Health Policy 62 (2002) 195– 209 www.elsevier.com/locate/healthpol Public attitude and knowledge on a new health policy for pharmaceutical care in Korea Hye-Young Kang a, Chong Yon Park b,*, Han Joong Kim b a Department of Public Health, The Graduate School of Yonsei Uni6ersity, 134 Shinchon-Dong, Seodaemun-Ku, Seoul 120 -752, South Korea b The Graduate School of Health Science and Management, Yonsei Uni6ersity, 134 Shinchon-Dong, Seodaemun-Ku, Seoul 120 -752, South Korea Received 11 November 2001; accepted 12 January 2002 Abstract Objecti6e: to assess college student’s attitude and knowledge of the ‘separation of dispensing and prescribing’ policy in Korea. Design: a self-administered questionnaire survey of 700 college students. Main outcome measures: the attitude was assessed by the degree of interest in the policy, agreement to the policy need, expectation for the policy effect, and perceptions of motivation for physician’s strike. The knowledge level was measured using four questions describing the goal/motivation of the policy and eight describing its operational rules. Results: the level of interest (2.60 on a four-point scale), and agreement to the need (2.66) and the potential effect of the policy (2.29–2.91) were not very high. Concern for economic loss was perceived as the strongest motivation for physician’s strike. While relatively well understood for the goals/motivations of the policy (mean score: 69.58 out of 100), the operational details of the policy were not well-informed (32.52). Interest and agreement with the policy need were the most significant factors affecting the knowledge level (PB 0.01). Conclusion: For other public policies in the future, policy makers in Korea need to ensure public consent for the necessity of the policy and to develop more effective strategies to inform the public of the practical details of the policy. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Health policy; Public knowledge; Prescribing; Dispensing * Corresponding author. Tel.: +82-2-361-5093; fax: + 82-2-392-7734 E-mail address: [email protected], [email protected] (C.Y. Park). 0168-8510/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 8 - 8 5 1 0 ( 0 2 ) 0 0 0 1 9 - 2 196 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 1. Introduction 1.1. Background and study objecti6e Recently, health care reform is a word-wide trend and one of the major concerns in industrialized countries. Though the proposed reforms of individual countries are different according to their cultural, historical, social, and political circumstances, they pursue common goals, namely, improvement of health care quality, efficiency, and satisfaction of consumers and providers, cost containment and achievement of equity [1,2]. After experiencing a national health insurance system for more than 2 decades, Korea is currently undergoing health care reform to resolve cumulated problems and to improve overall quality and efficiency of health care [3–5]. Among many problems in Korea, the lack of role differentiation between health care providers at various levels is in urgent need of attention because it causes duplication of services provided and waste of health care resources. Especially, duplicated practice by physicians and pharmacists in providing medication therapy has resulted in overuse and misuse of medicines among Korean people [6–8]. Since drugs are crucial in patient care and almost all medical encounters require medication therapy, consequences of this practice behavior have substantial impact over the entire health care system. Therefore, this issue became a priority subject of health care reform in Korea. To correct this problem, the Korean government carried out a health care reform by launching a new policy, called ‘separation of dispensing and prescribing,’ which redefined professional roles of physicians and pharmacists with respect to medication therapy and altered the way of providing or receiving pharmaceutical care [9,10]. Being effective on 1 July, 2000, Korean pharmacists are no longer allowed to prescribe and physicians are forbidden to dispense medicines in their offices or hospitals to outpatients. By classifying medicines into over-the-counter (OTC) and prescription medicines, practical restrictions were placed on the types of medicines that people could purchase through community pharmacies. Outpatients can receive prescription medicines only at community pharmacies with a condition that they present prescriptions written by physicians [6,11]. Thus, the policy aims to improve quality of pharmaceutical care and decrease drug expenditure by reducing the risk of misuse and overuse of medicines, which resulted from uncontrolled access to pharmaceutical products and undifferentiated professional roles of physicians and pharmacists. Although the necessity and expected effects of the policy were well recognized, the majority of Korean people express varying degrees of resistance to adopting the new system, mainly due