Social and Behavioral Aspects of Pharmaceutical Care

PHARMACEUTICAL PRODUCTS PRESS Pharmaceutical Sciences Mickey C. Smith, PhD

Executive Editor

New, Recent, and Forthcoming Titles:

Principles of Pharmaceutical Marketing edited by Mickey C. Smith

Pharmacy Ethics edited by Mickey C. Smith, Steven Strauss, John Baldwin, and Kelly T. Alberts

Drug-Related Problems in Geriatric Nursing Home Patients by James W. Cooper

Pharmacy and the U.S. Health Care System edited by Jack E. Fincham and Albert I. Wertheimer

Pharmaceutical Marketing: Strategy and Cases by Mickey C. Smith

International Pharmaceutical Services: The Drug Industry and Pharmacy Practice in Twenty-Three Major Countries of the World edited by Richard N. Spivey, Albert I. Wertheimer, and T. Donald Rucker

A Social History of the Minor Tranquilizers: The Quest for Small Comfort in the Age of Anxiety by Mickey C. Smith

Marketing Pharmaceutical Services: Patron Loyalty, Satisfaction, and Preferences edited by Harry A. Smith and Joel Coons

Nicotine Replacement: A Critical Evaluation edited by Ovide F. Pomerleau and Cynthia S. Pomerleau

Herbs of Choice: The Therapeutic Use of Phytomedicinals by Varro E. Tyler

Interpersonal Communication in Pharmaceutical Care by Helen Meldrum

Searching for Magic Bullets: Orphan Drugs, Consumer Activism,

and Pharmaceutical Development by Lisa Ruby Basara and Michael Montagne

The Honest Herbal by Varro E. Tyler

Understanding the Pill: A Consumer's Guide to Oral Contraceptives by Greg Juhn Pharmaceutical Chartbook, Second Edition edited by Abraham G. Hartzema

and C. Daniel Mullins

The Handbook of Psychiatric Drug Therapy for Children and Adolescents by Karen A. Theesen

Children, Medicines, and Culture edited by Patricia J. Bush, Deanna J. Trakas, Emilio J. Sanz, Rolf L. Wirsing, Tuula Vaskilampi, and Alan Prout

Social and Behavioral Aspects of Pharmaceutical Care edited by Mickey C. Smith and Albert I. Wertheimer

Studies in Pharmaceutical Economics edited by Mickey C. Smith

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Social and Behavioral Aspects of Pharmaceutical Care

Mickey C. Smith Albert I. Wertheimer

Editors

informa healthcare New York London

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CRC PressTaylor & Francis Group6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

© 1996 by Taylor & Francis Group, LLCCRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government worksVersion Date: 20130401

International Standard Book Number-13: 978-1-4822-0783-5 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guid-ance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.

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CONTENTS

About the Editors xvii

Contributors xix

Foreword xxxi

Henri R. Manasse Jr.

PARTI: THE SICKNESS CAREER

SECTION A: CONCEPTS OF HEALTH AND ILLNESS

Chapter 1. Definitions and Meaning of Health 3 Richard M. Schulz David A. Holdford

The Paradox of Health 3 The Meaning of Health 4 Definitions of Health 7 Health, Pharmaceutical Care, and Quality of Care

Assessment 8 Health Beliefs 11 A Model of Health Behavior 13 Wellness and Health 15 Health Promotion and Disease Prevention 15 Conclusion 17

Chapter 2. Illness, Sickness, and Disease 21 Mickey C. Smith

Introduction 21 Definitions and Determinants of 111 Health 22 Behavior in Health and Sickness 24 The Pharmacist and Patient Behavior 36 Summary 36

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SECTION B: PATIENT RESPONSES TO SYMPTOMS

Chapter 3. The Meaning of Signs and Symptoms 41 Dennis A. Frate Juliet B. Frate

Introduction 41 Empirical Data 49 Discussion 60 Summary 62

Chapter 4. Acute vs. Chronic Problems 65 Peter D.Hurd

Introduction 65 Chronic and Acute Symptoms 66 Attribution Errors and Symptoms 66 Symptoms and Change with Chronic Disease 74 Examples of Symptoms in Situations 79 Some Limitations of This Approach 80 Summary 81

SECTION C: CHOOSING A SOURCE OF CARE

Chapter 5. Images of Pharmacists and Pharmacies 85 Sheryl L. Szeinbach

Introduction 85 Background Information 85 What Is Image? 86 Changes Affecting Pharmacy 87 Conceptual Framework 88 Corporate Image 89 Market Image 90 Professional Image 90 Recent Studies on Professionalism and Image

in Pharmacy 91 Strategies for Image Improvement 94 Conclusion 96

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Chapter 6. Other Health Providers and the Pharmacist 99 Bernard Sorofman Toni Tripp-Reimer Richard Dehn Mary Zwygart-Stauffacher

Introduction 99 Continuity of Health Care 100 Changing Health Care Environment 100 Professionals in Society 103 The Adaptation of Medicine 105 Emergence of Physician Assistants 106 The Evolution of Nursing 108 The Practice of Dentistry 111 Other Healing Professions 112 Prescribing and Dispensing 112 Pharmacists and the Health Care Team 115

Chapter 7. Unorthodox Healing Systems 123 Albert I. Wertheimer

Introduction 123 Physical Therapies 125 Hydrotherapy 131 Nutrition 133 Plant-Based Therapies 135 Wave and Radiation 137 Mind and Spirit Healing 138 Self-Exercise 143 Comprehensive Systems 143 Summary 145

