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Social and Behavioral Aspects

of Pharmaceutical Care

PHARMACEUTICAL PRODUCTS PRESS


Pharmaceutical Sciences
Mickey C. Smith, PhD
Executive Editor
New, Recent, and Forthcoming Titles:

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Principles of Pharmaceutical Marketing edited by Mickey C. Smith


Pharmacy Ethics edited by Mickey C. Smith, Steven Strauss, John Baldwin,
and Kelly T. Alberts
Drug-Related Problems in Geriatric Nursing Home Patients
by James W. Cooper
Pharmacy and the U.S. Health Care System edited by Jack E. Fincham
and Albert I. Wertheimer
Pharmaceutical Marketing: Strategy and Cases by Mickey C. Smith
International Pharmaceutical Services: The Drug Industry and Pharmacy Practice
in Twenty-Three Major Countries of the World edited by Richard N. Spivey, Albert
I. Wertheimer, and T. Donald Rucker
A Social History of the Minor Tranquilizers: The Quest for Small Comfort
in the Age ofAnxiety by Mickey C. Smith
Marketing Pharmaceutical Services: Patron Loyalty, Satisfaction,
and Preferences edited by Harry A. Smith and Joel Coons
Nicotine Replacement: A Critical Evaluation edited by Ovide F. Pomerleau
and Cynthia S. Pomerleau
Herbs of Choice: The Therapeutic Use of Phytomedicinals by Varro E. Tyler
Interpersonal Communication in Pharmaceutical Care by Helen Meldrum
Searchingfor Magic Bullets: Orphan Drugs, Consumer Activism,
and Pharmaceutical Development by Lisa Ruby Basara and Michael Montagne
The Honest Herbal by Varro E. Tyler
Understanding the Pill: A Consumer's Guide to Oral Contraceptives by Greg Juhn
Pharmaceutical Chartbook, Second Edition edited by Abraham G. Hartzema
and C. Daniel Mullins
The Handbook of Psychiatric Drug Therapyfor Children and Adolescents
by Karen A. Theesen
Children, Medicines, and Culture edited by Patricia J. Bush, Deanna J. Trakas, Emilio
J. Sanz, Rolf L. Wirsing, Tuula Vaskilampi, and Alan Prout
Social and Behavioral Aspects of Pharmaceutical Care edited by Mickey C. Smith
and Albert I. Wertheimer
Studies in Pharmaceutical Economics edited by Mickey C. Smith

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Social and Behavioral Aspects


of Pharmaceutical Care

Mickey C. Smith
Albert I. Wertheimer
Editors

informa
healthcare
New York London

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CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
1996 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20130401
International Standard Book Number-13: 978-1-4822-0783-5 (eBook - PDF)
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CONTENTS
About the Editors

xvii

Contributors

xix

Foreword

xxxi
Henri R. Manasse Jr.
PARTI: THE SICKNESS CAREER

SECTION A: CONCEPTS OF HEALTH AND ILLNESS


Chapter 1. Definitions and Meaning of Health
Richard M. Schulz
David A. Holdford
The Paradox of Health
The Meaning of Health
Definitions of Health
Health, Pharmaceutical Care, and Quality of Care
Assessment
Health Beliefs
A Model of Health Behavior
Wellness and Health
Health Promotion and Disease Prevention
Conclusion
Chapter 2. Illness, Sickness, and Disease
Mickey C. Smith
Introduction
Definitions and Determinants of 111 Health
Behavior in Health and Sickness
The Pharmacist and Patient Behavior
Summary

3
3
4
7
8
11
13
15
15
17
21
21
22
24
36
36

SECTION B: PATIENT RESPONSES TO SYMPTOMS

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Chapter 3. The Meaning of Signs and Symptoms


Dennis A. Frate
Juliet B. Frate
Introduction
Empirical Data
Discussion
Summary
Chapter 4. Acute vs. Chronic Problems
Peter D.Hurd
Introduction
Chronic and Acute Symptoms
Attribution Errors and Symptoms
Symptoms and Change with Chronic Disease
Examples of Symptoms in Situations
Some Limitations of This Approach
Summary