to the inconvenience of receiving pharmaceutical care and the increased out-of-pocket costs resulting from the extended pathway to prescription drugs [12,13]. People also feel insecure because they do not know exactly how the new system differs from the old practice [12,14]. Because the policy requires people to give up their long customary behavior of receiving medical care and forces to adopt an unfamiliar system, strong resistance and noncompliance are anticipated during the initial period of policy implementation. However, without H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 197 having cooperation from the public, the policy will not be settled down in the society or achieve its goals. Thus, it is necessary that the government has a comprehensive understanding on how people perceives the policy and responds to the changes, in order to prepare an effective strategy for successful settlement of the policy. Though some studies have been conducted to investigate similar issues, they were done before the policy being actually implemented and both the focused issues and target population of the investigations were different from our interest [15,16]. Therefore, we conducted this study to examine people’s attitude and knowledge of the policy during the initial period of policy implementation, based on the survey of college students. Because of the general tendency that older generations are more inclined to resist changes and stick to the old customary practices, we considered that they do not have a room to objectively evaluate advantages and disadvantages of the policy. Thus, our investigation was focused on the attitude of young generation. Since college students are a group of people who will be the leaders of our society in the near future, we believe that it is meaningful to understand how the future leaders perceive this health care reform, which is quite different from the traditional concept of health services delivery in Korea. The attitude of the policy was examined along with four aspects: (1) the level of interest and (2) agreement to the necessity of adopting the policy, (3) expectation for the effects of the policy, and (4) perceptions of physicians’ strike against the policy. Further, this study examined how the attitude of the policy affect the degree of knowledge of the policy, in order to provide empirical evidence useful for the implementation of similar public policies in the future. 1.2. The concept of ‘separation of dispensing and prescribing (SDAP)’ SDAP can be defined as a system that enables physicians and pharmacists to perform their distinct professional roles such that physicians examine and diagnose their patients and then decide upon relevant treatments, and pharmacists dispense and administer the medicines according to the physicians’ prescriptions . As medication therapy becomes more complicated as a result of the increase in a variety of diseases and advances in technology, the meaning of SDAP is beyond the simple role differentiation and extended to the concept of team work and cooperation between the two professions based on their specialized knowledge and expertise . The potential effects of the SDAP are to improve quality of care and achieve cost reduction by decreasing abuse, overuse, and misuse of medications among patients and providers [8,17]. SDAP is not a new concept among the industrialized western countries where professional roles and ethics have been well defined and supported. However, in most of the Asian countries including Korea, Taiwan and Japan, SDAP is considered as an unnatural way of receiving care. It is partly because people are so submerged in customary practice behavior of oriental medicine doctors who 198 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 offered a full spectrum of care from clinical activities (i.e. examining, diagnosing, and deciding upon relevant treatments) to pharmacy function (i.e. dispensing and administering medicines) [6,9,18]. Moreover, due to the lack of health care professionals adequately trained in those countries in the past, it was inevitable that unqualified personnel such as pharmacists substituted professional roles of physicians to meet the rapidly increasing demand for health care . SDAP can be classified into two types: role separation and institution separation. Under the system of ‘role separation,’ physicians and pharmacists belong to the same organization but perform distinct roles. Taiwan is a good example of adopting this type, in which local clinics can own pharmacies and hire pharmacists . Thus, the two professions perform separate roles working in the same institution. Korean hospitals used to follow this type before the reform. A system of ‘institution separation,’ which has been adopted by industrialized countries for a long time and is currently being implemented in Korea after the reform, does not allow clinics or hospitals to possess pharmacies. Therefore, physicians and pharmacists not only perform separate roles but also are separated by working at different institutions. By keeping independent ownership and management between hospitals and pharmacies, physician’ decision making on medication therapy is not affected by economic incentives of prescribing more drugs and therefore overuse of medicines can be prevented. In addition, independence of pharmacists from physicians or hospitals would enhance pharmacist’s role of monitoring the quality of prescription. 