Dissertations / Theses on the topic 'Community-pharmacy'

The change in community pharmacists’ practice from compounding and effectively unregulated medicines supply through to the highly regulated and largely automated high-volume dispensing process of today has been challenging. The economic and social standing of community pharmacy was transformed creating a need for further adaptation. This thesis explores ‘how business and professional practice models for community pharmacy in England in ten to twenty years are likely to be structured?’. It has six sections, plus an overarching discussion. A work sampling study of ten community pharmacies found that pharmacists continue to spend two-thirds of their time on dispensing related activities, compared to one tenth on counselling. The accompanying analysis links this to an increase in prescription volumes and payments that have incentivised pharmacy contractors to focus on medicines supply. A significant decrease in the average prescription duration for eight chronic disease medications over the past decade is revealed, and its desirability questioned. Using the Kingdon model of the policy process as an evaluative framework, 16 interviews with ‘policy leaders’ provided insight into how seven factors (identified from a structured thematic review of the implementation of Medicines Use Reviews) have influenced the implementation of the New Medicines Service. In addition, role theory-based thematic analysis involving 17 stakeholders in pharmacy policy highlighted the tensions between community pharmacists’ roles as shopkeepers, clinicians and businessmen, and the effects that new technologies will have on them. The analysis identifies a need for pharmacy to embrace a new strategic direction that enhances pharmacy’s contributions to health outcomes. In conclusion, community pharmacy in England should offer timelier and economically efficient ways of solving contemporary health problems. The evidence presented here suggests that without stronger internal leadership and robust external stakeholder support medicines supply will split from the provision of clinical pharmacy in the community setting, leaving community pharmacies as ‘commodity cost’, low return medicines suppliers.

In South Africa the pharmacy profession has experienced a number of changes around the turn of the century such as the introduction of the National Drug Policy (NDP), pharmacy ownership and price regulation. With this the role and earnings of the pharmacy profession, as well as to what extent the pharmacist adds value to the profession and society, are being questioned. Community pharmacists are thus faced with the challenge to prove that the value that they add to society is meaningful. Therefore, the aim of the study was to document community pharmacy availability and activities in South Africa and based on this to quantify the perceived value that the community pharmacist adds to society through the delivery of pharmaceutical services and pharmaceutical care. In order to determine the pharmacist’s true value added two surveys were conducted in 2006; an original pharmacist survey and a general public survey. The results obtained were verified by a follow–up pharmacist survey in 2009 to confirm or reject the results obtained in the original survey. The study was representative of both the community pharmacies and the general public in South Africa and was primarily quantitative in design and analysis. More than half of the responding pharmacies (63.16%) were open seven days a week. The average hours of service per day ranged from 10 hours (Monday to Friday) through to 6.45 hours on Saturdays and 3 hours on Sundays. Pharmacists continuously upgraded their professional knowledge. More than three quarters of pharmacies had the necessary equipment available to perform the services investigated in the study. The general public was not aware of all the services provided by pharmacists and as a result, depending on the service, many people did not make use of these services. The general public that made use of services delivered by community pharmacies mainly perceived the services delivered to be of good quality. The main barrier to practicing pharmaceutical care was indicated by pharmacists as not receiving payment for the advice given followed by pharmaceutical care being time consuming, and that there was not enough time to talk to patients. The general public indicated that they found it difficult to ask questions in pharmacies because other patients could hear what was discussed, or other patients had to wait longer if they asked something, and pharmacy staff being too busy. The results of the original pharmacist and the general public survey were confirmed by the results of the follow-up survey with the exception of dispensing prescription medicine (8 minutes 28 seconds), OTC medicine (7 minutes 23 seconds), counselling of prescription medicine (8 minutes 51 seconds) and OTC medicine (8 minutes) which on average took longer to conduct than in the previous analysis. The study highlighted the value added to the wellness and quality of life of the community of South Africa through the delivery of pharmaceutical care and pharmaceutical services by community pharmacy staff, and proved that pharmacists are committed to the provision of pharmaceutical care and pharmaceutical services.

Thesis (MBA)--University of Stellenbosch, 2011.<br>On 16 January 2004, the Parliament of the Republic of South Africa published the Draft Regulations to the Medicines and Related Substances Act No. 101 of 1965 (Republic of South Africa, 2010a) for comments due by 16 April 2004. These regulations would change the retail pharmacy landscape that generations of pharmacists had become dependent on in supporting themselves and the communities that they served. These regulations proposed a single exit price (SEP) that manufacturers might charge pharmaceutical wholesalers, which included the distribution cost. The wholesaler in turn would sell the pharmaceutical to the pharmaceutical retailer at the listed SEP, thus prohibiting discounts and in the process creating transparency in the pharmaceutical industry. This transparency would ensure that all people would pay the same price for their medication with the aim of making it affordable and available to those in need. Preceding these draft regulations was the amendment to the Pharmacy Act No. 53 of 1974 (Republic of South Africa, 2010c) concerning pharmacy ownership, which allowed non-pharmacist and legal entities to own pharmacies as of 2003. This amendment posed the first external threat to the autonomy of pharmacists regarding independent pharmacy ownership. Pharmacists now had to compete not only amongst themselves but also with large corporate food and health shops with in-house pharmacies. The resources and capabilities inherent to independent community pharmacies given the events of the past few years proved inadequate in competing with the corporate retailers. These two amendments to acts that influenced the existing pharmacy landscape posed a real threat to the sustainability of independent pharmacy business models. This paper investigates the issues that independent community pharmacies in South Africa are facing and their strategic options in the pharmaceutical and services value chain.

Computers have, over the past 10 to 15 years, become an integral part of many activities carried out by British community pharmacists. This thesis employs quantitative and qualitative research methods to explore the use of computers and other forms of information technology (IT) in a number of these activities. Mail questionnaires were used to estimate the level of IT use among British community pharmacists in 1989 and 1990. Comparison of the results suggests that the percentage of community pharmacists using computers and other forms of IT is increasing, and that the range of applications to which pharmacy computers are put is expanding. The use of an electronic, on-line information service, PINS, by community pharmacists was investigated using mail questionnaires. The majority of community pharmacists who subscribed to the service, and who responded to the questionnaire, claimed to use PINS less than they had expected to. In addition, most did not find it user-friendly. A computer program to aid pharmacists when responding to their patients' symptoms was investigated using interviews and direct observation. The aid was not found to help pharmacists in responding to patients' symptoms because of impracticalities involved in its operation. Use of the same computer program by members of the public without the involvement of a pharmacist was also studied. In this setting, the program was favourably accepted by the majority of those who used it. Provision of computer generated information leaflets from pharmacies was investigated using mail questionnaires and interviews. The leaflets were found to be popular with the majority of recipients interviewed. Since starting to give out the leaflets, 27 out of 55 pharmacists who responded to the questionnaire had experienced an increase in the numbers of prescriptions they dispensed. 46 had experienced an increase in the number of patient enquiries they received.

Community pharmacy practice is changing, putting a greater emphasis on patient involvement and empowerment than on physical drug products. Developing practice philosophies, such as pharmaceutical care, are operationalised through an ever-evolving service proliferation. There is, however, a paucity of studies addressing the patients’ subjective perceptions of pharmacy services. The few studies that measure the impact of pharmacy services on humanistic outcomes show little or no effect. This might be due to the services, or the assessment instruments used. The aim of this thesis was to enhance the understanding of how patients perceive community pharmacy services, their preferences for community pharmacy services, and how these services could be evaluated from the patient perspective. This was done by: 1.exploring patients’ perceptions of an existing pharmaceutical care service using in-depth interviews; 2. exploring patient preferences for the ideal pharmacy visit using Q methodology, and characterising those patient groups that have different preferences and; 3. testing the validity of the Swedish version of the Pharmaceutical Therapy-Related Quality of Life (PTRQoL)-instrument, using think aloud methodology. Patients had vague, and sometimes erroneous, understandings about a pharmaceutical care service that they were currently receiving. They reported that the service had increased their feeling of safety, enhanced their knowledge, provided drug treatment control, and empowered them. Seven different viewpoints of the ideal pharmacy service were identified, which could be broadly divided into two groups, those emphasising the physical drug products as central to the encounter and those seeking a relationship with the pharmacist. Some differences between the group characteristics were identified, but not specific enough to guide individualised care practice. Several problems with the validity of the PTRQoL-instrument were detected. Overall, the thesis has highlighted various aspects of patient perspectives on community pharmacy services that could be used for the development andassessment of such services.

Background and Aims: One method for understanding the quality of care provided by community pharmacies is to assess it using objective measures such as indicators. These, however, should be based on a common frame of reference for describing quality. As no such definition exists specifically for community pharmacy, this research aimed to gain an understanding of community pharmacy quality and its assessment. Methodology: In order to conceptualise community pharmacy quality, ten focus groups were conducted across the northwest of England with 47 purposively sampled participants who had experiences with community pharmacy healthcare services. Constant comparative analysis was used to analyse the verbatim transcripts. To develop the quality indicators, a scoping review was conducted to identify descriptive statements which mirrored the quality attributes and quality dimensions analysed from the focus groups. Then, once customised into clearly defined statements with a measurable element, 458 potential quality indicators were arranged into four questionnaires to be rated on their face-validity. Finally, consensus was gathered on each indicator's face-validity by using a two-round modified Delphi technique. Panellists were recruited from across England and were community pharmacists or PCT employees who were involved with community pharmacies (second round: n₁=20, n₂=19, n₃=19, n₄=19). Findings: It emerged that community pharmacy quality can be conceptualised as dynamic and complex with interdependent dimensions of 'opportunity', 'effectiveness' and 'positive perceptions of the experience'. Each dimension contains structures, processes and associated outcomes. These were illustrated by a dynamic model of quality dimensions and by its related static framework of structures processes and outcomes. In the Delphi questionnaires, a total of 51 potential indicators were added by panellists, and after the second rounds, 452 indicators achieved consensus for having face-validity as community pharmacy quality indicators. These assessed one or more of the three quality dimensions and related to: the pharmacy environment, equipment and facilities; patient access to medicines, advice and services; effectiveness; and management and leadership in the pharmacy. Ten indicators achieved consensus for lacking face-validity, and 47 indicators did not achieve consensus. Discussion: This research provides a foundation for future work in community pharmacy quality, and could enable those who design, develop and provide pharmacy services to better target their efforts in delivering high quality care. The quality indicators may help with assessing pharmacies and with making changes based on objective data. Before the 452 quality indicators are implemented, future study should include testing them in pharmacies to determine their reliability, feasibility and acceptability. Other recommendations for research, policy and practice are outlined in the text.