41

41
49
60
62
65
65
66
66
74
79
80
81

SECTION C: CHOOSING A SOURCE OF CARE


Chapter 5. Images of Pharmacists and Pharmacies
Sheryl L. Szeinbach
Introduction
Background Information
What Is Image?
Changes Affecting Pharmacy
Conceptual Framework
Corporate Image
Market Image
Professional Image
Recent Studies on Professionalism and Image
in Pharmacy
Strategies for Image Improvement
Conclusion

85
85
85
86
87
88
89
90
90
91
94
96

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Chapter 6. Other Health Providers and the Pharmacist


Bernard Sorofman
Toni Tripp-Reimer
Richard Dehn
Mary Zwygart-Stauffacher
Introduction
Continuity of Health Care
Changing Health Care Environment
Professionals in Society
The Adaptation of Medicine
Emergence of Physician Assistants
The Evolution of Nursing
The Practice of Dentistry
Other Healing Professions
Prescribing and Dispensing
Pharmacists and the Health Care Team
Chapter 7. Unorthodox Healing Systems
Albert I. Wertheimer
Introduction
Physical Therapies
Hydrotherapy
Nutrition
Plant-Based Therapies
Wave and Radiation
Mind and Spirit Healing
Self-Exercise
Comprehensive Systems
Summary

99

99
100
100
103
105
106
108
111
112
112
115
123
123
125
131
133
135
137
138
143
143
145

SECTION D: CHOOSING A THERAPEUTIC AGENT


Chapter 8. Determinants of Prescribing Behavior
Dennis W. Raisch
Introduction: Why Are We Interested?
Prescribing Models/Theories: How Are Prescribing
Decisions Made?
Methods Used to Influence Prescribing

149
149
150
159

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Administrative Programs Used to Affect Prescribing:


Limiting Prescriber Choices
Changing Prescribing Knowledge and Drug Assessment:
How Can Pharmacists Educate Prescribers to Better
Utilize Drugs?
Designing Programs to Improve Prescribing: A Model
of Methods for Influencing Prescribing
Quality of Care Issues
Implications for Practice: Putting It All Together
Conclusions
Chapter 9. Pharmacists' Performance in Drug Product
Selection and Therapeutic Interchange
Nancy J. W.Lewis
Steven Erickson
Introduction
Drug Product Selection
Therapeutic Interchange
Conclusions
Chapter 10. Interprofessional Relations in Drug Therapy
Decisions
Jennifer A. Gowan
Louis Roller
Alistair Lloyd
Introduction
Formal and Informal Networks
Improvement of Therapeutic Outcomes
Barriers to Interprofessional Relations
Communication Skills to Improve Interprofessional
Relations
Patient, Prescriber, Pharmacist
Intervention
Conclusion

160
163
169
174
175
176

185

185
185
197
207

213

213
215
218
222
225
230
235
245

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Chapter 11. Consumer Behavior Regarding the Choice


of Prescription and Nonprescription Medications
Michael Montagne
Lisa Ruby Basara
Introduction to Consumer Medication Choice
Consumer Behavior
General Consumer Behavior Models
Prescription Medications and Consumer Goods
Are Different
Studying Medication Use from a Social and Behavioral
Perspective
Prescription Medication Use
Nonprescription Medication Use
Providing Pharmaceutical Care to Medication Consumers
Conclusion

253

253
254
255
261
263
271
276
285
289

SECTION E: MEDICATION-TAKING BEHAVIOR


Chapter 12. Determinants of Medication Use
Mickey C. Smith
Introduction
The Case of Laxatives
Analyzing the Medication Use Process
The Case of Minor Tranquilizers
Prescribing Studies
Utilization Studies
Prescribing Dilemmas
Look Ahead
Summary

295
295
296
299
304
305
307
314
317
319

Chapter 13. Predicting and Detecting Noncompliance


Mickey C. Smith

323

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

323
323
325
326

The Health Belief Model Can Help


Detecting Noncompliance
Why All the Fuss About Compliance?
Conclusion

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Chapter 14. Explaining and Changing Noncompliant


