1. IntroductionPatients in rural areas are known to experience inequities that contribute to healthcare disparities. Compared to urban areas, those in rural areas are more likely to have less education, reduced income, more children in poverty, and increased mortality [1]. South Dakota is one rural state with population characteristics that contribute to such healthcare disparities. The average population density of South Dakota is one of the lowest in the country at 11 people per square mile, far lower than the national average of 88.4 people per square mile [2]. Because of South Dakota’s rural nature, access to primary care providers (PCPs) and medical specialists is limited. Over three-quarters of South Dakota is categorized as a Health Profession Shortage Area and the same portion is considered a Medically Underserved Area/Population [3]. One survey of adults in South Dakota, Wyoming, North Dakota, and Montana reported that patients travel an average of 42 miles for a routine healthcare visit with some traveling more than 100 miles to see their PCPs [4].Needing to travel long distances to reach a clinic poses a challenge for many rural patients. Community pharmacies are a uniquely positioned resource since, among other benefits, they are more accessible to many patients. It is reported that 64% of those living in South Dakota are located within 15 min of a pharmacy and 81% are located within 30 min [5]. Pharmacists have historically been underutilized as medication experts [6]. They are highly skilled and trained to improve care through medication therapy management (MTM), disease state education, improved medication adherence, cost-lowering strategies, and immunizations [7].Such pharmacist-provided services are also positioned to help patients with diabetes, which is a major need throughout the United States, including in South Dakota. In 2018, 10.5% of the US population had a current diabetes diagnosis and 9.2% of the South Dakota population had a current diabetes diagnosis [8,9]. Each year, 1.5 million Americans are newly diagnosed with diabetes and in 2019, 26.8 of every 100,000 deaths in South Dakota were attributed to diabetes, higher than the national average of 21.6 per 100,000 deaths [8,9,10,11]. Diabetes is also linked to cardiovascular disease complications and patients with diabetes are two to four times more likely to die from heart diseases than those without diabetes [12]. The mortality implications of diabetes and cardiovascular disease in South Dakota is evident, with heart disease, stroke, and diabetes being three of the top ten leading causes of death in 2017 and poses a significant public health problem [13].Despite available resources offered by pharmacists, it is estimated that thousands of South Dakotans have diabetes but are undiagnosed, and pharmacists remain underutilized as a resource to improve diabetes screening and care for South Dakotans [3]. In addition to undiagnosed diabetes, an estimated 20,000 South Dakotans have prediabetes [3]. To prevent and manage diabetes, heart disease, and stroke by implementing and evaluating evidence-based strategies to manage diabetes and CVD, as well as prevent or delay onset in high-burden populations, the Centers for Disease Control and Prevention (CDC) released a call to action [3]. In response to this call to action, the authors from South Dakota State University partnered with the South Dakota Department of Health on a 5-year project, through a cooperative agreement. This five-year project was designed to identify barriers faced by patients and develop programs to improve the care of South Dakotans, focusing on expanded pharmacy services [14]. In the first year of the project, a landscape analysis was completed of patients with diabetes, heart disease, and stroke. One major finding from this landscape analysis was that patients are unaware of the pharmacy services available, including MTM. Once these services were explained more in-depth, however, there was a consensus from patients that MTM and similar expanded services would be beneficial to their care [15]. Strand et al. observed that pharmacists are found in most of our local communities and often have more interaction with patients than their primary care providers and can therefore play a key role in reducing or helping patients manage these major public health concerns [16].While pharmacists are present in most of our communities, there is currently insufficient data available on optimal ways to increase patient knowledge of pharmacy services in South Dakota. Thus, a need to improve awareness of various pharmacy-based services offered across the state was identified. Although awareness is directly linked to knowledge, it is important to also consider patients’ perspectives regarding pharmacy-based services. The Theory of Planned Behavior (TPB) is a theoretical framework that has previously been used to predict and describe health behaviors and intentions [17]. The TPB was first proposed in 1985 and has since been used to help motivate changes in public health areas such as smoking and alcohol cessation [18,19,20]. This theory has also been applied to motivating behavioral changes in patients diagnosed with diabetes and cardiovascular disease [21,22,23]. The TPB is unique because it takes into consideration personal intent. Intention is a central determinant of action and is impacted by attitude, perceived behavioral control, and social norms [24]. The TPB has previously demonstrated success in predicting health behaviors and offers great utility in public health projects [7].

