Basing pharmacy counselling on the perspective of the angina pectoris patient.

Abstract

A participatory action research study design was developed and tested in 40 Danish internship pharmacies as part of a 3-year study supported by the Research Centre for Quality in Medicine Use. The aim of the study was to create a foundation for improving the quality of counselling practice in pharmacies by comparing the pharmacy staff's views on, knowledge of and behaviour towards a specific patient group with the knowledge, perceptions and medication use of the same patients.
Pharmacy students in their fourth year collected data for the study. In 1999, the students carried out 123 qualitative interviews with angina pectoris patients and collected 569 questionnaires from pharmacy staff in 40 internship pharmacies.
The results indicate that discrepancies exist between the patients' and pharmacy staff's perspectives on important issues such as knowledge about medicines (patients)/provision of information about medicines (pharmacy staff), experienced side effects (patients)/information about side effects (pharmacy staff), knowledge on prevention and lifestyle (patients)/information on lifestyle and prevention (pharmacy staff) and expectations of pharmacies (patients)/initiatives started in pharmacies (pharmacy staff).
The study gives reason to believe that angina pectoris patients might benefit if pharmacies provided more information on the relationship between lifestyle factors and angina pectoris, the possible side effects of medicines and the function of medicines.

Full text

Page 1

Volume 24 No. 2 2002
Pharmacy World & Science
research rticle
Introduction
Several health services researchers have argued that
the patient’s perspective should be an important pre-
requisite for describing and prioritizing the patient
counselling practices of health professionals [1-5], the
reason being that patients’ perspectives on illness and
medicine use often differ from those of health profes-
sionals. Furthermore, comparative research on the
perspectives of patients and health professionals on
medicines and illness – the lay-expert perspective –
has only to a limited extent been carried out within
the pharmacy practice area [6-8]. The few studies
conducted in the medical, nursing and pharmacy
fields on the patient-expert perspective [4,7-11]
demonstrate the health care personnel’s relative igno-
rance of the lay perspective on medicine and illness.
71
Basing pharmacy counselling on the perspective of the angina pectoris patient
• Lotte Stig Haugbølle, Ellen Westh Sørensen, Birgitte Gundersen,
Kirsten Holme Petersen and Lene Lorentzen
Pharm World Sci 2002;24(2): 71-78.
© 2002 Kluwer Academic Publishers. Printed in the Netherlands.
Lotte Stig Haugbølle (correspondence) and Ellen Westh
Sørensen: Department of Social Pharmacy and Research
Centre for Quality in Medicine Use, The Royal Danish School
of Pharmacy, Universitetsparken 2, DK-2100 Copenhagen,
Denmark, (e-mail: lsh@dfh.dk). Birgitte Gundersen: Delfin
Pharmacy, Denmark. Kirsten Holme Petersen: Pharmakon
a/s, Denmark. Lene Lorentzen: Frederiksværk Pharmacy,
Denmark
Keywords
Angina pectoris patients
Interviews
Lay-expert perspective
Pharmacy practice
Pharmacy staff
Pharmacy students
Questionnaire
Abstract
Aim of the study: A participatory action research study design
was developed and tested in 40 Danish internship
pharmacies as part of a 3-year study supported by the
Research Centre for Quality in Medicine Use. The aim of the
study was to create a foundation for improving the quality of
counselling practice in pharmacies by comparing the
pharmacy staff’s views on, knowledge of and behaviour
towards a specific patient group with the knowledge,
