The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

THE PROVISION OF PHARMACEUTICAL CARE IN OMAN: PRACTICE AND PERCEIVED FACILITATORS AND BARRIERS TO IMPLEMENTATION

Awatif Al Abdullatif

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Department of Pharmaceutical Sciences University of Toronto

ABSTRACT

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Awatif Al Abdullatif Doctor of Philosophy Department of Pharmaceutical Sciences University of Toronto 2014

Objectives: The study purpose was to determine the extent of the implementation of pharmaceutical care (PC) in Oman and factors affecting its implementation.

Methods: A cross-sectional mail survey of all practicing pharmacists in Oman based on the

Theory of Planned Behavior (TPB) was conducted. The survey instrument was informed by a focus group study to identify behavioral, normative, and control beliefs amongst pharmacists in three practice settings: inpatient, outpatient, and community pharmacy.

Results: The survey useable response rate was 61.2%. Participants provided PC activities between ‘sometimes’ and ‘most of the time’; however, provision of advanced PC activities was limited. Provision of PC did not significantly differ across inpatient, outpatient, and community settings. Clinical knowledge, communication skills, pharmacist time, and adequate staffing were common facilitators across practice settings; worry about responsibility and culturally-based gender issues regarding patient care were common barriers. While having a private counseling area, and access to patient records and to drug information databases were facilitators identified in the public sector, their absence was a barrier in community pharmacies. Reimbursement was the main barrier in the private sector. Country of origin was significantly related to pharmacists’

beliefs about providing PC; specifically, Omani pharmacists had significantly different behavioral, normative, and control beliefs than their South Asian counterparts. All constructs of the TPB (attitude, subjective norm, and perceived behavioral control) were significant predictors of intention to provide PC, but the added construct—past behavior recency was not. The overall variance explained in intention was 43%. Of the two predictors of behavior in the TPB model, only perceived behavioral control was significant; intention was not. The explained variance in

PC behavior was 13.0%.

Conclusions: This is the first study to examine the implementation of PC in Oman. The findings of this study will inform the development of strategies for advancing PC practice, a mandate of

Ministry of Health and the pharmacy profession in Oman. The TPB was useful for explaining pharmacists’ intention to provide PC; however, a longitudinal study is recommended to test its predictive validity for PC behavior.

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ACKNOWLEDGEMENTS

I would like to express my gratitude to all of those who have helped me accomplish my studies and this insurmountable venture. Firstly, I would like to thank Dr. Linda MacKeigan, for it was under her guidance and wisdom, without which this thesis would not have been possible. She continued to stand by me and offer continuous feedback to ensure the quality of work delivered is of a high calibre. I also extend my utmost thanks to the members of the Advisory Committee;

Dr. Joan Marshman and Dr. Rhonda Cockerill. Their addition of perspective and sage advice enabled me to further improve the quality of my work.

Similarly, I would like to thank H.E. Minister of Manpower Mohamed Al Bakri, and former

Minister of Manpower H.E. Juma Ali, for making all of this possible in the first place by granting me this scholarship. Additional thanks goes to the Site Advisory Committee in Oman that consisted of Mrs. Sawsan Ahmed Jaffer, Dr. Ibrahim Al Zakwani, Mrs. Jehan Alfanna, Mr.

Qasim Al Riyami, Dr. Bryan Gunn, Mr. Osama Babiker, and Mr. Bakool Mehta. Their support in providing me with the information and data necessary was pivotal to my research.

I am also very thankful to the funding agencies that helped me finance my expenses and allowed me to carry out the necessary set ups to conduct my research; namely, the Ministry of

Manpower, Oman, Muscat pharmacy for sponsoring the survey study, and Oman Pharmaceutical

Products (OPP) for sponsoring the focus group study.

Along with every venture, there come several points in time where we require additional moral support and motivation to continue soldiering on. For those moments, I take this opportunity to

express my indebted gratefulness to my son Mohammed, who provided invaluable psychological and technical support, siblings (Alya, Adla, Afaf, Shabir, and Qasim), and nieces (Jannat,

Basmala, and Bushra) in Oman, whose prayers, hospitality, and continuous support will forever be remembered. I also thank Nedzad, my colleague and another student under Dr. MacKeigan, who also advised me throughout the whole process and assisted me whenever possible.

Additional thanks to Awsaf, Hussain, Shahzad, Maryam, Shoroog, Ivana, and Fatima for continuously acting as a supportive family and always sought to help me in every way possible. I also thank my friends in Oman for their support; Amal Jalal, Faten Ajeena, Hala Makharita, Dr.

Laila Emara, Dr. Bassem Elmenshawi, and Tahera Abdul Sattar. A special thanks, as well, to Dr.

Dena Taylor from the University of Toronto and Mr. Chris Corcoran from the Higher College of

Technology for their final editing, and to all the staff in the Pharmacy Department of the Higher

College of Technology,

Finally, I would like to thank the participants of my research, for it was through them that I received the data necessary to conduct my analysis.

Above all, I thank God, the most gracious, the most merciful for being blessed with all I mentioned earlier, and to all of you, I dedicate my work.

The author acknowledges that she was an employee of the Ministry of Health from 1989 – 2005, that is, until two years before the thesis work.

TABLE OF CONTENTS

ABSTRACT ...... ii ACKNOWLEDGEMENTS ...... iv TABLE OF CONTENTS ...... vi LIST OF TABLES ...... xii LIST OF FIGURES ...... xv LIST OF APPENDICES ...... xvi LIST OF ABBREVIATIONS ...... xvii GLOSSARY OF TERMS ...... xviii CHAPTER ONE: INTRODUCTION ...... 1 1. Health Care System in Oman ...... 1 2. Pharmacy Practice in Oman ...... 3 3. Study Rationale ...... 6 4. Theoretical Framework ...... 6 5. Study Goal and Objectives ...... 7 CHAPTER TWO: LITERATURE REVIEW ...... 9 Section I: Patient-Focused Care Models ...... 9 1. Clinical Pharmacy...... 10 2. Pharmaceutical Care ...... 10 3. Medication Therapy Management ...... 12 4. Relationship among Clinical Pharmacy, Pharmaceutical Care, and MTM ...... 13 5. Summary of Relationships amongst the Three Models ...... 14 Section II: Pharmaceutical Care in the Arabian Gulf Region ...... 14 1. Summary of Studies on Pharmaceutical Care in the Arabian Gulf Region ...... 21 Section III: Barriers to and Facilitators of Pharmaceutical Care Globally ...... 22 1. Individual Factors ...... 23 1.1. Pharmacist-Related Factors ...... 23 1.1.1. Awareness and Understanding of the Concept of Pharmaceutical Care ...... 23 1.1.2. Competency ...... 24 1.1.3. Personality ...... 27

1.1.4. Pharmacists’ Attitudes...... 28 1.2. Factors Related to Other Individuals ...... 29 1.2.1. Physician Attitude ...... 29 1.2.2. Patient Attitude ...... 31 1.2.3. Manager and Administrator Support ...... 32 2. Environmental Factors ...... 33 2.1. Situational Factors (Pharmacy-Related Factors) ...... 33 2.1.1. Time ...... 33 2.1.2. Support Personnel and Technology...... 34 2.1.3. Private Counseling Area...... 36 2.1.4. Documentation System ...... 36 2.2. Contextual Factors ...... 37 2.2.1. Health Care System-Related Factors...... 37 2.2.1.1. Reimbursement ...... 37 2.2.1.2. Access to Patient Data ...... 40 2.2.2. Social Context Factors ...... 41 2.2.2.1. Culture and Language ...... 41 3. Summary of Barriers to and Facilitators of Pharmaceutical Care ...... 42 Section IV: Practice Change Theories and Models ...... 43 1. Attitudinal Theories ...... 44 1.1. The Theory of Planned Behavior ...... 45 1.2. Other Attitudinal Theories ...... 47 1.2.1. The Theory of Trying ...... 47 1.2.2. The Theory of Goal Directed Behavior...... 50 1.2.3. The Triangle Model of Responsibility ...... 53 1.2.4. Summary of Studies Using Other Attitudinal Theories ...... 55 1.3. TPB Hybrid Models ...... 56 1.3.1. Summary of Studies Using Hybrid Models ...... 60 2. Motivational or Stages of Change Theories ...... 62 2.1. The Transtheoretical Model ...... 62 2.2. Summary of Studies Using Motivational Theories ...... 65 3. Organizational Theories ...... 66 3.1. Organization Change Theory and Social Network Theory ...... 66 3.2. Leavitt’s Organizational Model ...... 68 3.3. Quality Management Theory ...... 71 3.4. Summary of Studies Using Organizational Theories/Models ...... 71 4. Summary of Practice Change Theories/Models Used in Studies of Pharmaceutical Care ...... 72 vii

5. The Selected Model ...... 73 Section V: Chapter Summary ...... 76 CHAPTER THREE: METHODS ...... 78 Section I: Focus Group Study ...... 80 1. Study Design...... 81 2. Participants ...... 82 2.1. Inclusion/Exclusion Criteria ...... 82 2.2. Participant Recruitment ...... 82 2.2.1. Pharmacists Employed in Inpatient and Outpatient Settings of Public Hospitals ...... 83 2.2.2. Pharmacists Employed in Private Hospitals and Clinics ...... 84 2.2.3. Pharmacists Employed in Community Pharmacies ...... 84 3. Interview Guide ...... 86 4. Procedures ...... 86 5. Data Management and Analyses ...... 87 Section II: Mail Survey ...... 88 1. Study Design...... 88 2. Survey Instrument...... 88 2.1. Operationalization of Constructs ...... 89 2.1.1. Direct Measures...... 90 2.1.1.1. Past Behavior Recency ...... 90 2.1.1.2. Intention to Provide Pharmaceutical Care ...... 91 2.1.1.3. Attitude toward Providing Pharmaceutical Care ...... 91 2.1.1.4. Subjective Norm ...... 91 2.1.1.5. Perceived Behavioral Control ...... 92 2.1.2. Indirect Measures ...... 92 2.1.2.1. Behavioral Beliefs and Evaluation of Outcomes ...... 92 2.1.2.2. Normative Beliefs and Motivation to Comply ...... 93 2.1.2.3. Control Beliefs and Power ...... 93 2.2. Summary of Survey instrument ...... 94 3. Pilot Test ...... 94 3.1. Pilot Test Methods ...... 95 3.2. Pilot Test Data analysis ...... 96 3.3. Pilot Test Results ...... 96 3.4. Actions Taken ...... 96 3.5. Summary of Actions Taken as a Result of the Pilot Test ...... 98 4. Survey Participants ...... 98 viii

4.1. Inclusion/Exclusion Criteria ...... 98 4.2. Sample Size Estimation ...... 99 5. Survey Administration ...... 100 6. Data Management and Analysis ...... 101 6.1. Validity and Reliability of Measures ...... 102 6.2. Statistical Analyses ...... 105 Section III: Chapter Summary...... 108 CHAPTER FOUR: RESULTS ...... 109 Section I: Focus Group Study ...... 109 1. Participants ...... 109 2. Focus Group Themes ...... 109 2.1. Behavioral Beliefs ...... 111 2.1.1. Perceived Benefits of Pharmaceutical Care ...... 111 2.1.1.1. Patient ...... 111 2.1.1.2. Pharmacist ...... 112 2.1.1.3. Pharmacy ...... 113 2.1.1.4. Health System ...... 113 2.1.2. Perceived Negative Consequences to Pharmaceutical Care ...... 113 2.1.2.1. Patient ...... 114 2.1.2.2. Pharmacist ...... 114 2.1.3. Summary of Behavioral Beliefs ...... 115 2.2. Normative Beliefs ...... 116 2.2.1. Physicians ...... 116 2.2.2. Patients ...... 117 2.2.3. Pharmacy Management ...... 119 2.2.4. Hospital Administration ...... 119 2.2.5. Summary of Normative Beliefs ...... 120 2.3. Control Beliefs ...... 121 2.3.1. Pharmacist-Related Factors ...... 121 2.3.1.1. Competency ...... 121 2.3.1.2. Communication Skills ...... 123 2.3.2. Pharmacy-Related Factors...... 123 2.3.2.1. Time/ Staff/ Workload ...... 124 2.3.2.2. Access to Drug Information Resources ...... 125 2.3.2.3. Pharmacy Space ...... 127 2.3.3. Health Care-Related Factors ...... 128 2.3.3.1. Reimbursement ...... 128

2.3.3.2. Access to Patients’ Medical Records...... 128 2.3.4. Social Factors ...... 130 2.3.4.1. Cultural and Language Differences ...... 130 2.3.5. Summary of Control Beliefs ...... 132 3. Summary of Focus Group Results ...... 133 Section II: Mail Survey ...... 133 1. Response Rate...... 134 2. Non-Response Bias...... 134 3. Missing Values Analysis ...... 137 4. Demographic Characteristics of Survey Respondents ...... 137 5. Descriptive and Reliability Statistics for Multi-Item Scales Measuring Model Constructs ...... 140 6. Factor Validity of Multi-Item Scales ...... 143 6.1. Pharmaceutical Care Behavior Scale ...... 144 6.2. The Theory of Planned Behavior Model ...... 145 7. Inferential Analyses to Address Research Objectives ...... 146 8. Summary of Survey Results ...... 158 Section III: Chapter Summary...... 159 CHAPTER FIVE: DISCUSSION AND CONCLUSIONS ...... 160 Section I: Implementation of Pharmaceutical Care in Oman ...... 160 1. Extent of Implementation ...... 160 2. Barriers to and Facilitators of the Provision of Pharmaceutical Care ...... 164 2.1. Behavioral Beliefs ...... 164 2.2. Normative Beliefs ...... 167 2.3. Control Beliefs ...... 167 2.3.1. Clinical Knowledge ...... 168 2.3.2. Communication Skills and Language Abilities ...... 168 2.3.3. Staffing and Time ...... 169 2.3.4. Culturally-Based Gender Issues ...... 169 2.3.5. Private Counseling Area...... 170 2.3.6. Reimbursement...... 171 2.3.7. Access to Patient Records and to Electronic Drug Information Databases ... 171 3. Effect of pharmacist country/continent of origin on beliefs about pharmaceutical care 172 Section II: Suitability of the Theoretical Model...... 174 1. Predictors of Intention to Provide Pharmaceutical Care ...... 175 2. Predictors of Pharmaceutical Care Behavior ...... 176

Section III: Study Limitations ...... 178 Section IV: Implications of Study Results ...... 180 1. Recommendations for Policy Makers in Oman ...... 180 1.1. Changing Behavioral Beliefs ...... 181 1.2. Responding to Negative Control Beliefs ...... 183 2. Contributions of this Study beyond Oman ...... 186 Section V: Future Research ...... 187 Section VI: Conclusions ...... 188 REFERENCES ...... 190

LIST OF TABLES

Table 3.1. Reliability coefficients for pilot test multi-item scales ...... 97

Table 3.2. Timing of distribution of survey materials ...... 101

Table 4.1. Sample characteristics of focus group study participants ...... 110

Table 4.2. Analysis of surveys returned...... 135

Table 4.3. Crosstab analysis of demographic characteristics of early versus late survey respondents……………………………………………………………………………………..136

Table 4.4. Survey participant characteristics ...... 139

Table 4.5. Descriptive statistics for multi-item scales and reliability coefficients …………….141

Table 4.6. Summary of goodness of fit indices by model/scale ...... 145

Table 4.7. Mean weighted behavioral beliefs (mean belief strength x mean evaluation) by practice setting ...... 149

Table 4.8. Mean weighted normative beliefs (mean belief strength x mean motivation) by practice setting ...... 150

Table 4.9. Mean weighted control beliefs (mean belief strength x mean power) by practice setting ...... 151

Table 4.10. Descriptive statistics for weighted beliefs about pharmaceutical care behavior by country/continent of origin ...... 153

Table 4.11. Post-hoc pair-wise comparisons between countries/continents of origin on weighted behavioral, normative, and control beliefs using the Bonferroni test ...... 154

Table 4.12. Multiple regression analysis results for prediction of intention to provide pharmaceutical care ...... 156

Table 4.13. Multiple regression analysis results for prediction of pharmaceutical care behavior...... 157

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Table 5.1. Post hoc exploratory analysis of frequency of provision of each type of pharmaceutical care activity by practice setting ...... 162

Table 5.2. Post hoc exploratory analysis of proportions of regular providers of each type of pharmaceutical care activity by practice setting ...... 163

Table O.1. Extent of performing pharmaceutical care activities ...... 263

Table O.2. Intention to perform pharmaceutical care ...... 264

Table O.3. Pharmacists’ attitude toward pharmaceutical care ...... 265

Table O.4. Perceived social influences on pharmacists’ pharmaceutical care behavior ...... 266

Table O.5. Perceived control over performing pharmaceutical care ...... 267

Table O.6. Beliefs about the outcomes of pharmaceutical care ...... 268

Table O.7. Evaluation of the outcomes of pharmaceutical care ...... 269

Table O.8. Perceptions about important referents’ approval/ disapproval of pharmaceutical care ...... 270

Table O.9. Pharmacists’ motivation to comply with what each important referent thinks about performing pharmaceutical care ...... 271

Table O.10. Pharmacists’ assessment of the factors that affect their ability to provide pharmaceutical care ...... 272

Table O.11. Pharmacists’ evaluation of the power of factors affecting their ability to provide pharmaceutical care………...... 273

Table P.1. Principle component analysis of pharmaceutical care behavior rotated on 4 factors.275

Table P.1. Principle component analysis of pharmaceutical care behavior rotated on 3 factors.276

Table P.3. Principle component analysis of intention rotated on one factor…………………...277

Table P.4. Principle component analysis of attitude rotated on one factor……………………..277

Table P.5. Principle component analysis of subjective norm rotated on two factors…………..278

Table P.6. Principle component analysis of subjective norm rotated on one factor…………....278

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Table P.7. Principle component analysis of perceived behavioral control rotated on one factor…………………………………………………………………………………………..279

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LIST OF FIGURES

Figure 1. Theory of Planned Behavior…………………………………………………………..46

Figure 2. Theory of Trying………………………………………………………………………49

Figure 3. Theory of Goal Directed Behavior……………………………………………………51

Figure 4. The Triangle Model of Responsibility…………..………………………………….....54

Figure 5. The selected model………………………………………………………………… ...76

Figure 1. Predictors of pharmacists’ intention to provide pharmaceutical care…………………79

Figure 7. Predictors of pharmaceutical care behavior…………………………………………..79

Figure Q.1. Histogram of standardized residual intention scores with 15 outliers…………….281

Figure Q.2. Normal probability plot of standardized residual intention scores with 15 outliers………………………………………………………………………………………….281

Figure Q.3. Histogram of standardized residual intention scores without 15 outliers…………282

Figure Q.4. Normal probability plot of standardized residual intention scores without 15 outliers………………………………………………………………………………………….282

Figure Q.5. Scatter plot depicting the relationship between standardized predicted and residual intention scores without 15 outliers…………………………………………………………....283

Figure R.1. Normal probability plot of standardized residual pharmaceutical care scores……285

Figure R.2. Scatter plot depicting the relationship between standardized predicted and residual pharmaceutical care scores……………………………………………………………………..285

LIST OF APPENDICES

Appendix A. Telephone script for recruiting pharmacists

Appendix B. Memorandum from chain pharmacy head office to its employee pharmacists

Appendix C. Focus group information sheet/consent form

Appendix D. Focus group interview guide

Appendix E. Focus group participant demographics form

Appendix F. Pilot test introductory letter

Appendix G. Pilot test questionnaire, cover letter, and response postcard

Appendix H. Pilot test debriefing questions

Appendix I. Survey introductory letter

Appendix J. Survey questionnaire, cover letter, and response postcard

Appendix K. Survey first follow-up letter

Appendix L. Survey second follow-up letter

Appendix M. Questionnaire coding key

Appendix N. Summary of themes by the Theory of Planned Behavior

Appendix O. Descriptive statistics for individual items of multi-item scales

Appendix P. Exploratory factor analysis (principle component analysis) of pharmaceutical care behavior scale and the Theory of Planned Behavior Model

Appendix Q. Normality plots and scatter plots of intention to provide pharmaceutical care

Appendix R. Normality plot and scatter plot of pharmaceutical care behavior

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LIST OF ABBREVIATIONS

APhA American Pharmacists Association A.S.E. Attitude, Social influence, and Self-efficacy ASHP American Society of Health-System Pharmacists CFA Confirmatory Factor Analysis CFI Comparative Fit Index CPD Continuous Professional Development DGMS Directorate General of Medical Supplies DGPA&DC Directorate General of Pharmaceutical Affairs and Drug Control GCC Gulf Cooperation Council GFI Goodness of Fit Index ITP Internationally Trained Community Pharmacists KSA Kingdom of Saudi Arabia LEP Limited English Proficient MI Modification Indices MOH Ministry of Health MTM Medication Therapy Management MUR Medicines Use Review MV Missing Values NACDS National Association of Chain Drug Stores NFI Normed Fit Index RMSEA Root Mean Square Error for Approximation SEIPS Systems Engineering Initiative for Patient Safety SQU Sultan Qaboos University TD Therapeutic Duplication TGB Theory of Goal Directed Behavior TMR Triangular Model of Responsibility TPB Theory of Planned Behavior TRA Theory of Reasoned Action TT Theory of Trying TTM Transtheoretical Model UAE United Arab Emirates UK United Kingdom USA United States of America WHO World Health Organization

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GLOSSARY OF TERMS

Action A stage of the Transtheoretical Mode in which individuals have been engaged in the process of change for less than six months (Prochaska and DiClemente, 1984)

Actors One of four components of Leavitt’s Organizational Model that effect a change in an organization; defined as individuals in the organization (Leavitt, 1964)

Affect toward the means A construct from the Theory of Goal Directed Behavior defined as desirability of the means, which are intermediate behaviors that need to be carried out in order to achieve the desired goal (Bagozzi et al., 1992)

Agreeableness One of five personality traits according to the Big Five Model; defined as the individual’s attitude toward others (John et al., 1991)

Attitude toward failure A construct from the Theory of Trying defined as the individual’s overall evaluation of trying and failing to perform the behavior (Bagozzi and Warshaw, 1990)

Attitude toward process A construct from the Theory of Trying defined as the individual’s overall evaluation of the process of determination to reach the goal (Bagozzi and Warshaw, 1990)

Attitude toward success A construct from the Theory of Trying defined as the individual’s overall evaluation of trying and succeeding at performing the behavior (Bagozzi and Warshaw, 1990)

Attitude toward the A construct from the Theory of Planned Behavior defined as the behavior individual’s overall positive and negative evaluation of the behavior (Ajzen, 1985, 1991, 2002, and 2005)

Behavioral intention A construct from the Theory of Planned Behavior defined as perceived likelihood of performing the behavior (Ajzen, 1985, 1991, 2002, and 2005)

Behavioral beliefs A construct from the Theory of Planned Behavior defined as beliefs that the behavior is associated with certain outcomes (Ajzen, 1985, 1991, 2002, and 2005)

Chronic disease A proactive way of supporting patients with chronic conditions to xviii

management manage their medications, prevent disease progression, and improve their health (Mah et al., 2009)

Cognitive pharmaceutical The use of specialized knowledge by the pharmacist to promote services safe and effective drug therapy through interaction with patients and other health care providers (Hopp et al, 2005; Mandt et al, 2009; Raisch, 1993; Roberts et al, 2003)

Conscientiousness One of five personality traits according to the Big Five Model; defined as being thorough, careful, and efficient (John et al., 1991)

Contemplation A stage of the Transtheoretical Model in which individuals are interested and plan for a change within the following six months (Prochaska and DiClemente, 1984)

Control beliefs A construct from the Theory of Planned Behavior defined as beliefs about the presence of factors that likely facilitate or inhibit the performance of the behavior (Ajzen, 1985, 1991, 2002, and 2005)

Decisional balance A construct from the Transtheoretical Model defined as a way of demonstrating advantages and disadvantages of different choices for helping individuals decide on what to do in a certain situation (Prochaska and DiClemente, 1984)

Evaluation A construct from the Theory of Planned Behavior defined as the value attached to each outcome (Ajzen, 1985, 1991, 2002, and 2005)

Events One of three elements of the Triangle Model of Responsibility; defined as units of action (Schlenker et al., 1994)

Expectation of failure A construct from the Theory of Trying defined as the subjective probability of failing to perform the behavior (Bagozzi and Warshaw, 1990)

Expectation of success A construct from the Theory of Trying defined as the subjective probability of succeeding at performing the behavior (Bagozzi and Warshaw, 1990)

Extended role The involvement of pharmacists in activities that goes beyond dispensing and requires specialized skills (Ruston, 2001)

Extraversion One of five personality traits according to the Big Five Model; defined as being sociable, active, and talkative (John et al., 1991)

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Frequency of past behavior A construct from the Theory of Goal Directed Behavior defined as a measure of how frequent the behavior was performed in the past (Bagozzi et al., 1992; Bagozzi and Warshaw, 1990)

Identity images One of three elements of the Triangle Model of Responsibility; defined as actors’ roles and qualities (Schlenker et al., 1994)

Instrumental beliefs A construct from the Theory of Goal Directed Behavior defined as judgments that the means (intermediate behaviors) will likely lead to the behavior (Bagozzi et al., 1992)

Maintenance A stage of the Transtheoretical Model in which individuals have been engaged in the process of change for six months or more (Prochaska and DiClemente, 1984)

Medication review A clinical assessment of the patient’s drug regimen to promote safe and effective use of medications (Niquille et al., 2010)

Medicines use review An advanced service undertaken by accredited pharmacists that covers a comprehensive review for patients with polypharmacy to help them manage their medications and to identify any drug- related problems (Pharmaceutical Services Negotiating Committee, 2011)

Motivation to comply A construct from the Theory of Planned Behavior defined as motivation to do what each important referent thinks one should (Ajzen, 1985, 1991, 2002, and 2005)

Neuroticism One of five personality traits according to the Big Five Model; defined as being emotional, sad, worried, and insecure (John et al., 1991)

Openness One of five personality traits according to the Big Five Model; defined as being intellectual, creative, and independent (John et al., 1991)

Past behavior recency A construct from the Theory of Goal Directed Behavior defined as a measure of how recent the behavior was performed in the past (Bagozzi et al., 1992; Bagozzi and Warshaw, 1990)

Perceived behavioral A construct from the Theory of Planned Behavior defined as the control individual’s perception as to how easy/difficult it is to perform the behavior (Ajzen, 1985, 1991, 2002, and 2005)

Power A construct from the Theory of Planned Behavior defined as the xx

perceived effect of each factor in making the performance of the behavior difficult or easy (Ajzen, 1985, 1991, 2002, and 2005)

Precontemplation A stage of the Transtheoretical Model in which individuals are either unaware or uninterested in making a change in their behavior in the subsequent six months (Prochaska and DiClemente, 1984)

Preparation A stage of the Transtheoretical Model in which individuals have plans for the change within a month (Prochaska and DiClemente, 1984)

Prescriptions One of three elements of the Triangle Model of Responsibility defined as rules of conduct, which include information about goals and ways to approach these goals (Schlenker et al., 1994)

Responsibility A construct from the Triangle Model of Responsibility defined as a process that holds individuals accountable for their acts (Schlenker et al., 1994) - A construct from the Self-Efficacy Theory defined as the Self-efficacy degree of perceived confidence and control over a behavior (Bandura, 1982) - Also a construct from the Theory of Goal Directed Behavior where it is defined as the degree of perceived confidence and control over the means, which are the intermediate behaviors that need to be accomplished in order to achieve the desired goal (Bagozzi et al., 1992)

Structure One of four components of Leavitt’s Organizational Model that effect a change in an organization; defined as relationships between individuals in the organization (Leavitt, 1964)

Subjective norm A construct from the Theory of Planned Behavior defined as social pressure to engage in the behavior (Ajzen, 1985, 1991, 2002, and 2005)

Task One of four components of Leavitt’s Organizational Model that effect a change in an organization; defined as services provided (Leavitt, 1964)

Technology One of four components of Leavitt’s Organizational Model that effect a change in an organization; implies machines, programs, or protocols (Leavitt, 1964)

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CHAPTER ONE: INTRODUCTION

The pharmacy profession has gone through several shifts in practice since1860, from compounding, to dispensing, to clinical pharmacy, and, finally, to pharmaceutical care. The evolution of the philosophy of pharmaceutical care has shifted the pharmacist's role from product-centered to a more responsible patient-centered care (Holland and Nimmo, 1999a;

Wiedenmayer et al., 2006). Pharmaceutical care is an American model of practice which was first introduced in 1990 by Hepler and Strand, who defined it as "the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life" (Hepler and Strand,1990, p. 539).

Despite the popularity of the notion of pharmaceutical care, its adoption by pharmacists worldwide is uneven, even in its country of origin. Implementation of pharmaceutical care has been reported to be hindered by a number of barriers, including opposition from other health professionals; pharmacists’ competency and confidence; lack of demand and receptiveness by patients; and logistical barriers such as inability to access patients’ medical records (Al-Arifi et al., 2007; Christensen and Farris, 2006; Ngorsuraches and Li, 2006).

1. Health Care System in Oman

The Sultanate of Oman, located on the southeast coast of the Arabian Peninsula, is one of the six members of Gulf Cooperation Council (GCC) states. The country has about 3 million inhabitants, including about one million non-nationals. About 30% of the total population lives in Muscat, the capital and administrative center (Oman Ministry of National Economy, 2010).

The Omani health care system was established after the Omani Renaissance in 1970, with the issuance of a royal decree to establish the Ministry of Health (MOH). The MOH constitutes the central component of the Omani public health care system that is responsible for provision and management of the health care system in Oman. It runs hospitals and health centers at all levels, national and local. In addition to the MOH, the Omani public health care system is comprised of other government hospitals/clinics such as those administered by the Sultan

Qaboos University (SQU), Ministry of Defence, Royal Oman Police, Diwan of Royal Court, and

Petroleum Development Oman. The public sector provides about 80% of the health care in the country and it caters mainly to Omani nationals, GCC nationals, and non-Omani nationals employed in the government; the private sector provides the remaining 20%. The private sector is comprised of private hospitals, health centers/clinics and community pharmacies. It caters mainly to non-nationals employed outside the government sector and to Omanis who are willing to pay out of pocket to obtain better service or to avoid long waits in the government health institutions.

The health system in Oman is very similar to the health systems of the other Arabian Gulf

States, but varies substantially from the North American health system. The health system in

Oman has three health care levels: primary, secondary, and tertiary care. Primary care is delivered by health centers usually operated by general practitioners who act as gatekeepers for secondary care or tertiary care provided by hospitals. Almost all public sector health services, including medicines, are provided free of charge to nationals with a nominal registration fee paid at each visit.

2. Pharmacy Practice in Oman

Pharmaceutical affairs are administered by two directorate generals:

. The Directorate General of Pharmaceutical Affairs & Drug Control (DGPA&DC) is the

regulatory body responsible for pharmaceutical legislation. It has executive and

supervisory authority to ensure that all the pharmaceutical legislation is enacted. It is

responsible for the registration of pharmaceutical manufacturers and provides marketing

licenses for their products in Oman. It is also responsible for licensing community

pharmacies, pharmacists, assistant pharmacists, and medical representatives to be

employed in the private sector.

. The Directorate General of Medical Supplies (DGMS) is responsible for the supply and

distribution of drugs, medical, and laboratory items to all MOH hospitals and health

centers across the country. It also licenses pharmacists and assistant pharmacists

employed by the MOH in the hospitals and health centers (Oman Ministry of Health,

2000).

Pharmacist licensing requirements in Oman are completion of a five-year pharmacy degree from any university recognized by Ministry of Higher Education and passing the MOH licensing exam. To practice pharmaceutical care in inpatient settings in MOH institutions, a master’s degree in clinical pharmacy is required.

As of December 20101, there were 62 hospitals, 1,035 health centers and clinics, and 400 community pharmacies in Oman. Each governmental hospital and health center has an outpatient

1 Most recent data available

pharmacy where patients usually get their prescriptions filled. Patients who are not entitled to

MOH services get their prescriptions filled at community pharmacies or outpatient pharmacies of private hospitals and health centers/clinics. It is important to note that not all private health centers/clinics have pharmacies, and not all governmental health centers’ pharmacies are managed by pharmacists (Oman Ministry of Health, 2010).

The total number of licensed pharmacists in Oman is approximately 1,250; about 320 pharmacists are employed in the public sector and 930 in the private sector. Very few Omani pharmacists work in the private sector; pharmacists employed in this sector are mainly from

India, Jordan, Egypt, Iraq, and Pakistan. Further, there are only two new schools of pharmacy and they are private. The SQU, a public university, started a master’s program in clinical pharmacy in 2008 but has no undergraduate pharmacy program. Most of the older Omani pharmacists graduated from Iraq, Egypt, Syria, and UK where pharmacy programs, at that time, were not clinically-oriented.

In Oman, the pharmacy profession is in transition as it reorients itself from an exclusive focus on drug distribution to patient care. Pharmaceutical care is a new area of practice. So far, pharmaceutical care has not been widely implemented; dispensing of drugs remains the main focus, especially in the private sector. However, the provision of pharmaceutical care services is growing in governmental hospitals. The Omani MOH has supported the clinical orientation of the profession, in particular, by posting many pharmacists employed in the MOH hospitals abroad to study clinical pharmacy who in return will ply their trade in the inpatient settings.

The Omani government's interest in pharmaceutical care derived from the persistent efforts of the GCC executive office to advance the pharmacy profession and to raise practice

standards to correspond with international standards. In 2005, a recommendation on the necessity of having pharmaceutical care in practice was endorsed at the GCC's 58th conference, and

Ministerial Decree B-18 was issued as a result. This Decree mandated the establishment of a directorate for pharmaceutical care in each Ministry of Health in the six Gulf States, in addition to setting up a central committee for pharmaceutical care at the GCC level to establish the criteria and guidelines for the implementation of pharmaceutical care (The Gulf Cooperation

Council, 2007). Although the GCC committee was established in late 2005, a directorate for pharmaceutical care has not yet been established in Oman.

In spite of the supporting initiatives within Oman for the provision of pharmaceutical care, numerous difficulties in developing and providing such services remain. The main problems in general are a shortage of pharmacists and a lack of competent pharmacists to provide such services. Although each governmental tertiary care hospital in Muscat has 3 -7 clinical pharmacists practicing in the inpatient setting and those in other regions have at least one clinical pharmacist, this is insufficient to cover the needs of the population. To date, there are no national standards for pharmaceutical care services in Oman; each of the governmental hospitals has established its own standards of practice. The methods of delivering pharmaceutical care are determined by clinical pharmacists practicing in these hospitals.

On the other hand, pharmacists in the private sector (hospitals, health centres/clinics, and community pharmacies) have no incentive to provide pharmaceutical care nor do they have the training. Their wages in general are lower than what is paid in the governmental institutions; hence, they tend to have the minimum qualification to practice pharmacy. Furthermore, employers’ expectation in this sector is that pharmacists’ main responsibility is to dispense

medications. Additionally, it is anticipated that many pharmacists in the private sector, who received their education and have practiced in the old pharmacy paradigm (drug-product oriented), would resist the change in their daily practice. Thus, the implementation of pharmaceutical care is a challenge in the private sector.

3. Study Rationale

As evidenced by the Ministerial Decree in 2005, there is a strong political will to have pharmaceutical care in practice in the Arabian Gulf region, although the will to do so in Oman is less clear. Outside of inpatient settings, the extent to which pharmacists are providing pharmaceutical care is unknown. Further, there are system-related factors that are likely to affect the provision of pharmaceutical care. Omani national pharmacists, who mainly work in the public sector, have better professional opportunities, education, and salaries compared to pharmacists in the private sector who are predominantly non-nationals. These non-nationals come from different countries and professional cultures. This cultural diversity influences pharmacists’ health care perceptions, namely their beliefs about providing pharmaceutical care.

It is therefore likely that the extent of pharmaceutical care provision differs by pharmacist nationality and also by public versus private sector.

In addition, barriers to and facilitators of provision of pharmaceutical care have not been investigated. Overall, there is a paucity of research on pharmacy or pharmacy practice of any kind in Oman.

4. Theoretical Framework

A number of attitudinal theories were considered to select a theoretical framework for this study. Attitudinal theories help understand the factors that influence individual behavior and

thus seem to have the most relevance to the objectives of this study. The Theory of Planned

Behavior (TPB) developed by Ajzen (1985) was selected because it has shown good predictive validity for pharmacists’ intentions to provide pharmaceutical care and moderate predictive validity for behavior. The TPB is psycho-social in origin and it was developed to understand the relationships between beliefs, attitudes, subjective norms, perceived behavioral control, intentions, and behavior with a major goal of predicting and explaining individuals’ behaviors. A more detailed description of the theoretical framework is provided in Chapter 2.

5. Study Goal and Objectives

The overall purpose of the study was to determine the extent of the implementation of pharmaceutical care in Oman and factors affecting its implementation. The specific objectives were:

1. Determine the extent of the provision of pharmaceutical care in Oman, and compare its

provision across three practice settings: inpatient, outpatient, and community pharmacy.

2. Identify important perceived barriers and facilitators to the implementation of

pharmaceutical care as expressed in pharmacists’ behavioral beliefs, normative beliefs,

and control beliefs.

3. Examine the effect of pharmacists’ demographic characteristics, in particular, country of

origin on their behavioral beliefs, normative beliefs, and control beliefs relative to

implementation of pharmaceutical care.

4. Examine the individual and collective influences of attitude, subjective norm, perceived

behavioral control, and past behavior recency on pharmacists’ intention to implement

pharmaceutical care.

5. Examine the influence of perceived behavioral control and intention on pharmaceutical

care behavior.

6. Test the predictive validity of the Theory of Planned Behavior (TPB) in explaining

pharmacists’ pharmaceutical care behavior.

6. Approach to the Study

To meet these objectives a mail survey of Omani pharmacists was undertaken.

Development of the survey instrument was informed by three focus groups with pharmacists representing three practice settings in Oman: inpatient, outpatient, and community pharmacy.

CHAPTER TWO: LITERATURE REVIEW

This chapter provides the background for the research topic and the theoretical framework employed in this study. The first section discusses different patient-focused care models in pharmacy and the relationships among them. Section two summarizes studies that have investigated the implementation of pharmaceutical care in the Arabian Gulf region. The third section presents a review of literature addressing facilitators and barriers to the implementation of pharmaceutical care. In the fourth and last section, theories of clinical practice change that have been applied to the implementation of pharmaceutical care are discussed along with the pharmacy studies that used them. The chapter ends with a discussion of the theoretical framework selected for this study.

Section I: Patient-Focused Care Models

It is well-known that the profession of pharmacy is the profession that deals with the delivery of drug products. In contemporary pharmacy, several practice models call for a patient- focused type of drug delivery system, and aim at optimizing patient drug-therapy, that is, making drug-therapy more effective and safe. In chronological order, these practice models include clinical pharmacy (1960), pharmaceutical care (1990), and medication therapy management

(2006), all of which arose in the U.S.A. The three models more or less complement each other; however, there has been confusion as to how these models relate or differ. A brief account of each of these models and the relationships among them is given below to justify the selection of pharmaceutical care as the model of a patient-focused system of care to study in this project.

1. Clinical Pharmacy

The most recent definition of clinical pharmacy is “that area of pharmacy concerned with the science and practice of rational medication use” (American College of Clinical Pharmacy,

2008, p. 816). The need for clinical pharmacy was stimulated by an increase in the number of drugs, their complexity, and an increased awareness of their potential harm. Clinical pharmacy initially started as ‘ward pharmacy’ by adopting the unit dose system and the concept of satellite pharmacies to ensure the appropriateness of the drug distribution system. Over time, the presence of pharmacists in the wards, their availability for consultation by other health care providers, and their participation in medical rounds signaled the transition to clinical pharmacy (Smith, 2007;

Webb et al., 2012). Although clinical pharmacy is applicable to all practice settings, it was nurtured in teaching hospitals as their environment was more suitable and encouraging than other practice settings. The clinical functions to be rendered by the pharmacist according to the

American Report of the Task Force on Pharmacists’ Clinical Role (National Center for Health

Services Research and Development, 1971) were the following: 1) prescribing drugs, 2) dispensing and administering drugs, 3) documenting professional activities, 4) direct involvement with patients, 5) reviewing drug use, 6) education (physicians and others), and 7) consultation (giving advice to physicians).

2. Pharmaceutical Care

Although the term “pharmaceutical care” had been defined by Mikeal et al. in 1975, and by Brodie et al. in 1980, these definitions passed unnoticed. The philosophy of pharmaceutical care was introduced in the USA in 1989, in particular at the second ‘Pharmacy in the 21st

Century’ Conference (Kheir et al., 2004). In developing the philosophy, Hepler and Strand, built

upon clinical pharmacy concepts and defined pharmaceutical care as “the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life” (1990, p. 539). Pharmaceutical care goes beyond clinical pharmacy concepts and practice activities in that it assumes that the pharmacist works in collaboration with the patient and with the patient’s other health care providers in designing, implementing, and monitoring a therapeutic plan to ensure that the planned outcomes are achieved (Cipolle et al., 2004; Strand et al., 1991). Pharmaceutical care is therefore an outcome-oriented type of practice. Also, the philosophy holds that the pharmacist takes responsibility for the outcomes of the patient’s drug therapy and is held accountable for any therapeutic decision he or she makes. Pharmaceutical care not only requires that pharmacists be drug experts, but also helps patients to make the best use of their medications by providing the most effective, safe, and affordable medications to improve the patients’ quality of life.

The philosophy of pharmaceutical care was converted into a practice model by the

‘Minnesota Pharmaceutical Care Project’ in 1997 (Cipolle et al., 2004; Tomechko et al., 1995).

According to Cipolle et al. (2004), the standards of practice for pharmaceutical care comprise three categories:

1. Assessment: patient-related information is collected and analyzed to identify any drug-

related problems.

2. Care plan development: goals of therapy are identified and intervention plans are

developed to achieve these goals. Follow-up visits are scheduled to assess the

effectiveness and safety of the drug-therapy.

3. Follow-up: evaluation of patient outcomes to determine if the therapy goals were

achieved and if any other drug-related problems developed.

Pharmaceutical care is a general model, the application of which is not limited to a specific practice setting (Smith and Benderev, 1991; Strand et al., 1991). As opposed to clinical pharmacy, pharmaceutical care managed to penetrate community pharmacy; however, its uptake has been slow. Community pharmacists have reported a number of barriers to the provision of pharmaceutical care in their daily work. Lack of access to patient records, and drug information databases, resistance from other health care providers, lack of competence and confidence, and lack of a reimbursement mechanism are examples of these barriers (Al-Arifi et al., 2007; Blake et al, 2009; Pullinger and Franklin, 2010; Reebye et al, 1999).

3. Medication Therapy Management

Medication therapy management (MTM) has been defined as "a distinct service or group of services that optimize therapeutic outcomes for individual patients. Medication therapy management services are independent of, but can occur in conjunction with, the provision of a medication product" (Bluml, 2005, p. 572). The Medicare Modernization Act coined the term

MTM in 2003, and a coalition of 11 national pharmacy organizations developed the definition in

2004. Based on this consensus definition, a model framework was developed by the American

Pharmacists Association (APhA) and the National Association of Chain Drug Stores (NACDS)

Foundation in 2005. The five core elements of the MTM model are: medication therapy review, personal medication record, medication-related action plan, intervention and/ or referral, and documentation and follow-up. Because this model is based on the philosophy and process of pharmaceutical care, its five core elements are not very different from the practice standards of

pharmaceutical care (American Pharmacists Association and National Association of Chain Drug

Stores Foundation, 2008).

4. Relationship among Clinical Pharmacy, Pharmaceutical Care, and MTM

Pharmaceutical care and clinical pharmacy are very closely related concepts. In 2004,

Hepler wrote: “Pharmaceutical care describes the original purpose of clinical pharmacy, when it was understood as a professional practice rather than a health science. It describes a way that clinical pharmacy, especially specialists and subspecialists, could coordinate their work more effectively. The concept of clinical pharmacy adds essential clarity about the process component of pharmacists’ participation in, and strengthens the academic basis of, pharmaceutical care”

(Hepler, 2004, p. 1491).

According to Hepler (2004), the relationship between pharmaceutical care and clinical pharmacy can be discussed at two levels: philosophy and practice. The philosophy of pharmaceutical care emphasizes the importance of outcomes along with the responsibility for actions, while the philosophy of clinical pharmacy emphasizes cognitive clinical services without any mention of outcomes. Pharmaceutical care can be described as a system in which clinical pharmacy is a practice and a necessary element that advances the technical quality of the system.

The competencies required to practice clinical pharmacy are clear but the commitment to outcomes is ambiguous, and it is the reverse in the case of pharmaceutical care (Helper, 2004). In summary, the relationship between pharmaceutical care and clinical pharmacy is a mutual and a complementary relationship.

The goals, objectives, and elements of the MTM model are more or less similar to those of pharmaceutical care; however, pharmaceutical care can be viewed as a philosophy and the

MTM model as a structure in which to provide pharmaceutical care, as well as a strategy that enhances the implementation of pharmaceutical care in the community pharmacy setting as a routine pharmacy practice (American Pharmacists Association and National Association of

Chain Drug Stores Foundation, 2005; McGivney et al., 2007).

