The Impact of Community Pharmacy Services on

The Impact of Community Pharmacy Services on Rural Communities

A report prepared by Professor Bruce Sunderland, Mrs Suzanne Burrows and Ms Catherine Griffiths Curtin University of Technology School of Pharmacy

October 2003

Curtin University of Technology School of Pharmacy GPO Box U1987 Perth Western Australia 6845 Telephone: (+61 8) 9266 7369 Facsimile: (+61 8) 9266 2769 Email: [email protected]

Impact of Community Pharmacy Services

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Executive Summary The project was designed to investigate the role and perceived benefits of a single community pharmacy located in a small rural community. Community pharmacy, when practised in larger country towns, mainly follows the models of pharmacy practice evident in urban settings. Such towns are provided with doctors, pharmacists, other health professionals and availability of other medications. There are no substantial differences to those services provided in metropolitan areas, except access to teaching hospitals and specialist medical services.

The maintenance of pharmacies in smaller communities may be much more important as to its impact on those communities. Pharmacies potentially provide a significant resource that when not available result in unknown levels of hardship, dependent upon the availability of equivalent services in the town, such as dispensing doctors, range of pharmacy items provided in other stores and the distance from an existing pharmacy. Although there is likely to be considerable variation in access to services in individual towns, some preliminary studies need to be commenced to identify the impact a community pharmacy provides to a community in a small township.

Little data has been published on rural pharmacy services, therefore, this project was designed to identify and quantify basic issues relating to the access of pharmacy services to small communities. The project investigated two relatively isolated small townships, each having access to a local pharmacy (Moora and Jurien Bay) and two similar towns without pharmacies (Leeman and Three Springs). Specifically, the project investigated: •

the range and costs of non-prescription medications available in each of the towns

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how residents obtained prescription medicines and the costs and availability of these medicines

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how residents obtained specific groups of Schedule 3 (S3) medications and their costs

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the role and function of the nursing posts in each town with respect to the provision of medicines

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the availability of doctors in each town


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sources of advice on medicines in each community and the frequency of use of these sources

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the availability of health-related and health promotion initiatives provided from pharmacies, compared with availability in the non-pharmacy towns

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how minor ailments are managed in each location

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access to a range of other ancillary products and services

A questionnaire was designed to enable information to be collected from residents of the four towns, regarding their access to, and satisfaction with, pharmacy and other health services. Questionnaires were either mailed or delivered in person to a randomly selected number of residents in each of the towns. Each of the towns was visited by the researcher and data was collected on the range and costs of pharmacy goods available from local shops and pharmacies. Furthermore, the role and function of nursing posts was elicited by a short questionnaire administered to nurses in three of the towns, with the nurse in one of the towns declining to participate. Shire council officers in each town were also surveyed regarding their opinions about the value of various pharmacy services. Data concerning the level of prescribing and dispensing of medicines to residents of each of the towns was obtained from the Health Insurance Commission.

The results of the study identified the following significantly different outcomes:

In the towns without a pharmacy – •

A significant proportion of residents travelled long distances to access medical and pharmaceutical services. In one town, 40 percent of the residents travelled an average of 228 minutes to access pharmaceutical services

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Residents expressed concern regarding delays in obtaining prescriptions or other medicines quickly in an emergency

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The range of pharmaceutical products available from local stores and supermarkets in towns without a pharmacy was smaller than that in the towns with pharmacies

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The range of Schedule 2 (S2) medicines that could be made available under the licence provisions was also not available in non-pharmacy towns


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Local stores stocked a smaller range of medicines in non-pharmacy towns, compared to pharmacy towns, although some additional S2 medicines were available

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In one non-pharmacy town where a dispensing doctor service was available, that service was sought for minor ailments and minor emergencies (e.g. need for an asthma spray from the doctor) and accessed from the pharmacy in the towns where there is a pharmacy. This increases consultation costs and results in high costs of providing these medications as PBS prescriptions

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Access to a range of other pharmaceuticals varied, with the local shop or nursing post being favoured dependent on the town and urgency of the requirement

In the towns with pharmacies – •

The local pharmacies received a higher level of public support than the local medical services

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They were highly accessed for a wide range of health-based requirements, such as emergency pain relief (including period pain), emergency asthma treatment, emergency wound dressings and emergency burn treatment. They were also the major source for medications for hay fever, coughs and colds, skin problems and fungal infections

It was found that there was a notably increased tendency for children to have medical consultations in the metropolitan area, whereas elderly residents more strongly supported the local medical and pharmaceutical services. Both groups tended to support the pharmacy more strongly than the medical services.

It was notable that in the town with a dispensing doctor service, almost half of the prescriptions for the residents were dispensed in pharmacies elsewhere in the state.

In the town without pharmaceutical or medical services, the closest pharmaceutical and medical services were more often accessed, with the pharmaceutical service more strongly supported.


Authors

Professor Bruce Sunderland Curtin University of Technology School of Pharmacy GPO Box U1987 Perth Western Australia 6845 Telephone: (+61 8) 9266 7528 Facsimile: (+61 8) 9266 2769 Email: [email protected]

Mrs Suzanne Burrows Curtin University of Technology School of Pharmacy GPO Box U1987 Perth Western Australia 6845 Telephone: (+61 8) 9266 2534 Facsimile: (+61 8) 9266 2769 Email: [email protected]

Ms Catherine Griffiths Curtin University of Technology School of Pharmacy GPO Box U1987 Perth Western Australia 6845 Telephone: (+61 8) 9266 4404 Facsimile: (+61 8) 9266 2769 Email: [email protected]

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Acknowledgements

The authors would like to acknowledge the financial assistance provided for this grant. This project is funded by the Rural and Remote Pharmacy Infrastructure Grants Program as a component of the Rural and Remote Pharmacy Workforce Development Program funded by the Australian Government Department of Health and Ageing.

Valuable assistance was also received from the Health Insurance Commission of Australia, in regards to the provision of relevant data, and from the councils, nursing staff, pharmacy staff, shop staff and residents of the Shires of Three Springs, Coorow, Dandaragan and Moora.


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Introduction The objectives of the project are as follows –

1. To investigate the impact of a community pharmacy in a remote rural community

2. To determine the cost, access and availability of prescription and non-prescription medicines in remote rural communities

3. To provide information for models that could evaluate the benefits of a community pharmacy in remote rural communities

4. To provide data on how minor ailments are managed in towns with and without pharmacies

5. To determine how the management of health promotion in towns with and without pharmacies is achieved The desired outcomes of the project are as follows –

1. To identify a range of indicators that could lead to generalised models for the provision of pharmaceutical services in townships, taking into account the variation within town characteristics, such as population profile, support from employers, availability of health services and level of remoteness

2. To support pharmacists by providing important information on the impact rural pharmacies have in smaller, isolated towns and, therefore, would allow appropriate external support for their maintenance to be based on appropriate data

3. To contrast the roles and outcomes a community pharmacist has on the activities of other health care providers, such as doctors and nurses, in these settings


4. To provide information on issues to be addressed by non-pharmacy health care professionals in isolated towns without a pharmacist

5. To benefit Shires in providing information on the value of a pharmacy in more isolated rural communities and the level of support appropriate to that benefit

6. To provide comparative data regarding the costs of products and the value of the local availability of these pharmacy services in rural communities

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Literature Review The Impact of Community Pharmacy Services on Rural Communities It is recognised that there is a paucity of published research concerned with identifying the health status and health care needs of Australia’s rural population (Humphreys & Weinand, 1991). Of the research that has been conducted, the majority has focused on access to doctors, hospitals and speciality medical practitioners (Casey, Klingner, & Moscovice, 2002; Stratton, 2001). It has been found that rural people highly value doctors but that more attention needs to be given to expanding the health promotion and illness prevention roles of rural practitioners (Humphreys, Rolley, & Weinand, 1993).

This is particularly important in light of the fact that many rural communities are without a doctor, due to a severe maldistribution of medical services in Australia (DeFriese & Ricketts, 1989; Joseph & Bantock, 1982; Shepherd, 1995). In addition, compared to their urban counterparts, rural general practitioners tend to work longer hours, see more patients, earn less (Holden, 1990), receive less time off, have less back up from specialists and other health professionals, have a greater likelihood of being sued by patients and face greater social isolation (Lavelle, 2003). It is perhaps because of issues like these that rural areas of Australia face a shortage of at least 700 doctors (Lavelle, 2003).

Because of the nature of the doctor crisis in non-metropolitan areas, it is only very recently that researchers have begun to concentrate on rural access to pharmaceutical services, largely due to “increased utilization of prescription medications, the rising costs of drugs, and pharmacy closures and pharmacist shortages in some areas” (Casey, Klingner, & Moscovice, 2002, p. 467).

It is generally acknowledged that rural populations use fewer health services, suffer from poorer health than urban populations (Australian Health Ministers’ Conference, 1996; Gangeness, 1997; Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002; Kamien, 1995; Lavelle, 2003; Silver, 1994), have less access to health promotion information (Humphreys, Rolley, & Weinand, 1993; Lavelle, 2003; Watt, Franks, & Sheldon, 1994) and that the rural health care experience can be quite different from


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that experienced by urban populations (Australian Health Ministers’ Conference, 1994; Coburn et al., 2000; DeFriese & Ricketts, 1989; Department of Health and Family Services, 1998; Joseph & Bantock, 1982; Ricketts, 2000a).

Furthermore, certain rural areas have the highest mortality and morbidity rates and a greater number of people reporting to be in poor health (Ricketts, 2000a; Watts et al., 1999). For example, one estimate puts the rate of avoidable deaths as 40 per cent higher in rural areas of Australia than in capital cities (Strasser, 2000). Additionally, higher rates of heart disease, diabetes, skin cancer, mental problems and workplacerelated accidents can be found in rural areas (Lavelle, 2003). Non-urban communities may not be receiving their share of recent developments in medical technology, service and practice (Ricketts, 2000a; Ricketts, 2000b). This is one of the major problems faced by health policymakers (DeFriese & Ricketts, 1989) and is of particular concern if one considers that approximately 28 per cent of Australians live in rural areas (Australian Health Ministers’ Conference, 1994; Kamien, 1995).

By its very definition, rurality means a dispersed population of people scattered, to varying degrees, around small service centres and living some distance from major service centres (Coburn et al., 2000; Thouez, Bodson, & Joseph, 1988; Wakerman, 1999). Rural Australia includes larger towns, smaller settlements, mining communities and isolated farming stations (Australian Health Ministers’ Conference, 1994). Having to travel long distances to receive health care and a lack of local health facilities and providers, particularly in more specialised fields, are common problems for rural people (Australian Health Ministers’ Conference, 1994; Knapp, Paavola, Maine, Sorofman, & Politzer, 1999; Williams, Schwartz, Newhouse, & Bennett, 1983). It is also recognised that “the rural environment, especially where agriculture, mining, forestry, and fishing are important or dominant parts of the economy, presents extraordinary threats to health” (Ricketts, 2000a, p. 641). Therefore, the availability of, and access to, health services are important issues for those people residing in rural areas (Billow, Van Riper, Baer, & Stover, 1991; Casey, Klingner, & Moscovice, 2002; Straub & Straub, 1999).


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Although largely overlooked in research until recently, the pharmacist is a crucial part of any health care system (Billow, Van Riper, Baer, & Stover, 1991; Johnson et al., 1997; Miller & Scott, 1996) and plays an important role in “maintaining the health of all Australians. Often the local pharmacy is the first place people go to seek help with minor ailments or to look for basic information on health issues and products” (Australian Department of Health and Ageing, 2001b). One study found that 25 per cent of customers in rural areas seek medical advice from a pharmacist before seeing any other health professional (Selya, 1988).

Pharmacies are often seen as accessible because of their extended opening hours and availability independent of that of doctors (Knapp, Paavola, Maine, Sorofman, & Politzer, 1999; Straub & Straub, 1999). Furthermore, if pharmacy services and staff are perceived to be efficient, convenient and courteous, people tend to report feeling more satisfied with the overall health care services they receive (Briesacher & Corey, 1997). When the residents of small rural communities were asked what health services they believe are necessary to keep them healthy, a pharmacy service was ranked third only to a doctor and a hospital (Humphreys, Rolley, & Weinand, 1993; Humphreys & Weinand, 1991; Strasser, 2000). These findings were consistent even when a range of variables were controlled for (Humphreys, Rolley, & Weinand, 1993).

Australian governments have tended to be slow in responding to the specific health needs of non-metropolitan communities and, presently, the state of rural health in this country is still less than optimal (Bamford & Hugo, 2001; Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002). In the past, health funding has been delivered based on population density figures, with little regard for the fact that, despite having smaller populations, the direct costs of providing health care in rural areas are greater (Humphreys & Weinand, 1991; Wakerman, 1999; Watt, Franks, & Sheldon, 1994). Decision-makers may not have a full understanding of how rural communities operate, nor grasp the importance rural people place on having a strong community and being able to access essential services (Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002; Humphreys & Weinand, 1991). Of particular importance is the need for additional resources to be directed towards health services in rural communities and improved health infrastructure in rural areas (Humphreys, Hegney,


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Lipsocombe, Gregory, & Chater, 2002), particularly those areas deemed to be of highest need (Humphreys & Weinand, 1991).

In 2001, the Federal Government announced a range of allowances specifically designed to prevent rural pharmacy closures and increase the number of pharmacies operating in non-metropolitan areas of Australia (Australian Department of Health & Ageing, 2001a). Specifically, $60.4 million was allocated to providing assistance to rural pharmacies over a four-year period, under the categories of the Rural Pharmacy Maintenance Allowance, Start Up Allowance, Succession Allowance and Allowance for Pharmacist Support Services to Remote Area Aboriginal Health Services (Australian Department of Health and Ageing, 2001a).