This thesis describes the history of community pharmacy, and the current climate which has identified an extended role, particularly for 'over-the-counter' advice in response to symptoms and the reclassification of medicines. An electric methodology has been used to define current community pharmacy practice in Scotland, and to assess the attitudes of community pharmacists and GPs to an extended community pharmacy role. Attitudes of community pharmacists to medicines reclassification have been assessed nationally, and implications quantified. Clinical pharmacy guidelines for the treatment of dyspepsia have been developed and evaluated. A range of opinion formers have been interviewed to identify the different agenda which have contributed to medicines reclassification. Most of the more innovative tasks proposed are not yet commonly practised in Scotland. However most community pharmacists favour the extended role and the reclassification of medicines. Reclassification has little financial advantage for the community pharmacist, but would benefit the patient and the NHS. GPs were generally supportive of the extended role of the community pharmacist and the reclassification of medicines with a few caveats. These could be overcome by clinical pharmacy guidelines, which we demonstrated to have utility, patient acceptability and an educational value. Representatives of the medical and pharmaceutical professions, the government, the industry and the patient, revealed three agendas which have all influenced medicines reclassification. The government wish to shift the costs from the NHS to the patient. The industry wish to find additional markets and the pharmaceutical profession need a new paradigm to replace their largely redundant technical dispensing role. It is concluded that it is an opportune time for the community pharmacists to extend their professional role.

The purpose of this research project was to evaluate the role of the community pharmacist in screening, identifying, and referring ambulatory patients with high total blood cholesterol (TBC) in a community pharmacy. Fifty seven patients, out of 241 initially screened individuals, met the study inclusion criteria and were accepted into this study. Of these 57 patients, 51 patients completed the six month study period. The normal population group consisted of 164 participants with TBC < 200 mgjdL at the initial cholesterol testing (visit 1). The drop out group represented six patients who failed to continue attending the two follow up tests (visit 2 and 3). For screening purposes, a non-fasting whole blood sample was used to measure TBC using the Boehringer Mannheim Reflotron analyzer. The project was evaluated based on mean TBC levels obtained during the initial screening and the two follow up tests, pre-test and post-test scores, behavior and lifestyle changes, and the number of patients who received a physician's order for lipid analysis as a result of initial screening results. In addition, influence of age and educational background on lowering TBC in visits 2 and 3, patient acceptance of blood screening in a community pharmacy and willingness to pay for this service in the future were also determined. To assess the level of significance among the means of the tested parameters, both parametric (one-way analysis of variance, Scheffe's post hoc test and two sample t-test) and non-parametric statistics (Mann-Whitney and chi-square test) were used at a probability level of less than 0.05. There was a significant difference in mean TBC levels between visit 1 and 2, and between visit 1 and 3 (P< 0.01). However, no statistically significant difference was found between visit 2 and 3 (P= 0.48). In addition, there was no significant difference in the incidence of high blood cholesterol in terms of gender or age difference at the initial screening. Further, mean TBC levels between males and females remained statistically insignificant during the two follow up tests. However, younger patients were able to lower their mean TBC level in visit 2 and 3 compared with older patients (P=< 0.031). The one-way analysis of variance results showed that there was no statistically significant difference in TBC changes during the three visits by subjects categorized by educational background levels. Patient's attitude toward the idea of blood test measurement in community pharmacies was positive. Ninety eight percent of the study group stated that they strongly liked such an idea, 92.16% expressed a willingness to pay an average of $4.55 (range $3 or less to $10), and all agreed that it was a convenient service for them. It was concluded that cholesterol screening in this community pharmacy was effective and acceptable, and may prove to be financially feasible when effectively planned and marketed. This service provides the community pharmacist with an opportunity to offer a unique patient-oriented public service.

As the population ages, the use of information technology and telecommunications in healthcare delivery (often known as Connected Health, telehealth or e-health) has been proposed as a means of providing . patient-centred care to those with chronic conditions. Little research has been conducted into the involvement of community pharmacists in Connected Health delivery. This thesis aimed to investigate the potential role of community pharmacists in the delivery of Connected Health services. A systematic content analysis of print media was performed to explore reporting of Connected Health in UK and US newspapers. A qualitative interview study was conducted with community pharmacists and key stakeholders in Canada and Northern Ireland to gather their views on community pharmacist involvement in Connected Health. Informed by the latter qualitative study, an online questionnaire was distributed to community pharmacists in Northern Ireland to explore their views regarding their potential role in Connected Health. Finally, a feasibility study was carried out, in which community pharmacists sent patients mobile telephone medication reminders and remotely monitored their blood pressure . . Connected Health was positively reported by the print media in the US and the UK. Community pharmacist and key stakeholder interviewees were supportive of community pharmacist involvement in Connected Health, believing it would extend and promote ' their role. However, they had concerns regarding appropriate remuneration. Similar views were obtained from community pharmacist questionnaire respondents. The feasibility study showed that a community pharmacy-based Connected Health programme could be successfully implemented on a small scale. Participants involved were positive about community pharmacist involvement in Connected Health. Community pharmacist involvement in Connected Health has the potential to improve patient outcomes and ease pressure on the health service. However, barriers such as funding and general practitioner acceptance would need to be overcome and a sound evidence base established before routine pharmacist involvement becomes a reality.

Obesity rates in Australia have reached all-time highs, and the primary healthcare setting has been identified as a key area for the management of obesity. Community pharmacies are well positioned to provide weight management initiatives due to their accessibility and potential to identify at-risk consumers. In recent years, there has been a shift in pharmacy practice, with a growing focus on the provision of professional pharmacy services to better support public health needs. Pharmacies are a major outlet for over-the-counter weight-loss products, and there is opportunity for pharmacists to deliver evidence-based and sustainable interventions in this domain. The overarching aim of this thesis was to develop and test a best practice model for weight management services in community pharmacy in Australia, and to identify competencies related to weight management required by pharmacists to inform the development of an educational workshop. The research involved a comprehensive systematic needs assessment conducted through consultation with stakeholders, including pharmacists, consumers, experts in the field and representatives of the leading pharmacy professional organisations, to inform the development of a service model, which was subsequently pilot tested in community pharmacies. In addition, an educational workshop to upskill pharmacy students in weight management was developed and evaluated.

Class of 2017 Abstract<br>Objectives: To determine if there is a correlation between both awareness and utilization of pharmacy care services and patient satisfaction at an independent community pharmacy in Benson, Arizona. Subjects: Patients who visited the pharmacy within a 45-day period in 2016 and who have filled at least one prescription at that location. Methods: A self-reported questionnaire was administered by pharmacy staff to assess patients’ satisfaction ratings on the pharmacy’s performance. The questionnaire also inquired about patients’ awareness and use of pharmacy services as well as demographic information including a history of specific disease states. Data were evaluated using analytic software. Results: Questionnaires were completed by 48 men (mean age = 65.8; SD = 12.57) and 69 women (mean age 60.3; SD = 15.06), with the mean number of select health conditions being 1.63 (SD = 1.16) and 1.49 (SD = 1.24), respectively. There was no correlation between the number of services for which a patient was aware, nor the number of services utilized, and overall satisfaction (p=0.466 and p=0.384, respectively). However, there was a significant positive correlation between awareness and utilization of pharmacy services (r=0.208, p=0.019). Over 74% of respondents rated satisfaction for all measures “excellent,” with professionalism of the pharmacist (92.1%) and pharmacy staff (89.9%) ranking highest. The only category that received a “poor” rating was how well the pharmacist explains medication side effects. Conclusions There was no apparent correlation between awareness of pharmacy care services and patient satisfaction at The Medicine Shoppe in Benson, nor between utilization of pharmacy services and satisfaction. However, patient satisfaction scored high in all categories surveyed.

Objective To describe common facilitators, challenges, and lessons learned in 5 schools and colleges of pharmacy in establishing community pharmacy research fellowships. Setting: Five schools and colleges of pharmacy in the United States. Practice description: Schools and colleges of pharmacy with existing community partnerships identified a need and ability to develop opportunities for pharmacists to engage in advanced research training. Practice innovation: Community pharmacy fellowships, each structured as 2 years long and in combination with graduate coursework, have been established at the University of Pittsburgh, Purdue University, East Tennessee State University, University of North Carolina at Chapel Hill, and The Ohio State University. Evaluation: Program directors from each of the 5 community pharmacy research fellowships identified common themes pertaining to program structure, outcomes, and lessons learned to assist others planning similar programs. Results: Common characteristics across the programs include length of training, prerequisites, graduate coursework, mentoring structure, and immersion into a pharmacist patient care practice. Common facilitators have been the existence of strong community pharmacy partnerships, creating a fellowship advisory team, and networking. A common challenge has been recruitment, with many programs experiencing at least one year without filling the fellowship position. All program graduates (n = 4) have been successful in securing pharmacy faculty positions. Conclusion: Five schools and colleges of pharmacy share similar experiences in implementing community pharmacy research fellowships. Early outcomes show promise for this training pathway in growing future pharmacist-scientists focused on community pharmacy practice.

