Int J Pharm Pharm Sci, Vol 9, Issue 12, 212-217Original Article


Jamshid Tabeshpour1,2, Mohammad Reza Zirak1, Houshang Mirakhorli3, Bibi Sedigheh Fazly Bazzaz4, Monavar Afzalaghaee5, Mohammad Amin Kerachian6, 7, Saeid Eslami8,9, Zhila Taherzadeh10*

1Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran, 2Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran, 3Targeted Drug Delivery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran, 4Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran, 5Management and Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran, 6Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran, 7Department of Medical Genetics, Mashhad University of Medical Sciences, Mashhad, Iran, 8Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran, 9Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran, 10Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Received: 31 Jul 2017 Revised and Accepted: 02 Nov 2017


Objective: Healthcare providers play a key role in reducing medication errors and improving patient care, especially for those who suffer with chronic diseases. This study aims to assess pharmacist attitudes toward collaborative practice in northeastern Iran.

Methods: A face-to-face survey was offered to a sample of 124 pharmacists in Mashhad, Iran, and some other cities of the Razavi Khorasan province. This survey assessed the following elements of community pharmacists’ collaborative behaviour: “interactional determinants,” “environmental determinants,” and “pharmacist determinants.” Results were analyzed to determine how pharmacists’ attitudes and other variables would influence their collaborative behaviour.

Results: The survey response rate was 100%. Principal component analysis revealed that the attitudes towards collaboration instrument for pharmacists (ATCI-P) in our sample consisted of two factors: interactional determinants and pharmacist determinants, both with high internal consistency (Cronbach’s alpha = 0.83). The lowest and the highest scores in the interactional determinants domain were 19 and 35, respectively. The higher attitudes toward collaboration were obtained in the capital city, Mashhad, rather than in towns (P-value = 0.006). Multiple linear regression analysis of the complete model was significant (R = 0.38, P-value = 0.004). The age and city/community size were also found to be significant predictors of collaboration behavior (B = 0.300, p = 0.002 and B = 0.259, p = 0.004, respectively).

Conclusion: The community pharmacists in Razavi Khorasan, Iran, have a profound attitude toward collaboration with physicians, and their collaborative behaviour is influenced by the age and community size.

Keywords: Community Pharmacists, Attitude, Collaboration, Physician, ATCI-P, Iran


The role of pharmacists in the healthcare system is not separate from diagnostic and treatment services. In recent years, it has expanded to encompass areas beyond the dispensing function, and it has now extended to pharmaceutical care [1]. Pharmaceutical care is the provision of drug therapy with the goal of achieving definite therapeutic outcomes toward patients’ health and quality of life. This involves identifying, addressing and preventing medication-related problems [1]. Pharmacists are trained to optimize medication management, especially when regimens become complicated. Because of this specific expertise, adding pharmacists to in-patient services and speciality clinics can improve patients’ health outcomes [2]. One study provided proof of concept that community pharmacists, working in partnership with physicians, can have a major beneficial impact on cholesterol risk management [3]. This collaborative approach also has a positive impact on patients’ health outcomes in various chronic conditions such as asthma [4], hypertension [5-6], diabetes [7-8] and heart failure [9]. In addition, it improves patient safety outcomes such as medication appropriateness [10-11] and lowers the incidence of adverse drug events [12-14]. In another study, it was shown that a clinical pharmacist can conduct effective consultations with regard to elderly patients’ health [15-16].

The need to improve patient care by coordinating the activities of various healthcare providers has become a topic of increasing interest in the healthcare community. Pharmacists can provide the team with the expertise needed to improve a patient’s drug therapy and self-care skills. However, to optimize this contribution, pharmacists need to learn to work in a collaborative manner as members of an interdisciplinary team [17]. The World Health Organization (WHO) suggests that collaboration between the healthcare providers will result in improved health outcomes for the patients [18]. Furthermore, randomized controlled trials have shown that collaboration between pharmacists and physicians positively affects the clinical outcomes for their mutual patient [19-20]. In a study of primary care pharmacists and physicians, Zillich et al. [21] reported that exchange factors were especially important in developing collaboration between practitioners. Specifically, they reported that trustworthiness, role specification, relationship initiation, and professional interactions were completely associated with collaborative care.