In addition, the government provided funding for an emergency rural pharmacy locum service and expanded the Rural and Remote Undergraduate Scholarship Scheme (Australian Department of Health and Ageing, 2001b). Changes were also made to the pharmacy licencing procedure, in relation to rural towns. In the past, more than 700 rural towns were ineligible to apply for a licence for a local community pharmacy because their populations were under 3000 people (Bannister, 2001). However, a test case involving the town of Stratford paved the way for small towns to apply for a Special Rural Licence, which requires the pharmacy to be at least ten kilometres away from all other pharmacies and prevents the licence number from being re-located away from its original rural community (Bannister, 2001). Clearly these measures were put forward in recognition of the important role played by pharmacists in the health care system, particularly in rural areas of Australia. The Roles of a Pharmacist

Pharmaceutical care has been defined by Hepler and Strand (1990) as: the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life… These outcomes are (1) cure of a disease, (2) reduction or elimination of symptoms, (3) arresting or slowing of a disease process, and (4) preventing a disease or symptoms. (p. 539)


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Pharmacists are often trained in a several areas, such as pharmacokinetics, biopharmaceutics, pathophysiology of disease and recognising the interactions between different drugs and drugs and specific foods (Curtiss & Wertheimer, 1978). Pharmaceutical care is an essential part of any health care service and should be provided along with other important health services (Hepler & Strand, 1990).

The pharmacist is an integral part of the primary care system in any community and often the first place people needing health care and assistance go to (“MSPs highlight,” 2001; Pampling & Gregory, 1999; Selya, 1988). While, in the past, pharmacists may have practiced in relative isolation and been mainly involved with drug products and their preparation, today they are accessible and visible to customers and are more concerned with providing product and health information (Morgall & Almarsdottir, 1999).

In rural areas, pharmacists are often the most prevalent, approachable and accessible health care providers and people like dealing with pharmacists who they know well and who know them (Coburn & Ziller, 2000; Epstein, 1996; Mason & Svarstad, 1984; Selya, 1988). This is in contrast to urban pharmacists who generally do not have the opportunity to develop continuous relationships with their customers (Mason & Svarstad, 1984). Because they are more evenly distributed in rural areas than doctors, pharmacists may be able to assist in providing more comprehensive health care services to medically underserved communities (Ranelli & Coward, 1996; Selya, 1988).

Pharmacists can, like doctors, direct customers to additional health services and alternative health care options which may be of assistance (Miller & Scott, 1996; Selya, 1988; Uden & Larson, 1997; Van Amburgh, Waite, Hobson, & Migden, 2001). In addition to the dispensing of prescriptions and over the counter medicines (Norris, 1997; Pampling & Gregory, 1999) and the provision of information about how to use these medications safely (Baumgartner, Land, & Hauser, 1972; Leversha, Strasser, & Teed, 2001; Miller & Scott, 1996; Pampling & Gregory, 1999), pharmacists are often asked to assist with common health problems, such as providing first aid for emergencies which are non-life threatening, management and dosage for conditions


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such as hypertension and diabetes, allergies, skin irritations, poison control (Selya, 1988), asthma education and weight control (Doucette & Jambulingam, 1999; Knapp, Paavola, Maine, Sorofman, & Politzer, 1999). Pharmacies also stock a large range of retail goods, such as cosmetics and photographic goods and in some cases, approximately half of a pharmacy’s income may come from the sale of such products (Casey, Klingner, & Moscovice, 2002; Norris, 1997). The advice given to patients by pharmacists tends to be in the form of “recommendation, reassurance, instruction, information or referral” (Rogers, Hassell, Noyce, & Harris, 1998, p. 367). Their health promotion and illness prevention efforts play an important role in improving the health status of their patients and extending life chances (Gilbert, 1998; Humphreys, Rolley, & Weinand, 1993; Miller & Scott, 1996).

Therefore, it appears as though pharmacists are in a position to greatly facilitate the health of rural people, particularly in areas where access to doctors and other primary care services is limited (Knapp, Paavola, Maine, Sorofman, & Politzer, 1999; Pampling & Gregory, 1999; Selya, 1988). It has been shown that pharmacists who take on the role of being a complementary primary care provider in rural areas are more involved with their patients, offer cognitive or counselling services as well as standard dispensing services and promote improved patient outcomes (Mason & Svarstad, 1984; Ranelli & Coward, 1996; Stratton, 2001; Tripp & Straub, 2001).

Pharmacists are also well placed to lessen the demand on doctors’ services, in areas where doctors are over-worked and having trouble meeting the health care needs of all of the population (Rogers, Hassell, Noyce, & Harris, 1998; Shepherd, 1973). In monetary terms, it has been found that there are financial benefits arising from pharmacists taking on a greater role in patient care, that is, for every dollar spent on clinical pharmacy services, a saving of $16.70 is made for the health care system (Uden & Larson, 1997). These savings come from pharmaceutical treatments, which reduce rates of hospitalisations, emergency room, and doctor visits (Lum, 2001; Miller & Scott, 1996).

In addition, pharmacists can assist and serve sections of the population, such as drug addicts, who may be reluctant or unable to seek mainstream medical attention


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(Rogers, Hassel, Noyce, & Harris, 1998). “Pharmacists have important roles to play in influencing drug policy, drug use and outcomes as well as other aspects of health care” (“FIP and WHO,” 1993, p. 926) and help to prevent potentially life-threatening adverse drug reactions (Mason & Svarstad, 1984). In short, the presence of a pharmacy in a small town allows people quick and easy access to prescription medicines and the additional services commonly provided by pharmacies (Doucette, Brooks, Sorofman, & Wong, 1999). Issues Relating to Rural Pharmacy Practice

In Western Australia in the year 2000, there were 359 urban pharmacies and 110 rural pharmacies, with each urban pharmacy serving approximately 3 923 people and each rural pharmacy serving approximately 4 572 people (Commonwealth Department of Health and Aged Care, 1999). Kaiser (2000) states that the present spatial location of pharmacies in Western Australia is less than optimal, in terms of accessibility for the entire population. He estimates that Western Australians travel an average distance of 5.7 kilometres to the nearest pharmacy, however, rural residents often must travel much longer distances to reach a pharmacy service (Kaiser, 2000). Clearly, these findings indicate that rural residents are not receiving the same level of pharmaceutical care that is available to the urban population.

There are many issues that may hamper the provision of pharmaceutical services in rural areas (Uden & Larson, 1997). Often financial issues are identified as the major barrier to the provision of an adequate level of pharmacy access for the rural population (Casey, Klingner, & Moscovice, 2001; Gangeness, 1997). In financial terms, pharmacists in rural areas tend to earn lower incomes and have smaller profit margins than pharmacists practicing in urban areas, despite the fact that they commonly work longer hours (Gangeness, 1997; Lum, 2001; Ricketts, 2000c; Stratton, 2001). There may only be one pharmacist working at the pharmacy meaning that work may have to be completed on public holidays or weekends and finding a relief pharmacist is often difficult, if not impossible (Casey, Klingner & Moscovice, 2002; Epstein, 1996; Low, 1998; Lum, 2001; Stratton, 2001). Additionally, there is a shortage of qualified pharmacists who are willing and able to work in rural areas (Frederick & West, 2001; Gangeness, 1997; Low, 1998; Lum,


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2001; Ricketts, 2000a). Because of the perception of capital cities being superior to rural areas, with rural practice involving greater risks than metropolitan practice and the additional costs involved in servicing small populations over long distances, it is common for the perceived negative aspects of rural practice to overshadow opportunities for innovation and development in these areas (DeFriese & Ricketts, 1989; Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002; Joseph & Bantock, 1982; Low, 1998; Lum, 2001).

Also, few health care providers want to work in areas that are completely remote from all other health services and professional networks (Curtiss & Wertheimer, 1978; DeFriese & Ricketts, 1989; Low, 1998; Lum, 2001). The Federal Government has also claimed that the shortage of rural private pharmacists (and doctors) is a major reason why it should not be held responsible for the funding of alternative primary care providers in rural areas, where Medicare and Pharmaceutical Benefits Scheme cover is often limited (Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002).

In a bid to increase the number of rural pharmacists, some authors recommend emphasising or creating positive aspects of rural pharmacy practice, to offset the lower incomes that rural pharmacists can expect to earn (Australian Health Ministers’ Conference, 1994; Billow, Van Riper, Baer, & Stover, 1991; Byrt, 1994; Ricketts, 2000c). Such positive aspects may include living and working in a safe environment, providing job opportunities for a pharmacist’s spouse or partner, providing suitable housing, providing the pharmacist with a modern and up-to-date practice and creating attractive benefit packages (for example, relocation allowances and guaranteed relief to allow for holidays) (Australian Health Ministers’ Conference, 1994; Billow, Van Riper, Baer, & Stover, 1991; Low, 1998).

Universities and the federal government could also assist by implementing tuition and HECS exemptions for students who go on to practice in rural and remote areas (Billow, Van Riper, Baer, & Stover, 1991), developing courses specifically related to rural practice (Australian Health Ministers’ Conference, 1994; Gangeness, 1997) and by creating rural internship opportunities, because it has been shown that training experiences in rural areas can lead to a decision to practice in such areas (Department


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of Health and Family Services, 1998; Gangeness, 1997; Ricketts, 2000c; Scott, Neary, Thilliander, & Ueda, 1992).

The isolated nature of rural practice also means that business overheads may be higher and problems may arise if these higher costs are passed on to consumers, due to the fact that many rural residents have lower incomes than urban residents (Bills, 1989; Stratton, 2001). If these higher prices cannot be afforded, business may fall to such an extent that pharmacies are forced to close (Almarsdottir, Morgall, & Bjornsdottir, 2000). This may seriously affect the health care services that are available, particularly because many rural towns only have a single pharmacy and its closure is likely to result in reliance on mail-order prescriptions and the loss of health education and non-prescription pharmacy services (Norris, 1997; Stratton, 2001; Straub & Straub, 1999).

Of further concern is the finding that people will not optimally use medications, or may even defer buying them indefinitely, if their price is perceived to be too high and would mean that a trade-off with other everyday necessities would have to be made (Casey, Klingner, & Moscovice, 2002; Coburn & Ziller, 2000). Older rural residents have been found to perceive financial issues as more of a barrier to pharmaceutical care than transportation issues (Casey, Klingner, & Moscovice, 2002). Elderly people, who tend to be the highest users of prescription drugs and have smaller disposable incomes, are at particular risk of not being able to afford their medications (Coburn & Ziller, 2000; Doucette, Brooks, Sorofman, & Wong, 1999; Straub & Straub, 1999). The situation is even more serious for rural elderly due to the fact that they tend to be in poorer health and have smaller incomes than their urban counterparts (Coburn & Ziller, 2000; Gangeness, 1997).

The result of not using the correct amount of medication, or deferring medication use indefinitely, may be large increases in the morbidity and mortality rates of older rural people (Coburn & Ziller, 2000; Gangeness, 1997). In one study, rural elderly were also three times more likely than their urban counterparts to use mail order prescription services and, therefore, may miss out on receiving additional health advice and instructions on how to use medications safely from their pharmacist


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(Ranelli & Coward, 1996). Clearly then, rural pharmacists are in a position to improve the medication use of older people (Ranelli & Coward, 1996).

There is also the issue of allowing doctors to dispense medications, which has recently received attention in Britain (Byrt, 1994; “Dispensing threat,” 1998; Nathan, 1990; “Pharmacist’s rural role,” 1986) and Australia (“Au Doctors,” 2000). Problems may arise if doctors over-prescribe, because of reimbursement being based on the amount of medications dispensed, and because pharmacists are not available to check for prescription errors (Norris, 1997). As Miller and Scott (1996) state “mere dispensing of a drug does not constitute pharmaceutical care; in fact, it may be dangerous when drug interactions and adverse drug reactions are not prevented” (p. 7). Such a policy may also lead to the loss of business for smaller pharmacies, could prevent pharmacists from developing or extending their services to the level they would like and could result in pharmacy closures, depriving the local community of access to pharmaceutical services (“Dispensing threat,” 1998; Nathan, 1990; “Pharmacist’s rural role,” 1986).

Access can be defined as “the opportunities individuals have in relation to utilising health services,…in terms of the financial and opportunity costs to the individual receiving health care” (Wakerman, 1999, p.10). It is important for health services to be optimally located so that customers have easy access (Carreras & Serra, 1999). Convenient access is one important aspect of the customers’ perception of quality of service (Carreras & Serra, 1999). Some research has found that the majority of pharmacists believe that rural residents do not face access problems in relation to pharmacies, and state that delivery services to more isolated people largely overcome any existing transportation issues (Byrt, 1994; Casey, Klingner, & Moscovice, 2001).

However, delivery services are not always available and access to transportation and, therefore, pharmacies, is still an important issue for many rural people (Almarsdottir, Morgall, & Bjornsdottir, 2000; Australian Health Ministers’ Conference, 1994; Coburn et al., 2000; Douglas, 1999; Watts et al., 1999), particularly the elderly, parents with young children, low-income earners, adolescents who are reliant on public transport and people with disabilities and chronic illness (Almarsdottir, Morgall, & Bjornsdottir, 2000; Byrt, 1994; Douglas, 1999; Watt, Franks, & Sheldon,


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1994). Often it is people from these groups who are most in need of health care services (Byrt, 1994; Gangeness, 1997; Straub & Straub, 1999; Watt, Franks, & Sheldon, 1994) and who place the highest value on access to these services and on having their health care needs met (Watts et al., 1999).

In addition, people may have to travel long distances and pay high fuel costs to reach a pharmacy and often this journey may take place on substandard roads (Humphreys & Weinand, 1991; Kaiser, 2000; Lavelle, 2003; “MSPs highlight,” 2001; “Pharmacist’s rural role,” 1986; Wing & Reynolds, 1988). The same problems exist if it is necessary to refer patients to other, more specialised health practitioners in urban centres (Kurtzman, Heltzer, & Counts, 1977; Williams, Schwartz, Newhouse, & Bennett, 1983; Wing & Reynolds, 1988). Although it is important to note that the time people in some rural areas spend travelling to reach their closest health care providers may be similar to the time taken by residents of large capital cities to reach health services (Byrt, 1994; Newhouse, 1990). Notwithstanding this point, transport and access issues may partly explain the “distance decay” phenomenon, that is, why rural people are much less likely than urban people to seek help about medical problems, particularly when such problems are perceived as trivial or intermediate (Lavelle, 2003; Ricketts, 2000c; Silver, 1994; Thouez, Bodson, & Joseph, 1988; Watt, Franks, & Sheldon, 1994).

