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MH17104) and the National Institute on Drug gamblers in treatment: update and comparisons. Washington, DC: US Public Health Service; 1981.
Abuse (DA00209). J Gambling Behav. 1989;5:53-65. 19. Robins LN, Helzer JE, Croughan J, et al. The
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psychiatric admissions service. Hosp Commu- identification of pathological gamblers. Am J sion criteria of DSM-III: a study of co-occur-
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4. Lesieur HR, Blume SB, Zoppa RM. Alcoholism, 14. Volberg RA. The prevalence and demographics Psychiatry. 1984;41 :983-989.
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8. Ciarrocchi J, Richardson R. Profile of compulsive NIMHDiagnostic Interview Schedule. Version 3. ciation; 1994.
Promoting Skin Cancer Prevention
Counseling by Pharmacists
Joni A. Mayer, PhD, Laura Eckhardt, MPH, Barbara M. Stepanski, MPH,
James F. Sallis, PhD, John P. Elder, PhD, MPH, Donald J. Slymen, PhD,
. ......O :.Th.is st4d. . . . . . .
bjectiv.es. Lorri Creech, MPH, Gerald Graf, MS, Richard C. Palmer, MPH,
Christy Rosenberg, MPH, and Sandra T. Souvignier, MPH
Introduction that although willingness to offer skin cancer
prevention counseling was high, actual coun-
:;wdtrAt;:i:tcs:,.te of>ij To aid in the primary prevention ofboth seling rates were low." The randomized, con-
.. oneing rtsbft~n ie h melanoma and nonmelanoma skin cancers, trolled trial described in this paper tested the
US health organizations have endorsed the effects of a multicomponent, pharmacy-based
involvement of health professionals in pro- intervention called Project SUNWISE on skin
confedrts moting ultraviolet radiation (UVR) exposure cancer prevention counseling rates.
reduction behaviors among the general popu-
Cocaos Vt rslt lation.12 As one group of health professionals,
phannacists have great potential as skin cancer
prevention educators because they are viewed
proportions;were 3.1/o an66 7/~1 a as credible,3 have the opportunity to help the With the exception of James F. Sallis, who is with
respectivel (P..001 patient select an appropriate sunscreen product, the Department of Psychology, the authors are
come into contact with large numbers of indi- with the Graduate School of Public Health, San
that the ittsto a ucsfu n Diego State University, San Diego, Calif.
viduals, and routinely counsel patients on pre- Requests for reprints should be sent to Joni A.
scription and over-the-counter medicationsF7 Mayer, PhD, Graduate School of Public Health,
-role iin edcaigteukbo.an and other health topics.>'0 Results of an earlier Hardy Tower 119, San Diego State University, San
cancer
: ( IPub- survey conducted by our research group with Diego, CA 92182-4162.
lic Health. 1998;8 -1099) a random sample of pharmacists indicated This paper was accepted September 26, 1998.
