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Practicing Health Promotion Through Pharmacy Counseling Activities Ashish Chandra, Nathaniel Malcolm, II and Margery Fetters Health Promot Pract 2003; 4; 64 DOI: 10.1177/1524839902238293 The online version of this article can be found at: http://hpp.sagepub.com/cgi/content/abstract/4/1/64

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HEALTH PROMOTION PRACTICE / January 2003 ARTICLE

Practicing Health Promotion Through Pharmacy Counseling Activities Ashish Chandra, MMS, MBA, PhD Nathaniel Malcolm II, BS, PharmD Margery Fetters, MBA, MS

Dramatic changes in the U.S. health care system have emphasized the need to promote good health. To achieve this, different types of health care professionals have now started working together. These teams often include participants, such as doctors, pharmacists, and nurses. However, there are many health professionals, such as pharmacists, working in noninstitutionalized settings, such as pharmacies, who are not being fully utilized. One of the ways pharmacists can promote good health is by counseling patients. This article provides some insights regarding the various health promotion activities that are or can be performed by pharmacists. Health promotion educators can play a significant role in educating pharmacists to become effective health promoters. Some hypothetical scenarios and examples, as well as models, are also provided to demonstrate active health promotion through pharmacist counseling activities.

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ver the past few decades, the U.S. health care system has seen some significant changes. These dramatic changes have made the system, which includes both public and private health care institutions, more confusing, turbulent, and alarming for health care consumers (Ginter, Swayne, & Duncan, 1998). It has also been observed that many health care professionals are spending less time on patient evaluation. At the same time, through various media, consumers have become more aware of health care and are taking a greater interest in their health care status. When these situations are combined, there is great potential to create a volatile predicament for health care providers and consumers. Another major factor that has significantly affected the health care system relates to escalating health care costs. This is, perhaps, the main reason why more and more consumers are seeking added insurance benefits Health Promotion Practice / January 2003 Vol. 4, No. 1, 64-71 DOI: 10.1177/1524839902238293 ©2003 Sage Publications

from their employers. Many health insurance providers do not cover doctors’ visits to patients’ homes. This has drastically reduced the number of doctors making house calls. Most patients visit a doctor either at his or her private practice office or in a hospital. Expenditurewise, hospitals are, in fact, the largest segment of the health care industry, absorbing about 36% of all health care expenditure dollars. Drug and other medical nondurable products absorb only 9.4% of the overall health care expenditures (Cleverley, 1997). It has been commonly observed that if drug costs go up by only a few cents, the health care consumer becomes concerned. On the other hand, many consumers tend not to express concern if there is an increase of a few dollars at the health care institution. One of the main reasons for not questioning the increased expense could be that consumers may perceive that they are getting more service for their money. Hence, it is extremely important for pharmacies and pharmacists to provide a service that is considered of some value by the consumer. Pharmacists should alert consumers that they are also part of the health care team. There are many types of health care professionals involved in the treatment of a patient, such as doctors, nurses, and pharmacists. Besides these professionals, there are others who are also considered valuable members of the health care team offering important health care services to the patient. Doctors often provide patient care activities in both institutionalized and noninstitutionalized settings. The average physician writes about 8,000 prescriptions per year for prescription as well as nonprescription medications, and currently over 2 billion prescriptions are dispensed annually (Holt, McCrory, Norris, & Sandler, 1996). Nurses, on the other hand, provide most of the services in an institutionalized setting. Most pharmacists provide their services in an independent setting, often not located in the health care institution. Some of the pharmacists’ duties include monitoring patients’ profiles, recognizing possible adverse drug affects, compounding drugs as directed in the doctors’ prescription orders, and counseling patients regarding their prescription’s and over-thecounter medications’ interactions. Consumers purchase hundreds of millions of dollars worth of nonprescrip-

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tion (over-the-counter) medications (Mayo Clinic, 1993). In recent years, pharmacists have also begun going on rounds with physicians and providing patient counseling regarding drug therapies in an institutionalized setting. Counseling has become a very important component of the pharmaceutical profession. Most colleges of pharmacy have incorporated required courses to educate pharmacy students in counseling and communication skills (Molzon, 1992). Counseling is actually considered a free, value-added service offered in pharmacies by highly trained health care professionals. Counseling can help promote good health by intervening in, and often monitoring, patients’ drug therapy. This can be beneficial by early detection of possible adverse drug interactions, which can often be fatal or expensive if not detected early. Counseling can also help educate consumers regarding their condition and can facilitate patient compliance. In fact, the law in most states now requires counseling.