As a result, the TPB was deemed an appropriate guide to understand patient perceptions of utilizing pharmacy services that are provided in community settings. The overall goal of this project was to understand the impact of a public health awareness campaign on the perceptions of expanded pharmacy services offered in South Dakota among people with diabetes and cardiovascular disease.

2. Methods 2.1. Study Design

The study design for this project was a non-randomized pre and post design using a survey that was administered through an electronic approach, using the online tool QuestionPro, and mail delivery in South Dakota from January 2020 to February 2022. All project procedures involving human subjects were approved by the South Dakota State University Institutional Review Board (1901020-EXM). An informed consent was required for each participant prior to recruitment in this project.

2.2. Conceptual FrameworkA modified TPB (mTPB) was used to identify the salient constructs associated with pharmacy services, including MTM, Medication Therapy Review (MTR), diabetes education, cost-reduction, and medication adherence [18]. In conjunction with the mTPB, this project focused on factors that may influence participants’ motivation to get access to pharmacy services in the community setting. The TPB delineates theoretical constructs concerned with individual motivational factors as determinants of the likelihood of performing specific behaviors [18]. The three key constructs based on the TPB include (1) attitude, (2) perceived benefit and norms, and (3) perceived behavioral control. Attitude denotes an individual’s evaluation of gaining access to pharmacy services. For this project it was determined that a focus on perceived benefits versus the traditional construct of subjective norms, such as social pressure, would be more appropriate in assessing intent to utilize expanded pharmacy services. Perceived benefits and norms, then, are an individual’s perception about the use of pharmacy services by other members of the community. The perceived control represents an individual’s perceived ease or difficulty of approaching pharmacy services. While it is well recognized that these three constructs influence behavior, results from the landscape analysis in the first year of the CDC-funded project identified that a knowledge gap likely existed for patients in South Dakota. Thus, an assessment of knowledge was included in the survey design in addition to the three areas of the TPB. 2.3. Data Source

Recruitment of participants took place from October to December 2019 via newspaper and social media advertisements and flyers posted in community pharmacies across South Dakota. From the recruitment materials, potential participants called a central line to be screened for their eligibility in the survey. Screening was conducted by a research assistant who was not involved with the analysis of survey data collected. Inclusion criteria were individuals at least 18 years of age who self-reported a diagnosis of diabetes and/or cardiovascular disease. Individuals who were unable to complete a survey either electronically or via postal mail were excluded.

2.4. Awareness Campaign: “Your Pharmacist Knows”

An awareness campaign titled “Your Pharmacist Knows” was developed in Fall 2019. The campaign consisted of a 30-s commercial and print material, such as a poster, brochure, and business card. Additionally, the website Yourpharmacistknows.sdstate.edu housed all the information found on the print material and the commercial. The goal with these tools was to educate patients with diabetes and CVD on what pharmacists can do to better help their care. Topics covered included adherence tools, medication therapy management (MTM)/medication therapy review (MTR), immunizations, patient care and education, and cost-lowering measures.

Between Fall 2020 and Spring 2022, the poster was sent out to every pharmacy in South Dakota with the intention that it be displayed in the pharmacy to prompt patients to ask questions about the program and opportunities for them through the pharmacy. Pharmacies were asked to hang it on a visible bulletin board or near the register of the pharmacy or have it on counters for patients to view. The brochure was an alternative to the website. Pharmacies were asked to give these to patients who would like more information but may not be able to access the website due to limited internet access. The business cards were given to patients as a reminder to visit the website once they were home. Additionally, these materials were shared via social media across pharmacy organizations and the Department of Health social media pages. The commercial aired on various news stations and was streamed in 2-month blocks in Fall 2020, Spring 2021, Fall 2021, and Spring 2022.