SECTION D: CHOOSING A THERAPEUTIC AGENT

Chapter 8. Determinants of Prescribing Behavior 149 Dennis W. Raisch

Introduction: Why Are We Interested? 149 Prescribing Models/Theories: How Are Prescribing

Decisions Made? 150 Methods Used to Influence Prescribing 159

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Administrative Programs Used to Affect Prescribing: Limiting Prescriber Choices 160

Changing Prescribing Knowledge and Drug Assessment: How Can Pharmacists Educate Prescribers to Better Utilize Drugs? 163

Designing Programs to Improve Prescribing: A Model of Methods for Influencing Prescribing 169

Quality of Care Issues 174 Implications for Practice: Putting It All Together 175 Conclusions 176

Chapter 9. Pharmacists' Performance in Drug Product Selection and Therapeutic Interchange 185

Nancy J. W.Lewis Steven Erickson

Introduction 185 Drug Product Selection 185 Therapeutic Interchange 197 Conclusions 207

Chapter 10. Interprofessional Relations in Drug Therapy Decisions 213

Jennifer A. Gowan Louis Roller Alistair Lloyd

Introduction 213 Formal and Informal Networks 215 Improvement of Therapeutic Outcomes 218 Barriers to Interprofessional Relations 222 Communication Skills to Improve Interprofessional

Relations 225 Patient, Prescriber, Pharmacist 230 Intervention 235 Conclusion 245

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Chapter 11. Consumer Behavior Regarding the Choice of Prescription and Nonprescription Medications 253

Michael Montagne Lisa Ruby Basara

Introduction to Consumer Medication Choice 253 Consumer Behavior 254 General Consumer Behavior Models 255 Prescription Medications and Consumer Goods

Are Different 261 Studying Medication Use from a Social and Behavioral

Perspective 263 Prescription Medication Use 271 Nonprescription Medication Use 276 Providing Pharmaceutical Care to Medication Consumers 285 Conclusion 289

SECTION E: MEDICATION-TAKING BEHAVIOR

Chapter 12. Determinants of Medication Use 295 Mickey C. Smith

Introduction 295 The Case of Laxatives 296 Analyzing the Medication Use Process 299 The Case of Minor Tranquilizers 304 Prescribing Studies 305 Utilization Studies 307 Prescribing Dilemmas 314 Look Ahead 317 Summary 319

Chapter 13. Predicting and Detecting Noncompliance 323 Mickey C. Smith

Introduction 323 Noncompliance as a Behavioral Disease 323 Predicting Noncompliance 325 Just Ask Them! (In an Organized Way, of Course) 326

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The Health Belief Model Can Help 329 Detecting Noncompliance 330 Why All the Fuss About Compliance? 339 Conclusion 342

Chapter 14. Explaining and Changing Noncompliant Behavior 351

Dale B. Christensen

The Significance of the Noncompliance Problem 351 Explaining Noncompliant Behavior 354 Changing Noncompliant Behavior 362 Types of Noncompliant Behavior 363 Compliance Enhancement in Tomorrow's World

of Pharmacy Practice 3 70 Concluding Thoughts 374

SECTION F: OUTCOMES OF PHARMACEUTICAL CARE

Chapter IS. Clinical Outcomes 379 Charles E. Daniels

Introduction 379 Definition of Clinical Outcomes 380 Monitoring Outcomes 380 Disease State Management 382 Conclusion 383

Chapter 16. Economic Outcomes 385 Brian G. Ortmeier

Introduction 385 Perspective 386 Defining Costs and Consequences 388 Cost/Benefit Valuation 390 Types of Economic Analyses 392 Critical Evaluation of the Health Economic Literature 398 Applications for Health Economic Research 399

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Chapter 17. Humanistic Outcomes 403 Stephen Joel Coons Jeffrey A. Johnson

Introduction 403 Quality of Life 405 Patient Satisfaction 411 Quality of Life and Patient Satisfaction: Measurement

Issues 412 Humanistic Outcomes and Pharmaceutical Care 416 Summary and Conclusion 421 Appendix I: RAND 36-Item Health Survey 1.0 423 Appendix II: Short-Form Patient Satisfaction

Questionnaire (PSQ-18) 431 Appendix III: Satisfaction with Pharmacy Services

Questionnaire 435 PARTII: SPECIAL CLASSES OF PATIENTS

Chapter 18. Children and Medicines 449 Patricia J. Bush

Introduction 449 How Children Learn 451 Children's Medicine-Related Beliefs and Behaviors 456 Helping Children Learn About Medicines 464

Chapter 19. Adolescents and College Students 473 Tracy S. Portner

Introduction 473 Social and Health Issues 474 Self-Care Activities 483 Illness and Medication Use in Young Adults 484 Sources of Self-Care and OTC Product Information 487 Health Services Utilization 491 Role of the Family in Illness Care 492 Adolescents and Chronic Illness 493 Compliance in Adolescents 498 Minors' Legal Rights to Care 499 Pharmacists: Make a Special Effort 503 Conclusion 505

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Chapter 20. Ambulatory Elderly 515 Jack E. Fincham

Introduction 515 Demographics 516 Social and Behavioral Concerns 519 General Health Concerns 522 Medication-Specific Concerns 524 Conclusion and Commentary 531

Chapter 21. Long-Term Pharmaceutical Care: Social and Professional Implications 537