IS THE LAW: > COUNSELING ROLE OF OMNIBUS BUDGET RECONCILIATION ACT OF 1990 (OBRA 1990) IN PATIENT COUNSELING OBRA 1990 is one of the most important laws affecting patient counseling activities in a pharmacy setting. OBRA 1990 instituted an important pharmacy-related provision that went into effect on January 1, 1993. The key provisions of this legislation were to increase the pharmacist’s responsibilities to educate and counsel patients about prescribed drugs, to assure the appropriateness of the prescribed therapies or prospective drug utilization review, and to provide for the collection of patient information (OBRA, 1990; Perri, Kotzan, Pritchard, Ozburn, & Francisco, 1995). According to this provision, pharmacists must offer counseling to all Medicaid patients (Brenner, 1992; OBRA, 1990). Since then, most state boards of pharmacy (44 out of 50) have passed legislation mandating that pharmacists should provide patient counseling to all patients, not just Medicaid patients (Perri et al., 1995). OBRA 1990 established increased responsibilities for the pharmacist, from being only a dispenser of medications to a health professional who helps ensure proper use of prescribed medications. The passage of OBRA 1990 had specific implications for the practice of pharmacy. First, pharmacists were required to offer counseling to Medicaid patients when a new prescribed medication or a refill for an existing prescription was dispensed. Second, it required state Medicaid programs to establish drug use review programs that rely heavily on pharmacists’ expertise. Last, OBRA 1990 authorized demonstration programs to determine the effect of reimbursement of pharmacists for patient counseling (Christensen et al., 1999). OBRA 1990 has saved the Medicaid program millions of dollars annually by en-

The Authors Ashish Chandra, MMS, MBA, PhD, is an associate professor in the Graduate School of Management, Marshall University Graduate College, South Charleston, West Virginia. Margery Fetters, MBA, MS, is associate professor of marketing and management, North Central College, Naperville, Illinois, and currently owner of CS Consultants. Nathaniel Malcolm II, BS, PharmD, is a GlaxoSmithKline Pharmacoeconomic and Health Outcomes Post Doctoral Fellow and a candidate for the masters in pharmaceutical administration at The Ohio State University.

couraging manufacturers to give state Medicaid programs the opportunity to purchase drugs at the lowest prices available to any health care entity within the United States (Christensen et al., 1999). A study conducted at the University of Mississippi indicated that pharmacists derive professional satisfaction from counseling patients (Meade, 1995). Though data regarding the success or failure of OBRA 1990 are scarce, there is anecdotal evidence that this law is having a positive effect on patients and the pharmaceutical profession (Meade, 1995; Torg, 1992). A study conducted in Georgia indicated that even though the number of patients counseled by pharmacists has increased in the post-OBRA period, the amount of time spent collecting patient information and patient counseling has decreased (Perri et al., 1995). The same study also indicated that only 12.4% of consumers surveyed were aware of the OBRA 1990 legislation. Of those consumers who received prescriptions since the OBRA 1990 legislation took effect in January 1993, only 33% indicated that the pharmacist personally counseled them about their prescriptions. In an effort to comply with OBRA 1990 regulations, many pharmacists often face several barriers. Some of the factors affecting counseling activities, as determined by pharmacists, include excessive workload, lack of financial compensation, and patients’ attitudes. According to a study by Barnes, Riedlinger, McClosky, and Montagne (1996), almost half of the responding pharmacists indicated that OBRA 1990 regulations had not affected or changed their practice, one quarter of the pharmacists believed their practice was less rewarding after implementation of OBRA 1990, and about one fifth believed it was more rewarding. This demonstrates that patient interaction cannot be legislated but can be developed through motivation and appropriate reimbursement. In a study by Scott and Miller (1999), it was determined that pharmacists spend 13% of their day on patient counseling. These respondents reported that there was an increase in the time spent by them on counseling, which was a direct result of OBRA 1990. The average increase was 2.8 minutes at an estimated cost of $4.63 per prescription filled. As mentioned earlier, OBRA 1990 requires the pharmacist to offer counseling Chandra et al. / PHARMACY COUNSELING ACTIVITIES

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with each prescription filled for a Medicaid patient. However, a significant majority of the pharmacies and the pharmacists had not been compensated for these additional costs. Only 8% of the pharmacists have charged for patient counseling, and only 2.8% of those pharmacists were reimbursed. In essence, only 33% of those pharmacists who have charged for patient counseling have been paid or reimbursed (Scott & Miller, 1999). Pharmacists seem to have minimal economic incentive to provide patient counseling because it is unlikely that they will be reimbursed. Lack of pharmaceutical care can negatively affect both the physical and emotional well-being of the patient and adversely affect insurers who often bear the drug-induced morbidity and mortality costs. Clearly, it would be beneficial to the patient, the patient’s pharmacist, and the patient’s insurer to advance financial compensation policies that will foster increased patient access to pharmaceutical care and promote good health.