Behavior
Dale B. Christensen
The Significance of the Noncompliance Problem
Explaining Noncompliant Behavior
Changing Noncompliant Behavior
Types of Noncompliant Behavior
Compliance Enhancement in Tomorrow's World
of Pharmacy Practice
Concluding Thoughts

329
330
339
342

351
351
354
362
363
3 70
374

SECTION F: OUTCOMES OF PHARMACEUTICAL CARE


Chapter IS. Clinical Outcomes
Charles E. Daniels

379

Introduction
Definition of Clinical Outcomes
Monitoring Outcomes
Disease State Management
Conclusion

379
380
380
382
383

Chapter 16. Economic Outcomes


Brian G. Ortmeier

385

Introduction
Perspective
Defining Costs and Consequences
Cost/Benefit Valuation
Types of Economic Analyses
Critical Evaluation of the Health Economic Literature
Applications for Health Economic Research

385
386
388
390
392
398
399

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Chapter 17. Humanistic Outcomes


Stephen Joel Coons
Jeffrey A. Johnson
Introduction
Quality of Life
Patient Satisfaction
Quality of Life and Patient Satisfaction: Measurement
Issues
Humanistic Outcomes and Pharmaceutical Care
Summary and Conclusion
Appendix I: RAND 36-Item Health Survey 1.0
Appendix II: Short-Form Patient Satisfaction
Questionnaire (PSQ-18)
Appendix III: Satisfaction with Pharmacy Services
Questionnaire

403
403
405
411
412
416
421
423
431
435

PARTII: SPECIAL CLASSES OF PATIENTS


Chapter 18. Children and Medicines
Patricia J. Bush
Introduction
How Children Learn
Children's Medicine-Related Beliefs and Behaviors
Helping Children Learn About Medicines

449

Chapter 19. Adolescents and College Students


Tracy S. Portner
Introduction
Social and Health Issues
Self-Care Activities
Illness and Medication Use in Young Adults
Sources of Self-Care and OTC Product Information
Health Services Utilization
Role of the Family in Illness Care
Adolescents and Chronic Illness
Compliance in Adolescents
Minors' Legal Rights to Care
Pharmacists: Make a Special Effort
Conclusion

473

449
451
456
464

473
474
483
484
487
491
492
493
498
499
503
505

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Chapter 20. Ambulatory Elderly


Jack E. Fincham
Introduction
Demographics
Social and Behavioral Concerns
General Health Concerns
Medication-Specific Concerns
Conclusion and Commentary
Chapter 21. Long-Term Pharmaceutical Care: Social
and Professional Implications
Royce A. Burruss
Norman V. Carroll
Introduction
Long-Term Care: The Nursing Home
Long-Term Care: Assisted Living
Long-Term Care: Continuing Care Retirement Community
Long-Term Care: Home Health Care
Pharmaceutical Care: An Overview
The Case of AAA: Pharmaceutical Care in Action
Conclusion
Chapter 22. Hospitalized Patients
Andrew M. Peterson
Paul G. Pierpaoli
Introduction
Acute Health Care Services Revisited
The Hospitalized Patient: A Conceptual Basis of Care
Conclusion
Chapter 23. Pharmaceutical Care of Terminally
111 Patients
Arthur G. Lipman
Joni I. Berry
Introduction
Hospice Care
The Hospice Team

515
515
516
519
522
524
531
537

537
538
541
541
542
544
548
555
559

559
559
563
579
585

585
587
590

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The Pharmacist's Responsibility to Terminally 111 Patients 590


Hospice Pharmaceutical Care
593
Hospice Pharmacist Job Description
598
Principles of Palliative Care
600
Case Studies in Pharmaceutical Care of Terminally 111
Patients
605
Conclusion
607
Chapter 24. Mental Disorders
Julie Magno Zito
Introduction
Mental Disorders: Their Classification and Evaluation
Epidemiology of Mental Disorders
Selected Psychosocial Principles of Mental Disorder
Therapy
Antipsychotics for Psychosis and Other Disorders
Principles of Longitudinal Monitoring
Conclusion
Chapter 25. Cultural Issues in the Practice of Pharmacy
Pedro J. Lecca
Introduction
Cultural Practice Issues
Lack of Cultural Understanding
Holistic Assessment
Culturally Sensitive Practices
Culture and Pharmacy Management Practice
The Future of Culture in Your Practice
Cultural Training
Conclusion