5. Summary of Relationships amongst the Three Models

The three models, pharmaceutical care, clinical pharmacy, and MTM, have the common aim of improving patient drug-therapy. Their relationship is complementary in that pharmaceutical care is a philosophy that encompasses the other two models. Clinical pharmacy adds the technical quality to pharmaceutical care, while MTM may be viewed as a strategy for implementing pharmaceutical care in community settings.

Pharmaceutical care being a more comprehensive practice model than clinical pharmacy, that presents new concepts to meet patients’ drug related needs, has been adopted in Oman and the rest of GCC member states as the new model of pharmacy practice. On this basis, pharmaceutical care was selected to address the pharmacy practice needs in Oman.

Section II: Pharmaceutical Care in the Arabian Gulf Region

The Arabian Gulf region encompasses six countries (Kingdom of Saudi Arabia [KSA],

Oman, United Arab Emirates [UAE], Kuwait, Qatar, and Bahrain) that are in close proximity and have converging cultures and traditions. The health systems in this region are in continuous development; however, the implementation of pharmaceutical care is still in its infancy, especially in the community setting. Despite the issuance of the Gulf Corporation Council’s

(GCC) ministerial decree D-18 in 2005 (described in chapter one), and despite the development of pharmaceutical care standards and strategic plans by the central pharmaceutical care

committee for hospital pharmacists in 2007 (The Gulf Cooperation Council, 2007), and for community pharmacist in 2011 (The Executive Board of Health Ministers’ Council for GCC

States, 2012), effective implementation is yet to be achieved by the pharmacy regulatory bodies of the different Arabian Gulf States.

A literature search of MEDLINE, EMBASE, International Pharmaceutical Abstract databases and a Google search was conducted to identify published articles relevant to the implementation of pharmaceutical care in the Arabian Gulf region from 1990 (when the concept of clinical pharmacy was introduced in this region) to August 2013, using the search terms pharma*, care, clinical services, implementation, and the name of each country in the Gulf region. Only studies in the English language were retrieved.

The literature search identified 15 studies on pharmaceutical care in this region. Five studies examined the impact of the provision of pharmaceutical care on health outcomes in patients with diabetes mellitus or in patients with cardiovascular diseases, three of which were carried out in the United Arab Emirates (UAE) (Al Mazroui et al., 2009; Elnour et al., 2008;

Sadik et al., 2005); and the other two in the KSA (Al-Jazairi et al., 2008; Ibrahim et al., 1998).

One study in the KSA investigated the rate of documented pharmaceutical care activities (Al-

Ahdal et al., 2003).

Nine studies investigated the implementation of pharmaceutical care (Al-Aqeel and

Abanmy, 2008; Al-Arifi et al., 2007; Al-Arifi, 2008; Al-Fadhel and Nylor, 2002; Alomar et al.,

2011; Al-Shaqha et al., 2003; Awad et al., 2006; Hasan et al., 2011; Katoue et al., 2013). Only these nine studies are discussed due to their relevance to the research subject. They are presented in chronological order.

The first study to examine the implementation of pharmaceutical care in the Arabian Gulf region was done in Saudi Arabia. Al-Fadhel and Nylor (2002) surveyed 178 community pharmacists regarding their readiness to provide pharmaceutical care services to diabetic patients in Riyadh, the capital. The response rate was 60% and all respondents were non-nationals.

Participants believed that they provided proper instructions on drug administration; however, they agreed that they had limited knowledge in the area of diabetes, which prevented them from providing advice with regards to side effects, drug-drug interactions, dose adjustment, and proper storage conditions.

A second study from Saudi Arabia (Al-Shaqha and Zairi, 2003) utilized Total Quality

Management (TQM) and Continuous Quality Improvement (CQI) concepts (Al-Shaqha and

Zairi, 1998) to determine how well critical factors for practice management of pharmaceutical care were implemented in five major Saudi Arabian governmental hospitals. They also explored the extent to which pharmaceutical care services had been adopted, and identified barriers to its implementation. A multiple case study approach was used. Two out of the five hospitals had adopted and implemented the needed critical factors for pharmaceutical care practice management. These were: 1) understanding of pharmaceutical care definitions, 2) accessibility to patient-centered services, and 3) pharmacist’s role and attitude towards pharmaceutical care. The study identified several other factors that needed to be improved in order to enhance pharmaceutical care services. These factors were: pharmaceutical care mission statement, organizational structure that does not segregate patient care and drug delivery systems, human resources, automated dispensing systems, pharmaceutical care practice standards, pharmacist authority and responsibility, and collaboration among health care providers. The study also found

disparity in the provision of pharmaceutical care among the participating hospitals which was attributed to lack of clear short- and long-term goals pertaining to the implementation of pharmaceutical care and lack of pharmaceutical care practice standards. A number of barriers such as lack of time, lack of personnel, lack of management support, opposition of other health care providers, and lack of appropriate documentation systems were identified.

The study by Awad et al. (2006) described current pharmacy practice in general public hospitals in Kuwait, explored pharmacists’ awareness of pharmaceutical care, identified pharmacists’ willingness to implement pharmaceutical care practice, and identified barriers to implementation of pharmaceutical care. All 80 pharmacists working in four randomly selected general hospitals in Kuwait were approached and 61 (76.3%) agreed to participate in the study.

Data were collected by face-to-face structured interviews. Thirty (49.2%) participants reported providing pharmaceutical care in their practice settings. Several binary logistic regression models were constructed to examine the effect of pharmacist and practice characteristics on several indicators of pharmaceutical care (criterion variables): checking the appropriateness of prescriptions, medication counseling, and pharmacists’ awareness of pharmaceutical care concept, main focus, and objectives. Only gender (male) and university of graduation (Kuwait) were significant predictors of awareness of pharmaceutical care objectives, whereas the effect of pharmacist and practice characteristics was not significant on other criterion variables. Major barriers to the implementation of pharmaceutical care were lack of time, shortage of staff, lack of knowledge, training, resources, and communication skills.

Al-Arifi et al. (2007) surveyed a random sample of 800 pharmacists from Saudi Arabian hospitals, health centers, and community pharmacies to determine their understanding, attitudes,

and perceived barriers to the provision of pharmaceutical care. The response rate was relatively low (47%) and the respondents were mainly from the community pharmacies (72%), which are staffed exclusively by non-nationals. The self-administered survey instrument was delivered by hand to all participants and was collected by the same person. Participants showed relatively good understanding of pharmaceutical care with female and older pharmacists showing better understanding. Participants also had a favorable attitude toward pharmaceutical care with male pharmacists and those employed in community pharmacies having more positive attitudes than institutional pharmacists. The identified barriers were not very different from those identified in the two preceding studies. The most important barriers were lack of clinical knowledge, inability to solve drug-therapy problems, lack of drug information resources, no private counseling area, lack of time, and lack of support from managers.

Another study by Al-Arifi (2008) examined Saudi community pharmacists’ attitudes toward mental illness, providing pharmaceutical care to mentally ill patients, and perceived barriers to pharmaceutical care. Seventy pharmacists employed in community pharmacies authorized by the law to dispense controlled psychotropic drugs were approached and 43 (60%) participated in the study. Of the participants, 88% believed that mental illness was like any other illnesses, 66% agreed that mentally ill patients were different from other patients and could easily be identified, and 33% disagreed that judgment is impaired in mentally ill patients. In general, participants showed a positive attitude to mental illness, but were uncomfortable providing pharmaceutical care services such as counseling and performing follow-up assessment to mentally ill patients. Perceived barriers to providing pharmaceutical care to this population were lack of clinical knowledge, lack of communication skills, lack of private counseling area, lack of time, and shortage of staff.

The fifth Saudi study was by Al-Aqeel and Abanmy (2008), who randomly surveyed one pharmacist from each of 64 primary health centers in Riyadh in order to determine: 1) number and type of prescriptions dispensed, 2) interventions performed by pharmacists, 3) perceived barriers and facilitators to the implementation of pharmaceutical care, 4) the extent of pharmacists’ participation in continuing education programs. The response rate was 53%. In terms of pharmaceutical care services provided, most respondents (94%) claimed that they provided patient education regarding the dose and duration of therapy, and almost three quarters

(74%) monitored medication compliance, and to a lower extent (59%) monitored adverse drug reactions. Perceived facilitators of pharmaceutical care were considering pharmaceutical care as part of their duties and believing that it increased their job satisfaction. Perceived barriers were a shortage of pharmacists in health centers, lack of access to patients’ medical records, unavailability of a private counseling area, pharmacists’ lack of competency, and poor patient interest.

In the UAE, Alomar et al. (2011) used a simulated patient approach to investigate how community pharmacists performed patient counseling, since it is an important part of the pharmaceutical care model, for a prescription that contained diabetes and asthma drugs. The aim was to assess the type of information pharmacists provided to the patients and their way of dealing with a circumstance that involved some missing information such as patient age, duration of treatment, and instructions for use, as well as inclusion of an incorrectly prescribed medication. A performance assessment sheet based on the ASHP guidelines on pharmacist- conducted patient education and counseling was used. About 50% of the UAE pharmacies participated mainly from four emirates (Abu Dhabi, Dubai, Sharjah, and Fujairah). All community pharmacists involved in this study were non-nationals and the majority were from

South Asia. The majority (90%) of pharmacists filled the prescription without exploring the prescription’s missing contents or identifying the prescription error. None of the pharmacists contacted the prescriber for the missing information and only 9% recommended that the patient should approach the prescriber regarding the duration of treatment. Although 58% of the pharmacists explained how to use the prescribed inhaler, none of them demonstrated its use.

Only 35% of the pharmacists provided appropriate instructions on the dose and frequency of the prescribed medications, and only one pharmacist advised the patient that one of the prescribed drugs, prednisolone was contraindicated in her case. Important features of appropriate patient counseling which were found lacking in the UAE community pharmacists were clinical knowledge, attitude toward patient care, and communication skills whether with patients or with other health care providers.

A second study from the UAE (Hasan et al., 2011) examined community pharmacist/pharmacy characteristics and barriers to the provision of patient-centered services.

The self-administered survey was delivered by hand to one pharmacist from each 700 randomly selected community pharmacies. The response rate was 49%. Similar to previous studies (Al-

Arifi et al., 2007; Al-Fadhel and Nylor, 2002; Alomar et al., 2011), all respondents were non- nationals and mainly from India, followed by Egypt. The study identified several barriers such as lack of computerized drug information resources, lack of internet access, lack of time, resistance from physicians, and lack of patient demand. Additional barriers which were perceived to prevent professional development in the UAE were the high turnover of pharmacists and lack of professional organizations to represent the pharmacists.

The last and most recent study on the implementation of pharmaceutical care was from

Kuwait. Katoue et al. (2013) investigated community pharmacists’ awareness of metabolic syndrome (group of factors that increase the risk of cardiac diseases) and their involvement in identifying, managing, and monitoring such patients. A random sample of 225 pharmacists was approached to participate in the study and 220 (97.8%) agreed. Data were collected by face-to- face structured interviews. The study revealed that participants had very limited knowledge of metabolic syndrome. Of the 220 participants, only one participant managed to identify the conditions related to metabolic syndrome. The most frequently provided services for the identification and management of metabolic syndrome were height and weight measurement, blood pressure measurement, and blood glucose measurement. Waist size measurement and measurements of cholesterol and triglycerides levels were the least provided services.

Participants were highly involved in counseling patients about changing life style behaviors such as diet and exercise, but were less involved in follow-up assessment and documenting pharmaceutical care services.

1. Summary of Studies on Pharmaceutical Care in the Arabian Gulf Region

Most research on pharmaceutical care originated in the KSA (5 studies) followed by

Kuwait (2 studies) and UAE (2 studies). More than half of the studies (56%, n = 5) focused on community pharmacists (Al-Arifi, 2008; Al-Fadhel and Nylor, 2002; Alomar et al., 2011; Hasan et al., 2011; Katoue et al., 2013), while one third (33%, n = 3) examined institutional pharmacists

(inpatient or outpatient settings, or health centers) (Al-Shaqha and Zairi, 2003; Al-Aqeel and

Abanmy, 2008; Awad et al., 2006). Only one study examined both institutional and community pharmacists (Al-Arifi et al., 2007). Overall, it is apparent that the implementation of

pharmaceutical care in this region is still in its early stages and there is a lot to be done to enhance and routinize its practice. Perceived barriers to the provision of pharmaceutical care were similar across the Gulf States. They included pharmacist-based barriers (clinical knowledge and communication skills); pharmacy-based barriers (shortage of pharmacists, time, availability of a private counseling area, and access to drug information resources); and patient-based barriers (patient demand).

Section III: Barriers to and Facilitators of Pharmaceutical Care Globally

Older studies on pharmaceutical care have indicated that pharmacists showed high intentions and willingness to implement pharmaceutical care, but very few actually had developed this practice (Odedina et al., 1995; Farris and Schopflocher, 1999). Findings from recent studies have not been very different in that they showed that pharmacists either did not incorporate pharmaceutical care into their daily practice or provided limited pharmaceutical care services (AbuRuz et al., 2012; Fang et al., 2011; Hughes et al., 2010; Ngorsuraches and Li,

2006). Several barriers that inhibit the widespread adoption and implementation of pharmaceutical care have been discussed widely in the literature.

The purpose of this review is to identify barriers and facilitators of the implementation of pharmaceutical care that have been investigated globally in the literature and which can be used as the basis to effect a change in practice for this study. A search of MEDLINE, EMBASE, and

International Pharmaceutical Abstracts databases was conducted from 1990 to August 2013, using the search terms pharma*, care, cognitive services, disease management services, medication therapy management, medication management services, pharm* expanded services, clinical services, barriers, facilitators in different combinations. The database search was

complemented by a search of reference lists in relevant articles and by a Google search. Only empirical studies in the English language were retrieved.

Discussion of factors influencing pharmaceutical care provision is organized, according to Campagna and Newlin’s (1997) classification of factors influencing drug-therapy decision making, into individual and environmental factors.

1. Individual Factors

In the pharmaceutical care practice model, pharmacists work in collaboration with patients and their other health care providers to achieve positive therapeutic outcomes for the patient (Cipolle et al., 2004; Strand et al., 1991). Accordingly, individual factors that influence the provision of pharmaceutical care were categorized into those related to pharmacists and those related to individuals other than pharmacists.

1.1. Pharmacist-Related Factors

Factors specific to the pharmacist included: pharmacist awareness and understanding of the concept of pharmaceutical care, competency, attitudes, and personality. These are discussed in turn below.

1.1.1. Awareness and Understanding of the Concept of Pharmaceutical Care

Pharmacists in the Arabian Gulf region appear to have different levels of understanding of pharmaceutical care. Al-Shaqha and Zairi (2003) reported varied extent of understanding of the notion of pharmaceutical care amongst hospital pharmacists in Saudi Arabia. Interviewees from five major hospitals considered it as either patient-oriented, monitoring the outcomes of the therapy, identifying drug-drug interaction, or undertaking responsibility for patient outcomes.

Another survey of pharmacists in Saudi Arabia (Al-Arifi et al., 2007) also reported considerable differences in hospital and community pharmacists’ level of understanding of pharmaceutical care-related statements. In Kuwait, Awad et al. (2006) obtained similar findings: pharmacists from 4 secondary care public hospitals provided contradictory responses regarding the focus and objectives of pharmaceutical care. Only 18% of pharmacists had an appropriate understanding of the basic knowledge of pharmaceutical care.

In Xian city (Northwest China), a survey of community pharmacists assessed their basic understanding of the concept of pharmaceutical care and pharmacists’ role in it. Pharmacists’ responses revealed acquiescent response bias. They agreed on two false items included in the questionnaire, which indicated that they had limited understanding of the goal and functions of pharmaceutical care (Fang et al., 2011).

Understanding of pharmaceutical care services was better in other countries. For example, in New Zealand, more than 60% of community pharmacist correctly agreed with 10 statements that described pharmaceutical care services (Dunlop and Shaw, 2002). In Thailand,

70% of pharmacists had proper understanding of the main goal and basic concepts of pharmaceutical care based on the percentage of correct responses to six statements

(Ngorsuraches and Li, 2006).

1.1.2. Competency

Ten studies in four countries identified pharmacist competency as a barrier.

United States

In Iowa, a multi-case study design that sampled contrasting groups in which six pharmacy owners (3 pharmacies randomly selected from a group of 10 that changed their practices and another 3 from a group of 10 pharmacies that did not change their practices) were surveyed and interviewed to identify factors affecting pharmacy practice change. The factors discriminating provider pharmacies from non-providers were adequate clinical skills, training in pharmaceutical care, participating in continuing education seminar, and maintaining a membership with pharmacy organizations (Doucette and Koch, 2000).

In their web survey of Texas pharmacists to determine their confidence in and intentions to provide MTM services, Moczygemba et al. (2008) found that pharmacists were least confident in identifying medication-related problems and documenting the necessary steps to resolve these problems. Also, pharmacists had difficulty understanding laboratory results and detecting untreated conditions.

A survey of community pharmacists in West Virginia, USA, in 2009 demonstrated that pharmacists were least comfortable with preparing pharmacotherapy action plans and educating patients about disease prevention services. Respondents perceived their educational background as the most important facilitator (Blake et al., 2009). Another web survey of community pharmacists in West Virginia, USA, in 2010 reported that 73% of respondents believed that they had the necessary knowledge and skills to provide MTM services and 60% had the intention to provide MTM services; however, only 17.8% stated that their pharmacies provided MTM services. Confidence and educational background were regarded as facilitators to the provision of MTM services, while lack of time was the major barrier followed by physicians’ attitudes

(Blake and Madhavan, 2010).

In another recent national survey in the USA, 95.7% of community pharmacists who participated in a web survey showed their preparedness and readiness to provide MTM services.

Of those, 65% indicated that they were actually providing these services to Part D Medicare enrollees. Since a large proportion of participants (65%) had either residency or advanced training, results may have manifested self-selection bias (Law et al., 2009).

United Kingdom

In Scotland, most of the 16 community pharmacists and key policy-makers participating in qualitative interviews expressed the need for clinical knowledge and process-oriented courses for pharmacists to provide pharmaceutical care (Krska and Veitch, 2001). Another Scottish study indicated that community pharmacists in the Grampian area believed that young pharmacists possessed and used clinical skills all the time, which was attributed to the new pharmacy programs that are clinically oriented. Older pharmacists, on the other hand, were believed not to have clinical knowledge; however, they had a diverse set of skills (Dinnie at al., 2004).

In Great Britain, 30% of surveyed community pharmacists reported lack of confidence in adopting the ‘extended role’ activities2 that are associated with the clinical knowledge, and 82% felt that training should be undertaken before providing extended role activities. Level of education, level of autonomy, and regular contact with the health authority pharmaceutical advisor were identified as facilitators to involvement in extended role activities (Ruston, 2001).

2 Extended role is the involvement of pharmacists in activities that goes beyond dispensing and requires specialized skills (Ruston, 2001).

New Zealand

In New Zealand, more than half of community pharmacists surveyed identified lack of therapeutic knowledge and lack of problem solving skills as significant barriers to the implementation of pharmaceutical care, while only 16% considered communication skills as a facilitator (Dunlop and Shaw, 2002).

Spain

Thirty-three semi-structured interviews and two nominal group processes were conducted to identify and assess facilitators to pharmaceutical care services in community pharmacies in

Spain. The purposive sample constituted pharmacists who provided pharmaceutical care services and strategists who made decisions on the design and implementation of pharmaceutical care related programs. Clinical education at both under- and post-graduate level and pharmacists’ attitude toward the change in the practice were the top ranked facilitators by strategists; however, community pharmacists expressed their views differently believing that reimbursement was the most important facilitator, followed by a clinical component in university curricula (Gastelurrutia et al., 2009).

1.1.3. Personality

Personality trait factors have been posited to influence individual behavior (Ornstein et al., 1988); however, there has only been one study related to pharmacists’ personality as a facilitator of pharmaceutical care. Kittisopee (2001) investigated the effect of personality trait factors on the provision of pharmaceutical care behavior using the Big Five inventory. Of the five factors (extraversion, neuroticism, openness, agreeableness, and conscientiousness), only

openness, which is characterized by specific qualities such as intellect and autonomy, was found to be significantly related to the provision of pharmaceutical care.

1.1.4. Pharmacists’ Attitudes

Attitudes are beliefs, feelings, or values pharmacists attach to a behavior. Attitudes have received considerable attention in the literature as important factors that influence pharmacists’ behavior with respect to pharmaceutical care (Campbell, 1998; Raisch, 1993; Campagna and

Newlin, 1997; Hansen and Ranelli, 1994; Penna, 1990). Reluctance and lack of commitment among pharmacists themselves are examples of attitudes that have been regarded as major obstacles to pharmaceutical care (Campbell, 1998; Penna, 1990).

Several studies which investigated the relationship between pharmacists’ attitudes toward pharmaceutical care and pharmaceutical care behavior found that attitudes significantly influenced pharmaceutical care behavior (Kittisopee, 2001; Odedina et al., 1997; Zardain et al.,

2009).

Pharmacists’ positive attitudes toward pharmaceutical care have been reported in many studies from around the globe (Al-Arifi et al., 2007; Cordina, 1999; Dunlop and Shaw, 2002;

Latif and Boardman, 2008; Venkataraman et al., 1997). Surveyed pharmacists in Saudi Arabia and West Virginia, USA, had a positive attitude toward pharmaceutical care; however, more than

60% of Saudi pharmacists viewed it as a complex service (Al-Arifi et al., 2007; Venkataraman et al., 1997). In 2008, community pharmacists accredited to provide medicines use reviews (MUR)3

3 Medicines use review is an advanced service undertaken by accredited pharmacists that covers a comprehensive review for patients with polypharmacy to help them manage their medications and to identify any drug-related problems (Bradley et al., 2008; Latif and Boardman, 2008).

in the United Kingdom believed that MUR would extend their role in pharmacy practice and would provide a good opportunity to use their underutilized clinical skills (Latif and Boardman,

2008). Interestingly, three years later, the percentage of pharmacists who thought that MUR would extend their role dropped from 93% to 82%, and the percentage of pharmacists who regarded MUR as a waste of pharmacists’ time increased from 2% to 7% (Latif et al., 2011). In

New Zealand, 60% of community pharmacists viewed pharmaceutical care as the future of the pharmacy profession and 75% thought that providing such services would require advanced clinical knowledge (Dunlop and Shaw, 2002). A survey of community pharmacists in Malta revealed that 72% of pharmacists showed their willingness to provide pharmaceutical care and its perceived importance (Cordina, 1999).

1.2. Factors Related to Other Individuals

Not only does pharmacists’ attitude affect their pharmaceutical care behavior, but their normative beliefs, that is, beliefs that social influencers such as physicians, patients, and pharmacy managers approve or disapprove of their behavior do so as well (Latif, 1998).

The literature search identified 15 studies between1993 and 2010 that investigated the relationship between pharmacists and perceived important social influencers on the provision of pharmaceutical care. All these studies reflected the perceptions of pharmacists about the attitudes of physicians, patients, or pharmacy managers and administrators. The perceived attitude of each social influencer is presented in turn.

1.2.1. Physician Attitude

Most of the studies in this review regarded lack of physician support as a great barrier to the provision of patient care service. In a qualitative study, Canadian and Dutch pharmacists

expressed their concerns about the receptivity of physicians to their pharmaceutical care services.

Pharmacists stated that the concept of pharmaceutical care is difficult to implement and that physicians may perceive that, by providing pharmaceutical care, pharmacists are seeking power and invading their territory (Reebye et al, 1999). Interesting findings were obtained from a telephone survey of community pharmacists in Florida, USA, by Odedina et al. (1995), in which physicians’ attitudes were viewed differently. Half of pharmacists who were non-providers of pharmaceutical care thought that their physicians were not cooperative and cited this attitude by physicians as a barrier to pharmaceutical care. Conversely, providers of pharmaceutical care believed that their physicians were cooperative, citing this as a factor that facilitated their provision of pharmaceutical care services. In a qualitative study, 11 community chain pharmacists in Indiana, USA, stated that physicians were not receptive to their intervention, especially older physicians, and viewed accessibility of physicians as the greatest barrier to their provision of asthma management services (Amsler et al., 2001). A national web survey in the

USA found that 71% of responding outpatient and community pharmacists had difficulties accessing primary care providers and 62% reported lack of physicians’ recognition of pharmacists as providers of MTM services as a barrier (Loundsbery et al., 2009).

In England, a multi-method study of pharmacists in primary care organizations identified lack of physician support as the most important barrier to the implementation of MUR services.

Sixty-two percent of survey respondents reported that physicians were not cooperative, an opinion that was supported by interviewees’ comments. Lack of communication and disagreements about the appropriateness of the intervention and the type of patient to target adversely affected the pharmacist-physician relationship (Bradley et al., 2008). In Switzerland, a

qualitative study of community pharmacists on medication review services4 revealed that collaboration with physicians was considered as an important barrier. Physicians were difficult to contact, hard to convince to accept pharmacists’ recommendations, and viewed pharmacists as only drug dispensers (Niquille et al., 2010). Similarly, in a qualitative study by Gastelurrutia et al. (2009), community pharmacists and strategists (pharmacists who make decisions on the design and implementation of pharmaceutical care programs) viewed the relationship between

Spanish physicians and pharmacists as mainly negative and very limited, and was perceived to be a barrier. The Physicians’ Professional Association in Spain publicly declared that pharmacists should limit their activity to dispensing and that pharmaceutical care has no scientific basis. This relationship adversely affected the implementation of pharmaceutical care services (Gastelurrutia et al., 2009).

1.2.2. Patient Attitude

While physicians’ attitudes toward pharmacist provision of pharmaceutical care were considered as an important barrier, patients’ attitudes were perceived to be less negative. In a survey of pharmacists in the state of Washington, USA, more than 50% of pharmacists viewed their patients’ attitude toward themselves and their cognitive pharmaceutical services5 as favorable (Christensen and Hansen, 1999). On the other hand, a survey of New Mexico community pharmacists, found that patients were uninterested in pharmacists’ cognitive

4 Medication review is a clinical assessment of patients’ drug regimen to promote safe and effective use of medications (Niquille et al., 2010).

5 Cognitive pharmaceutical services are defined as the use of specialized knowledge by the pharmacist to promote safe and effective drug therapy through interaction with patients and other health care providers (Hopp et al, 2005; Mandt et al, 2009; Raisch, 1993; Roberts et al, 2003).

pharmaceutical services (CPS) and listed this barrier as important (Raisch, 1993). Lack of patient interest in pharmacists’ pharmaceutical care services was also reported by pharmacists in Saudi primary health centers (Al-aqeel and Abanmy, 2008). Almost 88% of those surveyed described their patients as always being in a hurry and not interested in pharmaceutical care services. Lack of patient expectation for pharmaceutical care services was reported by 25% of community pharmacists surveyed in a Danish study, who identified this patient attitude as a barrier (Rossing et al., 2001). A survey of community pharmacists in New South Wales, Australia, found that patients were the major perceived barrier to the provision of asthma management services.

Patient-related barriers stemmed from patients opposing the pharmacists due to their faith in physicians (Kritikos et al., 2010).

1.2.3. Manager and Administrator Support

Lack of management support is another factor that influences pharmacists’ provision of pharmaceutical care. In a Saudi study that interviewed pharmacists from five major hospitals, pharmacists reported that pharmacy departments were not given much attention by their administrators, which was perceived as a great barrier (Al-Shaqha and Zairi, 2003). In a survey of rural community pharmacies in West Virginia, USA, pharmacists’ attitude toward providing patient care services was found to be correlated with owners’ support and time (Venkataraman et al., 1997). A survey by Latif (1998), also in the USA, examined the relationship between normative beliefs of community pharmacists about important others (managers and patients) and pharmacists’ clinical decision-making (as part of pharmaceutical care activities) behavior.

Pharmacists’ perception of the support of important others was important to and accounted for

7.6% of the variance in their clinical decision making behavior.

2. Environmental Factors

According to Campagna and Newlin (1997), environmental factors can be situational

(internal situation within the pharmacy) or contextual (external factors to the pharmacy and related to health care systems or to social factors that influence pharmacist professional acts).

Pharmacy-level situational factors identified in this review included time, support personnel and technology, private counseling area, and documentation system. Contextual factors at the health care system-level were reimbursement and access to patient clinical data, while those related to the social context were cultural and linguistic.

2.1. Situational Factors (Pharmacy-Related Factors)

2.1.1. Time

It is apparent that lack of time is a universal barrier; almost all published work on barriers to pharmaceutical care identified this factor irrespective of the type of practice setting (Al-Arifi et al., 2007; Awad et al., 2006; Blake et al., 2009; Blake et al., 2010; Dinnie et al., 2004; Dunlop and Shaw, 2002; Kritikos et al., 2010; Krska and Veitch, 2001; Latif and Boardman, 2008;

Lounsbery et al., 2009, Mah et al., 2009; Niquille et al., 2009; Raisch, 1993; Rossing et al., 2001; van Mil et al., 2001; Venkataraman et al., 1997).

Although the above mentioned studies identified time as a barrier to the provision of pharmaceutical care, none mentioned how it affected its provision. Only the studies that discussed the influence of time on pharmacists’ performance of pharmaceutical care are presented here. Lack of time was cited by five out of 15 clinical pharmacists working in five major hospitals in Riyadh, Saudi Arabia, as a barrier to extending their patient focused services to all patients; three pharmacists felt that lack of time prevented them from having a chance to

provide pharmaceutical care at all (Al-Shaqha and Zairi, 2003). Pharmacists working in chain pharmacies in Indiana, USA, also reported that due to lack of time only new prescriptions, drugs with complicated instructions, and paediatric medicines received the highest level of counseling, while counseling for refills was ignored since patients were familiar with their drugs (Amsler et al., 2001). A national web survey of outpatient and community pharmacists in the USA revealed that lack of time not only hindered the provision of pharmaceutical care services, but also affected ability to document the services provided. Pharmacists documented their interventions only when such services were reimbursed (Lounsbery et al., 2009).

2.1.2. Support Personnel and Technology

Shortage of staff has been reported as an important barrier to pharmaceutical care services by many researchers in the USA, Great Britain, Denmark, and Kuwait (Awad et al.,

2006; Lounsbery et al., 2009; Rossing et al., 2001; Ruston, 2001). Awad et al. (2006) suggested delineation of pharmacist and pharmacy technician roles and hiring more pharmacists to support the provision of pharmaceutical care in Kuwaiti hospitals. Researchers from the USA and

Scotland reported, based on pharmacists’ opinions, that availability of pharmacy technicians frees pharmacists from dispensing to perform pharmaceutical care (Amsler et al., 2001; Krska and Veitch, 2001). Raehl et al. (1992) found a positive association between technician use and providing clinical services in the USA hospitals. The use of technicians was dependent on hospital size, teaching affiliation, and ownership, and on the education level of pharmacy managers.

Teamwork and delegating tasks were facilitators of practice change reported by a purposive sample of Australian community pharmacists and strategists participating in semi-

structured interviews. According to participants, teamwork and task delegation involved employing new support staff to help maintain the provision of CPS, reassigning work duties, motivating staff by making them feel responsible for the task and part of the pharmacy team. The outcome of this was freeing pharmacists’ time to focus on the CPS (Roberts et al., 2005).

Support personnel were also identified as a facilitator of patient education activities in a 2001 study of community pharmacists in Denmark who reported that educating and motivating technicians, and delegating tasks to them assisted in patient education activities (Pronk et al.,

2001).

Other solutions that were suggested to free up pharmacists’ time were the availability of technical support such as computers to assist in recording patient information and medication histories and the use of automated dispensing devices (Amsler et al., 2001). However, some researchers have also reported that computers were not used to the fullest extent in many community pharmacies in Saudi Arabia and Scotland, respectively (Al-Arifi et al., 2007; Krska and Veitch, 2001). Lack of drug information databases to obtain up-to-date information about medications or lack of summarized drug information were also reported in these two studies and an additional study (Hasan et al., 2011). Information technology was found to be a facilitator in two recent qualitative studies. The use of a computer system for prescription management, patient information, and supportive drug information; and use of the internet were believed to be very useful tools that assisted Norwegian and Danish community pharmacists in detecting drug- related problems, facilitating their prescription interventions, and implementing CPS (Hopp et al., 2005; Mandt et al., 2010). In summary, the availability of pharmacy technicians, computer systems, and drug information databases has been perceived as a facilitator of pharmaceutical care provision.

2.1.3. Private Counseling Area

Several researchers in the USA have reported that pharmacists believed that the pharmacy layout should be redesigned to accommodate a private area for counseling their patients. Lack of privacy was reported to be particularly problematic when counseling about sensitive medical conditions or stigmatized diseases (Amsler et al., 2001; Berger and Grimley,

1997; Raisch, 1993). In Canada, Saudi Arabia, and Scotland, pharmacists thought that their pharmacies lacked the appropriate layout to provide pharmaceutical care (Al-Arifi et al., 2007;

Cockerill et al., 1996; Dinnie et al., 2004; Krska and Veitch, 2001). In Great Britain, surveyed community pharmacists perceived lack of a private area for consultation as a barrier and reported that only 24% of pharmacies had private consultation areas and just 14% of pharmacies had a private room (Ruston, 2001). This barrier had not been resolved by 2008 when a survey found that about 25% of pharmacists employed in one UK community pharmacy chain reported that their pharmacies lack an accredited private consultation area in which to provide MUR services

(Latif and Boardman, 2008).

2.1.4. Documentation System

Documenting pharmaceutical care activities is necessary to facilitate continuity of care and is a tool to evaluate drug use. Lack of a documentation system has a negative impact on the quality of patient care and patient outcome (Al-Ahdal et al., 2003). The study by Al-Shaqha and

Zairi (2003) showed that interviewed pharmacists in the five major hospitals in Saudi Arabia rarely documented their pharmaceutical care activities because of the unavailability of a well- established documentation system. Another study of pharmacists in Saudi hospitals by Al-Ahdal et al. (2003) investigated the rate of documentation of their interventions. They found that about

37% of surveyed pharmacists in 16 hospitals actually documented their interventions.

Pharmacists with post graduate education and those who graduated from North American universities documented their interventions at a rate higher than graduates of other universities.

Barriers were lack of time to document (59%), lack of a documentation system (50%), lack of access to patient records (27%), and no perceived need to document (4%). In the UK, multimodal methods were used to determine barriers to documentation of inpatient pharmacists’ interventions in London Hospital. The pharmacist survey found that 74% of participants preferred writing their interventions on sticker notes or providing verbal recommendations rather than documenting them in patients’ medical records. Focus group discussions revealed that most pharmacists were worried about liability issues and the criticism they would receive from physicians if they attempted to document their input. Few reported that they did not document due to lack of time or unavailability of patients’ medical records (Pullinger and Franklin, 2010).

2.2. Contextual Factors

2.2.1. Health Care System-Related Factors

2.2.1.1. Reimbursement

This contextual factor is only relevant to community pharmacy settings. Studies prior to the implementation of a reimbursement structure for pharmaceutical care services recognized lack of reimbursement as the most common barrier (Krska and Veitch, 2001; Rossing et al.,

2001; van Mil et al., 2001; Venkataraman et al., 1997). Recent studies have not identified reimbursement per se as a barrier; however, issues related to billing were mentioned. This may be due to the application of some reimbursement policies in the UK and parts of North America, which has created billing issues. For instance, in the UK, MUR and prescription intervention services provided by accredited pharmacists have been reimbursed since 2005 (Department of

Health, 2005; Pharmaceutical Services Negotiating Committee, 2011). In Canada, most

provinces reimburse pharmacies for pharmaceutical care services (Canadian Pharmacists

Association, 2012). State Medicaid programs in some US states, such as North Carolina,

Minnesota, Missouri, Mississippi, Wyoming, Florida, and Iowa reimburse pharmacies for MTM services (American Society of Health-System Pharmacists, 2008; McGivney, 2007).

According to Nutescu and Klotz’s analysis (2007), barriers in seeking reimbursement in the USA from the Medicaid and Medicare programs, and third-party payers for patient care services, such as pharmaceutical care and MTM services, included: 1) third party payers being unfamiliar with pharmacists’ role in patient care, 2) no proper billing codes for pharmacists’ patient care services, and 3) lack of understanding of reimbursement mechanism on the part of pharmacists.

Lack of understanding of reimbursement systems for patient care services in community pharmacies has been reported in several studies. A survey by Law et al. (2009) indicated that one of the top barriers perceived by community pharmacists in the USA was the uncertainty of reimbursement. Health plans with different specifications for MTM services, different billing procedures, and reimbursement requirements confused pharmacists and led to more time consumed on reimbursement issues, which in turn affected the development and expansion of

MTM services in the community pharmacies. Lounsbery et al. (2009) found that reimbursement related issues was one of the most commonly identified barriers to MTM services in the USA among pharmacists working in outpatient settings. Their web survey covered providers of MTM who were reimbursed for their services by several health plans, providers who were not reimbursed, and non-providers. Almost 71% of those who were reimbursed felt the amount was

insufficient, while 67% reported lack of understanding on how to bill the payers and lack of success to obtain reimbursement.

In a survey of community pharmacists in Québec City, factors positively associated with pharmacists’ billing behavior for cognitive services (pharmaceutical opinions to physicians and refusal to dispense) were categorized as: 1) predisposing factors, which included young age, attending continuing education programs on cognitive services, and being familiar with the billing process; 2) enabling factors, which included availability of technical staff and computer programs that support pharmacists’ decision making process; and 3) reinforcing factors, such as pharmacists’ perception that their intervention was reimbursed by the provincial drug plan. The most common barriers to the billing process as perceived by the community pharmacists were no personal financial benefit, lack of time, physicians’ negative response, and complicated billing process (Kroger et al., 2000). The findings of a survey, in 2005, of community pharmacists in

Nova Scotia, Canada, regarding billing behavior for inhaled respiratory medication were different: young age and continuing education were not influential. However, other facilitators and barriers were similar. The main facilitators were awareness of the fee paid for education and counseling of Aerochamber users, and that the claims were always reimbursed. The main barriers were the tedious and time consuming billing process (Murphy, 2005).

In their web survey of community pharmacists in Alberta, Canada, Mah et al. (2009) reported that 97% of participants felt that reimbursement for chronic disease management services6 should not be combined with the dispensing fee, 59% thought that pharmacists should

6 Chronic disease management is a proactive way of supporting patients with chronic conditions to manage their medications, prevent disease progression, and improve their health (Mah et al., 2009).

have a share of the reimbursement that the pharmacy receives, and 76% suggested that the payment should be in the form of a fee-for -service. Of note, this was prior to any government reimbursement for pharmaceutical care services in Alberta, which was implemented in July 2012

(Alberta Health, Health Benefits and Compliance, 2012).

2.2.1.2. Access to Patient Data

In a study of hospital pharmacists in Riyadh, Saudi Arabia, almost 27% of pharmacists surveyed pointed out that they had no access to their patients’ medical files. This barrier was predominant in private sector hospitals (Al Ahdhal et al., 2003). In another Saudi study, most pharmacists (73%) employed in public health centers in Riyadh city agreed on the importance of having access to patients’ health records to render pharmaceutical care services (Al-Aqeel and

Abnamy, 2008). Lack of access to patients’ health records has been identified as a major impediment to the provision of pharmaceutical care by both chain pharmacists and their patients in Indiana, USA. Pharmacists believed that they would be in a better position to provide more focused interventions if medical history, lab results, and treatment protocols could be easily accessed, while patients strongly recommended having their medical records electronically linked between pharmacists and physicians, so that their information would need to be obtained only once (Amsler et al., 2001). Fifty percent of respondents to a survey of community pharmacists in the United Kingdom also felt that lack of access to patients’ health records affected the value of the provided MUR services (Latif and Boardman, 2008).

2.2.2. Social Context Factors

2.2.2.1. Culture and Language

The main cultural and linguistic barriers encountered by North American health care providers are with patients from minority groups of immigrants from South Asia, South

America, and China (Lai, 2005; March and Gong, 2005). In contrast, in the Arabian Gulf region, due to a shortage of local health care providers, most health care providers are from foreign countries, especially South Asia. In both cases patients suffer. Verbal communication is an important element in quality patient care, without which conveying medication instructions to patients is problematic. Patients already have trouble dealing with complex drug regimens. They do not need the additional burden of inability to communicate with their health care providers.

Weiss et al. (2007) studied New York City community pharmacists’ access to, and provision of, comprehensible medication instructions for limited English proficient (LEP) patients. Eighty eight percent of pharmacists reported that they encountered LEP patients on a daily basis but less than 40% provided translated prescription labels. The most important factors affecting the availability of multilingual drug information were access to multilingual resources such as translation software and electronic dictionaries, personnel translating capacity, cost, time, and concerns about the accuracy and practicality of translated information.

Cultural barriers are as important. Pharmacists need to know how to deal with culturally sensitive issues to gain patients’ trust and assure their compliance, and they should be knowledgeable of their patients’ cultural beliefs. In a medical center in Seattle, USA, a factor that facilitated the success of a program that offered diabetes classes to culturally diverse patients

was the sessions pharmacists, along with the multidisciplinary team, had with a cultural mediator for three to six months to learn about the cultures and health beliefs of their patients (Lai, 2005).

A study of internationally trained community pharmacists (ITP) in Great Britain has captured both language and cultural challenges. ITPs participating in eight focus groups reported that they had difficulty understanding patients’ native accents, especially when they were first appointed. However, participants did not recognize that their own accent could also be a barrier until some of their British patients requested a British pharmacist instead to counsel about their medications, which made the ITPs feel angry and embarrassed. Also, two participants noted a problem advising female patients on emergency hormonal contraception due to their cultural values (Ziaei et al., 2011).

3. Summary of Barriers to and Facilitators of Pharmaceutical Care

A review of the pharmaceutical care literature identified hundreds of articles that investigated the factors that influenced the provision of pharmaceutical care. It is obvious that problems hampering the growth and the delivery of pharmaceutical care, whether related to individual, environmental, or contextual factors are almost the same around the globe, though they may vary in their intensity from one practice setting to another or from one geographic region to another. Most of the aforementioned studies explored facilitators and barriers in the community pharmacy setting. Pharmacists working in this setting are more prone to face barriers when implementing pharmaceutical care than pharmacists working in other settings such as inpatient or outpatient hospital pharmacies (Holland and Nimmo, 1999c). Pharmacists who work in the hospital setting do so in the context of a multidisciplinary team where physicians are more accessible and patient records are readily available (Holland and Nimmo, 1999c). Because these

do not exist in the community settings, delivery of pharmaceutical care is more challenging.

Attitudinal factors have received most attention in the literature (Baker, 1979; Campagna and

Newlin, 1997; Hansen and Ranelli, 1994; Holland and Nimmo, 1999b; Knapp, 1979; Nelson et al., 1984). However, the importance of environmental factors cannot be ignored (Roberts, 2005).

Therefore, it can be said that both attitudinal and environmental factors should be the focus of change and the basis for selecting a theoretical framework for this study.

Section IV: Practice Change Theories and Models

For over half a century, researchers, academics, health authorities, and health associations and organizations in North America have made continued attempts to effect a change in pharmacy practice towards the implementation of patient-focused care. Despite these efforts, pharmacists themselves have not routinized the provision of pharmaceutical care in their practice. Norgaard (2000) has suggested that employing theory in pharmacy practice research will provide breadth and depth in our understanding of pharmacists’ behavior and its social context.

In this section, a number of theories and models that have been used to explain change in clinical practice and that have been applied to the implementation of pharmaceutical care are discussed. The studies that applied these theories to pharmaceutical care are also discussed. The purpose of this review was to identify a theoretical framework that could be employed in this study to explain adoption of pharmaceutical care in Oman. The theories are categorised according to Grol et al.’s typology of professional practice change theories (2005) into attitudinal, motivational, and organizational theories.

A search of MEDLINE, EMBASE, International Pharmaceutical Abstracts, Web of

Science, Scholars Portal, and PsycINFO databases was conducted from 1990, when the concept of pharmaceutical care originated, to August 2013, using the search terms pharma*, care, cognitive services, disease management services, medication therapy management, medication management services, pharm* expanded services, clinical services, survey, implementation, theory, framework, model, community, pharmacy, hospital, pharmaceutical services in various combinations. The database search was complemented by a search of the reference lists of retrieved articles. The search was restricted to empirical studies in the English language.

1. Attitudinal Theories

The main focus of attitude theories of behavioral change is the relationship between attitude, intention, and behavior (Grol et al., 2005). The Theory of Reasoned Action (TRA)

(Fishbein and Ajzen, 1975) and its expanded version, the Theory of Planned Behavior (TPB)

(Ajzen, 1991 and 2005), are the most popular of these theories in health care (Glanz et al., 1990,

1996, 2002, & 2008). The TRA suffers from a major limitation, which is the inability to predict behaviors when they are not under individuals’ complete control (Ajzen, 1985; Bagozzi and

Warshaw, 1990; Bagozzi, 1992). For that reason, the TPB and other theories, such as the Theory of Trying (TT) (Bagozzi and Warshaw, 1990) and the Attitude, Social influence, and Self- efficacy (A.S.E.) model (de Vries et al., 1995), either expanded upon the TRA or modified it.

The TPB is the theory that has been most frequently used in studies that explain the implementation of pharmaceutical care. These studies either used the TPB as is (Herbert et al.,

2006) or in hybrid models (Farris and Schopflocher 1999; Kittisopee, 2001; Odedina et al.,

1997). Other attitudinal theories that were employed in the studies described in this section

include: the Theory of Trying (TT), the Theory of Goal-Directed Behavior (TGB) (Bagozzi et al., 1992), the Triangle Model of Responsibility (TMR) (Schlenker et al., 1994), and the A.S.E. model. The attitudinal theories and the studies that employed them are presented in three groups: the TPB, other attitudinal theories, and hybrid models.

