Petra Plunger
4. Health promotion in Community Pharmacy - a background paper
Petra Plunger, Alice Grundböck, Karl Krajic, Ursula Reichenpfader, Jürgen M. Pelikan; June 2000

Content:
1 Introduction
1.1 Methods
1.2 Material
2 Results
2.1 HP in community pharmacy policy
2.2 HP in community pharmacy scientific literature
2.3 Community pharmacy practice: some examples of HP initiatives and models
2.4 Health promotion in community pharmacy from a HP perspective
3 Conclusions
4 References


1 Introduction

What is the current understanding of health promotion in community pharmacy as expressed in policy statements, scientific literature and models/initiatives? How does the profession conceptualise health promotion? What are the main tasks carried out in this area? How should health promotion interventions/health promoting interventions be carried out? How do these findings relate to important distinctions from the perspective of health promotion?

The project tried to answer these questions for the purpose of developing a common understanding in the project by conducting a document and literature search between October 1999 and January 2000.
The search was looking for the understanding of health promotion in three types of texts:
- community pharmacy professional policy statements
- scientific literature
- descriptions of models and initiatives

These professional perspectives have been complemented by a chapter outlining some important distinctions from a health promotion perspective.

1.1 Methods

The paper puts together the results of an analysis of published material (scientific and relevant professional journals)

The material has been retrieved by a systematic literature research of 28 databases: BMG Pressemitteilungen, Medline, Oldmedline, Toxline, Gerolit, Amed, Psyndexalert, Psyndex, Somed, Psycinfo, Sociological abstracts, Toxbio, Solis, Ipa, Foris, Embase, ISTP/ISSHP, ISTPB, Scisearch, Social Scisearch, Embase alert, Toxcas, Healthstar, Heclinet, Meditec, Cab Health, Int, Health Techn: Ass

The search history/key words used were: "health promotion" and ("community pharmacy" or "pharmacy" (title, abstract) not ("hospital pharmacy" and "clinical pharmacy"))

1.2 Material

A total of 281 abstracts were retrieved, 84 of which were excluded since they did not meet the set criteria, that is to say, the main actors were not Community Pharmacists or the main setting was not a Community Pharmacy.

Country of origin/ national distribution
USA: 80 abstracts
Europe: 80 abstracts
UK: 58, GER: 4, SLO: 3, AUT: 2, CH: 2, FL: 2, IRL: 2, NL: 2, SW: 2, FR: 1, SP: 1, TUR: 1
other countries: CAN: 18, AUS: 8, S.AFR: 2, NZ: 3, INDIA: 1
International organisations: WHO: 4, FIP: 1

The material derived from the literature research in the databases mentioned above was complemented by publications from professional organisations, material derived from the internet (mostly from professional organisations) and publications from previous literature research.

For this report, material of European origin has been considered due to its relevance for the project (especially in the area of descriptions of models or initiatives). It is complemented by a few conceptual articles on the role of the pharmacists in health promotion derived from the USA.


2 Results

2.1 Health promotion in community pharmacy professional policy statements

To get an understanding of professional concepts of health promotion on the policy level, publications from national and international (mainly European) professional organisation were analysed.

Following the documents, the discussion seems to be centred around four main topics: life-style advice, screening and diagnostic testing, advice on appropriate use of health services and improvement of co-operation between all interested parties.

2.1.1 Lifestyle advice to promote and support healthy lifestyles

Documents: (PGEU 1999), (PGEU 1998), (FIP 1993; Royal Pharmaceutical Society of Great Britain 1997; Maine 1998) consell de col.legis farmaceutics de catalunya

Life-style advice has to be tailored according to the different cultural and behavioural patterns and specific physiological and pathological conditions of individual patients, which often means personal, one-to-one support. (PGEU 1998; Maine 1998). Advice should be supported by the appropriate material and the use of an appropriate format (Maine 1998).

Life-style advice is conceptualised as supporting the development of the extended role of the community pharmacist, especially in UK (Clucas 1986) and also includes the early detection of risk factors (Maine 1998).

