Factors affecting pharmacists' pediatric asthma counseling

Factors affecting pharmacists' pediatric asthma counseling

research Research Factors affecting pharmacists’ pediatric asthma counseling Françoise G. Pradel, Nour A. Obeidat, and Mona G. Tsoukleris Received D...

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research Research

Factors affecting pharmacists’ pediatric asthma counseling Françoise G. Pradel, Nour A. Obeidat, and Mona G. Tsoukleris

Received December 5, 2006, and in revised form April 26, 2007. Accepted for publication May 26, 2007.

Abstract Objective: To explore various factors that may influence community pharmacists’ pediatric asthma counseling. Design: Cross-sectional. Setting: Maryland from September 2002 through March 2003. Participants: Random sample of 400 community pharmacists. Intervention: Mail survey. Main outcome measures: Pharmacists’ attitude, subjective norm, perceived behavioral control, intention to provide pediatric asthma counseling, and reported counseling using the theory of planned behavior as a framework; demographic and pharmacy characteristics. Results: 98 of 389 (25%) eligible pharmacists responded. Most acknowledged the importance of providing asthma counseling to children (54%) or caregivers (68%). However, only a small number reported demonstrating to children or caregivers or asking them to demonstrate how to use antiasthmatic medications. Multivariate logistic regressions revealed that intention to counsel was a significant predictor of providing counseling for children or caregivers (odds ratio [OR], 3.95 and 3.09, respectively). Intention to counsel children was significantly associated with subjective norm (OR, 1.88) and perceived ease of counseling (OR, 1.48); intention to counsel caregivers was significantly associated with perceived ease (OR, 1.45). Pharmacists also reported the following barriers that made counseling difficult: lack of time, lack of parent’s interest, and lack of placebo devices useful for demonstration of inhalation technique. Conclusion: Despite a positive attitude toward providing asthma counseling, the majority of pharmacists reported not fully engaging in counseling. A number of barriers to counseling were reported that, if targeted, could improve the management of pediatric asthma through pharmacist-initiated counseling. Keywords: Pediatrics, asthma, patient counseling, patient education, barriers, pharmacists, surveys, role theory. J Am Pharm Assoc. 2007;47:737–746. doi: 10.1331/JAPhA.2007.06138

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Françoise G. Pradel, MS, PhD, is Associate Professor, and Nour A. Obeidat, MS, is Research Assistant and Doctoral Graduate Student, University of Maryland School of Pharmacy, Department of Pharmaceutical Health Services Research, Baltimore. Mona G. Tsoukleris, PharmD, BCPS, is Associate Professor, University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore. Correspondence: Françoise G. Pradel, MS, PhD, School of Pharmacy, University of Maryland, 220 Arch St., Baltimore, MD 21201. Fax: 410-706-5394. E-mail: [email protected] rx.umaryland.edu Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: Supported by an American College of Clinical Pharmacy Aventis Allergy/ Asthma Research Award. Acknowledgments: To Stuart Haines, PharmD, for providing feedback on the questionnaire and to Vanjya Sikirica, PharmD, and Tze Wah Vivian Leung, PharmD, for participating in the development of the questionnaire and for helping in the implementation of the survey, respectively, during their work as student pharmacists. Previous presentation: American College of Clinical Pharmacy 2003 Annual Meeting, Atlanta, November 2–5, 2003.

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ediatric asthma is the most common chronic disease in children1 and is associated with substantial morbidity and mortality,2,3 translating to billions of dollars in health care spending.3–5 Despite advances in the management of asthma and evidence of declining morbidity and mortality rates, asthma outcomes can be improved further, particularly in children.6–8 The National Heart Lung and Blood Institute and the American Academy of Pediatrics, in conjunction with the American Academy of Asthma, Allergy, and Immunology, have emphasized the importance of patient education in the management of asthma and, in the case of pediatric asthma, have stressed the need for direct involvement of children who have asthma in the education process.9,10 Furthermore, a wealth of literature suggests that patient education can improve health outcomes in children with asthma.11–15 To involve pharmacists in this important component of asthma management, the National Institute of Health published a guide for pharmacists regarding their potential roles as health care professionals in the asthma education process.16 While involvement of pharmacists is impor-

At a Glance Synopsis: In response to a mail survey, 98 Maryland pharmacists indicated that it was important to provide asthma counseling to children (54%) or caregivers (68%), and intent to counsel children or parents in the near future was expressed by 46% and 63%, respectively. However, fewer pharmacists reported counseling a child (29%) or parent/caregiver (47%). A high number of pharmacists also reported that individuals whose opinions were of value to them were very likely to approve of their involvement in pediatric asthma counseling of children (75%) and parents/caregivers (82%). Overall, 55% of pharmacists indicated a perceived difficulty in providing asthma counseling to children, while 36% reported difficulty in counseling parents. Analysis: Pharmacists believed asthma counseling in pediatric patients was important and that such behavior would be supported by valued others, implying that perceived barriers (e.g., lack of time, parent interest, and placebo devices for demonstration of inhalation techniques) were responsible for the low percentages of pharmacists who actually performed pediatric asthma counseling. Lack of time—a barrier that has been reported previously—requires increased attention at an organizational level, in order to allow pharmacists the time needed to perform their crucial patient counseling role. Educating parents/caregivers on the importance of asthma counseling could help to remedy a perceived lack of interest, and the lack of placebo demonstration devices in pharmacies can be easily addressed.

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tant,17 the extent of counseling provided to patients appears to be variable. In fact, several studies indicate that pharmacists do not always provide comprehensive patient counseling and have yet to fully assume their roles as health educators.18–22 The limited participation of pharmacists in patient counseling, particularly pediatric patient counseling, may result from various factors. Research indicates that performing patient counseling is associated with several internal (sociocognitive) factors, such as the pharmacist having or developing the confidence (self-efficacy) and perceived control to counsel.23,24 Having knowledge of the changing cognitive abilities of children and modifying counseling techniques accordingly will also ensure that the educational process is compatible with the developmental age of the child.10,25,26 We attempted to explore sociocognitive aspects of patient education using a well-established theoretical framework, the Theory of Planned Behavior (TPB) (Figure 1).27 The TPB has been used to study, for example, health-related behaviors (e.g., cancer screening), lifestyle-related behaviors (e.g., eating, exercise), and pharmaceutical counseling.23,24,28,29 According to the TPB, the most important determinant of a behavior is an individual’s intention to perform the behavior (i.e., in our study, intention to perform pediatric asthma counseling). In turn, the direct determinants of an individual’s intention are his or her attitude toward performing the behavior, subjective norm associated with the behavior, and perception of control over the behavior. The model also posits a direct effect of perceived behavioral control on behavior. Thus, pharmacists who have a positive attitude toward counseling, who believe that people important to them will approve of them providing pediatric asthma counseling, and who perceive that counseling is under their control are more likely to intend to provide, and subsequently provide, pediatric asthma counseling. In addition to the consideration of internal factors that may influence the provision of patient counseling, pharmacists must be placed in a practice setting that is conducive to counseling in order to minimize external factors that have been reported to affect counseling, such as lack of time, lack of space or privacy, financial constraints, lack of patient motivation, lack of training, difficulty in accessing a patient’s physician, and language barriers.22,30–34 Other related pharmacy and demographic characteristics have been associated with the provision of counseling and include pharmacist position, pharmacy type, state regulations, and demographic characteristics such as pharmacist age.22,33,35 Thus, we also attempted to study external factors that influenced the provision of pediatric asthma counseling. In summary, a multitude of internal and external factors may affect the provision of counseling services in pharmacies. However, little is known about the determinants of pediatric asthma counseling by community pharmacists. Furthermore, few established behavioral models have been used to explore sociocognitive variables that may be associated with the provision of specific pediatric asthma counseling behaviors. These Journal of the American Pharmacists Association