July 1998, Vol. 88, No. 7
1096 American'Journalof'fPblc "ea
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Methods TABLE 1-Analysis of Verbal Counseling at Posttest Using Generalized
Estimating Equations
Study Design and Settings
Regression Estimate SE P
This study employed a randomized con-
trol group design, with phmacy site as the Model 1
unit ofrandomization. From 3 large phrmacy Condition (1 = intervention, 0= control) 3.72 1.023 <.001
chains in San Diego County, 54 sites (out of Model 2
Condition 3.53 1.012 <.001
88) were selected on the basis ofhighest pro- Age (continuous) 0.004 0.022 .85
portions of non-Hispanic Whites in the site's Sex (1 = female, 0 = male) -0.011 0.571 .98
census tract12; skin cancer risk is highest in
this group.'3"4 Within each chain, half of the
selected sites were randomly assigned to the
control group and half to the intervention diately prior to intervention and 4 times in the intervention consisted oftaining provided by a
group. week following intervention; there was a 7- videotape'6 and accompanying print materials;
As part of the informed consent proce- week pretest-posttest interval. All visits feedback on the site's weekly skin cancer pre-
dures, all pharmacists were informed that "on occurred during the summer of 1996. Confed- vention counseling performance, plus incen-
several occasions during the study, project staff erates were blinded to pharmacy study condi- tives for the "winning" perfommance; and envi-
will visit the pharmacy posing as patients and tions. ronmental prompts. The 23-minute videotape
will note whether pharmacists discuss skin On entering the pharmacy, the confeder- contained didactic information about skin can-
cancer prevention." Only one pharmacist ate asked to speak to the pharmacist ifanother cer prevention, a model ("Ask, Advise, and
requested that she not be observed by the study staff person (e.g., a technician) was present. Assist") to help phannacists give brief coun-
confederates. Pretexts were administered only to pharma- seling to their patients,'7 and 6 brief scenes
cists pernanently employed at the site. During showing pharmacist-patient interactions. In
Dependent Measures the interaction, the confederate detenrined the each scene, the patient and phannacist are dis-
pharmacist's identity from his or her name tag. cussing an issue (similar to the pretext topics)
The primaIy dependent measure was the Immediately upon exiting the pharmacy, the and the pharmacist provides skin cancer pre-
rate of skin cancer prevention counseling by confederate recorded the pharmacist's name vention counseling. Intervention pharmacists
on-duty pharmacists as assessed by confeder- and specific verbal response to the pretext and had the option of receiving 1 CEU if they com-
ates. Eight individuals were trained to serve noted whether or not the pharmacist gave the pleted the program's posttest.
as evaluation confederates who posed as confederate a project-supplied skin cancer Project staff delivered the video programs
patients, and each rotated once through all 54 brochure and/or sunscreen sample. (one per phannacist) to the intervention sites
sites. Confedertes initiated an interaction with To be considered counseling, the phar- and met with each pharmacy manager to
the pharmacist using a "pretext," which was macist's verbal response had to include a gen- explain all intervention components. This phar-
a pre-assigned question (one routinely asked by eral or specific recommendation about reduc- macist was instructed to distribute the remain-
patients) about an over-the-counter or pre- ing UVR exposure. For example, the following ing materials and explain the program to the
scription medication. Pretexts, which were response to a photosensitizer pretext met the other permanent pharmacists.
developed through extensive formative evalu- criterion for counseling: "Ths medication will Approximately 3 weeks after the video
ation, consisted of 4 matched pairs of ques- increase your chance of burning and you programs were delivered, procedures related to
tions asked of the pharmacists; the items in should wear a good sunscreen." An example of the feedback component were initiated. Three
each pair were counterbalanced between pre- a response that did not meet the criterion was times per week over a 3-week interval, 9 feed-
and postintervention visits. The 8 pretexts were "This medication can cause sun sensitivity, back confederates, who were different from the
nested within confederates. Pretexts were especially since you have fair skin." evaluation confederates, visited the interven-
designed to give varying levels of cues regard- During the intervention, the project pro- tion sites and administered pretexts similar to
ing UVR exposure and fell into 3 categories. vided large quantities of skin cancer prevention those used in the evaluation. Each confederate
Photosensitizer pretexts (one matched pair), brochures. Brochure counts were used as a was assigned one pretext and visited each site
which the investigators predicted would pro- process measure to estimate the number of once. There were 3 pretexts in each category
vide the strongest cues, asked about a photo- patients reached. The number of intervention (photosensitizer, outdoor activity, and general.)