Aims The aims of this study were to increase community pharmacists’ willingness and confidence to provide consultations for people with depression, and to enhance patients’ awareness of the pharmacists’ developing role. Research Design To observe pharmacist-patient consultations, the researcher developed a patient scenario. Pharmacist knowledge and attitude questionnaires were adapted, and a skills observation checklist was developed. Assessments of patient satisfaction levels took place before and after pharmacist training, which included a simulated consultation and action planning. The consultations were both video recorded and observed. Participants undertook a short interview with the researcher and each pharmacist developed his/her own plan for continuing professional development (CPD). An exploration of the interview transcripts was undertaken qualitatively. A University Ethics Panel approved the project. Results There were twenty-two pharmacists who took part in the study, comprising eighteen males and four females. MPharm students comprised one female and two males, and community pharmacists made up three females and sixteen males. The quantitative results: It was found that pharmacists possessed appropriate knowledge (the mean score was 75%, which showed that the pharmacists were aware of the safety and action of anti-depressants). The mean score for attitude was 54%, which tends towards the positive. When observing the simulated consultations, the mean score for initiating a consultation session was recorded at 28%. This indicates that the pharmacists were not very interested in initiating rapport with patients. However, the highest mean score calculated was 61%, which corresponded with closing a consultation. For data collection and action, the mean scores were 42% and 35%, respectively, and this indicates the need for improvement in these areas. The qualitative findings: The pharmacists demonstrated good knowledge about anti-depressants and held positive attitudes towards people with depression. However, the pharmacists were not very willing to exercise the responsibilities of their extended role or provide additional services for patients. The pharmacists lacked certain skills and opportunities to be able to enhance the patients’ satisfaction. The pharmacists in this study needed to improve their soft skills in some areas and engage in mutual discussion with patients in order to enhance patients’ expectations with the service provided. Conclusion/discussion The knowledge and attitude of pharmacists were good, but their consultation skills could be improved. Although simulated consultation allowed pharmacists to review their skills and practice the apparent impact on patient care was limited. This study has enable greater understanding of pharmacist strategies when consulting people with depression, and the findings could be used by those developing training programmes for enhancing pharmacists skills.

Class of 2005 Abstract<br>Objectives: The objectives of this study were to 1) describe Japanese pharmacists’ perceptions about community pharmacy on a variety of issues and 2) compare the perceptions between different groups. Methods: A questionnaire was administered to a convenience sample of community pharmacists in the Tokyo metropolitan area and Hiroshima prefecture. Pharmacists were surveyed on various issues such as job satisfaction, the separation of prescribing and dispensing, their relationship with patients and physicians, and pharmacy education. A five-point Likert scale was used to measure responses. Results: One hundred forty-four questionnaires were completed. Eighty-four percent of respondents were female, 37.5% had more than ten years of practice experience, and 81.9% worked in Tokyo. Japanese community pharmacists are neutral or satisfied with their jobs. However, respondents were not satisfied with the current state of community pharmacy in Japan (2.81 + 0.83), did not feel respected by patients (2.74 + 0.99) and physicians (1.99 + 0.95), felt that four years of education was not enough to provide adequate patient care (1.96 + 1.01), and would like to do more clinical oriented activities (3.77 + 0.84). Significant differences were found in some responses between groups such as males versus females and pharmacists with more versus less than ten years of practice experience. Conclusions: Respondents were not satisfied with the current state of community pharmacy in Japan. Areas that could use improvement are respect from patients and physicians, involvement in clinical activities, and assistance at work. Significant differences were found in the perceptions of the groups studied.

Background: Recently, health plans have initiated pay-for-performance (P4P) programs to incentivize pharmacies to focus on medication-related quality measures. Little research exists as to what attributes help a pharmacy to perform well in a P4P program. Objectives: This study aimed to: (1) propose a conceptual framework evolved from theories pertaining to economic, psychology, and organizational behavior disciplines that may contribute to a pharmacy's performance in a financial incentive program; (2) develop theoretically-derived questionnaires designed to elicit from pharmacists and pharmacy management pharmacy characteristics and pharmacy personnel factors thought to be associated with achieving quality measures specified for a pharmacy P4P program; (3) psychometrically assess these two newly developed questionnaires designed to collect information from community pharmacies eligible to participate in a pharmacy P4P program; (4) assess the magnitude of the relationship between pharmacy-related and construct redundancy of latent variables identified in objective 3; and (5) examine pharmacy factors' association with community pharmacies achieving quality measures in a pharmacy P4P program. Methods: Two survey instruments were created from a theoretically-derived conceptual framework to measure pertinent pharmacy characteristics and pharmacy personnel factors using a multi-step, mixed-methods process. Questionnaire development entailed semi-structured interviews, item generation, expert content validation, and cognitive debriefings. Developed questionnaires were evaluated in a non-experimental, cross-sectional survey of pharmacists and pharmacy management. Pharmacy personnel surveyed for this study were affiliated with pharmacies in Inland Empire Health Plan's (IEHP's) community pharmacy network. Using items measured in each questionnaire, specified groups of items were hypothesized to have a certain underlying latent variable. Latent variables hypothesized for items measured in the pharmacist questionnaire included: (1)"adherence management -services," (2)"adherence management-counseling," (3) "asthma management," (4) "pharmacist-prescriber relationship," (5) "chronic disease management," (6) "non-dispensing ability," and (7) "workload impact". For items measured in the pharmacy management questionnaire, eight latent variables were hypothesized: (1) "program understanding," (2) "program financial salience," (3) "program involvement," (4) "organization's adaptability," (5) "organization's innovativeness," (6) "organization's proactiveness," (7) "organization's risk-taking." and (8) "organization's focal emphasis." For hypothesized latent variables with four or more items, the value thresholds of three assessment indexes were employed as criteria to evaluate each measurement model's goodness-of-fit. Indexes included: (1) 2 test statistic (i.e.,>0.05), (2) root mean square error of approximation (RMSEA) (i.e., 0.05), and (3) comparative fit index (CFI) (i.e.,>0.95). The statistical significance of item factor loadings was assessed for latent variables with (1) four or more items deemed to have adequate model fit per index criteria and (2) only three items, for which goodness-of-fit may not be assessed. Structural modeling was used to explore associations between (1) pairs of latent variables with adequate model fit and/or statistically significant factor loadings; and (2) latent variables with medication-related quality measures. The strength of associations among latent variable pairs was measured with correlation coefficients. Latent variable pairs with significant correlations greater than 0.50 were evaluated for construct redundancy, for which a change in CFI was used as the comparison criteria to determine whether the latent variables are better represented as one (i.e., (CFI<-0.01) or two constructs (i.e., (CFI ≥ -0.01). Mediation-related quality measures specified as dependent variables in structural models included: diabetes medication adherence, hypertension medication adherence, hypercholesterolemia medication adherence, absence of controller therapy in patients with asthma, use of high-risk medications in elderly, and generic dispensing rate. Results: The empirically derived conceptual framework outlined four major domains proposed for consideration when evaluating pharmacy P4P programs: (1) incentive; (2) pharmacy; (3) other influencing factors; and (4) P4P program measures. From this framework, two questionnaires were developed with the aim of measuring pharmacists' and pharmacy management's pharmacy attitudes and perspectives of a community pharmacy P4P program. The pharmacist survey instrument consisted of five sections: (i) community pharmacy P4P program; (ii) pharmacy services; (iii) pharmacist workload; (iv) pharmacy practice site; and (v) pharmacist's background. The pharmacy management questionnaire consisted of four sections: (i) pharmacy P4P program; (ii) pharmacy organization's characteristics; (iii) pharmacy practice site; and (iv) respondent's background information. Among the 604 pharmacies invited to participate, pharmacists from 114 unique pharmacies (19%) and pharmacy management from 100 unique pharmacies (17%) participated in the survey. This study identified psychometrically validated measurement models for latent constructs with items measured in the pharmacist ("adherence management-counseling," "asthma management," "workload impact" ) and pharmacy management ("program involvement," "organization's innovativeness," "organization's proactiveness," "organization's risk-taking" ) questionnaires). With the exception of "program involvement," the latent constructs measured in the pharmacy management questionnaire were identified to be significantly correlated (𝛹>0.50, p<0.001) and more parsimoniously represented as one factor rather than two (∆CFI<-0.01). No significant associations were identified in exploratory analyses of validated measurement models from the pharmacist questionnaire with targeted medication-related quality measures in IEHP's community pharmacy P4P program. Conclusion: This study collected data for two questionnaires evaluating (1) pharmaceutical care services conceptualized to be associated with targeting medication-related quality measures and (2) pharmacy management's attitudes toward a pharmacy P4P program. Furthermore, psychometric assessment of each questionnaire supplied initial validity evidence for three constructs for the pharmacist questionnaire ("adherence management-counseling," "asthma management," and "workload impact" ) and four constructs for the pharmacy management questionnaire ("program involvement," "organization's innovativeness," "organization's proactiveness," and "organization's risk-taking" ). Subsequent validation of these latent constructs in larger sample sizes is required. Continued study of pharmacy factors and their association with medication-related quality measures is needed to improve our understanding of pharmacies' performance in financial incentive programs. As pharmacy organizations are increasingly integrated into more financial incentive programs aimed at targeting process- and outcomes-related quality measures, it is essential to be able to measure pharmacy and management factors in order to determine which factor(s) impact pharmacy performance.