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Attitude toward providing pediatric asthma counseling

Subjective norms of providing pediatric asthma counseling

Intention to provide pediatric asthma counseling

Performing pediatric asthma counseling

Perceived behavioral control over providing pediatric asthma counseling Figure 1. Constructs of the Theory of Planned Behavior Adapted from Ajzen (reference 27).

areas are important to explore, since a substantial proportion of asthma patients are children.

Objectives The purpose of this study was to identify and describe the sociocognitive factors associated with the provision of pediatric asthma counseling by community pharmacists (attitudes, subjective norms, perceived behavioral control, and intention), to identify the external (pharmacy/pharmacist-related) factors that most influence pediatric asthma counseling, and, finally, to use both sociocognitive and external factors to evaluate the intentions and behaviors of pharmacists with regard to providing pediatric asthma counseling.

Methods We conducted a cross-sectional mail survey of 400 randomly selected community pharmacists currently licensed to practice in Maryland. This roster was obtained from the Maryland Board of Pharmacy. The study was approved by the University of Maryland Institutional Review Board of the Office for Research Subjects (H-21464). The self-administered questionnaire was developed using the TPB as a conceptual framework, including items that assessed respondents’ behaviors, behavioral intentions, and attitudes.

were demonstrating the use of inhaled antiasthmatic medications to children or parents and having children or parents demonstrate to the pharmacist how they administer these medications. Overall counseling was defined as “covering with children or their caregivers the key educational messages delineated in the 1997 National Asthma Education and Prevention Program recommendations: essential information about asthma, role of medications, self-management skills, environmental control, and actions to take based on responses to change in asthma severity.” For the purpose of this study, we also defined children as patients between 5 and 12 years of age. Based on findings that established that behavior is strongly associated with recent past behavior,24 each behavior was measured by asking respondents to report the frequency of performing the behavior of interest in the past month using a 7-point Likert-type scale (1, never; 2, almost never; 3, a few times; 4, fairly often; 5, often; 6, very often; 7, always). Behavioral intention

Pharmacists’ behavioral intention to provide pediatric asthma counseling was measured by asking respondents to indicate the degree of likelihood of performing the behavior of interest in the next month using a 7-point Likert-type scale (1, very unlikely; 2, quite unlikely; 3, slightly unlikely; 4, neither; 5, slightly likely; 6, quite likely; 7, very likely).

Behaviors

Attitude

Three behaviors were explored. The main behavior of interest was self-reported overall pediatric asthma counseling performed by the pharmacist. The other two behaviors explored

Attitude of pharmacists toward the behavior of interest was measured by asking respondents to indicate the degree of importance of performing the behavior using a 7-point

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Likert-type scale (1, very unimportant; 2, unimportant; 3, somewhat unimportant; 4, neither; 5, somewhat important; 6, important; 7, very important).

Subjective norm was measured by asking respondents to indicate on a 7-point Likert-type scale the likelihood (1, very unlikely, to 7, very likely) that people whose opinion they valued would approve of them providing pediatric asthma counseling. Pharmacists also indicated the likelihood of caregivers, children, physicians, colleagues, pharmacy managers, and family or friends influencing their decision to counsel a child with asthma.

Pharmacists participating in the pilot study were removed before a random sample of 400 pharmacists was selected for the survey. We mailed the final questionnaire with a cover letter from the principal investigator explaining the purpose of the study, the benefits/risks of participating, and how confidentiality would be ensured. A prestamped return envelope was also enclosed. Potential participants had the option to deny further contact by returning a postcard. Two weeks after the initial mailing, a second survey package was mailed to nonrespondents. As an incentive, participants were offered free access to a 2-hour continuing education program on asthma inhaled medications.

Perceived behavioral control

Statistical analysis

Two subconstructs (i.e., perceived self-efficacy and perceived controllability) were used to measure pharmacists’ perceived behavioral control regarding provision of pediatric asthma counseling. Pharmacists were asked to rate, on a 7-point Likert-type scale, both the ease/difficulty (1, very difficult; 2, quite difficult; 3, slightly difficult; 4, neither; 5, slightly easy; 6, quite easy; 7, very easy) of performing a behavior (e.g., instructing children on proper inhaler use) and the degree of control they believed they had over the performance of this behavior (1, strongly disagree; 2, disagree; 3, mildly disagree; 4, neither; 5, mildly agree; 6, agree; 7, strongly agree). Other variables were measured, including major barriers to pediatric asthma counseling. Pharmacists who reported that they found difficulty in performing the behavior were asked to indicate the reasons for perceived difficulty. A list of barriers (e.g., lack of time, lack of space, lack of reimbursement, store policy, lack of training, lack of placebo inhalation devices, other barriers) was provided. In addition, pharmacists were asked to report whether they provided counseling for other disease states. Demographic variables collected included pharmacist age, gender, position, family status, and pediatric training. Finally, pharmacy practice characteristics (i.e., pharmacy type, location, staffing, counseling area, number of prescriptions per day, percentage of time children accompany caregivers to the pharmacy) were captured. A copy of the questionnaire appears as Appendix 1 in the electronic version of this article, available online at www.japha.org.

A descriptive analysis was performed to generate frequencies, as well as measures of central tendency (mean or median) and dispersion (range, mode, or standard deviation), as relevant. Bivariate analyses assessed correlations among TPB constructs and correlations of TPB constructs with age using Spearman’s correlation coefficients. Because behaviors and other TPB variables such as intention were not normally distributed, we used the Mann–Whitney test in bivariate analyses to compare median scores of behaviors by select pharmacy and demographic characteristics. Specifically, median scores for performing the behaviors of interest were compared by gender, having a child, having a counseling area, type of pharmacy degree (PharmD versus other), pharmacist position (owner or manager versus staff), availability of additional pharmacist support, prescription volume of the pharmacy (high [>1,800 prescriptions/week] versus low [≤1,800 prescriptions/week]), type of pharmacy (chain or merchandiser versus independent or franchise), pediatric training (continuing education versus none), and asthma training. Multivariate logistic regressions were performed to test the simultaneous effect of select sociocognitive and pharmacyrelated variables on the two main constructs of the TPB, behavioral intention and the behavior itself. Predictors of these two constructs were explored with regard to the child and the parent. Behavioral intention and behavior were operationalized as follows: pharmacists who reported that they intended to provide or that they provided asthma counseling “always,” “very often,” “often,” or “fairly often” were categorized as having an intention to perform the behavior or as performing the behavior, whereas pharmacists who stated that they intended to engage in asthma counseling or that they engaged in asthma counseling “never,” “almost never,” or “a few times” were categorized as not having the intention to perform the behavior or as not performing the behavior. Using a cutoff of P < 0.1, only sociocognitive or pharmacy/ pharmacist characteristic variables that were significantly associated with behavioral intention or reported behavior in the bivariate analysis were included in the multivariate logistic regressions. The level of statistical significance in the multivari-