sensitizing drug. However, the questions were pharmacists who obtained the continuing edu- At each site, after each week's visits had been
unrelated to the drug's photosensitizing side cation unit (CEU) offered by the project was completed, written feedback on the site's coun-
effects (e.g., "I am taking Minocin. Can I have also monitored. seling perfomce (entage counseled out of
a glass of wine or beer with dinner?"). Out- the 3 opportuities) was posted on the employee
door activity pretexts (2 pairs) noted that the Intervention Procedures bulletin board and placed in the pharmacists'
patient would be spending time outdoors and mailboxes. The performance ofthe other inter-
inquired about a related product (e.g., "I'm The goal of the intervention was to train vention sites, as well as general feedback on
going sailing this weekend. Is Dramamine the phannacists to encourage all patients to reduce number of brochures and samples given out,
best thing to take for seasickness?"). General UVR exposure by verbal counseling or by pro- was also posted. Informal contacts by project
pretexts (1 pair) contained no cues related to viding a skin cancer brochure or sunscreen staffwere used to enhance the written feedba
UVR exposure or photosensitivity (e.g., "How sample. Phannacists were trained to counsel For the feedback, in order to reward any
long can I take a medication after it has on the combination of avoidance of UVR expo- attempts at skin cancer prevention education, a
expired?"). sure during peak sunlight hours and use of sun- broader definition of counseling was used (i.e.,
Each pharmacy was visited by evalua- screen with a sun protection factor of 15 or either counseling verbally, giving a brochure,
tion confederates 4 times in the week imme- higher, protective clothing, and shade.'5 The or givmg a sunscreen sample). Pharmacists were
July 1998, Vol. 88, No. 7 American Journal of Public Health 1097
Public Health Briefs
informed that the site in each chain having the the model controlled for age and sex. Table 1 of a chain pharmacy, data that we collected
highest performance would win a $50 donation presents the results from this analysis. Verbal over a 4-week interval indicated that 35.5%
to each pharmacist's favorite charity. counseling was performed more frequently in of the 4379 prescriptions filled produce pho-
Prior to the initiation of the feedback con- the intervention sites than the control sites even tosensitivity (unpublished data, 1997). Dis-
federate visits, each intervention site was after adjustment for pharmacists'age and sex. cussion of UVR exposure reduction specific
stocked with skin cancer prevention As a secondary analysis, for intervention to photosensitizing medications provides a log-
brochures8" 9 and sunscreen samples, which sites at posttest, the verbal counseling distri- ical bridge to counseling on routine UVR expo-
were to be kept behind the counter and handed butions by pretext type were assessed. The sure reduction for lowering one's risk of skin
to patients. Additional prompts included but- photosensitizer pretexts were followed by cancer and has the potential to reach numerous
tons to be wom by the pharmacists, posters counseling 48.1% (13/27) of the time. The individuals.
encouraging patients to "ask your pharmacist proportions for the outdoor activity and general The group feedback component of the
about skin cancer prevention," and ceramic pretexts were 29.6% (16/54) and 3.7% (1/27), intervention served to inform the pharmacists
mugs encouraging pharmacists to "tell your respectively. A generalized estimating equa- about their counseling performance and moti-
patients about skin cancer prevention." tion analysis accounting for clustering by site vate them to counsel at higher rates. Anecdo-
was performed. With general pretexts used as tally, although the procedure generally was
a reference, the log-odds of verbal counseling well received, on several occasions pharma-
Results following outdoor pretexts was 2.39 (P= .011) cists expressed frustration that the feedback
and the log-odds of counseling following pho- was underestimating their (perceived) coun-
Observations tosensitizer pretexts was 3.18 (P = .002). seling rates. Also, if this strategy is to be insti-
At intervention sites during posttest con- tutionalized, a less labor-intensive monitoring
A total of 432 evaluation observations federate visits, pharmacists verbally counseled, system will be needed.
were attempted by the confederates. Eight distributed a brochure, and/or distributed a The objective outcome measure was an
(3.7%) ofthe data points for pretest had to be sunscreen sample on 40 occasions. Verbal important strength of the study. However, it is
discarded because it was later discovered that counseling occurred on 30 (75%) of these possible that the intervention pharmacists at
the pharmacist on duty was not a permanent occasions, and of these 30 occurrences, ver- posttest recognized the pretexts and thus iden-
employee or was altemating between an inter- bal counseling was accompanied by the dis- tified the study confederates. If this did occur,
vention and a control site. Complete posttest tribution of a brochure and/or sunscreen sam- the posttest counseling rates would overesti-
data were available for analysis. ple 25 times (83%). mate "true" counseling behavior. Anecdotal
Across all observations, 138 pharma- evidence indicates that the confederates gen-
cists were observed. Of these, 33 were Process Data erally remained incognito. Also, the distribution
observed at pretest only, 25 were observed of over 10 000 brochures helps to substanti-
at posttest only, and 80 were observed at both A total of 10 373 brochures were distrib- ate that pharmacists were not "performing"
times. Intervention site pharmacists (n = 71) uted, with a site mean of 384 (SD = 319) and a only when interacting with the confederates.