611
611
614
616
619
623
627
629
635
635
637
639
640
641
642
643
644
644

PART III: REVIEW OF USEFUL CONCEPTS/MODELS


Chapter 26. A Macro View: Public Policy
Lon N. Larson
Background and Objectives
The Mechanisms of Action of Public Policies
The Demand for and Supply of Public Policy

651
651
653
657

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Approaches to Improving Health Status


Values in Health Care Services Delivery
Public Input and Participatory Democracy

659
662
669

Chapter 27. The "Rebirth" of Cognitive Services


Kent H. Summers
Introduction
The Evolution of Modern Pharmacy Practice
Gaining Reimbursement for Cognitive Services
Conclusion

675

Chapter 28. Recent Developments in Behavioral Medicine


Donna E. Dolinsky
What Is Behavioral Medicine?
What Is Health Psychology?
What Behaviors Are Related to Illness?
What Are Behavioral Medicine's Interventions?
Why Is Behavioral Medicine Important for Patients
and for the Health Care System?
Do the Nondrug Treatments of Behavioral Medicine
Have a Place in Pharmaceutical Care?
What Does This Mean for a Pharmacist?

715

Chapter 29. Expectations, Education, and Technology


Sheldon Xiaodong Kong
Stephanie Y. Crawford
Introduction
Expectations
Technology
Pharmacy Education
Conclusion

675
675
691
706

715
717
718
725
729
730
731
737

737
739
749
757
764

Chapter 30. Ethical Concerns in Drug Research


Kenneth A. Speranza Sr.
Amy M. Haddad

773

Introduction
Ethical Principles Underlying Drug Research

773
775

Ethical Norms of Drug Research


Additional Considerations for the Practicing Pharmacist
Conclusion
Appendix A: The Nuremberg Code
Appendix B: Declaration of Helsinki
Epilogue

781
791
794
794
796
801

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Albert I. Wertheimer
Index

809

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ABOUT THE EDITORS


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

XVll

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CONTRIBUTORS
Lisa Ruby Basara, RPh, MBA, is Research Assistant in the
Research Institute of Pharmaceutical Sciences and a doctoral candi
date in the Department of Pharmacy Administration at the Univer
sity of Mississippi. Her research and publications have concentrated
on the evaluation of consumer-oriented pharmaceutical marketing
strategies, such as direct-to-consumer advertising and patient educa
tion programs, as well as the development of attitudinal and demo
graphic profiles of consumers who are likely to respond to direct
pharmaceutical marketing efforts. Additionally, Basara has studied
the quality of patient education materials and the attitudes of health
professionals toward the use and impact of these materials. Basara is
a member of the American Pharmaceutical Association, the Drug
Information Association, and the American Marketing Association.
Joni I. Berry, RPh, MS, is Consultant Pharmacist at Hospice of
Wake County in Raleigh, North Carolina and Clinical Assistant
Professor in the School of Pharmacy, University of North Carolina
at Chapel Hill. Berry was a founding member of die Board of
Directors of Hospice of Wake County. She has published on phar
maceutical services in hospice care and in pain and symptom control
in terminal disease. Berry's research interests include outcome mea
surements of interventions in palliative care and physicians' knowl
edge of symptom management issues.
Royce A. Burruss, RPh, MBA, is General Manager at HILLMED
Home Medical Systems in Ashland, Virginia. He is also a doctoral
candidate in Pharmacy Administration at the School of Pharmacy,
Medical College of Virginia, Virginia Commonwealth University,
Richmond, Virginia.
Patricia J. Bush, PhD, is Adjunct Professor in the Department of
Family Medicine, Georgetown University School of Medicine,
Washington, DC. As a pharmacosociologist, she has long been
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Social and Behavioral Aspects of Pharmaceutical Care

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interested in the medicine use process and, especially, the socializa


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

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Contributors

xxi

cine, School of Medicine, University of California, San Diego.