Van et al. have shown collaborative behaviour is influenced directly by interactional and environmental determinants, and indirectly by practitioner determinants [22]. An attitude toward collaboration is an important subject that may influence the degree to which physicians and pharmacists collaborate with each other. Past investigations have considered this collaboration from the view of physicians [21], and several studies have been conducted on the influential factors in the development of physician-pharmacist collaboration and from the view of physicians [23]. The aim of this study was to assess the attitude of pharmacists to collaborate with physicians from the pharmacists’ point of view, through standardized questionnaires.


Study design

A cross-sectional paper-based survey was conducted in a random sample of 124 practicing pharmacists in Razavi Khorasan Province, in northeastern Iran. The study was approved by the university ethical institutional review board of Mashhad University of Medical Sciences. The samples were randomly selected from the database of the food and drug department in Mashhad (the capital of the province), supported by Mashhad University of Medical Sciences.

The study was carried out independently of any commercial entity. A face-to-face survey was conducted between the years 2015 and 2016. This survey was comprised of a three-page questionnaire and was delivered to practicing pharmacists in all regions of the province. The pharmacists’ attitudes toward collaboration with physicians were measured using nineteen items adopted from Van et al. [22], on a four-point Likert-type scale (1, strongly disagree; 2, disagree; 3, agree; 4, strongly agree) for each statement [23]. The questionnaire also included items about practice characteristics and demographics such as the pharmacists’ age and gender, the location of the pharmacy, the number of years they have been in practice, the years they graduated from college and their distance from a medical centre.

Data collection

We collected data through an adopted 19-item questionnaire, “ATCI-P in Primary Care” [22]. ATCI-P stands for “attitudes towards collaboration instrument for pharmacists”. The ATCI-P measures included: interactional determinants, environmental determinants and pharmacist determinants. The interactional determinants domain encompasses components of interpersonal relationships and includes key components of collaboration identified as communication (items 1, 2), trust (items 3, 4), mutual respect (item 5) and willing to collaborate (items 6, 7, 8, 9). Environmental determinants designate the settings under which the practitioner practices, including elements of proximity to physician’s office (item 10), systems for collaboration (item 11), interprofessional education (item 12), remuneration (item 13) and physician contact during training (item 14). Finally, the pharmacist determinants domain includes the recognition of roles (items 14-16) and expectations (items 16-19), and it comprises features correlated to the pharmacist individually

To use the ATCI-P, a cross-cultural adaptation and validation process was performed, comprising translation, synthesis of translation, back translation, expert committee review and pretesting [24]. The pretesting of the questionnaire was conducted by ordering it to a convenient sample of 15 pharmacists whose names were not included in the sampling frame for the main study. Cronbach’s alpha was used to measure the reliability and assess the item consistency of the instrument. Values above 0.7 were considered acceptable.

After cross-cultural adaptation and validation, the resulting questionnaire was given to a sample of 124 practicing pharmacists. The researcher physically traveled to each respondent’s location to conduct a personal interview and administered the questionnaire in a face-to-face manner; therefore, respondents answered all of the questions.

Each of the identified pharmacists was asked to complete a survey of basic background and demographic information along with the questionnaire. Demographic information was collected to describe the respondent and context characteristics that could influence the relationships being studied.

Data analysis

Statistical differences of gender, the location of the pharmacy and distance from a medical center were evaluated by independent sample t-tests or one-way analysis of variance (ANOVA) followed by John Tukey’s post-hoc test. We used backward elimination regression to establish the important explanatory variables. A probability value (p-value) of less than 0.05 was considered significant, and in regression, if variables were under the significance level, they were retained in the model. Finally, the backward stepwise protocol was performed in order to establish the most influential variables. The data analysis was conducted using SPSS 11.5 statistical software for Windows (SPSS, Chicago, IL).