had a mean age of 40 years and 54% were range of 15 to 1300. As ofJuly 1997, 34 (37%) For this study, the confederate strategy offered
male. Control site pharmacists (n = 67) had of the 93 intervention pharmacists who had the best approximation to actual patient coun-
a mean age of 42 years and 69% were male. received the video program had applied for seling rates, without the potential biases of
The observed pharmacists constituted 78% the CEU related to it. self-report and patient-report measures. This
of the permanent pharmacists who were measurement approach has been used in sev-
employed at the 54 sites at the time of the eral other studies of pharmacists' counseling
study. Discussion performance.2>26
In conclusion, a combination of video-
Counseling Outcomes The results of this study indicate that the based training, feedback, and environmental
intervention was successful in increasing skin prompts produced a significant, dramatic
At pretest, 2 (7.4%) of the control sites cancer prevention counseling by pharmacists, increase in pharmacists' skin cancer preven-
and none of the intervention sites provided with two thirds ofthe intervention phannacies tion counseling specific to encounters involv-
counseling after at least 1 of the pretexts. At providing counseling at least once at posttest. ing photosensitizing drugs and outdoor expo-
posttest, 1 (3.7%) of the control sites and 18 Counseling was more likely to occur during sure. If implemented on a large scale, this
(66.7%) of the intervention sites provided interactions related to photosensitizing med- relatively simple, low-cost intervention could
counseling. This posttest difference was ications or to the patient's being outdoors and have an important public health effect. Addi-
significant (X2 [ 1] = 23.5, P <.001 . Of the 18 was not likely to occur in response to the gen- tional research should focus on dismantling
intervention sites that provided counseling at eral pretexts.. By definition, the general pre- the most important intervention components,
posttest, 10 counseled only once, 5 counseled texts provided no cues to the pharmacist understanding the specific roles played by the
twice, 2 counseled 3 times, and only 1 coun- regarding counseling. Additionally, the incor- brochures and sunscreen samples relative to
seled all 4 times. The 1 control site that coun- poration of skin cancer prevention counseling the verbal advice, determiniing how long-term
seled did so only once. into some general conversations may have effects can be achieved, and assessing the
To assess group differences in verbal been perceived as insensitive or otherwise inap- effects of counseling on patient behavior. C:
counseling while accounting for site cluster- propriate.
ing, generalized estimating equations were Yet even if counseling occurred only dur- Acknowledgments
used.20'2' The outcome variable was whether ing conversations about photosensitizing drugs, This study was funded by grant AR 43025 from the
verbal counseling was performed following the public health impact could be substantial. National Institute of Arthritis and Musculoskeletal
the pretext; this is a dichotomous variable. A There are at least 12 classes of photosensitizing and Skin Diseases. Production of the videotape was
logistic model, corresponding to a logit link drugs, encompassing hundreds of prescription funded, in part, by a nonrestrictive educational grant
and a binary mean-variance relation, was fitted; and over-the-counter products.22 At one site from Glaxo Wellcome Inc.
1098 American Journal of Public Health July 1998, Vol. 88, No. 7
Public Health Briefs
We thank Dr Ray A. Wolf and Genny 2. National Conference to Develop a National Skin 15. Healthy People 2000: National Health Promotion
McGlothlin of Glaxo Wellcome Inc for sponsoring Cancer Agenda. Executive Summary and Pro- and Disease Prevention Objectives: Full Report,
the videotape production and Barry Solomon of the ceedings. Washington, DC: American Academy with Commentary. Washington, DC: US Dept
California Employee Pharmacists Association for of Dermatology and Centers for Disease Con- of Health and Human Services; 1991. DHHS
providing the CEUs. We also thank Patrick Contra- trol and Prevention; 1995. publication PHS 91-50212.
do and Alan G. Sanford (Thrifty Drugs/PayLess 3. The Gallup Organization. The Gallup Poll: Pub- 16. Skin Cancer Prevention: A Role for Pharmacists
Drug Stores), Lawrence Sharp (American Drug lic Opinion 1995. Wilmington, Del: Scholarly [videotape]. San Diego, Calif: Project SUNWISE,
Stores-Sav-on Drugs), and Connie Urban (Longs Resources Inc; 1995. 1996.