PROMOTION BY > HEALTH WAY OF COUNSELING A well-accepted definition of health promotion is the “science and art of helping people change their lifestyle to move toward a state of optimal health” (O’Donnell, 1986, p. 4). Over the years, it has been observed that health care professionals have changed the way they provide health care services to their patients. The patient care model of practice has changed from being a practitioner-centered model, in which the patient was acted upon, to being a patient-centered model in which the patient is considered an active participant in the treatment regimen (Tindall, Beardsley, & Kimberlin, 1994). In the practitioner-centered model, the patient’s opinion was not considered paramount. It was thought that the health care provider’s opinion superceded any opinion expressed by the patient. However, with the increasing adoption of the patient-centered model, health care professionals have started paying more attention to the opinions expressed by patients. Patients are also being encouraged to take a more active role in their health care, and, as a result, counseling is now considered an invaluable aspect of any patient care services. This includes pharmaceutical care provided by health care professionals such as doctors and pharmacists. Currently, pharmacists are in an excellent position to actively promote good health through patient counseling activities. Pharmacists are considered one of the most respected health care professional groups. In a Gallup poll ranking 25 different professions for honesty and ethics among its practitioners, two thirds of the respondents rated pharmacists as the most respected of all professionals (Haddad, 1990). A study titled “Patients’ Perceptions of Increased Pharmacy Contact” found that patients desired and appreciated greater contact with pharmacists because they sensed that pharmacists were approachable and were highly regarded for their ability to communicate useful health-related information 66

(Erstand, Draugalis, Waldrop, Scheurer, & Namanny, 1994). Perhaps one of the most enticing factors for patients was that pharmacists do not charge for their counseling services. Counseling is important for pharmacists and patients. Very often, patients do not fully understand another health professional’s advice. They may think of additional questions they intended to ask the health care provider but were unable to ask due to lack of time during their office visit. The inability to get an answer to their question may be quite disturbing to patients. If they get the answer to their question, they will have greater peace of mind. The next source for answering the patient’s questions is perhaps the local pharmacist, and often patients ask the pharmacist the most daunting questions. Many pharmacists take time to provide adequate answers to the patients’ questions in a manner that is nontechnical and can be understood by a layperson. As a result, patients may be very receptive to information provided by the pharmacist, irrespective of whether it is new information or reinforcement of information given earlier. Pharmacists have many opportunities to counsel and intervene at the individual level. Counseling can include intervening in a patient’s drug therapy, providing education to patients about their condition, and, ultimately, helping improve patient compliance. Pharmacist Intervention in Drug Therapy Intervention is necessary to prevent any potential health problems caused by adverse drug reactions. There are some common steps that a pharmacist takes to prevent potential drug-related problems. In the case of a new prescription for a patient, the pharmacist reviews the patient’s profile for patient history and obtains additional history from the patient, if necessary, such as over-the-counter drug product use. The pharmacist may assess the patient’s profile on the computer for current drug use, interacting medications, duplicate therapies, contraindications to the patient’s condition, and patient’s age. If there are potential problems, the pharmacist contacts the patient or physician who prescribed the medication for further information to intervene with appropriate recommendations (Rupp, 1992). Pharmacists usually intervene in patient drug therapy with the elderly. Elderly patients are most likely to be taking multiple medications and may have a potential adverse drug reaction. According to a study, age itself has not correlated with adverse drug reactions, but the presence of multiple conditions or multiple medications do correlate with the incidence of adverse drug reactions (Grymonpre, Mitenko, & Sitar, 1988). The number of medications taken is also correlated with the number of potential drug interactions and drug problems in the elderly (Johnson, 1991). Pharmacists can easily detect drug problems by identifying multiple medications the patient is taking by reviewing the patient’s profile on the pharmacy’s com-

