concept papers
country reports
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Cross Analysis | General Practice | Community Pharmacy |
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Karl Krajic
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Petra Plunger
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Ursula Reichenpfader
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Jürgen M Pelikan
A. Introduction
2. What are supporting factors and barriers for health promotion in community pharmacy? From the material available, several factors can be identified regarding supportive and hindering preconditions for health promotion in community pharmacy, mostly based on self description of professionals. However, no systematic overview is available on the extent of perceived supportive factors and barriers. It has been mentioned in some country reports, but also in the available literature and in personal communication that individual factors of pharmacy staff such as knowledge (e.g. on health and healthy lifestyles) and skills (e.g. communication skills) and attitudes and preferences related to professional practice (e.g. professional vs. business orientation and perceived contradiction between these two approaches) have considerable impact on how far health promotion has been implemented in daily practice - for the most part described as barriers hindering a broader involvement in health promotion . From a social science perspective, individual factors are shaped by a range of other -structural - factors. Community pharmacists are being socialised in various ways: - through institutions dealing with education and training (e.g. universities, professionally established training institutions, continuing education, postgraduate training). Within these institutions, knowledge and skills, but also attitudes and preferences are being developed. - through professional organisations, bundling professional interests and creating a collective identity with regard to the specific role of the community pharmacist and the relations towards others, such as health policy, patients, other health professions. - through research which defines and continuously modifies the professional knowledge base (also as a legitimisation of professional status) through education and training, but also through communication within professional bodies - through infrastructure for professional practice - the material and social framework for daily professional action. We are using the term infrastructure in a broad sense and see it as being influenced by various relevant actors, the most important being
These factors are not independent, but influence each other. The model laid out above forms the framework for the analysis of the available country reports, complemented by an analysis of literature and information derived from personal communication. The following areas will be explored: - role definition and perception of professional role of community pharmacists related to health promotion by relevant actors - community pharmacy infrastructure - education and training - research 3. Role definition (and self-understanding) and perception of professional role of community pharmacists by relevant actors with respect to health promotion 3.1 What is the position of professional bodies regarding health promotion in community pharmacy? - According to professional bodies, the core of the professional role of the community pharmacist is centred around expertise on medicines including state of the art supply of medicines, monitoring effective and safe use on the population level, management of drug therapy on prescription on individual level, ensuring safe and responsible self-medication, prescribing advice for physicians. (for further information, see community pharmacy country reports and also: http://www.pgeu.org) It has been mentioned in the Danish country report that individual pharmacists hold various self perceptions about their professional role, ranging from a "technical" perception focused on drugs, the proper administration of drugs and a passive obeying patient, a "business" perception focusing on the pharmacist as an expert selling a healing commodity with the purpose to increase pharmacy turnover, to a "holistic" perception emphasising the patient's/ user's active role and the importance of teamwork within the healthcare team. Clearly, these are ideal types. Individual judgement and self perception on knowledge and skills related to health promotion will depend on the self perception held by community pharmacists. - following statements made in the country reports and from the available literature, the perception of this role has broadened significantly in the last years, now positioning the community pharmacist as an important actor in public health and the community pharmacy as a "centre for health", offering advice on medicines, and on a range of health related matters. This has also been expressed by shifting its main emphasis from a product oriented to a more patient/ user oriented approach (expressed e.g. in concepts/ models like patient oriented pharmacy practice, health education and counselling, Pharmaceutical Care). Looking at the available literature, one can conclude that principles of health promotion considerably overlap with these professional development strategies (Royal Pharmaceutical Society of Great Britain 1992; Tromp 1997; International pharmaceutical federation 1998; Hepler 1990; Hepler, Grainger-Rousseau 1995).