A total of 124 pharmacists participated in our survey. We had face-to-face interviews and the response rate was 100%. The demographic characteristics of the participants are shown in table 1.

Table 1: Demographic characteristics of participants

Characteristics Mean (SD)/N (%)
Age (mean, SD), Y 39.73 (10.87%)
Years in practice (mean, SD), Y 13.65 (9.51%)
Gender Male 69 (55.64%)
Female 55 (44.35%)
Community size Capital city 90 (72.58%)
small town 34 (27.41%)
Years after college graduation, year student 9 (7.25%)
Up 10 48 (38.7%)
10–20 39 (31.45%)
20–30 22 (17.74%)
30–40 6 (4.83%)
Distance from a medical center Same location1 45 (36.29%)
Near2 60 (48.38%)
Far3 19 (15.32%)

Data of age were expressed as mean±SD (standard deviation); others were shown as frequency (percentage), 1The pharmacy was located in the medical center building, 2The pharmacy was located ≤ 500 meters from the medical center, 3The pharmacy was located more than 500 meters from the medical center.

Of the respondents, 56% were male and 44% were female; 85.5% were permanently responsible pharmacists, compared to 14.5% temporarily responsible pharmacists; and 73% lived in Mashhad while 27% resided in other cities.

The preliminary study (15 experts) showed that the interactional determinants and pharmacist determinants domains had reliability (Cronbach’s alpha>0.7), but the environmental determinants domain was excluded due to lack of reliability (Cronbach’s alpha ˂ 0.5). The environmental determinants domain included items like preferred methods and frequency of communication, methods for improving collaboration and history of contact in the past.

Measured ATCI-P scores throughout the questionnaire ranged from 33 to 57 (the minimum and maximum possible scores were 15 and 60, respectively). There was no significant difference between male and female pharmacists’ scores (p = 0.53). Likewise, the mean score of temporary and permanently responsible pharmacists was statistically the same (p = 0.76). The ATCI-P mean score was higher in small towns than in the capital city (p = 0.006). The mean score of pharmacists with the same location or near a medical centre was higher than those of pharmacists far from a medical centre; however, it was not statistically significant (p = 0.2) (table 2).

Table 2: Attitudes towards collaboration instrument for pharmacists (ATCI-P) score

Factors Score (mean±SD) P-value
Gender Male 45.01±5.57
Female 45.47±6.47
Community size Capital city 44.37±5.87
small town 47.44±5.72
Distance from a medical center Same location 45.17±6.59
Near 45.91±5.28
Far 43.10±6.28

Statistical differences of gender and location were evaluated by independent sample t-tests. For analysis of distance, we used one-way ANOVA followed by a Tukey post-hoc test.

As depicted in fig. 1, pharmacists agreed that collaborative practice can result in better health outcomes for patients (100% agreement). Furthermore, they declared that physicians thought the same way. There was a high level of agreement among pharmacists that for an improved collaboration, they should respect each other and have an honest and frank relationship with physicians (100% agreement).

Fig. 1: Attitudes toward collaborative practice (interactional determinants)

Most of the pharmacists believed that physicians had enough abilities and skills to provide high-quality healthcare services, and since they cared about patients’ health, they communicated with the pharmacists in necessary situations (fig. 2).

Fig. 2: Attitudes toward collaborative practice (pharmacist determinants)

Table 3 represents the multiple regressions stepwise, backward developed using ATCI-P as a dependent variable, and distance, age, gender, city, and type of pharmacy as predictors. The age (p = 0.002) and city/community size (p = 0.004) were detected as important simultaneous influent variables. Backward elimination, which involves starting with all candidate variables and testing them one by one for statistical significance, deleted any factor that was not significant [25].