Subjective norm

Implementation of survey

Using the TPB as a framework,27,36 and with guidance from a pharmacist who specializes in asthma, an initial list of questions was developed. The survey was then further evaluated by pharmacy faculty members who specialize in ambulatory (clinic and community settings) and pediatric care. Minor modifications were made, and the survey was mailed to a random sample of 30 community pharmacists practicing in Maryland for pilot testing. This pilot study allowed for the refinement of the questionnaire in terms of clarity of items, feasibility, and directions for completing the questionnaire. 740 • JAPhA • 47: 6 • N o v / D e c 2 0 07

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ate analysis was set at 0.05. Analyses were conducted with SAS version 8.2 (SAS Institute, Inc., Cary, N.C.).

Table 1. Demographics and pharmacy characteristics for sample of responding pharmacistsa

Results

Age, years (n = 97) Range Mean ± SD Gender, n (%) (n = 98) Men Women Degree, n (%) (n = 97)b BPharm PharmD Graduate Position, n (%) (n = 97) Owner or manager Staff Pharmacy type, n (%) (n = 97) Independent/franchise Grocery/chain No. pharmacists per shift with respondent (%) (n = 96) None ≥1 No. technicians per shift with respondent (%) (n = 95) None 1 ≥2 No. prescriptions dispensed per week (%) (n = 98) Low volume (≤1,800) High volume (>1,800) Availability of counseling area, n (%) (n = 98) Counseling area available No counseling area in pharmacy Availability of DMPs for patient, n (%) (n = 96) Expertise in pediatrics, n (%) (n = 97)b No training Pediatric residency Previous degree/specialized training Pediatrics/family practice clinic/program Continuing education Other Expertise in asthma management, n (%) (n = 98)b No training Continuing education Participation in asthma clinic Respondent or family member has asthma

Of the 400 surveys mailed, 109 were returned. Eleven surveys were excluded because respondents were either retired or did not see any patients on a typical workday. This resulted in 98 usable surveys and an overall response rate of 25%. Univariate analysis

An analysis of demographic and pharmacy characteristics is presented in Table 1. The respondents’ mean (±SD) age was 45 ± 12 years, and 51% were men, with approximately equal numbers of owners/managers and staff pharmacists. More than two-thirds of respondents reported having a counseling area available, and the majority (79%) worked in grocery or chain pharmacies. Additional demographic data are presented in Table 1. The majority of pharmacists believed that providing asthma counseling to children (54%) and parents (68%) was important or very important. The majority of pharmacists also reported that people whose opinion they value were quite/very likely to approve their involvement in pediatric asthma counseling of children (75%) and parents (82%). With respect to perceived ease of counseling, 55% of pharmacists reported difficulty in providing asthma counseling to children, while 36% reported difficulty in counseling parents. Lack of time, lack of parent interest, and lack of placebo devices for demonstration were among the most common factors contributing to perceived difficulty. In a related measure, some form of disagreement about having control over the provision of counseling was expressed by 35% of pharmacists in regard to children and 27% of pharmacists in regard to parents. Respondents’ mean and median scores for attitude, subjective norm, and perceived behavioral control are presented in Table 2. Pharmacists’ mean score of attitude toward (perceived importance of) counseling children or their caregivers fell between somewhat important and important (5.25 and 5.57, respectively). Similarly, pharmacists’ mean scores of subjective norm (approval of counseling initiatives by relevant people) were relatively high on the 7-point scale, with means of 5.85 (counseling initiatives toward children) and 6.1 (counseling initiatives toward parents). Finally, in terms of TPB constructs, although the mean scores for perceived control over counseling were high on the 7-point scale (approximately 5), the mean scores for perceived ease of counseling behaviors were relatively low (3.7 for children and 4.5 for parents). A descriptive analysis of frequencies of the two outcomes of interest, intention to counsel and performing counseling, is shown in Figure 2. While 46% and 63% of pharmacists expressed intent to counsel children or parents, respectively, in the near future, a lower fraction of pharmacists reported counseling the child or the parent (29% and 47%, respectively), implying the existence of barriers that prevented pharmacists Journal of the American Pharmacists Association

24−78 45 ± 12 50 (51) 48 (49) 82 (85) 15 (15) 7 (7) 50 (51) 48 (49) 21 (22) 76 (78) 59 (61) 37 (38) 2 (2) 39 (41) 54 (57) 69 (70) 29 (30) 65 (67) 33 (33) 12 (13) 36 (37) — 3 (3) 2 (2) 57 (59) 5 (5) 9 (9) 83 (85) 4 (4) 6 (6)

Abbreviations used: DMP, disease management program; BPharm, bachelor of science in pharmacy degree; PharmD, doctor of pharmacy degree a Numbers do not always total 98 because of missing data. b Does not always sum to 100% because of multiple answers.

from performing their counseling intentions. In addition, a low proportion of pharmacists (28%) spoke directly to children when present at the pharmacy. Attitude to and performance of other behaviors of interest were also evaluated (Table 3). While the majority of pharmacists agreed that specific behaviors, such as demonstrating use of an inhaler to children/parents or having children/parents demonstrate use of an inhaler, led to beneficial health outcomes, a substantially lower proportion of pharmacists actually performed these counseling behaviors when filling an asthma prescription for the first time or when refilling an asthma prescription. w w w. p h a r m a c i s t . c o m

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Table 2. Measures of dispersion for main constructs in the TPB

Measures of dispersion

Median score TPB constructs n (interquartile range) Counselinga Child 97 3.0 (2.0–4.0) Parent 98 3.0 (3.0–5.0) Intention to counsela Child 96 3.0 (2.0–5.0) Parent 97 4.0 (3.0–6.0) Importance of counseling (attitude)b Child 97 6.0 (5.0–7.0) Parent 97 6.0 (5.0–7.0) Others’ approval of counseling (subjective norms)c Child 98 6.0 (5.0–7.0) Parent 98 6.0 (6.0–7.0) Ease of counseling (control)d Child 98 3.0 (2.0–5.0) Parent 98 5.0 (3.0–6.0) Perceived control over counseling (control)e Child 97 5.0 (3.0–6.0) Parent 97 6.0 (3.0–6.0)

Means ± SD 3.02 ± 1.44 3.96 ± 1.44 3.64 ± 1.60 4.38 ± 1.49 5.25 ± 1.78 5.57 ± 1.95 5.85 ± 1.21 6.10 ± 0.95 3.74 ± 1.85 4.54 ± 1.80 4.59 ± 1.82 4.96 ± 1.77

Abbreviations used: TPB, theory of planned behavior; SD, standard deviation. a 1, never; 2, almost never; 3, a few times; 4, fairly often; 5, often; 6, very often; 7, always. b 1, very unimportant; 2, unimportant; 3, somewhat unimportant; 4, neither; 5, somewhat important; 6, important; 7, very important. c 1, very unlikely; 2, quite unlikely; 3, slightly unlikely; 4, neither; 5, slightly likely; 6, quite likely; 7, very likely. d 1, very difficult; 2, quite difficult; 3, slightly difficult; 4, neither; 5, slightly easy; 6, quite easy; 7, very easy. e 1, strongly disagree; 2, disagree; 3, mildly disagree; 4, neither; 5, mildly agree; 6, agree; 7, strongly agree.