One alternative to the problem of accessing some common pharmacy medicines for rural people may be to introduce telepharmacy in select locations (Underwood, 1997). Telepharmacy is defined as “the provision of pharmaceutical care through the use of telecommunications and information technologies to patients at a distance” (Casey, Klingner, & Moscovice, 2002, p. 475). This may involve using computerised video link ups, the Internet and telephones (Lum, 2001; Ricketts, 2000c; Underwood, 1997) and automatic dispensing machines to provide common dosages of certain frequently used medicines under the supervision of an authorised health care provider, such as a doctor or nurse (Casey, Klingner, & Moscovice, 2002; Lum, 2001). Telepharmacy may go some way towards improving access to pharmaceutical products for rural residents (Casey, Klinger, & Moscovice, 2002; Underwood, 1997) and help to overcome the problem of uneven and unreliable supplies of certain medicines (Almarsdottir, Morgall, & Bjornsdottir, 2000).


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Similarly, mobile pharmacies, whereby a pharmacist travels with supplies and rotates among several small towns that do not have a pharmacy, may assist in improving pharmacy access for residents in such towns, providing licensing regulations are taken into account (Billow, Van Riper, Baer, & Stover, 1991; Watt, Franks, & Sheldon, 1994). Such initiatives may be helpful in reducing the need for rural residents to travel to other towns for their medicines or, alternatively, have to wait a few days to get a prescription filled (Almarsdottir, Morgall, & Bjornsdottir, 2000).

Pharmacies in rural areas may also be affected by the increasing use of alternative medicines and therapies, such as, herbal medicine, homeopathy and megavitamins (Tripp & Straub, 2001). People are becoming more comfortable using such alternative treatments, for example, one study found that approximately 62 per cent of rural respondents would be willing to use alternative medicines (Tripp & Straub, 2001). Therefore, pharmacies will have to incorporate such products into their stock, as well as offering education and counselling about the safe use of such products and preventing possible negative effects which may arise from the simultaneous use of prescribed and alternative medications (Tripp & Straub, 2001). It may be the case that providing a range of alternative or complementary pharmacy products and services could improve lagging profits and allow pharmacies to remain competitive in the market place (Tripp & Straub, 2001). Pharmacies are part of the retail sector as well as the health sector and, therefore, need to be oriented towards consumers (Doucette, Brooks, Sorofman, & Wong, 1999; Selya, 1988).

Competitiveness is also reliant on the level of service provided by pharmacy staff to their customers (Larson, Rovers, & MacKeigan, 2002). If patients perceive the staff to be good communicators and courteous towards them, and feel the store is in a convenient location, satisfaction with pharmacy services will tend to be high (Briesacher & Corey, 1997; Epstein, 1996; Straub & Straub, 1999). This in turn will influence compliance with taking medications and continuity with a specific pharmacy, that is, when patients are satisfied, they are more likely to follow instructions when taking medications and less likely to change to another pharmacy service (Briesacher & Corey, 1997). In areas with a small population, it is particularly important for pharmacies to be able to satisfy and retain their client base because, if


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patients are lost through dissatisfaction, they are unlikely to be replaced by additional customers (Epstein, 1996).

Client bases may also be reduced or lost as a result of the out-migration of the population from rural areas to urban areas (Gangeness, 1997), which is generally caused by the “erosion of the economic bases of these communities” (Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002, p, 7). The trend towards economic restructuring, service rationalisation and centralisation has been blamed for having negative effects on rural industry and employment levels and cited as a major cause of out-migration (Australian Health Ministers’ Conference, 1994; Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002; Humphreys, Rolley, & Weinand, 1993; Lavelle, 2003; Lum, 2001; Watt, Franks, & Sheldon, 1994).

Smaller populations mean that governments are less willing to offer increased resources for improving health services and money tends to be redirected to areas experiencing population growth (Lavelle, 2003). Due to the economic downturn in areas facing population decline, those who choose to stay tend to have less money to spend on accessing health services (Lavelle, 2003). Furthermore, often those who leave are the youngest and healthiest of the population, meaning that those who remain are more in need of health care services due to a higher rate of illness and social problems, such as alcohol abuse, which can negatively affect health (Lavelle, 2003). Therefore, the growing gap in economic prosperity between urban and rural areas has been a cause of poor heath care service levels in non-metropolitan areas (Humphreys, Hegney, Lipscombe, Gregory, & Chater, 2002; Lum, 2001).

The issue of the licensing of pharmacies, to improve access in rural areas, has also been addressed by researchers (Norris, 1997). If the market place alone is allowed to determine pharmacy location, it is likely that replication of pharmacy services will occur, that is, many pharmacies will operate in the same area (Norris, 1997). However, by allowing the government to determine where pharmacists can practice through a licensing system, some redistribution of services to previously under-served areas would occur. This would result in improved access to pharmacy services for rural people (Norris, 1997). Similarly, allowing stores in country towns without a


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pharmacy to stock a small range of pharmacy-supplied prescription medicine improves access to over-the-counter medications (Norris, 1997).

Researchers believe that rural pharmacies can survive if they offer additional services, such as home delivery, home care and diabetes monitoring, and form partnerships with local doctors and other health care providers in order to devise comprehensive health care plans and to allow central access to patients’ medical information (Albro, 1992; Billow, Van Riper, Baer, & Stover, 1991; Epstein, 1996; Gilbert, 1998; Leversha, Strasser, & Teed, 2001; Low, 1998). The latter is in recognition of the fact that pharmaceutical care should be provided in collaboration with other health care providers, not in isolation (“FIP and WHO,” 1993; Lum, 2001; “Pharmacist’s rural role,” 1986). “In the broadest sense, the pharmacist is perceived as an active member of the health care team with responsibility for inter-professional as well as patient consultation” (Morgall & Almarsdottir, 1999, p. 1254). Pharmacists could also take on the role of monitoring the health of patients with chronic diseases in the times between the patients’ doctor visits (Epstein, 1996).

Furthermore, continuing education programs, training and up-skilling and additional pharmacists are needed in rural areas (Leversha, Strasser, & Teed, 2001), particularly if pharmacists are planning to form teams with other health care providers in order to improve patient outcomes (Knapp, Paavola, Maine, Sorofman, & Politzer, 1999). Greater resources for pharmacies, both tangible (for example, staff, stock, equipment and facilities) and intangible (for example, knowledge bases, routines and organizational processes), will also assist in strengthening rural pharmacy practice (Doucette & Jambulingam, 1999).

The boundaries between the work and non-work environments are less defined in rural areas, pharmacy staff have a closer relationship with their customers in terms of giving more advice and offering additional services, and staff experience a blurring of job roles to a greater extent than in urban pharmacy practices (Rogers, Hassell, Noyce, & Harris, 1998; Scott, Neary, Thilliander, & Ueda, 1992). However, one potential negative influence on small town pharmacy practice is perceived (or actual) lack of anonymity by patients (Ranelli & Coward, 1996). If the pharmacy is not designed with areas for private conversations, patients may feel inhibited when


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discussing health concerns in the vicinity of other townspeople who may be their neighbours or acquaintances (Ranelli & Coward, 1996).

In small town pharmacies, staff-customer conversations are frequently more informal, including discussion of everyday life and enquiries about family members, which results in greater use of the pharmacy as a health and social resource for the local community (Rogers, Hassell, Noyce, & Harris, 1998). This is because general conversations with patients can help to engender trust and may create a positive relationship, whereby patients feel comfortable discussing issues relating to medication use, health concerns and quality of care (Cleary & McNeil, 1988; Ranelli & Coward, 1996).

Because of the quality of the relationship between pharmacists and residents in small towns, Epstein (1996) states that rural pharmacy “will be the model for the addedvalue pharmacy of the future…managed care must ultimately include pharmaceutical services in overall health-care models, and, when it does, the benefits of community pharmacy services will finally be recognized”(p. 62). Pharmacists will allow qualified technicians or automated dispensing units to take over most of the distributive functions, while they engage in consultative and clinical roles (Lum, 2001). Furthermore, rural populations should regard access to high quality health services as a basic human right (Wakerman, 1999).


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Profiles of the Four Towns Three Springs The town of Three Springs is situated 313 km north of Perth and the Three Springs district has a total population of approximately 725 people, consisting of 46% females and 54% males. Of this population, 83.31% are Australian born, including 4.97% Indigenous people, and 12.14% were born overseas, most commonly in the United Kingdom and New Zealand. The median age of residents is 38 years.

Most adult residents have completed a Year 10 (28%), Year 11 (8.41%), or Year 12 (23.31%) level high school education, with an additional 13.79% of people having completed TAFE or technical college qualifications, 5.66% having completed undergraduate degrees and 0.83% having post-graduate qualifications. Post-school qualifications were most commonly in the areas of engineering, health, agriculture and environmental studies, management and commerce and education.

The median weekly individual income of residents is $300-$399. The industries employing the largest number of residents are agriculture, forestry and fishing, mining and health and community services, with the most common occupations being management and administration, labouring and intermediate clerical, sales and service work. The unemployment rate for this district is 3.9%.

The majority of males and female adults are married and living with their partner (37.93%), with a smaller number being a partner in a de facto relationship (8.14%) or a single parent (2.34%). Additionally, 2.07% of residents are living in a non-family, group household and 9.93% of people are living by themselves. The mean household size for the Three Springs district is 2.3 people. (Australian Bureau of Statistics, 2001). Leeman The Coorow district includes the coastal town of Leeman, which is situated north of Perth, between Green Head and Dongara. Leeman’s population is approximately 750 people, while the Coorow district has a total population of 1341 people, consisting of


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45% females and 55% males. Of this population, 86.27% are Australian born, including 2.39% Indigenous people, and 8.50% were born overseas, most commonly in the United Kingdom and New Zealand. The median age of residents is 36 years.

Most adult residents have completed a Year 10 (25.88%), Year 11 (8.80%), or Year 12 (19.69%) level high school education, with an additional 16.78% of people having completed TAFE or technical college qualifications, 4.25% having completed undergraduate degrees and 0.45% having post-graduate qualifications. Post-school qualifications were most commonly in the areas of engineering, education, health, agriculture and environmental studies and management and commerce. The median weekly individual income of residents is $300-$399. The industries employing the largest number of residents are agriculture, forestry and fishing, mining, retail trades and construction, with the most common occupations being management and administration, trades and intermediate production and transport work. The unemployment rate for this district is 7.3%.

The majority of males and female adults are married and living with their partner (40.12%), with a smaller number being a partner in a de facto relationship (8.28%) or a single parent (1.42%). Additionally, 2.09% of residents are living in a non-family, group household and 7.53% of people are living by themselves. The mean household size for the Coorow district is 2.6 people. (Australian Bureau of Statistics, 2001). Jurien Bay The Dandaragan district includes the town of Jurien Bay, which is situated 257 km north of Perth and has a total population of approximately 3078 people, consisting of 45% females and 55% males. Of this population, 78.20% are Australian born, including 2.53% Indigenous people, and 11.89% were born overseas, most commonly in the United Kingdom and New Zealand. The median age of residents is 39 years.

Most adult residents have completed a Year 10 (24.59%), Year 11 (7.86%), or Year 12 (21.18%) level high school education, with an additional 17.28% of people having


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completed TAFE or technical college qualifications, 3.44% having completed undergraduate degrees and 0.81% having post-graduate qualifications. Post-school qualifications were most commonly in the areas of engineering, management and commerce, agriculture and environmental studies, education and health. The median weekly individual income of residents is $300-$399. The industries employing the largest number of residents are agriculture, forestry and fishing, retail trade, mining, accommodation and hospitality and construction, with the most common occupations being management and administration, labouring and trades. The unemployment rate for this district is 6.8%.

The majority of males and female adults are married and living with their partner (35.96%), with a smaller number being a partner in a de facto relationship (6.82%) or a single parent (1.62%). Additionally, 1.75% of residents are living in a non-family, group household and 7.08% of people are living by themselves. The mean household size for the Dandaragan district is 2.5 people. (Australian Bureau of Statistics, 2001). Moora The Moore district includes the town of Moora, which is situated 90 km from the coast and 172 km north of Perth. It is the largest town between Perth and Geraldton and a major rural centre north of Perth. It has a total population of 2585 people, consisting of 48% females and 52% males. Of this population, 83.44% are Australian born, including 9.83% Indigenous people, and 8.94% were born overseas, most commonly in the United Kingdom and New Zealand. The median age of residents is 33 years.

Most adult residents have completed a Year 10 (21.35%), Year 11 (8.47%), or Year 12 (23.06%) level high school education, with an additional 12.72% of people having completed TAFE or technical college qualifications, 3.95% having completed undergraduate degrees and 1.24% having post-graduate qualifications. Post-school qualifications were most commonly in the areas of engineering, education, agriculture and environmental studies, health and management and commerce.


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The median weekly individual income of residents is $300-$399. The industries employing the largest number of residents are agriculture, forestry and fishing, retail trade and education, with the most common occupations being management and administration, trades, intermediate clerical, sales and service work and labouring. The unemployment rate for this district is 5.7%.

The majority of males and female adults are married and living with their partner (35.51%), with a smaller number being a partner in a de facto relationship (7.15%) or a single parent (2.63%). Additionally, 2.24% of residents are living in a non-family, group household and 7.54% of people are living by themselves. The mean household size for the Moore district is 2.7 people. (Australian Bureau of Statistics, 2001).


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Method Participants Profile of the Three Springs Sample Of the 100 questionnaires that were mailed to residents, 56 were completed and returned, giving a response rate of 56%. Most primary respondents (26.8%) were aged 46-55, with another 25% aged 36-45. Their partners were most commonly in the 3645 age group (23.2%), with an additional 19.6% aged 56-65. Approximately two thirds of primary respondents were female (64.3%) and just over a third were male (35.7%). With regard to partners, 76.1% were male and 23.9% were female. The majority of households (65.5%) had no children residing in them. Of those 34.5% of households with children, the mean age of these children was 10.42 years. Most respondents (98.1%) were Caucasian, with 1.9% describing themselves as belonging to the ‘Other’ category. All partners were Caucasian. 81.8% of primary respondents stated their highest education level was high school graduate or above. The same was true for 78.7% of respondents’ partners. Farming was the main area of employment identified by 35.7% of respondents, followed by ‘Other’ (including pensioners, retirees and self-employed – 23.2%) and Home Duties (16.1%). Most of the respondents’ partners were employed in the Farming industry (39.3%), followed by ‘Other’ (including retirees, self-employed and mining workers – 21.4%). The majority of primary respondents reported having lived in the town for 40 years or more (23.2%), with another 17.9% having lived in Three Springs for between 21 and 30 years. Likewise, most of the respondents’ partners had lived in the town for 40 or more years (26.8%), with an additional 14.3% having lived there for between 21 and 30 years.