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

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Social and Behavioral Aspects of Pharmaceutical Care

Steven Erickson, PharmD, is an Assistant Professor of Pharmacy


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

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Contributors

xxm

training of preregistration pharmacy students, plus the development


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

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Center for Pharmaceutical Economics and enrolled in a PhD pro


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

Contributors

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research, fund raising, health/mental health research, substance abuse


training, AIDS research, grantsmanship, and resource development.
He has been associated with several institutions, including the Univer
sity of Illinois at Chicago, New York University, and St. John's Uni
versity. Prior to his appointment at the University of Texas, he held an
appointment as Assistant Commissioner of Mental Health/Mental
Retardation and Alcoholism Services for the City of New York. Lecca
has written over 20 books including monographs and more than a
score of articles.
Nancy J. W. Lewis, PharmD, MPH, is President of Lewis Con
sulting Group, Inc., a Delaware-based corporation that specializes in
pharmaceutical economics and outcomes research. She has served
as a consultant to pharmaceutical companies, pharmacy trade
associations, pharmacy benefit management companies, and gov
ernment agencies. Previously, Lewis was Assistant Professor of
Pharmacy Practice and a clinical pharmacist in Family Medicine at
Wayne State University, a health policy analyst for the Greater
Detroit Area Health Council, and the Associate Executive Director
for the Institute for Pharmaceutical Economics at the Philadelphia
College of Pharmacy and Science.
Arthur G. Lipman, RPh, PharmD, is Professor of Clinical Phar
macy in the Department of Pharmacy Practice, College of Pharmacy
and at the Pain Management Center, University Hospital, University
of Utah Health Sciences Center in Salt Lake City. He was an investi
gator in the National Cancer Institute Demonstration Project on
Hospice Care in New Haven, Connecticut in the 1970s. Lipman is a
former president and pharmacological consultant to Hospice of Salt
Lake. He is the author of over 80 articles, chapters, and monographs
and over 200 reviews and editorials. His research is in pharmacolog
ical management of pain and in symptom control of advanced dis
ease. Lipman is the founding editor of the Journal of Pharmaceutical Care in Pain & Symptom Control.
Alistair Lloyd, PhC, FPS, has been the Registrar of the Pharmacy
Board of Victoria and the Director of the Victorian Branch of the
Pharmaceutical Society of Australia since 1982. Prior to this he was
in community practice as a pharmacist for 25 years, during which
time he served on the Council and as President of the Pharmaceuti-

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cal Society at state level, and on the Council and as President of


what was then called the Pharmaceutical Society of Australia and
New Zealand. At present he is actively involved in administering a
national project to have pharmaceutical care adopted as the accepted
standard of practice by all Australian pharmacists.
Michael Montagne, RPh, PhD, is Associate Professor at Massa
chusetts College of Pharmacy. His research efforts have focused on
the social, cultural, and historical aspects of drug use, the pharma
coepidemiology of drug use problems, images of drugs and drug use
in mass media, the occurrence of drug epidemics in society, and the
development and testing of drug education programming. Mon
tagne's teaching activities include the social and behavioral consid
erations of medical and nonmedical drug taking. He has published
extensively on drug development and drug use, the occurrence of
drug-use problems, and consumer involvement in health care. Mon
tagne belongs to several professional associations, including the
American Association of Colleges of Pharmacy, the American Pub
lic Health Association, and the International Pharmaceutical Federa
tion (F.I.P.).
Brian G. Ortmeier, PharmD, PhD, is Director of Health Economics
& Outcomes Management of MedXL, a Hoechst-Roussel Health Care
Company. He is responsible for economic evaluation and disease state
modeling and implementation. Ortmeier jointed Hoechst-Roussel
Pharmaceuticals, Inc. (HRPI) in June 1994 as a manager, pharmacoeconomics in market development for managed health care. He has
been responsible for incorporating economic and outcome evaluations
into protocols during Phases 2-3B and 4 for HRPI products. He is a
member of the National Pharmaceutical Council Task Force on Com
pliance and Chair-Elect of the Drug Policy Section/Medical Care of
the American Public Health Association. Previously, Ortmeier was
Assistant Professor of Pharmacy Practice, Division of Behavioral and
Administrative Sciences and Faculty Associate, Center for Pharmaceu
tical Economics, at the University of Arizona. Ortmeier received his
PharmD from Creighton University School of Pharmacy and Allied
Health Professions in Omaha, Nebraska, and his PhD in Pharmacy
with emphasis in marketing and economics from the University of
Georgia.