Drug Stores California, Inc) for assistance with phar- 4. Kalman SH, Schlegel JF. Standards of practice 17. Glynn TJ, Manley MW. How to Help Your
macy recruitment; Wendy Grove-Newman, Stevens for the profession of pharmacy. Am Pharm. Patients Stop Smoking: A National Cancer Insti-
Cancer Center-Scripps Memorial Hospitals, for the 1979;NS19:133. tute Manual for Physicians. Bethesda, Md:
SunSmart brochures; and the American Cancer Soci- 5. Kirking DM. Pharmacists' perceptions of their National Cancer Institute; 1995. PHS publica-
ety for the Fry Now. Pay Later. brochures. The patient counseling activities. Contemp Pharm tion NIH 95-3064.
following companies are thanked for their sunscreen Pract. 1982;5:230-238. 18. Fry Now. Pay Later [brochure]. Atlanta, Ga:
donations: Fruit of the Earth, Inc; Chattem, Inc 6. Meade V. APhA survey looks at patient coun- American Cancer Society; 1994.
(Bullfrog); Banana Boat of California, Inc; Blistex, seling. Am Pharm. 1992;NS32:27-29. 19. Scripps Sun Smart. A Guide to Protecting Your-
Inc; Person & Covey, Inc (Solbar); PEDiNOL Phar- 7. Schommer JC. Higher levels of consultation ser- selfFrom the Sun [brochure]. San Diego, Calif:
macal Inc (Ti-Screen); and HT Marketing, Inc vices increase patient satisfaction. Am Pharm. Stevens Cancer Center-Scripps Memorial Hos-
(Hawaiian Tropic). We are grateful to the confeder- 1995;NS35:33-39. pitals; 1995.
ates for their participation in the study. We thank 8. Burton LM, McKay AB. Involvement of Mary- 20. Liang KY, Zeger SL. Longitudinal data analysis
Carol Riordan, David Sharpe, and the staff of land pharmacists in AIDS education. Patient using generalized linear models. Biometrika.
Instructional Technology Services of San Diego Educ Couns. 1990;15:239-247. 1986;73: 13-22.
State University for the videotape production. We 9. Smith MD, McGhan WF, Lauger G. Pharmacist 21. Zeger SL, Liang KY. Longitudinal data analysis
also thank Lauren Farber and the pharmacists who counseling and outcomes of smoking cessation. for discrete and continuous variables. Biomet-
participated in focus groups for assisting with the Am Pharm. 1995;NS35:20-32. rics. 1986;42:121-130.
development and refinement of study materials; Drs 10. Pharmacists' Guide to Patient Counseling: 22. Medications That Increase Sensitivity to Light-
Larry Eichenfield and Howard Taras for guidance Issues, Strategies, and Skills for the 1990's. 1992 USFDA Revised Listing. Springfield, Illinois
regarding the intervention; Debra Rubio for assis- Princeton, NJ: Bristol-Myers Squibb Co; 1992. Dept of Public Health; 1992.
tance in preparing the manuscript; and Maggie Price 11. Souvignier ST, Mayer JA, Eckhardt L. Educating 23. OTC advice: consumer survey. Pharm J.
for the graphic design of study materials. the public about skin cancer prevention: a role 1988:403-404.
for pharmacists. J Clin Pharm Ther. 24. Vanderveen RL, Adams C, Sanbom M. The phar-
1996;21 :399-406. macist as a drug consultant-five years later. Drug
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July 1998, Vol. 88, No. 7 American Journal of Public Health 1099