2.5. Sample and ProcedureA convenience sampling technique was applied for participant recruitment. In January of 2020, the survey was distributed to eligible participants using the participants’ preferred method of postal mail or QuestionPro electronic distribution. The surveys were to be completed and returned to the project team within three weeks of distribution. This timeframe was later extended to 10 weeks to allow for an adequate response rate. Each returned survey was deidentified and assigned a unique identification number by a team member who was not associated with data analysis to maintain blinding to the analyzing project members. The nine-page survey was designed to take participants 20–30 min to complete. After each cycle of the awareness campaign enrolled participants were invited to complete the posttest survey. An example of the survey used can be found in Appendix A. 2.6. MeasurementsTo evaluate participants’ perceptions of pharmacy services provided in the community pharmacy, a 73-item survey was developed based on literature review and prior project findings [15,25,26,27,28]. The survey encompassed four constructs to measure participants’ perceptions of expanded pharmacy services including knowledge (16 items), attitude (14 items), perceived benefits and norms (14 items), and perceived behavioral control (14 items). The scores for each construct were calculated as a simple sum of responses. Additionally, sociodemographic and medication information was collected (13 items). The expanded pharmacy services measured in each section covered medication adherence, MTM, MTR, diabetes education, and cost-reduction. In addition, two items measured participants’ past use and their intent to use pharmacy services.To ensure face and content validity, an expert panel consisting of seven pharmacy practitioners and educators examined the appropriateness of each survey item and resolved by consensus any issue encountered during the project [29]. Two different scoring systems were utilized to evaluate participants’ perceptions of expanded pharmacy services. In the knowledge section, a 3-point Likert-type scale (“True,” “False,” and “I don’t know”) was used to assess participant knowledge of pharmacy services. Correct marks were given a score of 1 and incorrect or “I don’t know” marks were scored as 0. The possible sum of knowledge scores ranged from 0 to 16; a higher score reflected greater awareness of pharmacy services provided in the community setting.

In the sections of attitude, perceived benefits and norms, and perceived behavioral control, each item was measured using a 5-point Likert-type scale with “strongly disagree” (score = 1) to “strongly agree” (score = 5) response options. The possible sum of scores for each subscale ranged from 14 to 70, with a higher score meaning a stronger attitude and perceptions of benefits and norms and behavioral control regarding the pharmacy services. Questions where a “strongly disagree” answer would be expected were scored inversely.

2.7. Statistical Analysis

Descriptive statistics, including mean, standard deviation (SD), and frequency were used to summarize the characteristics of the project samples. All continuous variables were expressed as the mean and SD and the categorical variables were expressed as numbers and percentages. The four primary outcomes included scores from each construct to include knowledge, attitude, perceived benefits and norms, and perceived behavior control regarding pharmacy services. Specific analyses conducted include independent samples t-tests to compare pre and post scores, chi-square analysis to compare group differences in both use of services and intent to use pharmacy services. Four separate multivariable linear regression analyses were performed to explore the association of each outcome variable with the six identified covariates based on literature review. Covariates used within the linear regression included age, gender, race, education, surrounding population density, and whether having health insurance impacted participants’ answers. The nominal covariates were categorized into dichotomous variables to minimize the risk of losing statistical power. Race was categorized as white and non-white and the highest education level was divided into two groups by using attainment of a high school diploma as the cutoff point. Surrounding population density was categorized in two groups depending on whether the geographic living area had more than 50,000 people, as reported by the participant. Health insurance status was divided into two groups: participants who self-reported having any type of health insurance and participants who self-reported not having health insurance.

Logistic regression was conducted to evaluate the impact of the mTPB constructs on intent to use services with a final logistic regression conducted to evaluate intent to use services as a predictor of services used. All statistical analyses were carried out using SPSS version 27.0 (IBM Corp; Armonk, NY), with the statistical significance level at a two-sided p-value 30]. As a result, a sample of at least 98 participants were required to reach a medium-sized effect (f2 = 0.15). 4. DiscussionThere is a fairly broad body of literature examining factors that affect pharmacists’ intention to utilize drug monitoring programs, engage in MTM therapy, or other pharmaceutical care services [31,32,33,34]. However, using the TPB as a model for patient perceptions of pharmacy services is an understudied area, particularly in regard to rural populations [35]. A limited number of studies that have been conducted looking at patients’ intentions to use expanded pharmacy services through the lens of the TPB exist. There are two related studies conducted in Malaysia that assessed patients’ intention to utilize newly implemented pharmacy services that found a significant impact of attitude, social norms, and perceived control on intention to utilize services [36,37]. Additionally, one study that examined a focused New York City population of South Asian individuals found that attitudes and perceived control were significant predictors of intention to access pharmacy services [38].We understand ours to be the first study to examine a rural population with the goal of understanding patient intentions to utilize pharmacy services related to diabetes and CVD. Ultimately, our work indicates the usefulness of using the TPB model to explore factors associated with patient perceptions of pharmacy services in rural areas. For our project, initial indication of lower baseline knowledge of pharmacy services came from focus groups and elicitation interviews in year one of the CDC 1815 project [16]. Information collected showed it was valuable to add a knowledge component to the TPB model. Since knowledge is shown to be an underlying component of intent, efforts to improve patient knowledge could be used to improve all three components of the TPB, thus improving intent to utilize enhanced pharmacy services.