- The development of the professional role of the community pharmacist in the area of health promotion has also been supported by actors on an international level, e.g. the PGEU(5), the EuroPharm Forum(6) and FIP(7) in their policy statements or project protocols. - The role of the community pharmacist in health promotion is also communicated via professional(8) and customer journals(9), brochures, leaflets and other promotional material(10), also in the internet(11) with the aim to establish community pharmacy as an important partner in primary health care. Important partners in this task of creating awareness are national patient and consumer organisations, health foundations, and pharmaceutical industry (The Netherlands). 3.2 What is the professional understanding of health promotion in community pharmacy and how does it relate to the professional role? - Against the background of professional interest for health promotion and perceived supportive factors and barriers, the professional understanding of health promotion by relevant professional actors is centred around the following areas (for further details, see http://www.pgeu.org)
- Taking into account the professional understanding of health promotion and core processes in community pharmacy, health promotion activities in community pharmacy can therefore comprise the following issues: A. In the context of provision of prescribed drugs and provision of self medication: - information about adequate use of medicines in general to prevent abuse and misuse (when medicines should be used, alternatives to medicines) - information about all aspects of a condition-specific medication regimen: adequate, effective and safe use of prescribed medication, side effects, duration of medication regimen, interactions, expected outcome (emphasise client priorities, quality of life and clinical status ) to empower the user/ patient to make informed decision about her/his drug treatment and to manage and monitor the regimen (Chewning, Sleath 1996; PGEU 1998; Coulter, Entwistle et al. 1999) - lifestyle advice to promote and support healthy lifestyles, especially in the case of chronic illness where lifestyle is important/ to ensure the therapeutic goal by lifestyle interventions (complementary to information about safe use, storage , administration and disposal of medicines): e.g. related to asthma, COPD, osteoporosis, hypertension, diabetes II (PGEU 1999, PGEU 1998, FIP 1993; Royal Pharmaceutical Society of Great Britain 1997 , Maguire 1996; Maine 1998; N.N. 1997, Anderson 1998b, Anderson, Todd 1994 Marklund, Almroth et al. 1999, The Association of Finish Pharmacies 1999, N.N. 1997, Desselle, Schwartz et al. 1997, Chewning, Sleath 1996) - information about self help groups (Coulter, Entwistle et al. 1999)
- in the area of provision of prescribed drugs and provision of self medication, Pharmaceutical Care programmes figure prominently, especially with respect to chronic diseases
B. In the context of provision of health related goods/ products and services (group) health education/ advice/ counselling) - Information about adequate use, how products may contribute to maintain/ improve health, improve specific condition, about alternatives to these products - information about healthy lifestyles (PGEU 1999, PGEU 1998, FIP 1993; Royal Pharmaceutical Society of Great Britain 1997, Maguire 1996; Maine 1998; N.N. 1997 Anderson 1998b, Anderson, Todd 1994 Marklund, Almroth et al. 1999), supported by appropriate material/ using an appropriate format (Maine 1998) and wellness maintenance through health education; related to e.g. smoking, use of intoxicants (alcohol use, inappropriate use of medicines), physical exercise, weight, prevention of infectious diseases (needle exchange), safe sex, dental health (1983; The Association of Finish Pharmacies 1999, Royal Pharmaceutical Society of Great Britain 1997, Maine 1998) - information about adequate use of the health care system (Downie, Fyfe et al. 1990, Blenkinsopp, Panton 1992, Anderson 1994) e.g. immunisations (Grabenstein 1992) rehabilitation (Blenkinsopp, Panton 1992) Examples of models and initiatives (for further information on these projects, see respective country reports or http://www.univie.ac.at/hph/orahcs/www/datenbank.html) - Austria: "travel health" - Denmark: "Pharmacy-based smoking cessation services", "pharmacy based weight reduction services" - Finland: "Smoking cessation in Finnish pharmacies", "project to increase availability of syringes in pharmacies to prevent spreading of infectious diseases such as HIV and hepatitis", "self care guides for the public" - Germany: "Quit and win 2000" (smoking cessation), "Study to evaluate the effectivesness and safety of nicotinell ®/24h-patch in self medication" - Ireland: "smoking cessation project" - Portugal: "needle exchange programme", "Methadone substitution programme" - Sweden: "The pharmacies advice for life" (lifestyle advice via leaflets on a variety of issues, e.g. smoking cessation, diet, alcohol), "Quit smoking groups at the pharmacy", "osteoporosis groups" - UK: "Barnet High Street Health Scheme" (lifestyle advice on a variety of issues) C. In the context of screening & diagnostic testing - information about meaningfulness of testing: benefits and risks - information about/ explain parameters tested and implications of findings - information about influence of lifestyle issues on specific condition and general health and how to deal with it (potential) parameters: blood pressure, cholesterol, blood glucose, urine sugar, CO, pregnancy testing, BMI, body fat index, pregnancy testing, weight (Morrow, Maguire 1989, Maguire 1989)).