Royce A. Burruss Norman V. Carroll

Introduction 537 Long-Term Care: The Nursing Home 538 Long-Term Care: Assisted Living 541 Long-Term Care: Continuing Care Retirement Community 541 Long-Term Care: Home Health Care 542 Pharmaceutical Care: An Overview 544 The Case of AAA: Pharmaceutical Care in Action 548 Conclusion 555

Chapter 22. Hospitalized Patients 559 Andrew M. Peterson Paul G. Pierpaoli

Introduction 559 Acute Health Care Services Revisited 559 The Hospitalized Patient: A Conceptual Basis of Care 563 Conclusion 579

Chapter 23. Pharmaceutical Care of Terminally 111 Patients 585

Arthur G. Lipman Joni I. Berry

Introduction 585 Hospice Care 587 The Hospice Team 590

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The Pharmacist's Responsibility to Terminally 111 Patients 590 Hospice Pharmaceutical Care 593 Hospice Pharmacist Job Description 598 Principles of Palliative Care 600 Case Studies in Pharmaceutical Care of Terminally 111

Patients 605 Conclusion 607

Chapter 24. Mental Disorders 611 Julie Magno Zito

Introduction 611 Mental Disorders: Their Classification and Evaluation 614 Epidemiology of Mental Disorders 616 Selected Psychosocial Principles of Mental Disorder

Therapy 619 Antipsychotics for Psychosis and Other Disorders 623 Principles of Longitudinal Monitoring 627 Conclusion 629

Chapter 25. Cultural Issues in the Practice of Pharmacy 635 Pedro J. Lecca

Introduction 635 Cultural Practice Issues 637 Lack of Cultural Understanding 639 Holistic Assessment 640 Culturally Sensitive Practices 641 Culture and Pharmacy Management Practice 642 The Future of Culture in Your Practice 643 Cultural Training 644 Conclusion 644

PART III: REVIEW OF USEFUL CONCEPTS/MODELS

Chapter 26. A Macro View: Public Policy 651 Lon N. Larson

Background and Objectives 651 The Mechanisms of Action of Public Policies 653 The Demand for and Supply of Public Policy 657

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Approaches to Improving Health Status 659 Values in Health Care Services Delivery 662 Public Input and Participatory Democracy 669

Chapter 27. The "Rebirth" of Cognitive Services 675 Kent H. Summers

Introduction 675 The Evolution of Modern Pharmacy Practice 675 Gaining Reimbursement for Cognitive Services 691 Conclusion 706

Chapter 28. Recent Developments in Behavioral Medicine 715 Donna E. Dolinsky

What Is Behavioral Medicine? 715 What Is Health Psychology? 717 What Behaviors Are Related to Illness? 718 What Are Behavioral Medicine's Interventions? 725 Why Is Behavioral Medicine Important for Patients

and for the Health Care System? 729 Do the Nondrug Treatments of Behavioral Medicine

Have a Place in Pharmaceutical Care? 730 What Does This Mean for a Pharmacist? 731

Chapter 29. Expectations, Education, and Technology 737 Sheldon Xiaodong Kong Stephanie Y. Crawford

Introduction 737 Expectations 739 Technology 749 Pharmacy Education 757 Conclusion 764

Chapter 30. Ethical Concerns in Drug Research 773 Kenneth A. Speranza Sr. Amy M. Haddad

Introduction 773 Ethical Principles Underlying Drug Research 775

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Ethical Norms of Drug Research 781 Additional Considerations for the Practicing Pharmacist 791 Conclusion 794 Appendix A: The Nuremberg Code 794 Appendix B: Declaration of Helsinki 796

Epilogue 801 Albert I. Wertheimer

Index 809

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ABOUT THE EDITORS

Mickey C. Smith, RPh, PhD, is F.A.P. Barnard Distinguished Pro­fessor at the University of Mississippi School of Pharmacy. He has published more than 300 research and professional articles in more than 100 different journals. He has published eight books and pres­ented more than 150 papers at professional meetings. Smith is editor of the Journal of Pharmaceutical Marketing & Management and the Journal of Research in Pharmaceutical Economics and Executive Editor of the Pharmaceutical Products Press. His research interests include the determinants of medication use, medication compliance, and medication use in the elderly. Albert I. Wertheimer, PhD, is Vice President of Managed Care Pharmacy at First Health Services Corporation. He also holds a professorship at the School of Pharmacy of the Medical College of Virginia, in Richmond. Previously, he was Professor of Pharmacy Administration, Dean, and Vice President at the Philadelphia Col­lege of Pharmacy and Science. He earned a BS in Pharmacy at the University of Buffalo (1965), an MBA from the State University of New York at Buffalo (1967), and a PhD in Pharmacy Administra­tion from Purdue University (1969). His research interests involve the application of social science and managerial principles to the drug use process and its regulation. He is on the editorial boards of ten journals and is Vice President of the International Pharmaceuti­cal Federation (F.I.P.).

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CONTRIBUTORS

Lisa Ruby Basara, RPh, MBA, is Research Assistant in the Research Institute of Pharmaceutical Sciences and a doctoral candi­date in the Department of Pharmacy Administration at the Univer­sity of Mississippi. Her research and publications have concentrated on the evaluation of consumer-oriented pharmaceutical marketing strategies, such as direct-to-consumer advertising and patient educa­tion programs, as well as the development of attitudinal and demo­graphic profiles of consumers who are likely to respond to direct pharmaceutical marketing efforts. Additionally, Basara has studied the quality of patient education materials and the attitudes of health professionals toward the use and impact of these materials. Basara is a member of the American Pharmaceutical Association, the Drug Information Association, and the American Marketing Association.