46%

Intention to counsel child (n=96)

29%

Counseled children over past month (n=97)

Intention to counsel parent (n=97)

63%

Counseled parents over past month (n=98)

47%

28%

Spoke directly to child (n=96) 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pharmacists reporting intention or behavior a

Figure 2. Numbers of pharmacists with intention to counsel and performing counseling of children with asthma and their parents a

R esponses of “fairly often,” “often,” “very often,” or “always” by pharmacists for performing the behavior or having the intention to perform the behavior were grouped into a positive response.

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Table 3. Perceived benefits of specific behaviors on health outcomes as reported by pharmacists, and the frequencies at which pharmacists actually performed these behaviors No. respondents agreeing that listed behavior improves child asthma outcomes (%)a Behaviors Demonstrate inhaler technique to child 78 (81.2) Demonstrate inhaler technique to parent 83 (86.5) Let child demonstrate inhaler technique 71 (73.9) Let parent demonstrate inhaler technique 72 (75) a b

No. respondents reporting performing the behavior in the previous month (%)b For new prescription 21 (24.9) 31 (36.9) 12 (14.3) 13 (15.4)

For refill prescription 5 (5.9) 8 (9.4) 5 (5.9) 6 (7.1)

Pharmacists who reported they “agree” or “strongly agree” that performing the behavior improves outcomes were categorized as those who agreed that the behavior improved outcomes. Pharmacists who reported “fairly often,” “often,” “very often,” or “always” performing the behavior were categorized as those who performed the behavior in the previous month.

Bivariate analysis

Bivariate correlations were generated in order to verify interrelationships among individual constructs of the TPB. As posited by the TPB, attitude, subjective norm, perceived difficulty, and perceived control were significantly correlated with intention to provide counseling to parents (correlation coefficients 0.37, 0.33, 0.51, and 0.37, respectively; P < 0.05). Perceived difficulty, perceived control, and intention also were significantly correlated with performing counseling (0.54, 0.33, and 0.78, respectively; P < 0.05). With respect to counseling children, attitude, subjective norm, perceived difficulty, and perceived control were significantly correlated with intention to provide counseling to children (correlation coefficients 0.41, 0.35, 0.42, and 0.21, respectively; P < 0.05). Perceived difficulty and intention also were significantly correlated with performing counseling (0.48 and 0.80, respectively; P < 0.05). The comparison of median scores for general counseling behaviors/intention to counsel by demographic and pharmacyrelated variables revealed that pharmacy volume, availability of a counseling area, pharmacist position, and having pediatric continuing education were significantly associated with counseling behaviors/intention to counsel. Other pharmacist-related variables, such as age, gender, and degree, were not significant. Given these results, multivariate logistic regressions were performed to determine the simultaneous effect of the above significant variables on both provision of counseling and intention to counsel.

threefold increase in the odds of counseling a parent for every unit increase in the score of intention to counsel. Perceived ease of counseling and subjective norm were the sociocognitive variables significantly associated with intention to counsel a child (Table 5). As the score of perceived ease or perceived support of relevant people increased by 1 unit, the odds of having an intention to provide counseling to the child increased by approximately 1.5 and 1.9 times, respectively. Perceived ease of counseling was significantly associated with the intention to counsel a parent (odds ratio, 1.46; P = 0.012). To better understand subjective norm as it relates to the behavior of counseling a child, we evaluated the perceived influence that important people had on the decision to perform that behavior. The majority (71%) of pharmacists reported that parents were quite/very likely to influence their decision to counsel a child. Approximately 44% reported that pharmacy management and the child were quite/very likely to influence the decision to counsel a child. Physicians, colleagues, and friends/family were less likely to influence the decision to counsel (31%, 18%, and 16%, respectively). Finally, we investigated the barriers to counseling reported by pharmacists who perceived the provision of any asthma counseling behavior as difficult. The three most frequently cited reasons were lack of time (69% of respondents ranked this as their first reason), lack of parent interest (25% of respondents ranked this as their second reason), and no placebo demonstration devices to demonstrate the use of inhalers (33% of respondents ranked this as their third reason). Other reasons reported included lack of space and absence of the child.

Discussion Multivariate analysis

Results of the logistic regression models analyzed are presented in Tables 4 and 5. With respect to general child counseling, intention to counsel the child was a significant predictor of reported counseling (Table 4). Specifically, as the score of intention to counsel a child increased by 1 unit, the odds of reporting provision of counseling increased almost fourfold. A similar association was observed for parent counseling, with a Journal of the American Pharmacists Association

Although community pharmacists expressed a positive attitude toward the provision of asthma counseling to children and/or their parents, the majority did not report fully engaging in counseling practices. Our findings are in line with those of a patient survey in which patients with asthma reported that community pharmacists were not providing adequate counseling.20 Our study, like others,21,22 suggests that pharmacists are not assuming an active patient education role. w w w. p h a r m a c i s t . c o m

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Table 4. Multivariate logistic regression modeling for pharmacist counseling of child with asthma or parent Counsel child Independent variables OR (95% CI) Intention to counsel 3.95 (2.07–7.57)a Importance of 1.23 (0.84–1.78) counseling (attitude) Ease of counseling 1.30 (0.92–1.84) (control) Others’ approval of 0.82 (0.40–1.67) counseling (subjective norms) Pediatric training 0.44 (0.10–1.99) High-volume pharmacy Availability of counseling area Owner/manager

Counsel parent OR (95% CI) 3.09 (1.83–5.21)a 1.09 (0.81–1.47) 1.32 (0.93–1.87)

0.25 (0.06–1.00) 1.722 (0.483–6.14) 0.79 (0.24–2.59)

Abbreviations used: CI, confidence interval; OR, odds ratio. a P < 0.05.