1.1. The Theory of Planned Behavior (TPB) (Ajzen, 1985, 1991, 2002, and 2005)

The TPB (Figure 1) is psycho-social in origin. Its developer, Ajzen, expanded the Theory of Reasoned Action (TRA) by adding a construct, perceived behavioral control, to overcome the

TRA’s limitation in predicting behaviors that are under incomplete volitional control. Perceived behavioral control (the individual’s perception as to how easy/difficult it is to perform the behavior) is quite similar to Bandura’s construct of self-efficacy, which is defined as the degree of perceived confidence and control over the behavior (Bandura, 1982). It influences the behavior through two pathways, one direct, and the other indirect through intentions. In the TPB, behavioral intention (perceived likelihood of performing the behavior) is the central determinant of the behavior. It is a function of three independent predictors. The first is attitude toward the behavior (the individual’s overall positive and negative evaluation of the behavior). The second is subjective norm (the social pressure to engage in the behavior). The third predictor is perceived behavioral control.

Beliefs (behavioral, normative, and control) are the underlying determinants of attitude, subjective norm, and perceived behavioral control. Accordingly, the antecedents of attitude are behavioral beliefs (beliefs that the behavior is associated with certain outcomes) weighted by evaluation of potential behavioral outcomes (value attached to each outcome). Normative beliefs

(beliefs about whether each important referent approves/disapproves engaging in the behavior)

weighted by motivation to comply (motivation to do what each important referent thinks) are the antecedents for subjective norm. Control beliefs (beliefs about the presence of factors that likely facilitate or inhibit the performance of the behavior) weighted by perceived power (perceived effect of each factor in making the performance of the behavior difficult or easy) are the antecedents for perceived behavioral control.

The TPB posits that general background factors such as demographic characteristics can influence intention and behavior indirectly. This influence is mediated by behavioral, normative, and control beliefs. By investigating the influence of demographic characteristics on behavioral, normative, and control beliefs, one can further understand what drives the target behavior.

Figure 2. Theory of Planned Behavior (Ajzen, 1985)

The TPB was used in a study by Herbert et al. (2006) to predict community pharmacists’ intention to provide Medicare MTM services in Iowa. The selection of the TPB as a framework

for their study was based on a review of the TPB (Godin and Kok, 1996), which found that the

TPB had good predictive validity for intention to perform various health-related behaviors. A random sample of 500 community pharmacy managers was mailed 2 surveys, one to be filled out by them and the other by a staff pharmacist. The response rate was 21%. Multiple regression analysis showed that all of the TPB constructs were statistically significant predictors of behavioral intention (p < 0.05) and explained 63% of the variance in pharmacists’ intention to provide MTM services. Demographic variables and past experience in a care-based practice were not significant predictors of behavioral intention. In this study, the TPB was a good predictor of behavioral intention; however, the actual behavior of providing MTM services was not investigated.

1.2. Other Attitudinal Theories

The Theory of Trying (TT), the Theory of Goal-Directed Behavior (TGB), and the

Triangle Model of Responsibility (TMR) are discussed in this section, while the Attitude, Social influence, and Self-Efficacy (A.S.E.) model is discussed under motivation theories.

1.2.1. The Theory of Trying (TT) (Bagozzi and Warshaw, 1990)

The TT (Figure 2) has a management and marketing foundation. It modifies the TRA for the same reason that led its developer to alter it, that is, the TRA only deals with behaviors that have no obstacles that would prevent the individual, who formed the intention, from performing the behavior. The TT addressed the limitations of the TRA by:

. Adding three antecedents to attitude toward trying: attitude toward success weighted by

expectation of success, attitude toward failure weighted by expectation of failure, and

attitude toward the trying process. A linear combination of the multiplicative products of

these three antecedents is posited to influence attitude toward trying.

. Adding past trying recency (a measure of how recent the behavior was performed in the

past) as a co-predictor of trying behavior along with intention to try.

. Adding frequency of past trying (a measure of how frequent the behavior was performed

in the past) as a co-predictor of intention along with attitude and social norm, and as a

co-predictor of behavior along with intention and past trying recency.

According to the TT, intention to try is a function of attitude toward trying and social norm toward trying. Past trying is divided into two variables: frequency and recency of past trying. Frequency of past trying influences both intention to try and trying behavior, while recency of past trying influences only trying behavior.

∑(beliefs Attitude toward * Evaluations) success Frequency Recency of past of past Expectation toward trying trying success

∑(beliefs Attitude toward * Evaluations) failure Attitude Intention toward to try Trying Expectation toward trying failure

∑ (beliefs Attitude toward * Evaluations) process Social norm toward ∑(normative beliefs trying *motivation to comply)

Figure 3. Theory of Trying (Bagozzi and Warshaw, 1990)

Farris and Kirking (1995) studied Michigan community pharmacists’ intention to try to prevent and correct drug therapy problems by exploring the relationships between their attitude, social norm, frequency of past trying, and intention to try using the TT. Although the TT had had very limited applications that supported its use, Farris and Kirking believed the TT possessed some advantages over the TRA that recommended its use. As opposed to the TRA, the TT acknowledges that behaviors encounter barriers and individuals have incomplete control over performing them.

Farris and Kirking surveyed a random sample of 555 community pharmacists in

Michigan. The overall response rate was 71% with a useable response rate approaching 50%.

Only social norm and frequency of past trying were found to be significant predictors of

pharmacists’ intention to try to prevent and correct drug-therapy problems, while attitude toward trying was not. Together, social norm and frequency of past trying accounted for 17% of the variance in pharmacists’ intention to try. The multiplicative products of attitude toward success and expectation of success, and attitude toward failure and expectation of failure did not predict attitude toward trying. Also, the multiplicative product of normative beliefs and motivation to comply was not a significant predictor of social norm. Only the direct effects of attitude toward success and attitude toward the process significantly predicted attitude toward trying, and normative beliefs significantly predicted social norm. Demographic characteristics and type of practice setting were not significant predictors of intention to try. In brief, the TT exhibited poor predictive validity in explaining pharmacists’ intention to try to prevent and correct drug-therapy problems.

1.2.2. The Theory of Goal Directed Behavior (TGB) (Bagozzi et al., 1992)

According to Bagozzi et al. (1992), the role of intention has been the focus of research on consumer behavior and little importance has been given to the processes between intention and behavior. They criticized the TRA and the TPB as being concerned with the antecedents of intention and not the consequences that follow intention to perform the behavior. They also criticized the TT for oversimplifying the processes of trying. They developed the TGB in an attempt to explain the intention-behavior linkage.

The TGB, like the TT, comes from the field of marketing, and it assumes that once individuals form an intention, there are ‘necessary means’, which are intermediate behaviors that need to be carried out in order to achieve the desired goal (the ultimate behavior). These means are appraised by individuals through three processes that determine how the goal will be

accomplished. The appraisal processes mediate the link between the intention and the behavior, and are posited to include: self-efficacy (degree of perceived confidence and control over the means), instrumental beliefs (judgments that the means will likely lead to the behavior), and affect toward the means (desirability of the means). Bagozzi et al. borrowed Bandura’s construct of self-efficacy; however, they defined it as beliefs about self-confidence to perform each of the intermediate behavior ‘means’ instead of the ultimate behavior. The theory also hypothesizes that the three appraisal processes should interact multiplicatively to influence the behavior.

Recency and frequency of past behavior are also co-predictors of the behavior.

Figure 4. Theory of Goal Directed Behavior (Bagozzi et al., 1992)

Following their study using the TT (1995), Farris and Kirking studied the enactment of intentions using the TGB to predict the means pharmacists would select to prevent and correct drug-therapy problems. Farris and Kirking (1998) used two surveys, identical except for the

drug-related problems presented—either drug-drug interaction or therapeutic duplication (TD). It was hypothesized that the choice among means would vary according to the type of drug-related problem. Each survey was mailed to about 50% of a random sample of 550 community pharmacists in Michigan. The questionnaire included seven ‘means’ measured by 7-point bipolar scales and participants were asked how likely they were to undertake (each of the seven means) if they identified a TD:

1) asking the patient if the TD was discussed with him/her by the prescriber

2) directing the patient to contact the prescriber

3) counseling the patient about the TD

4) communicating over the phone with someone in the prescriber’s office about the TD

5) communicating with the prescriber directly about the TD

6) providing drug-therapy recommendation to the prescriber

7) believing that the prescribers know what they do and hence no action is taken

The overall response rate was 70%. Exploratory factor analysis of the scores for the seven ‘means’ identified three factors which were labeled as high (means #1-4), medium (means

#5-6), and low (mean #7) effort means. Only high and medium effort means were investigated.

Two regression models were constructed to examine the influence of the three appraisal processes and frequency of past trying on high and medium effort means. The two regression models explained 66.2% and 72.8% of the variance in medium and high effort means, respectively. The three way interaction of the appraisal processes, hypothesized by the TGB, was

not statistically significant for either medium or high effort means. Due to multicolinearity, frequency of past trying was included in the models instead of past behavior recency; however, it was not found to be significant in any of the models. Pharmacy type and self-schemata were significant moderators of the predictors of high effort means. The hypothesis that choice among means would vary according to the type of drug-related problem was tested using a paired t-test, and was not confirmed.

1.2.3. The Triangle Model of Responsibility (TMR) (Schlenker et al., 1994)

The TMR is based in the discipline of psychology. It offers a model for understanding the conditions that affect individuals’ perceived responsibility for an event. In the TMR, responsibility is a process that holds individuals accountable for their acts. The TMR comprises three elements: prescriptions (codes of conduct), events (units of action), and identity images

(actors’ roles and qualities). According to Schlenker, “responsibility acts as a psychological adhesive that connects an actor to an event and to relevant prescriptions” (1994, p. 632). The

TMR hypothesizes that responsibility is a direct function of the combined strengths of three links: the prescription-event link, the identity-event link, and the identity-prescription link. The stronger the link between the three elements, the higher is the responsibility and high responsibility directs behavior. The prescription-event link indicates the ‘clarity of standards’ that guide the behavior; the identity-event link refers to ‘self-efficacy or personal control’; and the identity-prescription link refers to ‘professional duties’.

Figure 5. The Triangle Model of Responsibility (Schlenker et al., 1994) Adapted from Schlenker et al., 1994.

Planas et al. (2005) developed a pharmacist model of perceived responsibility for drug- therapy outcomes (the foundation of the philosophy of pharmaceutical care) based on the TMR.

They surveyed a random sample of pharmacists in community and ambulatory care settings in

Florida. Of the 1284 mailed surveys, 437 were returned and useable (useable response rate =

34%). The patient care domain of the Behavioral Pharmaceutical Care Scale (BPCS) (Odedina and Segal, 1996) was used to operationalize pharmaceutical care. Construct validity was tested by examining the relationships between the three factors of the TMR model and scale items using confirmatory factor analysis. Goodness of fit indices indicated that the model had a good fit to the data χ2/df =3.02, CFI (.95), and SRMR (.051). A path analysis model was used to test the relationships hypothesized by the TMR. Each of the three links (clarity of standards [β =

.089, p < .05], personal control [β = .141, p < .001], and professional duties [β = .454, p < .05]) had a significant indirect effect on the provision of pharmaceutical care through perceived

responsibility, and only clarity of standards [β = .269, p < .001] had a significant direct effect on the provision of pharmaceutical care.

1.2.4. Summary of Studies Using Other Attitudinal Theories

Three studies carried out in the USA between 1995 and 2005, each employing a different attitudinal theory (the TT, the TGB, and the TMR) other than the TPB (Farris and Kirking 1995,

1998; Planas et al., 2004) have attempted to explain pharmaceutical care behavior. The relationships hypothesized by the TT and the TGB were not supported.

For the TT, the hypotheses that the multiplicative antecedents of attitude toward trying and the multiplicative antecedent of social norm predicted attitude and social norm, respectively were not supported. Only the direct effects of some of the predictors (attitude toward success, attitude toward the process, and normative beliefs) were significant with regards to intention to try. According to Carsrud et al. (2009), the prediction of attitude toward trying from attitude predictors is unstable, and attitude toward failure and expectation toward failure do not predict attitude most of the time. This weakness of the TT was also identified by the developer of the theory and other researchers (Bagozzi and Dholakia, 1999; Bay and Daniel, 2003).

Similarly, the three way interaction of the appraisal processes, hypothesized by the TGB, did not statistically predict medium- or high-effort “means” to prevent and correct drug-therapy problems. The direct effects of self-efficacy, instrumental belief, and affect towards means were significant for medium-effort means, while only the direct effect of self-efficacy and instrumental beliefs was significant in case of high-effort means. These findings may compromise the effectiveness of both the TT and the TGB in predicting intention to prevent and correct drug-therapy problems in the former, and of behavior in the latter. In contrast, the

theoretical relationships hypothesized by the TMR were well supported and the three links

(clarity of standards, personal control, and professional duty) were found to be significantly related to perceived responsibility, which in turn, was significantly related to the provision of pharmaceutical care.

1.3. TPB Hybrid Models

Three studies of pharmaceutical care either have merged the TPB with other theories

(Odedina et al., 1995, 1996, 1997; Odedina and Segal, 1996; Kittisopee, 2001) or combined selected constructs from the TPB and other theories (Farris and Schopflocher, 1999). Positing that previous attempts to change pharmacists’ practice behaviors had not been successful because the interventions had not been guided by an appropriate framework, Odedina et al. (1997) developed a Pharmacists’ Implementation of Pharmaceutical care (PIPC) model using constructs from 4 attitude theories: the TRA, the TPB, the TT, and the TGB. The TRA provided the basic structure. Additions were perceived behavioral control from the TPB, and the appraisal processes and past behavior recency from the TGB. As per the TT, behavior was operationalized as trying to implement pharmaceutical care.

The researchers mailed two surveys six weeks apart to a random sample of 1,235 community pharmacists in Florida. In the first survey, predictors of intention (attitude, subjective norm, and perceived behavioral control) and predictors of behavior (intention, past behavioral recency, and the appraisal processes) were measured. The second survey was sent to respondents to the first survey. It measured pharmacists’ actual behavior relative to trying to provide pharmaceutical care using the Behavioral Pharmaceutical Care Scale (BPCS) (Odedina and

Segal, 1996). The BPCS consists of 34 pharmaceutical care activities in three domains: direct

patient care, referral and consultation, and instrumental activities. Six-hundred and seventeen useable questionnaires were returned, representing a total response rate of 50%. Regression analysis indicated that attitude, subjective norm, and perceived behavioral control explained 44% of the variance in intention to try to provide pharmaceutical care, with attitude being the most important predictor. Fifty-seven percent of the variance in trying to provide pharmaceutical care was explained by intention, perceived behavioral control, past behavioral recency, and the three appraisal processes. Past behavior recency alone accounted for 49% of the variance. A regression model which only included intention and perceived behavioral control (predictors of the behavior according to the TPB) explained 20% of the variance in the behavior. The appraisal processes or their interactions were not significant predictors when added to past behavioral recency; they accounted for only 2 % of the variance in the behavior. However, in the absence of past behavior recency, they explained 14% of the variance in behavior.

Although 51% of the surveyed pharmacists showed high intention to try to provide pharmaceutical care, the majority (76%) did not provide pharmaceutical care (Odedina et al.,

1996). A telephone interview was conducted with ten providers and ten non-providers to investigate the factors that either positively or negatively influenced their implementation of pharmaceutical care. Interestingly, the facilitators that were reported by the providers resembled the barriers reported by the non-providers. These factors included pharmacist’s abilities, support staff (pharmacy technicians), pharmacy layout, practice orientation, patients’ awareness of pharmaceutical care services, patient records, computer support, and physician cooperation

(Odedina et al., 1995).

Farris and Schopflocher (1999) explored the relationship between intention and behavior relative to the implementation of pharmaceutical care, employing the three appraisal processes from the TGB and perceived behavioral control from the TPB as predictors of behavior. A 20% random sample of Alberta community pharmacists were surveyed twice two weeks apart, a longitudinal design similar to that of Odedina et al. (1997), to determine the relationship between intention to try and trying behavior. The first survey, mailed to 320 pharmacists, measured intention, self-efficacy, beliefs, affect, and perceived behavioral control. The second survey, sent to the 230 respondents, measured which 20 pharmaceutical care behaviors (derived from Hepler and Strand’s [1990] nine-step process of pharmaceutical care) had been provided to at least one patient during the prior two week period. One-hundred eighty-two pharmacists responded to both surveys, representing a total response rate of 58%. A recursive causal model was constructed to predict pharmaceutical care behavior from perceived behavioral control, beliefs, affect, and self- efficacy. Variables were ordered in a linear way so that the variables on the left influenced those on the right, but not vice versa. Perceived behavioral control had a direct effect on the three appraisal processes and an indirect effect on pharmacists’ pharmaceutical care behavior through these three appraisal processes. Of the three appraisal processes, only self-efficacy had a direct effect on the behavior. There was a linear relationship among the three appraisal processes. Thus, the proposed three way interaction of the appraisal processes by the TGB (Bagozzi et al., 1992) was not supported. Although intention was measured, it was not included in the analysis. Only the variables that influenced the intention-behavior link were examined.

The third hybrid model discussed in this section combined the TPB, the Five Factor

Model of Personality (FFMP), and three practice environment factors (Kittisopee, 2001). The

FFMP is a psychological model that dates back to 1936. It is sometimes called the “Big Five”.

This model classifies personality traits into: extraversion (sociable, active, and talkative); neuroticism (emotional, sad, worried, and insecure); openness (intellectual, creative, and independent); agreeableness (individual’s attitude toward the others); and conscientiousness

(thorough, careful, and efficient). Kittisopee (2001) combined the TPB and the FFMP because the FFMP attributes differences in human behavior to differences in personality traits and when combined with social cognition factors, personality trait factors influence decisions made by individuals to pursue the behavior. Kittisopee (2001) used the hybrid model of the TPB and the

FFMP to study factors influencing Iowa pharmacists’ behavior relative to pharmaceutical care.

Three practice environment factors believed to influence the provision of pharmaceutical care: type of practice setting, workload, and adequacy of resources were added as control variables.

The five dimensions of personality were operationalized using the “Big Five Inventory” (John et al., 1991) and pharmaceutical care was operationalized using 11 activities from the BPCS scale

(Odedina and Segal, 1996).

Out of 600 randomly selected Iowa pharmacists surveyed, 341 useable questionnaires were obtained, giving a 60% response rate. A regression model consisting of the five dimensions of personality, the three practice environment factors, and pharmaceutical care behavior was constructed. It explained only 20.5% of the variation in the provision of pharmaceutical care.

Openness was the only personality trait significantly related to the provision of pharmaceutical care. Of the three practice environment factors, adequacy of resources and practice type were significant predictors of pharmaceutical care behavior. Two regression models were constructed to examine the combined effects of the five personality traits, TPB constructs, and environmental control variables in predicting pharmacists’ intention and behavior, respectively, relative to the provision of pharmaceutical care. The regression model for intention explained 78% of the

variance. Attitude toward pharmaceutical care, perceived behavioral control, subjective norm, and agreeableness significantly predicted intention. On the other hand, the regression model for behavior explained 45% of the variance, with intention and perceived behavioral control being the significant predictors. A post hoc analysis was conducted to examine the effect of each variable in the model on pharmaceutical care behavior using stepwise regression. The regression model explained 47% of the variance in the behavior, with attitude, perceived behavioral control, adequacy of resources, and practice type being the significant predictors.

1.3.1. Summary of Studies Using Hybrid Models

Three studies from the USA used hybrid models to explain intention to provide pharmaceutical care (Kittisopee, 2001; Odedina et al., 1997) or pharmaceutical care behavior

(Farris and Schopflocher, 1999; Kittisopee, 2001; Odedina et al., 1997). TPB constructs were common to all three models. In terms of intention to provide pharmaceutical care, Odedina et al.

(1997) found all TPB constructs to be significant predictors of intention, while Kittisopee (2001) found one personality dimension ‘agreeableness’ along with the TPB constructs to be significant predictors. The findings from these two studies indicate that the TPB could be the best model to predict pharmacists’ intention to provide pharmaceutical care. With regards to pharmaceutical care behavior, of the TPB constructs, perceived behavioral control was significantly associated with pharmaceutical care behavior in the three studies (Farris and Schopflocher, 1999;

Kittisopee, 2001; Odedina et al., 1997), though it was not the sole predictor. Past behavior recency added the highest incremental R2 among the predictors of behavior. Thus, it was the most important predictor of pharmaceutical care behavior in this review. As for the three appraisal processes from the TGB, neither the study by Farris and Schopflocher (1999), which

explored the linear effect of the appraisal processes on pharmaceutical care behavior, nor the study by Odedina et al. (1997), which examined their effect through past behavior recency, were able to confirm the three-way interaction of these appraisal processes.

The high explained variance in two of these studies, whether in intention to provide pharmaceutical care (R2 = 78%, Kittisopee, 2001), or pharmaceutical care behavior (R2 = 57%,

Odedina et al., 1997) may be attributed to good operationalization of the constructs and/or addition of other variables to the TPB model. The study by Kittisopee outperformed all others in terms of predicting intention. This may be due to use of a specific definition for pharmaceutical care behavior on which to base measures of each TPB construct. Kittisopee adapted 11 activities from Odedina’s Behavioral Pharmaceutical Care Scale (BPCS) and divided them into three domains: patient assessment, drug-related problems resolution, and documentation. He then operationalized each TPB construct based on each of these three domains. For example, intention was assessed using three items that followed a common stem but applied to different behavioral domains: ‘I intend to perform the above patient assessment activities for one of my patients....’;

‘I intend to perform the above drug-related problem resolution activities for one of my patients...’; ‘I intend to perform the above documentation activities for one of my patients….’.

This may have increased the compatibility between intention and the other TPB constructs in the model and thus increased the explained variance in intention. The study by Odedina et al. (1997), on the other hand, outperformed the other studies in terms of predicting pharmaceutical care behavior. The reason behind this was the addition of ‘past behavior recency’ to the TPB model.

Past behavior recency alone accounted for 49% of the explained variance. Of note, Odedina utilized the BPCS scale to measure both past and future pharmaceutical care behavior. The high compatibility between past and future behavior due to the use of similar wording, which is

known as ‘common method variance’, might have increased the explained variance in future behavior.

2. Motivational or Stages of Change Theories

Motivational theories focus on the process of change. These theories posit that individuals pass through several motivational phases and, in order to proceed from one phase to the following phase, individuals need a different strategy of change. These theories categorize individuals into groups with different intervention requirements. The Transtheoretical Model

(TTM) and Diffusion of Innovations theory are examples of motivational theories (Grol et al.,

2005). Two studies that used motivational theories to explain pharmaceutical care behavior are covered in this section (Berger and Grimley, 1997; Zardain et al., 2009).

2.1. The Transtheoretical Model (TTM) (Prochaska and DiClemente, 1984)

The TTM originated in the field of psychotherapy and was developed for the purpose of designing interventions for smoking cessation. The TTM assumes that when individuals attempt to change behaviors they proceed through five stages:

. Precontemplation, in which individuals are either unaware or uninterested in making a

change in the subsequent six months.

. Contemplation, in which individuals are interested and plan for a change within the

following six months.

. Preparation, in which individuals have plans for the change within a month.

. Action, in which individuals have been engaged in the process of change for less than six

months.

. Maintenance, in which individuals have been engaged in the process of change for six

months or more.

The TTM includes constructs from other theories such as self-efficacy from Social

Cognition Theory (Bandura, 1982), and pros and cons from Decisional Balance Theory (Janis and Mann, 1977).

The TTM was used by Berger and Grimley (1997) to evaluate pharmacists’ readiness to render pharmaceutical care with respect to four domains of pharmaceutical care activities: patient assessment, patient follow-up, documentation, and billing. A convenience sample of pharmacists who attended the annual meeting of the American Pharmaceutical Association in March 1996 was surveyed. Of the 148 respondents, 84% fell in the pre-contemplation and contemplation stages for all four activities.

Five multivariate analysis of variance (MANOVA) models were constructed with stage of change for each pharmaceutical care activity domain as the independent variables and sample and practice characteristics, such as age, position in the pharmacy, practice site, and the need to redesign the pharmacy as the dependent variables. Action and maintenance stages were collapsed due to small cell counts. For the first MANOVA, significant age differences were detected for those in the action/maintenance stage versus the preparation stage with respect to patient assessment behavior only. Pharmacists in the preparation stage were younger than those in the action and maintenance stages. For the other four MANOVAs, the need to redesign the pharmacy was significantly different for those in the precontemplation stage versus all other stages across three pharmaceutical care domains (patient assessment, patient follow-up, and documentation). Also, position in pharmacy was significantly different for those in the

action/maintenance stage versus all other stages with respect to the domain of billing. Managers and owners of pharmacies were more likely to be in the action/maintenance, while staff were more likely to be in the other stages.

Another four MANOVAs were conducted to determine differences in the pros and cons of adopting the behavior among the four stages of change. Pros and cons for three pharmaceutical care domains (patient assessment, patient follow-up, and documentation) were significantly different for pharmacists in the action/maintenance and preparation stages versus those in precontemplation stage, except with regards to billing for services. Pros were more salient than cons for pharmacists in the action/maintenance and preparation stages than those in precontemplation stage. The findings of this study are consistent with the TTM premise that the mainstream is in precontemplation and contemplation stages for any new behavior and that the cons for a new behavior are more significant in these two stages.

The TTM was also employed in a study by Zardain et al. (2009) to investigate the stage of Spanish pharmacists toward the implementation of pharmaceutical care. They also employed the Attitude, Social influence, Self-efficacy (A.S.E) Model (de Vries et al., 1995) to determine pharmacists’ attitude toward pharmaceutical care, perceived social influence, self-efficacy, needs, and motivations toward pharmaceutical care across the stages of change. The A.S.E. model expands Fishbein and Ajzen’s (1975) TRA (Theory of Reasoned Action) by adding

Bandura’s self-efficacy as a predictor of intention, as well as perceived barriers (needs) and skills

(motivations) to mediate the intention-behavior link. The A.S.E. model departs from the TRA in that it does not imply multiplicative functions (interactions of antecedents) of attitudes and social influence.

Zardain et al. (2009) surveyed all 19,250 pharmacy owners in Spain, with a response rate of around 10%. Similar to the results obtained by Berger and Grimley (1997), most of participants (65%) were in the precontemplation stage and only about 12% were in action and maintenance stages. Consistent with the TTM, significant differences were found in the mean scores of attitude, social influence, self-efficacy, motivations, and needs between pharmacists in the extreme stages, precontemplation and maintenance. It is not clear as to how the dependent variable, pharmaceutical care behavior, was measured, nor how participants were classified into the five stages of change. However, the dependent variable was dichotomized into non- pharmaceutical care performance (non-providers), which included pharmacists in the first three stages; and pharmaceutical care performance (providers), which included pharmacists the last two stages. The logistic regression analysis of pharmacist and pharmacy characteristics, the

A.S.E. variables, intention, needs, and motivations explained 50% of the change of behavior from ‘not performing’ to ‘performing’ pharmaceutical care. The A.S.E. variables had the highest influence on model fit: when added to the regression model that included pharmacist and pharmacy characteristics, the Negelkerke R2 increased from 19% to 46%. Intention contributed an additional 3.2%. Needs (barriers) and motivations (skills) were not statistically significant predictors. The needs identified by the precontemplators included availability of training programs, practice guidelines, and supportive computer software, while those in the maintenance stage identified the need to enhance communication and coordination among health providers.

2.2. Summary of Studies Using Motivational Theories

Two studies employed the TTM (Berger and Grimley, 1997; Zardain et al., 2009); however, they did not utilize it to its fullest extent. Zardain et al. (2009) utilized the TTM merely to sort pharmacists into the different stages of change, which were later collapsed into two

categories, providers and non-providers of pharmaceutical care. Operationalization of pharmaceutical care and the criteria used to sort pharmacists into the five stages of change were not stated. Zardain et al. also omitted the construct of decisional balance, that is, pros and cons, while Berger and Grimley (1997) omitted self-efficacy. Neither provided a rationale for their omission. The findings of the study by Zardain et al. indicated that the A.S.E. constructs (another version of the TPB constructs) were the best predictors of pharmaceutical care behavior. This is consistent with findings of other studies that utilized the TPB.

3. Organizational Theories

Implementing a change in an organization may take place at an individual-level, such as pharmacist or pharmacy manager, or at an organizational-level, where internal and external cultural and environmental factors come into play. Organizational theories focus on structural, administrative, economic, and/or organizational conditions and reforms. These include theories of innovative organizations, theories of quality management, and theories of organizational learning (Glanz et al., 2008; Grol et al., 2005). The literature search identified five studies that employed organizational theories/models: those by Al-Shaqha and Zairi (2003), Chui et al.

(2012), Hopp et al. (2005), Mandt et al. (2010), and Roberts et al. (2005).

3.1. Organization Change Theory and Social Network Theory (Borum, 1995 and Scott, 1998)

Roberts et al. (2003) developed an organizational theory framework for cognitive pharmaceutical services (CPS) based on two theories: the theory of organizational change

(Borum, 1995) and Social Network Theory (Scott, 1998). The theory of organizational change

(Borum, 1995) classifies organizational change strategies into rational, natural, political, and open. Social Network Theory (Scott, 1998) uses intra-organizational and inter-organizational

relations to identify key players, understand the relationship between the key players, and how this relationship impacts the process of practice change. The resultant hybrid theoretical framework for CPS was used to structure an interview guide and assist in understanding the process of practice change. The interview guide covered four domains: personnel roles and goals in practice change, personnel experience with CPS, change strategies employed, and networks essential for practice change.

In 2005, Roberts et al. used the developed interview guide to investigate the process of practice change and its facilitators with regard to CPS provided by the Australian community pharmacists. Thirty-six in-depth semi-structured interviews were conducted with a convenience sample of pharmacy practice researchers; representatives of professional pharmacy organizations; and community pharmacy managers, practicing pharmacists, and pharmacy technicians working in pharmacies either accredited by the Quality Care Pharmacy Program

(QCPP) or registered to provide Home Medicines Review (HMR) services. Five themes were extracted from the interviews: change strategies, social networks, drivers of change, motivators, and facilitators of practice change. The main elements of change strategies were education, training, availability of procedures and check lists. Social networks were not restricted to within pharmacy relations; they extended to other health care providers, academia, and pharmacy associations. At the organization level, practice change was driven by the health authority and pharmacy associations, while professional satisfaction was the motivator of change at the individual level. Several other factors identified as facilitators of the practice change process were reimbursement, role models or opinion leaders, teamwork, and restructuring work duties.

3.2. Leavitt’s Organizational Model

Leavitt’s organizational model, also known as Leavitt’s Diamond, has a business management origin. It describes the organization as a structure that consists of four components that interact with each other to effect a change in the organization (Leavitt, 1964). These are task

(services provided), structure (relationships between individuals in the organization), technology

(machines, programs, or protocols), and actors (individuals in the organization) in coexistence with environment (influences all four components).

Hopp et al. (2005) used Leavitt’s organizational model to investigate the implementation process for CPS in Danish community pharmacies that participated in three or more projects related to CPS implementation, and to understand factors that influenced the implementation process. Twenty semi-structured interviews with pharmacy owners and pharmacy staff members identified 51 factors that were divided into 9 dimensions and linked to the relevant elements of

Leavitt’s model.

The ‘environmental-related’ facilitators identified were attributed to several external organizations such as the Danish Pharmaceutical Association, the Danish College of Pharmacy

Practice, and the Danish University of Pharmaceutical Sciences. These organizations increased pharmacists’ knowledge about CPS by providing specialized courses, educational materials, consultation services, evaluation of CPS, and exchanging professional pharmacists between pharmacies. ‘Technology-related’ facilitators included electronic systems for prescription handling, electronic safety alerts, electronic patient medication record, and access to the internet.

Pharmacy owners’ enthusiasm to impose a change and pharmacist competency were the key

‘actor-related’ facilitators. ‘Structure- related’ factors that deemed necessary to CPS

implementation and continuity were a structured working environment and a good learning environment.

The identified barriers, on the other hand, were lack of time, heavy daily drug distribution workload, lack of strategies that dealt with time pressure, lack of pharmacist interaction with general practitioners, lack of pharmacists’ competence, creativity, and confidence.

Another study (Mandt et al., 2010) also used Leavitt’s organizational model to explore differences in prescription intervention practice among Norwegian community pharmacies and factors influencing the prescription intervention process. Prescription intervention was defined as activities such as detecting prescription errors, identifying drug-related problems, patient counseling, and solving logistic problems. Two focus groups with 14 pharmacists from both rural and urban regions were conducted. Emerged themes were linked to the components of

Leavitt’s model.

Two patterns of prescription intervention practice were identified: fast dispensing process

(dealing only with information available on the prescription) and active dispensing process

(interacting with patients and prescribers). Both types of dispensing processes were practiced by the same pharmacist and within the same pharmacy depending on the circumstance and time available. Patients were the most influential factor in the prescription intervention process as they involved pharmacists in solving issues related to changes in their prescriptions, whereas pharmacist's prescription intervention practice was usually carried out without contacting the prescriber. Due to difficulty faced in accessing the prescribers, pharmacists tended to limit their contact to situations where patients requested changes in their treatment or asked the patients to approach the prescribers to explain their problems.

The facilitators identified were similar to those in the study by Hopp et al., 2005. These were pharmacist competency and colleague consultation (actors); availability of decision support computer software combined with internet access (technology); and a pharmacy layout that allows pharmacist-patient interaction, delegating tasks to pharmacy technicians, and maintaining documentation systems (structure).

A third study (Chui et al., 2012) adapted the Systems Engineering Initiative for Patient

Safety (SEIPS) model to identify work system change factors related to implementation of CPS.

The SEIPS model integrates Donabedian’s structure-process-outcome model and the work system model (Smith and Carayon, 1989), which is very similar to Leavitt’s organizational model. Six community pharmacists from Wisconsin, USA, were selected for interview from 24 pharmacies participating in a CPS demonstration program of the Wisconsin Pharmacy Quality

Collaboration. Selection of participants was based on success in introducing changes to work systems to enhance provision of CPS. From the six interviews, 21 themes were identified and classified according to the components of the SEIPS model.

Change factors that pharmacists identified were pharmacists' skills related to communication with physicians and patients, and to time management (actors); assigning additional responsibilities to pharmacy technicians and initiating new services (tasks); availability of a private counseling area with a computer with access to patient records and drug information (environment); electronic aids such as dispensing computer systems and non- electronic tools such as forms and pocket cards (technology); and good management with foresight, which supports and motivates pharmacy staff (organization).

3.3. Quality Management Theory

Total Quality Management (TQM) and Continuous Quality Improvement (CQI) have a management science origin. These concepts were used in the study by Al-Shaqha and Zairi

(2003) because, according to the researchers, poor practice management had not been addressed as a barrier to the provision of pharmaceutical care in the Saudi context. TQM and CQI were utilized to identify practice management factors that would improve the quality and efficiency of pharmaceutical care services being delivered in Saudi hospitals. Management factors identified were: understanding of pharmaceutical care definitions, presence of a mission statement and practice standards; organizational structure; pharmacist’s role, authority, responsibility, and attitude with respect to pharmaceutical care; collaboration among health care providers; qualification of pharmacists; access to patient-care services; and automated dispensing systems.

This study is discussed in the Arabian Gulf region section of this literature review.

3.4. Summary of Studies Using Organizational Theories/Models

Five studies from Australia, Denmark, Norway, USA, and Saudi Arabia have employed one or more organizational theory, model, or concept to help understand practice change management of organizations and identify key factors influencing the adoption of pharmaceutical care. All studies used a qualitative approach and investigated pharmacists in either inpatient or community pharmacy settings. Several factors that affected the practice of pharmaceutical care in each setting were identified. These factors were similar to those identified in other studies in this review.

4. Summary of Practice Change Theories/Models Used in Studies of Pharmaceutical Care

A variety of theories and models from the fields of psychology (TMR and five personality trait), psychotherapy (TTM), socio-psychology (TPB and A.S.E.), marketing (TT and

TGB), management (TQM and CQI), and business management (Leavitt’s Diamond) have been used to explain the implementation of pharmaceutical care across 13 studies in six countries over a 17-year period. Six are attitudinal theories, two are motivational models, and five are organizational theories. The TPB, an attitudinal theory, was the most commonly used (5 studies).

The theories and models applied to pharmaceutical care have been tested in different health systems, both Western and Middle Eastern cultures, and both developed (USA, Australia,

Norway, Denmark, Spain) and developing countries (Saudi Arabia). They have also been applied in institutional settings (1), all settings (1), and community pharmacy settings (11).

Pharmaceutical care is multifaceted and complex in nature (Al-Shaqha and Zairi, 2003;

Farris and Schopflocher, 1999; Roberts et al., 2005). It requires substantial change in pharmacists’ practice from a product to patient focus. Not only does it require that the pharmacist have the clinical competence to identify, resolve, and prevent drug-related problems, but it also stipulates that the pharmacist should collaborate with patients and other health care providers to achieve the desired therapeutic outcomes; and that the pharmacist should be accountable for any therapeutic decision or recommendation he or she makes. Adoption of this practice philosophy requires changes in attitudes, beliefs, and values. Thus, it can be argued that the focus of the practice change process relevant to pharmaceutical care should be the individual pharmacist.

That being said, the importance of other environmental and contextual factors cannot be

underestimated. Therefore, a theory that can represent both individual and environmental factors in practice change was desired for this study. Attitudinal theories met this requirement.

Of the attitudinal theories discussed in this review, the TPB showed good predictive validity for pharmacists’ intentions and moderate predictive validity for pharmaceutical care behavior, whereas the TGB and the TT exhibited moderate to poor predictive validity for either intentions or behaviors. Notwithstanding the above, it may be premature to conclude that the TT does not predict pharmaceutical care since only one study tested it. Another point in favor of the

TPB is that it has received considerable attention in the health education, health behavior and preventive medicine literature, and it is considered as one of the ten most frequently used theories in health research (Glanz et al., 2008). The other attitudinal theories/models have not been as widely used in health research. Furthermore, the TPB is described as a consistently supported model (Campagna and Newlin, 1997) that has superior predictive validity for intentions across health-related behaviors (Godin and Kok, 1996; McAuley and Courneya 1993).

Therefore, based on the findings of this literature review and the opinions expressed in other literature reviews, the TPB was selected as the theoretical framework for this study of factors that influence pharmacist provision of pharmaceutical care.

5. The Selected Model

The proposed model for this study (Figure 4) used the TPB as the basic framework. The construct ‘past behavior recency’ from the TGB (Bagozzi et al., 1992) was added to attitude, subjective norm, and perceived behavioral control as a predictor of intention, and as a predictor of behavior along with intention and perceived behavioral control. Reasons for doing so follow.

Several researchers have argued about the nature of the relationship between intention, past, and future behavior (Aarts and Dijksterhuis, 2000; Ajzen, 2011; Ajzen and Fishbein, 1980;

Bagozzi et al., 1992; Bagozzi and Warshaw, 1990; Bagozzi and Warshaw, 1992; de Vries et al.,

1995). Bagozzi et al. (1992) stated that the more recent the experience is, the more it is available in the memory, and if activated, the more it is likely to stimulate the behavior. Thus, past behavior recency might activate the behavior without an intention being formed, suggesting that it exerts its effect directly on the behavior and not through intention. From Ajzen and Fishbein’s

(1980) point of view, past behavior may influence behavior indirectly through intention and a person who has experienced the behavior will form a realistic intention to perform the behavior which is expected to be stable. In contrast, the intention of those who had no past experience with the behavior may change once they have to deal with the behavior. Past behavior; however, was not added as a construct to the TPB, because Ajzen and Fishbein believed that instead it had a moderating effect on intention. Early research has shown that past behavior also influences the behavior directly without being mediated by intention (Ajzen and Driver, 1991; Beck and Ajzen,

1991). However, Ajzen (1991) argued that with this limited number of studies it was too soon to draw conclusions about adding past behavior to the TPB model. In a recent comment, Ajzen

(2011) clarified that the high compatibility between the measures of past and future behavior (as both measure the frequency of performing a behavior or the performance of the behavior) results in high explained variance in future behavior, as opposed to intention, which is measured as the likelihood of performing the behavior.

Recently, many studies from various fields have investigated the relationship between intention, past, and future behavior and found that past behavior influences both intention and future behavior (Bath, 2009; Godin et al., 2009; Hoie et al., 2010; Kovac et al., 2009; Kwan et

al., 2009; Lee, 2009; Pelling and White, 2009; Raudsepp et al., 2010; Wong and Mullan, 2009).

However, only two studies have investigated these relationships in pharmacy (Herbert et al.,

2006; Odedina et al., 1997). This study will investigate the influence of past behavior on intention to practice pharmaceutical care, since the cross-sectional design of this study does not permit investigation of its influence on behavior.

According to Ajzen (2003), past behavior can be used as a proxy for future behavior if the behavior shows high temporal stability (past behavior is not different from future behavior), and the correlation between intention and past behavior can be considered indicative of the predicative validity of intention for future behavior. Pharmaceutical care is a complex behavior; thus, it is anticipated that pharmacists who practice pharmaceutical care will continue practicing it, while those who have not experienced it will not practice it in the near future, even if they form the intention to do so. This is due to barriers that hinder the practicing of pharmaceutical care. According to the theory, future behavior should be assessed shortly after assessing intention because individuals’ intentions are subject to change over time. Barriers to pharmaceutical care are not expected to resolve within a short period of time; thus, not practicing pharmaceutical care behavior will remain stable, that is, future behavior will not be very different from the recent past behavior; in other words, pharmaceutical care behavior will have high temporal stability.

Therefore, in this study, past behavior recency was used as a proxy for future behavior.

Figure 6. The selected model Dotted arrow and box indicate the parts of the model that were not tested

Section V: Chapter Summary

Pharmaceutical care is an overarching philosophy of pharmacy practice that calls for a patient-centered practice model. It was adopted across North America in 1990 as a pharmacy profession mandate (Kassam et al., 2009). In the Arabian Gulf region, a Ministerial Decree at the

GCC level was issued in 2005 to pave the way for its implementation. However, owing to a variety of barriers faced by pharmacists in their daily practice, the adoption of pharmaceutical care has been slow in the Arabian Gulf States and worldwide. Hundreds of articles have investigated barriers and facilitators to the implementation of pharmaceutical care and identified both individual and environmental factors. The theoretical framework selected for this study is capable of representing both types of these factors as predictors of practice change.

Amongst various theories and models that have been used to explain the implementation of pharmaceutical care, attitudinal theories have the most relevance to the objectives of this study. Of the attitudinal theories, the TPB has been shown to be the best for predicting pharmacists’ intentions to provide pharmaceutical care. Therefore, the TPB was selected as the framework for this study. The construct ‘past behavior recency’ from the TGB was added as a co-predictor of intention to provide pharmaceutical care. This modified TPB framework guided the development of a focus group interview guide, the survey instrument, and the interpretation of study results.

CHAPTER THREE: METHODS

The overall aim of the study was to determine the extent of the implementation of pharmaceutical care in Oman and factors affecting its implementation. The specific objectives were to:

1. Determine the extent of the provision of pharmaceutical care in Oman, and compare its

provision across three practice settings: inpatient, outpatient, and community pharmacy.

2. Identify important perceived barriers and facilitators to the implementation of

pharmaceutical care as expressed in pharmacists’ behavioral beliefs, normative beliefs,

and control beliefs.

3. Examine the effect of pharmacists’ demographic characteristics, in particular, country of

origin on their behavioral beliefs, normative beliefs, and control beliefs relative to

implementation of pharmaceutical care.

4. Examine the individual and collective influences of attitude, subjective norm, perceived

behavioral control, and past behavior recency on pharmacists’ intention to implement

pharmaceutical care.

Figure 6. Predictors of pharmacists’ intention to provide pharmaceutical care

5. Examine the influence of perceived behavioral control and intention on pharmaceutical

care behavior.

Figure 7. Predictors of pharmaceutical care behavior Dotted box indicates the part of the model that was not tested

6. Test the predictive validity of the Theory of Planned Behavior (TPB) in explaining

pharmacists’ pharmaceutical care behavior.

In order to meet the study objectives, a survey based on the TPB was undertaken with pharmacists who practice in Oman. To construct the survey instrument, a focus group study was conducted. The main intent of the focus group study was to elicit pharmacists’ beliefs relevant to the implementation of pharmaceutical care in Oman.

This chapter covers the study design, sampling techniques, data collection instruments and procedures, and data management and analyses techniques used in the two study phases: the focus group study and the mailed survey, as well as in the pilot study. Approval for all phases of the study was obtained from the University of Toronto Health Sciences I Review Ethics Board and the Omani Ministry of Health Research Ethics and Review Committee.

To assist with implementation of the study in Oman, a site advisory committee was recruited by the investigator. This local committee consisted of two pharmacists representing the public and private sector regulatory bodies of the Ministry of Health (MOH), a clinical pharmacist representing other government health institutions, a pharmacy practice faculty member at the University of Nizwa, a consultant pharmacist, a clinical pharmacist representing the MOH hospitals, and a community pharmacy manager. This committee provided assistance with procuring updated sampling lists, recruiting pharmacists for focus groups, reviewing the survey questionnaire, and administering the pilot study.