perceptions and medication use of the same patients.
Method: Pharmacy students in their fourth year collected
data for the study. In 1999, the students carried out 123
qualitative interviews with angina pectoris patients and
collected 569 questionnaires from pharmacy staff in 40
internship pharmacies.
Results: The results indicate that discrepancies exist between
the patients’ and pharmacy staff’s perspectives on important
issues such as knowledge about medicines
(patients)/provision of information about medicines
(pharmacy staff), experienced side effects
(patients)/information about side effects (pharmacy staff),
knowledge on prevention and lifestyle (patients)/information
on lifestyle and prevention (pharmacy staff) and expectations
of pharmacies (patients)/initiatives started in pharmacies
(pharmacy staff).
Conclusion: The study gives reason to believe that angina
pectoris patients might benefit if pharmacies provided more
information on the relationship between lifestyle factors and
angina pectoris, the possible side effects of medicines and
the function of medicines.
Accepted October 2001
This paper describes and discusses how a new study
design was developed and tested in 40 Danish
internship pharmacies and shows the results from
comparing patient data to pharmacy staff data. The
purpose of the study was to create a foundation for
improving the quality of counselling practice in phar-
macies by comparing the pharmacy staff’s views on,
knowledge of and behaviour towards a specific
patient group with the knowledge, perceptions and
medication use of the same patients.
Design of the study
Internship pharmacies
Currently, 60% of all 288 Danish pharmacies have the
status of internship pharmacies. The selection of
internship pharmacies is based on the pharmacy’s wil-
lingness to be an internship pharmacy, a professional
assessment of each pharmacy and the supervisor’s
professional qualifications. The supervisor is the com-
munity pharmacist in the pharmacy responsible for
training the pharmacy students. Other aspects of
Danish pharmacy context are described in Table 1.
Acceptance from internship pharmacies and setting
up a project group
Two researchers in charge of the internship program-
me presented the idea of a joint study between the
School of Pharmacy and the internship pharmacies at
the annual supervisors meeting in 1998. The supervis-
ors found the proposal for a joint study very interes-
ting. A project group comprising pharmacy practice
researchers, community pharmacists, hospital phar-
macists and students was set up, the role of which
was to co-ordinate, develop and write all project
material for the project. The study was run as a parti-
cipatory research study [12]. In contrast to conven-
tional research, the aim of participatory research is to
initiate action in a local setting, to raise the level of
knowledge of local people (in this case pharmacy stu-
dents and pharmacy staff) and to allow local priorities
to determine the topic of study, just as participatory
research is characterised by collaboration between
researchers and practitioners.
Choice of patient group
Angina pectoris patients were chosen as the study’s
patient focus group, since this patient group with one
exception [13] had largely been neglected by com-
munity pharmacy. In addition, since the Danish
Pharmaceutical Association had designated 1999 a
campaign year for cardiovascular diseases, pharma-
cies were already expected to meet the requirements
for participating in a study on angina pectoris
patients.
Involving the pharmacy students
Fourth-year pharmacy students doing their pharmacy
internship produced data for the study. The students