Another important finding of our study is that although pharmacists reported that they tended to address the information needs of parents, they did not frequently communicate with and counsel children. Including children with asthma in the educational encounter is supported by the American Academy of Asthma, Allergy, and Immunology and the American Academy of Pediatrics.10 Our results suggest that the provision of counseling for the various behaviors addressed in the survey was consistently lower for the child than for the parent/caregiver. Scores of perceived importance and ease of counseling also were lower for counseling children than parents. Furthermore, none of the respondents in our survey preferred to communicate only with the child. Rather, 23% preferred to communicate only with the caregiver, while 77% preferred to communicate with both the child and the caregiver. However, respondents also reported that children accompanied their parents less than 40% of the time. Thus, the opportunity to tailor important asthma management information to the needs of children was frequently missing in pharmacies. Most pharmacists reported that the performance of behaviors such as demonstrating the use of inhaler devices (or having parents/children demonstrate inhaler device use) for firsttime prescriptions was important. Still, many did not perform these behaviors, with even fewer performing them in the case of refill prescriptions. Previous studies have shown the benefits of demonstrating inhaler use and the potential for pharmacists to perform such counseling activities.37,38 This role has been reinforced by the National Asthma Education and Prevention Program and the National Heart, Lung, and Blood Institute.9,16 Thus, pharmacists need to be aware of key issues when counseling children about the use of inhaler devices. For example, in a summary of misconceptions held regarding children and inhaler devices, Brand39 mentions two critical points: that correct inhaler use is in fact not an easy skill to master, and that proper inhaler use, when achieved, may not persist over time, 744 • JAPhA • 47: 6 • N o v / D e c 2 0 07

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Table 5. Multivariate logistic regression modeling intention to perform general child or parent counseling about antiasthmatic medications Intention Independent to counsel child variable OR (95% CI) Importance of 1.257 (0.952–1.659) counseling (attitude) Ease of counseling 1.480 (1.128–1.942)a (control) Others’ approval 1.879 (1.056–3.344)a of counseling (subjective norms) Pediatric training 1.319 (0.485–3.587) High-volume pharmacy Availability of counseling area Owner/manager

Intention to counsel parent OR (95% CI) 1.235 (0.962–1. 586) 1.455 (1.087–1.949)a 1.515 (0.871–2.634) 1.247 (0.457–3.4) 0.489 (0.159–1.499) 1.883 (0.649–5.462) 1.852 (0.680–5.042)

Abbreviations used: CI, confidence interval; OR, odds ratio. a P < 0.05.

but is likely to require reinforcement and correction. Given the low frequency of demonstrating inhalation technique to children, pharmacists in our study may not have been fully aware of such issues, particularly for refills. In our sample of pharmacists, we observed a high mean score for perceived control over providing counseling but a relatively low mean score for perceived ease of counseling, perhaps suggesting that although pharmacists believed they were capable of counseling, other influences may exist that deter the decision to provide counseling. Our results indicate that counseling of children by pharmacists was influenced by sociocognitive factors, such as perceived ease of counseling and subjective norm, as well as external barriers. Addressing the reasons why pharmacists perceive child counseling as difficult, therefore, is important, as is educating and empowering pharmacists in specific areas that can increase their likelihood to counsel. Determining which parties influence pharmacists’ decision to counsel—in an effort to encourage counseling behaviors through these parties (e.g., management, patients)—is also important. Other sociocognitive variables that were not detected in our multivariate analysis may have influenced the decision to counsel. (Our study was not powered to perform a comprehensive multivariate logistic regression.) Our frequencies indicate that attitude may also affect whether counseling is provided because a small fraction of pharmacists did not perceive patient counseling as important. External barriers that appear to influence pharmacists’ decision to counsel also must be addressed. Time has been frequently cited a barrier in the past,22,33 and its persistence in our findings reinforces the need for more attention to organizational solutions that allow pharmacists to dedicate more time to counseling. Pharmacists in our survey also mention lack of parental Journal of the American Pharmacists Association

Counseling of pediatric patients with asthma

interest, which can be corrected by educating parents or caregivers about the importance of being counseled and, for specific asthma management behaviors, recounseled by health professionals such as pharmacists. Finally, a third barrier reported in our results that can be easily addressed is the lack of placebo administration devices in pharmacies. In summary, while the importance of patient counseling and the role of pharmacists have been long discussed, the continuing existence of barriers hinders expansion of the pharmacist’s role in the community. Our study sheds light on important aspects of patient counseling. Further research is needed on a larger and more generalizable sample of pharmacists and, perhaps, patients. Research should also be encouraged to evaluate other counseling behaviors of interest and other potential behavioral models that can explain pediatric asthma counseling behaviors. A sound knowledge of the barriers to pediatric asthma counseling that generally exist would enable the performance of controlled interventions aimed at removing such barriers and improving the pharmacist’s role in asthma management.

Limitations Sample bias may exist in our study due to low response rate, possibly affecting the generalizability of our findings. Whether differences existed between respondents and nonrespondents is unknown because we were unable to obtain any information on nonrespondents. Furthermore, although respondents were told that their individual data would remain confidential, social desirability may have influenced the reporting of results. However, this is unlikely given the relatively low mean values of attitudinal measures and frequencies of behavior performance. Our survey only addressed certain behaviors (i.e., overall counseling, demonstrating the use of an inhaler device to children/caregivers, and having children/caregivers demonstrate the use of an inhaler device to the pharmacist) and did not gauge attitudes toward or performance of other important counseling activities such as demonstrating the use of peak flow meters or monitoring refill patterns in children with asthma. Furthermore, our definition of overall counseling, based on the National Asthma Education and Prevention Program’s definition, was a broad one. It is unknown whether responding pharmacists performed counseling in a different manner and whether the discrepancy, if one existed, between the respondent’s perceived idea of counseling and the definition used in the survey led to misreporting of counseling behaviors. For example, pharmacists who performed individualized or unique counseling that did not cover all of the aspects included in the survey definition of counseling may have underreported such counseling if they believed it did not correspond with our definition. Future research could also gauge the perceived definition of counseling and attempt to cover other more specific pharmacist–patient interactions. Our questionnaire was pilot tested and its face validity assessed by pharmacists. However, we did not test the internal Journal of the American Pharmacists Association

Research

validity of the TPB constructs. This would have required the administration of a longer questionnaire, which likely would have further reduced the response rate. Instead, we used the TPB as a framework to explore potential sociocognitive factors that could explain pharmacists’ counseling decision. This work adds to other studies that have shown the importance of certain behavioral constructs, such as perceived control in understanding whether pharmacists perform patient counseling.23,24 This is the first study to investigate pharmacist pediatric asthma counseling behaviors using the TPB framework. We performed several multivariate analyses, but because of the small sample size, we were unable to have a fully comprehensive model. Thus, other independent variables undetected here may be important predictors of patient counseling. Finally, our study is cross-sectional; therefore, the direction of causality between our independent and dependent variables may not be definite.