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puter system and providing intervention as appropriate. Providing appropriate intervention can improve a person’s health. A study by Chin, Muller, and Lucarelli (1995) evaluated pharmacists’ contribution to patient care through an intervention program. The most common interventions that had an impact on patient care were recorded, 2,499 in all. The most common types of interventions were clarification and change of prescription order (18%), consultation on how medications work in the body (16%), and review of patients’ charts and profiles (13%). These interventions had impact on patients. Forty-one percent of the people had decreased drug toxicity levels, 17% had decreased money spent on medication, 16% avoided drug interaction, and 8% improved compliance with the medication. If it is determined that the prescription drug should be dispensed, the pharmacist will counsel the patient about the appropriate use of the drug product and potential drug interactions. The pharmacist usually discusses signs and symptoms of potential problems, how to avoid problems, and the importance of compliance. After counseling the patient, the pharmacist may also provide an information leaflet about the newly dispensed medication for the patient to take home (Kimberlin, Bernardo, Pendergast, & McKenzie, 1993). Educating Patients About Their Diseases Educating patients may help people to be more motivated to maintain good health. The pharmacist can provide added motivation to the patient by demonstrating an interest in the patient’s progress through his or her therapy and disease state. A motivated patient is more likely to engage in positive lifestyle changes. By educating patients about their diseases, the pharmacist can help them assume more responsibility for restoring and maintaining their health. The scenarios below are examples of how health promotion is included in pharmacy practice: Scenario 1 A mother presents a prescription for an antibiotic for her child’s upper respiratory tract infection. The pharmacist notes from the child’s patient profile that the child has had recurrent respiratory tract infections in the past 3 months. While being counseled on the proper use of the medication, the mother expresses concern about her child’s frequent infections. The pharmacist asks her if anyone in the household smokes, and she replies that she does. At this time she may be willing to consider the fact that her smoking may aggravate her child’s infections, and she and her child could benefit if she stopped smoking. The pharmacist, at this opportunity, may point out these benefits and refer her to a program to stop smoking or to see a physician. The pharmacist can also point out the various over-the-counter smoking cessation aids that are readily available to consumers. However, in doing so, the pharmacist should not breach the concept of fidelity, that is, push for the

best product available and not the one that will make the most profit (Tindall, Beardsley, Kimberlin 1994). Scenario 2 A man with high blood pressure comes into the pharmacy to have his prescription for an antihypertensive drug refilled. Before filling the prescription the pharmacist may ask him if he has had his blood pressure checked. He replies that he has not checked his blood pressure in a while and wonders about his blood pressure level. The pharmacist may ask the patient if he has consumed meals high in sodium, and he replies yes. The pharmacist tells the man that food high in sodium may elevate blood pressure, that it would benefit him to reduce his intake, and that he should go back to see his physician. At this point, the patient may realize the importance of the pharmacist’s advice and take appropriate action to prevent any further complications associated with high blood pressure.

Counseling Improves Compliance Often when the pharmacist asks a patient “What problems are you having with your medicine?” the response is “None.” Although in many cases this is the truth and the patient is not experiencing any adverse effects, the pharmacist may raise more specific questions. The pharmacist may use a head-to-toe approach, which involves inquiring about adverse effects one at a time, from head to toe (Lewis, Lasack, Lambert, & Connor, 1997). For example, a patient prescribed Coumadin (generic name warfarin) could be asked about nosebleeds, bleeding gums, or unusual bruising. Going from head to toe helps the pharmacist keep track of the questions and provides some continuity for the patient as well. At the time of assessing for compliance the pharmacist can make the patient feel comfortable, especially if the pharmacist senses that the patient has not been fully compliant. If the patient feels comfortable, he or she will more willingly be truthful. Also, pharmacists may inform patients that change in their drug therapy might be based on the physician’s understanding of what medication they are taking. For example, a patient with uncontrolled blood pressure due to noncompliance may be started on new medications. Often, the patient is unhappy because he or she does not want to take another medication. It is important for the patient to understand that if compliance is achieved, medications might then be eliminated.