Of those respondents reporting to suffer from current illnesses, hypertension and ‘Other’ (including significant weight problems, reflux, high cholesterol, epilepsy and chronic fatigue) were the most common, at 17.9% and 12.5% respectively. For partners, hypertension was the most common (16.1%), followed by arthritis and ‘Other’ (9% each), with the ‘Other’ category including glaucoma, hernia, chronic


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fatigue and high cholesterol. Profile of the Jurien Bay Sample From the 200 questionnaires that were delivered to the random samples in Jurien Bay, 74 were completed, giving a response rate of 37%. The primary respondents were generally aged 66 to 75 years (25.7%) or 36 to 45 years of age (21.6%) and the majority were female (67.1%). Their partners largely belonged to the 56 to 75 age group (44.6%) and the majority were male (66.7%). Most of the households were child-free (76.7%) but of those households where children were present, the mean age of the children was 7.45 years. Nearly all of the respondents (98.6%) and their partners (98.2%) identified themselves as Caucasian, with the remainder identifying themselves as ‘Other’.

The highest level of education reported by the majority of respondents and their partners was completion of high school (42.3% and 40.7% respectively). In terms of area of employment, most respondents identified themselves as belonging to the ‘Other’ category (40.5%), with many reporting that they were retired or pensioners. Home Duties was the next most frequent area of employment (18.9%). The respondents’ partners were also most frequently described as belonging to the ‘Other’ category (36.5%), with many being identified as retired or pensioners. Being a Tradesperson was the next most frequent area of employment (12.2%). The majority of respondents had lived in Jurien Bay for between 11 and 20 years (28.4%), closely followed by those having lived there for between two and five (27%) and six and ten years (27%). Partners had lived in the town for a similar length of time, with 24.3% having lived there for between 11 and 20 years, 23% having lived there for between two and five years and 20.3% having lived there for between six and ten years.

Of those primary respondents reporting to have some form of current illness, the ‘Other’ category was the most common (17.6%) and included illnesses such as high cholesterol, blood clotting (DVT), reflux, thyroid problems, bronchitis and prostate problems, followed by hypertension (16.2%). With regard to partners, 17.6% of those reported to have a current illness suffered from arthritis, followed by ‘Other’ (including high cholesterol, heart condition, prostate problems, hernia, Ross River virus and thyroid problems - 13.5%) and hypertension (12.2%).


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Profile of the Moora Sample Of the 200 questionnaires that were delivered to residents, 65 were completed and returned, giving a response rate of 32.5%. Most primary respondents (20.3% each) were aged 36-45 and 46-55, with another 17.2% aged 56-65. Their partners were most commonly in the 56-65 age group (27%), with an additional 21.6% aged 36-45. Approximately two thirds of primary respondents were female (62.5%) and just over a third were male (37.5%). With regard to partners, 68.4% were male and 31.6% were female. The majority of households (60.9%) had no children residing in them. Of those 39.1% of households with children, the mean age of these children was 8.85 years. Most respondents (96.9%) were Caucasian, with 3.1% describing themselves as Aboriginal/Torres Strait Islander. Similarly, most partners were Caucasian (94.7%), with 2.6% being described as Aboriginal/Torres Strait Islander and 2.6% being described as ‘Other’. 85.9% of primary respondents stated their highest education level was high school graduate or above. The same was true for 76.3% of respondents’ partners. The ‘Other’ employment category (including pensioners, retirees and government workers) was chosen by 37.5% of respondents as their main source of employment, followed by Home Duties (17.2%) and Professional (10.9%). The ‘Other’ employment category (including retirees and government workers) was also the main employment of respondents’ partners (35.9%), followed by Retail/Shop Work and Tradesperson (12.8% each). The majority of primary respondents reported having lived in the town for 40 years or more (25%), with another 18.8% having lived in Moora for between 21 and 30 years. Likewise, most of the respondents’ partners had lived in the town for 40 or more years (26.8%), with an additional 14.6% having lived there for between two and five and 31 and 40 years. Of those respondents reporting to suffer from current illnesses, hypertension was the most common, at 34%. Arthritis followed at 24.67%. For partners, hypertension was the most common (35%), followed by arthritis and heart disease (27.2% each). Profile of the Leeman Sample Of the 100 questionnaires that were delivered to residents, 41 were completed and


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returned, giving a response rate of 41%. Most primary respondents (34.1%) were aged 36-45, with another 24.4% aged 46-55. Their partners were most commonly in the 3645 age group (31.7%), with an additional 22% aged 46-55. Just over two thirds of primary respondents were female (70.7%) and just under a third were male (29.3%). With regard to partners, 77.1% were male and 22.9% were female. The majority of households (60%) had no children residing in them. Of those 40% of households with children, the mean age of these children was 9.28 years. All respondents (100%) were Caucasian. Similarly, most partners were Caucasian (97%), with 3% being described as Aboriginal/Torres Strait Islander. 82.9% of primary respondents stated their highest education level was high school graduate or above. The same was true for 80% of respondents’ partners. The ‘Other’ employment category (including pensioners, retirees, mining workers and government workers) was chosen by 31.7% of respondents as their main source of employment, followed by Home Duties (14.6%) and Fishing Industry (14.6%). Fishing Industry was the main employment of respondents’ partners (28.6%), followed by the ‘Other’ employment category (including retirees, pensioners and teachers – 17.1%) and Other Local Industry (17.1%). The majority of primary respondents reported having lived in the town for between 11 and 20 years (26.8%), with another 24.4% having lived in Leeman for between six and ten years and 22% having lived there for between two and five and 21 and 30 years. Most of the respondents’ partners had lived in the town for between two and five years (29.4%), with an additional 23.5% having lived there for between six and ten and 11 and 20 years. Of those respondents reporting to suffer from current illnesses, hypertension was the most common, at 17%. Asthma followed at 14.6%. For partners, hypertension was the most common (19.5%), followed by ‘Other’, which included reflux, gout and high cholesterol (12.2%). Materials An 11-page questionnaire was developed for the purpose of this study (see Appendix A). It was comprised of three sections – 1. Demographic Information, 2. Access to Primary Health Services and 3. Opinions about the Provision of Health Services in the Locality.


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Section one asked respondents to supply demographic data such as their age, gender, ethnicity, education level, employment status, length of residence in the town, whether any children resided with them, the ages of these children and whether they were being treated for any illnesses. Space was provided for primary respondents to supply data relating to their partners, if applicable (see Appendix A).

Section two asked respondents how often they obtained non-prescription and prescription medicines, where prescriptions were collected from, the distance and time travelled in order to collect medicines, how much was spent on prescriptions in an average month, how often a doctor was visited, the time and distance travelled to reach this doctor, how often a community nursing post was visited, the time and distance travelled in order to reach this nursing post, how much was spent on medicines from nursing posts, whether the internet or mail order was ever used to purchase medicines and, if not, would the respondent ever consider using these services in the future. Respondents were also presented with a list of non-emergency and emergency goods and services and asked where they would be most likely to visit in order to obtain each good or service from a list of six possibilities (pharmacy, doctor, nursing post, local shop, other or unsure/not applicable) (see Appendix A).

The final section asked respondents to provide an indication of how strongly they agreed or disagreed with a series of eight statements, using a five-point Likert scale (1 = strongly agree, 2 = agree, 3 = unsure, 4 = disagree, 5 = strongly disagree). These statements included the following – there is too long a delay from when I need a medication to when it is available to me, I have to travel too far to get prescriptions filled, the health services in my town are adequate for my needs and I think my town needs more access to pharmacy services. Space was also available for respondents to provide open-ended responses to the questions of what they saw as being the main benefits of having a local pharmacy and, conversely, what they saw as being the main disadvantages of not having a local pharmacy (see Appendix A). Procedure The aim of the study was to directly survey rural residents regarding their level of access to, and preferences towards, pharmacy and other health services (Casey, Klingner, & Moscovice, 2002). Previous research has found there to be a lack of


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studies which have given attention to differences between pharmacies operating in different areas (Rogers, Hassell, Noyce, & Harris, 1998). Therefore, in the present research, four separate communities were studied, two of which had pharmacies. Questionnaires were given to participants for self-administration because this allowed for greater confidentiality for participants and greatly reduced data-gathering costs (Ware, Snyder, Wright, & Davies, 1983). The design of the questionnaire allowed for completion by individuals living alone or in shared accommodation or by people living with a partner and/or children (see Appendix A).

Demographic questions covered the variables of age, gender, presence of children in the home and their ages, ethnicity, employment status, presence of illness and length of residence in the town (see Appendix A). These variables were chosen because they have been used by researchers in the past to investigate differences in satisfaction with pharmacy services (Johnson et al., 1997; Larson, Rovers, & MacKeigan, 2002). That is, people of varying age, gender, ethnicity and socio-economic group have been found to value and need different aspects of health services and, therefore, these variables must be considered when investigating health service provision (Bamford & Hugo, 2001). The range of illnesses presented as response options in Question 8 were chosen based on earlier research by Johnson et al. (1997). This question was included because health status has been found to influence respondents’ level of satisfaction with health services (Cleary & McNeil, 1988).

Access to pharmacy and other health services has been found to be a, if not the, major determinant of satisfaction with these services, closely followed by the availability and convenience of services (Cleary & McNeil, 1988). Therefore, questions dealing with these issues were asked of respondents, with regard to pharmacies, doctors and nursing posts, such as Silver Chain.

Silver Chain nursing posts have provided health and aged care in various rural communities and small towns in Western Australia for over 80 years (Lorraine, 1999). Staffed by a Remote Area Nurse Practitioner, these centres provide accident and emergency care and have recently expanded their role to that of primary health care provider, encompassing services such as health education, infant and child health, palliative care, home care and allied health provision (Lorraine, 1999). Because the


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Silver Chain nurses may be the only health professionals easily accessible to surrounding communities, these nursing posts are seen as an essential part of such communities (Lorraine, 1999). Furthermore, in areas where there is no readily available doctor, nurse practitioners have recently been granted the power to take over some of the functions of a doctor, such as diagnosing and treating minor illnesses, performing minor procedures and ordering basic medical tests (Lavelle, 2003; Scott & Health Matters, 2003).

Specifically, survey questions dealt with the frequency with which medications were purchased, where medications were purchased, the time and distance involved in purchasing them, their cost and whether medications had ever been purchased via the internet or mail order (see Appendix A). Preferences were also asked, with regard to where respondents would be most likely to go for a range of non-emergency (e.g. vitamins, cosmetics, general health advice) and emergency (e.g. stomach pains, fever in a baby or child, diarrhoea) goods and services (see Appendix A). These questions were included because they provided a gauge of who participants saw as being the most accessible health care provider(s) and identified who participants had most confidence in (Curtiss & Wertheimer, 1978). Furthermore, allowing respondents to give preferences regarding their use of health services has been found to be a reliable measure of the actual level of use of various health service providers (Humphreys & Weinand, 1991).

Questions regarding individuals’ satisfaction with pharmacy services were asked because the quality of health and pharmaceutical care is increasingly being measured by patient satisfaction ratings (Johnson, Coons, & Hays, 1998; MacKeigan & Larson, 1989; Schommer & Kucukarslan, 1997). This is because satisfaction ratings bring unique information to the health service industry and provide opportunities for patient evaluations of the standard and outcomes of the care they receive (Johnson, Coons, & Hays, 1998; MacKeigan & Larson, 1989; Ware, Snyder, Wright, & Davies, 1983). Satisfaction ratings have been shown to predict “patient behaviours such as utilisation of care, continuity with provider, and compliance” (MacKeigan & Larson, 1989, p. 522).


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Examples of instruments used to measure satisfaction include the Pharmacy Encounter Survey (PES) (Briesacher & Corey, 1997) and the Satisfaction with Pharmacy Services Questionnaire (MacKeigan & Larson, 1989). Patient satisfaction with pharmacies is a multidimensional concept (Johnson, Coons, & Hays, 1998; Ware, Snyder, Wright, & Davies, 1983) and is commonly predicted by factors such as the convenience or accessibility of the store, quality of customer service, quality and price of the goods purchased, familiarity with the pharmacist, pharmacist’s professional knowledge and manner, information provided and waiting times to get prescriptions filled (Briesacher & Corey, 1997; Cleary & McNeil, 1988; Flores, Umenai, & Wakai, 2001; Johnson et al., 1997; Larson, Rovers, & MacKeigan, 2002; MacKeigan & Larson, 1989; Straub & Straub, 1999; Ware, Snyder, Wright, & Davies, 1983).

A Likert scale, providing five response options (strongly agree, agree, unsure, disagree, strongly disagree), was used to gather satisfaction data from participants via a series of eight questions. These questions covered the issues of suitability of prescriptions, availability of advice, waiting times, travelling times, access to pharmacies and privacy (see Appendix A). Using Likert scales has been found to facilitate item completion because participants can become familiar with response choices quickly (Ware, Snyder, Wright, & Davies, 1983). Furthermore, using five response options, as opposed to three or seven, has been shown to yield more information and have greater response reliability and reduced skewness (Ware, Snyder, Wright, & Davies, 1983). Therefore, this approach was adopted.

The final section of the questionnaire provided respondents with an opportunity to list the three most important factors for them in relation to a). a pharmacy being present in their town and b). there being no pharmacy in their town (see Appendix A). These questions allowed respondents to provide open-ended responses and perhaps mention issues which had not been covered in the questionnaire.

The completed questionnaire was sent to practicing pharmacists in two rural towns, and a pharmacist from the Rural Subcommittee of the Pharmacy Guild of Australia (WA Branch), for comments with regard to improving the questionnaire design and content, in terms of clarifying any ambiguous questions and reducing potential non-


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response to unclear questions (McKinley, Manku-Scott, Hastings, French, & Baker, 1997). Feedback from the pharmacists was largely positive, with only minor changes suggested. These changes were made and ethical approval for the use of the questionnaire, and to conduct the study itself, was granted by Curtin University’s Human Research Ethics Committee.