2.1.1.1 Health promotion aspects related to sale of medicines/ dispensing prescribed medication

Documents: (Anderson 1998), consell de col.legis farmaceutics de catalunya
Paying attention to life-style is important for the non-pharmacological treatment of typical chronic illnesses, e.g. asthma, COPD, osteoporosis, hypertension, diabetes II (The Association of Finish Pharmacies 1999), as is giving advice on minor illnesses (Clucas 1986)consell de col.legis farmaceutics de catalunya

2.1.1.2 Provision of preventive services

Documents: ( 1983; The Association of Finish Pharmacies 1999) (Royal Pharmaceutical Society of Great Britain 1997) (Maine 1998)

primary prevention (not specifically related to core tasks, but potentially to the sale of health care products): wellness maintenance through health education; topics: smoking, use of intoxicants (alcohol use, inappropriate use of medicines), physical exercise, weight, prevention of infectious diseases (needle exchange), safe sex, dental health

2.1.1.3 Community pharmacy services as part of (community) health strategy: (Hawksworth 1994)

This involves giving advice on health and hygiene aspects of the home environment, e.g. controlling such things as the house dust mite and mould spores. Furthermore, advising on drug abuse prevention, life-style e.g. smoking, alcohol and diet, as well as advice on minor illness to encourage individuals to take greater responsibility of their health is discussed. (Department of Health 1992)

2.1.2 Screening and diagnostic testing (PGEU 1998) (Royal Pharmaceutical Society of Great Britain 1992; 1999) consell de col.legis farmaceutics de catalunya, (Royal Pharmaceutical Society of Great Britain 1997) (Maine 1998)

Health promotion is greatly supported by early detection of disease (Maine 1998) and several forms of diagnostic testing and screening could be carried out by pharmacists with adequate and appropriate training (PGEU 1998). However, to ensure consistent and acceptable standards, protocols should be established (PGEU 1998) (Royal Pharmaceutical Society of Great Britain 1992) and this is best aided by effective communication with general practitioners (PGEU 1998). Thus, pharmacists would be able to give appropriate and sound advice and to refer the patient to a general practitioner or specialist if necessary (PGEU 1998). Useful in its own right, this can also be recognised as part of a wider purpose, e.g. to reinforce health campaign messages (weight, CO, BP, cholesterol) and to support work of other local health care professionals (GP) as information gatherers (The Association of Finish Pharmacies 1999).

2.1.3 Advice on appropriate use of health services: screening services, self-help groups, voluntary services, needle exchange schemes ( 1995)

2.1.4 Co-operation

2.1.4.1 Co-operation with other providers as part of integrated local effort to meet national objectives for public health (Royal Pharmaceutical Society of Great Britain 1997; Hawksworth 1994)

This includes such initiatives as e.g. services for intravenous drug users like needle and syringe exchange schemes (Bedfordshire Health 1995; Hawksworth 1994) and on a broader scope, the disposal of unwanted medicines (Hawksworth 1994).

A focus on public health also implies a quality improvement of core tasks - dispensing and provision of OTC drugs: patient monitoring/patient medication records, out of hours services, provision of support material, ADR reporting system, OTC sales protocols/ formularies. (Health Education Authority 1995)

2.1.4.2 Co-operation with other health care professionals (FIP 1993; PGEU 1998), (Clucas 1986)

Pharmacists are in an ideal position to promote and participate in HP activities and campaigns at a national level, especially in the area of medicines: drug abuse and misuse, post-marketing surveillance and ADR reporting (Croydon Health 1995; 1999) (PGEU 1998), (FIP 1993), (KNMP 1996). This is augmented by joint training and meetings (Croydon Health 1995; The Association of Finish Pharmacies 1999; Pinder) and domiciliary services (Clucas 1986) like visiting residential homes, nursing homes, shelters, hospices: to inform about the safe use, storage, administration and disposal of unused or out-of-date medicines (Bedfordshire Health 1995), which a key aspect of their role in health education (Clucas 1986)