D. Health promotion initiatives outside community pharmacy premises - Community pharmacists are also gaining visibility outside their premises by providing health education and counselling on medicines e.g. in schools, for the population in general, for health groups, groups with special needs, in nursing homes, for conscripts
3.3 What is the perspective of health policy regarding health promotion in community pharmacy? - Health Policy usually has an influence on the professional role (via legal regulations(12)), on rights and duties, on education, on research and especially on infrastructure (e.g. through remuneration schemes) - it could use this influence in various areas to facilitate community pharmacists' involvement in health promotion, e.g. via inclusion in national campaigns and programmes, or via including community pharmacy in national health policy(13). - According to the perception of professional bodies of community pharmacy, the potential of community pharmacy in the area of health promotion has not yet been fully recognised by national health policy in most countries. However, partners from Denmark(14), the UK(15) , Sweden(16), Ireland(17) and Finland(18) mentioned in their country reports that the role of community pharmacy in health promotion has been emphasised by the relevant health policy actors in their policies and programmes. 3.4 What do patients expect regarding health promotion in community pharmacy? - With respect to patients/ clients/ users of community pharmacy services, knowledge on patients' /users' expectations is almost exclusively based on research carried out in the UK (Anderson 1998a, Ghalamkari, Rees et al. 1997; Hesketh, Lindsay et al. 1995).
- According to the literature (Anderson 1994; Anderson, Alexander 1997; Anderson 1998a; Anderson 1998c), most people enter a community pharmacy to get a prescription dispensed or buy self medication medicines, and although they seem to be sympathetic to the idea of community pharmacists providing health related advice, only a few explicitly ask for it, prescription consumers and high users of CP services (chronically ill, elderly, young mothers) being more likely to do so. The community pharmacist is recognised as the expert on medicines, but not so much as an important and valuable source of health-related advice (this has also been mentioned in the country report of The Netherlands). - Patient/user expectations are changing, now being centred around involvement and commitment of the community pharmacist with a focus on provision of care and patient involvement (instead of production, distribution of medicines) (Beun 1996). - co-operation exists in many member states with patients' organisations, mainly with regard to provision of training for chronically ill people, but also by organising campaigns
- It has been suggested that patients'/ users' expectations and preferences shall be more systematically explored(19), paying attention to cultural differences (also of different groups of users/patients according to age, gender, socio-economic status, etc) and contextual factors related to community pharmacy practice(20). 3.5 What are future perspectives on the development of the professional role in health promotion - From the material available and following discussions within the profession, it may be inferred that further progress can be and has to be made in the area of health promotion, resulting in a somewhat uneven picture the profession might give to other actors beyond professional boundaries. This might also explain the sometimes perceived lack of recognition of community pharmacists in health promotion by other relevant actors: It has been emphasised in the literature and in several country reports that the role of the community pharmacist in health promotion should get greater visibility and recognition outside the profession, addressing other professionals in health care, health policy and patients. This would mean better integration of community pharmacy in primary health care, e.g. by inclusion of community pharmacy in health promotion programmes and policies. 4 Community pharmacy infrastructure It has been mentioned in the available literature (Anderson 1996, Anderson 1997; Anderson 1998b; Anderson 1999) and in the country reports that factors related to organisation of work in community pharmacy, to resources and to co-operation with others have a significant impact on community pharmacists' involvement in health promotion. However, from the information available no conclusions can be drawn on the prevalence of these factors. 