Introduction: In recent year, the role of the pharmacist has evolved from product-focused to patient-focused activities. Following this evolution, new professional pharmacy services were simultaneously developed by researchers and started to be legally implemented and remunerated for community pharmacists around the world. Implementation, essential to ensure a good programme delivery and therefore its effectiveness, was seen as a passive process for which diffusion and dissemination were sufficient to translate research into practice. However, the transition from theory to practice is often difficult as different factors hinder or facilitate the implementation of such services. In consequence of that, implementation research started to be developed in the community pharmacy field to understand and fil the gap between theory and practice.Objectives of the thesis: Three projects were conducted in Belgium and Switzerland; (1) to understand the implementation of an existing programme in Belgium; the isotretinoin pregnancy prevention programme (PPP) (Chapter IV, point 4.1), and (2) to study the implementation of two new developed pharmaceutical services, which include an interview between the pharmacist and the patient and require interprofessional collaboration; the medication adherence program in Switzerland and the medication review in Belgium (Chapter IV, point 4.2). Methods: To understand the implementation of the isotretinoin PPP, two studies were conducted. The first study was a survey sent to health care professionals (pharmacists, general practitioners and dermatologists) and patients. The outcomes of the survey were the PPP awareness and compliance to safety recommendations related to the teratogenic risk of isotretinoin. The second study was cross-sectional and analysed the reimbursed prescription data of the Belgian population taking isotretinoin between January 2012 and August 2015. The outcomes were medication adherence to isotretinoin and to contraception, and the concomitant use of contraception and isotretinoin. Medication adherence was measured using the medication possession ratio (MPR), dividing the total days of medication supplied within the refill interval by the number of days in the refill interval. The concomitant use of isotretinoin and contraception was realised in combining prescription database of both isotretinoin and contraception of women between 12 and 21 years old, who received at least one prescription of isotretinoin during the study period.To study the implementation of the medication adherence program in Switzerland and the medication review service in Belgium, two prospective and observational studies were conducted with a mixed method approach (quantitative and qualitative outcomes). The defined outcomes, based on the RE-AIM model, were; reach of the target patients, adoption of the service by health care professionals providing the service, implementation (facilitators, barriers and fidelity or the extent to which the intervention is delivered as intended), and maintenance (the extent to which the intervention become institutionalized or part of the routine activity). Outcomes were collected through web platforms for quantitative data, and interviews and focus groups for qualitative data.Results and discussion: The study of the isotretinoin PPP implementation showed that two safety recommendations related to the teratogenic risk were particularly poorly applied by interviewed health care professionals. These two recommendations were the use of a second contraceptive method (like condoms) and the monthly pregnancy test. They considered these two recommendations as unnecessary for women taking an effective contraceptive method. Through the prescription refill data analysis, we observed that 46.1% of patients were adherent to isotretinoin (MPR ≥ 0.8) and 74.0% of women taking isotretinoin to their prescribed contraception (oral contraceptive, rings and patches). Lastly, 83.4% of women between 12 and 21 years taking isotretinoin did not receive an effective contraceptive method one month before, during and one month after isotretinoin treatment. However, the proportion of women receiving at least one prescription of contraception during (74.1%) and after (72.1%) isotretinoin treatment was higher than one month before isotretinoin treatment (35.7%). Regarding these results, less adopted recommendations should be reviewed by an expert committee and interventions focused on the improvement of the use of contraception during isotretinoin treatment could be developed.The two studies related to two new developed pharmaceutical services showed that their implementation was feasible in community pharmacy practice. Most of pharmacists participating in both projects had positive attitude regarding the implementation of these services in their daily practice. They considered it as professionally satisfying and important for patients and perceived the benefits of the programs. However, similar barriers were observed; difficulties to include patients and lack of interprofessional collaboration, and lack of time (related to lack of staff, administrative burden and lack of team adoption). According to participating health care professionals, the development of new strategies to overcome these barriers is necessary to anticipate the future implementation and the maintenance of these services at the national level. Following these results, the proposed strategies are for example the development of broad based media campaigns (for health care professionals and patients), or the development of specific trainings focusing on interprofessional collaboration, service-process, practice change management and leadership. Conclusion: The legal evolution of the pharmacists’ role is a positive progress but insufficient to ensure a full implementation in practice. Implementation strategies should be considered at different implementation stages (exploration, preparation, testing, operation and maintenance) and levels (individual, pharmacy, local setting, and system). The use of implementation science would allow a quicker and more effective implementation of these new professional pharmacy services. The anticipation of change and the selection of appropriate strategies would allow a higher fidelity level to the different components of the service by health care professionals and therefore a higher effectiveness, e.g. clinical and economic outcomes. Health care professionals, professional associations, academics and policy makers should be aware of implementation science and integrate it in the development of the new pharmacists’ role. As shown in our results, it should also be considered for existing programmes such as the isotretinoin PPP.<br>Doctorat en Sciences biomédicales et pharmaceutiques (Pharmacie)<br>info:eu-repo/semantics/nonPublished

Aim: To develop and evaluate a training package for community pharmacy personnel to improve the counselling in smoking cessation provided in community pharmacies. Method: A training in smoking cessation counselling, based on the <I>stage of change</I> model, was developed. A randomised controlled trail was used to evaluate the training; additionally, interviews were used to gain an in depth insight into the pharmacy support process. All 76 non-city community pharmacies registered in Grampian were invited to participate. All intervention personnel were invited to attend the training. The effect of the training on the participants' knowledge and attitudes was assessed by questionnaire at zero, two and 12 months. Both groups recruited customers over a 12-month period. The effectiveness of the training was assessed by comparing the smoking cessation rates of the two groups at one, four and nine months. Results: 62 pharmacies (82%) were recruited. The training was well received by the 94 participants (40 pharmacists, 54 assistances). At both two and 12 months the intervention pharmacy teams were more knowledgeable (2 months: p=0.00001; 12 months: p=0.00001), self-confident (2 moths: p=0.046; 12 months: p=-0.026) and positive about the outcome of pharmacy counselling (2 months: p=0.022; 12 months: p=0.069) than the controls. 492 customers (224 intervention, 268 controls) were recruited. Assuming non-responders had lapsed, significantly more intervention subjects were not smoking at each follow up. The one-month point prevalence was 37% intervention and 29% controls (p=0.059); four months' continuous abstinence was achieved by 20% intervention and 13% controls (p=0.021); and nine months' continuous abstinence by 12% intervention and 7% controls (p=0.089). Conclusions: The intervention was associated with greater knowledge and confidence, increased and more useful counselling and higher smoking cessation rates, demonstrating that appropriately trained community pharmacy personnel have the potential to make a significant contribution to national smoking cessation targets.

Since the latter half of the 20th century there has been a re-emergence of the practice of self-care, particularly for minor ailments. Community pharmacies are an important location in consumer self-care practices, providing a source of non-prescription medicines, information, and a point of referral to medical practitioners. The aim of this thesis was to explore the facilitation of self-care in community pharmacy; including current practice, factors which may influence this facilitation, and interventions to modulate this practice. Methods: A series of qualitative and quantitative studies were conducted, including a survey of pharmacy consumers, several simulated patient studies, and a systematic review of the literature. Novel application of simulated patient methodology to explore implicit bias is also reported. Results: A consumer survey identified consumers with a higher level of education and previous use of a medicine were more likely to request a medicine directly rather than seek assistance with symptoms. Simulated patient studies identified considerable variation in practice, with evidence of sub-optimal practice, particularly by non-pharmacist staff. Numerous factors which influence facilitation of self-care relating to the consumer, pharmacy, and system were identified; including implicit bias and change in regulatory schedules of medicines. Repeated audit and feedback appeared to improve pharmacy staff management of minor ailments, although this varied between scenarios. A facilitated self-care pathway and the application of role theory in this context are presented. Conclusions: Practice is variable in the area of facilitated self-care, with many factors influencing it. Repeated audit and feedback improved the facilitation of self-care. Future work with representative sampling is required to further characterise facilitation of self-care, factors which influence it, and the design and implementation of interventions to optimise it.

Thesis (Ph.D.)--University of Florida, 2004.<br>Typescript. Title from title page of source document. Document formatted into pages; contains 173 pages. Includes Vita. Includes bibliographical references.

The aim of this study is to evaluate the supply of markers for the identification of syringes distributed by pharmacy needle exchanges and to determine if this product and service delivery offers a feasible method of marking syringes to promote the reduction of accidental sharing of syringes and needles amongst injecting drug users (IDU) and thereby reduce the risk of transmission of blood borne viruses (BBVs) and other related infections. This study involves the assessment, implementation and evaluation of syringe markers as a pilot study within three community pharmacy sites in Glasgow. The secondary aims of the study were to identify whether the supply of syringe markers from community pharmacy needle exchanges was acceptable to IDU and if it enabled them to mark their syringes. The literature review demonstrates that providing a means of identification of personal injecting equipment has been proposed as a viable option that should be promoted to prevent the inadvertent accidental sharing of syringes within a group setting. Needle exchanges (NEX) are important component parts of the harm reduction responses designed to reduce the physical health harms caused to individuals through injecting drug use. The literature is reviewed on BBV transmission and the historical, legal and policy context associated with the development of NEXs. Community pharmacies act as a source of health advice and can help to facilitate access to treatment services for those attending the NEX. However the specific aim of this study is not to investigate the totality of the benefits of a NEX but to examine the supply of a potential means of reducing accidental and unintentional sharing of all injecting equipment and thereby contribute to minimising some of the health harms linked to injecting drug use. Three established community pharmacies were identified as suitable sites to pilot the supply of syringe markers. A number of criteria were used to select the sites. These included an assessment of the geographic locations, staffing arrangements, NEX attendances and transactional activity and the availability of private consultation facilities. The health board central database which holds records on a range of factors including, the characteristics of those who attend NEX and detailed information on all transactions, was used to identify the most suitable sites to pilot the new intervention. This indicated that the characteristics of those who attended the three chosen sites were broadly similar to the wider NEX attending population. The evaluation was conducted in two separate periods. The first 4 week period was the supply phase where markers were distributed over this period to all patients receiving NEX packs from the 3 pharmacies. The second data collection phase was undertaken in the following 4 week period. Data was collected by means of a structured questionnaire. In order to reduce the potential interviewer bias it was decided to incorporate the use of peer researchers in the administration of the questionnaire. The Scottish Drugs Forum (SDF) was approached and agreement was reached to use members of the Service User Involvement Group (SUIG) to assist with the design and administration of the questionnaire. A submission was made to the health board Research Ethics Committee (REC) and approval was given to enable the study and the research evaluation to proceed. Before the start of the study, joint briefing and training sessions were held for pharmacy staff from the 3 sites and the 6 participating SUIG members. A total of 177 questionnaires were completed during the second data collection phase of the evaluation. Information was collected on personal details and injecting behaviours (including deliberate and accidental sharing), any current means of syringe identification, use of the markers and on the usefulness of the instruction card. Most individuals (75%, n=132) had been supplied with the markers to trial during the first supply phase of the study with 63% of the 132 (n=83) of those individuals reporting use of the markers. The results of the evaluation and subsequent analysis of the findings indicated that the syringe marker supply could be successfully implemented using pharmacy NEXs. The product and the supply method were acceptable to both staff and service users. Initial bivariate analysis was conducted using a number of dependent and independent variables identified within the questionnaire. These findings highlighted a number of areas worthy of further exploration, including emerging differences between male and female respondents, and indicated specific target groups for future developments in syringe identification. The contribution of the peer researchers was found to be a significant factor in successfully completing the evaluation. However it is not possible to make any definitive statements on how effective the intervention is in terms of reducing the transmission of BBVs and other related infections. The findings of the evaluation indicated a number of potential areas of work that could be usefully explored to investigate the effectiveness of the markers in reducing the transmission of infections. The limitations of the evaluation became apparent during the course of the study and the implications of these limitations are discussed.