2.1.4.3 Co-operation with physicians (ABDA 1998) and GPs (Clucas 1986)

Pharmacists and physicians can work together to make more efficient use of health care resources (Clucas 1986) and to exchange information on medicines, mainly in the area of prescribed medicines/dispensing, more specifically: cost effective/ generic prescribing/ prescribing policies, formulary development, reviewing repeat prescriptions, brown bag review, referrals (also in connection with advice on minor illnesses), reviewing patient drug treatment, domiciliary visits, development of guidelines for advice on and recommendation of OTC, self medication, compliance and collaborative care (Clucas 1986; Croydon Health 1995)

2.1.4.4 Co-operation with users/ patients:

Information exchange and co-operation with local patient organisations (KNMP 1996) is vital in properly supporting the community by assessing information needs and how life-styles, values and aspirations determine actions (PGEU 1998).

2.1.4.5 Co-operation with community-based services (Maine 1998)

Patient education issues are selected on the basis of community needs (Maine 1998) and are explored through group health education (Maine 1998) A central focus of this education is instruction in medication safety (Maine 1998), which aims to
- promote safe storage, use and disposal of medicine,
- prevent medication-related poisonings,
- prevent contamination of the environment
- provide information regarding potential abuse and misuse of medicines (Maine 1998)

2.2 HP in community pharmacy scientific literature

2.2.1. Lifestyle advice

2.2.1.1 In the course of dispensing prescribed treatment (Anderson, Todd 1994)

In conjunction with, and complementary to disseminating information about safe use, storage, administration and the appropriate disposal of medicines, the community pharmacist remains the expert on medicines and aims to ensure the therapeutic goal by applying his/her specialist knowledge to life-style interventions (Maguire 1996).

2.2.1.2 Advice on minor illness and self medication, (Anderson, Todd 1994; Fritsch-Koepsch, Schulz 1996; Marklund, Almroth et al. 1999)

Opportunistic advice-giving can often mean going beyond suggesting life-style changes and actively striving for health gain (Anderson 1998).

2.2.1.3 Screening and diagnostic testing (Allison, Page et al. 1994; Maguire 1989; Morow, Maguire 1989)

Properly trained, pharmacists are well positioned and capable of carrying out various types of screening and diagnostic testing (Allison, Page et al. 1994), (Maguire 1989; Morrow, Maguire 1989), measuring: blood pressure, cholesterol, blood glucose, urine sugar, CO, pregnancy testing, BMI, body fat index (Maguire 1989; Morrow, Maguire 1989)

All of this ties in with secondary prevention associated with dispensing as part of a wider purpose, e.g. to reinforce health campaign messages (weight, smoking, diet) and to support the work of other local health care professionals (GP) as an information gatherer (Blenkinsopp, Panton 1992; Morrow, Maguire 1989) p. 26. An example of this would be the integrated programme on heart disease screening programme offering cholesterol and BP measuring, weight control and life-style advice on risk factors (Blenkinsopp, Panton 1992) p. 26.

Despite the potential gains, this is a controversial area and reservations have been expressed concerning: the lack of a patient register, context, quality of testing equipment, adequate procedures, the setting and patients' privacy, and the inherent risks associated with the taking of blood samples (Allison, Page et al. 1994)

2.2.2 Co-operation with other providers in PHC (mainly GPs)

2.2.2.1 With GP: cost effective/generic prescribing/prescribing policies, formulary development, review of repeat prescriptions, brown bag review, referrals (also in connection with advice on minor illnesses), review patient drug treatment, domiciliary visits, development of guidelines for advice on and recommendation of OTC, self-medication, compliance, collaborative care (Bond, Bradley 1996; Bradley, Taylor et al. 1997; Jepson, Strickland-Hodge 1995; Wells E 1997)

2.2.2.2 PHC team: joint training and meetings, co-operation in national campaigns and in local health care (Anderson, Todd 1994)

2.2.3 Other topics:

Also available are descriptions of the provision of services for specific user groups, namely intravenous drug users and/or patients with HIV/AIDS. These outline initiatives in: needle and syringe exchange, sale of injection equipment, dispensing controlled drugs and offering health education material (Anderson, Alexander 1997; Blenkinsopp, Panton 1992; Sheridan, Strang et al. 1996) p. 26.