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xxvu

Andrew M. Peterson, PharmD, is Assistant Director of Pharmacy/


Clinical Services at Thomas Jefferson University Hospital and Clin
ical Assistant Professor at the Philadelphia College of Pharmacy
and Science, Philadelphia, Pennsylvania. Peterson received his BS
in Pharmacy from Rutgers College of Pharmacy and his PharmD
from the Medical College of Virginia. He also completed a hospital
pharmacy residency at Rush-Presbyterian St. Luke's Medical Cen
ter and an advanced administrative residency at Thomas Jefferson.
Peterson has an interest in developing new practice roles and models
for providing pharmaceutical care.
Paul G. Pierpaoli, MS, is Director of Pharmacy Services at RushPresbyterian St. Luke's Medical Center and Professor in the Depart
ment of Pharmacology, Rush Medical College, Chicago, Illinois. He
also holds the rank of Assistant Professor, Health Systems Manage
ment, Rush University School of Health Sciences. Over the last 30
years, he has been a director of pharmacy services in a number of
major U.S. hospitals and has been active in developing and evaluat
ing innovative pharmacy service programs. He has held leadership
positions in a number of national professional organizations and has
served as President of the American Society of Hospital Pharma
cists. Pierpaoli is the author of numerous articles in the pharmacy
and health care literature.
Tracy S. Portner, RPh, PhD, is Assistant Professor in the Depart
ment of Clinical Pharmacy, University of Tennessee College of
Pharmacy. Her research interests include evaluation of the provision
and outcomes of pharmaceutical care in ambulatory care environ
ments, economic evaluations of community and institutional phar
macy services, and the organization and provision of medication
information to patients. A specific area of interest is pharmacists'
activities in patient care and mechanisms of obtaining compensation
for those services. Portner teaches students in the areas of pharmacoeconomics, managed care, and community pharmacy practice
management.
Dennis W. Raisch, RPh, PhD, is the Associate Chief of the Veter
ans Affairs Cooperative Studies Program Clinical Research Phar
macy Coordinating Center and a Research Assistant Professor at the
University of New Mexico. He has conducted research on programs

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designed to influence and improve prescribing, pharmacist interac


tions with physicians and patients, and pharmaceutical education.
His primary research interests are evaluating methods for improving
drug prescribing, assessing pharmacy services, and pharmacoeconomics. He has authored 14 and co-authored five research publica
tions in peer-reviewed pharmacy journals. He is currently serving
on the Annals of Pharmacotherapy editorial advisory panel for
pharmacoeconomics.
Louis Roller, PhD, is Associate Professor in the Department of Phar
macy Practice, Victorian College of Pharmacy, Monash University,
Melbourne, Australia. He is also Associate Dean (Teaching) and Stu
dent Counsellor of the College and a Senior Associate of the Medical
Faculty, University of Melbourne. He is a practicing pharmacist, has
been involved in professional continuing education for almost three
decades, and has lectured regularly interstate and overseas. He is a
member of the Pharmacy Board of Victoria with a strong involvement
in the educational aspects of the board. He is on the editorial boards of
two international journals of pharmacy practice, and has published
widely in the area of pharmacy practice.
Richard M. Schulz, RPh, PhD, is Associate Professor of Phar
macy Practice at the University of South Carolina. He received a BS
in Pharmacy from the University of Maryland in 1976 and an MS
and PhD in Pharmacy Administration from the University of North
Carolina in 1980 and 1983, respectively. Prior to joining the Univer
sity of South Carolina faculty in 1986, he was on the faculty at West
Virginia University School of Pharmacy from 1982 to 1986.
Schulz's research focuses on quality of life and patient compliance
with therapeutic regimens. His work has been published in the phar
macy, health care, communication, and business literature.
Bernard Sorofman, RPh, PhD, is Associate Professor of Phar
macy in the Clinical and Administrative Pharmacy Division, Col
lege of Pharmacy, University of Iowa. His research focuses on
issues surrounding the patient's use of the health care system, cul
tural issues in care, and delivery of pharmaceutical care to the rural
elderly. Recent publications have appeared in the Annals of Pharmacotherapy, Social Science and Medicine, and International Journal of Cross-Cultural Gerontology.

