PRINCIPIOS Y DERECHOS CONSTITUCIONALES

1) Some pharmacists had forgotten that they had agreed to be interviewed on a particular day and had arranged locum cover. This problem was addressed by confirming appointments on the day of the interview or the previous afternoon.

2) A minority of respondents regarded the interview situation as a licence to conq)lain about pharmacy and politics in the UK. The researcher had to work hard to steer the conversation back to the interview schedule and to encourage the interviewee to answer the questions.

3) Initially the majority of pharmacists were surprised at the open-ended nature of the questions and were hesitant, not knowing what length of answers they were expected to give. The researcher had to allow interviewees time to think and then encourage them to voice their own ideas.

4) One pharmacist lacked motivation to answer the questions. The interview had been arranged by his very enthusiastic non-pharmacist wife, on his behalf, who wanted the researcher to consider buying the pharmacy when her husband retired in a couple of years. A situational problem arose, with the wife trying to answer the questions on the pharmacist's behalf. No attempt was made to tape-record this interview and the pharmacist was given great encouragement to respond by both his wife and the researcher. Although the pharmacist refused to answer some questions, it was important to obtain as much information concerning his beliefs about health promotion as possible, as his views may well have represented those of pharmacists who were unwilling to participate in the research.

5) In most cases production of the tape-recorder appeared to cause some apprehension at the start of the interview, but this uneasiness always disappeared after a few minutes. 6) The mean time taken to conduct the interviews, including interruption time was 91 minutes (range: 40 to 210 minutes). In 4 cases the interviews were completed on another day, due to the large number of interruptions on the occasion of the first visit to the pharmacy.

7) The interviews were arranged at a time of day and day of the week when the pharmacy was usually at its most quiet period so that the interview would proceed with the minimum of interruptions and elicit high quality responses. In most cases this criterion for arranging appointments meant that the majority of interviews were conducted during the early afternoon, or on a Saturday. As a result of this, and due to the various geographical locations of pharmacies, only rarely was it possible to conduct more than one interview on the same day and the data took almost 5 months to collect Interviews took place between 2 6 ^ February and 23^^ July 1992.

8) Interruptions affected the flow of the interviews, and the respondents' concentration. It was particularly important to minimise interruptions while asking Section A questions, which seemed to require more thought than the questions in Sections B and C. One solution to the problem of interruptions would have been to conduct interviews outside normal business hours. However it would have been difficult to interview 50 pharmacists at a time outside normal business hours, and this would not have enabled concurrent observation in the pharmacy.

After collection, interview data was analysed as described in chapters 3 and 4, and was used to inform the design of the postal questionnaires.

2 3 . PHASE 2: POSTAL QUESTIONNAIRES. 2.3.1 Choice of Method.

During this phase, a method of self-report was used because the survey aimed to measure pharmacists' attitudes and beliefs.

2.3.1.1 Reasons for using Postal Questionnaires.

1) To enable data collection riom a relatively large sample size. The aim was to survey 899 pharmacists, in order to collect data which would be as representative of the North Thames (East) Region as possible. A study of the literature revealed that the number of pharmacists currently involved in diagnostic testing on the premises is low (Ranscombe et al 1991, Walsh et al 1990) and in order to gather data from this sub-group of pharmacists it would be necessary to use a large sample size.

2) Postal surveys are a relatively cheap means of data collection (Moser and Kalton, 1971; Dillman, 1978). Costs of postage are far less than any expenses incurred whilst interviewers or observers are sent to gather data, e.g. the interviewers' time, travel and expenses.

3) Postal questionnaires enable a wider geographical distribution of the population to be surveyed than personal interviews and observation studies (Moser and Kalton, 1971). 4) The postal questionnaire was the only feasible method of attempting to collect responses on a large number (349) of variables, by asking closed questions, fix>m 889 pharmacists at the same time, given the resources of time, and money. It had the advantage of enabling administration to many people simultaneously in a relatively short time period (Moser and Kalton, 1971; Henerson et al, 1987).

5) It was necessary to use closed questions which would be quick and easy for the respondent to answer, and such questions are well suited to postal questionnaires.

6) The analysis of responses to closed format questions is easier and quicker than for open-ended questions and this advantage becomes increasingly important as the number of respondents increases (Henerson et al, 1987).

7) When a large range of questions are to be asked, which are single enough for respondents to answer after reading printed instructions, a postal questionnaire is the most appropriate method of data collection (Moser and Kalton, 1971; Henerson et al, 1987). Since pharmacists are well educated, it is assumed that as long as the instructions

for completion are clear, they should have no difticulty interpreting the printed instructions and a postal questionnaire is an appropriate method of data collection.