Specific user groups are given information about access to and most appropriate use of health services (Downie, Fyfe et al. 1990; Blenkinsopp, Panton 1992), which is intended to encourage patients' uptake of preventive services (Anderson 1994) e.g immunisations and counselling patients about vaccinations (Grabenstein 1992), and educating patients about rehabilitation (Blenkinsopp, Panton 1992).

A focus on public health also implies a quality improvement of core tasks - dispensing and provision of OTC drugs: patient monitoring/patient medication records, out of hours services, provision of support material, ADR reporting system, OTC sales protocols/ formularies (Bond, Bradley 1996)

HP and Pharmaceutical Care

According to Dr Schulz (speaking during the kick-off meeting of the project), Pharmaceutical Care initiatives and models share some common ideas with health promotion. Therefore, the project will also look at Pharmaceutical Care models and explore features relevant for health promotion. First, a short description of the concept of Pharmaceutical Care will be provided:

Definition: "Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient's quality of life."
(Hepler, Grainger-Rousseau 1995) "... Structured controllable intensified care of the pharmacist for an optimal pharmacotherapy, in which the individual patient and his condition are the primary concern. The aim is to improve Health Related Quality of Life."
(van Mil, Tromp 1996)

Characteristic features of Pharmaceutical Care:
- clearly defined intake
- patient focus: shared responsibility between pharmacist, patient, GP
- defined structure
- continuity of care
- continuous documentation and evaluation

Strategies

patient assessment
- eliciting patient's expectations on drug treatment
- assessment of drug-treatment (indication and security, effectiveness, )
- identification and prevention of drug-related problems

intervention
- development of a treatment plan with the patient and the GP
- communication with health care providers
- setting specific treatment goals
- carrying out treatment
- patient education
- setting a monitoring plan

outcomes assessment
- continuous documentation of treatment
- evaluation of treatment according to previously set goals

Pre-requisites

fostering communication between pharmacist and GP
re-orienting pharmacists' training: pharmaceutical core competencies, clinical pharmacy, Pharmaceutical Care

re-organising pharmacies (organisational, "culture"): number of pharmacists/pharmacy, number of users/pharmacy, stressing the importance information and counselling

patient medication records (in pharmacies): to allow continuous data collection and management

Specialisation

Disease-oriented (disease management): asthma, diabetes, CHD, headache,
targeting specific groups of users: young mothers, elderly patients with restricted cognitive abilities
risk group oriented: elderly multi-morbid patients
action oriented: identification, documentation and solving of drug related problems, pharmacovigilance (recording of side effects)

The following aspects seem to be relevant with respect to HP:

related to lifestyle advice:
take an active role in all aspects of patient's wellness, advise on lifestyle modification (Desselle, Schwartz et al. 1997), guiding patient self-care, referring patients in necessary (Fritsch-Koepsch, Schulz 1996; Hepler, Grainger-Rousseau 1995)
related to screening and diagnostic testing:
screening and diagnostic testing as part of a Pharmaceutical Care plan (Desselle, Schwartz et al. 1997)
related to co-operation:
team approach and communication to integrate drug therapy with other elements of health care (Hepler 1990; Hepler, Grainger-Rousseau 1995)
related to how HP intervention should be carried out:
"maintain(ing) a caring, friendly, responsible relationship with patients" has been mentioned. (Desselle, Schwartz et al. 1997)

However, it must be mentioned that this is not to subsume the concept of Pharmaceutical Care under the heading of health promotion, but to show that there is a relevant intersection between both approaches that warrants further attention. (van Mil, Tromp 1996)

2.3 Community pharmacy practice: Some examples of HP initiatives and models

These examples are based on the above mentioned literature, complemented by material derived from participants at the kick-off meeting in Vienna in September 1999.

