Claire Anderson
Keynote Lecture
KL 3 / Health promotion in the High Street - the Perspective of Community Pharmacy

The talk gave an overview of many health promotion models and initiatives in community pharmacy practice and demonstrated a wide range of activities. It should be noted that the talk was based on data from the country reports received by November 2000 and therefore, may have important omissions. The country reports should be referred to if further information about any of the projects is required.

Abstract

There is evidence that community pharmacists have a very important role to play in health promotion. They are probably the most accessible health professionals. In much of Europe, community pharmacies are accessible by most of the population and pharmacists are available to advise people without an appointment. Community pharmacists in the UK see over 90 % of the population every year. Pharmacists see both well people and those with diseases. There is an increasing demand for health and wellness products and services, and pharmacist are often well placed to provide these. Pharmacists can enable individuals to promote and protect their health. They are in a good position to give information and advice to people who have been prescribed medicines, those who are seeking self-medication and when they are providing health related products and services.

Pharmacy education and training is changing and health promotion is now part of the undergraduate pharmacy curriculum in a number of countries. There is an increasing amount of research into the effects of pharmacy health promotion and a number of examples of good practice. Some of the research will be summarised and some examples of good practice highlighted. The contribution that pharmacists can make will be discussed along with some of the issues that will need to be overcome if pharmacists are to become health promoters.

Pharmacy an important setting for health promotion

Community pharmacists work in both professional and commercial settings. The professional role is primarily centred around the provision of medicines to patients and advice about medicines to patients, carers, prescribers, nursing home staff and so on. The commercial role of pharmacists revolves around the sale of over-the-counter (OTC) medicines and other non-medical, but often health-related, merchandise. Pharmacists are considered by both the primary care team and the public to be experts on medicines and pharmacists have a strong ethic of service to the community that frequently overrides purely commercial considerations

Pharmacists are knowledgeable specialists who are currently under-utilised in Europe’s health systems. They are in an unique position, in that they are available for at least eight hours a day without an appointment. They see the healthy as well as the ill. Their location enables their premises to be used for health promotion campaigns that will reach a large number of people. Pharmacists build up relationships with patients, customers and their families over several years. These are all key factors in considering their influence. Opportunities to promote and develop health occur every day with both healthy and sick individuals. It is extremely difficult to say that health gain has resulted from isolated health promotion events without considering all the other influences on an individual’s health, such as media, friends and family, education and other health professionals. However, the advice that pharmacists give contributes to the overall achievement of health gain in the population.

Pharmacists can make a significant contribution to local campaigns and can reinforce the messages that are given out in other settings. In the UK, they see the most vulnerable people in society, including the elderly, mothers and their young children, those with chronic illness and those in the lower (C2DE) social classes who are less likely to be empowered for self care (1). So pharmacists are ideally placed as health promoters due to their: accessibility, availability, relationships and informality

The Ottawa charter talks about health promotion under three headings (2). I will illustrate how pharmacy fits into these:
- Advocating health in the community
Pharmacists work with schools and local groups, using pharmacy window space to promote health
- Enabling people to promote and protect their health,
Provide access to information on health, facilitating skills development, strengthening health opportunities
- Mediating within the community
bringing self-help groups together, a leader for health promotion activity beyond individual pharmacy practice

Policy

Pharmacy health promotion features in a number of European national policy documents. Examples include:
“Pharmacies have an important role in the efforts of improving public health in Denmark, including services on smoking cessation, asthma in schools, dietary advice, dose dispensing etc” (Danish Government White Paper 2000(3))

“Pharmacists provide a range of services to the public and have a direct impact on public health. Community pharmacists see most adults and many children regularly. The wide distribution of pharmacies means that professional information and advice are available in diverse communities on UK and local health initiatives….” (Working Together for a Healthier Scotland, 1998(4))

Pharmacies should promote heart health in their activities and customer contacts in cooperation with the rest of the healthcare system on non-governmental organisations (Action plan for promoting Finnish heart health: consensus statement 1998(5))

Pharmacists are able to promote health when carrying out two of their key roles, i.e. the provision of prescribed medicines and provision of medicines for self-medication.

