high education-low privacy conditions, with the low educationlow privacy conditions, and with the low education-high privacy conditions were all significant at p <.05 or better. Not only were communications and understanding maximized by education in private, so too was patient compliance. Discussion
Perhaps the most striking feature of these findi!1gs was the high degree of consistency among all the measures. Attempts to edu ~ cate were optimized by privacy; in fact, in some cases they were effective only when
Table 5. Percent of noncompliers as a function of privacy and education Privacy
Educationalt Effort ~
High Low
Cell sizes are same as in Table 1. Values sharing one or more letter subscripts are different at p < .05.
some measure of privacy was provided.·The fact that patient understanding was maximized by privacy makes the finding of greater communication more than trivial. That patient compliance was improved uniquely by education in private has important implications. Heretofore, evidence for meaningful effects of patient education on compliance has been meager indeed. This study's findings assume their greatest importance in the promise they hold for effecting greater participation by patients in their prescribed treatment regimens. A question of theoretical interest is whether the effects of privacy and education on patients were the direct result of these factors or whether these effects resulted indirectly as the consequence of greater pharmacist counseling in the high privacy and high education conditions. In other words, would privacy and education have affected patient measures if the amount of pharmacist talking had been controlled? An analysis of covariance reveals the answer to be an unqualified yes. When pharmacist talking is controlled statistically as a covariate, privacy and education still caused greater patient talking (F = 62.48, P <.001 for privacy and F = 11 . 13, P < .001 for education) . By the same token , an analysis of covariance reveals pharmacist talking to have been greater in the high privacy condition (F = 50.1, P <.001) and in the high education condition (F = 84.5, P < .001) when patient talking is controlled as the covariate. The percentage of noncompliance reported in this study is somewhat lower than figures previously reported in the literature. Thirty-five percent noncompliance is not uncommon 18 and noncompliance among hypertensives may be as high as 85 percent. 19 The lower figures reported in this study are due, at least partially, to our relatively liberal definition of compliance. Noncompliers.in this study were defined in terms of the fit between a count of untaken medication and the appropriate number called for by the treatment regimen. Roth et al. 20 have pointed out that the problems with this measure of compliance relate primarily to assumptions about the fate of missing medications. Presumably, they could have been given away or dropped in the sink. Nevertheless, there is no reason that one group of patients would be more prone than another to such deceptions. Therefore, we assume the comparisons between groups to
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be valid as measures of relative compliance. These find ings point to several factors which should be considered when planning a patient counseling program . Communication , patient understanding and compliance can be enhanced by a well-constructed educational program administered in a setting that offers some measure of privacy for personal interaction. When considering ways to improve rapport with patients, pharmacists should be .mindful of the environment which they offer to the pubiic. Privacy allows both pharmacist and patient to express doubts and deeply felt personal concerns, to ask questions, to listen more effectively, to evaluate more judiciously and to express enlightened and honest opinions. Several patients commented to th~ follow-up interviewers that they were very grateful to the pharmacists for supplying Informati on about their medications in a private room away from the interference of the crowded waiting room. The advantages of counseling patients in private (better rapport, understanding and compliance) can be bought at a very small price, the average pharmaCist-patient exchang~ having lasted only three-and-a-half minutes even in the high privacy-high education condition. The cost-benefit ratio of implementing a high privacy pharmacy setting would appear to be quite low. • References 1. Barker, R : Ecological psychology, Stanford University Press, Palo Alto, California, 1968. 2. Maas, R : Evaluating treatment environment , John Wiley and Sons, New York , 1974. 3. Esser, A , editor: Behavior and environment, Plenum Press, New York , 1971 . 4. Barker, K. N.: Planning a hospital pharmacy facility, Am. J. Hosp. Pharm. 28: 422-446 (June) 197 1. 5. Swenson, E. S.: An innovative deSign in hospital pharmacy fac ilities, Am. J. HO$p. Pharm. 28: 422-446 (June)
197 1. 6. Dickson, W. M., and Rodowskas, C. A : Verbal communication of community pharmacists, Me.d. Care 13: 486-498 (June) 1975. 7. Linkewich , S. A.: The effect of packaging and instruction on outpatient compliance with medication regimens, Drug Intel!. Clin. Pharm. 8: 10- 15 (Jan.) 1974. 8. Clinite, J. C., and Kabat, H. F.: Improving patient compliance, J. Am. Pharm. Assoc. NS 16: 75- 85 (Feb.) 1976. 9. Blackwell, B.: The drug defaulter, Clin. Pharmacol. Ther. 13: 84 1-848 (Nov.- Dec.) 1972. . 10. Becker, M. H., and Mai man, L. A : Sociobehavioral determin ants of compliance with health and medical care recommendation, Med. Care 8: 10-24 (Jan .) 1975. 11 . Sharpe, T., and Mikeal, R : Patients compliance with anti biotic regimens, Am. J. Hosp. Pharm. 31: 479-484 (May) 1974. 12. Arnhold, R G. et al.: Comprehension and compliance with medical instructions in a su burban pediatric practice, Clin. Pediatr. 9: 648 (Nov.) 1970. 13. Anon.: Problems of aged persons taking meds at home, Nurs. Res. 12: 52 (Jan.- Feb.) 1968. 14. Stewart, R B.: A study of outpatients' use of medications, Hosp. Pharm. 7: 108-1 17 (Apr.) 1972. 15. David, M. S.: Physiological, psychological, and demographic factors in patient compliance with MD orders, Med. Care 6: 115 (Mar.-Apr.) 1968. 16. Sackett, D. D. et al.: Randomized clinical trial of strategies for improving medication compliance in primary hypertension, Lancet 1: 1206 (May 31) 1975. 17. Winer, B. J.: Statistical principles in experimental design, McGraw-Hili, New York, 197 1. 18. Marston, M. V.: Compliance with medical regimens: a review of the literatu re, Nurs. Res. 19: 312, 1970. 19. Wood, E. et al. : Guidelines for the detection, diagnosis, and management of hypertenSion population, Circula tion 44:
4623, 197 1. 20. Roth, et al.: Measuring intake of prescribed medication, a bottle count and tracer technique compared , Clin. Pharmacol. Ther. 11: 228 (Apr.) 1970.
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