Table 3: Backwards stepwise regression results (n = 124)

Model Predictors R P-value of model
1 (Constant), distance, age, gender, city, type of pharmacy, years in practice 0.388 0.004*
2 (Constant), age, gender, city, type of pharmacy, years in practice 0.386 0.002*
3 (Constant), age, city, type of pharmacy, years in practice 0.383 0.001*
4 (Constant), age, city, years in practice 0.372 <0.001*
5 (Constant), age, city 0.347 <0.001*

*Statistically significant,

The multiple linear regression for pharmacist attitude was statistically significant (R = 0.38, p = 0.004). The regression analysis showed that age and city are significant predictors of collaboration (table 4).

Table 4: Pharmacist attitude toward collaboration with community pharmacist regression, complete model

Belief measures (independent variables) Standardized beta coefficient P-value
Gender 0.045 0.602
Age 0.300 0.002*
Community size 0.259 0.004*
Distance 0.032 0.712
Type of pharmacy 0.083 0.384
Years in practice -0.30 0.094

* Statistically significant


Several studies on pharmacist-physician collaboration have been accomplished from the viewpoint of physicians, but there are only a few studies on this collaboration from the viewpoint of pharmacists. As far as we know, this is the first study to examine the attitudes of pharmacists in collaboration with physicians in Iran. Pharmacists agreed that collaborative practice can result in better health outcomes for patients (100% agreement), as we can observe in the third domain (pharmacist determinants). This domain measures the extent of interdependence between pharmacists and physicians. This interdependence is important in a lower stage of the collaborative relationship [17]. In this area, the healthcare perception of the professional role is a significant factor to form an effective team and it is a key component of collaboration [26]. Our study showed that there was a high level of agreement among pharmacists that for an improved collaboration they should respect each other, and have an honest and frank relationship with physicians (100% agreement) which can be perceived from the first domain (interactional determinants). This domain evaluates the interpersonal relationship. It is obvious for pharmacists that team-based approaches to the delivery of healthcare where pharmacists work collaboratively with physicians can significantly improve the quality of care and clinical outcomes [27].

The pharmacists who participated in our study were interested in having more collaboration with the physician in all areas identified, although some areas were of greater concern. Age and city/community size are independent predictors of collaborative behaviour. Many of the pharmacists from this study believed that the communication and collaboration between healthcare professionals are more beneficial for patients (items 1, 2). They also believed that there should be mutual respect between physicians and pharmacists, and should work together as partners instead of subordinates and superiors (item 5). We also showed that the pharmacists have a strong willingness to collaborate because they agree that collaborative practice can benefit the patients (item 9), but they are not sure if physicians wish to collaborate with them as well (items 6, 7, 8). The pharmacists in cities other than the capital (Mashhad) are more interested in collaborating with physicians than have been able to so far. Also, collocated or closely located physicians and pharmacist had a stronger attitude toward collaboration. It means that shorter geographical distances between pharmacists and physicians would make them more reachable to one another and thus it would increase their likelihood of inter-professional collaboration.

As the physician-pharmacist relationship is established, followed by initial discussions and then shared professional experiences, the roles of each party become clear. Over time, the professional interactions that proceed favourably will tend to be repeated because the roles are more clearly defined. As the relationship advances to more collaborative levels, the professional interactions become associated with collaboration [28]. Within the medication use process, roles for pharmacists can include multiple activities such as educating patients, monitoring drug therapy and communicating with physicians. When pharmacists and physicians jointly determine specific roles, the relationship is more likely to become collaborative [23]. Patients’ conditions also improve when pharmacists participate successfully in medication therapy management. Several studies have reported that physician-pharmacist collaboration has led to health improvements for patients diagnosed with hypertension [29], diabetes [30], high cholesterol [31] and depression [32].