1. Provision of Prescribed Medicines
- Pharmaceutical care/medicines management – especially in the case of chronic diseases, e.g. asthma, COPD, hypertension, diabetes
- Lifestyle advice - linked to achieving a given therapeutic goal, e.g. advice regarding diet and exercise for people with diabetes
- Providing information about self-help groups

2. Provision of self-medication
- Information – to prevent misuse
- Referral if self-medication is not appropriate
- Lifestyle advice
- Self-help

In a number of EU countries, pharmacists can also promote health when

3. Providing health-related goods
- Health maintenance
- Wellness

4. Providing group health education
- Information
- Healthy lifestyles
- Use of the health care system
- Immunisation, rehabilitation
- Use of medicines

5. Providing screening and diagnostic testing
- Information giving
- Explaining the meanings of tests: benefits and risks
- Explaining parameters tested and implications of findings
- Influence of lifestyle issues on specific condition and general health and how to deal with it

Health promotion is included in undergraduate courses in a number of countries, notably the UK and Scandinavia. In the UK, it is included in Postgraduate Diploma and Masters programmes and in continuing education programmes. Pharmacy assistants have also been trained in the UK. Two text books on pharmacy health promotion have recently been published in the UK(6)(7). Interprofessional training has taken place in Belgium, Netherlands and the UK.

In the past, health promotion has concentrated on simple leaflet displays and reactive information giving. There is a move away from this to more planned and systematic educational and consulting interventions. Examples of pharmacist involvement in health promotion from the country reports include:
Netherlands, Belgium, UK

Medicines

Hypertension week – Netherlands
The aim of the project was to improve well-being and quality of life. Patients on anti- hypertensive medicines were informed of the project one month before and invited for a medication review. They were given information, including advice about healthy lifestyles. 4489 Patients contacted 221 pharmacies over the week.

Diabetes circles. Live well with diabetes – Sweden
Study circles facilitated by a pharmacist were set up to support people with NIDDM. The main aim has been to teach people, via experiential learning, to monitor their blood sugar values towards normal levels They also receive information regarding diet and exercise. The programme was well received and an economic feasibility study indicated that if people could maintain a lower HbA1c (approximately one percent unit decrease after six months), the cost of training would be recovered by a factor of two.

Diabetes year 2000 – Denmark
This was set up by the Danish Pharmaceutical Association, in association with diabetes patient groups. This covered primary prevention, detection of undiagnosed disease and support for those with diagnosed disease.

Medicines and health – Finland
This initiative was coordinated by the Association of Finnish pharmacists, along with the national alcohol company ALKO’s research department. The project aimed to increase knowledge of the risks of simultaneous use of prescribed medicines and alcohol, inform about the health risks associated with alcohol use and make materials concerning alcohol and drug use available through pharmacies. Information spots were also arranged on TV The project was well accepted.

Travel health – Austria
In Austria, pharmacist give travel health advice about anti-malarials, sunscreens and so on.

Disease management : asthma, diabetes, hypertension - Portugal
In Portugal, pharmacists are involved in disease management projects that involve lifestyle advice as well as advice regarding pharmacotherapy

Folic acid - Netherlands, UK
In the Netherlands, pharmacists have been involved in advising women about pre-conception folic acid use, in order to prevent neural tube defects, which has included adding a label to oral contraceptives. In the UK, the National Pharmaceutical Association worked with a local health authority and the health education authority to develop a resource pack for pharmacists to give advice about folic acid(8).

Emergency contraception – UK
In the UK, there are a number of schemes whereby emergency hormonal contraception and contraceptive advice is prescribed by pharmacists under a scheme called patient group directions. This has greatly increased the access to emergency contraception. A progestogen-only emergency hormonal contraceptive, Levonorgestrel (Levonelle) has recently been deregulated and can be sold from pharmacies without a prescription.