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xxix

Kenneth A. Speranza Sr., PhD, is Associate Professor of Phar


macy Administration at the University of Connecticut School of
Pharmacy. His areas of teaching and research specialization are
pharmacy law, pharmacy and research ethics, and human resources
development in managed care systems. Speranza has published
extensively in educational, scientific, and professional journals and
has made numerous presentations to professional and lay audiences.
He is a past Chairman of the Council of Faculties and Section of
Teachers of Social and Administrative Sciences, and a past member
of the Board of Directors of the American Association of Colleges
of Pharmacy.
Kent H. Summers, RPh, PhD, is the Vice President of Drug Uti
lization and Pharmacoeconomics, Prudential Pharmacy Manage
ment. He is responsible for drug utilization reviews and interven
tions, as well as pharmacoeconomic research. Prior to this,
Summers was an Assistant Professor at the University of Missis
sippi School of Pharmacy. He has authored and coauthored over 40
articles in peer-reviewed and trade journals. His research interests
include investigations of patients' and physicians' decisionmaking,
as well as pharmacoeconomic and outcomes assessments of phar
maceutical therapy. Summers received a BS in Pharmacy (1978)
and a PhD in Pharmaceutical Sciences (1989) from the University
of Missouri-Kansas City School of Pharmacy. Summers has worked
in chain drugstores and in healdi maintenance organizations. In
addition, he has over ten years of experience in the pharmaceutical
industry.
Sheryl L. Szeinbach, RPh, PhD, is currently Associate Professor
in the Department of Pharmacy Administration and Research
Associate Professor in the Research Institute of Pharmaceutical
Sciences at the University of Mississippi. She received her BS in
Pharmacy from the University of Texas at Austin (1980), MS in
Pharmacology from the University of Kentucky (1983), and PhD in
Pharmacy Administration from Purdue University in 1989. Her
research interests include the distribution of pharmaceutical prod
ucts and services, decision-making processes and risk management,
technology (automation), and pharmacoeconomic techniques used
in utility assessment. She has published over 60 papers in peer-

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reviewed journals, including the Journal of Structural Equation


Modeling, American Journal of Hospital Pharmacy, American
Journal of Pharmaceutical Education, Journal of Applied Business
Research, Journal of Health Care Marketing, Journal of Pharmaceutical Marketing & Management, Journal of Research in Pharmaceutical Economics, and The Consultant Pharmacist.
Toni Tripp-Reimer, RN, PhD, is Professor of Nursing and
Anthropology at the University of Iowa. She is Director of the
Office of Nursing Research, Development and Utilization; Director
of the Gerontological Nursing Research Center; and Director of the
Iowa-Veterans Affairs Research Consortium. Her research focuses
on self-care behavior in cultural context with an emphasis on ethnogerontology. She has over 200 published scholarly articles, book
chapters, and books.
Julie Magno Zito, PhD, is Associate Professor of Pharmacy Prac
tice and Science and Research Associate Professor of Psychiatry at
the University of Maryland at Baltimore. Her research area is phar
macoepidemiology and drug treatment refusal among those with
mental disorders. During the past ten years, these studies have been
supported by funding from the National Institutes of Mental Health
and by a state mental health agency. She is the editor and major
author of the Psychotherapeutic Drug Manual, a handbook on drug
therapy for mental disorders published by Wiley in 1994. She has
co-authored more than 20 journal articles in journals such as the
American Journal of Psychiatry and written book chapters on adult
and child psychiatry for books in the fields of pharmacoepidemiol
ogy and child psychiatry.
Mary Zwygart-Stauffacher, RN, PhD, is Assistant Professor of
Nursing and Head of the Gerontological Nurse Practitioner Program
at the University of Iowa. She maintains a primary care practice in
rural Iowa and Wisconsin. Her research is focused on long-term
care issues with emphasis on medication management.