2. Methods 2.1. Study subjects and data source A self-administered questionnaire survey was conducted with a sample of college students residing in Seoul and its adjacent area, between November 1 and 15, 2000, which was some four months after the policy became effective. Students enrolled in medical or pharmacy schools were not included in this study due to the potential bias associated with their professional interests in the policy. Out of the initial study sample of 700 students, 540 completed the questionnaire, yielding a response rate of 77.1%. About 43.1% of the respondents were majoring in social science, 42.6% in natural science, and 13.7% in nursing (Table 1). Among 220 students involved in the study (41.0%) were male. The majority of the respondents were either freshman (27.7%) or sophomores (41.2%). Approximately, 21.5% of the respondents rated their health status as poor or very poor. The proportion of the respondents having a physician and/or a pharmacist in their families was about 21.0%. The mean health behavior score among the respondents was 10.77 (91.94), which is a composite measure of smoking, drinking, eating, and exercising behavior and ranges from 4 to 16 with the higher score reflecting healthier behavior. H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 199 2.2. Measurements 2.2.1. Need and interest of the policy Respondents were asked to indicate the degree of agreement to the necessity of adopting the policy in Korea on a four-point Likert-type scale, 1 referring to strongly disagree, 2 to slightly disagree, 3 to slightly agree and 4 to strongly agree. In order to assess the extent to which people agreed to the need of changing the current practice, the survey also asked opinions as to whether pharmacists should be forbidden to prescribe or dispense medication without physician’s prescriptions. The extent of personal interest in the policy was also investigated on a four-point scale. 2.2.2. Expectation for the effect of the policy By asking the degree of agreement to the potential effects of the policy that the government campaigned, we explored how positively people considered the potential outcomes of the policy. The policy effect was summarized into five aspects: (1) Table 1 Selected characteristics of the respondents Variables No. of respondents (%) Major area Social science Natural science Nursing 233 (43.1) 230 (42.6) 74 (13.7) Gender Male Female 220 (41.0) 320 (59.0) School year Freshman Sophomore Junior Senior 148 220 113 53 (27.7) (41.2) (21.2) (9.9) Self-assessed health status Excellent Good Fair Poor Very poor 27 173 219 111 5 (5.0) (32.0) (40.6) (20.6) (0.9) Medical professionals in family Physicians or/and pharmacists Other health care professionals None 113 (21.0) 118 (21.9) 309 (57.2) Health behavior scorea Mean ( 9SD): 10.77 ( 91.94) a The health behavior score is a composite measure of smoking, drinking, eating and exercising behavior and ranges from 4 to 16 with the higher scores reflecting healthier behavior. 200 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 to improve public health level by reducing the risk of overuse and misuse of medicines; (2) to improve professional roles of physicians with respect to diagnosing and prescribing; (3) to improve professional roles of pharmacists in dispensing and administering medicines; (4) to reduce the proportion of drug expenditure among the total national medical expenditure; (5) to resolve the problem of corruption related to the distribution channel of pharmaceutical products. 2.2.3. Perceptions of physicians’ strike against the policy To investigate how people perceived physician’s strike against the policy, which occurred right after the implementation of the policy, the survey asked the respondents to assign a four-point scale to each of the four underlying motivations for strike, according to the level of agreement. The four motivations were: (1) the policy would result in profit loss; (2) the policy would interfere their professional rights; (3) the policy would negatively affect the public health; and (4) the policy would increase economic burden of patients. 2.2.4. Knowledge le6el of the policy The knowledge level was measured by listing four question items that described the goals and motivations of the policy and eight items describing its operational rules. In the questionnaire, some of these items were described correctly and some incorrectly. For each of these items, respondents were asked to mark whether the description was true or false. These 12 items were identified from issues and controversies addressed most frequently in newspapers, journals and various internet sites during the course of policy development, and were selected to reflect the basic principles and contents of the policy, which people should understand to be able to know how the new system would operate. 