4.1 Factors related to organisation of work in community pharmacy - Community pharmacies are often the first point of contact with the health care system, since they are easily accessible (concerning e.g. opening hours, geographical distribution) and therefore provide specific opportunities for advice on medications and other health related advice by skilled staff (Anderson 1997) - In the literature, it has been mentioned that organisation of community pharmacy practice related to organisation of workflow and development of the physical setting, e.g. counselling areas, should follow the emphasis on patient/ user centred practice (e.g. self care departments in Danish and Finnish community pharmacies). Also, skills and knowledge of qualified staff should be more recognised, e.g. by optimising assignment of tasks to get more time for community pharmacists for counselling and advising patients/ users (Anderson 1994). Information to what extent both demands have been realised so far in European pharmacies is not available. 4.2 Remuneration systems/ adequate resources - With regard to cognitive services provided by community pharmacists like e.g. counselling, health education, several challenges to further development have been mentioned in some country reports and the literature, including rather generally "shortage of time" and "lacking remuneration". - More specifically, the remuneration system in community pharmacies (predominantly based on margins and/ or a fixed amount of money per drug and only to a very limited extend on fees for defined services) seems to pose an important constraint to greater focus on cognitive services in the area of health promotion. This is true also for professional concepts with strong overlap with health promotion, e.g. Pharmaceutical Care, where a considerable amount of time is devoted to counselling - Fees for cognitive services exist only to a limited extent, mostly related to specific projects like e.g. in the UK and Finland or in connection with specific services like e.g. in Denmark, where pharmacists are obliged to charge for pharmaceutical and health promotion services (for further information on these projects, see respective country reports) 4.3 Co-operation - Co-operation has been mentioned as an area of relevance especially in countries where a tradition of co-operation exits between health care providers also supported by health policy, and where community pharmacists have been integrated only to a limited extent into pre-existing (primary) care teams so far (see also e.g. country report UK). Nevertheless, co-operation seems to be a key priority for community pharmacists throughout Europe, and it has also been mentioned as an important factor related to health promotion in community pharmacy (see e.g.: http://www.pgeu.org ) - Relevant partners and areas of co-operation include
- co-operation is expected to be especially beneficial in the area of counselling and advising the patient (e.g. in the area of drug-therapy), to ensure that the same message is given (related to pharmacotherapy, lifestyle advice, …) - for the most part, co-operation is reported (personal communication with project partners) to work well on the local level, while it might become more difficult when moving up to the regional and national level. It has been mentioned in the German country report that pressure on physicians to reduce prescription of medications may also be a barrier to better co-operation. Patient organisations - co-operation is carried out mainly in campaigns or in specific projects(22) - topics: patient oriented management of drug therapy National/ regional/ local authorities - purpose: to ensure that health targets are reached(23), ensure continuity of care, integrated health care - topics: management of drug therapy, counselling on lifestyle issues - barriers: lacking recognition of community pharmacy as a partner in health care Pharmaceutical industry - purpose: organisation of campaigns(24), development of training materials, lobbying - It has been suggested in the literature that better recognition of community pharmacists as health professionals and better integration in the health care team will support co-operation with other partners in general (Anderson, Todd 1994) From the information available in the country reports and in the literature, it seems that integration of community pharmacy in primary health care and co-operation especially with other providers largely depends on health policy measures furthering this approach, at least from the perspective of the profession. 5 Education and training 5.1 What is the status quo on education and training related to health promotion? - Up until now, health promotion and/ or topics related to health promotion (under the heading of e.g. "Social Pharmacy") have only sporadically been integrated in university training, mainly in the UK(25) and Scandinavian countries(26). - As compared to university training, topics related to health promotion seem to figure more prominently in vocational training and continuing education, and also in courses sponsored by pharmaceutical industry (although the focus of these courses may be more business oriented)