Page 2

Pharmacy World & Science
Volume 24 No. 2 2002
72
had acquired the necessary skills for collecting data
during their training at the School of Pharmacy and
by reading about the pathology and pharmacothera-
py of angina pectoris in pharmacology books.
Besides, all students used the same data collection
instruments (interview guide and questionnaire) and
throughout the entire study got the same instructions
from the project group.
Research questions
There is no need for pharmacy staff to change their
patient counselling practices in areas where patients
and pharmacy staff are in agreement or in areas
where patients possess a high knowledge level.
Therefore, this paper only presents results revealing
patient and pharmacy differences or disagreements,
which can be interpreted as areas where pharmacy
staff can benefit from knowing about the patient’s
perspective, all with the purpose of improving advice
giving to patients. The research issue addressed in the
paper is thus:
– What are the inconsistencies between pharmacy
staff’s assumptions, knowledge of and behaviour
towards angina pectoris patients seen in relation to
the patient’s factual illness- and medicine-related
knowledge, perceptions, medication use and
needs?
Methods
The study was undertaken according to a typical par-
ticipatory action research design with researchers and
practitioners developing and agreeing upon all
aspects of the data collection process, analysis of data
and evaluation. All internship pharmacies with phar-
macy students in the period concerned could volun-
teer for the study. In the autumn of 1998, the study
was pilot-tested in 7 internship pharmacies (see Table
2). The project group improved the data collection
tools before the main study was rolled out in the
spring of 1999. For instance, additional focus was put
on collecting data on drug-related problems in the
patient interviews, just as the students were instruc-
ted to prepare themselves better pharmaco-therapeu-
tically before carrying out interviews in the main
study.
Patient interviews
In 1999, 70 fourth-year pharmacy students participa-
ted in the main study by interviewing angina pectoris
patients and collecting pharmacy staff questionnaire
in 40 internship pharmacies (14% of all Danish phar-
macies and 70% of all internship pharmacies) (see
Table 2). Qualitative interviews were chosen as the
method of collecting patient data since the students
were to gain in-depth knowledge about each indivi-
Table 1 The Danish pharmacy context (in year 2000)
Number of pharmacies
in Denmark
Served population
per pharmacy
Average pharmacy staff
per pharmacy
Prescription control
288
18,450 inhabitants
1 pharmacy proprietor (a trained pharmacist), 2.2 community pharmacists
and 8.6 pharmacy technicians (converted into full-time employees
Typically the pharmacist. About 70% of the pharmacy technicians are
authorised to control prescriptions
Pharmacy proprietor, community pharmacists, pharmacy technicians,
pharmacy technician students
Takes 5 years. In their fourth year, pharmacy students complete a 6-month
pharmacy internship in either a community or a hospital pharmacy.
Pharmacy technician training Takes 3 years (20 weeks at college, the rest in a pharmacy)
Staff counselling
Pharmacists training
Table 2 Study phases
PhasePeriodPharmacies
involved
Patient
interviews
Pharmacy staff
questionnaires
Pilot study
Main study, phase I:
Data collection and
analysis
Sept. - Dec. 1998
April – May 1999
7
40
18
123
75
In all 569:
• 133 pharmacists
(response rate 73%)
• 391 pharmacy technicians
(response rate 74%)
• 44 pharmacy technician students
(response rate 81%)
Main study, phase II:
Presentation of results
in the pharmacy and
evaluation
June 1999 33––
Main study, phase III: From June 1999
Implementation of
new initiatives
29––