The application of this model to rural communities of South Dakota contributes another layer of uniqueness to our project. By gathering rural patients’ perspective of expanding pharmacy services through the lens of the mTPB, a future educational campaign can be tailored to improve patient knowledge, attitude, perceived benefits and norms, and perceived behavior control of these services. Thus, a deeper dive into our findings, including those related to knowledge, attitude, perceived benefits and norms, and perceived behavior control, as well as how each of those factors are impacted by patient gender, education, insurance status, and race, will help unfold areas for future education for this rural population.

Patient knowledge regarding expanded pharmacy services was the strongest predictor of intent within our model. Initial patient knowledge was heavily influenced by patient demographics with demographic variables accounting for 25.6% of the adjusted variance. It is not surprising that pre-existing knowledge or familiarity with expanded pharmacy services was the most powerful predictor of intent. What we can learn from this, however, is that those with the most knowledge regarding pharmacy services were generally female, of younger age, and educated. This finding is not surprising since females are typically care givers and may have the tendency to frequent pharmacies more often as opposed to their male counterparts. Studies have shown that females in general utilize more prescription medication than males so it may be possible that females spend more time in pharmacies than men out of necessity [39,40]. While it is encouraging that younger adults and those with education had better knowledge of these services, patients often needing care and management for conditions such as diabetes and CVD tend to be older in age and those that have a lower educational status. This potentially indicates gaps within marketing or awareness strategies for these services and that a significant portion of pharmacy consumers are not being reached directly.Patients’ pre-conceived attitudes had a similar predictive effect as knowledge and was the second most influential construct on intent and consistent with observations from other studies using the TPB [41]. Demographic variables accounted for the most predictive power of attitude out of all the mTPB constructs with demographics accounting for 35.4% of the variance. As with knowledge, the primary predictors were female gender and education, as well as health insurance. Since the construct of preconceived attitudes was related to patients’ perceptions of the relevance of the services and confidence in their pharmacist’s ability to deliver the services, this can provide useful information when marketing these services to the public. For example, over 68.4% of patients disagreed with the statement that it was easy for them to find ways to lower medication costs and 42.4% disagreed with the statement that medication cost saving tools were available. Patients were largely supportive of the ability of pharmacists to deliver disease specific care but seemed unsure of economic services that pharmacists could assist with. These types of economic factors can be important when patients are older and may have more medication needs or be uninsured or underinsured, one of the key components of social determinants of health. For example, a third of the patients in this project missed receiving their refills due to costs or going back to see a doctor to get a refill. Pharmacists can play a significant role by working with the patients’ physician to recommend cost-effective options for patients. Additionally, they can seek cost-saving options for medications that are expensive. Patients unaware of these services offered by pharmacists may fail to seek out pharmacists in time of need. Interestingly, our findings echoed comments made by elicitation interview and focus group participants who shared that as a result of being unable to fill their high-cost medications, they had to bear serious consequences, such as a foot amputation or being hospitalized. Adding more direct messaging across pharmacies and increasing awareness around how pharmacists can work with the patients’ physicians to help them receive more cost-effective care will be critical.Perceived benefits and norms had a significant influence on patients’ intent to seek services. The perceived benefits and norms questions assessed patient’s beliefs in the benefits of expanded pharmacy practice services and whether they believed patients were utilizing them. Respondents predominately reported a “neutral” rating in over 70% of questions related to perceived benefits and norms. This indicates that participants need additional messaging regarding the benefits of pharmacy services particularly related to medication therapy review and the benefits of having a 90-day supply of medication as opposed to a 30-day supply. While most of our patients came from more populated areas in the state, the 90-day refill model would certainly help patients and families living in more rural parts of the state. Studies have found multiple trips to the pharmacy can lead to medication non-adherence due to gaps in fill dates [42]. Within perceived benefit, race had the largest impact, with non-white individuals perceiving better benefits surrounding pharmacy services. Interestingly, race demonstrated significance only in regard to perceived benefit. South Dakota is home to a large population of Native Americans, many of whom are served by the United States Indian Health Service (IHS). The IHS has long been known for holistic pharmacy services provided to patients [43,44,45]. IHS pharmacists have established standards of pharmacy practice by accessing patients’ health record, immunization status, and past medical history to assess the appropriateness of drug therapy and manage medication therapy and disease. This could explain the difference in the perceived benefits that differ between communities. For those that use the IHS system for their healthcare, pharmacists providing expanded services may be more commonplace than in other areas of South Dakota.