Section I: Focus Group Study

A focus group is an open, thorough discussion, led by a moderator, among a small number of participants, usually 6 to 10, about a certain topic of interest (Krueger and Casey,

2000). More than one focus group may be needed to generate sufficient ideas about one topic.

Focus groups have been used as a tool or a mechanism to obtain individuals’ knowledge, experience, and concerns. They provide an opportunity for participants to discuss different ideas and opinions, a feature not available in individual interviews where participants merely respond to questions. Thus, focus group findings reflect breadth and depth of opinions. Focus groups have also been widely used as precursors for surveys (Green and Thorogood, 2009; Krueger and

Casey, 2000).

In order to determine pharmacists’ beliefs pertaining to the implementation of pharmaceutical care in Oman, it was essential to understand these beliefs from the perspective of the population being studied. Therefore, a focus group study was conducted with Omani pharmacists to elicit their behavioral beliefs, normative beliefs, and control beliefs with respect to pharmaceutical care. A secondary objective was to obtain pharmacists’ own wording of their beliefs so that survey items could be written in a way that is more credible and comprehensible to the participants.

1. Study Design

Three focus groups with pharmacists from Muscat, the capital of Oman, were held in a

Higher College of Technology meeting room. One focus group was conducted for each of the three practice settings: inpatient, outpatient, community pharmacy. Muscat was selected because, first, it is the most highly populated region in Oman (30% of the total population lives in

Muscat). Second, more than 55% of the total practicing pharmacist population worked in Muscat at the time of conducting this study. Third, due to funding and time constraints, it was not possible to incorporate pharmacists from other regions of Oman in this phase of the study.

2. Participants

2.1. Inclusion/Exclusion Criteria

Pharmacists in Muscat whose main role was to provide direct patient care and who had worked in inpatient or outpatient settings of either public or private health organizations or community pharmacies for at least three years were eligible to participate in focus group discussions. The criterion of three years experience was applied to increase the likelihood that recruited pharmacists would have experienced pharmaceutical care. Pharmacy managers who did not provide direct patient care, as well as pharmacists working in regulatory affairs, drug supply and distribution, the pharmaceutical industry, marketing, and retired pharmacists were not eligible to participate.

2.2. Participant Recruitment

As of August 2009, the total number of practicing pharmacists in Muscat was approximately 370, of whom 297 were in the private sector (hospitals, clinics, and community pharmacies) and about 75 were in the public sector (hospitals and health centers). The general aim was to have a sample of 6 -10 pharmacists from both public and private sectors, and preferably pharmacists who provide pharmaceutical care in each focus group. The community pharmacy focus group was an exception because it had representatives only from the private sector. According to the director general of the Directorate General of Pharmaceutical Affairs and Drug Control (DGPA&DC), the licensing body for pharmacists employed in the private sector, pharmaceutical care is not provided in the private sector. Therefore, pharmacist selection for the community focus group, private hospitals, and clinics was not based on provision of pharmaceutical care.

The inpatient and outpatient settings included pharmacists from three strata: the MOH hospitals, hospitals run by other government health institutions, and private sector hospitals. The target mix of participants for the inpatient focus group was 5 pharmacists from MOH settings + 4 from other government health institutions + one from private hospitals; while the target for the outpatient focus group was 5 pharmacists from MOH settings + 3 from other government health institutions + 2 from private hospitals or clinics. The number from each stratum represented the proportion of pharmacists providing pharmaceutical care in that stratum, as estimated by the site advisory committee members. Since pharmaceutical care is not provided in the private sector, at least one pharmacist was targeted to represent private hospitals or clinics. For the community pharmacy focus group, the target was one pharmacist from each of the 7 largest chain pharmacies with the exception of 3 pharmacists from a chain pharmacy that has over 60 outlets.

2.2.1. Pharmacists Employed in Inpatient and Outpatient Settings of Public Hospitals

Two of the site advisory committee members were hospital pharmacists familiar with staff pharmacists who provide pharmaceutical care in government-owned inpatient and outpatient health care sites in Muscat. A third member was a representative of the Directorate

General of Medical Supplies (DGMS), the licensing body for pharmacists employed in MOH hospitals and health centers; he was also aware of pharmacists providing pharmaceutical care in

MOH settings. Each of these three members nominated 6 pharmacists from inpatient settings and

6 from outpatient settings from both MOH and other government health institutions who met the eligibility criteria. One of these three members was an employer of pharmacists who were eligible for the study. He was instructed not to limit his nominations to pharmacists he employed.

For the inpatient focus group, the investigator first stratified the list of the 18 nominated pharmacists on the basis of being employed in the MOH or in other government health institutions. She then randomly selected and contacted pharmacists from each stratum (see

Appendix A for telephone script) until the target number of 9 pharmacists (5 from MOH settings and 4 from other government health institutions) was achieved. The same procedure was repeated for the outpatient focus group to achieve a target number of 8 pharmacists (5 from

MOH settings and 3 from other government health institutions). Site advisory committee members were not informed about who agreed or declined to take part in the study.

2.2.2. Pharmacists Employed in Private Hospitals and Clinics

A fourth site advisory member, who was the representative of the DGPA&DC, was asked to provide a list of pharmacists employed in the private hospitals/clinics in Muscat. The investigator randomly selected and contacted pharmacists from the private hospital/clinic list until one pharmacist was recruited for the inpatient focus group and another two for the outpatient group.

2.2.3. Pharmacists Employed in Community Pharmacies

The DGPA&DC representative was also asked to provide a list of pharmacists employed in chain pharmacies in Muscat. The investigator stratified pharmacists on the basis of chain and then randomly selected 3 pharmacists from a pharmacy chains that has over 60 outlets and one pharmacist from each of the next 7 largest pharmacy chains. At the time the community pharmacy focus group was conducted (February, 2010), community pharmacies in Muscat exclusively employed non-national pharmacists. However, recruiting pharmacists from this sector was generally difficult. Upon invitation to take part in the study, most of the contacted

pharmacists revealed their willingness to participate in the study only provided that their employers approved their participation. A probable explanation is that non-national pharmacists are worried about their job security. To facilitate recruitment of community pharmacists, the investigator therefore contacted senior managers at each corporate head office to request that they circulate a memorandum (Appendix B) to their employee pharmacists in Muscat stating the chain’s support for pharmacists wishing to participate in the study. The memorandum also stated that the decision to participate (or not) rested with the individual pharmacist, and that the chain head office would not be informed about who agreed or declined to take part in the study. Four days after the distribution of the memorandum, pharmacists were contacted until the target number of 10 pharmacists was achieved.

In summary, a total of 30 pharmacists was recruited to participate in the study, 10 for each focus group in case there were no shows, e.g., due to illness. An information sheet and consent form (Appendix C) was e-mailed to the recruited pharmacists. They were asked to sign and then fax the consent form to the investigator, and bring the original copy with them to the meeting.

Pharmacist contact information was obtained from the DGMS and the DGPA&DC lists of registered pharmacists. For pharmacists employed by other government health institutions such as Sultan Qaboos University Hospital, Royal Oman Police Hospital, and Armed Forces

Hospital, the investigator approached each institution individually and obtained contact information for their pharmacist employees.

3. Interview Guide

A semi-structured interview guide was developed to elicit pharmacists’ behavioral, normative, and control beliefs pertaining to pharmaceutical care. The development of focus group questions was guided by a manual for TPB researchers (Francis et al., 2004). The interview guide (Appendix D) had five main sections, each of which included several open- ended questions.

1) Section 1: included introductory questions about work experience with pharmaceutical

care and interest in providing pharmaceutical care.

2) Section 2: asked about the positive and negative consequences of providing

pharmaceutical care (behavioral beliefs),

3) Section 3: focused on beliefs about whether important people in pharmacists’

professional life approve/disapprove of them providing pharmaceutical care (normative

beliefs).

4) Section 4: explored factors that facilitate or hamper the implementation of

pharmaceutical care (control beliefs) with probing questions based on barriers and

facilitators to the provision of pharmaceutical care identified from the pharmacy

literature.

5) Section 5: requested additional comments from the participants regarding pharmaceutical

care.

4. Procedures

All focus group discussions were facilitated by the investigator and were conducted in

English. With the permission of the participants, discussions were digitally voice recorded. A

recording secretary was present to make notes of the meetings and operate the voice-recorder.

Each focus group meeting lasted for about one and half hours. Demographic characteristics were collected from the participants before the focus group meetings began, using the form in

Appendix E. The focus groups were conducted over an approximately one-month period, from

January 25, 2010, to February 18, 2010.

Although Arabic is the official language in Oman, it was not possible to use Arabic as the language for this study because Arabic speakers (Omani nationals and Arab non-national pharmacists) comprise only 30% of the pharmacy workforce. These Arabic speakers as well as the rest of the non-national pharmacists, who are mainly from South Asia, speak English as a second language. Furthermore, English is the official language used in pharmacy correspondence and daily practice, specifically, when communicating with other health professionals. Therefore,

English language was the best alternative for this study.

5. Data Management and Analyses

The recorded focus group discussions were transcribed verbatim by a second party, who was an experienced secretary and was present during the focus groups. All transcripts were verified by the investigator for accuracy. To ensure confidentiality, all identifiers were removed after verification. Each focus group transcript was content analyzed (Krueger and Casey, 2000).

This involved independent coding by the investigator and another researcher who met repeatedly to compare and discuss the coding, and resolve disagreements through discussion. Major themes that emerged from content analysis were then grouped into three main categories: behavioral, normative, and control beliefs. Qualitative analysis software (NVivo 7, 2008) was used to facilitate coding and analysis of participants’ responses.

Section II: Mail Survey

1. Study Design

The study design was a cross-sectional, population survey of pharmacists who practice in

Oman.

2. Survey Instrument

The self-administered survey questionnaire was built on the proposed theoretical framework which included 8 major constructs:

- past behavior recency (also used as a proxy for pharmaceutical care future

behavior)

- intention to provide pharmaceutical care

- attitude toward providing pharmaceutical care

- subjective norm

- perceived behavior control

- pharmacists’ behavioral beliefs and evaluation of outcomes

- normative beliefs and motivation to comply

- control beliefs and power

The development of questionnaire items was based on guidelines provided by the developer of the TPB on how to operationalize each construct (Ajzen, 2006), previous survey instruments using the TPB in pharmacy (Badejogbin, 1994; Kittisopee, 2001), and on focus group findings. Items measuring each construct constituted separate sections of the questionnaire, as did items on the demographic characteristics of participants.

The themes extracted from the focus group discussions were used to formulate items for the survey questionnaire if the theme was raised by participants from all three groups, the theme addressed an important feature of pharmaceutical care, or the theme addressed an issue central to a specific practice setting, e.g., reimbursement for pharmaceutical care services in community pharmacies. The survey materials were written in English and were not translated into the Arabic language; however, the language level was simplified to facilitate understanding of the survey materials.

2.1. Operationalization of Constructs

According to the TPB, the constructs intentions and behavior are only measured directly, while the other TPB constructs such as attitudes, subjective norms, and perceived behavior control are measured either directly or indirectly (Ajzen, 2006; Francis et al., 2004). The direct measure for attitude, for instance, can be approached by asking participants about their evaluation of the behavior. In terms of indirect measure of attitude, participants are asked two questions, one about their beliefs regarding the outcomes of performing the behavior and the other on how they evaluate each outcome. Either type of measure can be used although the direct approach has been more common. In the current study, both approaches were used. The indirect measures (behavioral, normative, and control beliefs) were used to identify the perceived attitudinal, social, and control barriers and facilitators to the implementation of pharmaceutical care (study objective 2).

Of note, the number of items, used to operationalize each construct listed in this section, refers to the final version of the questionnaire.

2.1.1. Direct Measures

With the exception of behavior (or its proxy, past behavior recency), all direct measures

(intention, attitude, subjective norm, and perceived behavioral control) are global and were thus measured by a standard format suggested by the theorist (Ajzen, 2006; Francis et al., 2004).

2.1.1.1. Past Behavior Recency (proxy for behavior)

Past behavior recency was measured by a list of 16 behavioral activities. This list included pharmaceutical care activities that were based on ideas obtained from a text book on pharmaceutical care (Cipolle et al., 2004), and from the Medication Therapy Management

(MTM) Service Model (2008). Pharmacists were asked to indicate how often in the past week they had provided these activities to patients with chronic conditions, e.g., diabetes, hypertension, or asthma. The item response scale was a five-point rating scale ranging from 0

(never) to 4 (all the time). The total score for past behavior recency was the mean sum of scores obtained for each of the 16 activities.

Past behavior recency represented the past and the actual pharmaceutical care behavior in this study because it used a previous one-week time-frame to measure pharmacists’ performance of the behavior. It was also used as a proxy for pharmaceutical care future behavior, the primary dependent variable. This is because the cross-sectional design of the study did not allow testing the future pharmaceutical care behavior; however, pharmaceutical care behavior has a high temporal stability which allows the use of past behavior as a proxy for the future behavior

(details are given in chapter 2).

2.1.1.2. Intention to Provide Pharmaceutical Care

Intention to provide pharmaceutical care was operationalized as three items asking pharmacists about their intentions to practice pharmaceutical care on a regular basis. The item response scale was a 7-point rating scale ranging from 7 (extremely likely) to 1 (extremely unlikely) rating scale. The total score for intention was the sum of the three item scores.

2.1.1.3. Attitude toward Providing Pharmaceutical Care

Attitude was operationalized by asking pharmacists about their feelings toward providing pharmaceutical care on a regular basis. Three questions following a single stem were used to measure attitude. For example, “For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be:…”. The response scale was a 7-point semantic differential scale. Three types of bipolar adjectives were used to anchor the scales: instrumental (worthless to valuable), experiential (frustrating to rewarding), and overall evaluation (good and bad). The highest score

(7) represented the most favorable response while the lowest score (1) represented the most unfavorable response. The sum of the scores of the three items constituted the direct measure of attitude.

2.1.1.4. Subjective Norm

Five items were used to assess subjective norm: two of them were the injunctive type

(what colleague pharmacists/important people in the pharmacist’s professional life think pharmacists should do in terms of practicing pharmaceutical care), and the other three were the descriptive type (whether these colleague pharmacists themselves are practicing pharmaceutical care). Item response scales were 7-point rating scales ranging from 1 (unlikely or I should not) to

7 (likely or I should). The direct measure of subjective norm was the sum of the scores of the five items.

2.1.1.5. Perceived Behavioral Control

Four items addressed pharmacists’ capability for practicing pharmaceutical care (how easy or difficult it was for them), and their control over practicing it (controllability). Responses were indicated on a 7-point scale ranging from 1 (difficult or no control) to 7 (easy or complete control). The sum of the four items constituted the direct measure of perceived behavioral control.

2.1.2. Indirect Measures

The indirect measures are specific and belief-based. They represent the product of each belief (behavioral, normative, and control) and its corresponding value (evaluation, motivation, and power). Beliefs elicited from the focus group study were used to develop the following types of belief items.

2.1.2.1. Behavioral Beliefs and Evaluation of Outcomes

A total of six positive and negative outcomes to the provision of pharmaceutical care were identified from the findings of the focus group study: patient safety, patient health improvement, pharmacist’s image, pharmacist/team relationship, patient respect/trust, and pharmacist liability risk. Two questions were asked for each outcome: one assessed the strength of the belief about the outcome, e.g., “If I were to practice pharmaceutical care on a regular basis, it would increase patient safety”. The response was indicated on a 7-point extremely likely/extremely unlikely rating scale with 1 representing (extremely unlikely) anchor and 7 representing (extremely likely) anchor. The second question evaluated the outcome, e.g.,

“Increasing patient safety is:…”. The response scale was a 7-point good/bad semantic differential scale with 1 representing (bad) anchor and 7 representing (good) anchor. The score for each belief strength was multiplied (weighted) by the score for its corresponding evaluation, and the sum of the six product scores formed the measure of weighted behavioral beliefs.

2.1.2.2. Normative Beliefs and Motivation to Comply

Four important referent people were identified from the focus groups: physicians, patients, pharmacy managers/chief pharmacists, and hospital administrators. Two questions were asked for each referent: one assessed the strength of the belief that the referent would support/reject the pharmaceutical care behavior, e.g., “The doctors in my workplace whose patients I see think that (I should not/I should) practice pharmaceutical care on a regular basis”.

The second question evaluated the pharmacist’s motivation to abide by what each referent thinks that they should do, e.g., “When it comes to pharmaceutical care, how important is it to you to do what the doctors think you should do?” (not at all important/extremely important). The responses for both of the questions were indicated on a 7-point rating scale with 1 representing (I should not or not at all important) and 7 representing (I should or extremely important). The score for each normative belief item was weighted by the score for its corresponding motivation and the sum of the four product scores formed the measure of weighted normative beliefs.

2.1.2.3. Control Beliefs and Power

Ten factors that either facilitated or inhibited the provision of pharmaceutical care were identified from the focus groups: pharmacist competency, pharmacist communication skills, culturally-based gender issues, language differences, staffing, time, computer-based drug information databases, private counseling area, access to patients’ medical records, and

reimbursement. Two questions were asked for each factor: one assessed the strength of the belief that the factor affected ability to provide pharmaceutical care, e.g., “I do NOT have adequate clinical knowledge and experience to practice pharmaceutical care” (true/false). The other question evaluated the power of the factor in affecting ability to provide pharmaceutical care, e.g., “If I did NOT have adequate clinical knowledge and experience, it would make practicing pharmaceutical care much more difficult for me” (extremely agree/extremely disagree). The responses for both of the questions were indicated on a 7-point rating scale ranging from 1 (true or extremely disagree) to 7 (false or extremely agree). The score for each control belief item was weighted by the score for its corresponding power and the sum of the ten product scores formed the measure of weighted control beliefs.

2.2. Summary of Survey instrument

The final questionnaire constituted 10 pages, including an instruction page, and 9 sections. Each section represented a construct and the last section incorporated participant demographic characteristics. The questionnaire comprised a total of 81 items.

3. Pilot Test

The objectives of the pilot test were to assess the readability and clarity of the survey materials, obtain comments on their content, and to assess the reliability of the summated scales of direct measures (intention, attitude, subjective norm, and perceived behavioral control) in order to select a final set of items for each construct that shows a high degree of internal consistency (Ajzen, 2006).

3.1. Pilot Test Methods

The survey instrument was pilot tested with a convenience sample of pharmacists from the three different practice settings in Oman. Three members of the site advisory committee (a clinical pharmacist from one of the MOH hospitals, a clinical pharmacist from one other government health institution, and a community pharmacy manager) were asked to personally distribute the pilot test materials to their interested pharmacist colleagues and to follow-up in person on return of completed questionnaires in a week’s time. The plan was to test the questionnaire with 20 participants (7 from each of the MOH hospitals and other government health institutions; and 6 from community pharmacies). However, the clinical pharmacist from one other government health institution distributed only 6 pilot test packages, which brought the number of the participants to 19 pharmacists. Pilot test materials included an introductory letter explaining the purpose of the pilot test and participant task (Appendix F); the questionnaire, post card, and cover letter (Appendix G); as well as a list of debriefing questions (Appendix H). The debriefing questions asked for comments on the readability and clarity of the questions and the cover letter, the length of the questionnaire, and for suggestions to amend the questionnaire and the cover letter. The data obtained from the pilot test were used to improve the quality of the research materials.

For the convenience and confidentiality of pilot test participants, participants were asked to return the pilot test materials in a week’s time, enclosed in a sealed envelope with their signature on the seal, in person to the person who delivered the pilot test package to them. The three members of the site advisory committee then returned the materials by express mail to the investigator in Canada.

3.2. Pilot Test Data analysis

Data were entered manually into a Statistical Program for Social Sciences (SPSS) database (version18.0). Descriptive statistics (means, standard deviations, and ranges) were calculated for all items and multi-item scales. The internal consistency of the direct multi-item scales (attitude, subjective norm, perceived behavioral control, and intention) was also assessed by Cronbach's alpha.

3.3. Pilot Test Results

A total of 19 completed questionnaires was returned (response rate = 100%; n = 7 MOH pharmacists, n = 6 community pharmacists, and n = 6 pharmacists from other government health institution), and 17 debriefing forms were completed. Most of the comments were from the

MOH pharmacists while the community pharmacists’ contribution was minimal. The reported time to complete the questionnaire ranged from 17 to 90 mins, and the mean time was 36.5 mins

(MOH = 39 mins, community pharmacists = 47 mins, and other governmental institutes = 23 mins). Six out of 17 participants (35%) who responded to the question regarding the length of the questionnaire thought that the questionnaire was quite lengthy, and recommended that it be shortened.

3.4. Actions Taken

Four items were deleted because the activities they described do not take place in Oman.

Another problem was contradictory or infeasible responses from 3 of the 6 community pharmacists to another 2 items on the pharmaceutical care scale. These and most other pharmaceutical care scale items were rephrased to make them clearer for participants.

To ensure uniform directionality of items, the response scale for 4 items was recoded such that a higher score represented the most favorable response, and the lower score represented the least favorable response. Most of the control belief items were negatively worded; consequently, their response scales were reverse scored. In order to reduce the number of questionnaire items, “workload” items were deleted because there were other items covering this topic.

Seven items were deleted based on the internal consistency of multi-item scales. Alpha coefficients for multi-item scales before and after deletion of these items are presented in table

3.1.

Table 3.1. Reliability coefficients for pilot test multi-item scales

Multi-Item Scale Before Deletion After Deletion

Number of Cronbach’s Number of Cronbach’s Items/Scale alpha coefficient Items/Scale alpha coefficient

Attitude 5 .90 3 .93

Subjective Norm 7 .88 5 .86

Perceived Behavioral 6 .54 4 .86 Control

Intention 4 .88 3 .83

Response choices for the 2 country of origin items were slightly amended to better reflect the array of countries/continents represented by pharmacists working in Oman. An item about practice type was divided into two items, one item enquiring about practice type (inpatient,

outpatient, independent pharmacy, and chain pharmacy) and the other item about sector (public or private). An item about the pharmacist’s current position was added.

3.5. Summary of Actions Taken as a Result of the Pilot Test

Thirteen out of 92 items were deleted based on participants’ feedback and on the

Cronbach’s alpha coefficient values for construct-based scales. One item was added, and one item was divided into two. Therefore, the final set comprised 81 items. Most pharmaceutical care scale items were rephrased to make them more comprehensible for participants.

4. Survey Participants

A list of registered pharmacists who were employed in inpatient and outpatient settings of private sector hospitals and clinics and community pharmacies was obtained from the

DGPA&DC representative. Another list of registered pharmacists who were employed in inpatient and outpatient settings of MOH hospitals and health centers was obtained from the

DGMS representative. Other government health institutions which included the Armed Forces

Hospital/Ministry of Defence, the Royal Oman Police Hospital, and the Sultan Qaboos

University Hospital were approached individually and their pharmacist employee lists were obtained.

4.1. Inclusion/Exclusion Criteria

Just as with the focus groups, pharmacists who were eligible to participate in the survey were those who provided direct patient care and who had been working in inpatient or outpatient settings of either public or private health care organizations or in community pharmacies in

Oman. However, unlike the focus groups, no conditions for participating were applied based on years of experience.

4.2. Sample Size Estimation

The sample size estimate was based on sample size requirements for both factor analysis and multiple regression analyses since both techniques were employed in the study. Factor analysis was conducted to verify the summated scales for each construct in the TPB and multiple regression analyses were undertaken to address three of the research objectives. The larger of the two calculated sample sizes was selected.

According to Aday and Cornelius (2006), the required sample size for multiple regression analysis is 10 to 15 times the number of predictor variables. Thus, the required sample size for the 4 predictor variables in our model (attitude, subjective norm, perceived behavior control, and past behavior recency) was 60.

For factor analysis, there are different guidelines on sample size estimation. Gorsuch

(1983) has suggested a minimum of five subjects per item provided that at least 100 subjects were included. Tabachnik and Fidell (1996) have suggested 300 as an adequate sample size for factor analysis. Nunnally (1994) has suggested a ratio of 10 subjects to 1 item. Since the questionnaire had 31 items that constituted the summated rating scales which would be validated by factor analysis, according to Gorsuch’s guideline 155 respondents would be required.

Nunnally’s guideline suggested a sample size of 310 would be required, which exceeded the sample size of 300 suggested by Tabachnik and Fidell. The most conservative estimate, that is, a minimum sample size of 310, was selected. This sample size would also exceed the sample size required for the regression analysis. Adjusting for a 50% response rate, the survey would have to be sent to 620 pharmacists. This approximated the total number of practicing pharmacists in

Oman, which justified the use of a population survey.

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The estimated response rate of 50% was conservative in comparison to recent Saudi surveys of pharmacists which reported 53% (Al-Aqeel and Abanmy, 2008) and 60% (Al-Ahdal et al., 2003) response rates. These surveys were either hand-delivered (Al-Ahdal et al., 2003), distributed via the pharmaceutical care department in the Ministry of Health (Al-Aqeel and

Abanmy, 2008), or administered in one region only of Saudi Arabia (Al-Aqeel and Abanmy,

2008; Al-Ahdal et al., 2003). It was thought that a mail survey was unlikely to achieve as high a response rate.

5. Survey Administration

Survey materials were mailed to pharmacists' business addresses as obtained from the

MOH and other government health institutions’ lists of registered pharmacists. Undelivered surveys were re-sent if a new address was provided.

To maximize the survey response rate, Dillman’s total survey design method (Dillman,

1991 & 2000) was used:

1. Prior to mailing the survey, an introductory letter (Appendix I) explaining the purpose of

the survey was sent to all eligible pharmacists.

2. One week later, the questionnaire along with a cover letter and a response postcard

(Appendix J), as well as two pre-paid addressed envelopes were sent. To prevent

unnecessary follow up and to protect respondent anonymity and confidentiality,

pharmacists were asked to return the postcard separate from the questionnaire, after

checking the box indicating that they had mailed a completed questionnaire or that they

had opted not to participate.

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3. A follow-up letter (Appendix K) was sent one week after the first mailing of the survey to

thank all who returned the questionnaire and remind those who did not respond to do so.

4. A second reminder (Appendix L) with a replacement questionnaire and a pre-paid

addressed envelope were sent three weeks later, to those pharmacists who had not

responded to the first mailing.

The timing of the survey procedures is outlined in Table 3.1.

Table 3.2. Timing of distribution of survey materials

Date Procedure

December 14, 2010 Mail introductory letter (Appendix I) to all eligible participants

December 20, 2010 Mail questionnaire + cover letter + postcard (Appendix J)

December 28, 2010 Mail first follow-up letter (Appendix K)

January 18, 2011 Mail second follow-up letter + replacement questionnaire (Appendix L)

An additional strategy was used to enhance participation in the survey. Two members of the site advisory committee, who represent the public and private sector regulatory bodies of the

Omani MOH respectively, co-signed the introductory letter, the cover letter accompanying the survey, as well as the follow-up letters.

6. Data Management and Analysis

The survey responses were entered manually, according to the coding key (Appendix M) into a Statistical Program for Social Sciences (SPSS) database (version19.0). Data were verified for accuracy by a visual double check. Frequency analysis (range) was used to check invalid values. Missing data analysis was conducted for the survey items to decide on replacing the missing values, since most statistical tests eliminate the cases with missing values, which results

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in lowering the statistical power. Cases (entire questionnaires) were deleted if missing data exceeded 30%. The useable response rate (RR) was determined by using the following equation:

Non-response bias was assessed by comparing the characteristics of early respondent pharmacists who responded after the first survey mailing to late respondents who responded after the second survey mailing (Public Works and Government Services Canada, 2009). Ten demographic variables were used: age, gender, highest degree in pharmacy, country of origin, country where highest degree in pharmacy was obtained, years of experience, practice type, years in current practice, sector, or current position. Also, the provision of pharmaceutical care was compared between the two groups because it was assumed that early responders responded early because they had more interest in providing pharmaceutical care than the late responders.

The differences between early and late responders were determined by using Pearson’s chi square for categorical variables and student’s t-test for continuous variables. Descriptive statistics (frequencies, means, and standard deviations) were calculated for all items and multi- item scales.

6.1. Validity and Reliability of Measures

In order to establish the validity of the survey instrument, several procedures were performed. The content validity of the survey instrument was assessed by the thesis advisory committee and the site advisory committee in Oman. The list of pharmaceutical care activities was also reviewed by a clinical pharmacy faculty member at the University of Toronto. The comments and suggestions provided were taken into consideration and the survey instrument was

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amended accordingly. Face validity was evaluated by pilot testing the questionnaire with a convenience sample of 19 pharmacists from three different practice settings in Oman: inpatient, outpatient, and community pharmacy.

Exploratory factor analysis (principle component analysis with Varimax rotation and

Kaiser Normalization) was conducted to identify the factor structure of the hypothesized pharmaceutical care scale (16 items) and the Theory of Planned behavior (TPB) model (15 items). A separate analysis was done for each. To determine the number of factors to retain, three criteria were used: 1) eigenvalue ≥ 1, 2) scree test (a plot of eigenvalues vs. factors). 3) item loadings of .40 or higher (Stevens, 2002). The factor structure was verified later by confirmatory factor analysis (CFA) using LISREL 8.80 software.

Confirmatory factor analysis (CFI) differs from exploratory factor analysis in that the researcher hypothesizes the number of factors. In this analysis, the pharmaceutical care behavior scale was hypothesized to load on one factor “pharmaceutical care behavior”. Although pharmaceutical care includes an array of activities that cover more than one domain, some researchers (Odedina, 1996; Kittisoppee, 2001) have combined all pharmaceutical care activities into one summated scale and thus treated it as one variable. The objectives of this study also treat pharmaceutical care as one entity. The TPB model consists of four constructs: intention, attitude, subjective norm, and perceived behavioral control. The hypothesized pattern of factor loadings was therefore:

- Three items (items 57-59 of Appendix J) on “attitude” - Five items (items 60-64 of Appendix J) on “subjective norm” - Four items (items 65-68 of Appendix J) on “perceived behavioral control”

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- Three items (items 69-71 of Appendix J) on “intention”

The chi-square statistic was used to assess overall model fit but chi-square is sensitive to sample size (Byrne, 2010; Norman and Streiner, 2008) and therefore other statistics known as fit indices were used to assess model fit. These indices were the goodness of fit index (GFI), normed fit index (NFI), comparative fit index (CFI), and the root mean square error for approximation (RMSEA). The GFI, CFI, and NFI range from 0 to 1, with values over 0.95 indicating a good fit and values over 0.90 an adequate fit. A value of less than .05 for the

RMSEA indicates a good fit and below .08 an adequate fit (Byrne, 2010). In the current study, the chi-square and the four fit indices were examined to judge the overall fit of the model; where the value of the fit indices indicated that the fit of the model was adequate or less than adequate, modification indices (MI) were examined to determine how the fit of the model could be improved. MI provides solutions to discrepancies between the proposed model and the data. MI indicates how much the model is improved when a constraint parameter is freed, that is, allowed to be estimated in the analysis. Parameters with the largest MI values are usually addressed only if they make substantive sense. If a specific modification is not theoretically meaningful, the next largest MI is addressed (Byrne, 2010).

After conducting CFA and identifying the best fitting model, reliability analysis was conducted separately for each of the factors identified to examine the internal consistency of that factor. Cronbach's alpha coefficient is the statistic used to measure this kind of reliability; a value of 0.70 or greater was used as a criterion threshold. Reliability analysis was not conducted for the indirect measures because beliefs (whether behavioral, normative or control beliefs) people possess about a behavior are inconsistent and vary from one individual to another. For example,

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beliefs about a behavior could be positive or negative depending on how individuals link the behavior to certain outcomes, and the same applies to normative and control beliefs. Thus, internal consistency reliability is not valid in the case of beliefs (Ajzen, 2006). Test-retest reliability (temporal stability) is usually used to establish the reliability of beliefs in longitudinal studies (Ajzen, 2006; Francis et al., 2004). However, it was not possible to establish test-retest reliability for the beliefs in this study as it was cross-sectional.

6.2. Statistical Analyses

Statistical analyses are described below for each of the research objectives. The a priori level of statistical significance was established at p ≤ 0.05 for all statistical tests.

Objective 1

The extent of the provision of pharmaceutical care was determined from the mean total score on past behavior recency scale presented as a percentage of the maximum possible score of the scale (as determined in a previous study, Hughes et al., 2010). Regular providers were defined as those who perform pharmaceutical care activities either all the time or most of the time, that is, scored 48-64 on pharmaceutical care scale. One-way analysis of variance

(ANOVA) was used to compare the provision of pharmaceutical care across the three practice settings. The Kolmogorov-Smirnov Z test and Levene’s test were used to check the assumptions of normality and homogeneity of variance, respectively, for the ANOVA model.

Objective 2

Perceived facilitators and barriers to the implementation of pharmaceutical care were identified by examining the mean score on each weighted belief item (each belief item’s score within the indirect measures [behavioral, normative, and control belief] multiplied by its

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corresponding value score [evaluation, motivation to comply, and power]). Scores below the midpoint 16 (≤15) were considered potential barriers to the implementation of pharmaceutical care and scores above the midpoint (≥17) were considered facilitators.

Objective 3

The effect of pharmacists’ country of origin on their beliefs (behavioral, normative, and control) relative to providing pharmaceutical care was assessed by using one-way multivariate analysis of variance (MANOVA). Responses to countries/continents of origin were recoded.

Participants represented four countries/continents, Oman, Middle East, Africa, and South Asia.

Africa was collapsed with the Middle East for two reasons: one, small cell count (9); two, some

Egyptian pharmacists considered themselves from Africa, while the others considered themselves from the Middle East. The assumptions of multivariate normality (that is, the dependent variables are multivariately normally distributed for each level of the factor) and homogeneity of variance and covariance among the dependent variables across all levels of the factor, country of origin, were checked. Kolmogorov-Smirnov Z test of normality and Box’s test for homogeneity of variance were used to test these assumptions.

Objectives 4, 5, & 6

Multiple regression analyses were employed to test objectives 4, 5, and 6. Several diagnostic tests were conducted to check the assumptions of regression analysis. The assumption that the residuals (errors) are normally distributed was tested by examining normal P-P plot of standardized residuals (observed values vs. predicted values) (Munro, 2005). The residuals fall close to the diagonal line if they are from a normal population (Tabachnick and Fidell, 2012). If the normality assumption was not met, the presence of outliers was examined by the use of

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residual statistics (standardized residuals or studentized deleted residuals). Cook’s distance statistic was used to identify influential outliers. Cook’s distance values >1 usually require scrutiny.

The assumptions of linearity and homoscedasticity were checked by examining a residual scatter plot (standardized residual vs. standardized predicted values). If the variance of the dependent variable is the same for all values of the predictor variables, the residuals are randomly distributed around the horizontal line and the assumptions of linearity and homoscedasticity are met (Osborne and Waters, 2002).

Multicollinearity was assessed using the collinearity statistic (tolerance). Tolerance values range from 0 to 1 with tolerance values close to 1 indicating absence of multicollinearity.

Values close to 0 indicate that two or more predictor variables are highly correlated in the model and that one variable can be predicted by other predictors, and therefore does not add to the prediction of the dependent variable (Norman and Streiner, 2008).

For objective 4, intention was regressed on attitude, subjective norm, perceived behavior control, and past behavior recency. The F test was used to examine if the regression model performed significantly better than the null model and if the linear combination of the four predictor variables was significantly related to the dependent variable. The adjusted R2 determined the amount of variance in the dependent variable explained by linear combination of the predictor variables. The size of the standardized regression coefficient (Beta) for each predictor variable was examined to determine the contribution or the effect of each predictor variable on the dependent variable in relation to each other. Standardized regression coefficients

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were used instead of the unstandardized regression coefficients because they provide more meaningful interpretation of the results.

For objectives 5 and 6, past behavior recency was regressed on intention and perceived behavioral control. Tests were conducted as described above and the predictive validity of the proposed model was assessed by examining the amount of variance (R2) in past behavior recency explained by the linear combination of predictor variables: intention and perceived behavioral control (past behavior recency was used as a proxy for pharmaceutical care future behavior).

Section III: Chapter Summary

To examine the extent of the provision of pharmaceutical care in Oman and identify facilitators to and barriers of its implementation, the population of Omani pharmacists was surveyed using a mail method as per Dillman’s total survey design method. Prior to the survey, three focus groups were held in Muscat to elicit pharmacists’ behavioral, normative, and control beliefs related to the implementation of pharmaceutical care for the purposes of constructing the survey instrument. Several analytical techniques such as ANOVA, MANOVA, and multiple regression analysis were used to address the study objectives.

CHAPTER FOUR: RESULTS

The first part of this chapter presents the results of phase I of the study, the focus group study, while the second part covers the results of phase II, the cross-sectional population survey of practicing pharmacists in Oman.

Section I: Focus Group Study

The purpose of the focus group study was to elicit pharmacists’ beliefs pertaining to the implementation of pharmaceutical care in three practice settings in Oman: inpatient, outpatient, and community pharmacy.

1. Participants

In total 23 pharmacists participated in three focus groups (n = 6 inpatient pharmacists, n

= 7 outpatient pharmacists, and n = 10 community pharmacists). Table 4.1 below presents a summary of participants’ demographics.

2. Focus Group Themes

There were no notable differences in the findings from the three focus groups; hence, the major themes that emerged were combined. They were then stratified into three categories according to the TPB belief constructs: behavioral, normative and control beliefs. Participants’ responses are identified by the letters IP, OP, and CP, corresponding to inpatient, outpatient, and community pharmacy focus groups respectively.

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Table 4.1. Sample characteristics of focus group study participants

Sample Characteristics Inpatient Outpatient Community Pharmacy

Total Number of Participants (N = 23) 6 7 10 ≤ 29 1 2 1 Age 30-39 4 3 3 40-49 - - 3 ≥ 50 1 2 2 Missing - - 1 Gender Female 4 4 2 Male 2 3 8 Sector Public 6 6 - Private - 1 10 Highest Education Level Bachelor’s Degree - 4 9 Master’s Degree 5 3 1 PhD Degree 1 - - Country/ Continent of Origin Oman 5 5 - Middle East - - 1 Africa 1 - - South Asia - 2 9 Continent/ Region where Middle East - 2 1 Highest Level of Education in Europe 5 3 - Pharmacy was Completed Africa 1 - - South Asia - 2 9 Years in Pharmacy Practice 0-5 - 1 1 6-10 2 3 3 11-15 1 - 1 16-20 2 1 1 > 20 1 2 4 Years in Current Practice ≤ 10 3 6 7 11-19 3 1 - ≥ 20 - - 3 Current Position Manager or Director - 2 - Assistant/ Associate 2 - - Manager or Director Supervisor 1 1 2 Staff Pharmacist 3 4 8

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2.1. Behavioral Beliefs

In response to the moderator’s question about the positive and negative outcomes of providing pharmaceutical care, a consistent pattern of responses emerged across the three focus groups. All participants believed that almost all outcomes of providing pharmaceutical care were positive. Nevertheless, very few negative outcomes were also reported. Therefore, two major categories were identified, perceived benefits of pharmaceutical care and perceived negative consequences of pharmaceutical care. The themes emerged under these two categories were classified at the patient, pharmacist, pharmacy, and health care system level.

2.1.1. Perceived Benefits of Pharmaceutical Care

2.1.1.1. Patient

All three focus groups participants believed that providing pharmaceutical care prevents medication errors, thus enhancing patient safety from adverse events and drug-drug interactions:

Definitely presence of the pharmacist is very important point because we can alleviate most of these ADRs. [IP]

The main benefit is patient safety. [OP]

Also, participants believed that by providing pharmaceutical care, they would educate patients about their medications, and as a result of patients’ better understanding of their disease conditions and medications, they would adhere to their therapeutic regimen, and therefore their health would improve:

They [patients] will improve because if they will understand what their case is and why they are using [medications]. And there will be the trust between pharmacist and patient so the patient will go and take [the medication]. They will be complying. [OP]

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2.1.1.2. Pharmacist

Most of the participants thought that providing pharmaceutical care would redefine the pharmacist’s perceived role and change physicians and patients’ predominant image of pharmacists as pill dispensers:

It’s changing the old mentality.... they think that pharmacist is only dispensing and giving like how many times a day....that’s their job. [OP]

Another belief was that providing pharmaceutical care services fosters the relationship between pharmacists and the multidisciplinary team, so that pharmacists would earn trust and respect from other health care providers:

So even other multidisciplinary members, they start to trust you, they start to take your word. [IP]

In our hospital the physicians depend on the pharmacy to a great extent for each and everything. They call the pharmacy first for having an opinion, pharmacy opinion and suggestions. [OP]

Pharmacists would also be respected and trusted by the patients:

Patients start to look up to you and they come and look for you and respect you a lot and respect your opinion. [IP]

There will be trust between pharmacist and patient. [OP]

Many patients here even if the doctor writes [a prescription], they come to me and they used to ask me whether this is the [right medication].That is the trust we have developed and the relation that we have developed. [OP]

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2.1.1.3. Pharmacy

From a business perspective, community pharmacists believed that providing pharmaceutical care also establishes trustworthiness of the pharmacists, ensuring return business from existing patients, and creating new customers as a result of customer referrals:

Yes, certainly because satisfied patient will come back to you. [CP]

When the patient got convinced....So often he refers to his friends this guy does good job, you can go over there....the things will spread up like anything then you will get more patients....The remuneration also to the company also will goes up directly or indirectly. [CP]

2.1.1.4. Health System

Pharmaceutical care was viewed by inpatient and outpatient groups as an important factor in reducing health care expenditure:

If they are having their proper [medication] management then they will not come again for another admission and thus you preventing further admissions.[IP]

The visiting to the hospitals will be less and that it will save a lot of things, time, cost. [OP]

2.1.2. Perceived Negative Consequences to Pharmaceutical Care

Most of the participants were in agreement that there were no negative consequences to pharmaceutical care, if it was carried out in an appropriate manner:

I do not see anything negative if you do it properly. [IP]

If right pharmaceutical care is provided, there is no negative, absolutely no negative. [OP]

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2.1.2.1. Patient

Some participants thought providing unskilled pharmaceutical care services, e.g., providing too much unnecessary information about adverse effects might frighten the patient to the extent that he/she might not adhere to his/her medication regimen or, in the opinion of community pharmacists, not having the prescription filled, thus negatively affecting the pharmacy’s business:

While counseling patients, the first thing we tell my colleagues when we train them is that never give too much information to the patient, never give too less information, give the right information for that particular patient. You have to assess it....otherwise you will frighten him and he will not take his medicine. [OP]

Sometimes giving too much information that also will end up not buying anything. That is a direct loss to the pharmacy. [CP]

2.1.2.2. Pharmacist

The liability risk associated with the provision of pharmaceutical care was mentioned mainly by inpatient pharmacists. Pharmacists believed that, in Oman, the responsibility of therapeutic decision making is the physician’s jurisdiction, and physicians are held responsible and accountable for any harm. Such thinking, pharmacists stated, should change and pharmacists should share the responsibility:

If anything harm happens to that patient then the doctor will be the one who is responsible for that, despite that the pharmacist is there and he should take the responsibility and accountability at the same time. But mainly in any hospital you won’t see that. It’s mainly the doctors and so I think this concept should be changed and we should share the responsibility. [IP]

I think we advocate patients and we are in advisory roles, still in transition. We haven’t legally been responsible for patient only if we intervene. [IP]

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Despite the fact that all of the inpatient pharmacists were practicing patient‐centered care, they disagreed about their risk concerns or level of comfort accompanying the responsibility of providing such care. A certain element of worry was expressed by one-third of participants:

Doctors make risk in their decision making, they make risk every day and we also unknowingly we are into that, but are we prepared to take that risk? Because there will be decision making, time, and stress and, the minimum, you know, information. So being practitioner is by default.... there will be a risk when we make a decision, but are we ready to take risk? [IP]

Some time you will provide pharmaceutical care but you will, you won’t sleep. Some time for example....you recommend.... a higher dose for antibiotic even if nephrotoxic drug, because you want to save the patient. In this situation but you are concerned about the nephrotoxicity and it is very difficult for you now to balance the risk and benefit, so you will give the dose, even some time a higher dose.... in term of risk and benefit here you’ll be worried at what you are providing, is it correct or it’s wrong. [IP]

2.1.3. Summary of Behavioral Beliefs

Two major categories were identified: perceived benefits of pharmaceutical care and perceived negative consequences of pharmaceutical care. The identified benefits of providing pharmaceutical care at the patient-level were patient safety and patient health improvement, while those at the pharmacist-level were pharmacist’s image, pharmacist/ team relationship, and patient respect/ trust. While pharmacy business enhancement was identified at the pharmacy- level, cost saving was identified at the health system-level. The main perceived negative consequence of providing pharmaceutical care was pharmacist liability risk at the pharmacist- level.

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2.2. Normative Beliefs

Four important social influencers were identified. These were the physicians, patients, pharmacy managers, and hospital administrators.

