Of the 1,250 pharmacists selected, eight did not work in community pharmacy. Twelve questionnaires were returned undelivered because the address was wrong. Following the first questionnaire mailing, we were informed that one pharmacist had retired, one was on maternity leave, and one declined (verbally) to take part. Ultimately, 577 completed questionnaires were returned. However, six were returned by non-eligible pharmacists (four did not work in community pharmacy, and two were not working in a traditional community pharmacy), for a total of 571 questionnaires returned out of 1,234 eligible pharmacists (response rate: 46.3%). More specifically, 249 questionnaires (43.6%) were received after the first questionnaire mailing, 114 (20.0%) after the postcard mailing, 149 (26.1%) after the second questionnaire mailing, and 59 (10.3%) after the third questionnaire mailing. The response rates for individual questions ranged from 87% to 100%, and 99% of questions had a response rate over 90%.
As reported in Table , the respondents were in majority women (63.2%), were staff pharmacists (65.3%), and reported having completed a mean 31 hours of continuing education during the past year. Their pharmacies were associated with a chain or a corporate banner (80.4%) and/or adjacent to a medical clinic (28.7%). The most prevalent clienteles were elderly patients and families of average to high socio-economic status. Furthermore, 53.5% of pharmacists reported that a nurse was present in the pharmacy for a mean 47 hours per month. Nutritionists (69 pharmacists) and naturopaths (11 pharmacists) were among other common health professionals employed in the pharmacy. Based on information from the Ordre des pharmaciens du Québec (OPQ), our respondents were similar to community pharmacists working in Quebec in terms of sex (62.4% women in OPQ) and pharmacist status (63.9% staff pharmacists in OPQ).
Characteristics of pharmacists and pharmacies
As Table shows, most respondents believed they should be either "very involved" or "involved" in providing all health-promotion and preventive services. The majority reported they should ideally be "very involved" in smoking cessation (84.3%); screening for hypertension (81.8%), diabetes (76.0%) and dyslipidemia (56.9%); and sexual health (61.7% to 89.1%). Most considered they should be "involved" in providing information and counseling about physical activity (71.1%), healthy eating (68.8%), weight management (63.4%), and alcohol consumption (63.8%). In contrast, 54.3% and 28.5% of pharmacists, respectively, considered they should have "little involvement" or "no involvement at all" in counseling on dental health and screening for suicide risk. The proportion of respondents who reported their community pharmacy as being actually "very involved" in each service was 5.7% for lifestyle-related activities, 44.5% for screening for hypertension, 34.8% for screening for diabetes, 6.5% for screening for dyslipidemia and 19.3% for sexual health. Most respondents reported their pharmacy as being either "involved" or "little involved" in lifestyle-related activities (84.5%), screening for dyslipidemia (57.8%), sexual health (74.5%) and infectious diseases and immunization (72.4%). Most appropriate primary-care providers for preventive counseling or screening were primary-care physicians, community pharmacists and nurses. They also deemed kinesiologists, nutritionists and physiotherapists well placed to offer lifestyle-related services.
Ideal and actual levels of involvement of community pharmacists and most appropriate primary-care providers for these services
As Table shows, the majority of respondents identified the pharmacist as the main provider of health-promotion and preventive services in their pharmacy, though nurses and technical assistants were also frequently cited. Most pharmacists reported that preventive services are given a "few times per week" or a "few times per month" regarding: lifestyle (69.5%), screening for hypertension (96.6%), screening for diabetes (86.2%), and counseling on sexual health (81.5%). Activities related to infectious diseases and immunization were reported for the most part to take place a "few times per month" or a "few times per year" (61.8%); 36.8% of respondents indicated that screening for dyslipidemia never occurred. Consultations were reported to last 10 minutes or less by most pharmacists. When cases are detected during screening, most pharmacists said the report is given to the patient only (67.4% for hypertension, 35.7% for dyslipidemia and 67.9% for diabetes); smaller percentages said the report is given to both the patient and the primary-care physician (33.5% for hypertension, 18.6% for dyslipidemia and 31.4% for diabetes).
Characteristics of health-promotion and preventive services
Pharmacists were also asked to report the actual specific activities provided in their pharmacy. As indicated in Table , the majority reported distributing written information, providing personalized counseling when dispensing medications and referring patients to external resources. A large proportion of respondents said personalized follow-up for smoking cessation (44.5%), hypertension (53.7%), diabetes (45.0%), and emergency oral contraception (40.7%) were provided. Many pharmacists provided no prevention activities regarding dental health (29.3%), suicide risk (27.6%) or needle exchange (35.2%). Many tasks were performed by a nurse or a nutritionist; 31 pharmacists thus reported that immunization was conducted by a nurse. Several pharmacists reported having a collective prescription for smoking cessation (39 pharmacists). Collective prescriptions enable authorized professionals, usually pharmacists or nurses, to perform certain tasks (for example, requesting laboratory tests and adjusting medication dosage) without first having to obtain an individual prescription from a physician [19
Specific activities conducted in health-promotion and preventive services in community pharmaciesa
As reported in Figure the main barriers to providing health-promotion and preventive services in their current practice were lack of time (86.1%), lack of coordination with other health care professionals (61.1%), lack of staff or resources (57.2%), lack of financial compensation (50.8%), and lack of clinical tools (45.5%). Six pharmacists also indicated that their limited prescription rights and the lack of collective prescriptions further hampered their involvement in prevention.
Self-identified barriers to the provision of health-promotion and preventive services in current pharmacy practicea.
aMore than one item could be checked.
bOther includes limited prescription rights for pharmacists and lack of collective prescriptions (n = 6); patients are often in a rush and don't have time for prevention activities (n = 3); patients are not "open" to change (n = 3); too many technical tasks performed by the pharmacist (n = 2); patients do not think of pharmacists for prevention activities (n = 2); no standardized practice model (n = 2); lack of access to lab-test results and other patient information (n = 2); pharmacists are overworked (n = 2); nurses already perform some of these activities (n = 2); lack of a closed office at the pharmacy (n = 1); low uptake of pharmacist's suggestions by physicians (n = 1); home visits are expensive (n = 1); pharmacy owners not often present at the pharmacy (n = 1); pharmacist shortage (n = 1); patients don't like to be "criticized" about their lifestyle (n = 1); relief pharmacists don't know the pharmacy's patients very well (n = 1); the logistics of implementation in general (n = 1); most of the pharmacy's patients are not regular patients (n = 1); lack of patient knowledge about the benefits of prevention (n = 1); lack of tools for patients (n = 1); pharmacy's patients do not need preventive activities because they are already educated about the subject (n = 1); lack of external resources to which patients can be referred (n = 1); lack of budget for prevention activities at the pharmacy (n = 1); lack of competent and stable staff (n = 1); lack of interest by pharmacy owners (n = 1); and the topic of prevention is very broad, so pharmacists provide counseling on a little bit of everything but about nothing in depth (n = 1).