Joni I. Berry, RPh, MS, is Consultant Pharmacist at Hospice of Wake County in Raleigh, North Carolina and Clinical Assistant Professor in the School of Pharmacy, University of North Carolina at Chapel Hill. Berry was a founding member of die Board of Directors of Hospice of Wake County. She has published on phar­maceutical services in hospice care and in pain and symptom control in terminal disease. Berry's research interests include outcome mea­surements of interventions in palliative care and physicians' knowl­edge of symptom management issues. Royce A. Burruss, RPh, MBA, is General Manager at HILLMED Home Medical Systems in Ashland, Virginia. He is also a doctoral candidate in Pharmacy Administration at the School of Pharmacy, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia. Patricia J. Bush, PhD, is Adjunct Professor in the Department of Family Medicine, Georgetown University School of Medicine, Washington, DC. As a pharmacosociologist, she has long been

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xx Social and Behavioral Aspects of Pharmaceutical Care

interested in the medicine use process and, especially, the socializa­tion of children into the use of medicines. In 1995, as Visiting Scholar at the United States Pharmacopoeial Convention, Inc., she facilitated the development of guidelines for educating children about medicines. She is the author of more than 70 books, book chapters, and journal articles on the medicine use process and chil­dren's health behaviors. Norman V. Carroll, RPh, PhD, is Professor of Pharmacy Admin­istration at the Medical College of Virginia, Virginia Common­wealth University. His research and teaching focus on financial management, pharmaceutical marketing, and pharmacoeconomics. Dr. Carroll's research has been published in a variety of journals, including Medical Care, Journal of Clinical Anesthesia, Journal of Health Care Marketing, and Journal of Research in Pharmaceutical Economics. His textbook entitled Financial Management for Phar­macists: A Decision Making Approach is widely used in schools of pharmacy. Dr. Carroll received a BS degree in pharmacy and MS and PhD degrees in pharmacy administration from the University of North Carolina at Chapel Hill. Dale B. Christensen, RPh, PhD, is Associate Professor of Phar­macy at the University of Washington School of Pharmacy and School of Public Health (adjunct). He has authored numerous articles, book chapters, and reports on the subjects of drug utiliza­tion, drug policy, drug-taking compliance, pharmacoeconomics, management, and computer applications in pharmacy. He has a particular interest in pharmacy practice in ambulatory and managed care settings. He currently serves as a consultant on drug use review to the state Medicaid program and to private third-party manage­ment of drug benefit programs. His research interests are in the areas of drug-taking compliance, drug use review evaluation, and compensation issues related to the provision of value-added phar­maceutical care services by pharmacists.

Stephen Joel Coons, RPh, PhD, is Associate Professor, Depart­ment of Pharmacy Practice and Director, Center for Pharmaceutical Economics, University of Arizona College of Pharmacy. He also holds an appointment as Assistant Clinical Professor, Division of Health Care Sciences, Department of Family and Preventive Medi-

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Contributors xxi

cine, School of Medicine, University of California, San Diego. Coons has worked as a pharmacist in community pharmacy prac­tice, in institutional pharmacy practice, and in a drug abuse treat­ment facility. His scholarly interests include enhancing patient com­pliance, the pharmacist's role in self-care/self-medication, and assessment of outcomes associated with the use of pharmaceuticals. Stephanie Y. Crawford, PhD, is Assistant Professor, Department of Pharmacy Administration, the University of Illinois at Chicago. Her research interests include the evaluation of pharmaceutical ser­vices and delivery systems, automation in health systems, and medication error outcomes and prevention initiatives. Charles E. Daniels, PhD, is Chief of the Pharmacy Department at the National Institutes of Health Clinical Center and Clinical Assis­tant Professor at the University of Minnesota College of Pharmacy. He is a graduate of the University of Arizona College of Pharmacy and earned a PhD in Social and Administrative Pharmacy from the University of Minnesota. Daniels has published and worked in the fields of clinical pharmacy services, pharmacy purchasing, quality improvement, cost management, and pharmacy systems. Richard Dehn, MPA, PA-C, is Assistant Director of the University of Iowa Physician Assistant Program and has a clinical appointment in the Department of Family Practice, College of Medicine. His major interest is in health care for underserved and rural patients. His research focuses on documenting the practice of physician assistants. Donna E. Dolinsky, PhD, is Professor of Pharmacy Administration at the Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York. Her experi­ence includes teaching, research, and presentations in applications of social and behavioral sciences to pharmacy practice. She has a PhD in educational psychology and has spent the last 16 years teaching at A&M Schwartz College of Pharmacy and at the Univer­sity of Illinois at Chicago College of Pharmacy. She is the author of more than 30 articles and five book chapters. She has given over 50 presentations and continuing education seminars. Her areas of inter­est are patient and health professional decision making, behavior, and communications.