TECHNIQUES AND > ALTERNATIVE CHANNELS OF COMMUNICATION FOR COUNSELING ACTIVITIES In the concept of pharmaceutical care, one of the most important services that a pharmacist offers is counseling a patient on the appropriate use of pharmaceutical products (Hepler & Strand, 1989). Patients should have a good understanding of the nature of their drug therapies. For example, the patient should know Chandra et al. / PHARMACY COUNSELING ACTIVITIES

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about the drug doses, how long the drug should be administered, and the possible side effects of the drug. Most pharmacies are not designed for effective pharmacist-patient interaction. In most instances, the pharmacist is physically removed from the patient by several feet—a counter, glass partition, or other physical barrier (Tindall et al., 1994). However, some pharmacies have designated private areas for confidential discussions, free Evolving Channel of Communication from distractions or interruptions. Aside from having an environment that may or may not be conducive to pharmacist-patient interaction, many pharmacists try to effectively communicate with the patients. Pharmacists will try to make the patient feel comfortable by allocating space for a more desirable one-on-one private conversation. Many people like to talk about their medical problems without other people standing next to them. Any element of privacy and confidentiality allows for better pharmacist-patient interaction. The most common communication techniques used in patient-pharmacist communication are the telephone and face-to-face, interpersonal communication. However, it has FIGURE 1 Information Flow and Modes of Communication Between been observed that in some pharmacies, Patient and Pharmacist patients are now communicating via e-mail (see Figure 1). This technologically advanced Online communication between the patient and the communication technique requires certain equipment, pharmacist is currently in its developmental stage (see such as computers, and technological skills for both Figure 1). The benefits of online communication are participants. This form of communication may not that pharmacies can provide a customer with written always be possible and feasible, however, considering product information, references to other sources of inthe cost of the technology for the consumer. formation, and updated information. It will take some Most of the time the patient-pharmacist interaction is time to determine whether or not both the consumer for the purpose of dispensing medication to the conand the pharmacist accept this technology-based comsumer. This may be for a new prescription or for a refill. munication technique. However, this form of communiFor a new prescription, the patient-pharmacist interaccation is quite prevalent between the pharmacy and the tion is often face to face. However, it has been observed insurance company. that more and more consumers are requesting refills via the telephone and come at a later time to pick them up. Technique of Adapting to Because a large percentage of requests for refills are bePatients’ Behavioral Changes ing made via the telephone, many pharmacies have installed an automated telephone system to reduce the Anyone who has ever tried to change a person’s bemanpower needed to answer each telephone request. havior knows how difficult it can be. A way for pharmaConsumer requests via the telephone appear on a comcists to understand patients’ behavioral changes is to faputer monitor and are sorted according to the time they miliarize themselves with recent developments in the were received. This sort of refill request has proved to study of scientific change. One study that integrates perbe quite beneficial for the pharmacists. They have more spectives to describe and explain behavioral change is time to perform other activities, such as counseling, bethe model developed by Procheska, DiClemente, and cause the pharmacy technician usually takes the request Norcross (1992). The key insight of the model is behavand fills the prescription. The pharmacist merely ior changes at each stage, and pharmacists need to gauge checks the prescription for proper dispensing and apwhat stage of change patients are at before deciding to propriate authorization by the insurance company. intervene (Procheska et al., 1992). For instance, a newly Other studies have indicated that telephone calls in diagnosed diabetic patient has different needs than a pharmacies do interfere with the professional duties of person who has lived with the disease for 10 years. A the pharmacist because a large percentage of the calls do person who needs to alter unhealthy behaviors has difnot even require the expertise of a pharmacist (Chandra, ferent needs than a person who is trying to maintain a Blake, & Holt, 1996). newly adopted healthy behavior.

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Because patients will be at varying stages of behavioral changes to improve their health and maximize therapeutic outcomes, the pharmacist’s counseling techniques need to adapt to change. Pharmacists may need to be more sensitive to the damage that illness can do to a patient’s self-image. Lambert, Street, and Cegala (1997) suggested that staying healthy is a matter of maintaining a balance between self-image and performance. Self-image is a person’s understanding of his or her own identity and performance of activities of daily living (Lambert et al., 1997). Pharmacists communicate effectively when they keep in mind each patient’s need to balance self-image and performance. New medications and new adverse drug reactions may upset this balance, with serious consequences for the patient’s quality of life (Lambert et al., 1997). For instance, a man who has hair loss may perceive himself as a healthy, sexually active male with a full head of hair. When this patient becomes impotent as a result of a medication to treat hair loss, the balance between self-image and performance is upset, and he begins to feel unhealthy. He may then change his selfimage and see himself as a bald, sexually active male instead of a sexually active male with a full head of hair. Also, he may alter his performance by stopping the medication or asking the doctor to prescribe a different medication to treat his hair loss. The option chosen by the patient may be at least partially dependent on his relationship with his pharmacist. That example points out the concept of balance, because it shows that patient counseling often requires the pharmacist to raise issues that may not be comfortable for the patient or the pharmacist to discuss. These discussions are sometimes necessary to enable the pharmacist to ensure appropriate drug therapy outcome. Pharmacist-Patient Communication Models Many patient counseling models are currently in place, and some of them are extremely valuable. Two of these models are the pharmacy consultation program by Pfizer (1995) and the health communication model by Svarstad (1986). The pharmacy consultation program was developed for pharmacists, whereas the health communication model was developed primarily for physicians but is often used by pharmacists. Irrespective of whom these models were created for, both had a common purpose to improve patient health through various promotional activities. The pharmacy-consulting program by Pfizer (1995) is based on open-ended questions that help determine the patient’s knowledge of his or her disease and medications. This ensures that by the end of the counseling session the patient understands how to use medications and what to expect from the medications. Open-ended questions usually start with words like how, why, what, or when. An example of an open-ended question is “What did the doctor tell you that your medication is