Conclusion Despite a strong positive attitude toward the provision of asthma counseling to children or parents, the majority of pharmacists reported not fully engaging in counseling practices. Our findings suggest a need for training programs tailored toward fostering community pharmacists’ role as primary providers of pediatric asthma education. Such programs must address both internal and external factors that prevent pharmacists from performing child counseling. Barriers reported in this study could be targeted by interventions designed to improve management of pediatric asthma through community pharmacist–initiated counseling. References

1. Bloom B, Dey AN. Summary health statistics for U.S. children: National Health Interview Survey, 2004. Vital Health Stat 10. 2006;1–85. 2. Lugogo NL, Kraft M. Epidemiology of asthma. Clin Chest Med. 2006;27:1–15, v. 3. American Academy of Allergy, Asthma & Immunology. Pediatric asthma: promoting best practice: 2002 update: epidemiology. Accessed at www.aaaai.org/members/resources/ initiatives/pediatricasthmaguidelines/01_Epidemiology.pdf, September 6, 2006. 4. National Heart, Lung, and Blood Institute. Morbidity & mortality: 2007 chartbook on cardiovascular, lung and blood diseases. Accessed at http://www nhlbi.nih.gov/resources/ docs/ 07a-chtbk.pdf, October 7, 2007. 5. Weiss KB, Sullivan SD, Lyttle CS. Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin Immunol. 2000;106:493–9. 6. Getahun D, Demissie K, Rhoads GG. Recent trends in asthma hospitalization and mortality in the United States. J Asthma. 2005;42:373–8. 7. Mellon M, Parasuraman B. Pediatric asthma: improving management to reduce cost of care. J Manag Care Pharm. 2004;10:130–41. 8. Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002;110: 315–22.

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9. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 2: guidelines for the diagnosis and management of asthma: update on selected topics 2002. Accessed at www.nhlbi.nih.gov/ guidelines/asthma/asthgdln.pdf, July 14, 2006. 10. American Academy of Allergy, Asthma & Immunology. Pediatric asthma: promoting best practice: 2002 update: patient education. Accessed at www.aaaai.org/members/resources/ initiatives/pediatricasthmaguidelines/09_PatientEducation. pdf, September 6, 2006. 11. Velsor-Friedrich B, Pigott T, Srof B. A practitioner-based asthma intervention program with African American inner-city school children. J Pediatr Health Care. 2005;19:163–71. 12. Ng DK, Chow PY, Lai WP, et al. Effect of a structured asthma education program on hospitalized asthmatic children: a randomized controlled study. Pediatr Int. 2006;48:158–62. 13. Teach SJ, Crain EF, Quint DM, et al. Improved asthma outcomes in a high-morbidity pediatric population: results of an emergency department-based randomized clinical trial. Arch Pediatr Adolesc Med. 2006;160:535–41. 14. Brown MD, Reeves MJ, Meyerson K, Korzeniewski SJ. Randomized trial of a comprehensive asthma education program after an emergency department visit. Ann Allergy Asthma Immunol. 2006;97:44–51. 15. Butz A, Pham L, Lewis L, et al. Rural children with asthma: impact of a parent and child asthma education program. J Asthma. 2005;42:813–21. 16. National Heart, Lung, and Blood Institute. The role of the pharmacist in improving asthma care. Accessed at www.nhlbi.nih. gov/health/prof/lung/asthma/asmapmcy.txt, July 25, 2006. 17. Calis KA, Hutchison LC, Elliott ME, et al. Healthy People 2010: challenges, opportunities, and a call to action for America’s pharmacists. Pharmacotherapy. 2004;24:1241–94. 18. Erickson SR, Landino HM, Zarowitz BJ, Kirking DM. Pharmacists’ understanding of patient education on metered-dose inhaler technique. Ann Pharmacother. 2000;34:1249–56. 19. Kradjan WA, Schulz R, Christensen DB, et al. Patients’ perceived benefit from and satisfaction with asthma-related pharmacy services. J Am Pharm Assoc. 1999;39:658–66. 20. Liu MY, Jennings JP, Samuelson WM, et al. Asthma patients’ satisfaction with the frequency and content of pharmacist counseling. J Am Pharm Assoc. 1999;39:493–8. 21. Ranelli PL, Bartsch K, London K. Pharmacists’ perceptions of children and families as medicine consumers. Psychol Health. 2000;15:829–40. 22. Suh D, Barone J, Duffy E, et al. Evaluation of pharmacists’ practice in providing asthma care. J Manag Pharm Care. 2001;1:41– 57. 23. Farris KB, Schopflocher DP. Between intention and behavior: an application of community pharmacists’ assessment of pharmaceutical care. Soc Sci Med. 1999;49:55–66.

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24. Odedina FT, Hepler CD, Segal R, Miller D. The Pharmacists’ Implementation of Pharmaceutical Care (PIPC) model. Pharm Res. 1997;14:135–44. 25. Bruzzese JM, Bonner S, Vincent EJ, et al. Asthma education: the adolescent experience. Patient Educ Couns. 2004;55:396– 406. 26. Pradel FG, Hartzema AG, Bush PJ. Asthma self-management: the perspective of children. Patient Educ Couns. 2001;45:199– 209. 27. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211. 28. Godin G, Kok G. The theory of planned behavior: a review of its applications in health-related behaviors. Am J Health Promot. 1996;11:87–98. 29. Herbert KE, Urmie JM, Newland BA, Farris KB. Prediction of pharmacist intention to provide Medicare medication therapy management services using the theory of planned behavior. Res Social Adm Pharm. 2006;2:299–314. 30. Raisch DW. Barriers to providing cognitive services. Am Pharm. 1993;NS33:54–8. 31. Schommer JC, Wiederholt JB. Pharmacists’ perceptions of patients’ needs for counseling. Am J Hosp Pharm. 1994;51:478– 85. 32. Amsler MR, Murray MD, Tierney WM, et al. Pharmaceutical care in chain pharmacies: beliefs and attitudes of pharmacists and patients. J Am Pharm Assoc. 2001;41:850–5. 33. Svarstad BL, Bultman DC, Mount JK. Patient counseling provided in community pharmacies: effects of state regulation, pharmacist age, and busyness. J Am Pharm Assoc. 2004;44:22–9. 34. Saini B, Krass I, Armour C. Specialization in asthma: current practice and future roles: a qualitative study of practicing community pharmacists. J Soc Adm Pharm. 2001;18:169–77. 35. O’Loughlin J, Masson P, Dery V, Fagnan D. The role of community pharmacists in health education and disease prevention: a survey of their interests and needs in relation to cardiovascular disease. Prev Med. 1999;28:324–31. 36. Ajzen I. Constructing a TPB questionnaire: conceptual and methodological considerations. Accessed at www.people. umass.edu/aizen/pdf/tpb.measurement.pdf, November 6, 2006. 37. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Counseling about Turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respir Care. 2005;50:617–23. 38. Hawksworth GM, James L, Chrystyn H. Characterization of the inspiratory manoeuvre when asthmatics inhale through a Turbohaler pre- and post-counselling in a community pharmacy. Respir Med. 2000;94:501–4. 39. Brand PL. Key issues in inhalation therapy in children. Curr Med Res Opin. 2005;21:S27–32.

Journal of the American Pharmacists Association

A Community Pharmacist Survey on Pediatric Asthma Counseling The purpose of this survey is to assess your attitudes and perceptions toward counseling children and their caretakers about their asthma medicines. There are no right or wrong answers. We would just like to find out what your thoughts are concerning the educational needs of these patients. Please note: For the purposes of this questionnaire we define children as: “patients who fall in between 5 years and 12 years of age.” Please fill in the survey and return it in the postage paid envelope provided. Thank you.