Page 3

dual patient’s medicine- and illness-related knowled-
ge, perception and actions. A non-random self-selec-
ting sampling technique [14] was used. In each phar-
macy, 2 to 4 patients were selected for an interview
on the basis of prescriptions for quick- or slow-acting
glyceryl nitrates handed in during 1 specific week.
The first patients contacted by phone or at the coun-
ter who were interested in participating in the study
were enrolled. The study thus provided a profile of a
pharmacy-based population of angina pectoris
patients using quick- or slow-acting nitrates. Patients
in residential care, patients with senile dementia,
patients not speaking Danish and psychotic patients
were excluded from the study. The patient interviews
were carried out on the basis of a semi-structured
interview guide, developed by the project group.
Theories on the self-regulation of medicine [3,15],
coping with illness [3,16-17], user perspectives on
medicine and illness [1,4,5,18], and drug-related pro-
blems [19-20] were used as the tool for developing
the interview guide and formed the foundation for
constructing the interview questions (see Table 3).
The interviews were carried out in the patient’s home.
The 123 interviews lasted on average 1 hour (114
interviews each lasted between 1/2 and 2 hours).
Under each question in the interview guide the stu-
dent wrote the patient’s answer either verbatim or in
the student’s own words. All completed interview gui-
des and questionnaires were sent to the project
group, whose members then analysed the data in
accordance with the strategies used during the pilot
study. Three pharmacy students entered all interview
data into a data-processing program, NSDStat, which
is compatible with SPSS [22]. The students typed and
categorised the first 30 interviews, and the data input
was discussed afterwards with the researchers to ens-
ure consistency. All matters of dispute that arose
during typing and categorisation were immediately
discussed with the project group.
Two researchers also group-coded and analysed
the data using the theoretical frame of references as
described in Britten [1], Fallsberg [3], Fallsberg et al.
[15], Viney & Westbrook [16], and Schaefer [20]. By
using a coding strategy of meaning-condensation
[21], where the patient’s statements and the student’s
statements about the patients were rewritten in short
sentences that retained the original meaning, data
from the interview were structured according to the
theoretical frame of reference. The first step of the
analysis involved the construction of different catego-
ries, the most important of which are shown in Table
4. The next step was to allocate each patient to the
most appropriate category. The third and final step
was to find quotations and/or descriptions from indi-
vidual interviews to illustrate the content of the cate-
gories.
Pharmacy staff questionnaire
A semi-structured questionnaire was used to collect
data from the pharmacy staff in the 40 pharmacies
(see Table 5). The respondents were well distributed
relative to the total actual workforce in Danish phar-
macies, as shown in Table 6.
In each participating community pharmacy, the
questionnaire was handed out to all staff who coun-
selled patients over the counter (community pharma-
cists, pharmacy technicians and pharmacy technician
students). The pharmacy staff answered the question-
naire either during a staff meeting or during a quiet
moment in the pharmacy. All questionnaire data were
treated confidentially and pharmacy staff members
were guaranteed anonymity in the later results.
Members of the project group initially content-ana-
lysed and categorised 20 randomly selected comple-
ted questionnaires, on the basis of all the questions
from the questionnaire. The categories were descri-
bed in a written manual handed out to the 3 pharma-
cy students, who typed the remaining questionnaire
data into NSDStat under project group supervision.
Presentation and discussion of results in the
participating pharmacies
When all questionnaire and interview data had been
processed, results relating to the research questions
were deduced. Questionnaire results from individual
pharmacies, general results from all participating
pharmacies and pooled results from all patient inter-
views were returned to the pharmacies in June 1999.
The students presented the results in the pharmacies
at staff meetings, in particular comparing the results
from their pharmacy with the general results from all
pharmacies. The results were discussed and decisions
were made about how to include the study findings
in the pharmacy’s initiatives to improve their service
for angina pectoris patients. The study results were
discussed at staff meetings in most pharmacies parti-
cipating (Table 2), and the supervisors filled in an eva-
luation questionnaire that showed the level of interest
73
Volume 24 No. 2 2002
Pharmacy World & Science
Table 3 Content of interview guide to patients
Main themesSub-themes
Everyday life with angina
pectoris and medicine
Knowledge and behaviour Use of medicines (dosage, storage, knowledge of effect of medicine), perception
in relation to angina of medicine use, side-effects (experienced, fear of side-effects, thoughts of
pectoris and medicineside-effects), other problems with medicine use, self-regulation of medicines
use (rationale, arguments)
Ill-health perceptions and Prevention of angina pectoris (smoking, exercise, food, etc.), strategies for
strategiesstaying healthy, ways of solving illness- and medicine- related problems,
current condition of health, use of social network
Satisfaction with Content and form of information (from pharmacy, GP, hospital, others) expec-
information and needs tation to the health care personnel
Coping Meaningfulness, comprehensibility and manageability of angina pectoris
Course of the illness, symptoms, living with angina pectoris (family, work, daily life)