1. HP a/o Pharmaceutical Care models and initiatives in UK

Barnet High Street Health Scheme
objectives:
- to provide knowledge and skills-based training for community pharmacists in health promotion
- to support community pharmacists in Barnet in their health promotion role by providing access to health education resources and advice
outcome objectives
- to provide an easily accessible source of health promotion advice to the public
- to ensure that the provision of diagnostic testing services in Barnet was consistent with that provided by other health promoters in the district
- to identify the pharmacist as a valuable member of the primary health care team
topics: chosen by considering CPs broad areas of activity in relation to HP
- CHD (because prevention via risk factor reduction is possible)
- asthma (because CPs are able to advise customers on use of inhalers, peak flow devices, prevent worsening of symptoms)
- diabetes (because of potential of CPs in disease management, blood glucose measurements)
- nutrition (because there are frequent questions by customers)
- drug misuse, AIDS/ HIV (because of the role of the CP in dispensing methadone, needle exchange schemes)
- evening courses on psychology of smoking cessation, child health, dental health, mental health

focus initially on screening: blood pressure, height, weight, BMI, body fat assessment, glucose (urine and blood), CO, peak flow monitoring
(Anderson 1996; Anderson, Greene 1999)

Wiltshire Scheme - topics
- CHD
- asthma
- diabetes and exercise
- nutrition and dental
- AIDS/ HIV and rug use
- mental health, travel health
(Anderson, Alexander 1997)

Somerset Pharmacy Health Promotion pilot project - topics:
- smoking cessation
- blood pressure monitoring
- sensible exposure to the sun and the need for skin protection
- pregnancy testing
- measurement of peak expiratory flow rate
- advice on infestations
(Ghalamkari, Rees et al. 1997)

more initiatives and models:
emergency contraception campaign (Sharma, Anderson 1998)
interactive health promotion - gastrointestinal disease (Hesketh, Lindsay et al. 1995; Lindsay, Hesketh et al. 1994; Lindsay, Hesketh et al. 1994; Lindsay, Hesketh et al. 1995)
Glasgow Pharmacy Summer Protection Campaign (information on HIV and safe sex for young people) (Morrison, Elliott et al. 1997)
coronary heart disease screening (Allison, Page et al. 1994)


2. HP a/o Pharmaceutical Care models and initiatives in Belgium

IOGA (co-operation with GP; pharmacotherapy)
Independent Information on Medicines (CP, GP, university)
Pharmaceutical Opinions (communication CP-GP)
Asmatom (asthma, preventive treatment , aerosol use)
Smoking Cessation
Diabetes Screening/ Detection (CP and patient org., agreement of GP)
Continuous Formation of Pharmacists and Pharmacy Assistants
DELPHI (databases on medications)
Look-Out Pharmacist (databases on use of certain medicines to detect e.g. stress symptoms)

The tools used in HP in community pharmacies in Belgium include: posters and leaflets (influenza, cot death, osteoporosis), pharmaco-therapeutic labels for medicines, dietetic cards, anti-AIDS bags, influenza coupons (in co-operation with GPs) and syringes for syringe-exchange. (source: Mr Elsen and Mr Libert, at the kick-off meeting of the project)