In accordance with the 1997 National Asthma Education and Prevention Program recommendations, we define asthma counseling as covering with children and their families the following key educational messages: 1. Essential information about asthma 2. Role of medications 3. Self-management skills 4. Environmental control 5. Actions to take based on response to change in asthma severity Please answer the following items with regard to asthma counseling as defined above. (Circle only one number per line): In general, How important is it for you to provide asthma counseling to…

Very unimportant

Unimport- Somewhat ant unimportant

Neither

Somewhat Very important Important important

1

2

3

4

5

6

7

1

2

3

4

5

6

7

Never

Almost never

A few times

Fairly often

Often

Very often

Always

1

2

3

4

5

6

7

1

2

3

4

5

6

7

Never

Almost never

A few times

Fairly often

Often

Very often

Always

5…children with asthma when filling their prescriptions?

1

2

3

4

5

6

7

6…parents/ caregivers of children with asthma? In general, In your opinion, how likely do you think that people whose opinion you value approve of your doing the following? 7…providing asthma counseling to children with asthma 8... providing asthma counseling to parents/caregivers of children with asthma?

1

2

3

4

5

6

7

Very unlikely

Quite unlikely

Slightly unlikely

Neither

Slightly likely

Quite likely

Very likely

1

2

3

4

5

6

7

1

2

3

4

5

6

7

Very difficult

Quite difficult

Slightly difficult

Neither

Slightly easy

Quite easy

Very easy

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1…children with asthma? 2…parents/caregivers of children with asthma? In general, In the past month how often did you counsel… 3…children with asthma whenever filling their prescriptions? 4…parents/caregivers of children with asthma whenever filling their prescriptions? In general, Within the next month, how often do you intend to counsel…

In general, Please indicate how difficult/easy it is for you to counsel… 9…children with asthma. 10…parents/caregivers of children with asthma.

1

Please indicate your level of agreement with the following statements: Strongly Mildly Mildly disagree Disagree disagree Neither agree

In general, I have control over whether or not I counsel a…

Agree

Strongly agree

11…child with asthma.

1

2

3

4

5

6

7

12…parent/caregiver of a child with asthma. When children with asthma accompany their parents to the pharmacy to fill an asthma prescription,

1

2

3

4

5

6

7

Never

Almost never

A few times

Fairly often

Often

Very often

Always

1

2

3

4

5

6

7

13… how often do you speak directly to the children about their medicine? Some pharmacists talk about asthma medicine to children and adults in the same way, others deliberately adapt information to the child’s level to facilitate comprehension. How do you present asthma medicine information to the children… 14...when the parent/caregiver is not present? 15...when the parent/caregiver is present?

At child’s level

At adult’s level

1

2

3

4

5

6

7

1

2

3

4

5

6

7

16. Who do you prefer to communicate with when filling a child’s prescription? ‰ Parent/Caregiver only ‰ Both Parent/caregiver & Child

‰ Child only

17. When filling an inhaled asthma prescription for a child, in your estimation approximately what percentage of the time do children accompany parents to the pharmacy? (Circle one number). 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Now we will ask you some specific questions on counseling children and their parents/caregivers on asthma inhaled medications. For this section, we will define the term asthma inhaler to signify the following inhaled devices: Metered Dose Inhaler and Dry Powder Inhaler (i.e. Discus, Aerolizer and Turbuhaler). This list does NOT include Nebulizers. Please indicate your level of agreement with the following statements: Whenever filling an inhaled asthma medication prescription for a child who has NEVER used that particular device, I believe it is very important to… 18...demonstrate to the child the proper way to use his/her inhaler 19...demonstrate to the parent/caretaker the proper way to use their child’s inhaler 20...have the child demonstrate the proper way to use their inhaler 21...have the parent/caretaker demonstrate the proper way to use their child’s inhaler Please indicate your level of agreement with the following statements: Whenever refilling an inhaled asthma medication prescription for a child, I believe it is very important to…

Strongly Mildly Mildly disagree Disagree disagree Neither agree

Agree

Strongly agree

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

Agree

Strongly agree

Strongly Mildly Mildly disagree Disagree disagree Neither agree

22...demonstrate to the child the proper way to use his/her inhaler 23...demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

1

2

3

4

5

6

7

24... have the child demonstrate the proper way to use their inhaler 25... have the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

1

2

3

4

5

6

7

2

Please indicate your level of agreement with the following statements: I believe that I can improve the asthma outcomes of children by… 26...demonstrating to the child the proper way to use his/her inhaler 27...demonstrating to the parent/caretaker the proper way to use their child’s inhaler 28... having the child demonstrate the proper way to use their inhaler 29... having the parent/caretaker demonstrate the proper way to use their child’s inhaler

Strongly Mildly Mildly disagree Disagree disagree Neither agree

Agree

Strongly agree

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

1

2

3

4

5

6

7

Very often

Always

30. In the last month did you ever fill an asthma inhaler prescription for a child (age 5-12)? Yes

Go to question 31 directly below.

No

Skip to question 39 at the bottom of this page.

In the last month, whenever filling an inhaled asthma medication prescription for a child who has NEVER used that particular device before, how often have you performed the following behaviors?

Never

Almost never

31.Demonstrated to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

32.Demonstrated to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

33. Had the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

34. Had the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

Never

Almost never

Very often

Always

35.Demonstrated to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

36.Demonstrated to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

37. Had the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

38. Had the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

Never

Almost never

Very often

Always

39.Demonstrate to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

40.Demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

41. Have the child demonstrate the proper way to use his/her inhaler

1

2

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4

5

6

7

42. Have the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

In the last month, whenever refilling an inhaled asthma medication prescription for a child, how often have you performed the following behaviors?

Within the next month, whenever filling an inhaled asthma medication prescription for a child who has NEVER used that particular device before, how often do you intend to perform the following behaviors?

A few times Fairly often Often

A few times Fairly often Often

A few times Fairly often Often

3

Within the next month, whenever refilling an inhaled asthma medication prescription for a child, how often do you intend to perform the following behaviors?

Never

Almost never

A few times

Fairly often

Often

Very often

Always

43.Demonstrate to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

44.Demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

45. Have the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

46. Have the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

In your opinion, how likely do you think that people whose opinion you value approve of you doing the following when filling an inhaled asthma medication prescription for a child with asthma?

Very Quite Slightly Slightly Quite unlikely unlikely unlikely Neither likely likely

Very likely

47.Demonstrate to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

48.Demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

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7

49. Have the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

1

2

3

4

5

6

7

50. Have the parent/caretaker demonstrate the proper way to use their child’s inhaler In your opinion, how likely do you think that the following groups of people influence your decision to counsel a child with asthma?