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xxii Social and Behavioral Aspects of Pharmaceutical Care

Steven Erickson, PharmD, is an Assistant Professor of Pharmacy Practice at Wayne State University. He practices as an ambulatory care clinical pharmacist specializing in geriatrics. His research has addressed patient counseling, medication compliance, and the deliv­ery of pharmacy services to older persons. Jack E. Fincham, RPh, PhD, serves as Dean and Professor of Pharmacy Practice at the University of Kansas School of Pharmacy. Fincham is a graduate of the University of Nebraska Medical Center College of Pharmacy. Fincham was a Kellogg Pharmaceutical Clini­cal Scientist Fellow at the University of Minnesota from 1980-1983. He obtained his PhD in Social and Administrative Pharmacy in 1983. Fincham has researched issues pertaining to the drug use process, including the outcomes of drug therapy and pharmacist interventions, adverse drug reactions, patient compliance, drug use in the elderly, and smoking cessation therapies and counseling. He serves as editor of the Journal of Pharmacoepidemiology, is an associated editor of the Journal of Pharmacy Teaching, and is on the editorial board of the Journal of Geriatric Drug Therapy. Dennis A. Frate, PhD, is Research Professor in the Research Insti­tute of Pharmaceutical Sciences, Professor of Pharmacy Adminis­tration, and Professor of Anthropology at the University of Missis­sippi. He has conducted health behavior research since 1971, including 15 years of research on rural, biracial populations in Mis­sissippi. One of his main areas of interest has been individual health care seeking behaviors. His research has been supported mainly by the National Institutes of Health. He has co-authored over 30 journal articles, including publications in Medical Care, Hypertension, Women and Health, the Journal of Rural Health, and the British Medical Journal. He has also coauthored and/or edited three books. Juliet B. Frate, BA, is a Research Associate in the Research Insti­tute of Pharmaceutical Sciences, University of Mississippi. She has conducted health behavior research since 1978,13 of those years on rural, biracial populations in Mississippi. She has co-authored three journal articles and over 20 papers presented at scientific meetings. Jennifer A. Gowan, PhC, Grad Dip Comm. Pharm., FACPP, is a practicing pharmacist and the Director of Training and Development of the Pharmaceutical Society (Victorian Branch) responsible for the

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Contributors xxm

training of preregistration pharmacy students, plus the development of new continuing professional education courses. Her courses emphasize the importance of patient medication counseling and effec­tive communication with patients, caregivers, and health care profes­sionals. She has published a number of pharmacy practice papers. Amy M. Haddad, PhD, is an Associate Professor and Assistant Dean for Administration and Research at the School of Pharmacy and Allied Health Professions at Creighton University. She is also a Faculty Associate of Creighton University's Center for Health Policy and Ethics. Her teaching and research interests include phar­macy ethics, the contextual dimensions of ethical decision making, and narrative ethics. Haddad has published several books and numerous articles in the area of applied ethics and clinical practice in a variety of health science disciplines. She recently chaired the Council of Faculties Committee on Ethics Content in the Curricu­lum and was Co-Chair of the Ethics Special Interest Group of the American Association of Colleges of Pharmacy for three years. David A. Holdford, RPh, MS, is a PhD candidate at the University of South Carolina. He has 11 years of hospital pharmacy experience in clinical and managerial positions. His main areas of interest are the evaluation of pharmaceutical service quality and the influence of pharmaceutical services and programs on patient clinical and eco­nomic outcomes. Peter D. Hurd, PhD, is Professor of Pharmacy Administration at the St. Louis College of Pharmacy. He is also Director of the Divi­sion of Pharmaceutical and Administrative Sciences and Director of Graduate Studies. His research includes the application of social psychological principles to the use of medications, health promotion in children and seniors, and the application of management tech­niques to pharmacy. He has been studying the medication use of national senior athletes, as well as their health-related behaviors, since 1989. Jeffrey A. Johnson, MSc, received his BSP (1988) and MSc (1994) from the University of Saskatchewan College of Pharmacy, Canada. He also completed a hospital pharmacy residency and was employed as a staff pharmacist at the Royal University Hospital in Saskatoon, Canada. He is currently a Research Assistant at the

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xxiv Social and Behavioral Aspects of Pharmaceutical Care

Center for Pharmaceutical Economics and enrolled in a PhD pro­gram in pharmaceutical economics at the College of Pharmacy, University of Arizona. His current research interests include mea­suring health-related quality of life in diabetic patients and assessing the impact of enhanced pharmacy services on patient outcomes. Sheldon Xiaodong Kong, PhD, is Assistant Professor in the Department of Pharmacy Administration, the University of Illinois at Chicago. His research interests are in the areas of pharmacoeco-nomics and quality of life studies. He also conducts research on social support and pharmacists' work-related attitudes (e.g., orga­nizational and career commitment). Lon N. Larson, RPh, PhD, is Associate Professor of Social and Administrative Pharmacy at Drake University in Des Moines, Iowa. He also serves as Director of the Drake Center for Health Issues, whose mission is to promote and enhance public participation in health ethics and health policy issues. Prior to his 1991 appointment at Drake, he was on the faculty at the University of Arizona. Larson received a BS in Pharmacy from Drake and an MS and PhD in Health Care Administration from the University of Mississippi. He worked in regional health planning and health insurance before beginning his academic career. Larson has an ongoing interest in managed care pharmacy, evaluation research, pharmacoeconomics, patient satisfaction with pharmacy services, and community health planning. He has presented and published several papers in these areas. Pedro J. Lecca, RPh, PhD, is Professor and Director of Health Care Specialization at the University of Texas at Arlington and the Director of the Southern Association of School and Colleges on Reaccreditation for U. T. Arlington. He has more than 15 years of experience in teaching, scholarship, research, and academic administration in higher education. Lecca received his BS from Fordham University, his MS from Long Island University, and his PhD from the University of Mississippi. He completed a postdoctorate at Baruch College of Busi-ness/Mt. Sinai Medical School in Health Services Research. Lecca has also completed a fellowship in higher education from the American Council on Education. He has special training in academic administra­tion, undergraduate and graduate education, planning, governance,

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Contributors xxv

research, fund raising, health/mental health research, substance abuse training, AIDS research, grantsmanship, and resource development. He has been associated with several institutions, including the Univer­sity of Illinois at Chicago, New York University, and St. John's Uni­versity. Prior to his appointment at the University of Texas, he held an appointment as Assistant Commissioner of Mental Health/Mental Retardation and Alcoholism Services for the City of New York. Lecca has written over 20 books including monographs and more than a score of articles.