2.3. Data analysis 2.3.1. Need, interest, effect of the policy and physician’s strike To examine overall attitude of the policy, descriptive statistics and frequency distribution were performed for each of the survey questions describing the need, interest, expectation for the effect of the policy, and perceptions of physician’s strike. Furthermore, comparative statistics were performed to observe differences in the attitude between the study participants with different major of their college study. 2.3.2. Le6el of knowledge For each of the twelve items describing the contents of the policy, the proportion of respondents who correctly marked whether the description for the policy was true or false was examined to assess the average knowledge level for each specific aspect of the policy. The total number of correct responses that the individual respondents made among the twelve questions was converted into a 0– 100 scale, which was called ‘knowledge score’ in this study. The mean knowledge score was computed for the twelve items to assess the overall knowledge level for the policy. H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 201 In addition, the mean knowledge scores were computed across the four question items concerning the goals and motivations of the policy, and then across the eight question items reflecting the operational rules of the policy. In order to assess the independent association between the knowledge level and individual attitude of the policy, multiple regression analyses were performed for the mean knowledge scores for overall aspects, goals/motivations, and the operational rules of the policy, respectively. Attitude toward the policy was operationalized with four variables: interest in the policy, need of the policy, expectation for the policy effect, and agreement to the motivation for the physician’s strike. For the variables of expectation and motivation for strike, the total scores across the questions describing each subject were used in the regression model. Covariates included in these models to adjust for potential confounding effects were: the extent of the respondent’s exposure to mass media in terms of obtaining information about the policy; the types of mass media used to obtain such information; and their experiences of health care after the introduction of the policy. Also demographic characteristics deemed to affect the knowledge level of the policy were included: major area in their college study; the number of years in college; self-assessed health status; health behavior score; the presence of physicians and/or pharmacists in his or her family; and gender. Validity of the instrument of a set of twelve questions to measure the degree of knowledge on the policy was evaluated by examining the correlation between the mean knowledge score of the twelve questions and the self-assessed level of knowledge on the policy. 3. Results Mean scores indicating the degree of agreement to the policy need and to the need for prohibiting pharmacist’s prescribing were 2.66 and 2.60 on a four-point scale, respectively (Table 2). Compared to the students majoring in social science (2.59) or natural science (2.50), nursing students more strongly agreed to the prohibition of pharmacist’s prescribing (2.96) (PB 0.001). The mean scores for the survey items exploring the level of expectation for the potential effects of the policy ranged from 2.29 to 2.91, which is within the range of ‘slightly disagree’ to ‘slightly agree’ response, indicating that the respondents had neutral expectation for the policy effect. Among the five aspects of the potential effects, the participants evaluated ‘improving public health level (mean score: 2.91)’ most positively, whereas they believed that ‘reducing the proportion of drug expenditure (2.29)’ would be least likely to be achieved through the policy. Although statistically insignificant, nursing students showed higher expectation for all the five aspects than other students. Regarding the underlying reasons for the physicians’ strike against the policy, the respondents believed that ‘concerns for losing their profits’ was the most prominent reason (mean score: 3.50 on a four-point scale), while ‘concerns for the increase of patient’s economic burden (2.00) and the negative impact on public health (2.11)’ 2.11 2.00 2.66 3.50 2.55 2.37 3.10 3.47 2.95 2.34 2.85 2.78 2.67 2.61 2.96 2.70 Nursing 2.07 1.94 2.60 3.53 2.92 2.31 2.73 2.72 2.53 2.69 2.50 2.61 Social science Meana by study major 2.00 1.95 2.58 3.49 2.88 2.26 2.79 2.69 2.61 2.66 2.59 2.57 Natural science Mean scores were measured by a four-point scale (1, strongly disagree; 