used for?” (Pfizer, 1995). Open-ended questions are usually better than closed-end questions because they give an opportunity to the patient to express their feelings, concerns, and expectations more clearly in their own terms. After using open-ended questions, many specific points should be discussed for every new medication, as suggested by OBRA 1990. The name, dosage, route of administration, and duration of use should be addressed when counseling a patient. Furthermore, the pharmacist should address common side effects, drug interactions, techniques for self-monitoring therapy, and prescription refill information (Martin, 1993). This will help the health care professional in identifying possible drug-related mishaps, such as drug interactions, noncompliance, and other concerns that may hinder the patients’ health and the patients’ perception of their health. Another patient counseling model is the health communication model (Svarstad, 1986). This model reflects the primary importance of the patient-health provider relationship in ensuring compliance and provides strategies for enhancing patient understanding. The strategies for enhancing patient comprehension are providing clear directions for what the patient is supposed to do and explaining the purpose of the therapy. This information should be repeated and patients should be provided simplified instructions in lay terms. Also, the health provider should offer written information together with the oral counseling. If there are multiple visits by the same patient, the health provider should offer consistent advice and recommendations.

OF HEALTH EDUCATOR > ROLE IN PREPARING PHARMACIST Now that patients are becoming active participants in their health care, it is extremely vital for pharmacists to be promoters of good health to consumers. The pharmacist must have a good understanding of the various social and behavioral aspects as well as the physiological aspects of the consumer. Though pharmacists are provided some understanding of these aspects in most pharmacy programs, there is now an increasing need to pay greater attention to these issues during their professional education. Health promotion educators often spend a great deal of time in understanding and analyzing the social and behavioral aspects of consumers’ health. Pharmacists, on the other hand, spend more time in understanding the physiological and other scientific aspects as they relate to consumers’ health. Hence, by training and education, health promotion educators may perhaps be the most effective individuals to educate pharmacists about the various sociobehavioral aspects of the consumer, making pharmacists effective and good health promoters. In the opinion of the authors, it would be better to have a nonpharmacist individual involved in health promotion training for pharmacists. We believe that Chandra et al. / PHARMACY COUNSELING ACTIVITIES

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these individuals may be able to provide the information in a nonscientific, unbiased manner. Even though the health promotion educators may not be scientifically trained health care professionals, they have the ability to provide knowledge and good health promotion strategies utilizing an outsider’s perspective. They can also be contributing members of the health care team. Health promotion educators can also assist pharmacists in developing innovative educational tools for high-risk individual consumers. They can help the pharmacists in the development of appropriate evaluation tools that can help assess the impact and effectiveness of the patients’ education efforts. It is highly recommended that these evaluations should be performed using standardized forms. These forms should be carefully modified, as and when necessary.

> CONCLUSIONS

Patient counseling should be viewed as only one component of the overall drug-use process. However, this activity should not be ignored or inadequately performed because it may hinder good health promotion practice. As consumers become more aware of the various laws that affect their health, such as OBRA 1990, it can be safely assumed that the demand for pharmacist counseling is likely to increase. To counsel patients effectively about use of medication, pharmacists need to appreciate the personal impact of illnesses and understand communication models. Pharmacists should become well accustomed to the various channels of communication, particularly the Internet and e-mail channel because it may be prevalent in the future. Health promotion educators can play a significant role in educating pharmacists regarding appropriate, effective communication styles. Hence, it is increasingly important to consider health promotion educators as vital members of the overall health care team. This article can serve as one of the starting points for a future study to assess the impact of the association between pharmacists and health promotion educators on consumers’ health.

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