Nancy J. W. Lewis, PharmD, MPH, is President of Lewis Con­sulting Group, Inc., a Delaware-based corporation that specializes in pharmaceutical economics and outcomes research. She has served as a consultant to pharmaceutical companies, pharmacy trade associations, pharmacy benefit management companies, and gov­ernment agencies. Previously, Lewis was Assistant Professor of Pharmacy Practice and a clinical pharmacist in Family Medicine at Wayne State University, a health policy analyst for the Greater Detroit Area Health Council, and the Associate Executive Director for the Institute for Pharmaceutical Economics at the Philadelphia College of Pharmacy and Science. Arthur G. Lipman, RPh, PharmD, is Professor of Clinical Phar­macy in the Department of Pharmacy Practice, College of Pharmacy and at the Pain Management Center, University Hospital, University of Utah Health Sciences Center in Salt Lake City. He was an investi­gator in the National Cancer Institute Demonstration Project on Hospice Care in New Haven, Connecticut in the 1970s. Lipman is a former president and pharmacological consultant to Hospice of Salt Lake. He is the author of over 80 articles, chapters, and monographs and over 200 reviews and editorials. His research is in pharmacolog­ical management of pain and in symptom control of advanced dis­ease. Lipman is the founding editor of the Journal of Pharmaceuti­cal Care in Pain & Symptom Control. Alistair Lloyd, PhC, FPS, has been the Registrar of the Pharmacy Board of Victoria and the Director of the Victorian Branch of the Pharmaceutical Society of Australia since 1982. Prior to this he was in community practice as a pharmacist for 25 years, during which time he served on the Council and as President of the Pharmaceuti-

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xxvi Social and Behavioral Aspects of Pharmaceutical Care

cal Society at state level, and on the Council and as President of what was then called the Pharmaceutical Society of Australia and New Zealand. At present he is actively involved in administering a national project to have pharmaceutical care adopted as the accepted standard of practice by all Australian pharmacists.

Michael Montagne, RPh, PhD, is Associate Professor at Massa­chusetts College of Pharmacy. His research efforts have focused on the social, cultural, and historical aspects of drug use, the pharma­coepidemiology of drug use problems, images of drugs and drug use in mass media, the occurrence of drug epidemics in society, and the development and testing of drug education programming. Mon­tagne's teaching activities include the social and behavioral consid­erations of medical and nonmedical drug taking. He has published extensively on drug development and drug use, the occurrence of drug-use problems, and consumer involvement in health care. Mon­tagne belongs to several professional associations, including the American Association of Colleges of Pharmacy, the American Pub­lic Health Association, and the International Pharmaceutical Federa­tion (F.I.P.).

Brian G. Ortmeier, PharmD, PhD, is Director of Health Economics & Outcomes Management of MedXL, a Hoechst-Roussel Health Care Company. He is responsible for economic evaluation and disease state modeling and implementation. Ortmeier jointed Hoechst-Roussel Pharmaceuticals, Inc. (HRPI) in June 1994 as a manager, pharmaco-economics in market development for managed health care. He has been responsible for incorporating economic and outcome evaluations into protocols during Phases 2-3B and 4 for HRPI products. He is a member of the National Pharmaceutical Council Task Force on Com­pliance and Chair-Elect of the Drug Policy Section/Medical Care of the American Public Health Association. Previously, Ortmeier was Assistant Professor of Pharmacy Practice, Division of Behavioral and Administrative Sciences and Faculty Associate, Center for Pharmaceu­tical Economics, at the University of Arizona. Ortmeier received his PharmD from Creighton University School of Pharmacy and Allied Health Professions in Omaha, Nebraska, and his PhD in Pharmacy with emphasis in marketing and economics from the University of Georgia.

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Contributors xxvu

Andrew M. Peterson, PharmD, is Assistant Director of Pharmacy/ Clinical Services at Thomas Jefferson University Hospital and Clin­ical Assistant Professor at the Philadelphia College of Pharmacy and Science, Philadelphia, Pennsylvania. Peterson received his BS in Pharmacy from Rutgers College of Pharmacy and his PharmD from the Medical College of Virginia. He also completed a hospital pharmacy residency at Rush-Presbyterian St. Luke's Medical Cen­ter and an advanced administrative residency at Thomas Jefferson. Peterson has an interest in developing new practice roles and models for providing pharmaceutical care.