The aim of the study was to evaluate a community pharmacy-based cardiovascular risk assessment (VRA) service introduced into two pharmacies in south Wales. A longitudinal methodology was adopted where participants had an initial assessment with a follow-up after 12 months. Body mass index, waist circumference, blood pressure and total/HDL cholesterol levels were measured and the Framingham 10-year cardiovascular risk was estimated and communicated to patients. Demographic details and lifestyle information (smoking, alcohol, diet and exercise) were obtained via self-complete questionnaires at each consultation. A total of 172 individuals accessed the service and had either a brief assessment (n=26) without the calculation of the Framingham score or a full VRA (n=146). Mean age was 60 years (±10.3), 59% were female and 25% (37/146) were at high risk (>20%) of developing cardiovascular disease. High satisfaction with the VRA was obtained via an anonymous questionnaire provided immediately after the initial consultation (74% response rate). The short-term outcomes of the service (including recall of advice, lifestyle improvement and/or making the visit to their GP if they were referred) were reported through a semi-structured telephone interview two weeks after the initial assessment. In total 105/172 (61%) who attended the twelve-month follow-up had results of the two assessments compared using paired Student’s t-test. There was a statistically significant increase in mean HDL 0.08 mmol/L (95% CI 0.02 to 0.14) and a statically significant reduction in mean systolic BP -8.5 mmHg (95% CI -11.0 to -5.9), diastolic BP -7.7 mmHg (95% CI -10.4 to -5.0) and Framingham score -1.07 (95% CI -1.9 to -0.2). A comparison between Framingham and QRISK2 algorithms showed the importance of using the most accurate tool available in estimating cardiovascular risk. This is the first study to investigate short- and longer-term outcomes of a community pharmacy-based VRA service in Wales and provides a basis for future research.

Community pharmacists are increasingly providing public health services in response to government policies. Published literature regarding the views of the general public related to pharmacy public health services, although important in ensuring uptake of these services, was limited. This study series aim to explore the general public's perspective on how to maximise the appropriate utilisation of community pharmacy services for improving public health. A large study comprising four sequential phases was designed and conducted in Sefton borough. Initially, to gather background information, focus group discussions (FGDs) and semi-structured interviews were undertaken with the general public and key stakeholders. The second phase involved the development and testing of a questionnaire extracted from the qualitative findings and a literature review. The questionnaire focused upon seven pharmacy public health services related to cardiovascular risks as well as views on factors influencing pharmacy use and advertising/promotion techniques. Geodemographic concepts, widely recognised in public health, were also included to identify potential benefits to pharmacy practice research. Next, a large scale survey was administered among the general public using eight survey modes, to additionally evaluate the range of methods available/for gathering public views. Finally, survey findings were evaluated by representatives of survey respondents using a FGD. Results indicated that, although stakeholders considered that community pharmacy can make an extensive contribution in supporting public health, pharmacy public health services are used at a relatively low level by the general public and awareness of services is also low. Survey respondents indicated a willingness to use services in the future. Important factors influencing pharmacy use include loyalty, location and convenient accessibility. Appropriate promotional campaigns are a key facilitator to help raise the public's awareness. The findings will help the profession to increase uptake of pharmacy public health services. The variety of survey modes used proved beneficial in obtaining diverse population demographics, with street survey being the optimal technique, however, the potential for social desirability bias must be considered with this and other interviewer-assisted approaches. MOSAIC™ as a geodemographic tool is potentially useful in helping to target services for specific groups and is recommended for use in further research.

Class of 2005 Abstract<br>Objectives: To evaluate the benefits of asthma and diabetes screening services at community pharmacies and determine patient satisfaction and willingness to pay. Methods: ASTHMA: A retrospective analysis of 342 patients were given one of two asthma screening surveys, based on whether or not they had asthma, which assessed asthma-related symptoms, associated conditions, family and social history, and the use of asthma medications. Peak flow measurements were also obtained and compared to predicted peak flow values. Based on these results, pharmacists referred patients to their physician or the emergency department if necessary. DIABETES: A retrospective analysis of 402 patients participated in diabetes screenings at Bashas’ United Drugs. Patients were given a questionnaire to complete, which included questions about diabetes diagnosis, related symptoms, and medication use. Level of control was measured by a fasting or casual finger-stick blood glucose test. Based on these results, pharmacists referred patients to their physician or the emergency department if necessary. PATIENT SATISFACTION: This is a retrospective analysis of patient satisfaction surveys collected from patients who volunteered to participate in asthma and diabetes screenings a t Bashas’ United Drugs stores. A total of 189 satisfaction surveys were collected, 73 from asthma screenings and 96 from diabetes screenings were used to evaluate patient awareness of pharmacist-run screening services, perception of pharmacist knowledge and ability to monitor health conditions, and willingness to pay for the screening services. Mean scores are based on Likert scaled data (1 = strongly disagree to 5 = strongly agree). Implications: The findings in this study suggest that community pharmacists play an essential role in the management of patients with asthma and diabetes. This study found community pharmacists are well trusted for their advice regarding medications, and would be receptive to other health related advice from their pharmacist. Respondents strongly agreed they would recommend this screening service to other patients and would be willing to pay for these services.

Class of 2005 Abstract<br>Objectives: 1) Determine the compliance rate with 12 dispensing workflow criteria; 2) note if any dispensing errors occurred; and 3) summarize characteristics of the pharmacies studied (pharmacy staffing, dispensing workload, presence of a drive-through window, etc.). Methods: At least fifty out-window (i.e., pharmacy prescription pick up window) transactions per store were observed within 18 community retail pharmacies. Based on the historic pharmacy error incidence reports, pharmacies were categorized as being either high- or low-risk pharmacies. The compliance rates for the dispensing workflow criteria were observed between high- and low-risk pharmacies and also between different employee categories. Employee categories included pharmacists, pharmacy interns, and pharmacy technicians who were involved in the dispensing process. Results: Between August 2004 and January 2005, a total of 950 out-window transactions were observed. There were statistically significant differences seen between high- and low-risk pharmacies and between the various categories of employees. The lack of the verification of patients’ name and number of prescriptions being picked up were procedures that were more commonly associated with pharmacies reported to have high dispensing error rates. Implications: This study identified several areas where the dispensing workflow criteria were not being performed. Based on this study, the lack of the verification of patients’ name and number of prescriptions being picked up were procedures that were more commonly associated with pharmacies reported to have high dispensing error rates.

Long-term conditions (LTCs) such as diabetes, cardiovascular diseases, respiratory diseases and cancers are recognised as the greatest challenge facing public healthcare systems globally in the 21st century. Healthcare provision for people with LTCs is shifting towards a model that puts patients at the centre of their own care through supported self-care. Self-care support has emerged as a distinct concept in the management of LTCs and is now considered an inseparable component of high quality healthcare provided by healthcare professionals. People with LTCs are regular users of community pharmacy where dispensing and other services provide opportunities for self-care support. While self-care support as a concept has been explored extensively in health disciplines like nursing, medicine and health psychology, there is a paucity of published literature in community pharmacy. The main aim of this programme of work was to explore the place and contribution of community pharmacy in self-care support of LTCs. A preliminary scoping literature review captured and synthesised the overarching components of self-care support of LTCs into a single theoretical framework consisting of collaborative care planning, self-care information and advice, self-care skills support and training, self-care support networks and self-care technology. The research programme of work employed a mixed methods design consisting of three Work Streams. The qualitative arm of the programme consisted of semi-structured interviews with 24 patients with LTCs and 24 community pharmacists in England and Scotland; these informed the quantitative arm, which was a cross-sectional, online survey of 10,000 community pharmacists in England. The survey instrument was informed and developed from the findings of the pharmacists’ interviews in combination with existing literature. Data collection and analysis in the three work streams incorporated the theoretical framework of self-care support. The qualitative data analyses were undertaken thematically, while quantitative data were analysed using a range of descriptive and inferential statistics. Interviews with patients explored their ‘lived experience’ with LTCs and found that self-care was an integral part of daily living; patients engaged in self-care in a variety of ways to attain normality in their lives. Patients used a wide range of resources for self-care support; family/carers, friends and healthcare professionals (mainly doctors and nurses). Patients viewed and used community pharmacy mainly for the supply of prescribed medicines and suggested that community pharmacy played minimal roles in self-care support. The interviews and survey of community pharmacists showed that pharmacists recognised the broad range of activities and principles of self-care. However, in terms of pharmacists’ contributions to self-care support, their perspectives were narrower and focussed on providing information and advice on medicines-use to patients, while other activities such as lifestyle advice were provided opportunistically. They indicated that they were already providing medicines-focussed self-care support through the services available in community pharmacy. The theoretical framework allowed detailed exploration of how community pharmacists operationalised the different elements of self-care support of LTCs. Collaborative care planning was viewed as important but not within the remit of community pharmacy. Self-care information and advice was unidimensional and provided opportunistically and one-off, using the paternalistic biomedical model. Pharmacists valued the roles of patients’ personal communities but were not proactive in signposting to other support networks. Self-care skills training and support and the use of self-care technologies were limited. Barriers to providing self-care support were priority accorded to dispensing activities, the structure of the community pharmacy contract, lack of incentives to provide self-care support and patients’ expectations and lack of awareness of community pharmacy’s role in LTCs management. The theoretical framework of self-care support of LTCs provided novel insights into the perspectives of patients and community pharmacists. The findings highlighted the need for a coherent LTC strategy if community pharmacy is to align with the self-care support paradigm. Recommendations are made for a comprehensive package of care, underpinned by self-care support. A case is also made for incorporating the often ‘unheard’ patient voice into community pharmacy research and interventions.