2.2.1. Physicians

With respect to physicians, one of the first points brought up when discussing pharmaceutical care was the attitude that physicians have towards pharmacists and the pharmacist’s role. The perceived receptivity of physicians to pharmacists’ interventions varied across settings. For the inpatient setting, participants reported a great resistance in the beginning; however, when physicians interacted with pharmacists and experienced pharmaceutical care, they became receptive to drug-therapy recommendations made by the pharmacists and became more appreciative of these recommendations:

There was a bad resistance and they kept on complaining who are they and what are they doing? Now if we are off, they will keep on calling, where is our pharmacist? At the beginning we were providing the care, now they are asking for the care....first they came and complained and now they are the one who cannot work without my advice. [IP]

When we started clinical pharmacy in [hospital name removed], we used to go to the wards and the doctors it seems that they were not accepting, you know, these invaders....so they were asking what are these people doing here? Sometimes they just neglect us....after one or two years we felt that if the clinical pharmacist is absent for any reason, then they will start asking where is the clinical pharmacist today? [IP]

In the outpatient setting group, there was more variability of opinion; some pharmacists believed that physicians were receptive to their interventions, while others had mixed feelings:

I remember in 2004, nobody was calling the OPD [outpatient department] pharmacy...but now they are calling us, could you please check; this patient is on dialysis, so what to do in term of his Fosamax? [OP]

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It depends upon the doctors’ mentality, there are some doctors who call the pharmacy...but other doctors neglect the pharmacy....their ego will not let them to call and to ask....they feel that it is something big to call the pharmacy. [OP]

Most of the physicians are supportive but some....still have a complex. [OP]

Community pharmacists uniformly reported tension between physicians and community pharmacist, and the pharmacists felt that physicians were not receptive at all to any intervention made by them:

Doctors are not cooperative at all. [CP]

They are writing on the prescription “don’t substitute the medicine without prior approval”. [CP]

Pharmaceutical care can be improved only when doctors realize the status of pharmacist. [CP]

2.2.2. Patients

The perceptions of patients towards pharmacists and their role were considered to be important. Patients’ receptivity to and interest in receiving pharmaceutical care services varied across settings; some found that patients were not only receptive to receiving this type of care, but expected it. This expectation seemed particularly prominent amongst patients in inpatient settings who had experienced pharmaceutical care:

Those who have the experience in the pharmaceutical care, they really wish to continue. [IP]

....Even wait for you. They may call you from home or from wherever....they may call the ward, the clinical setting they were admitted to, to ask for your advice. In another scenario, they would go to the pharmacy, they would pick up the medication and then they will come back to the ward to have it explained by yourself....so they make sure, especially, if they are chronic patients. They would know that you are a member of the team that looks after the medication and talk to them about the medications, so they

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would make it a point to interview you or to meet you at some point before leaving the hospital premises. [IP]

On the other hand, some other participants spoke of patients who were completely uninterested in receiving pharmaceutical care. Low expectations among patients were reported mainly by the outpatient group:

The barrier sometimes from patients. They don’t give us chance to explain to them the message. They have the old mentality, that no need to explain....so some of them they will just take and say no need, I know everything, it’s written there. I will just go and read and take it. [OP]

Other aspects of the patients’ attitude that hinder the provision of pharmaceutical care were brought up by community pharmacists. One issue was that the patients seemed to have more faith in physicians. Some patients would prefer to approach their physicians if encountering any medication‐related problems rather than discussing the problem with their pharmacist:

Because patients have that psychology doctors are more knowledgeable than pharmacists. [CP]

Definitely, he is having more trust in the doctor than the pharmacist. [CP]

The other issue brought up in this group was that patients viewed the advice and attention given by the pharmacists as a way to sell more drugs:

There is a psychological barrier that while prescribing or discussing this so much you want to sell more medicine, so that society mental growth is still not there for to accept the pharmaceutical care. [CP]

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2.2.3. Pharmacy Management

Pharmacy management was viewed as a significant element impacting the provision of appropriate patient care. Hospital pharmacists strongly agreed that they were well supported by department management in their pharmaceutical care activities. In fact, without this endorsement, there would have not been any services provided:

We have established clinical pharmacy services, and obviously without the role of the heads of our department then there would not be any service. [IP]

Our “in charge”, our head of the department, they always encourage us to do that [pharmaceutical care] and spending a lot of time. [OP]

In contrast, community pharmacists believed that their management or corporate head office was reluctant to agree to the provision of pharmaceutical care since it would negatively affect the number of prescriptions filled, and therefore, the pharmacy business. Pharmacists thought if pharmacy management could see the benefit of pharmaceutical care to the pharmacy’s business, they might be receptive to the provision of pharmaceutical care services:

The manager whomsoever in the higher category, so provided it should be beneficial to the company....the higher end they will agree if at all they are getting benefited. [CP]

2.2.4. Hospital Administration

Hospital administration did not seem open to supporting pharmaceutical care. Participants from both public and private hospitals complained that due to unawareness of the concept of pharmaceutical care among their hospital administrators, they did not respond to pharmacists’ frequent demands to hire clinical pharmacists or highly specialized pharmacists for critical areas,

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or to modify the layout of the outpatient pharmacy to facilitate the appropriate provision of pharmaceutical care:

May be lack of understanding from the admin side to what specialization in clinical pharmacy is. It is hard to convince them that you want to employ specialized staff and we are ready to pay them a lot of money, so you want to educate the admin and good luck there, because it is not easy to convince them. [IP]

You don’t have enough resources and the staff you employ are all fresh graduates, so this is a barrier that comes from our administration because of the pay and the grades. [IP]

Lack of professionalism particularly in our area, in my hospital I mean....as a private management, we don’t get sufficient support in terms of providing high competent pharmacists, because we don’t have a clinical pharmacist until now which has been put forward as early as 5 years back.[Investigator: So you mean there is no administrative support?] Yes, no administrative support. [OP]

The same thing, it is administrative support. No administrative support, and so patients when they coming in the crowd they want [us] to explain to them [how to use their medications], there is no any place [private counseling area] for them to sit. [OP]

2.2.5. Summary of Normative Beliefs

The support of the four identified social referents varied across settings. Inpatient pharmacists believed that their patients, physicians, and managers supported their provision of pharmaceutical care but not the administrators. Outpatient pharmacist believed that their provision of pharmaceutical care was unappreciated by their patients and administrators, and had mixed feelings about physicians’ support; however, they believed that their managers were the greatest supporters. Community pharmacists, on the other hand, felt that neither one supported their pharmaceutical care behavior.

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2.3. Control Beliefs

When participants were asked about factors that either facilitated or hampered their provision of pharmaceutical care, the inpatient group mainly discussed facilitators, as opposed to the outpatient and community groups, who for the most part talked about barriers. Ten themes that related to control beliefs were identified. Pharmacist-related factors were competency and communication skills in particular. Pharmacy-related factors were time, staffing, workload, access to drug information resources, and pharmacy space. Health care organization or health system factors were access to patients’ medical records and reimbursement. Social factors such as patient cultural beliefs and linguistic skills were also identified.

2.3.1. Pharmacist-Related Factors

2.3.1.1. Competency

Even though participants practiced in the same city, there was great disparity between the opportunities given to public sector pharmacists and those given to private sector pharmacists.

The MOH and the other government health institutions in Muscat recognized the central role of pharmaceutical care in optimizing drug-therapies and had adopted pharmaceutical care as the new mandate for pharmacy. Pharmacists in the public sector were given many opportunities to develop the necessary knowledge and skills to provide pharmaceutical care. These include post graduate education, continuous education programs, and on the job training:

We were prepared kind of, postgraduate training, and basically we are establishing a service. [IP] It’s part of the training that you get.... so the knowledge and the training and the qualifications and the experience....were sort of a facilitator to achieve this kind, this level of service. [IP]

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We tried in our pharmacy department to improve the staff performance and we concentrated on education and training.”[OP] We have seen those who have spent some time with us, with intensive training they got much much better, and I remember we have trained some who were planning to go abroad so as to complete their master’s degree. That [the training] was recommended, I think, by [University of] Strathclyde and we spent about three months just to prepare them and they did well. And they are doing very well now, and they are well known pharmacists. [IP]

While all inpatient pharmacists were posted abroad for their higher education, only a few from the outpatient setting were given this chance. They believed that they were less fortunate and did not get much opportunity to develop themselves:

We don’t get enough training and enough opportunity to develop ourselves. [OP]

Even in outpatient setting without clinical knowledge, especially, patho-physiology [of] disease conditions...if you are not trained in that level you cannot become a good professional. [OP]

Private sector pharmacists felt that their professional development was ignored. Neither the MOH nor their corporate head offices gave them assistance to acquire the skills needed to practice according to the new role for pharmacy. The annual seminars provided by the MOH were deemed unhelpful:

Here we are not getting any continuous training programs, so many drugs are launching daily, we are not getting the knowledge about that one [newly launched medications]. That is the main problem [why] we can’t council the patients. [CP] But if the ministry or other organizations or anything giving a continuous education program that will be a very good idea. [CP] In other countries, they are conducting the continuous education program and pharmacist should attend, must attend that program, then they will get renew their certificates. We here, we don’t have. [Investigator: The ministry [Ministry of Health] is not providing anything [continuing education programs] to the private sector?] Only

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once in a year that also [another participant: not regularly] that is not much beneficial also, just four or five lectures will be there and nothing.”[CP]

There should be some separate training more for us. [CP]

2.3.1.2. Communication Skills

All participants acknowledged the importance of having good communication skills to facilitate the delivery of patient-centered care. Such skills were not limited to interactions with care recipients, but also extended to include other health care providers and colleagues. Good communication skills were deemed necessary to attain patients’ and other health care providers’ trust:

Because 90 percent of pharmaceutical care what we are providing in outpatient pharmacy depends on good communication, even between the patients or between us as a staff or as a colleague. Communication and good personality will help a lot to make the work environment peaceful and good. [OP]

It’s very important, if we have good communication skills even with the patient they will trust you a lot. [OP]

Body language is always important in any profession, how you your body will speak before opening your mouth, your body will. How you respond to the person in front of you, your body give signal....your body language should be such a way that he [the patient] gets comforted with you. [CP]

2.3.2. Pharmacy-Related Factors

Five factors that influenced the implementation of pharmaceutical care were: time, staff, workload, access to drug information, and pharmacy space.

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2.3.2.1. Time/ Staff/ Workload

Time constraints, staffing, and workload were correlated factors, and thus were grouped.

The lack of time associated with a shortage of pharmacists or technicians, and increased numbers of patients was cited by all groups as a major impediment to pharmaceutical care:

If you are assigned to look after ward A or B and then X or Z is on leave and then another two wards will be added. Definitely that will affect your provision of service and your work. Instead of spending some time with the patient and in the ward you will be just....looking at that screen trying to finish with nonstop, and finish with the discharges which will be instead of discharging 5, you will be discharging 15 or 20, and that consumes a lot of time. So, I think....we have to tackle on this problem. [IP]

Sometimes we have a lot of patients so there is no time for every patient and the number of the staff is not that enough to provide for each and every patient, sometimes we can miss one of the patients in crowd. [OP]

Yes, we are facing shortage of pharmacists, almost all pharmacies are having one pharmacist and one assistant pharmacist....we are facing difficult to explain about the side effects, interactions and all. Time consuming process it is. [CP]

Almost half of community group participants reported that they worked alone, which made it even more difficult to cover both dispensing and pharmaceutical care activities. One participant stated that a pharmacy needs two staff members on duty at the same time in order to practice pharmaceutical care:

One staff in my case....staff shortage is the basic, so that leads to rest of the problems, timeframe, when the patients are crowded I can’t concentrate much. So much information I will not be able to give. [CP]

I am working alone in the pharmacy so [another participant: We are alone] no supportive personnel. [CP]

So for pharmaceutical care there should be two people. [CP]

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2.3.2.2. Access to Drug Information Resources

All participants acknowledged that there was a need for access to appropriate drug information databases to support decision making in pharmaceutical care:

Another barrier could be the lack of appropriate drug information. Many times you need, as I said, specific answers to the scenarios that you are dealing with, and if you are not having the proper support in terms or references or access to the information that you need, it could be a significant barrier towards providing care.[IP-Other government health institution]

In our practice....everyone is depending now on the evidence-based medicines. So there’s like a financial barrier because the Ministry will tell you this will cost us a huge budget to provide like access for the journals. Because now you cannot depend all the time on the books. There are new, as I told you at the beginning, off-licensed, off- labelled, and they are of benefit to the patient and they are used....so this I think is a very big barrier. [IP-MOH institution]

Yeah information [another participant: Yeah, information technology should be there, yeah] coming to the drug interaction package, that kind of systems we want, the packages, either it should be provided with the Ministry [MOH] or the management level, but it should be I feel it is a mandatory. [CP]

There was no uniformity in the drug information resources available to pharmacists between (public and private) and within groups (public health institutions). Pharmacists in one of the other government health institutions were better off than the MOH institution pharmacists who in turn were better off than the private sector hospital pharmacists; and community pharmacists employed in bigger chain pharmacies were in a better position than smaller pharmacies:

We have actually access to Micromedex and so many books and journals and we have also the library there. [IP-Other government health institution]

We have Micromedex and Medline and again internet and all these things.”[OP-Other government health institution]

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Micromedex, Medicine Complete, now recently Evidence Base, which is mainly of diagnosis, and that we have this three. And we are on the process of starting drug information center. On process of starting drug information system, you know, [hospital name removed] hospital they already brought all the facilities regarding documentation and some of the resources and we are still asking about that to have an access in journals. So we are on process we are going to implement this. Just we’re waiting for enough staff, somebody to be assigned in drug information center. [IP-MOH institution]

Reference books and everything is there but Micromedex and such electronic support is not there. [OP-Private hospital]

Because all people are not accessible to the pharmaceutical journals and all these things what are available in big institutions. But individual pharmacies can’t, small, small pharmacies they can’t subscribe even that for them.... because all the pharmacies even I think net [internet] is there now to get more information about what is happening also, but net facilities are also not available in small, small pharmacies. [CP]

Access to drug information resources not only varied across public and private sectors, but also varied within the MOH’s (the main health care provider) health care levels. While pharmacy departments in tertiary care institutions had almost all the electronic drug information resources, primary health care (health centers) pharmacists were not even provided with the simplest forms of pocket sized drug information references, the BNF (British National

Formulary) or the MIMS (Australian medicines reference).

I visited the primary health care before, they don’t have BNF in the pharmacy, they don’t have MIMS, they don’t have anything, so how they getting information for the doctors, I don’t know. [OP-Tertiary care hospital]

Only secondary, secondary they approved it already, but still not implemented. But primary still not approved it. But they said it will be available in the new system, because they are changing the system in the computer in our ministry. So instead of Shifa 1 or something they will call it Nabdh El-shifa. So in the Nabdh El-shifa will be all, Micromedex, everything for all, the primary, secondary, and tertiary. [OP-MOH Policlinic]

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2.3.2.3. Pharmacy Space

There was general acceptance among the outpatient and community focus group participants that a pharmacy layout which allowed some degree of privacy for pharmacist-patient interactions was required for proper provision of pharmaceutical care, and that limited pharmacy space affected the quality of the patient‐pharmacist interaction. The importance of a private counseling area was emphasized. Because peoples’ health and medications are a very personal matter, patients feel more comfortable discussing their medications in private. Participants acknowledged that lack of privacy held back their patients from fully engaging in the pharmaceutical care being providing to them:

But the main problem is I am explaining for him in front of all the patients, in front of all the staff. This is the main point of embarrassment. [OP]

I was counseling my patient in....doctors’ room for the HIV patient....HIV patient they feel that confidentiality and they were very happy....but when we talk to the other authority I mean administration, they said why it is confidentiality? I said even if some of the patients, sorry to say that, I am giving suppository for haemorrhoids, it is confidentiality. I am not supposed to talk [in front of] somebody else, because some of the patients they will took the drug and they don’t want anybody to counsel [them] because they feel shy. [OP]

While a few pharmacists stated that their pharmacies were spacious enough to take the patient aside and have a personal conversation, the majority of participants said that their pharmacies did not have a private area for patient interaction:

Main problem I find is space that’s a constraint, hospital doesn’t grow as we grow, that’s a problem. [OP]

For us, the place, we got limited place in outpatient pharmacy. We don’t have this counseling room, very limited small waiting area for the patients, very small area for us even to work and this is a big problem we are facing. [OP]

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Specifically no counseling area, but our pharmacy or my branch is, I mean, big large enough actually to have a personal conversation or anything like that, but as of now there is no separate room for counseling. [CP]

2.3.3. Health Care-Related Factors

2.3.3.1. Reimbursement

Reimbursement was identified by community pharmacists as one of the most crucial aspects required for implementation of pharmaceutical care. One participant suggested that the

MOH drug price control policy could be extended to cover the fees for patient‐centered care services:

When it comes to the monetary point of view.... if colleagues are not getting any benefit from that charges or some percentage they will not cooperate. [CP]

The government should also help to carry out this program. The companies who are doing the business in the private sector, they might have to recruit more people....so management will have extra burden. [CP]

Now at the moment, private sector have the price control, so whatever the additional cost or anything appears, the people who are doing the business in the private sector management, if they have some extra percentage by the MOH to cover part of fee. It helps the managements to help the pharmacist to go for that exercise. They will not have that extra burden or the pressure. [CP]

2.3.3.2. Access to Patients’ Medical Records

While access to patients’ medical records was a prominent obstacle encountered in the private sector, it was a facilitator in the public sector (inpatient and outpatient) since all pharmacists had access to these records. It is noteworthy that in the public sector all patient records are electronic, and pharmacist interventions are documented in the progress note section of the electronic medical record. One exception was a non-MOH hospital, where only the clinical and senior pharmacists had access to the full medical record including lab results and X-rays.

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Other pharmacists as well as the technicians had limited access, that is, could only view physicians’ comments and the drugs prescribed:

I think we have electronic patient data base; we are lucky. I think in [hospital name removed] and in the Ministries. That really helps us in accessing or preparing yourself to the round. [IP]

And even it’s a way now to record your documentations and interventions because now we have an access to write doctors in the progress notes. So even sometimes you can’t find the doctors, they are away, at least the on-call doctor will see your comments, your doses, your interventions. [IP]

Senior Pharmacists....have access to all the details, for example, an assistant pharmacist cannot go beyond doctors’ comments and the drugs prescribed. He cannot go to the lab results, he has no access. So it depends upon your level you have access. [OP]

We don’t have the access except for clinical pharmacists and for head of pharmacy department, according to the grade....this is one of the reasons which improved our practice when we had that access to see patients file otherwise we will just be a dispenser. [OP]

All community pharmacists concurred that a minimum amount of patient information was a requirement for rendering pharmaceutical care services. However, some worried because patients did not consistently visit the same clinic, and as a result private sector physicians could not maintain full patients’ medical records:

We should have the enough patient data to solve out anything. [CP]

Even the doctors are having? I am asking. No, the doctor even the doctors, he is going to a doctor, he is going to the different clinics, what doctor is having about that patient? [Investigator: Okay, so, even the doctors will not have the full [participant: No] medical [participant: No] record?]. [CP]

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Not only did community pharmacists lack access to patient’s medical records, but they also lacked access to physicians, especially those who are employed in hospitals, to enquire for patients’ information. The problem was worse on the weekends:

Especially the hospital doctors are not accessible. Any clinic, hospital doctors, private sector or public sector, doctors are not accessible. Yeah, if it is a small clinic you can call the doctor and rectify the thing immediately otherwise the patient has to wait. Second thing, to access the doctor is difficult in the weekends. After writing the prescription and to change [it by] the doctor, you have to advise him [the patient] to go [back] to the family doctor and ask his advice. [CP]

2.3.4. Social Factors

2.3.4.1. Cultural and Language Differences

Most health care providers in Oman, including pharmacists, are non-nationals who come from other cultures and speak different languages. Their appreciation of their patients’ cultural background can influence how they provide health care and in case of pharmacists, pharmaceutical care. Cultural differences between the pharmacists and their patients were discussed by all groups. However, discussion focused on gender-related issues. Although most of the pharmacists themselves had no problems dealing with both sexes, some patients had an issue dealing with a pharmacist of the opposite sex, specifically regarding sensitive medical conditions:

In one practice I also came across cultural barriers in terms of counseling patients in very restricted issues. There is a cultural barrier you cannot go beyond. There are some things you want to provide but because if I am a female and he is a male we cannot talk as openly, so I think this is one of the barriers to give proper counseling sometimes. [IP]

It depends on the individual, sometime being a lady, when I am dispensing something even some gents will talk freely to me. Sometime they will tell sorry mam but I have to ask this. But some people....will ask: no other person here? I am saying no, they will go

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back....It depends on individual person, but I am comfortable even if some gents are coming....because I am working, I have to, I will not feel shy....sometimes some ladies are coming they are very happy....that’s good you are here, now always we will come here. [CP]

But for me during the practice if I am giving any counseling to the male patient especially because we are having this derma [dermatology] department, you know, creams and sometimes it’s, it’s little bit embarrassment to tell the male patient to how to use. But for me I am trying to deal with it in a very professional way. [OP]

Pharmacists believed that this problem is more prevalent in the interior regions of Oman and amongst uneducated patients:

Of course, you see cultural variation will play a major role, like in the interior and all, you have more encounters like this with a female talking to a male pharmacist, but in the capital area to certain extent it is less. But it does play a major role. [CP]

Sometimes what happen, if this person in front of you he is not educated enough then this problem will, he will not say anything....but generally with educated person the gender of pharmacist is not coming in the picture, this is what I feel whether a male or female. The person in front of you is educated enough so that problem never comes in the picture. [CP]

On the other hand, in the public sector, a language difference between patient and pharmacist was not considered a salient impediment to interact with patients. Most of the government health institutions had bilingual pharmacists or staff who spoke the local dialects found in the community. Different approaches to overcome this barrier were employed, such as having pharmacists from more than one country in the same shift, or teaching their staff pharmacists some Arabic expressions that are usually used during dispensing or counseling to enable them to communicate with their patients:

I don’t think we came across lots of language barrier because our [staff], mostly Omani, will speak more than one language. We can manage and if we have a barrier

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like if a guy is talking in like Zanzibari [African language spoken by some locals] then X can help....with his support we manage it. [IP]

In our place we’ve noticed that language is one of the barriers so we changed our system....in three staff, there should one of them Arabic speaker. And we are trying always to ask the patient even if the patients....are Omanis but they are not Arabic speaker. They know other language, some of them English, some of them whatever, so we are trying in our department [to] have different languages speakers. Training even we are trying to train that person [staff pharmacist]....so the patients can understand....we have all languages so if you don’t understand Arabic or English we can bring someone can explain to you even Spanish. [OP]

On the contrary, community pharmacists, who were all non-nationals, viewed language differences as a barrier, the magnitude of which varied, based on the pharmacy location:

In my case where I am working there means English is the major language, so I don’t have any problem. But if someone [pharmacist working] in the interior means he [pharmacist] should have definite knowledge of Arabic. Now I am here for last 7 years but I don’t know Arabic and I am managing very nicely, because in that area locals also are coming who are very qualified and they can speak English very well, but otherwise language is a major barrier. [CP]

Very little extent, not much, very little extent, those who are coming from interior, they may not be able to understand. [OP]

2.3.5. Summary of Control Beliefs

According to the themes extracted, the common barriers towards the provision of pharmaceutical care amongst the three practice settings could be explained in terms of time, staffing, and workload, as well as culturally-based gender issues, while the common facilitator was pharmacist communication skills. Barriers prevalent in both outpatient setting and community pharmacies were pharmacy space, and access to drug information resources, while those uniquely specific to community pharmacies were pharmacist competency, access to

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patients’ medical records, language differences between pharmacist and patients, and reimbursement.

3. Summary of Focus Group Results

Three focus groups were conducted with pharmacists from three practice settings in

Muscat, Oman: inpatient, outpatient, and community pharmacy. Major themes that emerged from content analysis were grouped into three kinds of beliefs as distinguished by the TPB: behavioral, normative, and control beliefs; and were further disaggregated into subthemes at the patient, pharmacist, pharmacy, and health care system level (Appendix N). Pharmacists' behavioral beliefs were that pharmaceutical care benefits patients, pharmacists, pharmacy business, and health system cost saving. Physicians, patients, and managers/administrators were identified as social influencers on pharmacists' pharmaceutical care behavior. The extent to which pharmacists felt supported by physicians and managers depended on setting. Patient support depended on prior experience with pharmaceutical care. Pharmacists believed that their competency, communication skills, access to patient records and drug information, available time, cultural and language differences, availability of private counseling areas, and reimbursement affected their ability to provide pharmaceutical care.

Section II: Mail Survey

This section reports on the results of the mail survey of pharmacists. The results include the survey response rate, assessment of the potential for non-response bias, analysis of missing data, and characteristics of study respondents. This is followed by descriptive statistics and reliability of study variables. Next, validity of measures is discussed. Finally, the results of each research objective are presented.

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1. Response Rate

Of the 668 questionnaires mailed to all practicing pharmacists in Oman, nine were returned unopened to the investigator due to closure of their postal boxes. Thus, the adjusted sample size was 659 pharmacists.

Four-hundred and five questionnaires were returned (overall response rate 61.45%). Four questionnaires were excluded as one was blank, two were from pharmacists who did not meet the inclusion criteria (that is, one was a warehouse pharmacist and the other was a chief pharmacist who did not deal with patients), and the fourth questionnaire was excluded because the pharmacist tended to check the extreme positive responses on each item scale. Therefore, 401 were considered usable responses and the usable response rate was 61.2%. The response rate from public sector pharmacists was 75% (n = 121/161) and 55% (n = 280/507) from the private sector pharmacists.

2. Non-Response Bias

Non-response bias was assessed by comparing the characteristics of early respondent pharmacists who responded after the first survey mailing to late respondents who responded after the second survey mailing. It was not possible to determine the number of questionnaires returned after each of the three mailings (the first survey mailing, the first follow-up letter, and the second survey mailing) because there were national holidays during the period between the first survey mailing and the first follow-up letter, when almost all governmental and private institutes including the post office were closed for 9 days. Three hundred and twenty seven questionnaires were received after the first follow-up letter and 78 questionnaires were received after the second survey mailing. Overall, there were 401 usable questionnaires returned in a span

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of 63 days calculated from the day of mailing the first follow-up letter. Early responders were therefore defined as questionnaires received prior to the second survey mailing, and late responders were defined as questionnaires received after the second survey mailing (Jan 18,

2011). Table 4.2 shows the number of surveys received in each period.

Table 4.2. Analysis of surveys returned

Type of Responder Survey Return Period Number (%)

Early Dec 28, 2010 – Jan 17, 2011 32 (80.8%) Late Jan 18, 2011 – Feb 28, 2011 77 (19.2%)

There were no statistically significant differences between early and late responders in age, gender, highest degree in pharmacy, years in current practice, practice type, sector, or current position. However, there were significant differences with regards to country of origin, country where highest degree in pharmacy was obtained, and years of experience (Table 4.3)

Late responders were mainly from South Asia, obtained their highest degree in pharmacy there, and had 11-20 years of experience. Because few statistically significant differences were found in the characteristics of respondents and non-respondents, the chances of obtaining biased data due to non-response were low (Public Works and Government Services Canada, 2007).

Also, the provision of pharmaceutical care was compared between the two groups. It was hypothesized that early responders would be more likely to be providers of pharmaceutical care than late responders. However, no significant difference was found in the provision of pharmaceutical care between early and late responders, t(399) = 1.537, p = .125.

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Table 4.3. Crosstab analysis of demographic characteristics of early versus late survey respondents

Total Early Late χ2-statistic, Participant Characteristics (N = 401) (N = 324) (N = 77) p value Frequency (%) Age ≤ 29 93 78 (24) 15 (17.9) χ2(3) = 2.4, 30-39 214 174 (53.5) 40 (52.6) p = .50 40-49 63 47 (14.5) 16 (21.1) ≥ 50 31 26 (8.0) 5 (6.6) Gender Female 150 122 (37.5) 28 (36.4) χ2(1) = .4, Male 251 202 (62.4) 49 (63.6) p = .85 Pharmacy Education Level Bachelor 345 277 (85.5) 68 (88.3) χ2(3) = 2.2, Master 52 44 (13.5) 8 (10.4) p = .53 PhD 2 2 (.6) 0 (.0) Pharm D 2 1 (.3) 1 (1.3) Country/Continent of Oman 88 75 (23.1) 16.9 (16.9) χ2(3) = 13.8, Origin Middle East 59 55 (16.9) 4 (5.2) p = .003** South Asia 245 185 (56.9) 60 (77.9) Africa 9 9 (2.8) 0 (.0) Country/Continent of Oman 22 18 (5.5) 4 (5.2) χ2(6) = 15.7, Graduation North America 4 3 (.9) 1 (1.3) p = .02* Europe 41 39 (12) 2 (2.6) Middle East 78 69 (21.2) 9 (11.7) Africa 8 8 (2.5) 0 (.0) South Asia 274 186 (57.2) 61 (79.2) Australia/New Zealand 1 1 (.3) 0 (.0) Practice Type Inpatient 53 49 (15.1) 4 (5.2) χ2(2) = 5.4, Outpatient 124 99 (30.6) 25 (32.5) p = .07 Community Pharmacy 224 176 (54.3) 48 (62.3) Years of Experience 0-5 years 93 79 (24.5) 14 (18.4) χ2(4) = 11.4, 6-10 years 144 120 (37.2) 24 (31.6) p = .02* 11-15 years 83 63 (19.5) 20 (26.3) 16-20 years 40 26 (8.0) 14 (18.4) Over 20 years 39 35 (10.8) 4 (5.3) Missing 2 1 1 Years in Current Practice ≤10 326 268 (83) 58 (76.3) χ2(2) = 2.1, 11-19 58 43 (13.3) 15 (19.7) p = .35 ≥20 15 12 (3.7) 3 (3.9) Missing 2 1 1 Sector Public 121 102 (31.4) 19 (24.7) χ2(1) = 1.3, Private 280 222 (68.5) 58 (75.3) p = .25 Post Manager or Director 41 30 (9.3) 11 (14.3) χ2(4) = 5.7, Assistant Manager 8 5 (1.5) 3 (3.9) p = .22 Supervisor 40 31 (9.6) 9 (11.7) Staff Pharmacist 294 241 (74.6) 53 (68.8) Others 17 16 (4.9) 1 (1.3) Missing 1 1 *p<.05; **p<.01.

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3. Missing Values Analysis

Missing data analysis was conducted for measures of model constructs to determine whether they should be replaced. Of the 71 survey items, 30 had missing values. The maximum number of missing values per item was 4, except for items 35 and 36 where the missing values approached 10, and items 51 and 52 which had15 missing values each. A closer examination revealed that these 4 items were specific to certain practice settings; however, participants were instructed to answer these items only if they belonged to that particular practice setting but the instructions were not followed. Overall, the missing values were relatively small; therefore, it was decided not to replace them.

Missing data analysis per case (participant/questionnaire) was conducted to determine if any of the cases exceeded the exclusion criterion of 30%. The case with highest missing values

(MVs) was case 36 (22%, MVs = 18), followed by case 326 (11%, MVs = 9), and case 325

(9.9%, MVs = 8). All other cases (n = 398) had missing values ranging from 0 to 6. Overall, none of the cases had missing values that exceeded 30%, and therefore no cases were excluded.

4. Demographic Characteristics of Survey Respondents

The demographic characteristics of participants are shown in Table 4.4. Omani pharmacists represented 21.9% (n = 88) of the sample; however, the majority of participants were from South Asia 61.1% (n = 245), and to a lesser extent from the Middle East 17.0% (n =

68). Approximately 63.0% (n = 252) of the participants were male. More than half of the participants were between 30 and 39 years of age (53.1%, n = 213) and the majority (86.0 %, n =

345) had a bachelor of science in pharmacy degree. Slightly less than two-thirds (61.6%, n =

247) of participants earned their pharmacy degree from South Asia, while only 5.5% (n = 22)

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obtained their degree from Oman. Just over one-third (35.7%, n = 143) of the participants had 6-

10 years of relevant work experience, and about 81.0% (n = 325) had been working for 10 years or less in their current practice. More than two-thirds (69.6%, n = 279) of participants worked in the private sector, and about 54.0% (n = 150) of private sector participants worked in retail chain pharmacies. About 73.0% (n = 294) of respondents were staff pharmacists and about 10% were managers or supervisors.

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Table 4.4. Survey participant characteristics

Total Inpatient Outpatient Community Participant Characteristics (N = 401) (n = 53) (n = 124) (n = 224) Frequency (%) Age ≤ 29 93 (23.2) 15 (28.3) 46 (37) 31 (13.9) 30-39 213 (53.1) 27 (50.9) 57 (46) 129 (57.8) 40-49 63 (15.7) 6 (11.3) 15 (12.1) 43 (19.3) ≥ 50 31 (7.7) 5 (9.4) 6 (4.8) 20 (9) Missing 1 (.2) 1 (.4) Gender Female 150 (37.3) 35 (66) 67 (54) 48 (21.4) Male 251 (62.6) 18 (34) 57 (46) 176 (78.6) Pharmacy Education Level Bachelor 345 (86) 24 (45.3) 114 (91.9) 207 (92.4) Master 52 (13) 26 (49.1) 9 (7.3) 17 (7.6) PhD 2 (.5) 2 (3.8) - - Pharm D 2 (.5) 1 (1.9) 1 (.8) - Country/Continent of Oman 88 (21.9) 45 (84.9) 40 (32.3) 3 (1.3) Origin Middle East 58 (14.5) 2 (3.8) 14 (11.3) 42 (18.8) South Asia 245 (61.1) 2 (3.8) 66 (53.2) 177 (79) Africa 10 (2.5) 4 (7.5) 4 (3.2) 2 (.9) Country/Continent of Oman 22 (5.5) 4 (7.5) 16 (12.9) 2 (.9) Graduation North America 4 (1) 3 (5.7) 1 (.8) - Europe 41 (10.2) 31 (58.5) 10 (8.1) - Middle East 77 (19.2) 9 (17) 25 (20.2) 43 (19.2) Africa 9 (2.2) 2 (3.8) 5 (4) 2 (.9) South Asia 247 (61.6) 3 (5.7) 67 (54) 177 (79) Australia/New Zealand 1 (.2) 1 (1.9) - - Years of Experience 0-5 years 93 (23.2) 20 (37.7) 42 (34.1) 30 (13.5) 6-10 years 143 (35.7) 16 (30.2) 44 (35.8) 82 (36.9) 11-15 years 83 (20.7) 7 (13.2) 17 (13.8) 61 (27.5) 16-20 years 40 (10) 3 (5.7) 11 (8.9) 26 (11.7) Over 20 years 39 (9.7) 7 (13.2) 9 (7.3) 23 (10.4) Missing 3 (.7) - 1 (.8) 2 (.9) Years in Current Practice ≤10 325 (81) 33 (62.3) 113 (91.1) 180 (81.1) 11-19 58 (14.5) 19 (35.8) 8 (6.5) 30 (13.5) ≥20 15 (3.7) 1 (1.9) 2 (1.6) 12 (5.4) Missing 3 (.7) - 1 (.8) 2 (.9) Sector Public 120 (29.9) 53 (100) 66 (53.2) - Private 279 (69.6) - 58 (46.8) 222 (100) Missing 2 (.5) - - 2 (.9) Post Manager or Director 40 (10) 4 (7.5) 16 (13) 19 (5.8) Assistant Manager 8 (2) 4 (9.4) 1 (.8) 2 (.9) Supervisor 40 (10) 6 (11.3) 29 (23.6) 5 (2.2) Staff Pharmacist 294 (73.3) 22 (41.5) 76 (61.8) 197 (88.3) Others 17 (4.2) 16 (30.2) 1 (.8) - Missing 2 (.5) - 1 (.8) 1 (.4)

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5. Descriptive and Reliability Statistics for Multi-Item Scales Measuring Model Constructs

Descriptive statistics and Cronbach’s alpha coefficients for multi-item scales measuring: past behavior recency, intention, attitude, subjective norm, perceived behavioral control, behavioral beliefs and evaluation, normative beliefs and motivation to comply, and control beliefs and power are summarized in Table 4.5. Descriptive statistics for the individual items comprising the multi-item scales are presented in Appendix O, Tables O.1 to O.11.

5.1. Past Behavior Recency

This measure was also used as a proxy for future pharmaceutical care behavior. The mean score for past behavior recency was slightly above the midpoint (M = 43.7, SD = 8.8, scale range = 0-64), with 36.5% of respondents scoring 48 or above. The most frequently performed activity was checking the prescription to see if the dose was too high or too low (M = 3.5, SD =

0.7), while the least frequently reported activity was preparing a written plan for resolving an identified medication-related problem (M = 1.4, SD = 1.2). The Cronbach’s alpha coefficient for the past behavior recency scale was .83.

5.2. Intention to Provide Pharmaceutical Care

The mean score for intention was (M = 18.9, SD = 2.5, scale range = 1-21) with 39.0% of respondents scoring the highest possible score of 21. The Cronbach’s alpha coefficient for intention scale was .85.

5.3. Attitude towards Providing Pharmaceutical Care

The mean attitude score was (M = 19.5, SD = 2.0, scale range = 1-21). About 49.0% of participants had the highest possible score of 21. The scale alpha coefficient was .78.

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Table 4.5. Descriptive statistics for multi-item scales and reliability coefficients

Construct No of Item Min-Max Mean Median Range Cronbach’s Items Response Possible Scale (SD) alpha Scale Score coefficient*

Past behavior 16 0-4 0-64 43.7 44 14-63 .83 recency (8.8)

Intention 3 1-7 1-21 18.9 20 3-21 .85 (2.5)

Attitude 3 1-7 1-21 19.5 20 6-21 .78 (2.0)

Subjective norm 5 1-7 1-35 27.9 29 7-35 .82 (5.0)

Perceived behavioral 4 1-7 1-28 22.7 24 5-28 .80 control (3.9)

Behavioral beliefs X 6X6 1-7 X 1-7 1-294 227.5 221 89-294 NA Evaluation (28.1)

Normative beliefs X 4X4 1-7 X 1-7 1-196 117.6 118 17-196 NA Motivation to (36.5) comply

Control beliefs X 10X10 1-7 X 1-7 1-490 209.9 207 54-424 NA Power (65.6)

*All multi-item scales had a Cronbach’s alpha greater than .70.

5.4. Subjective Norm

The mean subjective norm score was (M = 27.9, SD = 5.0, scale range = 1-35). Injunctive items, that is, what important people in pharmacists’ professional life thought pharmacists should do in terms of providing pharmaceutical care, ranged from 80.0% to 84.3%. With respect to descriptive items, just over half of participants (50.2 – 51.4%) felt that important people themselves or colleague pharmacists performed pharmaceutical care on a regular basis. The alpha coefficient for the subjective norm scale was .82.

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5.5. Perceived Behavioral Control

The mean perceived behavioral control score was (M = 22.7, SD = 3.9, scale range = 1-

28). The alpha coefficient for the perceived behavioral control scale was .80.

5.6. Behavioral Beliefs and their Evaluation

The mean behavioral beliefs score was (M = 35.6, SD = 3.4, scale range = 1-42), and the mean evaluation score was (M = 37.7, SD = 3.4, scale range = 1-42). The perceived positive outcomes to providing pharmaceutical care were increased patient safety (93.2%), improved patient health (92.3%), change in the image people have about pharmacist being only a medicine dispenser (86.5%), and increased patients’ trust and respect in them (95.2%), but to a lesser extent improve their relationship with physicians (78%). Worry about being responsible for any intervention was the only negative outcome that had a mean score below the scale’s midpoint, and it was only slightly below the midpoint of 4 (M = 3.7, SD = 2.1). However, only 37.4% believed that providing pharmaceutical care was unlikely to make them worry about being responsible for their interventions.

The majority of participants evaluated the positive outcomes of practicing pharmaceutical care as good. These included increased patient safety (98.3%), improved patient health (97%), change in the image that people have about pharmacists (86.1%), improved relationships with physicians (93%), and increased patient trust (96.8%). Only 41.6% evaluated the negative outcome, worry about being responsible for the intervention they provide, as good.

5.7. Normative Beliefs and Motivation to Comply

The mean normative beliefs score was (M = 20, SD = 4.5, scale range = 1-28), and the mean motivation to comply score was (M = 19.7, SD = 4.5, score range = 1-28). Managers

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(80.8%), patients (72.6%), and hospital administrators (72.3%) were believed to be more supportive of pharmacists’ provision of pharmaceutical care than the physicians (60.8%).

5.8. Control Beliefs and Power

The mean control beliefs score was (M = 40.2, SD = 9.9, scale range = 1-70), and the mean power score was (M = 49.8, SD = 9.3, scale range = 1-70). The perceived available factors to perform pharmaceutical care were mainly pharmacist related. These were clinical knowledge, communication skills, and language abilities, and ranged from 63.9% to 80.8%. The factors external to the pharmacist that also were perceived to be available, but to a lower extent, were staff (42.9%) and time (44.1%). The perceived factors lacking for performing pharmaceutical care were external to the pharmacist. These were private counseling area, access to patients’ medical records, access to drug information databases, and reimbursement, and ranged from

49.9% to 74.2%. The only perceived social factor was the culturally-based gender issue and

24.5% had difficulties counseling patients of the opposite sex in sensitive medical conditions.

Regarding the power of controlling factors, lack of adequate clinical knowledge (78.3%), communication skills (81%), ability to speak patients’ language (73.1%), access to patients’ medical records (71.6%), shortage of staff (64.6%), lack of access to computer databases (59.3), lack of time (56.6%), and lack of a private counseling area (53.4%) were perceived to make practicing pharmaceutical care much more difficult for pharmacists than counseling patients of the opposite sex in sensitive medical conditions (26.7%), and lack of reimbursement (19.6%).

6. Factor Validity of Multi-Item Scales

Exploratory factor analysis (principle components analysis) was conducted to identify the dimensions underlying the 16 pharmaceutical care behavior items and to identify measurement

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scales for each of the constructs of the Theory of Planned Behavior model: intention, attitude, subjective norms, and perceived behavioral control.

6.1. Pharmaceutical Care Behavior Scale

A four factor solution met the eigenvalue criterion but not the scree test criterion. The rotated solution was examined for the size of item loadings (Appendix P, Table P.1). All 16 items loaded over .4 on at least one factor; however, two items (pharmaceutical care activity 7 and 13) showed cross loadings above .4 on the same second factor. Examining these two items revealed that each represented an important pharmaceutical care activity and thus should not be a candidate for deletion. Additionally, two of the four factors could not be meaningfully interpreted in the sense that each factor included items that conceptually did not fit with the other items loading high on that factor. Also, the 3-item scale based on the fourth factor had a low alpha coefficient (.433).

Based on the scree plot, three factors were subjected to varimax rotation (Appendix P,

Table P.2). However, 3 items (pharmaceutical care activities 7, 13, and 14) showed cross loadings on the second factor. Deletion of items 7 and 13 as mentioned earlier was not advisable.

Furthermore, the three factors could not be meaningfully interpreted. Because of these findings, it was decided to use CFI to assess the overall fit of the pharmaceutical care behavior scale, which was hypothesized to be unidimensional a priori.

The initial results of the confirmatory factor analysis indicated that a one factor model had a poor fit to the data. The chi-square was significant 2(104) = 757.47, p < .01, the GFI, NFI, and CFI were all below the acceptable standard of .90, and the RMSEA value was greater than the acceptable standard of .08. To identify the misfit in the model, modification indices were

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examined. Modification indices suggested that the error variances between some pairs of items be correlated (that is, to allow the error covariances between items to be freely estimated). This suggestion makes substantive sense as the items are contained within one factor and do have similar characteristics. These modifications to the model resulted in significant improvement to the overall fit of the model (see Table 4.6). The NFI and CFI values increased to be greater than

.95 and RMSEA value decreased to .067 but the GFI value (.87) did not meet the acceptable standard of .90. Despite the unacceptable GFI value, all other fit indices indicated that the model had an acceptable fit to the data.

Table 4.6. Summary of goodness of fit indices by model/scale

Model χ² Df GFI CFI NFI RMSEA

Pharmaceutical care behavior 257.95** 92 .87 .97 .95 .067

TPB 193.20* 81 .86 .99 .98 .059

Note. GFI = goodness of fit index; CFI = comparative fit index; NFI = normed fit index; RMSEA = root mean square error of approximation; TPB = the Theory of Planned Behavior. *p<.05; **p<.01.

6.2. The Theory of Planned Behavior (TPB) Model

This measurement model included the four TPB constructs: intention, attitude, subjective norm, and perceived behavioral control. Exploratory factor analysis (principle components analysis) was conducted separately for the set of items proposed for each construct. One factor was extracted for each of the intention, attitude, and perceived behavioral control item sets

(Appendix P, Tables P.3, P.4, and P.7). For subjective norm items, two factors were extracted

(Appendix P, Tables P.5). The 3 items (62, 63, and 64) that loaded on the first factor were the

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descriptive type, while the 2 items (60 and 61) that loaded on the second factor were the injunctive type; however, according to the TPB, both types of questions are necessary to measure subjective norm. Therefore, it was justifiable to run principal component analysis on one factor.

Table P.6 (Appendix P) shows factor loadings for subjective norm items when one factor was extracted.

The results of the confirmatory factor analysis indicated that the chi-square was significant, 2(83) = 300, p < .05. All of the goodness of fit indices except the GFI value (.80) indicated that the model had an adequate fit. Nevertheless, modification indices were examined.

The results of the modification indices suggested adding an error covariance term between items

60 and 61, items 60 and 62, and items 60 and 63. Not surprisingly, all these items measured subjective norm, which confirmed the previous findings of principle component analysis.