Perceived control had the lowest impact on patients’ intent to use services, though it was still a significant predictor. Perceived control measured the patient’s confidence that they could engage with the pharmacist and participate in the services offered at a pharmacy. Like with perceived benefits, patients had neutral responses to 65% of questions indicating that some patients may not have had a high level of confidence in the ease of accessing services. Patients did have a high level of agreement related to participating in and requesting MTM services, medication synchronization, and ease of speaking with their pharmacist about diabetes. Demographic factors had the smallest effect on perceived control in all the models with demographics only accounting for 7.2% of the variance. Insurance status was the only demographic characteristic that showed significant impact on perceived control among the independent variables tested. Whether this is due to those who are insured being of higher socioeconomic status, having a better grasp on their healthcare in general, or for other reasons is unclear and calls for further consideration.

Our findings prove beneficial for developing ways to better advertise pharmacy services to patients and educate patients on the benefits of these services to promote overall public health. Wood et al. highlighted the struggle of creating buy-in from patients regarding pharmacy services, including MTM and diabetes education services [46]. In their study, despite a plethora of advertising techniques including radio advertisement and personal selling of services to patients, less than 10% of patients enrolled in the offered services. To help avoid similar results, our theory-based approach to patient baseline awareness will help inform future development of educational intervention.The timeline for our project spans both pre-COVID and post-COVID periods, which introduced challenges. While there certainly has been recognition of the role of the pharmacist in public health emergency situations, there still seems to be hesitation across states on provider status and lack of awareness of the key roles pharmacists continue to play regarding public health. In rural and frontier states such as South Dakota where pharmacists do not currently have provider status but are almost always one of the most accessible healthcare workers, it is imperative that communities utilize pharmacists for prevention and management, especially as it relates to chronic conditions. Studies consistently show that pharmacists can have a significant impact in helping patients minimize their healthcare costs [47,48,49]. However, if patients do not recognize pharmacists as a resource or are not reaching out, healthcare costs across rural and underserved communities may continue to be negatively impacted. Future campaign initiatives would benefit from focusing on specific tools utilized by pharmacists or examples of how pharmacists can assist patients in these cost-saving measures.

From our results, we suggest addressing four specific areas to influence patient intention and behavior. By influencing patient knowledge, attitude, perceived benefits and norms, and perceived behavior control as it relates to pharmacy services, more successful education and awareness of patients should occur, whether that be on an individual level or for populations across rural and urban communities. To have the best potential impacts, since patient gender and education level impacted both knowledge and attitude, which were found to be the two biggest factors of the modified TPB, a focus for future awareness campaigns in South Dakota should be tailored more towards male patients and patients with lower education.

Strengths and Limitations

Strengths of this project include that the survey was theory driven, being rooted in the TPB. The extensiveness of this survey and a high initial patient participation rate also lend to its strengths. Additionally, regression data analysis that was controlled for covariates allowed for an in depth look at which variables influenced each of the three constructs of the TPB in addition to which variables influenced patient knowledge of expanded pharmacy services.

Limitations to this project include the low post survey response rate. It is possible that the length of the survey contributed to participant fatigue. Additionally, with the sample being a convenience sample, bias likely exists among the survey non-respondents. It is possible that participants who did not respond to the post survey may have had different perceptions that those found through our findings. Finally, the self-reported design of both our inclusion criteria and our survey response could have led to biases, such as social desirability, in patient reporting of certain data. Over fifty percent of respondents were from non-rural areas, future studies should attempt to capture more rural respondents as there is still a dearth of information regarding pharmacy access (pharmacy deserts) for truly rural inhabitants.