3. HP a/o Pharmaceutical Care models and initiatives in Germany

Pharmaceutical Care studies

Therapeutic Outcomes Monitoring of Asthma Patients (ABDA and Chamber of Pharmacists, Hamburg) (Bergmann, Schulz; Hanpft 1996; Schulz 1999)
OMA - Pharmaceutical Care for Elderly, Multimorbid Patients (Chamber of Westphalia-Lippe and Group of Professor Schaefer, Berlin) (Kahmen, Schaefer 1998; Müller-Jaeger, Schaefer 1996; Schaefer 1997)
Data Management in Pharmaceutical Care (Chamber of Pharmacists Nordrhine and Group of Professor Schaefer, Berlin)
Advice-giving in Self-Medication to Patients with Dyspepsia (Chamber of Pharmacists Hessen and Group of Professor Schaefer, Berlin)(Kahmen, Schaefer 1998; Krishnan, Schaefer; Krishnan, Schaefer 1998; Kahmen, Schaefer 1998)
Pharmaceutical Care for Patients with Metabolic Syndrome (Chamber of Pharmacists Saarland and Rhineland-Palatinate) (Morck 1999)S10-12, (Thome 1997)
Pharmaceutical Care for Patients with Type II Diabetes (Chamber of Pharmacists Baden-Württemberg an Group of Professor Schaefer, Berlin(Kahmen, Schaefer 1998; Schaefer 1997)
Detecting Drug-related Problems (Chamber of Pharmacists Bavaria and Group of Professor Schaefer, Berlin)
Pharmaceutical Care for Patients with Asthma (Project Group of Pharmacists, Augsburg and Chamber of Pharmacists Bavaria, Professor Schaefer Berlin)(Ganzer 1996; Kalb, Kommert et al. 1996; Kalb, Kommert et al. 1997)
Pharmaceutical Care in Small Community Pharmacies (Chamber of Pharmacists Bavaria and Group of Professor Schaefer, Berlin)
Pharmaceutical Care for Patients with Hypertension (Chamber of Pharmacists Thuringia and Group of Professor Schaefer, Berlin) (Morck 1999)S 4-9
Pharmaceutical Care for Patients with Pain (Chamber of Pharmacists Saxony, Institute of clinical Pharmacology Dresden and Group of Professor Ferber Cologne)
OMA - Pharmaceutical Care for Elderly, Multimorbid Patients (Chamber of Pharmacists Berlin and Group of Professor Schaefer, Berlin) (Belgardt, Keller et al. 1998; Kahmen, Schaefer 1998; Müller-Jaeger, Schaefer 1996)
Pharmaceutical Care for Patients with Cardiovascular Disease (Chamber of Pharmacists Mecklenburg - West Pomerania)


4. HP a/o Pharmaceutical Care models and initiatives in Denmark

Pharmaceutical Care studies:
TOM Therapeutic Outcomes Monitoring Asthma (Morck 1996)


5. HP a/o Pharmaceutical Care models and initiatives in the Netherlands

Pharmaceutical Care studies

OMA Pharmaceutical Care for Elderly Multimorbid Patients (van Mil, Tromp 1996; vanMill, Müller-Jaeger et al. 1997)
TOM Pharmaceutical Care for Asthma Patients (van Mil, Tromp 1996; vanMill, Müller-Jaeger et al. 1997)

6. HP a/o Pharmaceutical Care models and initiatives in Sweden

Quit Smoking at the Pharmacy (Isacson, Bingefors et al. 1998)

Pharmaceutical Care studies:

Pharmaceutical Care for Patients with skin Disease (Hammarstrom, Wessling et al. 1995) (abstract)
Asthma Year (Harding, Nettleton et al. 1990; Health Education Authority 1995; Hesketh, Lindsay et al. 1995; Lisper, Nilsson 1996; Maguire, Morrow et al. 1987; Panton, Blenkinsopp et al. 1989; Smith 1992)


7. HP a/o Pharmaceutical Care models and initiatives in Finland

"Questions to Ask About Your Medicines" campaign (Airaksinen, Ahonen et al. 1998)


8. HP a/o Pharmaceutical Care models and initiatives at European Level

EuroPharm Forum protocols and guidelines

smoking (Europharm Forum 1996)
diabetes
high blood pressure (Europharm Forum 1999) (WHO Regional Office for Europe 1997)
asthma (WHO, Europharm Forum 1998) (WHO Regional Office for Europe 1998)
use of medicines: "Ask About Your Medicines (QaM)" ( 1993)
HIV/ AIDS: "The Pharmacist and HIV/ AIDS"


2.4 Health promotion in community pharmacy from a Health Promotion perspective

Some distinctions from a Health Science/Health Promotion perspective (Pelikan et al. 1999) have been used to analyse the material:
(a) health (protection and development of health) vs. disease/ illness (treatment and prevention of disease/ illness) oriented interventions.
(b) Physical/biological - mental - social dimensions of health and illness
(c) expert interventions - lay participation/ empowerment/ co-operation/ co-production
(d) person oriented - settings oriented interventions