According to the TPB, items 60 and 61 are the injunctive type, while items 62 and 63 are the descriptive type and both are required for measuring subjective norm. Thus, it made sense to free these error covariances, that is, allow them to be estimated in the analysis. Freeing the error covariances resulted in improving the model fit (see Table 4.6); however, the GFI value (.86) remained below the acceptable standard of .90. Considering all other fit indices, it was decided that the model provided a reasonably good fit to the data.

7. Inferential Analyses to Address Research Objectives

Objective 1

The first objective was to determine the extent of the provision of pharmaceutical care in

Oman, and compare its provision across three practice settings: inpatient, outpatient, and community pharmacy. The extent of the provision of pharmaceutical care was determined from

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the mean total score on past behavior recency scale presented as a percentage of the maximum possible score of the scale, while one-way ANOVA was used to compare the provision of pharmaceutical care across settings.

Whether the data met the normality and homogeneity assumptions of the ANOVA model was first examined. Two approaches were used to assess normality, statistical and graphical. The test of normality (Kolmogorov-Smirnov Z) indicated that the pharmaceutical care scores for the inpatient setting were normally distributed (p = .200) but significantly skewed for outpatient (p =

.033) and community settings (p = .007). But, the visual examination of the histograms for outpatient and community settings showed a slight negative skew. The values of skewness and kurtosis to their standard errors were relatively small (< 2.5), but greater than 2 (Norman and

Streiner, 2008). Although these results indicate some departure from normality, overall ANOVA is robust to departures from normality, especially when the sample size is large, which was the case in this analysis (n = 400). Thus, normality should not be of concern in this analysis.

The assumption of equality of group variances (homogeneity) was not met, F(2,397) =

4.106, p = .017. The p value is not trustworthy when the assumption of homogeneity is violated and the cells have different sample size (Gravetter and Wallnau, 2008), which was the case across practice settings (inpatient = 53, outpatient = 124, and community = 223). Therefore, the

Brown-Forsythe F test (the Brown-Forsythe test performs ANOVA using an adjusted F statistic) was used in lieu of an ordinary ANOVA because it does not assume equality of group variances

(Green and Salkind, 2011).

The mean total score on the pharmaceutical care scale was 43.7 (SD = 8.8), which represents 68.2% of the maximum possible score for the scale, that is, the participants achieved

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68.2% on the pharmaceutical care scale. Although the mean score was higher in the inpatient setting 45.75 (SD = 9.35) versus the outpatient 42.91 (SD = 9.88) and community settings 43.68

(SD = 7.92), the Brown-Forsythe F test did not detect significant differences in the means, F

(2,193.59) = 1.75, p = .18. In addition, only 36.5% of participants were regular providers of pharmaceutical care, that is, provided pharmaceutical care either all the time or most of the time.

Regular providers of pharmaceutical care were more prevalent in inpatient settings than in the other two settings (43.4% inpatient, 38.7 % outpatient, and 33.6% community setting).

Objective 2

This objective was to identify important perceived barriers and facilitators to the implementation of pharmaceutical care as expressed in pharmacists’ behavioral beliefs, normative beliefs, and control beliefs. The mean scores on weighted belief items below the midpoint of 16 (≤ 15) represented barriers, while mean scores above the midpoint (≥17) represented facilitators. Table 4.7 displays the mean scores for the six weighted behavioral beliefs across inpatient, outpatient, and community pharmacy practice settings. Worry about responsibility was the only perceived barrier. It was identified in all settings.

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Table 4.7. Mean weighted behavioral beliefs (mean belief strength x mean evaluation) by practice setting

Mean Weighted Behavioral Belief (be) Outcome Inpatient Outpatient Community Pharmacy Increase patient safety 47.43 44.10 44.21

Improve patient health 45.20 44.66 43.43

Change pharmacist image 44.69 39.62 40.02

Improve relationship with physicians 42.88 42.05 38.03

Increase patient respect/trust 44.83 45.54 44.31 † Worry about responsibility 14.50* 14.73* 13.15* be: Mean weighted behavioral belief (mean belief strength x mean evaluation). Belief strength measured on a scale of 1(unlikely) – 7 (likely) and evaluation measured on a scale of 1 (bad) – 7 (good). †Reverse scored to adjust for negative phrasing. *A potential barrier (≤ 15).

Table 4.8 presents the mean scores for the four weighted normative beliefs by practice setting. All four referents (physician, patients, managers/chief pharmacists, and hospital administration) were perceived to be facilitators of the provision of pharmaceutical care.

However, physicians were the least influential, while pharmacy managers were more influential facilitators in the inpatient setting than in the other two settings.

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Table 4.8. Mean weighted normative beliefs (mean belief strength x mean motivation) by practice setting

Mean Weighted Normative Belief (nm) Normative Referent Inpatient Outpatient Community Pharmacy Physicians 32.71 30.88 30.78 Patients 32.50 34.19 36.24

Boss (chief pharmacist, manager) 39.69 36.41 36.45 Hospital administration 37.52 35.18 NA nm: Mean weighted normative belief (mean belief strength x mean motivation to comply). Belief strength measured on a scale of 1 (I should not) – 7 (I should) and motivation to comply measured on a scale of 1 (not at all important) – 7 (extremely important).

Table 4.9 presents the mean scores for the 10 weighted control beliefs by practice setting.

The common barrier across practice settings was culturally-based gender issues, while clinical knowledge, communication skills, language abilities, staffing, and time were the common facilitators. Lack of a private counseling area was a barrier along with access to drug information databases, and to patients’ medical records in community pharmacies, but were facilitators in the public sector. Reimbursement was the main barrier identified in the private sector (community pharmacy and private hospitals/clinics).

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Table 4.9. Mean weighted control beliefs (mean belief strength x mean power) by practice setting

Mean Weighted Control Belief (cp) Control Factor Inpatient Outpatient Community Pharmacy Clinical knowledge and experience 35.56 30.82 35.39 Communication skills 38.18 35.77 36.53 Language abilities 36.22 30.78 31.14 Culturally-based gender issues 13.37* 14.24* 14.37* Staffing 18.07 18.56 20.57

Time 23.69 20.95 18.60

Drug information database 29.64 21.18 14.72* † Private counseling area NA 16.16 11.14*

Access to patient records 41.96 24.69 11.89* ‡ Reimbursement NA 7.00* 6.58* cp: Mean weighted control belief (mean belief strength x mean power score). Belief strength measured on a scale of 1 (true) – 7 (false) and power measured on a scale of 1 (disagree) – 7 (agree). *A potential barrier (≤ 15); all other factors were perceived facilitators. †Questions asked of outpatient and community pharmacists only. ‡ Questions asked of private sector pharmacists only.

Objective 3

This objective was to assess the effect of pharmacists’ country/continent of origin on their beliefs (behavioral, normative, and control) relating to providing pharmaceutical care.

Before conducting one-way multivariate analysis of variance (MANOVA), the

MANOVA model assumptions of normality and homogeneity of scores were tested. The test of normality (Kolmogorov-Smirnov Z) indicated that weighted control belief scores were normally distributed across the three levels of the factor: Oman (p = .200), Middle East (p = .097), and

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South Asia (p = .200) and that weighted normative belief scores were normally distributed for

Oman (p = .200) and South Asia (p = .200) but significantly skewed for the Middle East (p =

.044). Visual examination of the histogram for the Middle East group showed a slight positive skew. This skewness was not of concern as it was supported by the small ratio (< 2) of the skewness and kurtosis values to their standard errors.

The distribution of weighted behavioral belief scores was normal for South Asia (p =

.200) but significantly skewed for Oman (p = .00) and Middle East (p = .033). However, the visual examination of the histogram for the Middle East showed a slight negative skew. The values of skewness and kurtosis to their standard errors were relatively low at 2.5 and .84, respectively (should be < 2). These results indicate slight departure from normality. Visual examination of the histogram for Oman showed a slight negative skew; skewness and kurtosis values to their standard errors were (4.5 and 3.9) greater than 2. These results indicate some departure from normality. According to Tabachnick and Fidell (2012), assessment of multivariate normality with small and unequal samples in each cell relies on judgment. The sample size in this study was relatively large (n = 400), and the smallest cell had 53 cases. The skewness was modest, so it can be assumed that the data fairly followed a normal distribution.

The results of Box’s M test indicated that the homogeneity of variances and covariances assumption for the MANOVA model was rejected F(12, 188495.554) = 2.041, p = .017. If Box’s

M test was significant, this might indicate increased possibility of Type I error. To avoid the likelihood of Type I error, a conservative alpha (.001) was used throughout the entire analysis.

On the other hand, Levene’s test showed the homogeneity of variances was achieved for each of the dependent variables. The correlation coefficients between the three dependent variables,

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behavioral, normative, and control beliefs, ranged from .159 to .323 indicating that there were no strong intercorrelations among these variables.

The one-way MANOVA revealed a significant main effect of country/continent of origin on the dependent variables (behavioral, normative, and control beliefs), Wilks’s Λ = .891,

F(6,790) = 7.839, p < .001. The multivariate eta square (η2) based on Wilks’s Λ was .056, indicating that 5.6% of the multivariate variance of the dependent variables was associated with the countries/continents of origin factor. Table 4.10 presents the means and standard deviations on behavioral, normative, and control beliefs for the three countries/continents.

Table 4.10. Descriptive statistics for weighted beliefs about pharmaceutical care behavior by country/continent of origin

Weighted Beliefs Country/Continent of Origin Behavioral Normative Control Mean SD Mean SD Mean SD Oman (n = 88) 237.78 24.25 134.05 36.92 228.11 62.85 Middle East (n = 68) 231.35 27.16 122.59 31.15 223.03 76.70 South Asia (n = 244) 222.55 28.68 110.08 35.60 198.98 62.03 N = 400

Given the significance of the overall test, analysis of variance (ANOVA) on each dependent variable (behavioral, normative, and control beliefs) was conducted as a follow-up test to the MANOVA. Significant univariate main effect for country/continent of origin was found for behavioral beliefs F(2,397) = 10.75, p < .01, η2 =.051; normative beliefs F(2,397) = 15.86, p

< .01, η2 =.074; and control beliefs F(2,397) = 8.30, p < .01, η2 =.040. Post hoc analyses of the significant univariate ANOVAs consisted of conducting pair-wise comparisons of

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country/continent of origin. Significant country/continent differences were detected for Oman versus South Asia with respect to behavioral, normative, and control beliefs. However, Middle

East and Oman, Middle East and South Asia did not significantly differ from each other (Table

4.11).

Table 4.11. Post-hoc pair-wise comparisons between countries/continents of origin on weighted behavioral, normative, and control beliefs using the Bonferroni test

Dependent Country of Country of Mean Standard P Variable Origin Origin Difference Error (a) (b) (a-b)

Oman Middle East 6.43 4.44 .149

Weighted South Asia 15.23* 3.42 .000 Behavioral Beliefs Middle East South Asia 8.79 3.77 .020

Oman Middle East 11.45 5.68 .044

Weighted South Asia 23.97* 4.37 .000 Normative Beliefs Middle East South Asia 12.51 4.83 .010

Oman Middle East 5.08 10.48 .628

Weighted South Asia 29.14* 8.07 .000 Control Beliefs Middle East South Asia 24.05 8.90 .007

* P < .001.

Objective 4

The fourth objective was to determine the individual and collective influences of attitudes, subjective norms, perceived behavioral control, and past behavior recency on pharmacists’ intention to implement pharmaceutical care. Multiple regression analyses were

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employed to test this objective, along with objectives 5 and 6. First, the assumptions of normality, linearity, and homoscedasticity were checked.

The histogram and normal probability plot indicated that regression residuals were not normally distributed (Appendix Q, Figure Q.1 and Figure Q.2). Outlier analysis was performed by the use of residual statistics. The range of standardized residuals (-7.928 to 2.952) was greater than ± 3 standard deviations from the mean. These residual values indicated the presence of a few outliers. Therefore, any standardized residual of more than ± 3 standard deviations from the mean was removed from the analysis. After the removal of the 15 identified outliers, the residuals became normally distributed (Appendix Q, Figure Q.3 and Figure Q.4). The assumptions of linearity and homoscedasticity were satisfied because the residual scatter plot

(Appendix Q, Figure Q.5) showed that the residuals were distributed above and below the horizontal line (Y axis = 0), and did not show any obvious pattern.

Multicollinearity was examined by the use of the collinearity statistic, tolerance.

Tolerance values for the four predictor variables were close to 1 (attitude = .889, subjective norm

= .751, perceived behavioral control = .739, and past behavior recency = .827), which indicated that multicollinearity was not a concern in this analysis.

Multiple regression analysis (with 15 outliers removed) found that the linear combination of attitude, subjective norm, perceived behavioral control, and past behavior recency was significantly related to intention, F(4,380) = 72.43, p < .01 (Table 4.12). The adjusted R2 was

0.43, indicating that 43.0% of the variance in intention was accounted for by these four predictor variables. However, only attitude (β = .364), subjective norm (β = .116), and perceived

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behavioral control (β = .399) were statistically significant predictors of intention (p < .05). Past behavior recency was not a significant predictor.

Table 4.12. Multiple regression analysis results for prediction of intention to provide pharmaceutical care

Variable B Standard β t statistic P value error

Attitude .381 .043 .364 8.892 .000** Subjective norm .048 .018 .116 2.601 .010* Perceived behavioral control .213 .024 .399 8.882 .000** Past behavior recency -.007 .010 -.032 -.745 .456

F(4,380) = 72.43, p < .01 2 N = 385, Adjusted R = .43 *P < .05, **P < .001.

Objective 5

This objective was to determine the individual influence of perceived behavioral control and intention on pharmacists’ pharmaceutical care behavior. The normality plot indicated that the normality assumption was met. Also, the residuals were randomly distributed around the horizontal line (Y axis = 0) and did not show any pattern, both of which indicate that the linearity and homoscedasticity assumptions were satisfied (see Appendix R, Figure R.1 and Figure R.2 for the normality plot and scatter plot for the regression residuals). The collinearity statistic

(tolerance = .814) indicated that multicollinearity was not a concern in this analysis.

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The multiple regression analysis (Table 4.13) found that perceived behavioral control (β

= .348) was a statistically significant predictor of pharmaceutical care behavior (p < .001).

Intention was not a significant predictor.

Objective 6

This objective was to determine the predictive validity of the TPB model in explaining pharmacists’ pharmaceutical care behavior. The predictive validity of the model was assessed by examining the amount of variance (R2) in self-reported pharmaceutical care behavior explained by the linear combination of predictor variables, intention and perceived behavioral control. The overall regression model for pharmaceutical care was significant, F(2,398) = 30.50, p < 0.001

(Table 4.13). The adjusted R2 was .13, which means that 13.0% of the variance in pharmaceutical care was explained by the predictor variables. Thus, the model had relatively low predictive power.

Table 4.13. Multiple regression analysis results for prediction of pharmaceutical care behavior

Variable B Standard β t statistic P value error

Perceived behavioral control .770 .115 .345 6.664 .000** Intention .145 .180 .042 .804 .422

F(2,398) = 30.50, p < .001 2 N = 398, Adjusted R = .13 **P < .001.

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8. Summary of Survey Results

Overall, study participants achieved 68% on the pharmaceutical care scale, but did not provide pharmaceutical care activities on a regular basis. The difference in the provision of pharmaceutical care across practice settings was not statistically significant. Facilitators to the provision of pharmaceutical care that were common across practice settings were clinical knowledge, communication skills, language abilities, time, and staffing, whereas worry about responsibility and culturally-based gender issues were the only common barriers across settings.

While having a private counseling area, and access to patients’ records and to drug information databases were the identified facilitators in the public sector, they were barriers in community pharmacies. Reimbursement was the main barrier in the private sector (community pharmacies and private hospitals/clinics).

The effect of country/continent of origin was significantly related to pharmacists’ beliefs pertaining to the provision of pharmaceutical care. Omani pharmacists significantly differed in their behavioral, normative, and control beliefs from their South Asian counterparts; however,

Omani pharmacists were not different from the pharmacists from the Middle East. Pharmacists from the Middle East and South Asia did not differ from each other in their beliefs.

Attitude, subjective norm, and perceived behavioral control were significant predictors of intention, while past behavior recency did not significantly add to the prediction of intention. As for pharmaceutical care behavior, of the two hypothesized predictors, only perceived behavioral control significantly predicted behavior; intention did not achieve significance. The proposed model explained intention to perform pharmaceutical care well, whereas its predictive validity of pharmaceutical care behavior was low.

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Section III: Chapter Summary

This chapter presented the results of phase I of the study, the focus group study, and the results of phase II, the population survey of practicing pharmacists in Oman. A total of 23 pharmacists participated in three focus groups representing three practice settings: inpatient, outpatient, and community pharmacy. Six behavioral beliefs about the outcomes of performing pharmaceutical care, four normative beliefs about social referents influenced pharmacists’ engagement in pharmaceutical care, and ten control beliefs about the perceived facilitators and barriers to the provision of pharmaceutical care were elicited from focus group discussions, and were later incorporated in the main survey instrument.

A total of 401 pharmacists participated in the survey leading to a useable response rate of

61.2%. Pharmaceutical care was not provided on a regular basis, and no significant differences in its provision were found across settings. Several facilitators and barriers to the provision of pharmaceutical care specific to each practice setting were identified. Omani pharmacists’ behavioral, normative, and control beliefs pertaining to the provision of pharmaceutical care were significantly different than the beliefs held by pharmacists from South Asia.

The modified model of the TPB showed good validity in predicting intention to provide pharmaceutical care, but marginal validity in predicting pharmaceutical care behavior. Perceived behavioral control was the most important predictor of intention and the only predictor of behavior.

CHAPTER FIVE: DISCUSSION AND CONCLUSIONS

The main goal of this study was to determine the extent of the provision of pharmaceutical care in Oman and identify potential factors influencing its implementation. An adapted Theory of Planned Behavior (TPB) was used as the theoretical framework. This chapter provides a discussion of the study findings and presents the conclusions. The discussion is organized into two sections: one for study objectives related to the implementation of pharmaceutical care in Oman (Section I), and the other for the study objectives related to the ability of the theoretical model to predict intention to provide pharmaceutical care or to the provision of pharmaceutical care (Section II).

Section I: Implementation of Pharmaceutical Care in Oman

1. Extent of Implementation

On average, study participants provided pharmaceutical care somewhere between

‘sometimes’ and ‘most of the time’. Although this appears relatively high, only slightly more than a third of participants were regular providers, defined as providing pharmaceutical care either all the time or most of the time. The proportion of regular providers was highest in the inpatient setting (43.4%), followed by the outpatient (38.7%) and community settings (33.6%); however, no statistically significant differences were found in the proportions across settings.

Similarly, no statistically significant difference was found in the extent of provision of pharmaceutical care (mean total score achieved on the pharmaceutical care scale) across inpatient, outpatient, and community settings. These two findings were surprising. Because all inpatient pharmacists in tertiary care hospitals are clinical pharmacists, we expected to find the

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extent of pharmaceutical care provision higher in this setting and we also expected to find a significantly higher proportion of regular providers. Therefore, post hoc analyses at each pharmaceutical care activity level were conducted to explore the reasons for failure to find significant differences.

Across all settings, the most frequently performed types of pharmaceutical care activities were informational interactions with patients, such as educating the patient on the appropriate use of their medications; and prescription-based activities, such as screening for dosage errors and drug-drug interactions. These are generic drug product-focused activities, which we considered to be traditional pharmacy practice. Conversely, advanced activities (individualized patient-focused clinical activities), such as preparing therapeutic care plans, documenting interventions, and performing follow-up evaluations were the least frequently performed.

Therefore, in the first post hoc analysis, the 16 items on the pharmaceutical care scale were divided into advanced (activities 7, 8, 13, 14, 16 of Table O.1, Appendix O) and traditional activities (activities 1- 6, 9-12, 15 of Table O.1, Appendix O). Summated subscales created for each grouping and mean scores for these subscales were compared across the three practice settings. Significant differences were found in the extent of provision of advanced and traditional activities across settings. Inpatient pharmacists scored higher on advanced activities than the outpatient and community groups. In contrast, the community group scored higher on traditional activities than the inpatient and outpatient groups (see Table 5.1). Thus, when scores for all pharmaceutical care items were summed, setting-based differences in advanced activities were neutralized by differences in the opposite direction for traditional activities.

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Table 5.1. Post hoc exploratory analysis of frequency of provision of each type of pharmaceutical care activity by practice setting

Frequency of Mean (SD) Cronbach’s F-statistic, p Provision of alpha value Pharmaceutical coefficient Care Activities Inpatient Outpatient Community Pharmacy n = 53 n = 124 n = 223

Advanced 13.85 10.57 8.85 .77 F(2,397) = Activities* (3.9) (4.5) (3.8) 33.77, p < .001

Traditional 31.90 32.34 34.83 .77 F(2,397) = Activities† (6.1) (6.3) (5.0) 10.95, p < .001

All 45.75 42.91 43.68 .83 F (2,193.59) = Pharmaceutical (9.4) (9.9) (7.9) 1.75, p = .18 Care Activities

*Advanced activities min-max possible frequency of provision score (0-20) † Traditional activities min-max possible frequency of provision score (0-44) N = 400

The second post hoc analysis was conducted to determine the proportions of regular providers of advanced and traditional activities in each practice setting. Subscales were dichotomized into regular providers and non-regular providers and then the proportions of regular providers of advanced and traditional activities were compared across settings. The results were similar to those from the previous analysis of mean scores, that is, significant differences were found in the proportions of regular providers of advanced and traditional activities across settings. The proportion of pharmacists who were regular providers of advanced activities was higher in the inpatient setting than the other two settings, and it was the opposite for community pharmacy setting, where the proportion of regular providers of traditional

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activities was higher. However, these differences disappeared when proportions of regular providers of all types of pharmaceutical care activities were used (Table 5.2).

Table 5.2. Post hoc exploratory analysis of proportion of regular providers of each type of pharmaceutical care activity by practice setting

Type of Frequency (%) KR-20 χ2-statistic, p Pharmaceutical coefficient value Care Activity Inpatient Outpatient Community for Activity Pharmacy Scale n = 53 n = 124 n = 223

Advanced 25 27 16 .57 χ2 (2) = 51.4, Activities (47.2%) (21.8%) (7.2%) p < .001 Traditional 24 70 157 .70 χ2 (2) = 14.6, Activities (45.3%) (56.5%) (70.4%) p = .001 All 23 48 75 .75 χ2 (2) = 2.1, Pharmaceutical (43.4%) (38.7%) (33.6%) p = .34 Care Activities

N = 400 KR = Kuder Richardson

It is apparent from the post hoc analyses that the study participants provided limited advanced pharmaceutical care activities, and that inpatient pharmacists provided advanced activities more frequently than pharmacists in the outpatient and community groups. Limited provision of advanced pharmaceutical care services has also been reported in community pharmacies in other developing countries, such as Jordan (AbuRuz et al., 2012), Thailand

(Ngorsuraches and Li, 2006), and China (Fang et al., 2011). In the developed world, a study that compared the provision of pharmaceutical care in community pharmacies across 13 European countries has also found, though to different degrees across countries, that traditional activities were practiced more than advanced activities such as implementation of therapeutic objectives, monitoring plans, and documentation (Hughes et al., 2010).

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2. Barriers to and Facilitators of the Provision of Pharmaceutical Care

Indirect measures (weighted behavioral, normative, and control beliefs) from the TPB guided the identification of potential barriers and facilitators of the implementation of pharmaceutical care in Oman. The barriers and facilitators identified from each type of belief are discussed below.

2.1. Behavioral Beliefs

Participants, in general, had favorable beliefs about the outcomes of performing pharmaceutical care. The only common barrier across the three settings was worrying about being responsible for their interventions. One of the main precepts of pharmaceutical care is that the provider assumes responsibility for the outcomes of a patient’s drug therapy (Hepler and

Strand, 1990). Taking responsibility for patient outcomes requires a shift in the pharmacist’s mindset and in his/her focus of practice from the product to the patient (Feinberg, 1991). Three different types of barriers might have played a major role in how much responsibility pharmacists were able or willing to take: resource-based (lack of access to patients’ medical records, and up-to-date drug information resources), pharmacist attribute-based (lack of confidence or inadequate competency), or legal liability-based barriers.

In this study, access to patients’ medical records and to drug information databases were identified as barriers in the community setting. In contrast to Western countries, not all community pharmacies in Oman have computers, especially those in the interior regions.

According to the community focus group pharmacists, pharmacies that do have computers

(mostly chain pharmacies) use them on a very limited basis, mainly for inventory control. Also, some have no internet connection, precluding access to online drug information.

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Pharmacy regulations in Oman do not require that pharmacies have a computer or an internet connection. Additionally, the regulations do not require that pharmacies maintain any patient records. The licensing requirement for drug information resources to be available in community pharmacies is limited to reference books, such as Martindale: The Complete Drug

Reference and the British National Formulary. Although drug reference handbooks are good sources of information, computerized systems are faster, provide point of care drug-drug interaction warning (Koppel et al., 2005), and are up-to-date with changes to licensed indications, safety alerts, and launching of new drugs (Walker and Whittlesea, 2012). Another factor that increases resource-based concerns and negatively influences the provision of pharmaceutical care in community pharmacies is that most owners are not pharmacists; their business goal is to maximize profits. Access to patients’ medical records and to drug information databases have also been identified as barriers in community pharmacy studies in other countries

(Al‐Ahdal, 2003; Amsler et al., 2001; Al-Arifi et al., 2007; Dunlop et al., 2002; Krska and

Veitch, 2001; Odedina et al., 1995).

The second contributor to survey participants’ reluctance to take higher levels of responsibility might be lack of confidence or inadequate competence to provide pharmaceutical care. Lack of confidence and inadequate competence are interrelated and arise from a shared root cause, which is lack of clinical knowledge and skills (Feinberg, 1991; Hopp et al., 2005;

Niquille, 2009; Ruston, 2001). In Oman, the majority of practicing pharmacists are graduates from India, Pakistan, Egypt, Jordan, and Iraq. Several studies have indicated that pharmacy programs in these countries have a weak clinical orientation (Albsoul-Younes et al., 2008; Al-

Wazaify et al., 2006; Basak and Sathyanarayana, 2009; Kheir et al., 2008; Kheir and Fahey,

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2011), and that it is more evident in India where pharmacy programs are tailored to satisfy pharmaceutical industry needs (Aaltonen et al., 2010; Basak and Sathyanarayana, 2009).

However, studies from advanced countries where pharmacy education programs are more clinically-oriented such as the US (Blake et al., 2009; Moczygemba et al., 2008), Great Britain

(Ruston, 2001), Scotland (Krska and Veitch, 2001), and Switzerland (Dunlop and Shaw, 2002) have indicated that pharmacists lacked confidence to provide advanced clinical pharmaceutical care activities that require specialized clinical knowledge. Therefore, lack of confidence could also be attributed to difficulty pharmacists encounter converting clinical knowledge from theory into practice (Hopp et al., 2005).

The third contributor to participants’ reluctance to take responsibility for patient outcomes might be that participants worry about being held liable for their recommendations.

Currently, pharmacists in Oman do not have professional liability protection, while physicians do. The Omani MOH has a medico-legal expert department, which represents physicians when they face legal actions for their malpractice. The MOH also has a compensation fund to which physicians contribute OR 20 (about $60) annually. It is used to compensate a patient when a malpractice claim is made against a physician. The MOH is in the process of developing a new regulatory appendix that will include pharmacists and other health care providers in the professional liability protection policy. In the new regulatory appendix, public sector pharmacists will have to contribute OR 20 to the compensation fund (as the physicians currently do), whereas community pharmacies and private sector hospitals/clinics will have to provide professional liability insurance to their staff pharmacists. This regulation is expected to be implemented soon.

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2.2. Normative Beliefs

All social referents (physicians, patients, managers, and administrators) were perceived to be supporters of the provision of pharmaceutical care (defined as weighted normative belief score ≥17), with physicians being the least supportive. This is consistent with studies of pharmaceutical care in North America and Europe. Pharmacists reported that physicians viewed them as only drug dispensers (Gastelurrutia et al., 2009; Niquille et al., 2010) and invaders of physicians’ territory (Reebye et al, 1999). Also, they were not recognized as providers of MTM services (Loundsbery et al., 2009), and that older physicians were not receptive to their interventions (Amsler et al., 2001).

On the other hand, pharmacy managers were perceived to be the best supporters of the provision of pharmaceutical care, especially in the inpatient setting. This was also found in the inpatient focus group: participants reported that they were given various opportunities by their department management to initiate pharmaceutical care services, and that without the endorsement of their department heads, no services could have been provided.

2.3. Control Beliefs

Participants’ control beliefs revealed that clinical knowledge, communication skills, language abilities, staffing, and time were common facilitators across all settings, and that culturally-based gender issues were the only common barrier across all settings. While availability of a private counseling area, access to drug information databases, and access to patients’ medical records were identified barriers in community pharmacies, they were facilitators in hospital settings. Reimbursement was the main barrier identified in the private sector (community pharmacies and private hospitals/clinics). Each of these perceived facilitators

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and barriers is discussed in turn. Of note, language abilities were merged with communication skills because they are considered a subset of communication skills.

2.3.1. Clinical Knowledge

In contrast to the researcher’s expectations, survey participants perceived that they had adequate clinical knowledge to practice pharmaceutical care, which was identified as one of the strongest facilitators of pharmaceutical care in this study along with communication skills.

Surprisingly, community pharmacists rated their clinical knowledge as high as did clinical pharmacists employed in inpatient setting, whereas the outpatient group, which included a number of clinical pharmacists rated their clinical knowledge much lower than did the inpatient group. This is inconsistent with the focus group finding that none of the community pharmacy participants was aware of the term ‘pharmaceutical care’. Community pharmacists may have perceived that the knowledge and skills they acquired during their training was the required clinical knowledge to provide pharmaceutical care. Also, some of the pharmaceutical care items in the survey were traditional pharmacy activities, which may possibly have reinforced this belief.

2.3.2. Communication Skills and Language Abilities

In contrast to the findings of studies from neighboring Arabian Gulf States (Alomar et al.,

2011; Awad et al, 2006), participants perceived their communication skills and language abilities to be facilitators of pharmaceutical care. In Oman, almost two thirds of the survey participants were from non-Arabic speaking countries, mainly from South Asia; older pharmacists from this region know some Arabic phrases used in pharmacy practice. In contrast, most Omani people speak at least two languages. They speak Hindi due to ancient commercial ties between Oman

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and India and due to mixing with the large Indian community in Oman; educated Omanis speak

English as a second language. According to participants in the hospital pharmacy focus group,

Omani hospital pharmacists also speak some of the local dialects. Also, pharmacists in all settings (as reported by focus group study participants) sometimes draw pictures to make the instructions clearer to patients with whom they cannot communicate orally. Thus, participants perceived that they had adequate language abilities and communication skills to deal with their patients.

2.3.3. Staffing and Time

This study identified time and staffing as very weak facilitators of pharmaceutical care across all settings (weighted control belief scores ranged from 18 to 23 and were slightly higher than the threshold 16). In contrast, most other studies of pharmaceutical care have found time constraints and staffing to be significant barriers to the provision of pharmaceutical care (Amsler et al., 2001; Blake et al., 2009; Blake and Madhavan, 2010; Kritikos et al., 2010; Latif and

Boardman, 2008; Mah et al., 2009; Niquille et al., 2009). The basis for this difference is uncertain as we have no evidence that the staffing of pharmacies in Oman is any more generous than it is in other countries.

2.3.4. Culturally-Based Gender Issues

Individual beliefs about health care are influenced by a number of factors including race, ethnicity, language, and gender (Ihara, 2004). Survey participants identified culturally-based gender-related issues as barriers to pharmaceutical care. Based on focus group discussions, this issue is more widespread in the interior regions of Oman and amongst uneducated patients. More specifically, counseling patients of the opposite gender about medications used for the treatment

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of sexual, genital, or anal conditions is considered to be a social taboo. To provide culturally competent health care services, focus group participants used simple strategies to deal with the gender barrier, such as involving a family member or a pharmacist colleague of the patient’s gender in the counseling process. The latter is more easily implemented in hospital settings because the availability of pharmacists or coworkers of the same gender is ensured; however, it may not be a possible solution in community pharmacies staffed by one pharmacist.

Culturally-based gender issues have also been identified among some international pharmacists practicing in Great Britain. In one focus group study, 2 out of 40 pharmacists stated that they had difficulties advising female patients on emergency hormonal contraception due to their culture-based values as well as the language barrier they had in rephrasing terms such as sexual intercourse (Ziaei et al., 2011).

2.3.5. Private Counseling Area

This study identified the lack of a private counseling area as a barrier to providing pharmaceutical care in community pharmacy settings, consistent with many studies from around the globe (Al-Arifi et al., 2007; Amsler et al., 2001; Berger and Grimley, 1997; Cockerill et al.,

1996; Dinnie et al., 2004; Krska and Veitch, 2001; Raisch, 1993; Ruston, 2001). In Oman, the

Law of Pharmacy Practice and Organization of Pharmaceutical Institutions (Directorate General of Pharmaceutical Affairs and Drug Control, 1996) states that the pharmacy area should not be less than 25 square meters; however, no statement is made about requiring a private counseling area. Because of the cost of changing the pharmacy layout in a community setting, community pharmacies are not likely to remodel their layout unless a regulation is put into effect.

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2.3.6. Reimbursement

Reimbursement for providing pharmaceutical care was identified as a crucial factor for implementation of pharmaceutical care in community pharmacies in this study and has been identified in other studies from the US (Lounsbery et al., 2009; Moczygemba et al., 2008;

Schommer et al., 2008), Great Britain (Dinnie et al., 2004; Krska and Veitch, 2001), and Canada

(Mah, 2009). ‘Fee for service’ reimbursement is now provided by government drug plans in these jurisdictions for selected medication therapy management services. For instance, accredited community pharmacies in the UK are paid to provide MUR and prescription intervention services (Department of Health, 2005). In some states of the USA, pharmacies are reimbursed for their MTM services (McGiveny, 2007). In Ontario, Canada, pharmacies are reimbursed for

MedsCheck (a medication review service) and pharmaceutical opinions (Lynas, 2011; Ontario

Ministry of Health and Long-Term Care, 2011). Also, recently a reimbursement model for pharmacist prescribing services has been applied in Alberta, Canada (Alberta Health, Health

Benefits and Compliance, 2012; Lynas, 2012). However, in Oman, there are no fees for dispensing or for clinical/patient care services. Community pharmacies generate their revenues from a markup on the drug cost.

2.3.7. Access to Patient Records and to Electronic Drug Information Databases

While access to patients’ medical records and to drug information databases were identified as barriers in the community setting in this study (discussed in section 2.1), they were facilitators in government hospital settings. Pharmacies in government hospitals have access to computer systems, such as Computerized Provider Order Entry (CPOE) or electronic prescribing, which enable pharmacists to access electronic patient records and document their

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interventions in the record. Also, pharmacists in secondary and tertiary hospitals have access to

Micromedex (Al Salmi, 2009), a database that includes a collection of drug databases such as

Martindale and Physician Desk Reference. Pharmacists in tertiary hospitals also have access to

Evidence-Based Medicine resources such as UpToDate database, in addition to access to electronic pharmaceutical journals.

In conclusion, the factors that participants perceived to be barriers to pharmaceutical care were regulatory, educational, and cultural. Therefore, responsibility to advance pharmaceutical care in Oman lies with pharmacy regulatory bodies, pharmacy schools, pharmacy leaders and the

Omani Pharmaceutical Society. A coordinated, collaborative effort by all pharmacy stakeholders is needed if widespread adoption of pharmaceutical care is to be achieved in Oman. Specific recommendations will be discussed later in this chapter (section 4).

3. Effect of pharmacist country/continent of origin on beliefs about pharmaceutical care

In this study, Omani pharmacists were not different from those from other Middle

Eastern countries in their behavioral, normative, and control beliefs pertaining to pharmaceutical care. Language, religion, health beliefs, and values are similar across countries in this region.

These factors in turn influence pharmacists’ control beliefs according to the TPB. Also, almost all countries in the Middle East and South Asia are members of the World Health Organization

(WHO), which sets guidelines pertaining to good pharmacy practice. These guidelines provide a perspective on the pharmacist’s role and future direction of the profession in adopting pharmaceutical care (Wiedenmayer et al., 2006; International Pharmaceutical Federation, 2011).

Because these guidelines are followed more by the Middle Eastern countries than the South

Asian countries, pharmacists from the Middle East are more influenced by these guidelines than

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their South Asian colleagues and thus are more likely to have similar behavioral beliefs about pharmaceutical care. Besides, health care systems in countries of the Middle East support the provision of pharmaceutical care (Everard, 1999; The Gulf Cooperation Council, 2007; The

Executive Board of Health Ministers’ Council for GCC States, 2012), which in turn influences pharmacists’ normative beliefs about pharmaceutical care.

Omani pharmacists significantly differed in their behavioral, normative, and control beliefs from their South Asian counterparts. In addition to the obvious cultural differences between these two countries/continents, several other factors could contribute to the variations in the beliefs. Omani pharmacists are mostly employed in government health institutions. As such, they have better practice opportunities than those who are employed in the private sector: they have more incentives and better ability to provide pharmaceutical care. For example, Omani pharmacists are given better opportunities to continue their education abroad in clinical pharmacy programs and to attend national or international seminars, workshops, and conferences. Higher wages offered by these institutions are an added motivational factor that may positively influence pharmacists’ behavioral and control beliefs to provide pharmaceutical care.

The Omani government has implemented an “Omanization” policy to reduce dependence on the expatriate workforce and increase self-reliance on competent nationals. This policy provides training and job opportunities to Omanis. Also, whereas expat pharmacists work on a two-year renewable contract basis, Omani pharmacists have the option of remaining in service until retirement, unless there are strong reasons for termination. This job insecurity could either demotivate expat pharmacists from introducing innovative changes in their practice or it could

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have the opposite effect, that is, motivate them to show their best to impress their employers thereby increasing the likelihood of their contract renewal.

Pharmaceutical care has been promoted in government health institutions since 2005, while not much is being done to promote it in the private sector. Hospital pharmacy managers in the public sector encourage and support their staff pharmacists to provide pharmaceutical care.

However, pharmacy managers in the private sectors or their corporate head offices have a different perspective; they do not support the provision of pharmaceutical care unless it generates revenues to the pharmacy, which in turn may influence pharmacists’ normative beliefs.

Pharmacists from the Middle East and South Asia did not differ in their behavioral, normative, and control beliefs. Although sharing some positive beliefs about pharmaceutical care with Omani pharmacists, those from other Middle Eastern countries also shared some concerns regarding providing pharmaceutical care with their South Asian counterparts. Pharmacists from these regions are outsiders in Oman with few professional opportunities and privileges, and less job security and income than Omani pharmacists. These factors may collectively discourage their professional development, which poses a negative influence on their behavioral, normative, and control beliefs.

Section II: Suitability of the Theoretical Model

The model that provided the framework for this study was the TPB, modified by adding the construct ‘past behavior recency’. The predictive validity of the model with respect to its ability to explain intention to provide pharmaceutical care or pharmaceutical care behavior is discussed below.

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1. Predictors of Intention to Provide Pharmaceutical Care

Intention to provide pharmaceutical care was significantly predicted by pharmacists’ attitudes, subjective norms, perceived behavioral control, and recent past behavior. The overall variance explained in intention was 43%; however, only attitudes, subjective norms, and perceived behavior control were significant individual predictors. Other studies have also found the three variables attitude, subjective norm, and perceived behavioral control to be the sole significant predictors of intention to provide pharmaceutical care (Herbert et al., 2006; Odedina et al., 1997).

Our assumption that past behavior recency would predict intention was not confirmed.

One possible explanation given by some researchers (Aarts and Dijksterhuis, 2000; Bagozzi et al., 1992) is that, applying their reasoning to pharmaceutical care, if the pharmacist provided any pharmaceutical care activities repeatedly in the very recent past (a one week period in this study), these activities would be available in the pharmacist’s memory and would automatically be activated, without forming the intention, when an opportunity presented itself. Another possible explanation is that past behavior recency may be behavior/situation dependent (Bagozzi et al.,

1992). Thus, in situations where barriers to perform the behavior are present, they may interfere with the formation of intention. Further, some researchers suggested that past behavior may exert its effect directly on the behavior and not through intention (e.g., Bagozzi et al., 1992; Bagozzi and Warshaw, 1990; de Vries et al., 1995). Two studies have investigated the relationship of past behavior with intention and behavior in pharmacy. Odedina et al. (1997) found that past behavior was a significant predictor of pharmaceutical care behavior, while Herbert et al. (2006) did not

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find it a significant predictor of intention to provide pharmaceutical care, which supports the hypothesis that past behavior recency affects behavior without the mediating effect of intention.

The 43% explained variance in intention was within the range reported (R2 = 32% -

46.8%) in a review of the use of the TPB to explain/predict 58 health-related behaviors (Godin and Kok, 1996), and similar to that reported in one study of pharmaceutical care (Adjusted R2 =

44%, Odedina et al., 1997), but lower than that reported in two other studies of pharmaceutical care (Adjusted R2 = 78%, Kittisopee, 2001; Adjusted R2 = 63%, Herbert et al., 2006). It is not fully possible to compare our results with the high explained variance in the Kittisopee (2001) and Herbert et al. (2006) studies because there is considerable variation in the operationalization of the TPB constructs across all three studies. While both this study and the study by Odedina et al. (1997) strictly followed the theorist’s instructions on operationalization of the TPB constructs, it was not the case in Kittisopee (2001) and Herbert et al. (2006) studies. (Detailed explanation is provided in chapter 2, section 4).

2. Predictors of Pharmaceutical Care Behavior

In this study perceived behavioral control was the only significant predictor of pharmaceutical care behavior (measured with a proxy variable—past behavior recency).

Intention did not, as hypothesized, predict behavior. Pharmaceutical care is complex in nature

(Al-Shaqha and Zairi, 2003; Farris and Schopflocher, 1999; Roberts et al., 2005), and due to numerous barriers, pharmacists have limited control over performing it. The findings of this study suggest that pharmaceutical care might not have much to do with pharmacists’ good intentions and more to do with their perceived control over performing pharmaceutical care.

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According to the TPB (Ajzen, 1991), behaviors are located on a continuum that extends from volitional control (complete control over the behavior when no constraints are in the way) to nonvolitional control (lack of control over the behavior due to presence of barriers). If volitional control over the behavior is high, intention is a good predictor of behavior while perceived behavioral control makes little, if any, contribution, and vice versa. If volitional control is low, perceived behavior control makes a valuable contribution to the prediction of the behavior. The contribution of intention and perceived behavior control to the prediction of a behavior is thus dependent on the type of the behavior and/or situation; as stated by Ajzen (1991, p. 185) “one may be more important than the other and, in fact, only one of the two predictors may be needed”.

The present study is consistent with research on weight loss that has identified perceived behavioral control as the only predictor of trying to losing weight (Schifter and Ajzen, 1985). In pharmacy, Odedina et al. (1997) found that perceived behavioral control was a more important predictor for pharmaceutical care behavior than intention.

The 13% explained variance in behavior was lower than the range reported (15.6% -

42.3%) in the previously cited review on the TPB and a variety of health-related behaviors

(Godin and Kok, 1996) and lower than that reported in other studies of pharmaceutical care

(adjusted R2 = 45%, Kittisopee, 2001; adjusted R2 = 20%7, Odedina et al., 1997). The possible reason for the higher explained variance in Kittisopee’s (2001) study has been explained earlier.

7 The adjusted R2 = 20% is for a reduced model that included only intention and perceived behavioral control.

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Section III: Study Limitations

Non-response bias is one of the major threats to the validity of mail surveys. The response rate was 61.2%, which is relatively good (50% is considered adequate response rate in social research mail surveys [Richardson, 2005; Babbie, 1973; Kidder, 1981]) and will thus reduce the chances for obtaining biased data. Several techniques were used in this study to estimate non-response bias. Firstly, demographic characteristics of early respondents (who responded after the first survey mailing) were compared to those of late respondents (who responded after the second survey mailing). This method assumes that late respondents are more similar to non-respondents than they are to early respondents. Out of 10 demographic characteristics, significant differences between early and late respondents were detected in three characteristics: country of origin, country where highest degree in pharmacy was obtained, and years of experience and the first two are highly correlated. The chances of obtaining biased data are slim when few significant differences are found in characteristics of respondents and non- respondents (Public Works and Government Services Canada, 2007). Secondly, it was hypothesized that early respondents would more likely be providers of pharmaceutical care than late respondents. However, comparing the provision of pharmaceutical care between early and late responders did not reveal any significant differences.

Social desirability response bias is inevitable in surveys as they rely on self-reported data.

Other than ensuring confidentiality of participants’ response, no methods were used to control for social desirability response bias in this survey. Instead, it was assumed that if social desirability bias was present, scores on advanced pharmaceutical care activities would be high in all practice settings and not just in inpatient setting, where advanced activities were practiced

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routinely by clinical pharmacists. The findings indicated that inpatient pharmacists scored higher on advanced pharmaceutical care activities than pharmacists in outpatient and community pharmacy settings, which confirmed the absence of this bias.