Introduction: Literature from around the world suggests that paediatric asthma care is not in line with guidelines and inhaler technique, adherence, asthma management knowledge and written asthma action plan ownership are suboptimal. Thus there is a need for multiple primary care professionals to be involved in paediatric asthma management. Community pharmacists are in an ideal position to address the issues in paediatric asthma stated above therefore this thesis sought to strengthen and improve the current role of community pharmacists in managing paediatric asthma patients within primary care. (Chapter 1) Aim 1: To better understand the status of paediatric asthma management in the Australian and U.S.A community pharmacy setting and to identify the educational needs of community pharmacists in relation to paediatric asthma management. To achieve this aim, a cross-sectional observational study was implemented by recruiting community pharmacists across Sydney metropolitan, Australia and southeast Michigan, U.S.A. Enrolled pharmacists completed a structured, self-reported questionnaire, assessing information on four general domains related to paediatric asthma management: (1) counselling strategies/practices following the dispensing of new asthma medicines and confidence around the use of inhaled corticosteroids; (2) confidence and frequency of use of communication and self-management strategies; (3) attitudes and barriers to the appropriate delivery of education and counseling (4) guideline awareness/use and continuing education. Community pharmacists in both Australia and the U.S.A reported confidence in general communication skills, while a lower proportion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen, decision-making and reviewing short-term and long-term goals with the patient and carer. Community pharmacists in both Australia and the U.S.A were not engaging in paediatric asthma continuing education and most were not using national guidelines to inform their practice. (Chapter 2) Aim 2: To gain a deeper understanding of the perception community pharmacists have of their current role, awareness, practices, interactions and needs in relation to paediatric asthma. Qualitative interviews were conducted with a convenience sample of 23 community pharmacists practising across southeast Michigan in order to address this aim. Interviews were audiotaped and transcribed verbatim, and transcripts were thematically analysed. Upon analysis of the qualitative interviews with pharmacists it was found that pharmacists do not believe their primary role is to engage patients in education and skills training on paediatric asthma self-management, but rather to supply medicine. Although most v pharmacists chose to communicate and provide patient-education, they tended to only engage in these activities if they had time or if requested by the patient/carer. Pharmacists were aware of the areas of suboptimal asthma self-management in children and reported interest in expanding their current role to include paediatric asthma counselling and education. However, numerous challenges and barriers have been identified that prevent pharmacists from delivering optimal education to carers and children with asthma. These included lack of time and reimbursement, challenges in managing the affordability of medicines and lack of a collaborative partnership with doctors in their pharmacy practice. Pharmacists also expressed the view that paediatric asthma continuing education programs are not readily available. (Chapter 3) Aim 3: To identify the needs of carers in terms of managing their child’s asthma, and explore the experiences and perceptions of carers of children with asthma with regards to the community pharmacist. An observational, cross-sectional study design was implemented. This involved the completion of a self-administered questionnaire by carers of children with asthma. Community pharmacists were the sole recruiters of study participants and were responsible for asking carers, who consented to participate, to complete the study questionnaire while waiting in the community pharmacy. Data relating to 3 domains were collected: 1. Child’s asthma status including; asthma control using the validated Childhood Asthma Control Test, emergency service utilisation, days missed from school/childcare, Written Asthma Action Plan possession and prescribed asthma medicines, 2. Carer related outcomes including; days missed from work due to their child’s asthma and carer asthma knowledge using a validated Parental Asthma Knowledge Questionnaire tool, and 3. Pharmacist-Carer interactions: satisfaction with pharmacist, communication/education around paediatric asthma management using an adaptation of the patient satisfaction with pharmacy services questionnaire. The results identified that a high proportion of carers in this study reported that their child had poorly controlled asthma, and less than half possessed a written asthma action plan. Carers missed an average of 1.96 days (s.e.m; ±0.31) of paid work over a 6-month period so that they could manage their child’s uncontrolled asthma. The asthma knowledge of carers was suboptimal particularly regarding the management of an acute attack of asthma and asthma maintenance treatment. Finally, almost all carers reported satisfaction with their pharmacist’s services. However given the status of asthma control and carer knowledge, perhaps this positive relationship is being underutilised. (Chapter 3) Aim 4: To develop an evidence-based paediatric asthma communication and education program for community pharmacists, to test the feasibility of the new program for pharmacy and to explore the impact of the program on pharmacists’ communication skills and asthma vi related practices over time. The feasibility of the newly developed Practitioner Asthma Communication and Education (PACE) for Pharmacy program was tested with 44 pharmacists practising in the Sydney metropolitan region. Pharmacists were trained in small groups in the PACE for Pharmacy program. Pharmacists’ confidence in using communication strategies pre- and post-workshop and self-reported behaviour change post workshop were evaluated. All 44 pharmacists attended the program and completed pre- and post-workshop questionnaires. The participants reported a high level of satisfaction and valued the interactive nature of the workshops. Following the PACE for Pharmacy program, pharmacists reported significantly higher levels in using the communication strategies, confidence in their application and their helpfulness. Pharmacists checked for written asthma action plan possession and inhaler device technique more regularly, and provided verbal instructions more frequently to paediatric asthma patients/carers at the initiation of a new medication. (Chapter 4) Following the feasibility study, the long-term impact of the PACE for Pharmacy program was evaluated through a parallel group, randomised, control versus intervention repeated measures study design, involving 40 control and 39 intervention pharmacists. Recruited pharmacists were assigned to the control or intervention group. Intervention group pharmacists were trained in the PACE for Pharmacy program, while control pharmacists continued with their regular practice. Both control group and intervention group pharmacists completed a selfadministered questionnaire upon initial enrolment into the study and 12 months later. This study identified that participation in the PACE for Pharmacy program was associated with significant improvements in intervention pharmacists’ self-reported scores, when compared with control, in the following areas; confidence and frequency of use of communication strategies, ability to reflect on the use/effectiveness of communication self-monitoring strategies, use of strategies when counselling on new medicines as well as confidence around monitoring/counselling on the use of inhaled corticosteroids. Improvements within these areas were sustained for at least 12 months. (Chapter 4) Aim 5: To gain an understanding of the educational/training needs of pharmacy students in relation to paediatric asthma. To achieve this aim the entire final year Bachelor of Pharmacy cohort was invited to participate in this study (212 pharmacy students). Students were asked to complete a structured, self-reported questionnaire to determine communication confidence, practices and attitudes in paediatric asthma management and multiple regression analyses were used to determine predictors towards pharmacy students’ confidence and use of communication/counselling strategies. Almost all (209) students completed the study vii questionnaire (98.6%). Most students reported confidence in forming an interactive conversation (54%), while 27% reported confidence in setting long-terms goals with patients/carers. Almost all (89%) students reported observing the patients’/carers’ behaviour as a cue for the effectiveness of their communication behaviour, while 75% reported reviewing key instructions about new medicines at the end of a consultation. Tertiary level training for pharmacy students enables the acquisition of generic communication skills. Integrating these skills within the therapeutic content may enhance the confidence levels of students when it comes to communicating about higher order self-management practices in paediatric asthma. (Chapter 5) Aim 6: To develop an evidence-based paediatric asthma communication and education program for pharmacy students and evaluate its impact on their communication skills and asthma related education practices. To address this aim a pre-post study was implemented. Pharmacy students were trained in the PACE for Pharmacy Students program. Students were asked to reflect on their encounters with paediatric asthma patients/carers during their clinical placements and to report on five domains pre and 1-month post completion of the PACE for Pharmacy student program. The first three domains related to their confidence, beliefs of the helpfulness and frequency of use of evidence-based communication strategies. The final two domains related to pharmacy students’ ability to self-reflect on the use of communication self-monitoring techniques and frequency of use of strategies when counselling on new asthma medicines. The mean pharmacy student self-reported scores for each item in domains 1–5 were calculated pre and 1-month post program completion and compared using a Paired Samples Student’s T -Test (significance 0.05, power 0.8). Pharmacy students (n=209) provided data pre and 1-month post participation in the PACE program. Pharmacy student self-reported data showed a statistically significant increase in confidence and frequency of use of evidence-based communication strategies, beliefs of the helpfulness of communication strategies, their ability to self-reflect on their use communication self-monitoring techniques and their frequency of use of strategies when counselling on new asthma medicines. The findings of this study support the value of integrating the evidence-based PACE program into the Pharmacy coursework. This may lead to an improvement in pharmacy students’ paediatric asthma related communication confidence and practices when they enter the workforce. (Chapter 5) Conclusion: The research within this thesis posits that an evidence-based communication and education program specifically tailored to focus on the needs of community pharmacists in viii paediatric asthma management, coupled with strategies to overcome barriers, can together support the development of a long-term pharmacist-patient relationship. This is essential for the achieving optimal management of a chronic disease like paediatric asthma. (Chapter 6)

Introduction Community pharmacy in Saudi Arabia faces many challenges. There is a lack of empirical research about medication safety in community pharmacy from the perspective of different stakeholders. A holistic approach is needed to identify medication safety problems. Aim To explore factors associated with medication safety in this setting. Methods Three empirical studies were undertaken. Focus groups explored medication safety problems using the Human Factors Framework and a Delphi exercise prioritised these problems. Interviews were conducted with pharmacy users to explore their willingness to share information with pharmacists during consultations using the Self-Regulatory Model. Results Four focus groups and four interviews (n=35 participants) identified seven main themes: commercialism; illegal supply of medication; lack of enforcement of regulations; the healthcare system; self-medication; trust in pharmacists; and communication and information exchange. Consensus was achieved with 28/84 items identified during the Delphi study. The top five priorities were: lack of pharmacy facilities; pharmacists' communication between pharmacists and physicians; patient databases; post-registration education; and pharmacists' long working hours. The interview study (n=21) identified that trust in pharmacists was the main enabler in sharing information. Barriers were pharmacists' perceived attitudes towards counselling, workload, lack of motivation, patient proxies, type of questions asked, gender and lack of privacy. Both the focus group study and the interview study highlighted pharmacy users' consumerist behaviour. Conclusion This research has shown that community pharmacy is a complex system involving many interacting factors. Multifactorial interventions are needed at individual (patient, pharmacist), pharmacy and organisational level. The effect of consumerist behaviour that pharmacy users exercise in purchasing medication without utilising the pharmacist's expertise and not engaging in dialogue on patient safety should be studied. Further research is needed to analyse pharmacy users' interactions with pharmacists to identify the factors that encourage communication and sharing of all relevant information with pharmacists.