Originally, it was planned to hand deliver questionnaires to 100 randomly selected households in each town and then return to each house within three days to collect completed questionnaires. Council officers in each of the four towns provided a list of every ratepayer in each town. Each resident was given a number and a table of random numbers was used to select 100 addresses from the list, with an additional 50 selected as reserves in case some residents were not home to receive a questionnaire. This process was initially followed for the town of Jurien Bay, with 25 questionnaires being hand delivered to randomly selected residents. However, several problems were encountered which drastically slowed down questionnaire delivery and made it necessary to alter the questionnaire distribution process. Additionally, most residents preferred to send their questionnaires back via a reply paid envelope, rather than have the researcher return within several days to collect it in person.

The vast majority of homes in Jurien Bay did not have a visible number indicating their street address, nor did they have a post box on their premises. Instead, the town still makes use of post office boxes, with residents collecting their mail from boxes located at the town’s post office. In order to speed up the distribution process and ensure that 100 questionnaires would be delivered in the available time, the remaining 75 questionnaires were left at the post office, to be put directly into the post office boxes belonging to the randomly selected residents. A reply paid envelope was included with the informed consent form (see Appendix B), and questionnaire to allow participants to respond easily. Later, in an effort to boost the number of responses from an initial 31%, telephone contact was made with non-respondents. This proved unsuccessful in improving the response rate so a second random sample of 100 Jurien Bay residents was selected, with questionnaires and reply-paid envelopes being sent to these people. After an initial response rate of 28% from this second sample, follow-up letters (see Appendix C) and questionnaires were sent to non-respondents in an effort to improve the response rate.


37

With regard to the town of Three Springs, residents collect their mail from post office boxes located in the town’s centre, so questionnaires were mailed to 100 randomly selected residents so as to try and avoid the problems with questionnaire distribution that had occurred in Jurien Bay. After an initial response rate of 40% from the Three Springs sample, follow-up letters (see Appendix D) and questionnaires were sent to non-respondents in an effort to improve the response rate.

Residents in the town of Moora generally have their mail delivered to a mailbox on their property, so this town was visited and 100 questionnaires were delivered to a random sample of local residents. In an effort to boost the response rate, participants were asked if they would be willing to complete the questionnaire on the spot. However, most said they would prefer to complete it at a more convenient time and return it in the reply-paid envelope provided. Questionnaires and reply-paid envelopes were left in the mailboxes of those people not at home, along with an explanatory letter (see Appendix E) and informed consent form. Once again, after an initial response rate of 28%, follow-up letters (see Appendix F) and questionnaires were sent to non-respondents in an effort to improve the response rate. Later, in order to ensure that at least ten percent of Moora’s total population had been surveyed, a second random sample of 100 Moora residents was selected and questionnaires, information letters, informed consent forms and reply-paid envelopes were mailed to these people. The response rate from this second sample of Moora residents was 26%. Because of time restraints, a follow-up of this second sample was not conducted.

Because of the higher response rate obtained from the residents of Three Springs, a similar method of questionnaire delivery was used for the town of Leeman. That is, a random sample of 100 residents were mailed a copy of the explanatory letter and questionnaire, with a reply-paid envelope enclosed so completed questionnaires could be mailed back. This resulted in a response rate of 25%, so follow-up letters (see Appendix D) and questionnaires were sent to non-respondents in an effort to improve the initial response rate.

Short questionnaires were also left for completion by the Shires’ Deputy Officer and Community Nurse, apart from the nurse at the Three Springs’ Community Health Clinic, who declined to participate. The Deputy Officer was asked about the personal


38

value placed on a range of goods and services provided by community pharmacies and what he or she saw as being the main benefits of having, or disadvantages of not having, a local pharmacy (see Appendix G). The Community Nurse was asked about the function of his or her organisation, the number of patients seen per week, the medicines most commonly supplied to patients, remuneration processes, the goods and services supplied by the nursing post and the main benefits of having, or disadvantages of not having, a local pharmacy (see Appendix H). Reply paid envelopes were also left with these questionnaires.

While in the towns, the researcher visited the local pharmacy (in Jurien and Moora) and local stores (all towns) to record the availability and price of Schedule 2 and Schedule 3 drugs. The checklist of medicines that would potentially be available at the two pharmacies was created by collating a list of all S2 and S3 Over-The-Counter (OTC) medicines available in Australia, as listed by the 2000 edition of the MIMS OTC manual. This resulted in a checklist which encompassed 40 categories of S2 and S3 products (see Appendix I). Similarly, a checklist of certain medicines stocked at a metropolitan Coles supermarket was used as a means of gauging the range of products available at eight local stores across the four towns (see Appendix J). This was necessary to determine if stores in the two towns without pharmacies stocked a larger range of pharmacy medicine to compensate and to compare the price and range of products throughout the four towns. The prices of items on the checklist were also recorded for a metropolitan Coles store to enable rural and urban prices to be compared.

In addition, eight data reports were obtained from the Health Insurance Commission (HIC). These reports provided information relating to where people in each of the four towns had medicines prescribed (i.e. the location of the doctor who wrote the prescription) and where prescriptions were dispensed (i.e. the location of the pharmacy which dispensed the prescription) for the period of March 1st 2002 to February 28th 2003. The total number of scripts prescribed or dispensed were provided for people in one of three age groups (0-16 years, 17-64 years and 65 years and over). Under the Privacy Act, HIC was only permitted to release data which met the minimum cell size rule, that is, each cell had to relate to a certain number of people before that data could be released. Therefore, these three age groupings were


39

chosen because it was thought that they would allow the maximum amount of data to be released by HIC for analysis. These groupings also roughly broke down the total number of scripts prescribed and dispensed into those relating to children (0-16 years), adults (17-64 years) and elderly people (65 years and over). This data was used to determine where people in the towns were going to have their scripts prescribed and dispensed and, specifically, if any differences existed in the distances being travelled by those people living in towns with and without local pharmacies.

There are many reasons why the present study is beneficial. It is acknowledged that pharmacies are important health care and information providers in the community and research should focus on determining the specific role that pharmacies play in health care provision, as viewed by the people they serve (Byrt, 1994; Doucette, Brooks, Sorofman, & Wong, 1999). Allowing people to provide an evaluation of the quality of health services they receive is essential in improving these services, as has been shown in the research trend towards obtaining patient assessments of pharmacy performance and quality (Larson, Rovers, & MacKeigan, 2002; Schommer & Kucukarslan, 1997).

In terms of pharmacies specifically, gaining patient feedback and evaluation allows for pharmacists to determine which areas of service need the most urgent improvement and to “develop, market, and refine pharmaceutical care services” (Larson, Rovers, & MacKeigan, 2002, p. 48). Pharmacists who take note of patients’ evaluations can actively improve the quality of service they provide and will, therefore, be at a competitive advantage (Larson, Rovers, & MacKeigan, 2002; Stasser, 2000). Not only are satisfied patients more likely to return to a specific pharmacy, ensuring repeat business, but satisfaction with pharmacy services has also been found to result in greater compliance with the taking of medicines and following of health advice, both of which have obvious health benefits (Briesacher & Corey, 1997).

In addition, this study was designed with the aim of determining the availability of health care resources and how they are used in rural areas (Australian Health Ministers’ Conference, 1996; DeFriese & Ricketts, 1989) because it has been acknowledged that the mere presence of health services does not equate with the


40

optimal use of these services (Humphreys & Weinand, 1991). There is also a lack of research concerned with identifying problems that occur for people trying to access community pharmacies and the important services they provide (Doucette, Brooks, Sorofman, & Wong, 1999). Access problems need research attention because of the expanding use of pharmacotherapy in the treatment of ambulatory patients (Doucette, Brooks, Sorofman, & Wong, 1999).

Therefore, research with the aim of developing a greater understanding of the relationship between resource availability and use may be beneficial in determining optimal levels of health care services, including staff, for rural communities (DeFriese & Ricketts, 1989). This is particularly important when health funding is limited due to budget constraints because it is essential that the health services that are delivered are those of most benefit to the community, that is, they are the services needed most and which will have the greatest impact on improving health (Strasser, 2000).

Likewise, research that addresses the issue of pharmacy location and the quality of goods and services provided is of use to pharmacists and policy makers (Doucette, Brooks, Sorofman, & Wong, 1999; Norris, 1997; Strasser, 2000). The government could then adopt health policies and plans which would direct more health resources towards those communities deemed to be underserved (DeFriese & Ricketts, 1989). Clearly, as governments continue to become aware of the importance of creating strong regional health care systems, research which identifies areas in need of improvement, and allows rural residents the opportunity to evaluate the services they receive, is of great importance (Connor, Kralewski, & Hillson, 1994; Strasser, 2000).


41

Results and Discussion Opinions of the Jurien Bay Deputy Chief Executive Officer (CEO) The Deputy CEO of the shire which encompasses Jurien Bay provided feedback regarding which community pharmacy goods and services he believes to be most important. The Officer believes that baby care advice, immunisations and advice on quitting smoking are pharmacy services of a high value to the local community, whereas the provision of complementary (herbal) medicines is of a low value. All other goods and services (cosmetics, wound dressings, general health advice, advice on a specific health issue/illness, managing a specific illness, treating a minor ailment, surgical aids and dental (oral) health treatments) were rated as being of neither high or low value.

With regard to the benefits of having a local pharmacy in the town, the Deputy CEO felt that reduced travelling time, less time wastage and availability of prompt advice were the three most important benefits. The three most important disadvantages in not having a local pharmacy were listed as – more travelling time, more time wastage and the non-availability of prompt advice. Profile and Opinions of the Jurien Bay Nursing Post Feedback from the manager of the Jurien Bay Health Centre, stated that the centre’s main function was providing primary health care to the community. Typically, more than 50 patients are seen in a week, with the most commonly dispensed medicines being analgesics and antibiotics. The Centre is a government-funded public health system facility, with doctors’ services being funded through Medicare and the services of staff who are private practitioners (dentist, physiotherapist etc.), being privately billed to patients. Services and products available from the Centre include baby care advice, immunisations, advice on quitting smoking, wound dressings, general health advice, advice on specific health issues or illnesses, management of specific illnesses, treatment of minor ailments, surgical aids and dental/oral health treatment. With regard to the benefits of having a local pharmacy in the town, the manager listed


42

the three most important as being – the availability of medications, the availability of health advice and providing consumers with the opportunity to make their own choices with regard to OTC medications. The three most important disadvantages in not having a local pharmacy were listed as – the Centre having to provide all the town’s medication needs, the Centre having to provide all the town’s health advice, and there being no opportunity for the community to make its own choices with regard to OTC medications. Opinions of the Three Springs Deputy Chief Executive Officer (CEO) When asked the relative importance of a range of goods and services provided by pharmacies, the Deputy CEO of the Shire of Three Springs stated that immunisations were of a very high value and that baby care advice, general health advice, advice on a specific health issue or illness, treatment of minor ailments, surgical aids and dental (oral) health treatments were of a high value. The remaining goods and services (vitamins, complementary (herbal) medicines, cosmetics, advice on quitting smoking and wound dressings) were rated as being of neither high nor low value. With regard to the benefits of having a local pharmacy in the town, the Deputy CEO felt that easy access for local people was the most important benefit, whereas having to travel elsewhere to reach pharmacy services was viewed as the main disadvantage of not having a local pharmacy. Profile and Opinions of the Three Springs Nursing Post The nurse at Three Springs declined to participate. Therefore, no information is available regarding the provision of health services to this town. Opinions of the Moora Deputy Chief Executive Officer (CEO) The Deputy CEO of the Shire of Moora provided feedback regarding which community pharmacy goods and services he believes to be most important. The Officer believes that cosmetics, wound dressings, advice on a specific health issue or illness, managing a specific illness, treating a minor ailment, surgical aides and dental (oral) health treatments are of high value, whereas the provision of vitamins, provision of complementary (herbal) medicines, baby care advice, immunisations, advice on quitting smoking and general health advice were rated as being of neither


43

high or low value. With regard to the benefits of having a local pharmacy in the town, the Deputy CEO felt that convenience, the availability of specialist advice and assistance (to complement medical advice) and product and service availability were the three most important benefits. The three most important disadvantages in not having a local pharmacy were listed as – more travelling time or greater postage costs to obtain products, greater strain placed on local doctors as people cannot visit the pharmacy for advice about minor/common ailments and a general lack of products and services. Profile and Opinions of the Moora Nursing Post Feedback was received from two members of the Moora Community Health Clinic. In terms of what they regard as being the most important functions of their organisation, one nurse stated that addressing health issues (e.g. child health, Aboriginal health, mental health, aged care), assisting with speech problems and occupational therapy, and conducting workshops were their primary tasks. The second nurse saw their main functions as being involved in primary health (i.e. early detection and intervention to prevent problems or correct health issues), education (both one-on-one and in group form) and to work as part of a team of health professionals in the town, to achieve holistic care of the community. Nurse One indicated she saw 11-20 patients per week, while Nurse Two estimated the number to be between 31 and 40. While no medicines are directly dispensed from the Clinic, although immunisations are given, nurses most commonly advised patients to obtain paracetamol, anti-fungal cream or oral treatment and Betadine®. The services provided by the Clinic are free to the community, due to Health Department funding. Services and products available from the Clinic include baby care advice, immunisations, advice on quitting smoking, wound dressings, general health advice, advice on a specific health issue/illness, management of a specific illness and treatment of minor ailments. With regard to the benefits of having a local pharmacy in the town, Nurse One listed the three most important as being – access to important medicines, availability of advice and quality service. She listed the main disadvantage of there being no pharmacy in the town as not being able to buy medicines. Nurse Two listed the three


44

main benefits of having a local pharmacy in the town as – being able to obtain medication (over-the-counter or via prescription) as needed, not having to travel to access pharmacy goods and services and the pharmacy having medication on hand, so there is no delay while waiting for medicines to arrive from Perth. This nurse listed the three main disadvantages of there being no pharmacy in the town as – having to travel two hours to Perth for medicines, having to wait to start a course of medication because products are not available and there being no help or information regarding medicines (e.g. what to take for a specific problem or what dosage is correct). Opinions of the Leeman Deputy Chief Executive Officer (CEO) The Deputy CEO of the shire which encompasses Leeman provided feedback regarding which community pharmacy goods and services he believes to be most important. The Officer believes that advice on quitting smoking, wound dressings, general health advice, advice on specific health issues/illnesses, surgical aids and dental (oral) health treatments are services provided by pharmacies that are of a very high value. Baby care advice, help in managing a specific illness and treating a minor ailment were given a high value. The provision of vitamins and complementary (herbal) medicines were given a low value and immunisations were given a very low value. Cosmetics were given neither a high or low value. With regard to the benefits of having a local pharmacy in the town, the Deputy CEO felt that the three most important advantages were – access to pharmacy products and services, having a source of pharmacy advice and having another business in the town. The Deputy CEO saw not having access to pharmacy products and services, not having a source of pharmacy advice and having one less business in the town as the three main disadvantages of not having a local pharmacy in Leeman. Profile of the Leeman Nursing Post The nurse at Leeman saw the primary function of the organisation as being to provide quality first aid to the community. In a typical week, she would see 31 to 40 patients and would most commonly supply antibiotics to patients. In terms of remuneration for services provided to the local community, donations and some government funding assist with costs. The following goods are services are provided by this nursing post – baby care advice, immunisations, advice on quitting smoking, wound dressings,


45

general health advice, advice on a specific health issue or illness, management of a specific illness and treating minor ailments. The provision of vitamins, complementary (herbal) medicines, cosmetics, surgical aids and dental (oral) health treatments are not undertaken by this nursing post.