Smoking cessation

Pharmacists throughout Europe have been involved in giving advice about smoking cessation. The Europharm forum has greatly supported pharmacists in this area.

Smoking Challenge 2000 -UK and Ireland.
This is a programme based on motivational interviewing and behaviour change developed by pharmacists in Northern Ireland. The first evaluation shows that the model, when used in practice, produces a cessation rate of 14.2 % at 12 months compared with 2.7 % cessation at 12 months in a control group(9).

Pro-Change
Boots the Chemists in the UK are using an adult smokers programme called Pro-Change based on the transtheroretical model(10)(11) Multimedia expert computer systems, manuals and trained pharmacists and staff support the smokers. The programme is also placed in primary care and other sites such as leisure centres. Initial research(12) has shown a 4 week quit rate of 41 %. In the UK, people living in areas of greatest social deprivation called Health Action Zones have been able to receive free Nicotine replacement therapy to support them as they try to quit.

Drugs and harm limitation
In a many countries, pharmacists are involved in services for drug misusers.
Injecting equipment exchange is common. In the UK and Ireland, pharmacists are involved in the supervised dispensing of methadone. The client actually drinks their methadone in the pharmacy, which is intended to reduce the chances of it reaching the black market. In Ireland, addicts sign up with a GP and a pharmacist, and are given a photo identity cared. Pharmacists have also gone into schools train teachers about drug misuse.

Barnet High Street Health Scheme

The author was involved in setting up and researching this seminal English project which was launched in December 1991(13)(14)(15)(16). For the first time, pharmacists were given intensive training and ongoing support for their health promotion role.
- >50 % of English health authorities were influenced by the scheme and it led to increased involvement in health promotion.
- pharmacists moved from a product-orientated to a patient-orientated role
- pharmacists had an increased psycho-social role
- Pharmacists made more appropriate use of health promotion materials

Health and wellness

There is an expanding market for selling health, and in some countries pharmacists are involved in selling health-related products and services. Boots the Chemists, a large UK chain pharmacy, are moving in this direction and have set up special stores where they provide health and beauty clinics and treatments. These services vary from physiotherapy and advice about diet and exercise, to the sale of, and advice about, complementary medicines, manicures and therapeutic massage.

Health literacy

Health literacy has been defined as
“Enabling people to gain access to, understand and use information in ways which promote and maintain good health“(17)

Pharmacists are ideally placed to
- Improve access to health information
- Bridge the digital divide
- Transform information into knowledge
- Empower patients
- Support behaviour change


This diagram after Eysenbach(18) illustrates the shift from clinical care to self-care and from healthcare professional informatics to consumer health informatics. Pharmacists are ideally placed to bridge the gap between professionals and lay knowledge, and to empower people for self-care. Pharmacists are able to transform information into knowledge in a number of ways. Traditionally, they have supplied leaflets on a number of health issues. New technology will enable leaflets to be individually tailored and thus more effective. Pharmacists will also be able to help people to interpret information that they have retrieved from sources such as the Internet. In the UK, pharmacy window space has been successfully used to promote health issues such as availability of emergency contraception, folic acid and stroke prevention. The Lloyds pharmacy chain in the UK has set up CHAT centres where advice is provided on social issues as well as health issues. Touch screen information kiosks are being placed in pharmacies in a number of countries.

The future will bring a number of challenges to pharmacy and other health professions including:
- Increased consumerism
- More patient-focus, less product-focus
- Longer consultations with greater information exchange
- More time reviewing evidence
- Increasing emphasis on health promotion and health development
- Increased inter-professional working
- More virtual health services

The remaining challenges for pharmacy include:
Moving towards a health-promoting philosophy - a ‘way of thinking and working’ rather than an ‘add-on’ activity
Moving towards negotiated forms of interventions - discussing not telling, the philosophy of concordance
Accessibility is good, but appointments may be necessary for longer interventions
Prescription customers seem more likely to seek and accept general health advice from the pharmacist
Non-prescription, healthy consumers and incidental passing trade pose more of a challenge
Need to develop training in communicating with patients and training in using information technology