Influences on general practitioner prescribing of drugs continue to be of interest and importance as cost containment becomes central to Government health policy. This thesis employs a plurality of research methods including quantitative and qualitative survey techniques for example, questionnaires, interviews and prescription analyses to investigate some of the factors which may influence GP prescribing such as information sources, hospital consultants and in particular the community pharmacist. When the use and influence of drug information sources by GPs was examined, the community pharmacist was given a relatively low rating as a source but a high rating, similar to that of the consultant, for helpfulness. Influences are needed to improve prescribing and reduce the incidence of iatrogenic disease for the benefit of the patient. The education and expertise of pharmacists and their familiarity with local prescribing habits places them in a unique position to meet the needs of local GPs. As 96.5% of the public always or nearly always take their prescriptions to the same pharmacy, patient medication records, now kept by 77.5% of pharmacies, provide a valuable check on the appropriateness and safety of patients' medication. The barriers to the pharmacist's greater involvement were shown to be suspicion by GPs of pharmacists' motivation, isolation of many community pharmacists, difficulties in leaving the pharmacy for domiciliary visits, residential home care and GP practice meetings. These barriers must be lowered if the pharmacist is to have a greater influence and involvement. It was concluded that changes are necessary in pharmaceutical education, staff training, organisation and remuneration. Some changes in the targeting of remuneration to the pharmaceutical care services provided and registration of patients with pharmacies would contribute greatly to these aims.

Class of 2009 Abstract<br>OBJECTIVES: To assess patients’ satisfaction with pharmaceutical care services provided in a community health center diabetes management clinic. METHODS: Patients who received diabetes-related pharmaceutical services from the clinical pharmacist at El Rio Health Center in Tucson, Arizona from November 2008 to January 2009 were contacted during a visit to the diabetes clinic and asked to complete the consumer assessment of pharmaceutical services questionnaire. The questionnaire included 14 likert-type items with response options ranging from “Never” to “Always” or “Disagree” to “Agree.” In addition, the patient’s most recent hemoglobin A1C (HgbA1C) was obtained from the electronic medical record. The survey instrument was also translated from English to Spanish to serve the Hispanic participants who could not communicate fluently in English. A descriptive cross-sectional analysis was completed in order to assess patient satisfaction. Dependent variables extracted from the survey were analyzed by Mann-Whitney U test. Interval and ratio data were analyzed by calculating means, standard deviations, and an independent t-test. Nominal data were analyzed using the Chi-Square test. RESULTS: A total of 46 patients completed the questionnaires, including 17 men and 29 women (mean age = 56, SD = 11.3, 80% Hispanic). All patients had seen the clinical pharmacist at least 3 times. Overall, this study showed that majority of the patients were satisfied with the service provided in the clinic. There was no statistically significant difference between English and Spanish patient populations in terms of satisfaction with pharmaceutical services provided about their disease management. CONCLUSIONS: Patients in this clinic were highly satisfied with the pharmaceutical care services provided by the clinical pharmacist.

Aims of study The overall aim of this study was to investigate factors affecting service delivery within a national pharmacy chain, from the perspective of pharmacists and consumers, using asthma services as an example. Data were collected to explore the current environment and opportunities available to pharmacy, the factors affecting service delivery, and to identify recommendations for future service models. The impact of the design and route of service implementation were studied through two different types of asthma services. Methods The brief intervention in asthma was designed centrally and implemented nationally, whilst the asthma service was designed and implemented locally by a group of pharmacists. A triangulation of qualitative and quantitative methods were used throughout this study, including an omnibus survey, audits, mystery customer research, customer and pharmacist interviews, and a review of the dispensing data. Results A total of 81 facilitators, 45 barriers and 23 motivators were identified. In addition to extending those factors that had been previously recognised within the literature, new factors were also identified. Firstly, the route and design of service implementation to promote local ownership and responsibility for delivery of services was found to be a key factor, as was having flexibility in the length and content of service delivery. Clear and visible benefits to the pharmacists delivering the service, the customers accessing the service, and the pharmacy organisation were also found to play an important role in the delivery of services. Conclusions This is the first large scale study of its kind to look at all the factors involved from the perspective of both customers and pharmacists, and many of the facilitators and barriers identified extend beyond those provided within the current literature. The motivators identified within the previous studies have been from the perspective of pharmacists only. This study has looked at the perspective of not only pharmacists, but also the motivators to customers and the service provider. Based on all the factors identified throughout this study, a number of recommendations have been made for future service delivery.

A clinical pharmacy service that determined blood potassium levels was implemented and evaluated in a community pharmacy practice. The pharmacy service utilization model was developed to guide the research. Data were gathered by two questionnaires. The study spanned four weeks at two locations. During one week at each location, blood testing was offered for a fee of $5, and on the other week it was free. A total of 320 subjects filled out a questionnaire. Patient attitude was positive toward the provision of blood level testing service in a community pharmacy. Subjects perceived a pharmacy to be a convenient place for the service, and they stated that they would use such a service if it were available. Subjects stated that they would pay a mean of $12.46 to use the service. Tests they were most interested in having were cholesterol, potassium, and glucose. Of the 320 subjects, 159 had a blood test; 63 paid a fee and 96 received it free. All subjects expressed satisfaction with the service and all said that they would use it again. The mean amount that those tested were willing to pay was $14.49. The proposed model was partially successful in describing the relationships involved in utilization of a clinical pharmacy service. Demographics did not correlate with other variables nor did the two measures of willingness to pay. All other relationships were significant. The service was shown to be financially feasible based on projections from the data collected. It was recommended that such services be implemented.

The Medicines Use Review (MUR) service was introduced in the UK in 2005 to improve patients' knowledge and use of medicines. The service, in essence, engages the patient and the pharmacist in a structured, private conversation about the patient's medicines. Pharmacies are permitted to deliver a limited number of annual MURs yet for a number of years service provision remained low. During the period of this investigation, the service attracted substantial controversy. In 2008 the UK Government called for improvements to be made to the 'quality' of service provision, with measurement of tangible patient outcomes a key concern. This thesis set out to investigate the potential value of the MUR service. First, using discourse analysis, this thesis considered the social construction of the MUR through written marketing material and its potential impact on uptake of the service, making suggestions for future situations. Next, based on a retrospective cross-sectional audit of MUR records, a practical tool for selecting patients who might benefit from an MUR consultation was developed and explained. Auditing MUR records was suggested by others as one way of tackling questions around service 'quality'. However, the cross-sectional audit suggested that such records were inadequate for assessing service quality and it is argued that quality measures should be based on the achievement of intended service outcomes. Finally, and relating to patient outcomes, this thesis includes a qualitative investigation of patients' MUR experiences, particularly patient satisfaction, as a measure of quality. In the absence of existing patient satisfaction questionnaires measuring the true dynamics of the MUR interaction, a novel conceptual framework for measuring patient satisfaction with this service was developed and is put forward. The results contained herein can contribute to the development of an intervention for measuring the benefits of the MUR versus usual care in terms of patient outcomes.

The past decades have witnessed significant changes in community pharmacy. As practice change in community pharmacy is a global phenomenon, there is a need to investigate these changes in the context of both developed and developing countries. This study aimed to investigate changes in the contemporary practice in both Australian and Indonesian community pharmacy. A series of in-depth semi-structured interviews involving key stakeholders in pharmacy and the healthcare system was conducted in Australia (n=27) and Indonesia (n=29). Subsequently, a nominal group discussion was conducted in Indonesia (n=34). Both the interviews and the group discussion were audio-recorded, transcribed verbatim and thematically analysed. The Australian studies highlighted the complex and dynamic situation in community pharmacy sector with factors related to the social, economic and policy context influencing the practice at a micro, meso and macro level. The interviews in Indonesia revealed that despite the good policy objectives of universal coverage to integrate community pharmacy within the primary care network, it has created some unintended and unpredictable consequences which may be detrimental to community pharmacy practice. Seventeen policy documents aimed to promote community pharmacy practice in Indonesia were identified. However, some were introduced in a piecemeal approach creating conflict with other policies. Four main recommendations targeting professional practice, education, policy enforcement and image of pharmacists were proposed in the group discussion. In conclusion, this study provides evidence of practice change in community pharmacies in developed and developing countries. Challenges occur as pharmacists’ professional practice evolves, and these challenges come from inside and outside the profession.