Very Quite Slightly Slightly Quite unlikely unlikely unlikely Neither likely likely

Very likely

51.Management (i.e. your employer)

1

2

3

4

5

6

7

52.Physicians

1

2

3

4

5

6

7

53.Parent/Caregiver

1

2

3

4

5

6

7

54.Child- Him/Herself

1

2

3

4

5

6

7

55.Colleagues

1

2

3

4

5

6

7

56.Family/Friends

1

2

3

4

5

6

7

Please indicate how difficult/easy it is for you to perform the following behaviors:

Very Quite Slightly Slightly Quite difficult difficult difficult Neither easy easy

Very easy

57.Demonstrate to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

58.Demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

59. Have the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

60. Have the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

If you answered 1, 2 or 3 to any of the above four items (57, 58, 59, or 60) please go to question 61 on the next page. If you answered 4, 5, 6 or 7, to ALL of the above four items (57, 58, 59, or 60) please skip to question 62 on the next page. 4

61. Please follow the directions provided below: a. In the following we provide some reasons that you may think make it difficult for you to perform the behaviors described in items 57 to 60. Feel free to list any additional reasons you encounter in the “other” lines. b. Next, check off the three reasons most likely to make it difficult for you to perform these behaviors. c. Then, rank these three reasons on the lines on the right-hand side, with 1 being the most probable reason to deter you from performing the behaviors described in items 57 to 60. Reason(s): ………………………………………………………..…...Your ranking:

‰ Lack of time……………………………………………………….. ‰ Lack of space……………………………………………………… ‰ Store policy………………………………………………………... ‰ No placebo devices to demonstrate………………………………... ‰ Lack of child’s interest…………………………………………….. ‰ Lack of parent’s interest…………………………………………… ‰ Lack of payment for the service…………………………………… ‰ Child is not present………………………………………………… ‰ Lack of training……………………………………………………. ‰ Not comfortable with the topic…………………………………….. ‰ Other (specify)

……………………..

‰ Other (specify)

……………………..

‰ Other (specify)

……………………..

Please indicate your level of agreement with the following statements: Strongly Mildly disagree Disagree disagree

I have control over whether or not I….

Neither

Mildly agree

Agree

Strongly agree

62…Demonstrate to the child the proper way to use his/her inhaler

1

2

3

4

5

6

7

63…Demonstrate to the parent/caretaker the proper way to use their child’s inhaler

1

2

3

4

5

6

7

64… Have the child demonstrate the proper way to use his/her inhaler

1

2

3

4

5

6

7

65… Have the parent/caretaker demonstrate the proper way to use their child’s inhaler

1

2

3

4

5

6

7

S you answered 1, 2 or 3 to any of the above four If items (62, 63, 64, or 65) please go to question 66 on the next page.

If you answered 4, 5, 6 or 7, to ALL of the above four items (62, 63, 64, or 65) please skip to question 67 on the next page. 5

66. Please follow the directions provided below: a. In the following we provide some reasons that you may think prevent you from performing the behaviors described in items 62 to 65. Feel free to list any additional reasons you encounter in the “other” lines. b. Next, check off the three reasons most likely to make it difficult for you to perform these behaviors. c. Then, rank these three reasons on the lines on the right-hand side, with 1 being the most probable reason to deter you from performing the behaviors described in items 62 to 65. Reason(s): …………………………………………………………….Your ranking:

‰ Lack of time……………………………………………………….. ‰ Lack of space……………………………………………………… ‰ Store policy………………………………………………………... ‰ No placebo devices to demonstrate………………………………... ‰ Lack of child’s interest…………………………………………….. ‰ Lack of parent’s interest…………………………………………… ‰ Lack of payment for the service…………………………………… ‰ Child is not present………………………………………………… ‰ Lack of training……………………………………………………. ‰ Not comfortable with the topic…………………………………….. ‰ Other (specify)

……………………..

‰ Other (specify)

……………………..

‰ Other (specify)

……………………..

Now we would like to ask you some information about you and your work environment: 67. Gender ‰ Male

‰ Female

68. Do you have any children? ‰ Yes ‰ No 69. Pharmacy Degree (Check all that apply) ‰ B.S. ‰ PharmD ‰ Graduate Degree 70. What position do you hold in the pharmacy? (Check all that apply) ‰ Owner ‰ Manager ‰ Staff ‰ Other (Please specify) 71. Age: ____________ years. 72. Employment/Pharmacy Type (Please check one) ‰ Independent ‰ Grocery/Pharmacy ‰ Franchise ‰ Chain ‰ Currently not employed ‰ Other (Please specify): 6

73. Do you have a ‘Drive-Thru’ option in your pharmacy? ‰ Yes ‰ No Go to question 74 directly below

Go to question 75 below

74. Approximately what is the percentage of the prescriptions for children with asthma that are filled through the Drive-Thru option?

75. Which of the following most closely identifies your responsibilities? (Check all that apply) ‰ Manage the pharmacy (finance, administrative issues) ‰ Check prescriptions filled by the technician ‰ Counsel patients on their medication, always ‰ Counsel patients on their medication, only if they ask for assistance ‰ Other (Please specify): 76. During a typical work shift, how many pharmacists do you work with? ‰ None ‰ 1 ‰ 2 ‰ 3 ‰ 4+ 77. During a typical work shift, how many technicians do you work with? ‰ None ‰ 1 ‰ 2 ‰ 3 ‰ 4+ 78. On average, how many prescriptions (of any type) does your pharmacy fill per week? ‰ 1201-1400 ‰ 200-400 ‰ 1401-1600 ‰ 401-600 ‰ 601-800 ‰ 1601-1800 ‰ 1801-2000 ‰ 801-1000 ‰ 2001+ ‰ 1001-1200 79. Do you have a designated counseling area in your pharmacy? ‰ Yes ‰ No 80. Does the volume of prescriptions reduce the amount of time that you would take to counsel a child or their parent/caregiver on the use of their inhaler(s)? ‰ Yes ‰ No 81. Which of the following best describes your training experience with asthma management? (Check all that apply) ‰ Continuing education (asthma or respiratory disease management) ‰ Work in/ run an Asthma Clinic/ Program ‰ No training ‰ Other (Please specify): 7

82. Which of the following best describes your pediatric training? (Check all that apply) ‰ Pediatric residency ‰ Previous degree/Specialized training (i.e. classes) in education/psychology or child development ‰ Continuing education (on pediatrics or childhood diseases) ‰ Attended/ attends a Pediatrics/ Family Practice Clinic/ Program ‰ No training ‰ Other (Please specify): ____________________________________________ 83. Does your pharmacy provide any disease state management programs? ‰ Yes ‰ No Go to question 84 directly below

Go to question 85 below

84. Please check off the specific programs your pharmacy offers to the left of each program written. If you work in any of these programs please check off the corresponding circles to the right. Programs Offered By Your Pharmacy ‰ Diabetes Program ‰ Anticoagulation Program ‰ Hyperlipidemia Program ‰ Weight Management Program ‰ Other: (Please specify:

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Those Programs You Actively Provide Care In o Diabetes Program o Anticoagulation Program o Hyperlipidemia Program o Weight Management Program o (Please specify: )

85. Which of the following programs on pediatric asthma counseling do you think should be available to pharmacists like you? ‰ CD-Rom based program ‰ Web-based program ‰ Live Continuing Education program ‰ None ‰ Other: (Please specify_________________________)

Please enclose the completed survey in the attached envelope and return to: Françoise G. Pradel, PhD University of Maryland Center on Drugs & Public Policy 515 W. Lombard Street- Office 254 Baltimore, MD 21201-1563 THANK YOU FOR YOUR TIME

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