Paul G. Pierpaoli, MS, is Director of Pharmacy Services at Rush-Presbyterian St. Luke's Medical Center and Professor in the Depart­ment of Pharmacology, Rush Medical College, Chicago, Illinois. He also holds the rank of Assistant Professor, Health Systems Manage­ment, Rush University School of Health Sciences. Over the last 30 years, he has been a director of pharmacy services in a number of major U.S. hospitals and has been active in developing and evaluat­ing innovative pharmacy service programs. He has held leadership positions in a number of national professional organizations and has served as President of the American Society of Hospital Pharma­cists. Pierpaoli is the author of numerous articles in the pharmacy and health care literature. Tracy S. Portner, RPh, PhD, is Assistant Professor in the Depart­ment of Clinical Pharmacy, University of Tennessee College of Pharmacy. Her research interests include evaluation of the provision and outcomes of pharmaceutical care in ambulatory care environ­ments, economic evaluations of community and institutional phar­macy services, and the organization and provision of medication information to patients. A specific area of interest is pharmacists' activities in patient care and mechanisms of obtaining compensation for those services. Portner teaches students in the areas of pharma-coeconomics, managed care, and community pharmacy practice management. Dennis W. Raisch, RPh, PhD, is the Associate Chief of the Veter­ans Affairs Cooperative Studies Program Clinical Research Phar­macy Coordinating Center and a Research Assistant Professor at the University of New Mexico. He has conducted research on programs

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xxvi'ii Social and Behavioral Aspects of Pharmaceutical Care

designed to influence and improve prescribing, pharmacist interac­tions with physicians and patients, and pharmaceutical education. His primary research interests are evaluating methods for improving drug prescribing, assessing pharmacy services, and pharmacoeco-nomics. He has authored 14 and co-authored five research publica­tions in peer-reviewed pharmacy journals. He is currently serving on the Annals of Pharmacotherapy editorial advisory panel for pharmacoeconomics. Louis Roller, PhD, is Associate Professor in the Department of Phar­macy Practice, Victorian College of Pharmacy, Monash University, Melbourne, Australia. He is also Associate Dean (Teaching) and Stu­dent Counsellor of the College and a Senior Associate of the Medical Faculty, University of Melbourne. He is a practicing pharmacist, has been involved in professional continuing education for almost three decades, and has lectured regularly interstate and overseas. He is a member of the Pharmacy Board of Victoria with a strong involvement in the educational aspects of the board. He is on the editorial boards of two international journals of pharmacy practice, and has published widely in the area of pharmacy practice.

Richard M. Schulz, RPh, PhD, is Associate Professor of Phar­macy Practice at the University of South Carolina. He received a BS in Pharmacy from the University of Maryland in 1976 and an MS and PhD in Pharmacy Administration from the University of North Carolina in 1980 and 1983, respectively. Prior to joining the Univer­sity of South Carolina faculty in 1986, he was on the faculty at West Virginia University School of Pharmacy from 1982 to 1986. Schulz's research focuses on quality of life and patient compliance with therapeutic regimens. His work has been published in the phar­macy, health care, communication, and business literature. Bernard Sorofman, RPh, PhD, is Associate Professor of Phar­macy in the Clinical and Administrative Pharmacy Division, Col­lege of Pharmacy, University of Iowa. His research focuses on issues surrounding the patient's use of the health care system, cul­tural issues in care, and delivery of pharmaceutical care to the rural elderly. Recent publications have appeared in the Annals of Phar­macotherapy, Social Science and Medicine, and International Jour­nal of Cross-Cultural Gerontology.

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Contributors xxix

Kenneth A. Speranza Sr., PhD, is Associate Professor of Phar­macy Administration at the University of Connecticut School of Pharmacy. His areas of teaching and research specialization are pharmacy law, pharmacy and research ethics, and human resources development in managed care systems. Speranza has published extensively in educational, scientific, and professional journals and has made numerous presentations to professional and lay audiences. He is a past Chairman of the Council of Faculties and Section of Teachers of Social and Administrative Sciences, and a past member of the Board of Directors of the American Association of Colleges of Pharmacy.

Kent H. Summers, RPh, PhD, is the Vice President of Drug Uti­lization and Pharmacoeconomics, Prudential Pharmacy Manage­ment. He is responsible for drug utilization reviews and interven­tions, as well as pharmacoeconomic research. Prior to this, Summers was an Assistant Professor at the University of Missis­sippi School of Pharmacy. He has authored and coauthored over 40 articles in peer-reviewed and trade journals. His research interests include investigations of patients' and physicians' decisionmaking, as well as pharmacoeconomic and outcomes assessments of phar­maceutical therapy. Summers received a BS in Pharmacy (1978) and a PhD in Pharmaceutical Sciences (1989) from the University of Missouri-Kansas City School of Pharmacy. Summers has worked in chain drugstores and in healdi maintenance organizations. In addition, he has over ten years of experience in the pharmaceutical industry.

Sheryl L. Szeinbach, RPh, PhD, is currently Associate Professor in the Department of Pharmacy Administration and Research Associate Professor in the Research Institute of Pharmaceutical Sciences at the University of Mississippi. She received her BS in Pharmacy from the University of Texas at Austin (1980), MS in Pharmacology from the University of Kentucky (1983), and PhD in Pharmacy Administration from Purdue University in 1989. Her research interests include the distribution of pharmaceutical prod­ucts and services, decision-making processes and risk management, technology (automation), and pharmacoeconomic techniques used in utility assessment. She has published over 60 papers in peer-