The main findings presented below are based on the review of material currently available:
2.4.1 Disease (treatment and prevention) vs. Health (protection and development):
(a) the entry point for HP interventions in community pharmacy is predominantly disease-focused:
(b) entry point treatment of disease: dispensing/treatment with prescribed drugs, self medication
(c) entry point prevention of disease: screening/diagnostic testing
(d) this focus seems to be in accordance with user expectations and preferences regarding the services provided in community pharmacy (Ghalamkari, Saltrese-Taylor 1999)
(e) nature of interventions: difficult to judge from available literature (especially distinction disease prevention - health protection) - rather "health related topics in a disease related context"
(f) mainly life-style interventions, disease-focused, especially in the case of chronic conditions (this seems to be plausible from the point of view that acceptable (for patients/ users and CPs); HP interventions will most likely be related to core tasks of CP
(g) health protection: related to use of medicines, e.g. medication safety (Bedfordshire Health 1995; Maine 1998)
(h) advice to nursing homes, shelters, hospices (Bedfordshire Health 1995)
(i) advice to community groups (Maine 1998)
(j) however, further development to include health-related interventions should not be rejected on this account

2.4.2 Addressing physical/biological - mental - social dimensions of health
(a) recognise and understand different dimensions of health (physical, emotional, mental, social, spiritual, societal) (Hargie, Morrow 1994))
(b) development of community pharmacy integration in community health strategies (Bedfordshire Health 1995)

2.4.3 Addressing expert interventions - lay participation, empowerment, co-operation, co-production
Discussions related to this distinction centre around "moving from product to patient focus/caring approach" (Anderson 1995; Anderson 1996) (Anderson 1997; Hargie, Morrow 1994)
An interpretation would be to distinguish between
(a) proactive vs. reactive interventions (Anderson 1995) in a first step
(b) information vs. advice and counselling in a second step, moving to a more complex understanding of the underlying root cause
- extension of expertise on drugs: "investigate underlying issues relevant to the symptoms presented and relevant to the client….explore nature of symptoms, possible causes and consider the implications" (Smith 1992)
- make patients feel that they are actively engaged in doing something positive rather than avoiding something negative - involved patient - CP can support positive attitude by positive feedback, demonstrating genuine interest in the patient's progress, involving patient in therapy decisions (Weber, Reed et al. 1989)
- involves helping individuals to feel in control of, or take responsibility for, or manage their situation (for example helping the individual cope with health related problems). "..individuals have a fundamental role in maintaining their health status, relationship with the health care professional should be a partnership.." (Smith 1992)
(c) however, it is argued that product-oriented pharmaceutical experience (as a key asset) should not be lost ( 1983; Hassell, Noyce et al. 1998; Moore, Craft et al. 1996; Moore, Cairns et al. 1995)

2.4.4 Person oriented - settings oriented interventions
Interventions described are primarily person-oriented, but there are also some indications that community-oriented interventions are being considered.
In community pharmacy policy documents:
(a) involvement in specific campaigns with other health professionals to ensure co-ordination of effort and consistency of advice, health promotion activities at a national level, including campaigns to minimise the abuse and misuse of medicines (PGEU 1998)
(b) medication safety (Maine 1998)
(c) group health education (Maine 1998)
(d) related to prescribing: cost-effective prescribing, generic prescribing, prescribing policies (Croydon Health 1995)
In scientific literature:
(a) in the area of medication: prescribing policies, medication safety (Bond, Bradley 1996; Bradley, Taylor et al. 1997; Jepson, Strickland-Hodge 1995; Wells E 1997)
In descriptions of models in daily practice:
(a) services for specific users e.g. needle exchange in Barnet Scheme
(b) Belgium: Look-Out Pharmacist (databases on use of certain medicines to detect e.g. stress symptoms)