2, slightly disagree; 3, slightly agree; and 4, strongly agree). * PB0.001. a Moti6ation of physician’s strike Concerns for public health Concerns for the increase of economic burden of patients Concerns for losing professional rights Concerns for losing profits 2.91 2.29 2.77 2.77 2.60 2.66 2.60 Need of the policy Need of the policy Need for prohibiting pharmacists’ prescribing Expectation for the effect of the policy To improve public health To reduce the proportion of drug expenditure To improve physician’s professional role To improve pharmacist’s professional role To resolve corruption problems in the distributing channel of pharmaceuticals 2.60 Interest in the policy Overall meana Table 2 Attitudes of the policy: interest policy need, policy effect, and physician’s strike against policy 13.30* 8.06* 10.22* 0.74 0.34 0.41 0.76 0.37 1.21 0.39 14.06* 0.29 F-test 202 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 203 were not perceived as strong forces to drive the strike. Significant variations were observed for this matter between the students with different major (PB 0.001), with an except for the reason of ‘concerns for losing profits,’ which shows consistently high score regardless of the type of study major (Table 2). Table 3 shows the proportion of the respondents who correctly marked whether each description of the policy was true or false. The question item describing the overall aim of the policy showed the highest proportion of respondents with a correct understanding (81.9%), followed by the item describing the high tolerance rate of Korean people for antibiotics (75.4%). Meanwhile, students poorly understood the issues of the pharmacists’ role of monitoring a physician’s prescribing error (15.7%), the application of higher dispensing fee for prescriptions filled during the evening than during the day (18.5%), and the proportion of OTC under the new drug classification system (19.3%). The mean knowledge score across all the twelve items was 44.88 on the 0– 100 scale, indicating that the overall knowledge level was not very satisfactory. Interestingly, for the four items describing goals/motivations of the policy, the mean score was relatively high (69.6), but the study population had a very poor knowledge of the issues dealing with the operational rules of the policy (32.5). Overall, students in nursing schools achieved higher knowledge scores than the other student groups. After adjusting for the differences in exposure level to information about the policy and selected demographic characteristics, the regression analysis results showed that personal interest and degree of agreement to the policy need were the most significant factors affecting the knowledge levels of overall aspects and goals/motivations (P B0.05 or B0.01). The extent of personal interest in the policy was the only attitude variable that had significant association with the knowledge on operational details of the policy (P B 0.01) (Table 4). The degree of expectation for the potential effects of the policy was positively associated only with the knowledge level of goals/motivations of the policy (pB 0.01). The extent of the agreement with the motivation of physician’s strike did not significantly affect knowledge level for any aspect of the policy. 4. Discussion Among the various health care reform efforts recently introduced in Korea, the policy of SDAP was one of the most controversial issues and brought substantial changes over the Korean health care delivery system. With a tradition of strong preference for medicines among Korean people and no prior experience of restriction on the types of pharmaceutical products purchased, the policy at first glance was taken as a very inconvenient system. Meanwhile, interested parties, especially physicians and pharmacies, faced uncertainties about the likely influence of the policy on their professional rights and advantages. These all caused debates and controversies over the policy implementation. The results of this study helped the policy makers to understand how the public, in particular, a group of college students viewed and perceived the policy. Although Operational rules 5. Selling OTCc drugs to individuals who request without presenting physician’s prescription is an illegal dispensing (False) 6. Physicians can use only brand names when writing prescriptions (False) 7. Pharmacists can substitute prescription medicines with other products having the same chemicals, doses and dosage forms, with a condition that patients consent(True) 8. Patients can have insurance coverage for the medicines written in prescription (True) 9. For OTCc drugs, pharmacists can unwrap individual pills and dispense them without prescription (False) 10. When pharmacists finds a prescribing error, they should inform the physician after dispensing the medicines (False) Mean knowledge scoreb for goals/motivation Goals/moti6ation 1. The aim of the policy was to enhance the professional roles of physicians, focusing