In terms of what the nurse saw as being the most important benefits of having a local pharmacy, convenience and no travelling time were rated as most important. The most important disadvantages of not having a local pharmacy were rated as – the inability to obtain medications, the time involved in obtaining medications and the distance needing to be travelled to reach a pharmacy.

Pharmacy Data

Regarding the level of availability of the 40 categories of S2 and S3 drugs in the two rural pharmacies, Table 1 (Moora pharmacy) and Table 2 (Jurien Bay pharmacy) show the total number of products that are potentially available for each of the categories, how many of these products were actually available in the Moora and Jurien Bay pharmacies, the range of products available in each category, the median prices of the products available in each of the categories, which pharmacy had lower prices and the saving involved. Using the median price of products in each category as a method of price comparison between pharmacies was seen to be most appropriate because the selection of different brands by consumers would result in varying prices, as would the selection of generic or proprietary items. Also, there tends to be less range in the products stocked by pharmacies, that is, pharmacies tend to stock more brand name products than shops.

Table 1 Availability, Range and Price of Moora Pharmacy Goods Medicine Category Hyperactivity, Reflux and Ulcers

Total No. Products Availablea

3

No. Available Moora Pharmacy

1

Rangebcd

Median Price ($)

G 33.3%

12.90

Lowest Cost Pharmacyf No comparison possible

Saving ($)


Antispasmodics

46

7 6

2 0

L 28.6% n/a

11.32 n/a

12

2

L 16.7%

14.92

Yes

19

0

n/a

n/a

Adrenergic Stimulants

2

0

n/a

n/a

No comparison possible No comparison possible

Anticoagulants, Antithrombotics Sedatives, Hypnotics

7

3

G 42.9%

6.10

No

7 8

2 3

L 28.6% G 37.5%

10.57 8.40

No Yes

60

7

L 11.7%

10.55

No

47

11

G 23.4%e

9.40

Yes

1.05

17

3

e

G 17.6%

7.85

Yes

1.60

9

3

G 33.3%

14.70

No

16

6

G 37.5%

12.57

Yes

Antidiarrhoeals Topical Anorectal Medication Antiangina Agents

Antiemetics, Antinauseants Simple Analgesics & Antipyretics Combination Simple Analgesics Nonsteroidal AntiInflammatory Agents Rubefacients, Topical Analgesics/NSAIDs Topical Vaginal Medication Erectile Dysfunction Agents Anthelmintics Expectorants, Antitussives, Mucolytics, Decongestants Bronchospasm Relaxants Bronchodilator Aerosols & Inhalations Antihistamines Topical Otic Medication Topical Nasopharyngeal Medication Topical Oropharyngeal Medication

No No comparison possible

1

0

n/a

n/a

No comparison possible

19 171

5 37

L 26.3% L 21.6%

13.60 14.95

No No

3

0

n/a

n/a


12

1

L 8.3%

13.30

No

45 2

21 2

G 46.7% G 100%

17.95 10.07

No Yes

0.28

0.05

0.38

3.38

26

0

n/a

n/a

27

8

G 29.6%e


10.10

No

3

0

n/a

n/a


Ocular Astringents, Decongestants Emollients, Antiprurities & Protective Preparations Psoriasis, Seborrhoea & Ichthyosis

19

7

G 36.9%

11.30

Yes

5

1

L 20%

13.45

3

0

n/a

n/a


Acne, Keratolytics & Cleansers Wart & Corn Removers

17

2

L 11.8%

20.20

Yes

0.50

8 8 44 5

1 3 10 1

L 12.5% G 37.5% G 22.8%e L 20%

12.85 12.85 13.77 20.80

Yes No No No

0.77

4

1

L 25%

57.15


Topical Ocular AntiInfective Preparations

Topical Corticosteroids Topical Antifungals Topical Antiseptics, Anti-Infectives Other Dermatological Preparations

0.65


Anaesthetics

14 27

4 6

L 28.6% L 22.2%

8.65 34.95

Vitamins (single agents) Minerals

6

1

L 16.7%

2.20

No

3

0

n/a

n/a

B Group Vitamins With Other Agents

3

0

n/a

n/a

Multivitamins & Minerals

1

0

n/a

n/a

No comparison possible No comparison possible No comparison possible

Agents Used in Drug Dependence

47

No No comparison possible

Iron

6 4 G 66.7% 8.10 No As listed in the 2000 edition of the MIMS OTC Manual. b L = Limited Range (i.e. the number of products available for the category in this pharmacy was less than 30% of the total number of products available for the category, as listed in the MIMS Manual). c G = Good Range (i.e. the number of products available for the category in this pharmacy was 30% or more of the total number of products available for the category, as listed in the MIMS Manual). d % = percentage of the total number of products per category that were available in this pharmacy. e these categories were classed as Good Range, rather than Limited range, because the products were all essentially the same, despite being different brands. f Comparison of Moora and Jurien Bay pharmacies. a

Therefore, in comparison with the total number of products available in each category as listed in the MIMS Manual, the Moora pharmacy stocked a good range of products in three categories (eye treatments, muscular aches and pains and topical vaginal treatments) and a limited range of products in eight categories (pain relief, gastric, burns/sunburns, tinea/fungal infections, cough/cold treatments, anti-asthma and related medications, worm treatments and other dermatological preparations). Table 2 Availability, Range and Price of Jurien Bay Pharmacy Goods

Medicine Category

Total No. Products Availablea

No. Available Jurien Bay Pharmacy

Rangebcd

Median Price ($)

Lowest Cost Pharmacyf

Hyperactivity, Reflux and Ulcers

3

0

n/a

n/a


Antispasmodics

7

4

G 57.1%

7.45

Yes

Antidiarrhoeals

6

1

L 16.7%

12.95


Saving ($)

3.87


Topical Anorectal Medication Antiangina Agents

48

12

2

L 16.7%

15.20

No

19

0

n/a

n/a

Adrenergic Stimulants

2

0

n/a

n/a


Anticoagulants, Antithrombotics Sedatives, Hypnotics

7

5

G 71.4%

5.45

Yes

0.65

7 8

2 5

L 28.6% G 62.5%

11.70 8.45

Yes No

1.13

60

13

G 21.7%e

8.45

Yes

2.10

47

7

L 14.9%

10.45

No

17

7

G 41.2%

9.45

No

9

2

L 22.2%

10.20

Yes

16

8

G 50%

12.95

No

1

0

n/a

n/a


19 171

5 38

L 26.3% G 22.2%e

8.45 14.20

Yes Yes

3

2

G 66.7%

12.95


12

2

L 16.7%

9.45

Yes

3.85

45 2

17 2

G 37.8% G 100%

15.95 13.45

Yes No

2.00

Topical Nasopharyngeal Medication Topical Oropharyngeal Medication Topical Ocular AntiInfective Preparations

26

11

G 42.3%

13.95


27

6

L 22.2%

9.45

Yes

3

2

G 66.7%

13.20


Ocular Astringents, Decongestants Emollients, Antiprurities & Protective Preparations Psoriasis, Seborrhoea & Ichthyosis

19

8

G 42.1%

11.95

No

5

0

n/a

n/a

3

0

n/a

n/a


Acne, Keratolytics & Cleansers Wart & Corn Removers

17

2

L 11.8%

20.70

No

8 8 44 5

6 1 15 1

G 75% L 12.5% G 34.1% L 20%

13.62 11.30 12.95 19.95

No Yes Yes Yes

4

0

n/a

n/a


14

1

L 7.1%

6.95

Yes

Antiemetics, Antinauseants Simple Analgesics & Antipyretics Combination Simple Analgesics Nonsteroidal AntiInflammatory Agents Rubefacients, Topical Analgesics/NSAIDs Topical Vaginal Medication Erectile Dysfunction Agents Anthelmintics Expectorants, Antitussives, Mucolytics, Decongestants Bronchospasm Relaxants Bronchodilator Aerosols & Inhalations Antihistamines Topical Otic Medication

Topical Corticosteroids Topical Antifungals Topical Antiseptics, Anti-Infectives Other Dermatological Preparations Anaesthetics

4.50

5.15 0.75

0.65

1.55 0.82 0.85

1.70


Agents Used in Drug Dependence

27

6

L 22.2%

No price available


Vitamins (single agents) Minerals

6

1

L 16.7%

4.95

Yes

3

0

n/a

n/a

B Group Vitamins With Other Agents

3

0

n/a

n/a

Multivitamins & Minerals

1

0

n/a

n/a

No comparison possible No comparison possible No comparison possible

49

2.75

Iron

6 4 G 66.7% 7.70 Yes 0.40 As listed in the 2000 edition of the MIMS OTC Manual. b L = Limited Range (i.e. the number of products available for the category in this pharmacy was less than 30% of the total number of products available for the category, as listed in the MIMS Manual). c G = Good Range (i.e. the number of products available for the category in this pharmacy was 30% or more of the total number of products available for the category, as listed in the MIMS Manual). d % = percentage of the total number of products per category that were available in this pharmacy. e these categories were classed as Good Range, rather than Limited range, because the products were all essentially the same, despite being different brands. f Comparison of Jurien Bay and Moora pharmacies. a

Therefore, in comparison with the total number of products available in each category as listed in the MIMS Manual, the Jurien Bay pharmacy stocked a good range of products in four categories (gastric, tinea/fungal infections, eye treatments and topical vaginal treatments) and a limited range of products in seven categories (pain relief, burns/sunburns, cough/cold treatments, muscular aches and pains, anti-asthma and related medications, worm treatments and other dermatological preparations).

Before comparing the prices of items in each of the 40 categories for the Moora and Jurien Bay pharmacies, it was necessary to remove 15 categories due to the absence of products in these categories or prices being unavailable for one, or both, of the towns (see Tables 1 and 2). Therefore, the median prices of products in the remaining 25 categories were added together, with the result being a comparable total median price for pharmacy goods in each town. The products in Moora totalled $297.07 and those in Jurien Bay totalled $280.77, therefore indicating that Jurien Bay is the lower cost provider of S2 and S3 pharmacy products, representing a saving of $16.30 over Moora.


50

Local Shop Data

In relation to the availability of products belonging to the 12 categories of medicines in the eight stores across the four towns, Tables 3 (Three Springs General Store), 4 (Three Springs Foodland), 5 (Three Springs Hey Jude), 6 (Leeman Seaside Supplies), 7 (Moora Foodland), 8 (Moora Supa Value), 9 (Jurien Bay Foodland) and 10 (Jurien Bay General Store) show the total number of products that are potentially available for each of the categories and their median prices as seen in a metropolitan Coles store, how many of these products were actually available in each country store, the range of products available in each category, the median prices of the products available in each of the categories, which store had lower prices and the saving involved between the lowest cost and next lowest cost store.

Table 3 Availability, Range and Price of Three Springs General Store Goods Medicine Category

Total No. Available in Coles & Median Price a ($)

No. Available Three Springs General Store

Rangebcd

Median Price ($)

Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs Coughs/Colds – Chest Rub Muscular Aches/Pains

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

10 6 1 3 0

G 43% L 26.1% L 10% L 27.3% n/a

3.39 3.61 3.97 4.30 n/a

No No Yes No No

2 – 7.21 9 – 5.90

1 3

G 50% G 33.3%

8.09 6.75

No No

7 – 6.54

2

L 28.6%

7.70

No

16 – 4.84

2

L 12.5%

6.23

No

3– 12.61

0

n/a

n/a


3 – 6.39

1

G 33.3%

7.38

Yes

10 – 5.80

4

G 40%

5.62

No

a

Lowest Cost Storee

Saving ($) f

1.10

0.42

As seen on the shelves of a metropolitan Coles supermarket. L = Limited Range (i.e. the number of products available for the category in this store was less than 30% of the total number of products available for the category, as seen in Coles). b


51

c

G = Good Range (i.e. the number of products available for the category in this store was 30% or more of the total number of products available for the category, as seen in Coles). d % = percentage of the total number of products per category that were available in this store. e Comparison of all eight stores. f As compared to the next lowest cost store.