3 Conclusions

Health promotion is being used as a concept for professional development, making visible the added value of CP
- Explicitly in the UK, as part of the extended role of CP ( 1997)
- Concepts with a (strong) link to HP are Pharmaceutical Care; ensuring quality of core task (medication management), also, the focus is shifting from product to patient, co-operation with physician/specialist (depending on condition)
- In the discussion, co-operation with other providers is often mentioned, as is the demand to become an integral part in the PHC team
Health promotion in community pharmacy is mainly disease-focused, regarding this as the entry point, but also to a large extent regarding the nature of interventions (although a reliable judgement in this case is difficult due to lack of material, the nature of publications/description of interventions).

Moving from product focus to patient focus seems to be important, however, concepts about the meaning of patient focus are notably absent in description of models and, focus of research so far has had a social psychology framework (Pilnick 1998)

Possible areas for further development could try to exploit the unique contribution the CP offers as the expert on medicines:
- e.g client-centred collaborative model of medical decision making and monitoring, shared decision making, partnership model of medicine taking and concordance in the area of drug treatment (Chewning, Sleath 1996), (Coulter, Entwistle et al. 1999), ( 1997; Lewis, Lasack et al. 1997)
- e.g. positive health education, focus on patient's experiences (Badura, Kickbusch 1991; Downie, Fyfe et al. 1990; Badura, Kickbusch 1991)


4 References

ABDA (1998): Apotheker und Ärzte: Leitfaden zur Zusammenarbeit. In: Pharmazeutische Zeitung, 143, 6, S. 48-52.

Airaksinen, M., Ahonen, R., Enlund, H. (1998): The "Questions to Ask About Your Medicines" Campaign

An Evaluation of Pharmacists and the Public Response. In: Medical Care, 36, No 3, S. 422-427.

Allison, C., Page, H., George, S. (1994): Screening for coronary heart disease risk factors in retail pharmacies in Sheffield. In: Journal of Epidemiology and Community Health, 48, S. 178-181.

Anderson, C. (1994): Health Promotion in Community Pharmacy

(1) Use of Leaflets and Posters. In: the pharmaceutical journal, 253, S. 254-256.

Anderson, C. (1995): A controlled study of the effect of a health promotion training scheme on pharmacists' advice about smoking cessation. In: Journal of social and administrative pharmacy, 12, 3, S. 115-124.

Anderson, C. (1996): Community pharmacy health promotion activity in England: a survey of policy and practice. In: health education journal, 55, S. 194-202.

Anderson, C. (1998): Guidance for the development of health promotion by community pharmacists. London: King's College London.

Anderson, C. King's College London (Hg.)(1997): Health Promotion by Community pharmacists.

Anderson, C., Alexander, A. (1997): Wiltshire pharmacy health promotion training initiative: a telephone survey. In: The international journal of pharmacy practice, S. 185-191.

Anderson, C., Greene, R. (1999): the Barnet high street health scheme: health promotion by community pharmacists. In: the pharmaceutical journal, 259, S. 223-225.

Anderson, C., Todd, J. (1994): Health promotion in Community pharmacy-(2) Contacts and the importance of team work. In: the pharmaceutical journal, 253, S. 284-286.

Badura, B., Kickbusch, I. (Hg.)(1991): Health Promotion Research. Towards a New Social Epidemiology. Copenhagen: World Health Organization, Regional Office for Europe. WHO Regional Publications, European Series, No. 37.

Bedfordshire Health (Hg.)(1995): The Community Pharmacy Strategy.

Belgardt, C., Keller, B., Lehmann, B.v. (1998): Pharmaceutical Care aus der Sicht der Studienapotheker. In: PZ, 143, 11, S. 43-46.

Bergmann, K.-C., Schulz, M. Empirische Evaluation des Modellprojektes 'Pharmazeutische Betreuung von Asthma-Patienten'. ABDA; Apothekerkammer Hamburg.

Blenkinsopp, A., Panton, R. (1992): Health Promotion for pharmacists. Repr. Oxford: Oxford Univ. Press. Oxford Medical Publications.

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