on diagnosing and prescribing and of pharmacists, focusing on the dispensing and administrating medicines (Truea) 2. The policy has been already adopted in the majority of industrialized countries (True) 3. The proportion of pharmaceutical costs to the total health care expenditure in Korea is greater than that in most of the industrialized countries (True) 4. The tolerance rate of Korean people for antibiotics is greater than that in other countries (True) Survey items used to measure the knowledge level (correct answer) Table 3 The level of knowledge of the policy 54.1 68.9 55.4** 23.0 52.8 73.3 39.8 15.7 73.3 ( 9 24.6) 69.6 ( 926.6) 40.5 79.7 75.4 40.7 63.5* 50.9 41.9 63.5 70.2 39.3 86.5 Nursing 13.7 49.8** 74.2 54.1 39.1 15.7 34.3** 73.5 51.3 43.0 38.3 67.1 ( 9 27.0) 70.5 ( 926.7) 39.5 71.3 47.4* 70.4 79.1 Natural science 77.7 49.8* 71.7 82.8 Social science Types of study major 81.9 Overall Respondents with correct answer (%) 1.81 5.29 0.41 0.20 0.38 0.24 0.15 1.73 2.99 0.91 1.18 F-test 204 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 18.5 18.9 32.4 ( 9 18.7) 45.1 ( 9 16.4) 21.6 34.3 ( 914.6) 47.3 ( 913.5) 19.3 32.5 ( 9 18.0) 44.9 ( 916.1) Social science 10.8 Nursing Types of study major 18.5 Overall Respondents with correct answer (%) 43.8 ( 9 16.6) 32.2 ( 9 18.3) 19.1 20.9 Natural science 0.27 0.68 0.14 1.89 F-test b Correct answers reflect the content of the policy at the time of the survey, 1–15 November, 2000. There have since been several changes in the contents. Knowledge score was obtained by converting the total number of correct responses that the individual respondents made into a 0–100 scale. c OTC refers to over-the-counter. * PB0.05. ** PB0.001. a Mean knowledge score for all 12 items b Mean knowledge scoreb for operational rules 11. The dispensing fee for prescription drugs is the same for all business hours at a pharmacy (False) 12. The proportion of OTCc drugs under the new drug classification system is higher than that of prescription drugs (False) Survey items used to measure the knowledge level (correct answer) Table 3 (continued) H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 205 206 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 Table 4 Regression results on the factors affecting the knowledge level of the policy Regression coefficients (S.E.) Overall knowledge Knowledge on Knowledge on goals/ motivation operational rules 1.66 (7.31) 4.81 (12.16) 0.09 (8.53) 0.99 (1.41) 0.81 (1.15) −1.68 (2.34) −1.10 (1.91) 2.34 (1.64) 1.76 (1.34) 2.40 (1.58) 2.44 (2.15) 1.47 (2.08) 2.59 (2.63) 0.72 (3.58) 2.60 (3.46) 2.30 (1.85) 3.30 (2.51) 0.91 (2.42) 4.37 (1.25)*** 3.27 (1.13)*** 0.31 (0.27) −0.04 (0.36) 5.13 8.89 1.25 0.53 3.99 (1.46)*** 0.46 (1.32) −0.17 (0.32) −0.33 (0.42) Study major Nursing (reference) Social science Natural science −1.08 (2.15) −1.48 (2.32) −1.72 (3.57) −3.53 (3.86) −0.76 (2.51) −0.45 (2.71) Health status Good or excellent (reference) Fair Poor or very poor 1.41 (1.50) 1.31 (1.78) 0.80 (2.50) −2.40 (2.96) 1.71 (1.75) 3.17 (2.07) Medical professionals in family None (reference) Physicians and/or pharmacists Other health care professionals −0.05 (1.66) 0.81 (1.64) 0.80 (2.77) −0.53 (2.73) −0.48 (1.94) 1.48 (1.91) −0.95 (1.63) 0.01 (0.73) 0.30 (0.38) 4.96 (1.35)*** −1.00 (2.72) −1.32 (1.21) 0.35 (0.64) 3.89 (2.24)* −0.92 (1.91) 0.67 (0.85) 0.28 (0.45) 5.49 (1.57)*** 5.648*** 0.147 5.231*** 0.136 3.697*** 0.091 Intercept Health care use under the policy None (reference) Yes Level of exposure to the information on the policya Types of mass media TV (reference) Newspaper Internet Others Attitude toward the policy Interest in the policya Agreement to the policy needa Expectation for the policy effecta Agreement to the motivation for the physician’s strikea Male No. of school years in college Health behavior scoreb Self-assessed level of understanding on the policya F-value Adj-R 2 a (2.08)** (1.88)*** (0.46)*** (0.60) Each variable was measured by a four-point scale with higher scores reflecting stronger tendency. Health behavior score is a composite measure of smoking, drinking, eating, and exercising, with a higher score reflecting healthier behavior. * PB0.1. ** PB0.05. *** PB0.01. b H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 207 young generation is not strongly affected by this reform because they are currently healthy and use relatively less health care services, it is meaningful to understand how youngsters, central strata of the future society, react on this progressive health policy. In addition, it is believed that young generation hold relatively neutral position in evaluating this policy as compared to older generations who are accustomed to the old system for longer period and much more sensitive to the impact of the policy. The mean scores for the need for the introduction of the policy (2.66) and for the prohibition of pharmacist’s prescribing (2.60) did not reach the response levels of slightly (3.0) or strongly agree (4.0). This implies