Community pharmacy practice is moving towards patient care and away from the mere dispensing of medicines. In this movement, which is guided by the philosophy of Pharmaceutical care (PC), new counselling services emerge. The purpose of the thesis was to add knowledge about the real-world provision of PC services by studying a defined PC service in Swedish pharmacies. Specific aims of this thesis were to investigate the experiences of professionals working with or close to the service and to describe the content of consultations, counselling behaviour and patterns of follow-up. Further aims were to characterise patients receiving the service and describe their perceived outcomes, in relation to standard service. Data were collected via focus groups, telephone interviews, observations, a patient medication record database and a cross-sectional survey. The practitioners reported greater use of their pharmaceutical knowledge and provision of more thorough patient support. Perceived barriers in delivering the service included difficulties in documenting and getting commitment from colleagues, managers and prescribers. Doctors working close to PC pharmacies held varying opinions about the service. Consultations dealt with issues potentially improving the outcomes of medical treatment, but the level of patient centredness varied and was limited by the practitioners’ focus on the computer screen. The rate of follow-up evaluations was modest, but was higher at pharmacies with a high volume of patients receiving the service. PC patients were mostly elderly and female, using about 10 prescription drugs. In comparison to patients receiving standard service, they were more worried, vulnerable and information-seeking. At the same time, their feelings of safety following the pharmacy visit were more pronounced than those of patients receiving standard service. They also felt better prepared for doctor visits. In order for community pharmacy to better meet patients’ needs and optimise PC services, increased attention should be given to implementation strategies, interprofessional collaboration and educational efforts focusing on patient centredness.

Introduction Management of coronary heart disease (CHD), a major cause of mortality and morbidity in the UK, in primary care, remains sub-optimal. This work aimed to: evaluate impact of a community pharmacy-led intervention on appropriateness of treatment and quality of life of CHD patients; describe opinions and experiences of community pharmacists and GPs and use management of change literature as an explanatory framework for the findings. Methods The thesis comprises: two literature reviews (pharmacy-led interventions for CHD and NHS-based studies using change theories); an RCT evaluating the service; questionnaire surveys and qualitative interviews with community pharmacists and GPs, and comparison of a new model of change with two change theories. Results Review of pharmacy interventions revealed only small-scale studies demonstrating benefit for CHD patients. The change review revealed use of change management theories to implement change and as explanatory frameworks for change initiatives, in the NHS, but not in the pharmacy setting. The RCT recruited 1493 patients (980 intervention, 513 control), 70 pharmacies (102 pharmacists) and 48 practices (208 GPs). No significant differences were found in primary outcomes (appropriateness of treatment or quality of life). Questionnaires revealed positive attitudes to the service but need for pharmacist access to patient records and improved GP/community pharmacist relationships. Qualitative interviews indicated more divergent views. Attitudes were influenced by understanding and previous experience of medicines management, change drivers and implementation processes. Themes conceptualised into a ‘change readiness’ model, had similarities with Lewin’s planned change approach and Pettigrew’s receptivity model. All three models identified areas of sub-optimal intervention implementation and delivery. The new service did not improve appropriateness of treatment or quality of life because it was implemented and delivered sub-optimally. There is a need for greater use of an evidence based systematic approach to introduce new services, but research is required to confirm this approach would confer the hypothesised benefits.

This research considers the effects of a major change in the provision of community pharmaceutical services in England. Commercial companies now provide the majority of the service with a marked decrease in provision by independent contractors. This change may be described as the corporatisation of community pharmacy. This is important because public policy assumes the service is of a uniform standard irrespective of the occupational status, working pattern and organisational setting of the practitioner. Professional policy has also subscribed largely to this belief, but allowed models of practice to develop in which pharmacists seem to have a considerable variation of control over their professional work. Commercial policy has been driven by organisations seeking to maximise profitability and develop cost effective models of professional practice. Pressures from these sources impact upon community pharmacists and give rise to concerns regarding their ability to carry out their professional responsibilities fully. Of particular concern is their professional autonomy, regarded by many commentators as the distinguishing characteristic of the professions. This research is an exploration of whether, and to what extent community pharmacists' professional autonomy has been affected by corporatisation. Empirical work undertaken led to an instrument that made use of practice based scenarios to locate the degree of professional autonomy that community pharmacists perceived they possessed. After two successful pilots, the instrument was used in a large-scale survey of community pharmacists throughout England. The results indicated that community pharmacists' perception of their professional autonomy varied considerably. The variation was linked to their occupational status and whether they worked on a full or part-time basis. These factors are closely related to the corporatisation of community pharmacy. The findings have considerable policy implications. From the perspective of professional policy, the erosion of professional autonomy found with respect to some categories of community pharmacists calls into question the professional status of pharmacy. From the perspective of public policy the tacit assumption that professional services provided through a variety of organisational structures are essentially the same has been shown to be naive. With regard to commercial policy the overwhelming strength of the commercial agenda risks deprofessionalising community pharmacy. The conclusion reached is that the existing contractor model for the provision of pharmaceutical services should be reviewed and consideration given to replacement with a model that takes into account the realities of current provision.

Background: Organisational culture refers to the way employees perceive, think and feel about their work and organisation, guiding their behaviours. The way community pharmacists perceive their work pressures, as well as organisational outcomes such as job satisfaction and commitment, turnover and performance may be influenced by organisational culture. However, there is little evidence of the link between organisational culture and community pharmacists’ perceptions of their workplace. Moreover, it is not possible to establish which outcomes can be linked to organisational culture, due to the lack of validated instruments capable of measuring aspects that are unique to community pharmacy. The aim of this study was to design and validate a questionnaire to measure organisational culture in community pharmacy in Great Britain. Methods of questionnaire design and testing: Qualitative interviews with 12 community pharmacists working in Greater Manchester and relevant literature were analysed to identify variables describing organisational culture in community pharmacy, informing the design of a new conceptual model. Survey items were drafted based on the conceptual model, and response categories for the questionnaire were chosen. Cognitive interviews established the content validity of the conceptual model and questionnaire. The questionnaire was then administered to a sample of community pharmacists in Great Britain (n=1000) obtained from the GPhC register of pharmacies. Factor analysis was conducted to validate the questionnaire and investigate its component structure. Inferential analysis was conducted to investigate differences in how community pharmacists perceived organisational culture. Results: Two-hundred-and-nine usable questionnaires were returned. Factor analysis revealed five dimensions comprising of 60 items. These dimensions are: Business and work configuration; Social relationships; Personal and professional development; Skills utilisation; and Environment and structures. The conceptual model was adjusted based on these dimensions and the items retained, describing how different variables interact to produce different cultures. The questionnaire demonstrated good psychometric properties, with high levels of validity and reliability. Findings from the questionnaire revealed differences in how community pharmacists perceived their cultures, suggesting different cultures: more positive ratings were associated with owners, pharmacists from ethnic backgrounds, and those working in independent pharmacies; more negative ratings were associated with relief pharmacists, white pharmacists, and pharmacists working in supermarket pharmacies. Discussion: Organisational culture influences the way individuals think and behave. Supportive cultures that facilitate workflow are paramount in shaping organisations’ professional image and determining its success. However, findings from the questionnaire indicate that the way community pharmacists perceive organisational culture varies, suggesting different organisational cultures. It is important for leaders to consider these differences and their impact on organisational outcomes. The validated conceptual model will be useful in future research by describing how different configurations produce different cultures. The questionnaire will allow the investigation of differences in how organisational culture is perceived in community pharmacy and their link to job outcomes, and identification of organisational variables which may be perceived as infrequent triggering change and guiding interventions to maximise positive outcomes, for both pharmacists and pharmacies.

In 1994 the author of this thesis proposed a new role of medicines management (MM)for dispensing community pharmacists, requiring systematic collaboration with GPs. In1998 the Minister for Health approved the proposal and commissioned pilot trials which are currently proceeding. This thesis explores cultural, inter-professional and operational factors which may impede or facilitate service roll-out nationally. A review of management literature explored two areas, marketing and change management theory, which could be applied to a community pharmacy context. This review revealed innovative ways of presenting new services to target audiences and novel means of engineering organisational change. 'Culture~; 'leadership~; 'motivation"; 'communications"; and, 'competitive force~ were studied alongside the psychology of 'attitudes'; 'needs'; and, 'wants'. The BurkeLitwin change model was selected as the most applicable to pharmacy service change. Triangulated field research has revealed forces which impede and facilitate change. A series of key informant interviews and focus groups helped identify crucial issues which informed the content and structure of national postal surveys to GPs (1000) and pharmacists (750). Key 'attitudes'; 'needs'; and, '~ants of both professions were revealed: i. 75% of GPs and 81 % of pharmacists wish to engage in MM; ii. 36% of GPs already receive pharmacist assistance at varying levels; iii. 58% and 48% of GPs respectively, do not support pharmacist involvement with medication selection or identification of sub-therapeutic dosage; and, iv. 89% of pharmacists do not have the ability and 81% do not have time to do MM. The literature research fmdings were theoretically applied to these issues and suggestions made for managing the proposed transformation of pharmacy service. This thesis recommends cultural support of the GP by styling and branding the MM service accordingly with the GP as the lead figure, directing the programme of work. It further recommends urgent action by pharmacy leadership, to provide the framework for dispensing pharmacists to acquire the knowledge and time to undertake this transformational service.

Class of 2009 Abstract<br>OBJECTIVES: To evaluate patients’ perceptions of receiving a pharmacist-administered influenza vaccine in the community pharmacy setting. METHODS: All patients receiving a pharmacist-administered influenza vaccine at a Safeway Pharmacy in Tucson, Arizona were invited to participate in the survey. Participants completed the survey in a waiting area outside the pharmacy. At the completion of the study time frame, surveys were collected, and each response was entered into an Excel spreadsheet for data analysis. RESULTS: Seventy-five patients completed the Flu Shot Survey. One hundred percent of patients reported that getting the influenza vaccine at a grocery store pharmacy is convenient. Respondents reported being either very confident (97.3%) or somewhat confident (2.7%) in pharmacists as immunizers. Only 18.7% reported having never received an influenza vaccine from a pharmacist, and 13.3% reported having no prior knowledge that Arizona pharmacists could administer the influenza vaccine. CONCLUSIONS: All patients responded that receiving the influenza vaccine from a community pharmacist was convenient. Patients wanted to receive the vaccine next year from a pharmacist, and the majority of respondents were confident in the pharmacist as an immunizer. Few patients reported never receiving the influenza vaccine from a community pharmacist, and even fewer patients were unaware that pharmacists in Arizona can immunize.