Mutual respect and trust are also important factors in teamwork practices. Trust is vital in the development of collaborative relationships, as in any relationship [23]. As time passes and the pharmacist is able to demonstrate his/her competence, the physician’s trust begins to grow. That is, the physician evaluates the pharmacist’s abilities through the quality of his/her medication recommendations. When useful recommendations are made consistently over time, then the physician comes to trust the pharmacist’s expertise [33-34]. This also is true for the pharmacist’s trust of the physician. As trust develops, communication becomes more open between the two professionals. Each party becomes willing to have frank discussions about approaches to managing conditions and about treating specific patients. Thus, trust is a contributing factor to the development of collaboration between pharmacists and physicians [23]. Most of the respondents agreed that their relationship with physicians should be based on honesty and truth. The ultimate goal of this collaboration is to provide the best solution for patients’ treatment. Pharmacists know that collaboration between themselves and physicians can be more beneficial to patients. Therefore, this can be a step forward in the creation of mutual understanding between the two professions.

Among the predictors of collaboration, age and city/community size were significant. Age is a significant predictor that pharmacists and physicians will believe that this collaboration impacts the prevention of medication-related problems. As their age increases so does their work experience. Therefore, the collaboration between two professionals would be facilitated. It may be debated that a positive assessment of physicians by pharmacists is, in fact, a criterion for strong interactions. Less agreement was seen in the pharmacist determinants domain. Role understanding and appreciation of other roles are important for effective collaborative practice [35]. Many of the pharmacists who participated in our study were not strongly sure if physicians recognized and appreciated them for their role in medication safety and effectiveness. This illustrates a need to improve the recognition of roles and expectations for the services provided [36].

This study has some limitations. It was done in only one province. However, there is a unique pharmacy education program in Iran. In addition, Mashhad is the second most populous city in Iran and Razavi Khorasan is one of the biggest provinces; they could be representative of Iran as a developing country. Face-to-face surveys still deliver the most representative results. However, even here, one should control potential biases such as interviewer bias, high cost per respondent, geographical limitations and time pressure on respondents.

For the future study, we suggest examining physician attitudes toward collaboration with pharmacists for improving patients’ care. We also suggest defining the barriers to collaboration. This continued focus on collaboration should make it possible to optimize the delivery of primary healthcare services.


We found that the pharmacists who participated in our study showed great inclination to collaborate with physicians, but this attitude has not reciprocated yet. Therefore, it is necessary for pharmacists to become familiar with professional communications in the health system—during their educational courses, during their continuing medical education and after graduation—and try to eliminate the existing imperfections. Furthermore, the curriculum at pharmacy schools could be improved by training pharmacists to better collaborate with physicians.


The authors are thankful to the Vice Chancellor of Research, Mashhad University of Medical Sciences for financial support. The present study is a Pharm. D thesis in the field of pharmacist education from Mr. Houshang Mirakhorli.


Fazly Bazzaz B. S jointly conceived the study with Afzalaghaee M and Eslami S; Taherzadeh Zh, Fazly Bazzaz B. S, Eslami S, Kerachian M. A participated in the design of the study and drafting the manuscript; Mirakhorli H participated in the data collection; Tabeshpour J drafted the manuscript; Zirak M. R performed the statistical analysis and Afzalaghaee M supervised its analysis and edited the manuscript; Taherzadeh Zh, Fazly Bazzaz B. S, Kerachian M. A and Eslami S revised the manuscript critically for important intellectual content; Taherzadeh Zh gave final approval of the version to be published; All authors read and approved the final manuscript.


All authors approved the manuscript and this submission. The author reported no conflict of interest and no funding was received for this work.


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About this article




community pharmacists, attitude, collaboration, physician, ATCI-P, Iran





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International Journal of Pharmacy and Pharmaceutical Sciences
Vol 9, Issue 12, 2017 Page: 212-217

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Authors & Affiliations

Jamshid Tabeshpour
Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
Iran, Islamic Republic of

Mohammad Reza Zirak
Department of Pharmacodynamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran

Houshang Mirakhorli
Targeted Drug Delivery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Bibi Sedigheh Fazly Bazzaz
Biotechnology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Monavar Afzalaghaee
Management & Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Islamic Republic of Iran

Mohammad Amin Kerachian
Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Saeid Eslami
Pharmaceutical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Zhila Taherzadeh
Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

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