that people were not very positive on the need of the policy or much ready to give up the old customary health care seeking behavior. Moreover, the overall level of expectation for the potential effects of the policy remains neutral, revealing that the college students participated in the survey did not have strong confidence that the policy will achieve its goals. Thus, our findings suggested that the overall attitude of the respondents toward the policy was not much affirmative. One noticeable phenomenon around this reform was a strong protest from physician group. Almost the entire health care system could not have normal function during the physician’s strike, putting the whole society in chaos. Some people argued that the strike was not simply motivated by protesting the policy. Instead, they believed that the policy worked as a triggering factor to explode accumulated dissatisfaction of physicians for problems of the Korean health care system, such as insufficient level of medical prices set by the government to provide quality care and irrational government mechanisms to control over the health care market [12,14]. Our investigation reveals that the respondents perceived that the major forces for physician’s resistance to the policy were concerns for losing their professional advantages in terms of professional rights (mean score: 2.66) and profits (3.50). On the contrary, the respondents had an impression that physicians’ strike was not motivated much by the concerns for potential negative impact on public good such as public health (2.11) and economic burden of patients (2.00). This finding is in agreement with the result of the Gallup poll, carried out 1 year after the policy initiation, that one of the prevailing impressions on the policy was group selfishness of health care professionals . The overall knowledge level for the policy details was not satisfactory high. The mean knowledge score of 44.88 is very similar to the results of another survey (47.44) conducted with a national sample of general population six months after the introduction of the policy . While our study assessed the knowledge level by examining whether people have clear understanding on each of the 12 specific principles of the policy, Song’s study (2001) measured by simply asking self-assessed level of understanding of the policy. Thus, it appears that our assessment for the knowledge level is more rigorous than Song’s study. From the study results, we learned that the respondents did not have a good understanding of how the new system would be operated, whereas the goals and motivations of the policy were relatively well understood. One of the important factors contributing to the successful implementation of a public policy is how well 208 H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 people are informed of the policy, so that they can prepare and adapt to the policy with minimal confusion [19– 21]. Especially, if the policy requires fundamental changes in the customary behavior of a society, it is incumbent upon the government to provide sufficient information to the public upon likely changes and how people should prepare for these changes. However, it appears that the government failed to provide practical information to people, while its efforts to give people a good feel for the reasons why such a policy was necessary were successful. By the multivariate analysis, some of the variables reflecting personal attitude toward the policy were found to be significant predictors for the knowledge level of the policy. In particular, the degree of interest in the policy was highly associated with the knowledge level for overall, goals/motivations, and operational details of the policy (PB 0.05 or B0.01). This implies that people tend to have clearer orientation of the policy if their interest in the policy is strong. While gaining public consent to the policy need affected the knowledge level of the goals/motivations of the policy, it did not enhance the public’s knowledge of the policy’s operational details. This is probably due to a deficiency in the information about the operational rules of the policy available to the public. The significant association between the knowledge level measured by the instrument developed in this study and the self-assessed level of knowledge supports the validity of the instrument (PB 0.10 or B0.01). Overall, nursing students had more positive attitude in terms of the need and potential effect of the policy and showed higher level of knowledge on the policy details than those majoring in social or natural science. This is probably because nursing students are more interested in health policy issues and had better access to the information about the health policy due to the nature of their study. Several shortcomings of the study are summarized as follows. First, since our investigation was based on the responses from college students, there should be a caution to generalize the finding of this