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Pharmacists can play a major part in achieving the Scottish Executive's health targets, Mr Bill Scott (chief pharmaceutical officer, Scottish Executive) told the conference. Mr Scott based his presentation around the publication "Social justice . . . a Scotland where everyone matters", which had been published in November, 1999, and which set out the Executive's long-term health targets for Scotland. Although it covered a wide spectrum of issues affecting social inclusion, there were specific milestones relating to improving the health and well being of children, young people, families, older people and communities. They included reducing the proportion of women smoking during pregnancy, the rate of dental caries in children, smoking and pregnancy in the teenage years, adult smoking and premature deaths from coronary heart disease and cancer, and drug misuse (particularly injecting and sharing needles).
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Bill Scott: pharmacists can play a major part in achieving targets |
Opportunities
Mr Scott described the population of an "average" pharmacy and the large number of people who visited a pharmacy each day. This provided opportunities for health education and promotion. Pharmacists could educate smokers about the benefits of giving up, provide information and leaflets, and organise smoking cessation clinics with the provision of nicotine replacement therapy and measurement of physiological functions. Pharmacists could participate in harm minimisation and detoxification for drug misusers through needle exchange and supervised methadone administration. They could also help to prevent misuse of prescribed and over-the-counter medicines. Premature deaths from coronary heart disease could be reduced by advice on diet and lifestyle, optimising therapy, improving compliance, and monitoring. Other health care professionals could be based in pharmacies to assist with smoking cessation.
Pharmacists helped to prevent cancer by providing leaflets, but there was a risk of over-reliance on these and it was essential to take opportunities to discuss concerns. The supply of sunscreens and sunglasses was an important contribution, but pharmacists had to be knowledgeable about these products and supply only those that were effective. In treating cancer and providing palliative care, pharmacists were involved in optimising therapy, counselling and advice, aseptic dispensing, and supplying drug delivery systems.
Mr Scott said that pharmacists reduced accidental overdose and poisoning by educating people about side effects of medicines and improving prescribing. Customers should be warned about taking more than one product containing paracetamol, and the elderly advised on the risk of falls when taking hypnotics. Dental and oral health could be improved by teaching good hygiene techniques, advising on the use of fluoride toothpaste and supplements, and encouraging the use of sugar-free medicines.
Mr Pete Evans (researcher, Market Research Scotland) presented the results of an evaluation of health promotion materials supplied to all community pharmacies in Scotland for National Smile Week in 1997. The aim had been to investigate community pharmacists' understanding of their role in health promotion and assess the general use they made of health promotion materials.
Health promotion specialists in 12 health boards had been interviewed via the telephone, 12 community pharmacists face-to-face, and a further 151 by telephone.
The majority of respondents (97 per cent) saw pharmacists having a health promotion role, mainly by distributing leaflets (91 per cent), displaying posters (84 per cent) and advising customers (82 per cent). Barriers were seen as time, materials, privacy, training and space. Most pharmacists (84 per cent) recognised the support of the local health promotion department, mainly by the provision of materials, with 91 per cent saying they always or usually displayed them.
In relation to the materials supplied for National Smile Week, 96 per cent thought they were relevant. Nearly all (99 per cent) used the leaflets, handbook (92 per cent), and handouts (87 per cent), with 60 to 66 per cent also using the hanging card, shelf talker, window sticker and "wobbler". Most had received a letter of explanation in advance of the materials and 56 per cent thought an explanation in advance was preferable. Half the pharmacists thought no improvement was needed to the campaign, but a fifth would have liked more general publicity. Links were made with other health care professionals, mainly dentists, by 11 per cent of the pharmacists, and 10 per cent undertook related activities such as dental promotions and competitions.
Dr Claire Anderson (director of pharmacy practice and social pharmacy, University of Nottingham) described several areas of health promotion research involvement. The Barnet High Street Health scheme had been established in 1991. Training for participating pharmacists had been provided and evaluated. The results showed increased involvement of pharmacists in health promotion, a move from product- to patient-orientation, an increased psychosocial role, and more appropriate use of health promotion materials. The scheme had influenced over half of the English health authorities and produced a favourable reaction from consumers.
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Claire Anderson: move to a health promotion philosophy |
Health gain
She said that pharmacists should move to a health promotion philosophy, including it in everything they did, so that all interactions with the public became health promoting. "We need to work for health gain, not just lifestyle changes', she said.
While all pharmacists should have a basic philosophy of health promotion there could be two levels of activity. Level one (generalist) would involve encouraging healthy behaviour, setting aside an area for health promotion information and using leaflets to highlight issues, giving simple advice with prescriptions and sales, and about treating symptoms. Level Two (specialist) would involve the pharmacist in actively seeking opportunities to promote health and, when appropriate, identifying stages of change and offering individualised advice and support.
Become more active
Dr Anderson said pharmacists should become more active in health promotion, developing from the display of leaflets to the use of leaflets in response to requests for advice and in opportunistic situations. Pharmacy premises could be used to promote health messages and patient medication records utilised to target specific groups for advice. Pharmacists could collaborate with local medical practices in promoting the uptake of immunisation and screening programmes, and provide health promotion clinics, eg, for smoking cessation and the menopause. Dr Anderson emphasised the importance of pharmacists becoming involved in lobbying for health change at all levels, for example, in tobacco control.