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Foreword
Things are just not as they seem to be. First impressions provide
stark reminders of that truism as one explores in greater depth the
phenomena from which the first impression is made. More often
than not, upon more reflective study and scrutiny, what seemed
simple and mundane becomes complex and difficult to understand.
That is eminently true with human behavior. It is equally true in
foreign affairs, the life cycle of a cell, the goings-on in an organiza
tion, and a host of other examples in life. So why should it not be
true in that aspect of life that is perhaps more personal and simulta
neously affects the entire planet's population: namely, illness, sick
ness, disease, healing, health practitioners, and the systems that
attempt to bring them all together. The latter we call the health care
system; however, most of us would agree that there is little relation
ship between the concepts of system and the why's, wherefore's,
where's, and how's of the care rendered to sick individuals.
Indeed, the relationships among the individual who is sick (by
whatever criteria that may be determined), the individual who is
sought out to determine a resolution to the sickness, the institutions
where the "cure" might be obtained, and the overarching aspects of
financing and assuring appropriateness of care form one of the most
complex webs of human and institutional interactions in society, a
web which few people understand. Social and behavioral scientists
have only recently begun to study systematically the intricacies of
the web and its components. Through these studies have come more
focused approaches to caring for the patient, educating future health
care professionals, and developing dialogues with policymakers
and the general public.
That is what this book is all about. In its 30 chapters, the diverse
authors attempt to take pieces of the complex web of pharmaceuti
cal care, describe the known microcosmic components of such care,
and then relate the pieces back to the integrity of the web. The
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scrutinizing reader of this collection of important essays will find


that the behavior of the patient, the prescriber, the systems that
allow for these interactions, and ultimately, the outcomes of
medication use are, in fact, not as simple as they appear.
Beginning with the decision to seek care, it will be noted that a
variety of perceptions of health and illness exist which are drawn
from various individual, cultural, and social interpretations. Some
people interpret their illness from the perspective of stoic tolerance,
while others perceive it as minor inconvenience and simply move
on. Still others will define it as a turning point in life and conse
quently seek out the best and brightest minds to find the cure. Why
is that? Some of the answers lie in the pages you are about to read.
On the other end of the spectrum lie the issues surrounding the
outcomes of illness and the care that has been provided. Specifi
cally with regard to medication use, are the desired outcomes being
achieved and if not, why not? We know the answers to the latter
questions are also not easily determined. Interwoven in medication
use are cultural and social interpretations of chemical treatment,
including the assurances related to compliance with therapy; the
decision structures that are in place to monitor drug therapy; and the
difficulties associated with defining and measuring outcomes.
The adventure upon which you are about to embark as you read
the varied chapters of this book will likely evoke an equally varied
set of responses. Students in the health professions typically do not
like the gray zones of the social and behavioral sciences. They find
more comfort in the black and white so often attributed to the
physical and biological sciences. For readers who find themselves
in that frame of mind, this text may prove to be frustrating reading.
They may find themselves reading words on many pages and not
finding the answers they expect. They will also miss the profound
ness of human behavior.
On the other hand, the reader who approaches the reading of this
text with a real desire to understand better how behavior links to the
complexities of an individual's or social group's actions and deeds
will find an exhilarating series in the following pages. This reader
will find that microcosms of the web are as fascinating as the web
itself. To be sure, there will be few definitive answers; rather, there
will be extensive description of phenomena known to be true but

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Foreword

xxxui

which are all subject to change when new variables are introduced.
That is what makes inquiry into the social and behavioral aspects of
pharmaceutical care both challenging and frustrating.
A better understanding of and appreciation for pharmaceutical
care and its behavioral underpinnings will assuredly better prepare
pharmacists for contemporary and future roles that more closely
bind them to their patients and the prescribing community. As the
functional role of the pharmacist as direct caregiver comes to be
better understood by the patient, the pharmacist can more effec
tively influence the behavior of the patient toward achieving better
outcomes with drug therapy. On the other side of the coin, as the
pharmaceutical caregiving pharmacist comes to understand the
patient better from a behavioral perspective, the pharmacist can
create a more effective partnership as care is rendered.
Enjoy your journey and find comfort in the gray zones.
Henri R. Manasse Jr.