study to general population. Second, the study sample was drawn from the students attending universities located at the capital city area. Thus, our finding has a limitation of not exploring opinions from people living in various local areas. Third, although we tried to list as many of the key policy issues as possible, we were limited to only 12 survey items to evaluate the knowledge level due to concerns over the length of the survey and the likely response rate. Also, because many of the specific details of the policy were still under the revision at the time of the investigation, we restricted our investigation to the issues that were clearly defined. Finally, answers for some of the questions used to measure knowledge level of goals/motivation of the policy are likely to reflect personal value rather than objective knowledge. In conclusion, the study results revealed that college students did not strongly recognize the need of the policy in Korea or have high expectation for the potential effects of the policy that the government proposed. The respondents were relatively well oriented to the goals and background of the policy while they lacked knowledge of practical issues. There is a need for the Korean government and health policy makers to devise more effective media communication strategies to effectively inform the public of the practical details of policies. In addition, policy H.-Y. Kang et al. / Health Policy 62 (2002) 195–209 209 makers should be aware that ensuring public interest and agreement for the necessity of a policy is very crucial to ensure that a newly introduced policy or health care reform is successfully understood and settled in the society. References  Gross R, Rosen B, Shirom A. Reforming the Israeli system: findings of a 3-year evaluation. Health Policy 2001;56:1 –20.  Chernichovsky D. Health system reforms in industrialized democracies: an emerging paradigm. The Milbank Quarterly 1995;73(3):339 –72.  Peobody JW, Lee SW, Bickel SR. Health for all in the Republic of Korea: one country’s experience with implementing universal health care. Health Policy 1995;31(1):29 – 42.  Shin YS, Lee KS. The health insurance system in Korea and its implications. World Hospitals 1995;31(3):3 – 9.  Anderson GF. Universal health care coverage in Korea. Health Affairs 1989;8f2:24-34.  Cho NC. Implementation of the policy of separation of dispensing and prescribing and adoption strategies of hospitals. Journal of the Korean Hospital Association 1998;27(2):42 – 51 (in Korean).  Yang BM. Desirable direction for the policy of separation of dispensing and prescribing. International Symposium of the Policy of Separation of Dispensing and Prescribing, http:// medroad.peacenet.or.kr/bunup, 1999 (in Korean).  Kim YI. Issues related to the policy of separation of dispensing and prescribing and the nation’s health. National Forum of the Policy of Separation of Dispensing and Prescribing, 1999 (in Korean).  Yoo CS. The welfare effect of mandatory prescription in Korea. Korean Journal of Health Policy and Administration 1999;9(4):65 –86 (in Korean).  Lee SY, Yoon TY, Kim CW. A study on policy making process in the separation of prescribing and dispensing. Korean Journal of Health Policy and Administration 2000;10(2):41 – 77 (in Korean).  Yang BM. The contents and the direction for the policy of separation of dispensing and prescribing. Journal of the Korean Hospital Association 1998;27(12):30 – 5 (in Korean).  Lee KD. Issues related to the policy of separation of dispensing and prescribing and the nation’s health. In: Lee JC, editor. Agenda for Medical Care in Korea. Seoul, Korea: Johap Gongdongchei Sonamoo Inc., 2000:114 –54 (in Korean).  Kim KT. Problems of the policy of separation of dispensing and prescribing. Journal of the Korean Hospital Association 1998;27(12):36 –41 (in Korean).  Kim HJ. A reflection on the struggles of 2000 around the separation of prescribing and dispensing. Korean Journal of Health Policy and Administration 2001;11(1):87 – 106 (in Korean).  Song HK, Lee JY, Sul DH. A survey of national perception of the separation of dispensing and prescribing. Seoul National University, The Institute of Social Development, 2001.  Korean Gallup Poll, 2001, http://www.p4care.net/gallup/sm-main.htm.  Lee EK. Concept and types of separation of dispensing and prescribing. Journal of the Korean Hospital Association 1998;27(12):18 –29 (in Korean).  Son AH. Modernization of the system of traditional Korean medicine (1876 – 1990). Health Policy 1998;44(3):261 –81.  Bernstein J, Stevens RA. Public opinion, knowledge, and Medicare reform. Health Affairs 1999;18(1):180 – 93.  Adeyanju MJ. Public knowledge, attitudes, and behavior toward Kansas mandatory seatbelt use: implications for public health policy. Journal of Health and Social Policy 1991;3(2):117 – 35.  Convissor RB, Vollinger RE, Wilbur P. Using national news events to stimulate local awareness of public policy issues. Public Health Reports 1991;105(3):257 – 60.