5.2 What are future scenarios for education and training related to health promotion? - It has been emphasised that education defines the knowledge base of the future, and therefore characterises the profession. According to the European Association of faculties of Pharmacy, responsibility should be shared between professional organisations and educational institutions, also taking into account the perspective of health policy. This should ensure that education and training prepare community pharmacists to tackle health problems and needs of patients and society, and integrate and respond to current trends, e.g. changing health care systems, changing patients'/ users' behaviour, new information and communication technologies, and new developments in biological and pharmaceutical sciences, biotechnology and pharmaceutical delivery. Lifelong learning will be a key issue, as well as problem based and student centred learning(27). So far, knowledge on health promotion topics, as well as communication skills and other competencies relevant for HP still seem to pose a challenge for community pharmacist. - It has been suggested in the literature to further initiatives at all levels of education and training addressing collaborative training(28) with other health care professionals and an increased patient/ client focus. The inclusion of Pharmaceutical Care in the university curriculum has also been suggested(29). - To ensure high quality of cognitive services like counselling and advising patients, it has been mentioned that certification may be employed as an important means by the government (The Netherlands)(30). - Further development of pharmacy practice via education and training is continuously supported by various actors like EuroPharm Forum(31), FIP(32), WHO(33), PCNE(34), and EAFP(35) 6 Research Issues related to health promotion research in community pharmacy have not been explicitly addressed in the framework for the country reports, the main source of information for this paper. Therefore, implications on the nature and extend of research relevant for health promotion in community pharmacy can only be drawn to a limited extend, addressing the most prevailing topics. 6.1 What is the status quo of research related to health promotion in community pharmacy? - It has been emphasised by the European Association of Faculties of Pharmacy that pharmacy as a profession must create its own knowledge base through research in all relevant areas(36). In order to strengthen the community pharmacists' role in health promotion, this will also apply to this area. - Research covering health promotion or related topics comes under the heading of "health promotion" e.g. in the UK, but also research activities labelled "pharmacy practice research" (e.g. in Denmark ) cover relevant topics/ models/ concepts and theories. Compared to research activities in traditional areas (e.g. pharmaceutical chemistry, pharmacology), it seems that research activities relevant for health promotion are realised only to a limited extend in Departments of Pharmacy. However, in several countries joint projects are carried out with researchers from other departments like psychology, sociology, medicine, management sciences (e.g. in The Netherlands ) and non university-based research institutions (e.g. Pharmakon in Denmark, owned by the Danish Pharmaceutical Association). 6.2 What are future perspectives for research in this area? - It has been emphasised in the literature that adequate models and concepts have to be developed/ employed to guarantee for a thorough theoretical grounding of research, also drawing on experiences gained in other settings, e.g. General Practice, nursing. - Moreover, as this is an area of applied research, it has been stated in the literature that co-operation between practitioners and researches, also from other health care professions, is important(37). Barriers to closer co-operation might be the predominantly science-based structure curriculum of pharmacists' university training, this is partly balanced where Departments of Social Pharmacy or Pharmacy Practice exist. References (1983): The pharmacist´s role in individual preventive health care. In: American Pharmacy, NS23, 7, S. 10-17. Anderson, C. (1994): Health Promotion in community pharmacy (4) The pharmacy as a health promotion centre. In: the pharmaceutical journal, 253, S. 1-2. Anderson, C. (1994): Health Promotion in Community Pharmacy (1) Use of Leaflets and Posters. In: the pharmaceutical journal, 253, S. 254-256. 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. (1998a): Health Promotion by community pharmacists :consumers´ view. In: The international journal of pharmacy practice, 6 , March 1998, S. 2-12. Anderson, C. 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