Table 4 Availability, Range and Price of Three Springs Foodland Goods Rangebcd

Median Price ($)

9 2 1 2 1

G 39.1% L 8.7% L 10% L 18.2% G 50%

3.41 6.88 6.64 4.56 7.48

No No No No No

2 – 7.21 9 – 5.90

1 6

G 50% G 66.7%

7.20 8.24

Yes No

0.16

7 – 6.54

1

L 14.3%

6.67

Yes

0.14

16 – 4.84

0

n/a

n/a

No

3– 12.61

0

n/a

n/a


3 – 6.39

2

G 66.7%

9.15

No

10 – 5.80

3

G 30%

4.57

No

Medicine Category


Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs Coughs/Colds – Chest Rub Muscular Aches/Pains

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

a

No. Available Three Springs Foodland

Lowest Cost Storee

Saving ($) f

As seen on the shelves of a metropolitan Coles supermarket. L = Limited Range (i.e. the number of products available for the category in this store was less than 30% of the total number of products available for the category, as seen in Coles). c G = Good Range (i.e. the number of products available for the category in this store was 30% or more of the total number of products available for the category, as seen in Coles). d % = percentage of the total number of products per category that were available in this store. e Comparison of all eight stores. f As compared to the next lowest cost store. b


52

Table 5 Availability, Range and Price of Three Springs Hey Jude Goods Medicine Category


Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs Coughs/Colds – Chest Rub

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

1 1 3 1 0

2 – 7.21 9 – 5.90

Muscular Aches/Pains

No. Available Three Hey Jude Store

Rangebcd

Median Price ($)

Lowest Cost Storee

L 4.38% L 4.38% G 30% L 9.1% n/a

4.90 6.65 13.58 4.40 n/a

No No No No No

1 0

G 50% n/a

12.40 n/a

No No

7 – 6.54

0

n/a

n/a

No

16 – 4.84

1

L 6.25%

7.80

No

3– 12.61

0

n/a

n/a


3 – 6.39

0

n/a

n/a

No

10 – 5.80

4

G 40%

8.24

No

Saving ($) f

Note. A limited range of S2 pharmacy products from the following categories were also found in this store - antispasmodics, antidiarrhoeals, antiemetics/antinauseants, simple analgesics/antipyretics, combination simple analgesics, nonsteroidal antiinflammatory agents, rubefacients/topical analgesics/NSAIDs, topical vaginal medication, anthelmintics, expectorants/antitussives/mucolytics/decongestants, antihistamines, topical otic medication, topical nasopharyngeal medication, ocular astringents/decongestants, topical antifungals, topical antiseptics/anti-infectives, agents used in drug dependence, vitamins (single agents) and iron. a As seen on the shelves of a metropolitan Coles supermarket. b L = Limited Range (i.e. the number of products available for the category in this store was less than 30% of the total number of products available for the category, as seen in Coles). c G = Good Range (i.e. the number of products available for the category in this store was 30% or more of the total number of products available for the category, as seen in Coles). d % = percentage of the total number of products per category that were available in this store. e Comparison of all eight stores. f As compared to the next lowest cost store.


53

The Hey Jude store in Three Springs stocked a limited number of general supermarket pharmacy items and was without general items in the following categories Tinea/Fungal Infection Treatments, Cough/Cold Liquids, Cough/Cold Nasal Sprays, Cold Relief Tablets and Chest Rub. However, this store did stock 72 S2 category pharmacy products from the following categories - antispasmodics, antidiarrhoeals, antiemetics/antinauseants, simple analgesics/antipyretics, combination simple analgesics, nonsteroidal anti-inflammatory agents, rubefacients/topical analgesics/NSAIDs, topical vaginal medication, anthelmintics, expectorants/antitussives/mucolytics/decongestants, antihistamines, topical otic medication, topical nasopharyngeal medication, ocular astringents/decongestants, topical antifungals, topical antiseptics/anti-infectives, agents used in drug dependence, vitamins (single agents) and iron.

Therefore, although there is no pharmacy in the town of Three Springs, the Hey Jude store provides many of the more commonly needed S2 pharmacy products and this means that only S3 products must be obtained from another source. Table 6 Availability, Range and Price of Leeman Seaside Supplies Goods Rangebcd

Median Price ($)

2 0 0 2 0

L8.7% n/a n/a L 18.2% n/a

3.99 n/a n/a 4.71 n/a

No No No No No

2 – 7.21 9 – 5.90

1 1

G 50% L11.1%

No No

7 – 6.54

2

L 28.6%

8.18 No price available 8.59

16 – 4.84

4

L 25%

5.90

Yes

3– 12.61

0

n/a

n/a


3 – 6.39

1

G 33.3%

7.60

No

Medicine Category


Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs Coughs/Colds – Chest Rub

No. Available Leeman Seaside Supplies

Lowest Cost Storee

Saving ($) f

No 0.33


Muscular Aches/Pains

10 – 5.80

2

L 20%

6.82

54

No

Note. A limited range of S2 products were also found in Leeman. These were Imodium®, Zovirax®, Combantrin®, Dramamine®, Ventolin Inhaler®, Kwells®, Bonjela® and Telfast®. a As seen on the shelves of a metropolitan Coles supermarket. b L = Limited Range (i.e. the number of products available for the category in this store was less than 30% of the total number of products available for the category, as seen in Coles). c G = Good Range (i.e. the number of products available for the category in this store was 30% or more of the total number of products available for the category, as seen in Coles). d % = percentage of the total number of products per category that were available in this store. e Comparison of all eight stores. f As compared to the next lowest cost store. Leeman Seaside Supplies store was without products in the following categories – Gastric Treatments, Constipation Medicines, Tinea/Fungal Infection Treatments and Cold Relief Tablets. However, an additional range of S2 products not stocked at the Moora or Jurien Bay stores were found in Leeman. Specifically, these were Imodium®, Zovirax®, Combantrin®, Dramamine®, Ventolin Inhaler®, Kwells®, Bonjela® and Telfast®. This may indicate that the Leeman store is partly compensating for the lack of a pharmacy by stocking a broader range of frequently used items.

Therefore, in the two towns without pharmacies, stores in Three Springs stocked a good range of products in four categories (eye treatments, coughs/colds - liquids, coughs/colds - chest rub, muscular aches and pains), a limited range of products in seven categories (pain relief, gastric, constipation, burns/sunburns, tinea/fungal infections, cough/colds - nasal, coughs/colds - lozenges) and no products in the coughs/colds – cold relief tablets category.

The store in Leeman stocked a good range of products in two categories (eye treatments and coughs/colds - chest rub), a limited range of products in six categories (pain relief, burns/sunburns, cough/colds - liquids, coughs/colds - nasal, coughs/colds - lozenges, muscular aches and pains) and no products in four categories (gastric, constipation, tinea/fungal infections and coughs/colds - cold relief tablets).


55

Table 7 Availability, Range and Price of Moora Foodland Goods Rangebcd

Medicine Category


No. Available Moora Foodland

Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

13 6 0 5 0

G 56.5% L 26.1% n/a G 45.5% n/a

3.06 6.45 n/a 4.95 n/a

No No No No No

2 – 7.21 9 – 5.90

0 5

n/a G 55.6%

n/a 7.93

No No

7 – 6.54

2

L 28.6%

6.81

No

16 – 4.84

0

n/a

n/a

No

3– 12.61

0

n/a

n/a


Coughs/Colds – Chest Rub Muscular Aches/Pains

3 – 6.39

2

G 33.3%

9.22

No

10 – 5.80

3

G 30%

4.58

No

Median Price ($)

Lowest Cost Storee

Saving ($) f

a


Table 8 Availability, Range and Price of Moora Supa Value Goods Medicine Category


No. Available Moora Supa Value

Pain Relief Gastric Constipation

23 – 3.09 23 – 5.23 10 – 8.82

17 5 2

Rangebcd

G 73.9% L 21.7% L 20%

Median Price ($)

2.76 5.29 5.15

Lowest Cost Storee

Saving ($) f

Yes No No

0.22


Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs

11 – 4.91 2 – 6.37

6 1

G 54.5% G 50%

3.84 7.41

Yes Yes

2 – 7.21 9 – 5.90

1 5

G 50% G 55.6%

7.36 6.43

No No

7 – 6.54

4

G 57.1%

6.67

Yes

16 – 4.84

0

n/a

n/a

No

3– 12.61

0

n/a

n/a



3 – 6.39

2

G 66.7%

9.08

No

10 – 5.80

5

G 50%

4.54

Yes

56 0.46 0.07

0.14

0.03

a


Table 9 Availability, Range and Price of Jurien Bay Foodland Goods Rangebcd

Medicine Category


No. Available Jurien Bay Foodland

Pain Relief Gastric Constipation Burns/Sunburns

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91

12 4 2 1

G 52.2% L 17.4% L 20% L 9.1%

3.02 3.44 5.28 4.92

No Yes No No

Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges

2 – 6.37

1

G 50%

7.55

No

2 – 7.21 9 – 5.90

1 6

G 50% G 66.7%

7.95 7.02

No No

7 – 6.54

2

L 28.6%

7.47

No

16 – 4.84

0

n/a

n/a

No

Median Price ($)

Lowest Cost Storee

Saving ($) f

0.17


Coughs/Colds – Cold Relief Tabs Coughs/Colds – Chest Rub Muscular Aches/Pains

3– 12.61

0

n/a

n/a


3 – 6.39

1

G 33.3%

11.12

No

10 – 5.80

3

G 30%

6.36

No

57

a


Table 10 Availability, Range and Price of Jurien Bay General Store Goods Total No. Available in Coles & Median Price a ($)

Pain Relief Gastric Constipation Burns/Sunburns Tinea/Fungal Infections Eye Coughs/Colds Liquids Coughs/Colds Nasal Coughs/Colds Lozenges Coughs/Colds – Cold Relief Tabs

23 – 3.09 23 – 5.23 10 – 8.82 11 – 4.91 2 – 6.37

6 1 1 3 0

L 26.1% L 4.3% L 10% L 27.3% n/a

2.98 4.41 4.07 5.20 n/a

No No No No No

2 – 7.21 9 – 5.90

1 4

G 50% G 44.4%

8.36 5.99

No Yes

7 – 6.54

1

L 14.3%

7.11

No

16 – 4.84

0

n/a

n/a

No

3– 12.61

0

n/a

n/a



3 – 6.39

1

G 33.3%

7.79

No

10 – 5.80

2

L 20%

5.80

No

a

No. Available Jurien Bay General Store

Rangebcd

Medicine Category

Median Price ($)

As seen on the shelves of a metropolitan Coles supermarket.

Lowest Cost Storee

Saving ($) f

0.44


58

b

L = Limited Range (i.e. the number of products available for the category in this store was less than 30% of the total number of products available for the category, as seen in Coles). c G = Good Range (i.e. the number of products available for the category in this store was 30% or more of the total number of products available for the category, as seen in Coles). d % = percentage of the total number of products per category that were available in this store. e Comparison of all eight stores. f As compared to the next lowest cost store.

Therefore, in the two towns with pharmacies, stores in Moora stocked a good range of products in six categories (pain relief, burns/sunburns, coughs/colds - liquids, coughs/colds - nasal, coughs/colds – chest rub, muscular aches and pains), a limited range of products in four categories (gastric, constipation, tinea/fungal infections, eye treatments) and no products in two categories (coughs/colds - lozenges, coughs/colds - cold relief tablets).

The stores in Jurien Bay stocked a good range of products in four categories (pain relief, eye treatments, coughs/colds - liquids, coughs/colds - chest rub), a limited range of products in six categories (gastric, constipation, burns/sunburns, tinea/fungal infections, coughs/colds - nasal, muscular aches and pains) and no products in two categories (coughs/colds - lozenges, coughs/colds - cold relief tablets).

Comparing the prices of items in each of the 12 categories across the eight stores, it was necessary to remove nine categories due to the absence of products in these categories or prices being unavailable for one or more of the towns (see Tables 3-10). Therefore, the median prices of products in the remaining three categories were added together, with the result being a comparable total median price for supermarket pharmacy goods in each town. The product totals (in order of least expensive to most expensive store) were – Moora Supa Value ($11.14), Three Springs Foodland ($12.54), Moora Foodland ($12.59), Three Springs General Store ($13.31), Jurien Bay General Store ($13.98), Jurien Bay Foodland ($14.30), Leeman Seaside Supplies ($15.52) and Three Springs Hey Jude Store ($17.54). As a point of comparison, the cost of these same products at a metropolitan Coles store was $13.80, bearing in mind that the greater range of products available at Coles may have resulted in a higher comparative median price for some product categories. Therefore, there was a $6.40


59

difference in price between goods at the least expensive store (Moora Supa Value) and the most expensive store (Three Springs Hey Jude Store).

Health Insurance Commission (HIC) Data

In relation to where people of the four towns go to have their scripts prescribed, data supplied by HIC shows that Moora residents of all ages visited a doctor in their own shire much more than doctors in other areas. For those aged 0-16 years, 34.36% visited a doctor in Moora for a script, with the remaining scripts prescribed across 15 metropolitan Local Government Areas (LGA) (31.28%) and 24 other regional/national LGA (34.36%). The most common other regional LGA was Mundaring (7.49% of total scripts for this age group). Moora shire doctors also prescribed 46.21% of the scripts for those locals aged 17-64, with prescribers in 22 metropolitan LGA (37.07%) and 61 other regional/national LGA (16.72%) accounting for the remaining prescriptions. The most common other regional LGA were Kellerberrin (3.08% of total scripts for this age group) and Mandurah (2.73%). Those aged 65 and over in Moora overwhelmingly favoured going to a local prescriber, with 66.97% of this age group obtaining prescriptions from a Moora shire doctor. The remaining scripts were prescribed across 18 metropolitan Local Government Areas (21.26%) and 19 other regional/national LGA (11.77%). The most common other regional LGA was Kellerberrin (4.99% of total scripts for this age group).

Of the 13 517 scripts prescribed to Moora residents over the 12 month period, 7 410 (54.82%) were prescribed by a local prescriber in the Shire of Moora, 4 033 (29.84%) were prescribed by a prescriber based in the Perth metropolitan area and 2 074 (15.34%) were prescribed by prescribers in other regional areas of the state or LGA in other states (see Figure1).

Residents of the Shire of Coorow, which includes the town of Leeman, did not visit a local prescriber to obtain prescriptions, but instead frequently travelled to the neighbouring Shire of Dandaragan. Those aged 0-16 years visited prescribers in nine metropolitan LGA half of the time (50.32%) and 11 other regional/national LGA half


60

Moora 100

Percentage

80

60

prescribed locally dispensed locally

40 prescribed metro dispensed metro 20 prescribed other dispensed other

0 0-16 years

17-64 years

65+ years

Age Figure 1. Location of the prescribers and dispensers of prescriptions, as visited by Moora residents from 1st March 2002 to 28th February 2003.

of the time (49.68%), with prescribers in Dandaragan accounting for 22.29% of total prescriptions for this age group. For those people aged 17-64, 42.28% of scripts were prescribed by a prescriber based in Dandaragan, with remaining scripts being prescribed by doctors from 24 metropolitan LGA (29.08%) and 31 other regional/national LGA (28.64%). Likewise, people in the 65 and over age group obtained 41.57% of their scripts from a Dandaragan prescriber, with 28.43% being obtained from 17 other regional/national LGA and 30% from 19 metropolitan LGA.