Page 4

of pharmacy staff in developing new initiatives for
angina pectoris patients.
Results
When nothing else is mentioned in the result section,
‘pharmacy staff’ refers to community pharmacists, phar-
macy technicians and pharmacy technician students.
What do angina pectoris patients know about the use
and function of their medication and what side effects
do patients experience from their medication?
On the whole, the patients knew how to use their medi-
cation, but a vast number lacked knowledge about how
the medicine functioned. Eighty-four patients (68%)
knew that quick-acting nitrates had to be placed under
the tongue or the lips to produce optimal effect. Thirty-
three patients (27%) were unaware of the action of
their quick-acting nitrates and 64 patients (52%) were
unaware of the action of their slow-acting nitrates.
Eighty per cent of the patients suffered from more than
one illness, and hence used different types of medica-
tion. Only 20 patients (16%) knew how these ‘other’
types of medication affected their body.
The problem most frequently experienced by angi-
na pectoris patients in relation to their medication
was side effects. As the data are based on the patient’s
subjective assessment of their own situation, it cannot
be ruled out that what patients experience as ‘side
effects’ from the medicines might instead be symp-
toms of their illness. Thus, 69 patients (56%) explai-
ned that they frequently experienced side effects
(headaches, stomach problems, tiredness etc.).
What repertoire of medicine-related information do
pharmacy staff use when informing patients?
Pharmacy staff did not provide much information to
angina pectoris patients about use of medicines. As
might be seen from Table 7, there was a tendency
though that pharmacists provided more information
than the pharmacy technicians and the pharmacy
technician students did. At least when carrying out a
X2-test (degree of freedom= 3), the p-values for the
pharmacist compared with pharmacy technicians and
pharmacy technician students were less than 0,05 in
6 out of 12 areas (area 1, 5, 7, 8, 9 and 12 in Table 7).
Only in one area, area 11 (Table 7), the pharmacy
technicians tended to inform more than the pharma-
cists. All groups (pharmacists, pharmacy technicians
and pharmacy technicians) typically drew on the fol-
lowing technical repertoire when informing about
medicines: technical use of the medicines and stora-
ge.
To what extent do pharmacy staff assess their
information-giving practices as sufficient?
One-hundred-and-eighty-three pharmacy staff (32%)
assessed their own information to angina pectoris
patients as ‘insufficient’, 216 pharmacy staff (38%)
rated their own information to angina pectoris
74
Pharmacy World & Science
Volume 24 No. 2 2002
Table 4 Most important categories for analysing patient interviews
CategoriesSub-categories/levels
Medication
Knowledge of own illness
Number and type of medication
Levels: No knowledge, medium knowledge, maximum knowledge
Knowledge of relationship between life-style factors and illness
Levels: No knowledge, medium knowledge, maximum knowledge
Categories: medicines as something ‘bad’, as a necessary evil or as something
‘good’ (inspired by Lisper et al. [18])
Categories: something ‘good’, accept or something ‘bad/irritating’
Identification and assessment of drug-related problems according to categories
suggested by Schaefer [20]
Daily administration of medicines
Perception of symptoms
The influence of the illness on everyday life
Reactions when meeting drug- or illness-related problems: problem identification
and solving, ‘laissez-faire’ attitude, use of social net (categories inspired by
Viney & Westbrook [16])
Categories for what patients require from the pharmacy
Knowledge of medicines
Perception of medicines
Perception of illness
Drug-related problems
Coping strategies
Needs
Sources for and assessment
of own knowledge Categories: Pharmacy staff, general practitioner, hospital staff, written/oral
information and satisfaction
Table 5 Themes in pharmacy staff questionnaire
Education
Estimated hours of weekly patient contact
Type, extent and frequency of information given to patients
The pharmacy’s information procedures and policies
Assessment of information given to patients
Sources of knowledge on angina pectoris
A list of typical symptoms of angina pectoris
Assessment of the patients’ knowledge and sources of knowledge on their illness and ideas for improving
services for angina pectoris patients