A major limitation of this study was the inability to appropriately address objective 5 (to determine the individual influence of perceived behavioral control and intention on pharmacists’ pharmaceutical care behavior) and objective 6 (to test the predictive validity of the TPB model in explaining pharmacists’ pharmaceutical care behavior). Because these two objectives focus on the prediction of future behavior they ideally require a longitudinal study design. The use of a cross-sectional research design might not have been suitable. Also, the use of past behavior recency as a proxy for future pharmaceutical care behavior may not have been valid. That is, it could be argued that use of past behavior recency in the behavioral intention model as a predictor of intention, as well as in the behavior model as a proxy for pharmaceutical care behavior created an illogical inconsistency. Furthermore, use of past behavior recency as a proxy for future behavior meant that the relationship between past behavior recency and future behavior was not tested, and thus that the full-TPB model could not be tested.

The effect of pharmacists’ country of origin on their behavioral, normative, and control beliefs relative to providing pharmaceutical care might be confounded with other factors such as practice setting and practice sector, which should have been controlled for at the stages of design or analysis. Categorizing country of origin into Omani nationals and non-nationals, might have provided a more credible comparison.

This study lacked a measurement model for the indirect belief-based measures, that is, behavioral, normative, and control beliefs and their corresponding value weights (evaluation,

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motivation, and power). A measurement model would have provided evidence of how well these indirect measures assessed attitude, subjective norm, and perceived behavioral control respectively.

Another limitation was participants’ English proficiency. This issue was first identified in the focus group study and, accordingly, the language level of the survey instrument and accompanying survey materials was simplified. However, it is possible that some participants did not understand some of the questions.

The pharmaceutical care scale developed for this study included a wide range of activities. Although combining the item scores for these activities served the study purpose of examining the extent of provision of pharmaceutical care as a whole, it did not provide a sufficiently precise assessment of the specific differences in the provision of pharmaceutical care across settings. In a post hoc analysis we explored grouping pharmaceutical care activities into advanced and traditional activities. The results indicated that inpatient pharmacists provided advanced pharmaceutical care activities more than pharmacists in outpatient and community pharmacy settings, while community pharmacists provided traditional activities more than the pharmacists in the other two settings.

Section IV: Implications of Study Results

1. Recommendations for Policy Makers in Oman

The political will of the Omani government and the governments of other members of the

Gulf Cooperation Council (GCC) is to enhance the practice of pharmaceutical care in the

Arabian Gulf region. Despite the directorate of pharmaceutical care of the GCC executive office issuing standards, criteria, and regulations in 2007 and 2012 to guide and regulate the practice of

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pharmaceutical care in hospital and community settings, respectively, the extent of the implementation of pharmaceutical care has not been assessed by any of the GCC states. The findings of this study are important because they identify gaps between government policy and actual pharmacy practice. Also, knowledge of the barriers identified by study pharmacists will help policy makers devise strategies to address them.

Several strategies are suggested below to change pharmacists' behavioral and control beliefs pertaining to pharmaceutical care.

1.1. Changing Behavioral Beliefs

In section 2.1, ‘worry about responsibility’ was discussed as a manifestation of three potential barriers: resource-based, pharmacist attribute-based, or legal liability-based barriers.

Strategies to resolve resource- based barriers are discussed in the control belief section.

Changing beliefs about confidence in providing pharmaceutical care is not an easy task.

In fact, without the support and assistance of pharmacy schools or associations, such a change is unlikely (Barner and Bennett, 1999; Farris et al., 1999). According to Grol et al. (2005), the first step deemed necessary to support change and improve health care is education of health care providers. Small homogenous groups and interactive programs of long duration are most effective. One way to mitigate pharmacists’ worries and increase their confidence and ability to adopt a more pharmaceutical care-based practice is to enhance pharmacists’ clinical knowledge and skills through practical training programs such as Continuous Professional Development

(CPD) programs.

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There is evidence from the pharmacy literature that practical training programs with more clinical emphasis are effective in helping pharmacists build confidence and develop their ability to provide pharmaceutical care (Barner and Bennett, 1999; Chen et al., 2004; Currie et al., 1997;

Farris et al., 1999; Locca et al., 2009; Mehra and Wuller, 1998; Odegard et al., 2011; Patterson,

1999). Such programs should be made available in Oman to those who are interested in providing pharmaceutical care. Materials for self-study could also be made available by adapting or tailoring relevant training tools developed by the APhA and the NACDS Foundation

(Moczygemba, 2008). The possibility of introducing the CPD programs should be negotiated by the MOH and the Ministry of Higher Education with pharmacy schools in Oman.

However, with regard to new-comers to the practice of pharmacy in Oman, different strategies should be considered. Two strategies come to mind—changing the standards for pharmacist licensing to include a training certificate in either clinical pharmacy or pharmaceutical care, or introducing programs similar to the International Pharmacy Graduate

Program (offered by the University of Toronto), which will assist international pharmacists to meet Omani pharmaceutical care-oriented practice standards. However; there is a key concern related to licensing bodies in Oman. There are two licensing and examining bodies in Oman. The

DGPA&DC is responsible for examining and licensing pharmacists to be employed in the private sector, while the DGMS is the examining and licensing body for pharmacists employed in the MOH institutions. This creates double standards, that is, pharmacists employed or to be employed in public and private sectors are assessed differently and a pharmacist may fail to pass one licensing body exam, but may manage to pass the other. It is therefore recommended that there be one standardized exam for pharmacists in both sectors.

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1.2. Responding to Negative Control Beliefs

Lack of a private counseling area, lack of access to patients’ records and to drug information databases, and lack of pharmacy reimbursement were barriers to the provision of pharmaceutical care in community pharmacies, while the only barrier common to all settings was culturally-based gender issues. The following strategies are recommended to address these barriers:

1. It is suggested that the Law of Pharmacy Practice and Organization of Pharmaceutical

Institutions be revised to require computer systems with internet access, the maintenance of electronic patient records, and private or designated areas for counseling in community pharmacies.

There is a huge gap between private and public pharmacy sectors in the available electronic resources. One reason public sector pharmacists are able to provide better and more advanced pharmaceutical care services is the availability of computer systems that provide access to different drug information databases, and patients’ medical records. The availability of computers and internet connection in community pharmacies is thus very crucial. It will help community pharmacists create patient records in which they can document their assessments, interventions, and keep track of their patients’ medications. It will also allow pharmacists to access to drug information databases and keep up-to-date in their knowledge of medications, and therefore provide better pharmaceutical care services.

2. It is suggested that the MOH develop a model for payers to reimburse community pharmacies for their pharmaceutical care services.

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Reimbursement for patient care services is necessary for community pharmacies to provide these resource-intensive services. In Oman, the MOH provides free health services including medications for all Omanis, GCC nationals, and expatriates employed in the public sector. Therefore, about 80% of the population do not have health insurance plans, but enjoy the service benefits provided by the MOH. Even so, many individuals with such entitlement prefer to visit private sector hospitals/clinics and pay out of pocket. Most of expatriate employees of private sector firms have health insurance plans from their employer and they constitute the remainder 20% of the population. A reimbursement system such as fee for pharmaceutical care services is suggested for those who are uninsured and are willing and are able to pay out of pocket, while the insurance companies add a set of fees for the different pharmaceutical care activities to their billing system. In order to establish a reimbursement model and prepare a fee schedule, it is suggested that the MOH nominate a committee that includes some pharmacy leaders and representatives from the Omani Pharmaceutical Society and community pharmacies.

Suggested billing guides for pharmacy services in the USA can be consulted (Pharmacist

Services Technical Advisory Coalition, 2010).

It might be too early for community pharmacies to provide pharmaceutical care because there are many barriers that need to be resolved first. However, it is suggested that interested pharmacies/pharmacists in providing these services and have the required resources be accredited, and the suggested fee for service be applied to these pharmaceutical care accredited pharmacies.

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3. It is recommended that the pharmacy regulatory authority (DGPA&DC), the licensing body for pharmaceutical manufacturers and their products, require manufacturers to provide patient educational materials for drug products used to treat sexual, genital, or anal conditions.

As mentioned earlier in this chapter, the presence of a family member or a pharmacist of the same gender would help solve the problem of culturally-based gender issues. However, when these options are not available, it is suggested that patients be provided with written educational materials for medications used for the treatment of sexual, genital, or anal conditions instead of direct counseling. Before taking this approach, however, patients should be asked about their preference. Such written educational materials should include drawings to convey the basic message to illiterate patients and be written in both Arabic and English.

4. Since the MOH is the main health care provider in Oman, it has to create a suitable environment for the advancement of the pharmacy profession in coordination with universities offering pharmacy programs, the Omani Pharmaceutical Society, and pharmacy leaders from both the government and private sectors. To start with, a directorate for pharmaceutical care should be established by the MOH as per the recommendations of the Ministerial Decree B-18 issued in 2005. This directorate should be responsible for devising a national strategy and practice standards for implementing pharmaceutical care, specific to each practice setting. All other GCC members have already established a directorate for pharmaceutical care and there is no reason preventing the MOH from doing so. In Saudi Arabia for instance, the directorate general of pharmaceutical care not only devises strategies and practice standards for pharmaceutical care provision, but also extends its activities to provide training, continuing education, and scholarships for pharmacists; support pharmaceutical care research; and assess

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quality and follow-up of rational use of medications (Directorate General of Pharmaceutical

Care, 2011).

2. Contributions of this Study beyond Oman

The findings of this study support those of previous research on the applicability of the

TPB to pharmaceutical care behavior (Herbert et al, 2006; Kittisopee, 2001; Odedina et al.,

1997). Also, this study demonstrates that the TPB provides a comprehensive structure that supports the design or intervention/change programs to enhance the implementation of pharmaceutical care.

Another contribution is that the survey instrument developed for this study can be used for research in other Arabian Gulf States, which have similar health care systems, similar imported pharmacy workforces and, more importantly, similar cultures and health beliefs. The survey instrument can also be used by countries beyond the Arabian Gulf region since, based on literature review, the factors it includes that might hamper or facilitate the provision of pharmaceutical care are likely to apply to other countries.

Although a cross-sectional survey design is a cost efficient proxy for a longitudinal design and may have validity when the behavior has a temporal stability (Rhodes and Plotnikoff,

2005), this study did not support the use of cross-sectional design in predicting pharmaceutical care behavior. We therefore recommend that a longitudinal design be used.

Finally, the construct, past behavior recency, proved to be a non-significant predictor of intention to provide pharmaceutical care in this study as it had in another study (Herbert et al.,

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2006). Thus, we do not recommend that this construct be used as a predictor of intention to provide pharmaceutical care.

Section V: Future Research

As stated above, a longitudinal study is recommended, not only to test the relationship between past behavior recency and future behavior, but also to confirm that intention has no important role in explaining pharmaceutical care behavior.

The pharmaceutical care scale developed for this study covered a wide range of activities, which were not grouped into domains. Based on a post-hoc exploratory analysis, the 16 pharmaceutical care activities were grouped into advanced and traditional activity domains.

Further research should be conducted with a multidimensional measure of pharmaceutical care behavior in order to draw more refined conclusions about pharmaceutical care practice in each setting.

Currently, there is a lack of research on the extent of providing pharmaceutical care in the

Arabian Gulf States. As these states have similar health care systems, converging cultures, similar imported pharmacy workforces, and more importantly share the same interest in pharmaceutical care practice, a study comparing the provision of pharmaceutical care across the six Gulf States should be undertaken. This would not only assist the GCC executive office to identify strategies for resolving barriers to the implementation of pharmaceutical care at the central level, but also could be used to validate the proposed survey instrument domains across this region.

This study examined the effect of pharmacists’ country/continent of origin on their behavioral, normative, and control beliefs. Future research should examine another important

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factor—Omanization policy, the ‘positive discrimination in favor of locals’ that may significantly influence pharmacists’ beliefs toward providing pharmaceutical care.

In pharmaceutical care practice, pharmacists work in collaboration with patients and other health care providers, particularly physicians. Thus, physicians’ and patients’ support and appreciation of the pharmacist’s role in managing patient drug-therapy is very important.

Although research has been conducted in three Arabian Gulf States on physicians’ and patients’ attitudes towards pharmacist pharmaceutical care services (Abu-Gharbieh, 2010; Bawazir, 2004;

Matowe et al, 2006), there has been no such research in Oman. This research is needed to help design intervention/change programs targeting physicians and patients that can maximize the collaboration among all parties.

Section VI: Conclusions

This study showed that self-reported provision of pharmaceutical care in Oman is limited and did not significantly differ across inpatient, outpatient, and community pharmacy settings.

However, post hoc analyses indicated that the provision of advanced pharmaceutical care activities significantly differed across the three practice settings, and that inpatient pharmacists provided advanced pharmaceutical care activities more frequently than outpatient and community pharmacists.

This study also found that clinical knowledge, communication skills, time, and staffing were perceived facilitators of the provision of pharmaceutical care across all settings, and that worry about responsibility and culturally-based gender issues were common barriers across settings. For community pharmacies, having a private counseling area, and access to patient records and drug information databases were additional identified barriers, and that lack of

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reimbursement was the main barrier in the private sector (community pharmacies and private hospitals/clinics).

Pharmacists’ country of origin affected their behavioral, normative, and control beliefs about providing pharmaceutical care. This could be attributed to differences in country cultures, professional cultures, health care systems, and national policies.

Given similarities in health care systems, cultures and health beliefs, and imported workforce, the study findings are likely applicable to other Arabian Gulf States as well.

The constructs of the TPB (attitude, subjective norm, and perceived behavioral control) were significant predictors of intention, while the added variable, past behavior recency, was not.

Of the two hypothesized predictors of pharmaceutical care behavior, perceived behavioral control was a significant predictor and intention was not. The results of this study support the large body of literature showing the validity of the TPB in predicting intention, and its weak validity in predicting behavior, as well as the importance of perceived behavioral control in predicting both intention and behavior.

By contributing to our understanding of the extent of the implementation of pharmaceutical care and the factors that influence its implementation in Oman, the findings of this study will help policy makers at the Omani MOH develop strategies for advancing pharmaceutical care practice.

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APPENDICES

Appendix A

Telephone Script for Recruiting Pharmacists

Hello, can I speak with (name)?

My name is Awatif Al Abdullatif, and I am a PhD student in the Department of Pharmaceutical Sciences at the University of Toronto.

I am doing my research on the implementation of pharmaceutical care in Oman.

Do you have few minutes to talk with me about this project? If not, when can I call you back?

I am calling you today to ask whether you would be interested in participating in a focus group of 6 – 10 pharmacists that I am conducting as part of my study.

The purpose of the focus group is to identify facilitators and barriers to the implementation of pharmaceutical care in your practice setting.

The meeting will take place in Muscat and is expected to take 1 ½ to 2 hours. You will be provided with a token gift of appreciation for your participation in this study.

Your name and any information you provide during these meetings will be kept confidential. Additional information about the study and your rights is provided in an information sheet that I will e-mail or fax it to you if you are interested.

Would you like to receive this information? You can read it over and then decide whether you agree to participate.

Thank you

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Appendix B

Memorandum from Chain Pharmacy Head Office to its Employee Pharmacists

Kindly be informed that Mrs. Awatif Al Abdullatif is conducting a study as part of her doctoral research. Her research is on the implementation of pharmaceutical care in Oman, and it covers two phases.

Phase I: Three focus groups will be held with pharmacists representing three practice settings in Oman: inpatient, outpatient, and private pharmacy setting.

Phase II: A mailed survey of pharmacists who work in Oman.

She may approach you now to participate in the private pharmacy focus group, and a few months later you will receive a mailed survey from her.

We kindly request you to cooperate with her and make her research project successful. Please note that despite our encouragement, the decision to take part in the study (or not) rests with you, and the head office will not be informed about your decision.

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Appendix C

FOCUS GROUP INFORMATION SHEET/ CONSENT FORM Please read this information sheet and consent form carefully Study: The Provision of Pharmaceutical Care in Oman: Practice and Perceived Barriers to Implementation Phase I. Focus Group Study Student Investigator: Awatif Al Abdullatif

Funding Agency: Oman Pharmaceutical Products Co. Thank you for your interest in participating in our focus group. Please read this information sheet and consent (approval) form carefully.

The purpose of the study: The purpose of this study is to explore factors that affect the provision of pharmaceutical care in three practice settings: inpatient, outpatient, and private pharmacy, in Oman.

Three focus groups will be held with pharmacists working in three practice settings in Oman: inpatient, outpatient, and private pharmacy. The information obtained from these focus groups will be used to help us to develop questions for next phase of the study, which is to conduct a mail survey of pharmacists who work in Oman.

This study is part of the student investigator’s doctoral research.

What is a focus group? It is an in-depth discussion among a small number of participants (usually 6-10), led by a facilitator (student investigator in this study) about a topic of interest.

The participants in this study The participants are pharmacists (both Omanis and expatriates/ females and males) who have been working in Oman for at least three years in inpatient/ outpatient settings of public or private hospitals or health centers/clinics, and in private pharmacies. All participants will be from the Muscat region.

We will conduct three focus group meetings, each with 6-10 pharmacists from one of the three settings: inpatient, outpatient, and private pharmacy. You are being asked to participate in this

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study because your experience and knowledge will help identify facilitators (enablers) and barriers (obstacles) to the implementation of pharmaceutical care in your practice setting (place of work).

Participants’ role If you agree to participate in this study, you will be asked to attend the focus group meeting related to your practice setting. The meeting is expected to take 1 ½ to 2 hours, and will be led by the student investigator. A secretary will be present to make notes of the meeting. During the meeting, a few questions will be raised by the student investigator to start the discussion. These questions will be about your views of the facilitators and barriers to the implementation of pharmaceutical care in your practice setting. We would like to hear different ideas and opinions from everyone; there are no right or wrong answers to the focus group questions, even if your answers do not match those of the other participants. In case you are not knowledgeable enough about the concept of pharmaceutical care, we will provide each participant with some readings on pharmaceutical care before the meeting takes place. With your permission, the discussion during the meeting will be tape-recorded so that we do not miss any comments made.

Meeting place The focus group meetings will be held in the main meeting room of the Higher College of Technology/ Ministry of Manpower in Al Khuwair/ Oman on the date and time mentioned below Practice setting Date Time

Conditions for participation Your participation in this study is voluntary. You may refuse to participate, or refuse to answer any question(s), and you may withdraw from the study up to one month after the date of your focus group. If you choose to withdraw from the study comments you made during the focus group discussion will not be quoted in any documents or reports.

Risks/ Benefits of participation There will be no negative outcomes from your participation in this study, refusing to participate at any point of time, or not participating in the study. There will also be no direct benefit to you from participating in this study. However, the discussion may stimulate your thinking and encourage you to decide to provide pharmaceutical care. You may get ideas about facilitators to pharmaceutical care from other participants and may work on resolving barriers to the implementation of pharmaceutical care in your practice setting.

Compensation You will be provided with a small gift of appreciation for your participation in this study.

Anonymity, confidentiality, and publication of results You will not be introduced to the other participants, but it is possible that you may already know or have met some of the participants previously. You will be asked what name you wish to be called by during the meeting and may decide to use your own name or an assumed name. Whatever name you use will be kept confidential by the student investigator, and participants

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will be instructed not to mention the names of other participants and not to talk about individual comments made during the focus group meeting. The research records, including the typed transcript of the discussion will not include your name, except for the consent form, which will be stored separately from other research records. All data related to the research will be stored in a filing cabinet located in a locked data storage room in the Leslie Dan Faculty of Pharmacy building at the University of Toronto, Toronto, Canada. The data will be accessible only to the student investigator and her supervisor. Electronic data obtained during this study will be saved in the student investigator’s password- protected computer in the locked research office, and a copy will be saved on a password protected USB key which will be stored in the locked research office. Electronic data will be securely stored for five years. Audiotapes of the focus group meeting will be transcribed (typed) into a word processing file and destroyed once their accuracy has been confirmed. Paper copies of the transcripts will be destroyed once data have been analyzed. The student investigator plans to publish and make public presentations about the results of this study. Should she wish to quote any of your comments in these presentations or publications she will first obtain your approval. Any quotations will be anonymous. A summary report of the focus group results will be sent to you, if you so wish, at the end of the study. If you have any questions or concerns about your rights as a research participant, please contact the University of Toronto Office of Research Ethics at 416-946-3273 or by email: [email protected]. If you wish to have further information please feel free to contact the student investigator or her supervisor at: Awatif Al Abdullatif BScPhm, MSc Linda MacKeigan, BScPhm, PhD PhD Student Associate Professor Leslie Dan Faculty of Pharmacy Leslie Dan Faculty of Pharmacy University of Toronto University of Toronto 144 College St. 144 College St. Toronto, ON M5S 3M2 Toronto, ON M5S 3M2 Tel: (1) 647-408-8455 Tel: (1) 416-978-3945 OR (968) 99280660/ Oman Fax: (1) 416 -978-1833 OR (968) 24482667/ Oman [email protected] Fax: (1) 416-978-1833 [email protected]

Please keep a copy of this information sheet/ consent form for your records

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FOCUS GROUP CONSENT FORM

Study: The Provision of Pharmaceutical Care in Oman: Practice and Perceived Barriers to Implementation Phase I. Focus Group Study You have been invited to participate in a focus group meeting, and you have the right to whether or not to participate in the focus group and stop at any time. Should you choose to withdraw from the study comments you made during the focus group discussion will not be quoted in any documents or reports. The focus group meeting will be tape-recorded.

In respect for each other, we ask that names of other participants (if known to you) and any discussion occurring during the meeting remain confidential.

I have read and understood this information and the attached information sheet. By signing this form, I agree to participate fully under the conditions stated above.

PARTICIPANT NAME (please print) ______

SIGNATURE OF PARTICIPANT ______

DATE (DD/MM/YY) ______/______/______

SIGNATURE OF INDIVIDUAL OBTAINING CONSENT ______

DATE (DD/MM/YY) ______/______/______

Please keep a copy of this information sheet/ consent form for your records

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Appendix D

Focus Group Interview Guide

Opening Questions

To start with, a general question: Were you aware of the concept of pharmaceutical care prior to receiving the readings for this meeting?

If yes, do you currently provide pharmaceutical care in your practice setting? Give some examples of your experiences with pharmaceutical care.

If you were not aware of the concept, do you want to provide pharmaceutical care?

A. Pharmacists’ Behavioral Beliefs

A. 1. Generally speaking, what do you think are the benefits for your patients, your pharmacy, and/or you of providing pharmaceutical care?

 PROBE: Would providing pharmaceutical care help ensure that your patients get the most benefit from their medications? Why or why not?

 PROBE: Would providing pharmaceutical care help you to identify and resolve your patients’ drug-related problems? Why or why not?

 PROBE: Would providing pharmaceutical care help you identify and address your patients’ concerns about their medications? Why or why not?

 PROBE: Would you think providing pharmaceutical care gives you prestige or professional pride? Why or why not?

 PROBE: Would providing pharmaceutical care enhance the reputation of the pharmacy with patient and physicians? Why or why not?

A.2. What do you think are the negative consequences for your patients, your pharmacy, and/or you of providing pharmaceutical care?

 PROBE: Would you be worried about potential harm to the patient’s health if you were to attempt to provide pharmaceutical care?

 PROBE: Would providing pharmaceutical care waste your time and effort that could be used in other more important activities? Explain.

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B. Normative Beliefs

B.1. What would important people in your work environment or amongst your pharmacist colleagues think about you providing pharmaceutical care?

 PROBE: Would the pharmacy manager or owner agree that you should provide pharmaceutical care?

 PROBE: Would physicians be receptive to you providing pharmaceutical care?

 PROBE: Would your patients be interested in pharmaceutical care services? What are their expectations from you? Would they appreciate you for providing them with pharmaceutical care services?

 PROBE: Would your workplace colleagues (pharmacists and technicians) be supportive of you providing pharmaceutical care?

 PROBE: Would your pharmacist colleagues outside of the work place be supportive of you providing pharmaceutical care? How?

C. Control Beliefs

C.1. If you have had any experience providing pharmaceutical care or have observed other pharmacists doing so, what factors have made this possible?

PROBES: Do you think:

 Your motivation

 Your clinical knowledge and skills

 prior experience with pharmaceutical care

 your personality

 adequacy and attitude of support personnel

 access to patient information e.g., medical records

 technological support e.g., information technology, automated dispensing technology

 pharmacy layout [specific to outpatient and community settings only]

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…..can help you in providing pharmaceutical care?

C.2. What are the barriers to the provision of pharmaceutical care in your practice setting? Consider barriers relating to the pharmacy work environment, pharmacy staff, yourself, patients, other health care professionals or anything else. Give examples.

 PROBE: Do you think cultural differences among pharmacists and patients, or language differences can impede the provision of pharmaceutical care? How?

 PROBE: Does work load or lack of time prevent you from providing pharmaceutical care?

Closing Question

In closing, do you have any additional comments in regards to challenges you perceive or encounter in your practice setting to provide pharmaceutical care?

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Appendix E

Focus Group Participant Demographics

Date: Time: Place:

Your age Your gender Your Sector Practice type

≤ 29 Female Public Inpatient

30-39 Male Private Outpatient

40-49 Community Pharmacy

≥ 50

What is the highest level of Where did you Country of How many years have education you have complete your Origin you been in pharmacy completed? highest level of practice (years of education? Oman experience)? Bachelor N. America Oman 0-5 Master Europe N. America 6-10 Pharm D Middle East Europe 11-15 Residency Asia Middle East 16-20 PhD China Asia Over 20 yrs Australia/ New China Zealand Australia/ New Zealand How many years have you Which of the following best describes your current been at your current position? practice site? Manager or Director Others (specify) ≤ 10 Assistant/ Associate Manager or Director 11-19 Supervisor ≥ 20 Staff Pharmacist

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Appendix F

Pilot Test Introductory Letter

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Ph.______

Thank you for agreeing to participate in this pilot test of our questionnaire about pharmaceutical care practice in Oman and factors affecting its implementation. The purpose of this pilot test is to have your comments and suggestions on the attached questionnaire to revise and improve it. We want you to tell us how easy or difficult it is to read and understand the questions, how long the questionnaire is, whether I forgot to mention any important factors, whether the length of the questionnaire is a reason for not completing it, and any suggestions you come up with. We also require your comments on the cover letter accompanying the questionnaire.

Attached you will find the questionnaire, and another short list of questions that you are requested to answer after you complete the questionnaire. Before you begin to answer the questionnaire, please write down the time in the box on the right corner of the first page of the questionnaire. In the same way, write down the time after you finish answering the questionnaire in the box at the last page. This will help us to estimate the time needed to complete the questionnaire. When you go through the questionnaire, put a mark next to any question you feel was unclear in any way. After completing the questionnaire, please go to the short list of questions and answer them briefly. Place the questionnaire along with the short list of questions in the envelope provided, seal the envelope and sign on the seal, and return it to the person who delivered it to you by hand.

Please note that this is only a pilot study, and your responses will not be used in the final study results. Your responses and comments will help us improve our research questionnaire. The student investigator Awatif Al Abdullatif may contact you by phone if your comments need further clarification.

Thank you for your cooperation.

Date: Awatif Al Abdullatif PhD Student Leslie Dan Faculty of Pharmacy University of Toronto

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Appendix G

Pilot Test Questionnaire + Cover Letter + Response Postcard

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Colleagues,

My name is Awatif Al Abdullatif, and I am a PhD student in the Department of Pharmaceutical Sciences at the University of Toronto. I am writing to invite you to participate in a survey on the extent of pharmaceutical care practice in Oman and factors affecting its implementation.

Your name was obtained either from the Ministry of Health lists of registered pharmacists, or from the governmental institution you work for.

Very little is currently known about pharmacists’ opinions on practicing pharmaceutical care in the Gulf States, and in particular in Oman. The information you provide will be extremely valuable in helping us understand your beliefs and feelings about this important pharmacy practice model. This information will also help the Ministry of Health to identify strategies for resolving the difficulties associated with practicing pharmaceutical care.

It is very important that all pharmacists participate in this study. This will help us to get true representative information about pharmacy practice in Oman, and will make our study valid.

If you Agree to participate in this study, we request that you: a) Complete the attached questionnaire and return it in the large brown envelope provided in this package within a week. b) Return the enclosed postcard in the small white envelope provided in this package after marking the box that says you have mailed the completed questionnaire.

If you Do Not wish to participate in the study, we request that you: a) Return the enclosed postcard in the small white envelope provided in this package after marking the box that says you do not wish to participate in the study.

The provided envelopes are self-addressed and prepaid for your convenience.

The questionnaire is expected to take (x) minutes to fill out. All of the information collected will be strictly confidential. The study results will be presented as aggregate numbers with no reference to any particular participant. The questionnaire does not carry your name. The

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postcard, which lists your name and address, is only to help us determine your decision to participate for the purpose of follow-up and it will be destroyed once the data collection process is completed. Please return the questionnaire and the post card SEPARATLEY, so that we cannot link the name on the postcard to your questionnaire. Please let me know if you wish to have a summary report of the survey results by marking the box that shows you are interested to receive the summary report in the postcard.

If you need any assistance with this survey, or have any question regarding this research project, please do not hesitate to contact Awatif Al Abdullatif at (99280660/ Oman) or by email at: [email protected] or Linda MacKeigan at 416-978-3945 or by email at: [email protected]. If you have any questions or concerns about your rights as a research participant, please contact the University of Toronto Office of Research Ethics at 416-946-3273 or by email at: [email protected].

Thank you for taking the time to answer this questionnaire. Your cooperation is greatly appreciated.

Awatif Al Abdullatif Sawsan Ahmed Jaffer Osama Babiker PhD Student Director General Head of Follow-up section Leslie Dan Faculty of Pharmacy Directorate General of Directorate General of University of Toronto Pharmaceutical Affairs Medical Supplies/ MOH & Drug Control/ MOH

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Response Postcard

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Pharmacist Name…[To be completed by the student investigator]……………….

Address…………………………………………………………………………….

……………………………………………………………………………………..

I have mailed the completed questionnaire. I do not wish to participate in this study.

I am interested to have a summary report of the survey results

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Pilot Test Questionnaire

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

I. Think about the patients who visited your (pharmacy/ hospital/ health center/ clinic) last week and had a chronic condition(s) such as diabetes, hypertension, or asthma. Please indicate HOW OFTEN you carried out the following activities during that week by circling the appropriate number corresponding to your answer.

Activities Never Rarely Sometimes Most of Almost all the time the time 1 Ask the patient about his/ her medical 1 2 3 4 5 condition (description of medical problems) and document it if it was not otherwise available to you 2 Ask the patient about his/ her 1 2 3 4 5 medication history (present medications, past medications, drug allergies, OTC, herbals) and document it if it was not otherwise available to you 3 Ask the patient about his/ her life style 1 2 3 4 5 factors (caffeine, alcohol, smoking, diet, exercise) and document them if they were not otherwise available to you 4 Screen the prescription to identify 1 2 3 4 5 medication-related problems such as over dose or low dose 5 Screen the prescription to identify 1 2 3 4 5 medication-related problems such as drug-drug interaction 6 Assess the patient to find any 1 2 3 4 5 symptoms that could be due to adverse reactions caused by any of her/ his medications

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7 Evaluate the patient’s laboratory 1 2 3 4 5 results 8 Develop a plan for resolving a 1 2 3 4 5 medication-related problem you have identified 9 Educate the patient or care giver 1 2 3 4 5 (family member) on the appropriate use of medications 10 Train the patient on how to use his/ 1 2 3 4 5 her medical device e.g. inhaler, glucose-meter, BP monitor 11 Check that the patient understands the 1 2 3 4 5 information you provide him or her 12 Evaluate the patient’s response to 1 2 3 4 5 drug-therapy (reaction to treatment), including effectiveness 13 Prepare a (manual or computerized) 1 2 3 4 5 record of all of patient’s personal medications 14 Provide the patient with a copy of his/ her personal medications 15 Prepare a (manual or computerized) 1 2 3 4 5 list of instructions for use by the patient for self- management 16 Provide the patient with a copy of the instruction list 17 Communicate with a doctor or other 1 2 3 4 5 health care professional regarding medication-related problems you have identified 18 Refer a patient to a doctor or other 1 2 3 4 5 health care professional for a problem that should be assessed by that other professional 19 Document interventions provided by 1 2 3 4 5 you on patient’s file, prescription, or medical report 20 Schedule a follow-up visit to evaluate 1 2 3 4 5 the patient’s progress

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INSTRUCTIONS FOR ANSWERING QUESTIONS ON THE FOLLOWING PAGES8

The questions in the following sections of the survey use 7-point rating scales. Circle the number that best describes your opinion. For example, if you were asked to rate “The weather in Oman” on such a scale, the 7 points will be read as follows:

The Weather in Oman is: good :_____1____:_____2____:_____3____:_____4____:_____5____:_____6____:_____7____: bad extremely quite slightly neither slightly quite extremely

If you think the weather in Oman is extremely good, then you would circle the number 1, as follows:

The Weather in Oman is: good :___ 1 ___:____2_____:_____3____:_____4____:_____5____:_____6____:_____7____: bad

If you think the weather in Oman is quite bad, then you would circle the number 6, as follows.

The Weather in Oman is: good :____1_____:_____2____:_____3____:_____4____:_____5____:___6 ___:____7_____: bad

If you think the weather in Oman is slightly good, then you would circle the number 3.

The Weather in Oman is: good :____1_____:_____2____:___3 ___:____4_____:_____5____:_____6____:_____7____: bad

If you think the weather in Oman is neither good nor bad, then you would circle the number 4.

The Weather in Oman is: good :____1_____:_____2____:_____3____:___4 ___:____5_____:_____6____:_____7____: bad

In making your ratings, please remember the following points: * Never circle more than one number on a single scale. * Never circle the words “good” or “bad”, or any other words at the ends of the scale.

8 Instructions for responses to this questionnaire have been adapted from Ajzen, 2003.

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II. Suppose that practicing pharmaceutical care involves carrying out the activities mentioned above (questions 1-20), Now, we would like to know your opinion about practicing pharmaceutical care by circling the number representing your opinion to the following statements.

21. If I was to practice pharmaceutical care on a regular basis, it would increase patient safety. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

22. Increasing patient safety is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

23. If I was to practice pharmaceutical care on a regular basis, it would improve patient health. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

24. Improving patient health is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

25. If I was to practice pharmaceutical care on a regular basis, it would change the image people have about the pharmacist being only a medicine dispenser. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

26. Changing the image people have about the pharmacist being only a medicine dispenser is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

27. If I was to practice pharmaceutical care on a regular basis, it would strengthen (improve) my relationship with doctors. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

28. Strengthening (improving) my relationship with doctors is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

29. If I was to practice pharmaceutical care on a regular basis, it would increase patient respect/ trust in me. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

30. Increasing patient respect/ trust in me is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

31. If I was to practice pharmaceutical care on a regular basis, it would make me worry about being responsible for any intervention I provide. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

32. Worrying about being responsible for interventions I provide is bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

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III. For each of the following statements, please circle the number representing your opinion.

33. The doctors in my workplace (or around my workplace) whose patients I see think that I should : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should not practice pharmaceutical care on a regular basis

34. When it comes to pharmaceutical care, how important is it to you to do what the doctors think you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

35. My patients think that I should : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should not practice pharmaceutical care on a regular basis

36. When it comes to pharmaceutical care, how important is it to you to do what your patients think you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

37. My boss (chief pharmacist/ pharmacy manager/ company head office) thinks that I should : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should not practice pharmaceutical care on a regular basis

38. When it comes to pharmaceutical care, how important is it to you to do what your boss (chief pharmacist/ pharmacy manager/ company head office) thinks you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

39. My hospital administration thinks that I should : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should not practice pharmaceutical care on a regular basis (This question is for hospital and health center pharmacists only)

40. When it comes to pharmaceutical care, how important is it to you to do what your hospital administration thinks you should do? (This question is for hospital and health center pharmacists only) not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

IV. Next, we would like to know what factors would help or prevent you from practicing pharmaceutical care. Please circle the number representing your opinion to the following statements.

41. I do not have adequate clinical knowledge and experience to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

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42. If I do not have adequate clinical knowledge and experience, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

43. I do not have adequate communication skills (the ability to listen, to speak, and to write in simple language) to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

44. If I do not have adequate communication skills (the ability to listen, to speak, and to write in simple language), it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

45. I do not always have adequate ability to speak my patient’s language to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

46. If I do not have adequate ability to speak my patient’s language, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

47. Being a male pharmacist, I am not able to counsel a female patient in sensitive (embarrassing) issues. OR [Being a female pharmacist, I am not able to counsel a male patient in sensitive (embarrassing) issues.] false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

48. As a male pharmacist, if I am not able to counsel a female patient in sensitive (embarrassing) Issues, it would make practicing pharmaceutical care much more difficult for me. OR [As a female pharmacists, if I am not able to counsel a male patient in sensitive (embarrassing) issues, it would make practicing pharmaceutical care more difficult for me.] disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

49. We do not have enough staff in my workplace for me to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

50. Shortage of staff in my workplace would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

51. I do not have enough time during my work hours to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

52. Lack of time during my work hours would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

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53. I have too heavy a workload in my workplace to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

54. Too heavy a workload in my workplace would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

55. I do not have a drug information database (pharmaceutical software packages) in my workplace to enable me to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

56. If I do not have a drug information database (pharmaceutical software packages) in my workplace, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

57. I do not have a private counseling area in my workplace to practice pharmaceutical care. (Do not answer this question if you are an inpatient pharmacist) false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

58. If I do not have a private counseling area in my workplace, it would make practicing pharmaceutical care much more difficult for me. (Do not answer this question if you are an inpatient pharmacist) disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

59. I do not have access to my patient’s medical records (patient medical information) in my workplace to enable me to practice pharmaceutical care. false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

60. If I do not have access to patients’ medical records (patient medical information) in my workplace, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

61. In addition to my salary, I am not being reimbursed/ compensated for my pharmaceutical care services in my workplace. (This question is for private sector pharmacists only) false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : true

62. If I am not reimbursed (compensated) for my pharmaceutical care services in my workplace, it would make practicing pharmaceutical care much more difficult for me. (This question is for private sector pharmacists only) disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

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V. Next, we would like to know how you feel about practicing pharmaceutical care. Please circle the number representing your opinion to the following statements.

63. For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: frustrating : 1 : 2 : 3 : 4 : 5 : 6 : 7 : rewarding

64. For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: unpleasant : 1 : 2 : 3 : 4 : 5 : 6 : 7 : pleasant

65. For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

66. For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: unenjoyable : 1 : 2 : 3 : 4 : 5 : 6 : 7 : enjoyable

67. For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: worthless : 1 : 2 : 3 : 4 : 5 : 6 : 7 : valuable

VI. Now, we would like to know what most pharmacists/ people in your professional life think about you practicing pharmaceutical care. Please circle the number representing your opinion to the following statements.

68. The pharmacists/ people in my professional life whose opinion I value would not support : 1 : 2 : 3 : 4 : 5 : 6 : 7 : support my practicing of pharmaceutical care on a regular basis

69. It is expected of me that I practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

70. Most pharmacists/ people in my professional life who are important to me think that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis

71. The pharmacists whose opinion I value do not practice : 1 : 2 : 3 : 4 : 5 : 6 : 7 : practice pharmaceutical care on a regular basis

72. Most pharmacists who are important to me practice pharmaceutical care on a regular basis. completely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : completely true

73. Many of my pharmacist colleagues practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

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74. Many pharmacists with the same pharmacy degree as me practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

VII. Please indicate how easy or difficult it is for you, personally, to practice pharmaceutical care, and how much control you have on practicing it by circling the number representing your opinion about the following statements.

75. For me to practice pharmaceutical care on a regular basis would be….. difficult : 1 : 2 : 3 : 4 : 5 : 6 : 7 : easy

76. For me to practice pharmaceutical care on a regular basis would be….. impossible : 1 : 2 : 3 : 4 : 5 : 6 : 7 : possible

77. If I wanted to, I could practice pharmaceutical care on a regular basis. definitely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : definitely true

78. How much control do you believe you have over your practicing pharmaceutical care on a regular basis? no control : 1 : 2 : 3 : 4 : 5 : 6 : 7 : complete control

79. It is mostly up to me whether or not I practice pharmaceutical care on a regular basis. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

80. The decision to practice pharmaceutical care on a regular basis is beyond my control. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

VIII. Please show your intention to practice pharmaceutical care on a regular basis by circling the number representing your opinion to the following statements.

81. I intend to practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

82. I will try to practice pharmaceutical care on a regular basis. definitely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : definitely true

83. I plan to practice pharmaceutical care on a regular basis. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

84. I will make an effort to practice pharmaceutical care on a regular basis. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

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IX. Finally, please answer a few questions about yourself 85. What is your age now? ≤ 29 30-39 40-49 ≥ 50

86. What is your gender? Female Male

87. What is the highest level of education in pharmacy you have completed? Bachelor Master PhD Pharm D Residency

88. What is your country of origin? Oman North America South America Europe Middle East South Asia China Australia/ New Zealand

89. Where did you complete your highest level of education in pharmacy? Oman North America South America Europe Middle East South Asia China Australia/ New Zealand

90. For how many years have you been practicing pharmacy (years of experience)? 0-5 6-10 11-15 16-20 Over 20 yrs

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91. What is your practice type? Retail pharmacy Retail chain pharmacy (3 or more branches) Outpatient clinic pharmacy Outpatient health center pharmacy Outpatient hospital pharmacy Inpatient setting

92. How many years have you been working at your present pharmacy/ hospital? ≤10 11-19 ≥20

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Appendix H

Pilot study Debriefing Questions

Please answer the following questions about the questionnaire, and the attached cover letter:

1. Were any of the questions unclear or difficult to understand? If so, please write down the number of the confusing question and what you thought was unclear.

2. Were there any questions that you felt you did not have an answer for? If so, please write down the number of the question and explain why.

3. Do you think the length of the questionnaire might be a reason for not participating in the study?

4. Was the questionnaire cover letter easy to understand? If not, please tell us how it could be improved.

5. Has any important aspect/ issue been ignored/ omitted?

6. Do you have any other comments on the questionnaire, and/or the cover letter?

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Appendix I

Survey Introductory Letter

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Colleagues,

My name is Awatif Al Abdullatif, and I am a PhD student in the Department of Pharmaceutical Sciences at the University of Toronto. I am writing today to tell you about a questionnaire that will be distributed in next few days, as a part of my doctoral research.

This survey aims to study the extent of pharmaceutical care practice in both governmental and private sectors in Oman, and factors affecting its implementation.

Pharmaceutical care is patient-focused care, and its main functions are to identify, resolve, and prevent problems associated with drug therapy. As you may know, pharmaceutical care is an increasingly common practice model for pharmacists worldwide, as well as in Oman.

If you have any questions regarding this research project, please do not hesitate to contact Awatif Al Abdullatif at (99280660/ Oman) or by email at: [email protected] or Linda MacKeigan at 416-978-3945 or by email at: [email protected]. If you have any questions or concerns about your rights as a research participant, please contact the University of Toronto Office of Research Ethics at 416-946-3273 or by email at: [email protected].

Thank you in advance. We look forward to your participation.

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Appendix J

Survey Questionnaire + Cover Letter + Response Postcard

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Colleagues,

Your name was obtained either from the Ministry of Health lists of registered pharmacists, or from the governmental institution you work for.

It is very important that all pharmacists participate in this study. This will help us to get true representative information about pharmacy practice in Oman, and will make our study valid.

The provided envelopes are self-addressed and prepaid for your convenience.

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Thank you for taking the time to answer this questionnaire. Your cooperation is greatly appreciated.

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Postcard

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Pharmacist Name…[To be completed by the student investigator]……………….

Address…………………………………………………………………………….

……………………………………………………………………………………..

I have mailed the completed questionnaire.

I do not wish to participate in this study.

I am interested to have a summary report of the survey results

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Survey Questionnaire

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

SECTION I

Think about the patients who visited your (pharmacy/ hospital/ health center/ clinic) LAST WEEK and had a CHRONIC CONDITION(S) such as diabetes, hypertension, or asthma. Please indicate HOW OFTEN you carried out the following activities for these types of patients during that week by circling the number that best correspond to your answer.

Activities Never Rarely Some- Most of All the times the time time 1 Make sure that you have information on the 0 1 2 3 4 patients’ medical condition(s) (medical problems) 2 Find out what prescribed medicines, herbal, 0 1 2 3 4 and OTC products the patient has been taking 3 Ask the patient about allergies before 0 1 2 3 4 dispensing the medicine(s) 4 Check that the medicine is prescribed for its 0 1 2 3 4 intended use 5 Check the prescription to see if the dose is too 0 1 2 3 4 high or too low 6 Check the prescription to see if there is a 0 1 2 3 4 possible drug-drug interaction 7 Follow-up with the patients to see if they have 0 1 2 3 4 side effects from a medicine(s) 8 Prepare a written plan for resolving a medicine- 0 1 2 3 4 related problem you have identified 9 Educate the patient or family member on the 0 1 2 3 4 appropriate use of her/ his medicines 10 Educate the patient on how to self-manage their 0 1 2 3 4 chronic condition through self-monitoring and appropriate adjustment of their medicines, diet, and exercise

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11 Train the patient on how to use a medical 0 1 2 3 4 device (e.g. glucose-meter or BP monitor) to monitor their medical condition 12 Assess whether the patient understands the 0 1 2 3 4 information you provide him or her 13 Evaluate how well a medicine is working by 0 1 2 3 4 asking the patient or examining lab test results if available 14 Communicate with the patient’s doctor 0 1 2 3 4 regarding any medicine-related problems you have identified 15 Refer a patient to a doctor or other health care 0 1 2 3 4 professional for a problem that should be assessed by that other professional 16 Document your intervention (what you did to 0 1 2 3 4 solve the patient’s medicine-related problem) on the patient’s file, or on the prescription

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INSTRUCTIONS FOR ANSWERING QUESTIONS ON THE FOLLOWING PAGES9

The Weather in Oman is: good :_____1____:_____2____:_____3____:_____4____:_____5____:_____6____:_____7____: bad extremely quite slightly neither slightly quite extremely

If you think the weather in Oman is extremely good, then you would circle the number 1, as follows:

The Weather in Oman is: good :____1____:____2____:____3____:____4____:____5____:____6____:____7____: bad

If you think the weather in Oman is quite bad, then you would circle the number 6, as follows.