Therefore, of the 5 344 scripts prescribed to Leeman residents over the 12 month period, none were prescribed by a local prescriber in the Shire of Coorow. Instead, 2 209 (41.37%) were prescribed by a doctor in the neighbouring Shire of Dandaragan, while 1 612 (30.16%) were prescribed by prescribers based in the Perth metropolitan area and 1 523 (28.47%) were prescribed by prescribers in other regional areas of the state or LGA in other states (see Figure 2).


61

Leeman 100

Percentage

80

60

40 prescribed metro dispensed metro

20

prescribed other dispensed other

0 0-16 years

17-64 years

65+ years

Age Figure 2. Location of the prescribers and dispensers of prescriptions, as visited by Leeman residents from 1st March 2002 to 28th February 2003.

Prescribers in the Shire of Dandaragan were also the favoured choice for the residents of Jurien Bay, which is part of the Shire. For those aged 0-16 years, 50.36% visited a doctor in Dandaragan for a script. The remaining scripts for this age group were prescribed from 16 metropolitan LGA (32.61%) and 11 other regional/national LGA (17.03%). The most common other regional LGA was Pingelly (6.88% of total scripts for this age group). Similarly, 54.45% of those in the 17-64 age group obtained a script from a local prescriber, with the remaining scripts being prescribed by prescribers in 23 metropolitan LGA (23.84%) and 45 other regional/national LGA (21.71%). The most common other regional LGA was Quairading (6.91% of total scripts for this age group). For older people aged 65 and over, 56.20% of scripts were prescribed by a doctor in Dandaragan, with prescribers in 24 metropolitan LGA accounting for 21.05% of scripts and those in 32 other regional/national LGA


62

accounting for 22.75% of scripts prescribed. The most common other regional LGA was Ravensthorpe (12.47% of total scripts for this age group).

Of the 10 364 total scripts prescribed to residents of Jurien Bay over the 12 month period, 5 730 (55.29%) were prescribed by prescribers based locally in the Dandaragan Shire, 2 338 (22.56%) were prescribed by prescribers in the Perth metropolitan area and 2 296 (22.15%) were prescribed by prescribers based in other regional areas of the state or LGA in other states (see Figure 3).

Jurien Bay 100

Percentage

80

60


40 prescribed metro dispensed metro

20

prescribed other 0

dispensed other 0-16 years

17-64 years

65+ years

Age Figure 3. Location of the prescribers and dispensers of prescriptions, as visited by Jurien Bay residents from 1st March 2002 to 28th February 2003.

Of the scripts for those Three Springs residents aged 0-16 years, 18.82% were prescribed locally. Just over a third (37.63%) of scripts were prescribed from 17 metropolitan LGA and 43.55% were prescribed from 15 other regional/national LGA, with the most common being Morawa and Northam (both 6.45% of total scripts for


63

this age group) and Geraldton (5.38%). For those residents aged 17-64, 45.34% of scripts were prescribed in the Shire of Three Springs itself, with 17.96% being prescribed in 19 LGA in the metropolitan City of Perth and the remaining 36.70% being prescribed in 29 other regional/national LGA. The most common regional LGA prescriber locations were Perenjori (6.65% of total scripts for this age group), Carnamah (4.61%) and Geraldton (4.02%). Of the scripts prescribed for Three Springs residents aged 65 and over, 59.63% were prescribed locally in the Shire of Three Springs, 3.75% were prescribed in nine metropolitan LGA and 36.62% were prescribed in 19 other regional/national LGA. The most common of these other regional/national LGA were Irwin (9.68% of total scripts for this age group) and Carnamah (8.37%).

Therefore, of the 4 258 total scripts prescribed to Three Springs residents over the 12 month period, 2 175 (51.08%) were prescribed by doctors in the Shire of Three Springs, 509 (11.95%) were prescribed by prescribers in the Perth metropolitan area and 1 574 (36.97%) were prescribed by doctors in other regional areas of the state or LGA in other states (see Figure 4).

With regard to the dispensing of prescriptions, Moora residents got the vast majority of their prescriptions dispensed locally by pharmacies within the Shire of Moora. For those aged 0-16 years, 63.34% of prescriptions were dispensed in Moora. Of the remaining scripts, 16.56% were dispensed in 11 metropolitan LGA and 20.10% were dispensed in 22 other regional/national LGA. The most common other regional LGA was Wagin (6.60% of total scripts for this age group). Likewise, 71.61% of prescriptions dispensed to those residents aged 17-64 were dispensed by pharmacies in Moora. Of the remaining scripts, 17 metropolitan LGA accounted for 12.55% and 45 other regional/national LGA accounted for 15.84%. The most common other regional LGA were Narrogin (1.96% of total scripts for this age group) and Mullewa (1.47%). An overwhelming majority of 84.21% of scripts dispensed for those people aged 65 and over were dispensed locally within the Shire. Of the remaining scripts, 10.10% were dispensed in 15 metropolitan LGA and 5.69% were dispensed in 18 other regional/national LGA. The most common other regional LGA was Dalwallinu (1.35% of total scripts for this age group).


64

Three Springs 70

60

Percentage

50

40


30

prescribed metro 20 dispensed metro 10

prescribed other

0

dispensed other 0-16 years

17-64 years

65+ years

Age Figure 4. Location of the prescribers and dispensers of prescriptions, as visited by Three Springs residents from 1st March 2002 to 28th February 2003.

Therefore, of the 14 961 total scripts dispensed to residents of Moora over the 12 month period, 11 501 (76.87%) were dispensed by pharmacies within the Shire, 1 740 (11.63%) were dispensed by pharmacies within the Perth metropolitan area and 1 720 (11.5%) were dispensed by pharmacies in other regional areas of the state or LGA in other states (see Figure 1).

The Shire of Coorow, which includes the town of Leeman, does not have a local pharmacy. Therefore, residents frequently travelled to the neighbouring Shire of Dandaragan to have their prescriptions dispensed. Just under one third (29.21%) of prescriptions dispensed for those aged 0-16 years were dispensed in 9 metropolitan LGA. Another 12 regional/national LGA accounted for 70.79% of scripts, with the most common being Dandaragan (34.27% of total scripts for this age group). For those aged 17-64 years, 55.90% of scripts were dispensed in Dandaragan, with the remaining scripts dispensed across 26 other regional/national LGA (28.13%) and 17


65

metropolitan LGA (15.97%). Most of the scripts (69.74%) dispensed to those aged 65 and over were dispensed in Dandaragan, with the remaining being dispensed in 18 other regional/national LGA (16.01%) and 15 metropolitan LGA (14.25%).

Therefore, of the 6 176 total scripts dispensed to Leeman residents over the 12 month period, none were dispensed locally in the Shire of Coorow. Instead, 3 855 (62.42%) were dispensed by pharmacies in the neighbouring Shire of Dandaragan, 955 (15.46%) were dispensed by pharmacies in the Perth metropolitan area and 1 366 (22.12%) were dispensed by pharmacies in other regional areas of the state or LGA in other states (see Figure 2).

For those Jurien Bay residents aged 0-16 years, 69.61% of prescriptions were dispensed locally in the Shire of Dandaragan, which includes the town of Jurien Bay. Nine metropolitan LGA accounted for 13.78% of scripts and 9 other regional/national LGA accounted for 16.61% of scripts. The most common other regional LGA were Merredin (4.95% of total scripts for this age group) and Exmouth (4.24%). Likewise, for those residents in the 17-64 age group, 73.47% of scripts were dispensed in the Dandaragan area, with the remaining scripts being dispensed across 21 metropolitan LGA (13.36%) and 30 other regional/national LGA (13.17%). The most common other regional LGA was the Lower Eyre Peninsula (2.19% of total scripts for this age group). The vast majority of scripts (83.99%) dispensed to those aged 65 years and over were dispensed locally in the Shire. Of the remaining scripts, 9.53% were dispensed in 16 metropolitan LGA and 6.48% were dispensed in 33 other regional/national LGA. The most common other regional LGA were Wongan-Ballidu (1.10% of total scripts for this age group) and Mundaring (1.03%).

Therefore, of the 11 556 total scripts dispensed to the Jurien Bay residents over the 12 month period, 9 152 (79.20%) were dispensed locally by pharmacies in the Shire of Dandaragan, 1 300 (11.25%) were dispensed by pharmacies in the Perth metropolitan area and 1 104 (9.55%) were dispensed by pharmacies in other regional areas of the state or LGA in other states (see Figure 3).

The town of Three Springs does not have a pharmacy itself, however scripts were still able to be dispensed within the Shire of Three Springs by a dispensing doctor. For


66

those aged 0-16 years, 27.86% of scripts were dispensed locally. Of the remaining scripts, 31.84% were dispensed in 8 metropolitan LGA and 40.30% were dispensed in 10 other regional/national LGA. The most common other regional LGA was Northam (12.94% of total scripts for this age group). The majority of scripts (44.12%) dispensed to those aged 17-64 were dispensed locally, with the remaining being dispensed in 14 metropolitan LGA (14.21%) and in 27 other regional/national LGA (41.67%). The most common other regional LGA were George Town (9.69% of total scripts for this age group) and Dandaragan (9.64%). For those residents aged 65 years and over, 60.65% of scripts were dispensed locally, with the remaining being dispensed in 8 metropolitan LGA (3.29%) and 10 other regional/national LGA (36.06%). The most common other regional LGA were Carnarvon (12.29% of total scripts for this age group) and Greenough (10.04%).

Therefore, of the 4 589 total scripts dispensed to residents of Three Springs over the 12 month period, 2 359 (51.40%) were dispensed locally by pharmacies within the Shire of Three Springs, 445 (9.70%) were dispensed by pharmacies in the Perth metropolitan area and 1 785 (38.90%) were dispensed by pharmacies in other regional areas of the state or LGA in other states (see Figure 4). In relation to the data supplied by the HIC, it is noteworthy that for all rural localities, parents of children in the 0-16 age range tended to take their children to the metropolitan area or other localities outside their town for treatment. However, approximately half of the residents in the pharmacy located towns returned and had their prescriptions subsequently dispensed by their local pharmacy.

This tended to be somewhat similar in Leeman, where a higher proportion tended to go to the metropolitan area for a medical consultation. More than half supported the local pharmacy in their region, although it was some 40 kilometres away. The case in Three Springs, where there is no pharmacy but a dispensing doctor, saw very few (18.8%) take their children to the local medical practitioner and approximately that number received their prescriptions from the same source.

It is notable that adults and those aged over 65 years received about 55-60% of their prescriptions from the local medical practitioner but had 84% of their prescriptions


67

dispensed at the local pharmacy. This could relate particularly to the convenience of the pharmacy for repeat prescriptions.

In Three Springs, where approximately the same number of prescriptions were written for those over 65 years as were dispensed to them, most had their prescriptions dispensed by the local doctor. Those who attended a doctor elsewhere seemed to return to the nearest pharmacies in Geraldton, Dongara, Moora or Jurien, which collectively dispensed 23.2% of prescriptions to this group.

In the case of Leeman, which has neither a medical or pharmaceutical service, few travelled to Jurien for their children’s medical needs and clearly preferred the metropolitan area. Some who travelled to Perth still had their prescriptions filled in Jurien, which is on the way back to Leeman. Most, however, used a metropolitan area pharmacy or one they passed before reaching Jurien on the journey home.

It is clearly evident that all of these towns generate significant income for metropolitan area doctors and pharmacists. Overall, 29.1% of prescriptions for residents in the four towns were written in the Perth metropolitan area, however, only 8.5% of these were dispensed in the metropolitan area. Some of this difference would be accounted for by repeat prescriptions being prescribed in the metropolitan area and dispensed by the local rural pharmacy. The exception to this is Three Springs, where those over 65 years of age have to travel to a pharmacy near to them in the country, which is a distance of at least 20 kilometres.

Questionnaire Responses

Data from the questionnaires was first subjected to frequency analysis to determine if any significant trends were visible. Then, using a significance level of p < 0.05, data was analysed using the Chi-Square test. Specifically, the data for Three Springs and Moora was compared, as was the data for Jurien Bay and Leeman, as these towns were determined to be most similar in characteristics and allowed a pharmacy and non-pharmacy town to be included in each pairing.


68

Three Springs and Moora

Q 10 Frequency of Obtaining Non-Prescription Medicines (%) Never TS 7.4

Once Every Couple of Years

M 12.3

TS 22.2

M 9.2

Several Times a Year TS 51.9

M 49.2

Monthly TS 14.8

Fortnightly

M 21.5

TS 3.7

p

M 7.7

.235

Number Three Springs (nts) = 54 Number Moora (nm) = 65

Although there was no statistically significant difference in the frequency with which Three Springs and Moora residents obtained non-prescription medicines (p = .235), Moora residents did tend to obtain these medicines more regularly, that is, a slightly higher percentage of Moora residents obtained non-prescription medicines on a fortnightly or monthly basis.

Q 11 Frequency of Obtaining Prescription Medicines (%) Never TS 5.4

M 3.1

Once Every Couple Of Years TS M 30.4 23.1

Several Times a Year TS M 28.6 35.4

Monthly TS M 30.4 30.8

Fortnightly

Weekly

TS 1.8

TS 3.6

M 3.1

p

M 4.6

.889

nts = 56 nm = 65

There was also no statistically significant difference in the frequency with which participants from the two towns obtained prescription medicines (p = .889), with most participants obtaining such medicines monthly, several times a year or once every couple of years.

Q 13.1 Frequency of Obtaining Prescription Medicines From Pharmacy (%) Always TS 17.0

M 89.2

Usually TS 18.9

M 4.6

Occasionally TS 22.6

M 1.5

Never TS 41.5

M 4.6

nts = 53 nm = 65

In relation to the frequency with which residents of Three Springs and Moora obtained their prescription medicines from a pharmacy, the vast majority of Moora respondents (89.2%) always obtained prescriptions from a pharmacy, compared to

p