8) The postal questionnaire is particularly suitable for collection of quantitative data and is often used by positivistic researchers. Generally in positivistic social research, it is the researcher who defines variables, which are linked by a hypothesis, and then this hypothesis is tested (Brannen, 1992). Such an approach was used to test the TRA.

9) Postal questionnaires permit anonymity, and this can help to improve response rates (Henerson et al, 1987). In this survey although the pharmacy premises could be identified by the serial number on the front of the questionnaire, the pharmacist who conq)leted the questionnaire remained anonymous.

10) Some evidence suggests that people are more likely to report less socially acceptable responses on a postal questionnaire than during a face-to-face interview (Moser and Kalton, 1971).

11) There are no problems of interviewer bias associated with mail surveys (Henerson et al, 1987; Moser and Kalton, 1971).

12) The postal questionnaire is an economical way of locating rare populations, which can be studied in more depth at a later stage (Moser and Kalton, 1971). For example the questionnaire data could be used to identify the small number of pharmacists offering diagnostic testing on the premises. This could enable a detailed study of this subgroup in future, e.g. by measuring the extent up uptake of diagnostic testing, or the quality of the service provided. In addition, identification of sub-groups enables comparison between sub-groups or sets of variables.

There are a number of disadvantages associated with the use of postal questionnaires:- 1) There is no flexibility in questioning and no opportunity for researchers to probe for information fi*om respondents (Moser and Kalton, 1971; Henerson et al, 1987).

2) It is easier for most people to express their views orally than in writing (Henerson et al, 1987).

3) (Questionnaire fatigue can be a problem with lengthy survey instruments.

response rates adversely. During the follow-up telephone calls, one respondent exclaimed that he had received 3 different questionnaires within the last 3 months.

5) A major disadvantage is that of non-response (Moser and Kalton, 1971). If the response rate is low, the results cannot be extrapolated to the survey population and there is a danger that the results are in fact biased. Previous response rates for surveys of community pharmacists in the North Thames (East) Region suggest that the postal questionnaire may be an appropriate instrument for the population in question (Shafford and Sharpe, 1988; Glanz et al, 1990).

6) The responses must be accepted as final (Moser and Kalton, 1971). An attempt was made to check a selection of questions from a sangle of replies, to provide a measure of correspondence between self-report of the community pharmacist and direct observation by the researcher.

7) Postal questionnaires are inappropriate for asking questions which require sequencing or for obtaining spontaneous answers (Moser and Kalton, 1971; Henerson et al, 1987). The pharmacists could read all of the questions before answering any of them.

8) Postal questionnaires provide no opportunity for the researcher to actively encourage the respondent to reply to particular questions (Moser and Kalton, 1971).

9) There is no guarantee that the responses are those of the respondents alone, and that they have not discussed the questions with other people (Moser and Kalton, 1971).

10) The researcher cannot be sure that the person who has completed the questionnaire is the person to whom it was addressed, especially if it was not addressed to that person by name (Moser and Kalton, 1971).

11) Postal questionnaires provide no opportunity for respondents' answers to be supplemented by observational data (Moser and Kalton, 1971).

For the purposes of achieving the objectives of phase 2, the advantages of administering a postal questionnaire far outweighed the disadvantages. The decision to use a postal survey was largely influenced by the nature of the research questions.

2JL2 Content of the Survey Instrument

The postal questionnaire was designed to provide the following measures in relation to the 8 disease prevention services (Appendix 4):-

2) perceived customer demand (Section A -question 3)

3) the pharmacist's attitude towards providing the service in an ideal situation (Section B -question 1)

4) the pharmacist's attitude towards providing the service, given current working constraints (Section B -question 2)

5) the pharmacist's intention towards providing the service within the next 6 months (Section B -question 3)

6) the pharmacist's subjective norm (Section C -question 1)

7) whether the decision to provide the service lies with the pharmacist completing the questionnaire (Section C -question 2)

8) the salient beliefs of the pharmacist (Section D and Section G) 9) the normative beliefs of the pharmacist (Section E and Section F)

10) socio-demographic information (Section H -question 1 to 10, and 15) 11) previous availability of related services (Section H -questions 12 to 14).

Socio-demographic variables were included to determine whether service provision was associated with any of these variables in particular. The status of pharmacists may influence their attitudes, e.g. owners may be more concerned with financial viability than employee pharmacists. Pharmacist who have been on the register for over 30 years will have undergone different methods of training than those more recently qualified and this may affect both their attitudes and behaviour towards health promotion.

The content of the postal questionnaire was largely determined by the variables that had to be measured in order to test the TRA. The "perceived customer demand" variable and the question of with whom the decision for service provision lay, were included after consideration of the findings of phase 1. The nature of the TRA dictated that the majority of the questionnaire would be used to measure pharmacists' attitudes and beliefs towards disease prevention services.