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xxx Social and Behavioral Aspects of Pharmaceutical Care

reviewed journals, including the Journal of Structural Equation Modeling, American Journal of Hospital Pharmacy, American Journal of Pharmaceutical Education, Journal of Applied Business Research, Journal of Health Care Marketing, Journal of Pharma­ceutical Marketing & Management, Journal of Research in Phar­maceutical Economics, and The Consultant Pharmacist. Toni Tripp-Reimer, RN, PhD, is Professor of Nursing and Anthropology at the University of Iowa. She is Director of the Office of Nursing Research, Development and Utilization; Director of the Gerontological Nursing Research Center; and Director of the Iowa-Veterans Affairs Research Consortium. Her research focuses on self-care behavior in cultural context with an emphasis on eth-nogerontology. She has over 200 published scholarly articles, book chapters, and books. Julie Magno Zito, PhD, is Associate Professor of Pharmacy Prac­tice and Science and Research Associate Professor of Psychiatry at the University of Maryland at Baltimore. Her research area is phar­macoepidemiology and drug treatment refusal among those with mental disorders. During the past ten years, these studies have been supported by funding from the National Institutes of Mental Health and by a state mental health agency. She is the editor and major author of the Psychotherapeutic Drug Manual, a handbook on drug therapy for mental disorders published by Wiley in 1994. She has co-authored more than 20 journal articles in journals such as the American Journal of Psychiatry and written book chapters on adult and child psychiatry for books in the fields of pharmacoepidemiol­ogy and child psychiatry.

Mary Zwygart-Stauffacher, RN, PhD, is Assistant Professor of Nursing and Head of the Gerontological Nurse Practitioner Program at the University of Iowa. She maintains a primary care practice in rural Iowa and Wisconsin. Her research is focused on long-term care issues with emphasis on medication management.

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Foreword

Things are just not as they seem to be. First impressions provide stark reminders of that truism as one explores in greater depth the phenomena from which the first impression is made. More often than not, upon more reflective study and scrutiny, what seemed simple and mundane becomes complex and difficult to understand. That is eminently true with human behavior. It is equally true in foreign affairs, the life cycle of a cell, the goings-on in an organiza­tion, and a host of other examples in life. So why should it not be true in that aspect of life that is perhaps more personal and simulta­neously affects the entire planet's population: namely, illness, sick­ness, disease, healing, health practitioners, and the systems that attempt to bring them all together. The latter we call the health care system; however, most of us would agree that there is little relation­ship between the concepts of system and the why's, wherefore's, where's, and how's of the care rendered to sick individuals.

Indeed, the relationships among the individual who is sick (by whatever criteria that may be determined), the individual who is sought out to determine a resolution to the sickness, the institutions where the "cure" might be obtained, and the overarching aspects of financing and assuring appropriateness of care form one of the most complex webs of human and institutional interactions in society, a web which few people understand. Social and behavioral scientists have only recently begun to study systematically the intricacies of the web and its components. Through these studies have come more focused approaches to caring for the patient, educating future health care professionals, and developing dialogues with policymakers and the general public.

That is what this book is all about. In its 30 chapters, the diverse authors attempt to take pieces of the complex web of pharmaceuti­cal care, describe the known microcosmic components of such care, and then relate the pieces back to the integrity of the web. The

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scrutinizing reader of this collection of important essays will find that the behavior of the patient, the prescriber, the systems that allow for these interactions, and ultimately, the outcomes of medication use are, in fact, not as simple as they appear.

Beginning with the decision to seek care, it will be noted that a variety of perceptions of health and illness exist which are drawn from various individual, cultural, and social interpretations. Some people interpret their illness from the perspective of stoic tolerance, while others perceive it as minor inconvenience and simply move on. Still others will define it as a turning point in life and conse­quently seek out the best and brightest minds to find the cure. Why is that? Some of the answers lie in the pages you are about to read.

On the other end of the spectrum lie the issues surrounding the outcomes of illness and the care that has been provided. Specifi­cally with regard to medication use, are the desired outcomes being achieved and if not, why not? We know the answers to the latter questions are also not easily determined. Interwoven in medication use are cultural and social interpretations of chemical treatment, including the assurances related to compliance with therapy; the decision structures that are in place to monitor drug therapy; and the difficulties associated with defining and measuring outcomes.

The adventure upon which you are about to embark as you read the varied chapters of this book will likely evoke an equally varied set of responses. Students in the health professions typically do not like the gray zones of the social and behavioral sciences. They find more comfort in the black and white so often attributed to the physical and biological sciences. For readers who find themselves in that frame of mind, this text may prove to be frustrating reading. They may find themselves reading words on many pages and not finding the answers they expect. They will also miss the profound­ness of human behavior.

On the other hand, the reader who approaches the reading of this text with a real desire to understand better how behavior links to the complexities of an individual's or social group's actions and deeds will find an exhilarating series in the following pages. This reader will find that microcosms of the web are as fascinating as the web itself. To be sure, there will be few definitive answers; rather, there will be extensive description of phenomena known to be true but

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Foreword xxxui

which are all subject to change when new variables are introduced. That is what makes inquiry into the social and behavioral aspects of pharmaceutical care both challenging and frustrating.

A better understanding of and appreciation for pharmaceutical care and its behavioral underpinnings will assuredly better prepare pharmacists for contemporary and future roles that more closely bind them to their patients and the prescribing community. As the functional role of the pharmacist as direct caregiver comes to be better understood by the patient, the pharmacist can more effec­tively influence the behavior of the patient toward achieving better outcomes with drug therapy. On the other side of the coin, as the pharmaceutical caregiving pharmacist comes to understand the patient better from a behavioral perspective, the pharmacist can create a more effective partnership as care is rendered.

Enjoy your journey and find comfort in the gray zones.

Henri R. Manasse Jr.

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