The Weather in Oman is: good :____1____:____2____:____3____:____4____:____5____:____6____:____7____: bad

If you think the weather in Oman is slightly good, then you would circle the number 3.

The Weather in Oman is: good :____1____:____2____:____3____:____4____:____5____:____6____:____7____: bad

If you think the weather in Oman is neither good nor bad, then you would circle the number 4.

The Weather in Oman is: good :____1____:____2____:____3____:____4____:____5____:____6____:____7____: bad

9 Instructions for responses to this questionnaire have been adapted from Ajzen, 2003.

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SECTION II

Suppose that practicing pharmaceutical care involves carrying out the activities mentioned above (questions 1-16), Now, we would like to know your opinion about practicing pharmaceutical care. Please circle the number representing your opinion on each of the following statements.

17. If I were to practice pharmaceutical care on a regular basis, it would increase patient safety. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

18. Increasing patient safety is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

19. If I were to practice pharmaceutical care on a regular basis, it would improve patient health. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

20. Improving patient health is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

21. If I were to practice pharmaceutical care on a regular basis, it would change the image people have about the pharmacist being only a medicine dispenser. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

22. Changing the image people have about the pharmacist being only a medicine dispenser is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

23. If I were to practice pharmaceutical care on a regular basis, it would strengthen (improve) my relationship with doctors. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

24. Strengthening (improving) my relationship with doctors is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

25. If I were to practice pharmaceutical care on a regular basis, it would increase patients’ respect/trust in me. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

26. Increasing patients’ respect/trust in me is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

27. If I were to practice pharmaceutical care on a regular basis, it would make me worry about being responsible for any intervention I provide. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

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28. Worrying about being responsible for interventions I provide is…. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

SECTION III

For each of the following statements, please circle the number representing your opinion.

29. The doctors in my workplace (or around my workplace) whose patients I see think that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis.

30. When it comes to pharmaceutical care, how important is it to you to do what the doctors think you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

31. My patients think that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis.

32. When it comes to pharmaceutical care, how important is it to you to do what your patients think you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

33. My boss (chief pharmacist/ pharmacy manager/ company head office) thinks that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis.

34. When it comes to pharmaceutical care, how important is it to you to do what your boss (chief pharmacist/ pharmacy manager/ company head office) thinks you should do? not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

35. My hospital administration thinks that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis. (This question is for hospital and health center pharmacists only)

36. When it comes to pharmaceutical care, how important is it to you to do what your hospital administration thinks you should do? (This question is for hospital and health center pharmacists only) not at all important : 1 : 2 : 3 : 4 : 5 : 6 : 7 : extremely important

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SECTION IV

Next, we would like to know what factors would help or prevent you from practicing pharmaceutical care. Please circle the number representing your opinion on each of the following statements.

37. I do NOT have adequate clinical knowledge and experience to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

38. If I did NOT have adequate clinical knowledge and experience, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

39. I do NOT have adequate communication skills (the ability to understand, speak, and write in simple language) to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

40. If I did NOT have adequate communication skills (the ability to understand, speak, and write in simple language), it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

41. I do NOT always have adequate ability to speak my patient’s language to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

42. If I did NOT have adequate ability to speak my patient’s language, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

43. It is NOT easy to provide medication counseling to a patient of the opposite sex regarding sensitive issues. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

44. Counseling a patient of the opposite sex in sensitive issues would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

45. We do NOT have enough staff in my workplace for me to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

46. Shortage of staff in my workplace would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

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47. I do NOT have enough time during my work hours to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

48. Lack of time during my work hours would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

49. I do NOT have a computer based drug information database in my workplace to enable me to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

50. If I did NOT have a computer based drug information database in my workplace, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

51. I do NOT have a private counseling area in my workplace to practice pharmaceutical care. (Do not answer this question if you are an inpatient pharmacist) true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

52. If I did NOT have a private counseling area in my workplace, it would make practicing pharmaceutical care much more difficult for me. (Do not answer this question if you are an inpatient pharmacist) disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

53. I do NOT have access to my patients’ medical records in my workplace to enable me to practice pharmaceutical care. true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

54. If I did NOT have access to my patients’ medical records in my workplace, it would make practicing pharmaceutical care much more difficult for me. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

55. I do NOT receive additional reimbursement/compensation for my pharmaceutical care services in my workplace beyond my salary. (This question is for private sector pharmacists only) true : 1 : 2 : 3 : 4 : 5 : 6 : 7 : false

56. If I did NOT receive additional reimbursement/compensation for my pharmaceutical care services in my workplace, it would make practicing pharmaceutical care much less desirable for me. (This question is for private sector pharmacists only) disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

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SECTION V

Next, we would like to know how you feel about practicing pharmaceutical care. Please circle the number representing your opinion to the following statements.

For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be:

57. frustrating : 1 : 2 : 3 : 4 : 5 : 6 : 7 : rewarding

58. bad : 1 : 2 : 3 : 4 : 5 : 6 : 7 : good

59. worthless : 1 : 2 : 3 : 4 : 5 : 6 : 7 : valuable

SECTION VI

Now, we would like to know what most people in your professional life think about you practicing pharmaceutical care. Please circle the number representing your opinion to the following statements.

60. It is expected of me that I practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

61. Most people in my professional life who are important to me think that I should not : 1 : 2 : 3 : 4 : 5 : 6 : 7 : I should practice pharmaceutical care on a regular basis.

62. Most pharmacists who are important to me practice pharmaceutical care on a regular basis. completely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : completely true

63. Many of my pharmacist colleagues practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

64. Many pharmacists with the same pharmacy degree as me practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

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SECTION VII

Please indicate how easy or difficult it is for you, personally, to practice pharmaceutical care, and how much control you have over practicing it, by circling the number representing your opinion about each of the following statements.

65. For me to practice pharmaceutical care on a regular basis would be.... difficult : 1 : 2 : 3 : 4 : 5 : 6 : 7 : easy

66. For me to practice pharmaceutical care on a regular basis would be.... impossible : 1 : 2 : 3 : 4 : 5 : 6 : 7 : possible

67. If I wanted to, I could practice pharmaceutical care on a regular basis. definitely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : definitely true

68. How much control do you believe you have over your practicing pharmaceutical care on a regular basis? no control : 1 : 2 : 3 : 4 : 5 : 6 : 7 : complete control

SECTION VIII

Please show your intention to practice pharmaceutical care on a regular basis by circling the number representing your opinion to the following statements.

69. I intend to practice pharmaceutical care on a regular basis. unlikely : 1 : 2 : 3 : 4 : 5 : 6 : 7 : likely

70. I will make an effort to practice pharmaceutical care on a regular basis. definitely false : 1 : 2 : 3 : 4 : 5 : 6 : 7 : definitely true

71. I plan to practice pharmaceutical care on a regular basis. disagree : 1 : 2 : 3 : 4 : 5 : 6 : 7 : agree

SECTION IX

Finally, please answer a few questions about yourself.

72. What is your age now? ≤ 29 30-39 40-49 ≥ 50

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73. What is your gender? Female Male

74. What is the highest level of education in pharmacy you have completed? Bachelor Master PhD Pharm D Residency

75. What is your country/ continent of origin? Oman Europe Middle East South Asia (India, Pakistan, Bangladesh, & Sri Lanka) Africa Others (specify) ______

76. Where did you complete your highest level of education in pharmacy? Oman North America Europe Middle East Africa South Asia (India, Pakistan, Bangladesh, & Sri Lanka) Australia/ New Zealand

77. How many years of experience do you have as a pharmacist? 0-5 6-10 11-15 16-20 Over 20

78. What is your practice type? Retail pharmacy Retail chain pharmacy (3 or more branches) Outpatient pharmacy Inpatient setting

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79. How many years have you been working at your present pharmacy/ hospital? ≤10 11-19 ≥20

80. What is your sector? Public Private

81. Which of the following best describes your current position? Manager or Director Assistant/ Associate Manager or Director Supervisor Staff Pharmacist Others (specify)

Thank you for taking the time to complete this survey

If you require clarification of any items above or have any other questions about answering this survey, please contact the student investigator, Awatif Al Abdullatif at Oman -99280660

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Appendix K

First Follow-up Letter

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Colleagues,

Last week, I sent you a questionnaire asking your opinion about pharmaceutical care practice in Oman. If you have already completed and returned it to us please accept our sincere thanks. If not, please do so today. We hope you will agree to participate as your opinions are very important to us and we really want to learn about your practice.

It is estimated that it will take you (x) minutes to complete the questionnaire. All of the information collected will be strictly confidential. The study results will be presented as aggregate numbers with no reference to any particular participant. The questionnaire does not carry your name, and the postcard, which lists your name and address, only helps us determine your decision to participate. The postcard cannot be linked to your questionnaire provided that you return them in separate envelopes as requested. The postcards will be destroyed as soon as the data collection is completed

If you decide not to participate in the study, please return the postcard in the small white envelope provided in the package after marking the box that says you do not wish to participate in the study. In that case, you will not receive any further follow-ups.

If you need any assistance with this survey, or have any questions regarding this research project, please do not hesitate to contact Awatif Al Abdullatif at (99280660/ Oman) or by email at: [email protected] or Linda MacKeigan at 416-978-3945 or by email at: [email protected]. If you have any questions or concerns about your rights as a research participant, please contact the University of Toronto Office of Research Ethics at 416-946-3273 or by email at: [email protected].

Thank you. We look forward to receiving your completed questionnaire.

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Appendix L

Second Follow-up Letter

The Provision of Pharmaceutical Care in Oman: Practice and Perceived Facilitators and Barriers to Implementation

Dear Colleagues,

About three weeks ago, I sent you a questionnaire about your pharmacy practice. As of today, we have not yet received your response.

We began this study with an aim of developing a better understanding of the current situation in Oman with respect to pharmaceutical care practice. I am sending you this reminder once again because of the importance of your response for the validity of this study. In order to have true representative information about pharmacy practice in Oman, it is essential that all pharmacists complete and return their questionnaire. This is the last time we will try to contact you.

In case your questionnaire has been misplaced, another copy is enclosed. All of the information collected will be strictly confidential.

Your immediate response is highly appreciated. Thank you for your cooperation.

Awatif Al Abdullatif Sawsan Ahmed Jaffer Osama Babiker PhD Student Director General Head of Follow-up Section Leslie Dan Faculty of Pharmacy Directorate General of Directorate General of University of Toronto Pharmaceutical Affairs Medical Supplies/ MOH & Drug Control/MOH

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Appendix M

Questionnaire Coding key

Item number Variable name Response option Code Pharmacists ID NA Serial no. 1 PCAct1 Never 0 Rarely 1 Sometimes 2 Most of the time 3 All the time 4 2 PCAct2 - II - - II - 3 PCAct3 - II - - II - 4 PCAct4 - II - - II - 5 PCAct5 - II - - II - 6 PCAct6 - II - - II - 7 PCAct7 - II - - II - 8 PCAct8 - II - - II - 9 PCAct9 - II - - II - 10 PCAct10 - II - - II - 11 PCAct11 - II - - II - 12 PCAct12 - II - - II - 13 PCAct13 - II - - II - 14 PCAct14 - II - - II - 15 PCAct15 - II - - II - 16 PCAct16 - II - - II - 17 BehB1 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5 Quite likely 6 Extremely likely 7 18 Eval1 Extremely bad 1 Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 19 BehB2 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5

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Quite likely 6 Extremely likely 7 20 Eval2 Extremely bad 1 Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 21 BehB3 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5 Quite likely 6 Extremely likely 7 22 Eval3 Extremely bad 1 Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 23 BehB4 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5 Quite likely 6 Extremely likely 7 24 Eval4 Extremely bad 1 Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 25 BehB5 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5 Quite likely 6 Extremely likely 7 26 Eval5 Extremely bad 1

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Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 27 BehB6 Extremely unlikely 1 Quite unlikely 2 Slightly unlikely 3 Neither 4 Slightly likely 5 Quite likely 6 Extremely likely 7 28 Eval6 Extremely bad 1 Quite bad 2 Slightly bad 3 Neither 4 Slightly good 5 Quite good 6 Extremely good 7 29 NorB1 I should not 1 | 2 | 3 | 4 | 5 | 6 I should 7 30 Motiv1 Not at all important 1 | 2 | 3 | 4 | 5 | 6 Extremely important 7 31 NorB2 I should not 1 | 2 | 3 | 4 | 5 | 6 I should 7 32 Motiv2 Not at all important 1 | 2 | 3 | 4

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| 5 | 6 Extremely important 7 33 NorB3 I should not 1 | 2 | 3 | 4 | 5 | 6 I should 7 34 Motiv3 Not at all important 1 | 2 | 3 | 4 | 5 | 6 Extremely important 7 35 NorB4 I should not 1 | 2 | 3 | 4 | 5 | 6 I should 7 36 Motiv4 Not at all important 1 | 2 | 3 | 4 | 5 | 6 Extremely important 7 37 ContB1 True 1 | 2 | 3 | 4 | 5 | 6 False 7 38 Power1 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7

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39 ContB2 True 1 | 2 | 3 | 4 | 5 | 6 False 7 40 Power2 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 41 ContB3 True 1 | 2 | 3 | 4 | 5 | 6 False 7 42 Power3 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 43 ContB4 True 1 | 2 | 3 | 4 | 5 | 6 False 7 44 Power4 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 45 ContB5 True 1 | 2 | 3

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| 4 | 5 | 6 False 7 46 Power5 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 47 ContB6 True 1 | 2 | 3 | 4 | 5 | 6 False 7 48 Power6 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 49 ContB7 True 1 | 2 | 3 | 4 | 5 | 6 False 7 50 Power7 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 51 ContB8 True 1 | 2 | 3 | 4 | 5 | 6

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False 7 52 Power8 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 53 ContB9 True 1 | 2 | 3 | 4 | 5 | 6 False 7 54 Power9 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 55 ContB10 True 1 | 2 | 3 | 4 | 5 | 6 False 7 56 Power10 disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7 57 Attit1 Frustrating 1 | 2 | 3 | 4 | 5 | 6 Rewarding 7 58 Attit2 Bad 1 | 2

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| 3 | 4 | 5 | 6 good 7 59 Attit3 Worthless 1 | 2 | 3 | 4 | 5 | 6 Valuable 7 60 SubN1 Unlikely 1 | 2 | 3 | 4 | 5 | 6 Likely 7 61 SubN2 I should not 1 | 2 | 3 | 4 | 5 | 6 I should 7 62 SubN3 Completely false 1 | 2 | 3 | 4 | 5 | 6 Completely true 7 63 SubN4 Unlikely 1 | 2 | 3 | 4 | 5 | 6 Likely 7 64 SubN5 - II - - II - 65 PBC1 Difficult 1 | 2 | 3 | 4

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| 5 | 6 Easy 7 66 PBC2 Impossible 1 | 2 | 3 | 4 | 5 | 6 Possible 7 67 PBC3 Definitely false 1 | 2 | 3 | 4 | 5 | 6 Definitely true 7 68 PBC4 No control 1 | 2 | 3 | 4 | 5 | 6 Complete control 7 69 Int1 Unlikely 1 | 2 | 3 | 4 | 5 | 6 Likely 7 70 Int2 Definitely false 1 | 2 | 3 | 4 | 5 | 6 Definitely true 7 71 Int3 Disagree 1 | 2 | 3 | 4 | 5 | 6 Agree 7

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72 Age ≤ 29 1 30-39 2 40-49 3 ≥ 50 4 73 Gender Female F Male M 74 PhEdL Bachelor 1 Master 2 PhD 3 Pharm D 4 Residency 5 75 COrigin Oman 1 Europe 2 Middle East 3 South Asia 4 Africa 5 Others 6 76 HPhEdCG Oman 1 North America 2 Europe 3 Middle East 4 Africa 5 South Asia 6 Australia/ New Zealand 7 77 YrsPr 0-5 1 6-10 2 11-15 3 16-20 4 Over 20 yrs 5 78 TypePr Retail pharmacy 1 Retail chain pharmacy 2 Outpatient pharmacy 3 Inpatient setting 4 79 YrsCrPr ≤10 1 11-19 2 ≥20 3 80 Sector Public P Private V 81 Post Manager or Director 1 Assistant/ Associate Manager or 2 Director 3 Supervisor 4 Staff Pharmacist 5 Others

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Appendix N Summary of themes by the Theory of Planned Behavior belief constructs

Themes Behavioral Beliefs Normative Beliefs Control Beliefs

Factors Setting/ Sector Facilitators/ Barriers Pharmacist-related Positive outcomes Competency Public Facilitator - Pharmacist role/ image Private Barrier - Pharmacist respect/ trust Communication skills All settings Facilitator - Pharmacist-team relationship Negative outcomes - Pharmacist liability risk Patient-related Positive outcomes Patient Cultural Issues All settings Barrier - Patient safety Language differences Public Facilitator - Patient health Private Barrier improvement - Patient compliance Negative outcomes - Patient non-adherence Pharmacy-related Positive outcomes Managers Time/ Staff/ Workload All settings Barrier - Pharmacy business Access to drug Public information resources - Tertiary care Facilitator - Secondary care Barrier - Primary care Barrier Private Barrier - Hospitals Barrier - Chain pharmacies Barrier - Others Barrier Pharmacy space Outpatient Barrier Community pharmacies Barrier Health system-related Positive outcomes Physicians Access to patients’ Public Facilitator - Health care cost saving records Private Barrier Administrators Reimbursement Private Barrier

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Appendix O

Descriptive Statistics for Individual Items of Multi-Item Scales

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Table O.1 Extent of performing pharmaceutical care activities

Pharmaceutical care activities (Past Behavior Recency) Frequency (%) Mean Never Rarely Sometimes Most of the time All the time No (SD) (0) (1) (2) (3) (4) response Make sure that you have information on the patients’ medical condition(s) 6 20 92 193 90 - 2.9 (medical problems) (1.5%) (5.0%) (22.9%) (48.1%) (22.4%) (0.9) Find out what prescribed medicines, herbal, and OTC products the patient 11 24 135 143 88 - 2.7 has been taking (2.7%) (6.0%) (33.7%) (35.7%) (21.9%) (1.0) Ask the patient about allergies before dispensing the medicine(s) 17 43 106 134 98 3 2.6 (4.2%) (10.7%) (26.4%) (33.4%) (24.4%) (0.7%) (1.1) Check that the medicine is prescribed for its intended use 1 6 45 144 204 1 3.4 (0.2%) (1.5%) (11.2%) (35.9%) (50.9%) (0.2%) (0.8) Check the prescription to see if the dose is too high or too low 3 5 24 113 256 - 3.5 (0.7%) (1.2%) (6.0%) (28.2%) (63.8%) (0.7) Check the prescription to see if there is a possible drug-drug interaction 5 19 77 155 145 - 3.0 (1.2%) (4.7%) (19.2%) (38.7%) (36.2%) (0.9) Follow-up with the patients to see if they have side effects from a 31 85 130 109 46 - 2.1 medicine(s) (7.7%) (21.1%) (32.4%) (27.2%) (11.5%) (1.1) Prepare a written plan for resolving a medicine-related problem you have 104 121 95 59 22 - 1.4 identified (25.9%) (30.2%) (23.7%) (14.7%) (5.5%) (1.2) Educate the patient or family member on the appropriate use of her/ his 2 13 34 127 225 - 3.4 medicines (0.5%) (3.2%) (8.5%) (31.7%) (56.1%) (0.8) Educate the patient on how to self-manage their chronic condition through 7 23 95 151 124 1 2.9 self-monitoring and appropriate adjustment of their medicines, diet, and (1.7%) (5.7%) (23.7%) (37.7%) (30.9%) (0.2%) (1.0) exercise Train the patient on how to use a medical device (e.g. glucose-meter or BP 20 27 41 79 234 - 3.2 monitor) to monitor their medical condition (5.0%) (6.7%) (10.2%) (19.7%) (58.4%) (1.2) Assess whether the patient understands the information you provide him or 2 10 27 153 209 - 3.4 her (0.5%) (2.5%) (6.7%) (38.2%) (52.1%) (0.8) Evaluate how well a medicine is working by asking the patient or 35 70 162 95 39 - 2.1 examining lab test results if available (8.7%) (17.5%) (40.4%) (23.7%) (9.7%) (1.1) Communicate with the patient’s doctor regarding any medicine-related 22 42 91 96 150 - 2. 8 problems you have identified (5.5%) (10.5%) (22.7%) (23.9%) (37.4%) (1.2) Refer a patient to a doctor or other health care professional for a problem 29 41 72 127 132 - 2.7 that should be assessed by that other professional (7.2%) (10.2%) (18%) (31.7%) (32.9%) (1.2) Document your intervention (what you did to solve the patient’s medicine- 124 83 74 59 61 - 1.6 related problem) on the patient’s file, or on the prescription (30.9%) (20.7%) (18.5%) (14.7%) (15.2%) (1.4)

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Table O.2 Intention to perform pharmaceutical care

Intention Anchors Frequency (%) Mean (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

I intend to practice pharmaceutical care on Unlikely/ Likely 2 1 3 4 39 145 207 - 6.3 a regular basis (0.5%) (0.2%) (0.7%) (1.0%) (9.7%) (36.2%) (51.6%) (0.9)

I will make an effort to practice Definitely false/ 1 1 4 9 44 124 21 8 - 6.3 pharmaceutical care on a regular basis Definitely true (0.2%) (0.2%) (1.0%) (2.2%) (11%) (30.9%) (54.4%) (0.9)

I plan to practice pharmaceutical care on a Disagree/ Agree 4 3 3 16 33 115 22 7 - 6.3 regular basis (1.0%) (0.7%) (0.7%) (4.0%) (8.2%) (28.7%) (56.6%) (1.1)

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Table O.3 Pharmacists’ attitude toward pharmaceutical care

Attitude Scale Frequency Mean Anchors (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Ex tremely No (1) (2) (3) (4) (5) (6) (7) response

For me, as a pharmacist, to practice *Frustrating/ 4 2 2 11 28 139 214 1 6.3 pharmaceutical care on a regular basis Rewarding (1.0%) (0.5%) (0.5%) (2.7%) (7.0%) (34.7%) (53.4%) (0.2%) (1.0) would be:

For me, as a pharmacist, to practice *Bad/ Good - - 2 3 9 100 28 6 1 6.7 pharmaceutical care on a regular basis (0.0%) (0.0%) (0.5%) (0.7%) (2.2%) (24.9%) (71.3%) (0.2%) (0.6) would be:

For me, as a pharmacist, to practice *Worthless/ 1 1 3 2 17 114 26 2 1 6.6 pharmaceutical care on a regular basis Valuable (0.2%) (0.2%) (0.7%) (0.5%) (4.2%) (28.4%) (65.3%) (0.2%) (0.8) would be:

*Bipolar adjectives

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Table O.4 Perceived social influences on pharmacists’ pharmaceutical care behavior

Subjective Norm Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

It is expected of me that I practice Unlikely/ Likely 2 5 2 16 53 173 150 - 6.1 pharmaceutical care on a regular basis (0.5) (1.2%) (0.5%) (4.0%) (13.2%) (43.0%) (37.4%) (1.0)

Most people in my professional life who I should not/ I should 1 3 1 14 44 162 17 6 - 6.2 are important to me think that….practice (0.2%) (0.7%) (0.2%) (3.5%) (11%) (40.4%) (43.9%) (0.9) pharmaceutical care on a regular basis

Most pharmacists who are important to completely false/ 12 15 11 58 104 125 76 - 5.3 me practice pharmaceutical care on a Completely true (3.0%) (3.7%) (2.7%) (14.5%) (25.9%) (31.2%) (19%) (1.4) regular basis

Many of my pharmacist colleagues Unlikely/ Likely 9 24 17 47 97 130 76 1 5.2 practice pharmaceutical care on a regular (2.2%) (6.0%) (4.2%) (11.7%) (24.2%) (32.4%) (19%) (0.2%) (1.5) basis

Many pharmacists with the same Unlikely/ Likely 17 20 19 45 93 136 70 1 5.2 pharmacy degree as me practice (4.2%) (5.0%) (4.7%) (11.2%) (23.2%) (33.9%) (17.5%) (0.2%) (1.6) pharmaceutical care on a regular basis

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Table O.5 Perceived control over performing pharmaceutical care

Perceived Behavioral Control Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quit e Extremely No (1) (2) (3) (4) (5) (6) (7) response

For me to practice pharmaceutical care on Difficult/Easy 6 16 34 31 79 158 77 - 5.4 a regular basis would be (1.5%) (4.0%) (8.5%) (7.7%) (19.7%) (39.4%) (19.2%) (1.4)

For me to practice pharmaceutical care on Impossible/ Possible 1 5 4 18 89 160 12 4 - 5.9 a regular basis would be (0.2%) (1.2%) (1.0%) (4.5%) (22.2%) (39.9%) (30.9%) (1.0)

If I wanted to, I could practice Definitely false/ 4 9 7 26 64 136 15 5 - 5.9 pharmaceutical care on a regular basis Definitely true (1.0%) (2.2%) (1.7%) (6.5%) (16%) (33.9%) (38.7%) (1.3)

How much control do you believe you No control/ Complete 4 7 16 45 97 151 81 - 5.5 have over your practicing pharmaceutical control (1.0%) (1.7%) (4.0%) (11.2%) (24.2%) (37.7%) (20.2%) (1.2) care on a regular basis?

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Table O.6 Beliefs about the outcomes of pharmaceutical care

Behavioral Beliefs Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

If I were to practice pharmaceutical care on a Unlikely/ Likely 2 1 2 4 18 128 246 - 6.5 regular basis, it would increase patient safety (0.5%) (0.2%) (0.5%) (1.0%) (4.5%) (31.9%) (61.3%) (0.8)

If I were to practice pharmaceutical care on a Unlikely/ Likely 1 - 2 5 23 146 224 - 6.4 regular basis, it would improve patient health (0.2%) (0.5%) (1.2%) (5.7%) (36.4%) (55.9%) (0.8)

If I were to practice pharmaceutical care on a Unlikely/ Likely 4 5 2 16 27 105 242 - 6.3 regular basis, it would change the image people (1.0%) (1.2%) (0.5%) (4.0%) (6.7%) (26.2%) (60.3%) (1.1) have about the pharmacist being only a medicine dispenser

If I were to practice pharmaceutical care on a Unlikely/ Likely 3 1 8 23 53 152 161 - 6.0 regular basis, it would strengthen (improve) my (0.7%) (0.2%) (2.0%) (5.7%) (13.2%) (37.9%) (40.1%) (1.1) relationship with doctors

If I were to practice pharmaceutical care on a Unlikely/ Likely - 1 - 4 14 116 266 - 6.6 regular basis, it would increase patients’ (0.2%) (1.0%) (3.5%) (28.9%) (66.3%) (0.6) respect/trust in me

*If I were to practice pharmaceutical care on a Unlikely/ Likely 61 89 59 48 32 53 57 2 3.7 regular basis, it would make me worry about (15.2%) (22.2%) (14.7%) (12.0%) (8.0%) (13.2%) (14.2%) (0.5%) (2.1) being responsible for any intervention I provide

*Scale was reverse coded because the item was negatively phrased

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Table O.7 Evaluation of the outcomes of pharmaceutical care

Evaluation Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

Increasing patient safety is Bad/ Good - - 1 1 5 44 350 - 6.8 (0.2%) (0.2%) (1.2%) (11%) (87.3%) (0.4)

Improving patient health is Bad/ Good - - - 2 10 51 338 - 6.8 (0.5%) (2.5%) (12.7%) (84.3%) (0.5)

Changing the image people have about the pharmacist Bad/ Good 20 6 8 11 11 64 281 - 6.2 being only a medicine dispenser is (5.0%) (1.5%) (2.0%) (2.7%) (2.7%) (16%) (70.1%) (1.6)

Strengthening (improving) my relationship with Bad/ Good - - 1 7 20 114 259 - 6.6 doctors is (0.2%) (1.7%) (5.0%) (28.4%) (64.6%) (0.7)

Increasing patients’ respect/trust in me is Bad/ Good - - - 2 11 70 318 - 6.8 (0.5%) (2.7%) (17.5%) (79.3%) (0.5)

Worrying about being responsible for interventions I Bad/ Good 53 44 27 55 52 92 75 3 4.5 provide is (13.2%) (11.0%) (6.7%) (13.7%) (13.0%) (22.9%) (18.7%) (0.7%) (2.1)

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Table O.8 Perceptions about important referents’ approval/ disapproval of pharmaceutical care

Normative Beliefs Anchors Frequency (%) Mean (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

The doctors in my workplace (or around my I should not/ I 11 17 11 53 61 146 99 4 5.4 workplace) whose patients I see think that…. should (2.7%) (4.2%) (2.7%) (13.2%) (15.2%) (36.4%) (24.4%) (1.0%) (1.5) practice pharmaceutical care on a regular basis

My patients think that…. practice I should not/ I 1 1 3 45 59 139 152 1 6.0 pharmaceutical care on a regular basis should (0.2%) (0.2%) (0.7%) (11.2%) (14.7%) (34.7%) (37.9%) (0.2%) (1.1)

My boss (chief pharmacist/ pharmacy manager/ I should not/ I 6 1 7 34 26 99 224 4 6.2 company head office) thinks that…. practice should (1.5%) (0.2%) (1.7%) (8.5%) (6.5%) (24.9%) (55.9%) (1.0%) (1.2) pharmaceutical care on a regular basis

*My hospital administration thinks that…. I should not/ I 3 4 5 14 13 45 83 10 6.0 practice pharmaceutical care on a regular basis should (1.7%) (2.3%) (2.8%) (7.9%) (7.3%) (25.4%) (46.9%) (5.6%) (1.4)

*This item was addressed to inpatient and outpatient pharmacists

271

Table O.9 Pharmacists’ motivation to comply with what each important referent thinks about performing pharmaceutical care

Motivation to Comply Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

When it comes to pharmaceutical care, how Not at all important/ 6 13 15 46 67 136 117 1 5.6 important is it to you to do what the doctors Extremely important (1.5%) (3.2%) (3.7%) (11.5%) (16.7%) (33.9%) (29.2%) (0.2%) (1.4) think you should do?

When it comes to pharmaceutical care, how Not at all important/ 11 12 10 26 48 133 159 2 5.8 important is it to you to do what your Extremely important (2.7%) (3.0%) (2.5%) (6.5%) (12.0%) (33.2%) (39.7%) (0.5%) (1.5) patients think you should do?

When it comes to pharmaceutical care, how Not at all important/ 6 9 12 35 47 127 163 2 5.9 important is it to you to do what your boss Extremely important (chief pharmacist/ pharmacy manager/ (1.5%) (2.2%) (3.0%) (8.7%) (11.7%) (31.7%) (40.6%) (0.5%) (1.4) company head office) thinks you should do?

*When it comes to pharmaceutical care, how Not at all important/ 4 3 5 14 20 53 68 10 5.8 important is it to you to do what your Extremely important (2.3%) (1.7%) (2.8%) (7.9%) (11.3%) (29.9%) (38.4%) (5.6%) (1.4) hospital administration thinks you should do? *This item was addressed to inpatient and outpatient pharmacists

272

Table O.10 Pharmacists’ assessment of the factors that affect their ability to provide pharmaceutical care

Control Beliefs Anchors Frequency Mean (%) (SD)

Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

I do NOT have adequate clinical knowledge and experience True/ False 16 21 34 27 26 94 182 1 5.6 to practice pharmaceutical care (4.0%) (5.2%) (8.5%) (6.7%) (6.5%) (23.4%) (45.4%) (0.2%) (1.8) I do NOT have adequate communication skills (the ability True/ False 18 16 12 10 19 80 244 2 6.0 to understand, speak, and write in simple language) to (4.5%) (4.0%) (3.0%) (2.5%) (4.7%) (20.0%) (60.8%) (0.5%) (1.7) practice pharmaceutical care I do NOT always have adequate ability to speak my True/ False 13 30 53 18 29 109 148 2 5.3 patient’s language to practice pharmaceutical care (3.2%) (7.5%) (13.2%) (4.5%) (7.2%) (27.2%) (36.7%) (0.5%) (1.8) It is NOT easy to provide medication counselling to a True/ False 38 60 60 39 40 78 84 2 4.4 patient of the opposite sex regarding sensitive issues (9.5%) (15.0%) (15.0%) (9.7%) (10.0%) (19.5%) (20.9%) (0.5%) (2.1) We do NOT have enough staff in my workplace for me to True/ False 90 60 39 21 19 60 112 - 4.1 practice pharmaceutical care (22.4%) (15.0%) (9.7%) (5.2%) (4.7%) (15.0%) (27.9%) (2.4) I do NOT have enough time during my work hours to True/ False 55 60 55 27 27 79 98 - 4.3 practice pharmaceutical care (13.7%) (15.0%) (13.7%) (6.7%) (6.7%) (19.7%) (24.4%) (2.2) I do NOT have a computer based drug information database True/ False 153 47 33 18 16 34 100 - 3.5 in my workplace to enable me to practice pharmaceutical (38.2%) (11.7%) (8.2%) (4.5%) (4.0%) (8.5%) (24.9%) (2.5) care *I do NOT have a private counseling area in my workplace True/ False 186 41 21 13 15 24 35 13 2.5 to practice pharmaceutical care (53.4%) (11.8%) (6.0%) (3.7%) (4.3%) (6.9%) (10.1%) (3.7%) (2.2) I do NOT have access to my patients’ medical records in True/ False 147 57 39 19 19 33 85 2 3.4 my workplace to enable me to practice pharmaceutical care (36.7%) (14.2%) (9.7%) (4.7%) (4.7%) (8.2%) (21.2%) (0.5%) (2.4) †I do NOT receive additional reimbursement/compensation True/ False 174 34 12 16 9 15 19 1 2.2 for my pharmaceutical care services in my workplace (62.1%) (12.1%) (4.3%) (5.7%) (3.2%) (5.4%) (6.8%) (0.4%) (1.9) beyond my salary

*This item was addressed to outpatient and community pharmacists †This item was addressed to private sector pharmacists

273

Table O.11 Pharmacists’ evaluation of the power of factors affecting their ability to provide pharmaceutical care

Power Anchors Frequency (%) Mean (SD) Extremely Quite Slightly Neither Slightly Quite Extremely No (1) (2) (3) (4) (5) (6) (7) response

If I did NOT have adequate clinical knowledge and experience, Disagree/ 20 8 11 14 32 84 230 2 6.0 it would make practicing pharmaceutical care much more Agree (5.0%) (2.0%) (2.7%) (3.5%) (8.0%) (20.9%) (57.4%) (0.5%) (1.6) difficult for me If I did NOT have adequate communication skills (the ability to Disagree/ 22 11 7 9 26 102 223 1 6.0 understand, speak, and write in simple language), it would make Agree (5.5%) (2.7%) (1.7%) (2.2%) (6.5%) (25.4%) (55.6%) (0.2%) (1.6) practicing pharmaceutical care much more difficult for me If I did NOT have adequate ability to speak my patient’s Disagree/ 13 14 7 14 59 115 178 1 5.9 language, it would make practicing pharmaceutical care much Agree (3.2%) (3.5%) (1.7%) (3.5%) (14.7%) (28.7%) (44.4%) (0.2%) (1.5) more difficult for me Counseling a patient of the opposite sex in sensitive issues Disagree/ 85 70 32 40 66 71 36 1 3.7 would make practicing Agree (21.2%) (17.5%) (8.0%) (10.0%) (16.5%) (17.7%) (9.0%) (0.2%) (2.1) pharmaceutical care much more difficult for me Shortage of staff in my workplace would make practicing Disagree/ 42 28 12 18 42 102 157 - 5.3 pharmaceutical care much more Agree (10.5%) (7.0%) (3.0%) (4.5%) (10.5%) (25.4%) (39.2%) (2.1) difficult for me Lack of time during my work hours would make practicing Disagree/ 38 33 14 31 58 110 117 - 5.1 pharmaceutical care much more difficult for me Agree (9.5%) (8.2%) (3.5%) (7.7%) (14.5%) (27.4%) (29.2%) (2.0) If I did NOT have a computer based drug information database Disagree/ 21 24 18 32 68 88 150 - 5.4 in my workplace, it would Agree (5.2%) (6.0%) (4.5%) (8.0%) (17.0%) (21.9%) (37.4%) (1.8) make practicing pharmaceutical care much more difficult for me *If I did NOT have a private counseling area in my workplace, Disagree/ 21 20 22 25 61 71 115 13 5.3 it would make practicing Agree (6.0%) (5.7%) (6.3%) (7.2%) (17.5%) (20.4%) (33.0%) (3.7%) (1.8) pharmaceutical care much more difficult for me If I did NOT have access to my patients’ medical records in my Disagree/ 8 18 16 23 49 101 186 - 5.8 workplace, it would make practicing pharmaceutical care much Agree (2.0%) (4.5%) (4.0%) (5.7%) (12.2%) (25.2%) (46.4%) (1.5) more difficult for me †If I did NOT receive additional reimbursement/compensation Disagree/ 98 45 19 30 32 30 25 1 3.2 for my pharmaceutical care services in my workplace, it would Agree (35.0%) (16.1%) (6.8%) (10.7%) (11.4%) (10.7%) (8.9%) (0.4%) (2.1) make practicing pharmaceutical care much less desirable

*This item was addressed to outpatient and community pharmacists †This item was addressed to private sector pharmacists

274

Appendix P

Exploratory Factor Analysis (Principle Component Analysis) of Pharmaceutical Care Behavior Scale and the Theory of Planned Behavior Model

275

Table P.1 Principle component analysis of pharmaceutical care behavior rotated on 4 factors

Item Factors Loading Cronbach’s No Pharmaceutical Care Scale Items 1 2 3 4 alpha coefficient 2 Find out what prescribed medicines, herbal, and OTC products the patient has been .660 .154 .236 .062 .73 taking 3 Ask the patient about allergies before dispensing the medicine .759 .073 .196 .017

10 Educate the patient on how to self- manage their chronic condition through self- .621 .135 .057 .366 monitoring and appropriate adjustment of their medicines, diet, and exercise 11 Train the patient on how to use a medical device (e.g. glucose-meter or BP monitor) to .716 -.214 -.047 .266 monitor their medical condition 7 Follow-up with the patients to see if they have side effects from a medicine .467 .571 .274 -.042 .77 8 Prepare a written plan for resolving a medicine-related problem you have identified .162 .809 .118 .106 13 Evaluate how well a medicine is working by asking the patient or examining lab test .441 .570 .140 .143 results if available 14 Communicate with the patient’s doctor regarding any medicine-related problems you -.114 .542 .336 .397 have identified 16 Document your intervention (what you did to solve the patient’s medicine-related -.225 .789 .164 .150 problem) on the patient’s file, or on the prescription 1 Make sure that you have information on the patients’ medical condition(s) (medical .222 .337 .506 -.009 .69 problems) 4 Check that the medicine is prescribed for its intended use .230 .069 .680 .178 5 Check the prescription to see if the dose is too high or too low -.057 .115 .834 .185 6 Check the prescription to see if there is a possible drug-drug interaction .186 .218 .619 .123 9 Educate the patient or family member on the appropriate use of her/ his medicines .133 .083 .095 .645 .43

12 Assess whether the patient understands the information you provide him or her .160 -.006 .250 .711 15 Refer a patient to a doctor or other health care professional for a problem that should be .094 .192 .047 .550 assessed by that other professional Boldface indicates highest factor loadings (absolute value ≥ .4) Underlined numbers indicate cross loading Cumulative variance = 58.16%

276

Table P.2 Principle component analysis of pharmaceutical care behavior rotated on 3 factors

Item Factors Loading Cronbach’s No Pharmaceutical Care Scale Items 1 2 3 alpha coefficient 1 Make sure that you have information on the patients’ medical condition(s) (medical problems) .471 .198 .285 .78 7 Follow-up with the patients to see if they have side effects from a medicine .647 .435 .084 8 Prepare a written plan for resolving a medicine-related problem you have identified .795 .135 .094 13 Evaluate how well a medicine is working by asking the patient or examining lab test results if available .584 .424 .140 14 Communicate with the patient’s doctor regarding any medicine-related problems you have identified .545 -.113 .487 16 Document your intervention (what you did to solve the patient’s medicine-related problem) on the patient’s file, or on the prescription .762 -.248 .176 2 Find out what prescribed medicines, herbal, and OTC products the patient has been taking .237 .652 .159 .73 3 Ask the patient about allergies before dispensing the medicine .160 .751 .100 10 Educate the patient on how to self- manage their chronic condition through self-monitoring and appropriate adjustment of their medicines, diet, and exercise .126 .639 .279 11 Train the patient on how to use a medical device (e.g. glucose-meter or BP monitor) to monitor their medical condition -.215 .741 .155 4. Check that the medicine is prescribed for its intended use .237 .227 .557 .65 5 Check the prescription to see if the dose is too high or too low .306 -.064 .671 6 Check the prescription to see if there is a possible drug-drug interaction .367 .174 .468

9. Educate the patient or family member on the appropriate use of her/ his medicines .022 .173 .541 12 Assess whether the patient understands the information you provide him or her -.028 .205 .696 15 Refer a patient to a doctor or other health care professional for a problem that should be assessed by that other professional .124 .124 .432 Boldface indicates highest factor loadings (absolute value ≥ .4) Underlined numbers indicate cross loading Cumulative variance = 50.13%

277

Table P.3 Principle component analysis of intention rotated on one factor

Item Intention Items Factor Loading Cronbach’s alpha No coefficient 1 I intend to practice pharmaceutical care on a regular basis .878 .85 2 I will make an effort to practice pharmaceutical care on a regular basis .910 3 I plan to practice pharmaceutical care on a regular basis .854 Boldface indicates highest factor loadings (absolute value ≥ .4) Cumulative variance = 78%

Table P.4 Principle component analysis of attitude rotated on one factor

Item Attitude Items Factor Loading Cronbach’s No alpha coefficient 1 For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: .806 .78 Frustrating.…Rewarding 2 For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: .879 Bad….Good 3 For me, as a pharmacist, to practice pharmaceutical care on a regular basis would be: .868 Worthless….Valuable Boldface indicates highest factor loadings (absolute value ≥ .4) Cumulative variance = 73%

278

Table P.5 Principle component analysis of subjective norm rotated on two factors

Item Subjective Norm Items Factors Loading Cronbach’s No 1 2 alpha coefficient 1 It is expected of me that I practice pharmaceutical care on a regular basis .200 .867 .76 2 Most people in my professional life who are important to me think that .201 .884 3 Most pharmacists who are important to me practice pharmaceutical care on a .795 .305 .87 regular basis 4 Many of my pharmacist colleagues practice pharmaceutical care on a regular basis .896 .237 5 Many pharmacists with the same pharmacy degree as me practice pharmaceutical .896 .099 care on a regular basis Boldface indicates highest factor loadings (absolute value ≥ .4) Cumulative variance = 80%

Table P.6 Principle component analysis of subjective norm rotated on one factor

Item Subjective Norm Items Factor Loading Cronbach’s No alpha coefficient 1 It is expected of me that I practice pharmaceutical care on a regular basis .665 .82 2 Most people in my professional life who are important to me think that .675 3 Most pharmacists who are important to me practice pharmaceutical care on a regular .825 basis 4 Many of my pharmacist colleagues practice pharmaceutical care on a regular basis .868 5 Many pharmacists with the same pharmacy degree as me practice pharmaceutical care .788 on a regular basis Boldface indicates highest factor loadings (absolute value ≥ .4) Cumulative variance = 59%

279

Table P.7 Principle component analysis of perceived behavioral control rotated on one factor

Item Perceived behavioral Control Items Factor Loading Cronbach’s alpha No coefficient 1 For me to practice pharmaceutical care on a regular basis would be.... .802 .80 Difficult or Easy 2 For me to practice pharmaceutical care on a regular basis would be.... .853 Impossible or Possible 3 If I wanted to, I could practice pharmaceutical care on a regular basis .800 4 How much control do you believe you have over your practicing pharmaceutical .722 care on a regular basis? Boldface indicates highest factor loadings (absolute value ≥ .4) Cumulative variance = 63%

280

Appendix Q Normality Plots and Scatter Plots of Intention to Perform Pharmaceutical Care

281

Figure Q.1. Histogram of standardized residual intention scores with 15 outliers.

Figure Q.2. Normal probability plot of standardized residual intention scores with 15 outliers.

282

Figure Q.3. Histogram of standardized residual intention scores without 15 outliers.

Figure Q.4. Normal probability plot of regression standardized residual intention scores without 15 outliers.

283

Figure Q.5. Scatter plot depicting the relationship between standardized predicted and residual intention scores without 15 outliers.

284

Appendix R Normality Plot and Scatter Plot of Pharmaceutical Care Behavior

285

Figure R.1. Normal probability plot of standardized residual pharmaceutical care scores.

Figure R.2. Scatter plot depicting the relationship between standardized predicted and residual pharmaceutical care scores.