Dr Anderson went on to describe a number of initiatives undertaken in Ealing, Hammersmith and Hounslow. These included (i) using pharmacy windows to display material on emergency contraception, diabetes, folic acid, smoking cessation and stroke, (ii) using pharmacists and nurses as coronary heart disease facilitators and (iii) promoting HIV and AIDS harm limitation through needle exchange and supervised methadone administration.
An EU project was looking at health promotion in primary care, both general practice and community pharmacy. Dr Andesron was a member of the expert group that was developing a definition of health promotion in community pharmacy, and would produce general guidance on best practice, with practical examples. She was also involved in the Boots Pro-Change project on smoking cessation, which had been piloted in Northumberland and was moving to 200 sites in Boots pharmacies and GP surgeries.
Finally, Dr Anderson listed a number of remaining challenges. These included recognising individuals' decisions and choices, seeing health promotion as a way of working, providing accessibility for longer interventions, changing customers' perception that the pharmacist was always busy and recognising the need for greater privacy. Remuneration was also an issue. Dr Anderson said that pharmacists had to take risks and look at space utilisation. Many people were prepared to spend money on their health, and pharmacists should capitalise on this. Prescription customers were more likely to seek and accept general health advice from the pharmacist; other customers posed more of a challenge.
Mr Niall Coggans (senior lecturer, University of Strathclyde) reported two studies of customers' perceptions of health promotion in a pharmacy setting. The first had been based on an initiative by Greater Glasgow health board, which had funded five pharmacy health promotion facilitators to provide training, resource materials and campaign support. Some 591 customers from 14 pharmacies were interviewed at the start of the initiative and again six months later (410, 70 per cent). Over the period there had been an increase in the number who reported learning something useful. Fewer said they had been questioned about their medicines, but more had been questioned about their general health.
There was a decrease in the number of customers who saw pharmacists understanding the difficulties of lifestyle changes, and a decline in those who saw assistants as knowledgeable or helpful. Mr Coggans commented that the negative results might have occurred because of increased expectations.
The aims of the second study, commissioned by the Scottish Executive, had been to identify what aspects of health promotion pharmacy customers were most responsive to, and what methods were appropriate for delivering health promotion in pharmacies. The report was nearing completion.
Unwillingness
The study involved interviewing 20 customers in each of 30 pharmacies in five health board areas, and a pharmacist and assistant from each of the pharmacies. The preliminary results showed that 15 per cent of customers were unwilling to discuss prescribed medicines with the pharmacist, 40 per cent were unwilling to discuss smoking cessation, 65 per cent were unwilling to seek help or information on healthy eating, and 80 per cent were unwilling to discuss taking exercise. Eighty-five per cent of the customers interviewed said there was not enough privacy to discuss personal matters in the pharmacy.
Mr Coggans concluded that health promotion in community pharmacy was an evolving process and there was a need to take customers forward with pharmacy.
Dr Claire Anderson (University of Nottingham) asked Mr Coggans if people who were unwilling to discuss smoking cessation with a pharmacist were also unwilling to discuss it with other people. Mr COGGANS replied this was possible.
Ms Debbie Jamieson (National Pharmaceutical Association) asked if the study had provided any information on why people were unwilling to ask their pharmacist. Mr Coggans replied that privacy was a major issue. People were comfortable with the level of privacy experienced in a GP surgery, but did not necessarily want this in pharmacies at present. This would probably change.
Ms Catherine Hamilton (Lothian Health) said the advice areas provided in Lothian varied from a sign indicating advice was available to a partitioned area of the counter. Pharmacists' views of the success of these arrangements varied, and there was some evidence that people did not want to be seen going into private areas.
Ms Catriona West (associate director, System Three) presented the results of a qualitative evaluation of pharmacy health promotion training sessions delivered jointly by Scottish Centre for Post Qualification Pharmaceutical Education (SCPPE) tutors and health promotion specialists in 1998. The objectives of the training sessions had been to explain the theory and concepts of health promotion, improve knowledge of, and access to, resources, and develop skills in opportunistic health education.
The evaluation aimed to measure the impact on the pharmacists' health promotion activities, identify the factors promoting and hindering such activities, and the extent and nature of partnerships with health promotion specialists. Trainers and attendees had been interviewed face-to-face and by telephone, and the researchers observed activities in community pharmacies.
The views of the trainers varied depending on their previous experience and whether they knew each other. They thought the training objectives had been achieved, though the sessions had been very full, with no time to develop action plans and a lack of concrete examples. SCPPE tutors were more aware of the demands in a community pharmacy and the health promotion specialists felt more distant from the needs of a pharmacy setting. There was a mixed response to working together.
Pharmacists had positive views of the formalised approach to health promotion, increased awareness of health promotion specialists and others involved, and were motivated with a reinforced belief in their contribution. However, they commented on the lack of practical help and specific action plans. They would have preferred a topic-based approach and more on managing health promotion in a pharmacy setting.
The research identified a number of environmental factors that facilitated the development of health promotion in pharmacies, including the public's changing perception of pharmacy, a stable customer base, customers' familiarity with staff, and accessibility.
The main barriers were seen as time and competing demands, lack of space and privacy, and uncertainty about the role. After the training there were more referrals to other health care professionals, increased use of printed materials and other resources, and greater use of counter staff for health promotion activities.