Page 5

patients as ‘sufficient’ and 129 pharmacy staff (28%)
could not decide whether their information was suffi-
cient or insufficient (13 pharmacy staff (2%) did not
answer the questions).
What do patients know about prevention/lifestyle fac-
tors and angina pectoris, and what do pharmacy staff
think patients know about prevention/life style factors
and angina pectoris?
Fifty-six patients (45%) were aware of a relationship
between a lifestyle factor (smoking, exercise, stress,
etc) and angina pectoris, or they considered the
illness to be hereditary (14 patients (11%) did not
answer the questions).
Pharmacy staff seemed to disagree internally on
patients’ knowledge of the relationship between life-
style factors and angina pectoris. One-hundred-and-
sixty-six pharmacy staff (29%) stated that the majori-
ty of patients did not have sufficient knowledge about
this relationship. One-hundred-and-sixty-one phar-
macy staff (28%) mentioned the difficulty of generali-
sing about angina pectoris patients, since the patient
group was far too heterogeneous for generalised sta-
tements. According to 126 pharmacy staff (22%),
patients had sufficient knowledge of the relationship
between lifestyle factors and angina pectoris. One-
hundred-and-seven pharmacy staff (19%) did not
know whether patients were aware of any relations-
hip between lifestyle factors and angina pectoris (2%
of staff did not answer the question).
One reason for the small amount of information
provided by pharmacy staff to patients relates to the
staff’s own limited knowledge about the relationship
between risk factors and angina pectoris. One-hund-
red-and-ninety-eight pharmacy staff (35%) knew
about a relationship between angina pectoris and
smoking, 156 pharmacy staff (27%) were aware of
the relationship between angina pectoris and being
overweight, and 142 pharmacy staff (25%) claimed
that stress and angina pectoris were related.
What decisions did pharmacies make about changing
practices towards angina pectoris patients and what
do angina pectoris patients want from the pharmacy
(expectations)?
In 29 pharmacies (85%), decisions were made follo-
wing the project to develop and implement different
activities for angina pectoris patients. The remaining
pharmacies (11 pharmacies, 15%) either had not dis-
cussed the results from the study (7 pharmacies) or
they had given priorities to other initiatives they
found more important in the pharmacy (4 pharma-
cies). Two main types of activity were suggested by
the 29 pharmacies: staff-oriented and patient-orien-
ted activities. Staff-oriented activities such as organi-
sing and holding meetings for pharmacy staff, deve-
loping or adapting brief instructions to staff on angi-
na pectoris, and developing or changing policies and
instructions on counter procedures were initiated in
23 pharmacies. Patient-oriented activities such as
handing out pamphlets, improving over-the-counter
counselling and holding open meetings for pharmacy
users were initiated in 9 pharmacies.
Patients were fairly satisfied with the service provi-
ded by community pharmacies; in fact 51 patients
(41%) had no expectations whatsoever of their phar-
macy. The other patients had fairly low expectations
of the pharmacy. Twenty-three patients (19%) simply
wanted the pharmacies to have their medicines in
stock, so that they could get their medicines quickly
whenever they handed in a prescription, 16 patients
(13%) merely expected an answer when they asked a
question, 8 patients (7%) wanted the pharmacy to
provide medicine-related information and 2 patients
(2%) wanted the pharmacy to hand out written infor-
mation on medicines and illness (11 patients (9%) did
not answer the question).
Discussion
Discussion of the study design
We consider the internal validity of the study to be
fairly high. There are several reasons: first, the results
have been presented to staff in all participating phar-
macies without their questioning the findings of the
study. The mere fact that as many as 54 internship
pharmacies volunteered to participate in the second
part of the study in year 2000 on type 2 diabetes
leads us to believe that the results provide a rather
authentic portrait of the study field, at least if the field
is limited to the Danish internship pharmacies. It is far
more difficult to predict anything definite about the
external validity of the study. First of all, one has to
bear in mind the sampling strategy used for selecting
patients and pharmacies. As mentioned earlier,
Danish pharmacies are only authorised to term them-
selves ‘internship pharmacies’ if they live up to certain
professional and educational standards, and the phar-
macies in this study thus presumably already provide
a relatively high level of counselling service compared
to other Danish pharmacies, and all results might thus
not be generalisable to all Danish pharmacies, let
alone pharmacies internationally.
75
Volume 24 No. 2 2002
Pharmacy World & Science
Table 6 Response rate compared with the total workforce in Danish pharmacies
Answers from
the 40
pharmacies
Possible answers
from the
40 pharmacies
Distribution of
workforce in all 288
Danish pharmacies
Category Number (percentage)Number (percentage) Number (percentage)
Not answered
Community pharmacist
Pharmacy technicians
Pharmacy technician students
Total
1 (0.2)
133 (23.4)
391 (68.7)
44 (7.7)
569 (100)
182 (23.9)
525 (69.0)
54 (7.1)
761 (100)
1026 (23.4)
3041 (69.3)
319 (7.3)
4386 (100)