The Pharmaceutical Journal
Vol 273 No 7313 p266-267
21 August 2004

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International Social Pharmacy Workshop

Think beyond the clinical effects of drugs when determining their impact

As medicines continue to form an increasing part of people’s lives, social aspects cannot be separated from clinical or technical decisions about the best use of medicines, stated Louis Deguara, Minister for Health, Government of Malta. Dr Deguara believes that the time has passed when one could consider the costs and distributions of medicines outside the context of sustainability. The ability of the pharmacist to achieve sustainable solutions by careful clinical and financial planning is essential. Of main concern is the concept of social justice. “Can we say that social justice is carried out as regards the distribution of medicines in our world,” he asked. It is not only the availability of new, expensive medicines that concern governments globally, but the sustainability needed to ensure that all citizens reap the benefits of medicines. Epidemiological studies have shown that drug use alone does not save societies from devastation due to cancer, cardiovascular disease, infectious diseases, HIV, AIDS, etc. Rather, one should focus on attaining good social care and attention in preventive health practice, combined with medication that concentrates on quality of life as a relevant parameter. Dr Deguara suggested that the patient’s physical and mental quality of life can be improved through pharmacists’ interventions via the practice of social pharmacy, ie, by actively promoting healthy living and educating patients on medicines use.

Social and cultural phenomena within health care

Medicines are social and cultural phenomena, explained Sjaak van der Geest, lecturer in cultural and medical anthropology, University of Amsterdam, the Netherlands. Aspects that are usually overlooked with medicines include their social, cultural, economic, religious, psychological or emotional effects. This, combined with their therapeutic effects, leads to the total drug effect in a patient. He believes that social pharmacy researchers and health professionals should pay more attention to these aspects in order to understand fully the meaning that medicines play in a patient’s (or carer’s) life. By way of illustration, Professor van der Geest described various social phenomena, a few of which are outlined below.

He presented participants with the scenario of mothers who buy cough medicines in order to alleviate the symptoms of a child’s distressing cough. The social context, he suggested, demands the use of the medicine as they signify that:

· They may help cure the child faster
· They confirm to the child that the mother cares
· They confirm to the mother that she is a good mother
· These messages are repeated to the husband, neighbours and others
· These messages reinforce the health restoring effect on the sick child

Were the child to be ill and the mother did not purchase medicines to help the child, when the husband comes home from work and hears the child coughing, he blames the mother. These social concepts are thus what manufacturers of medicines rely on within advertising campaigns in order to sell more of their products.

Professor van der Geest went on to describe a research project undertaken on communication between doctors and their patients. Following 50 patients before, during and after an encounter with their doctor in a rural health unit, the researcher found that doctors and patients hardly communicated with one another. The practitioner did not hear the patient’s complaint and the patient did not understand the doctor’s diagnosis but, miraculously, both parties felt satisfied about the encounter, which always ended in a prescription.

This research revealed various facets about prescribing medicines that create the illusion of communication and satisfaction among both doctors and patients. It was a way of dealing with uncertainty where often the doctor and patient do not know the exact nature of the complaint or what to do about it and prescribing a medicine gives both parties the feeling of having dealt with the problem. Prescribing is a show of concern on the part of the doctor that indicates he or she is a good doctor. It is also, in many countries, the prerogative of the doctor and this reaffirms their authority over patients and colleagues. The prescription itself, as a written document, signifies in a visual way the superior knowledge and authority of the doctor and is highly significant to the patient. Most of all, for doctors with busy case loads all over the world, it is a ritual and effective way of managing the length of the consultation and allows the patient to leave in a positive mood.

A final illustration of social phenomena within health care concentrated on policy makers. Professor van der Geest said that the term implied that policy makers make policy. Thus, with regard to medicines, this would mean they plan and organise a fair and efficient distribution of medicines. An alternative to this, he suggested, is that they produce paper documents that speak about efficient and equitable medicine distribution. Thus, the culture of policy making is mainly a paper culture and the task of the policy maker is to write documents before a certain deadline and get them accepted by those with political authority. Medicines are therefore just words on paper: real medicines and their safe and fair distribution in society would be a significant political achievement, lending credibility to governments. Medicines are seen as the hard-core of health care, so one would expect policy makers to grab the chance to provide for the health of their population just as the mother cares and provides for her sick child. In reality, although the paperwork relating to medicines may be perfect, inefficiencies and lack of commitment and corruption still exist in governments.

Professor van der Geest urged participants to investigate further issues, such as power and inequality, conflicts of interest, poverty and affluence, economic rationality and globalisation and use these findings to interrogate public health paradigms and professional practice. He concluded: “There is a need to engage more fully in concrete projects of social action and for that we need social insight, political argument, commitment, media involvement and much more, especially in areas such as antibiotic resistance and other major areas of public health.”

Pharmacists can perform role of patient advocate

The practice of pharmacy is a personal and human activity traditionally guided by compassion, justice, dignity and truth, according to Emmanuel Agius, professor of moral theology and philosophical ethics, University of Malta. In recent times, these values have been overshadowed by technological innovations such as pharmacogenetics. However, as human values are so completely integrated with modern health policies, the ideal of a highly technical, purely clinical and “value-free” practice of pharmacy is neither possible nor desirable. Central to this is a professional code of ethics which encompasses beliefs and behaviours to which the professional subscribes, as well as the cultivation of appropriate attitudes and character traits. Pharmacists should be caring and emotionally committed to their patients as individuals who deserve their compassion, concern and trust, in order to manage their health condition and associated lifestyle or therapy changes. This is the way to increase the patient’s autonomy and empowerment. Professor Agius believes that in providing patients with full information regarding risks and benefits in an understandable form, the pharmacist could not only perform the role of educator, but extend this into the new area of patient advocacy. As a patient advocate, pharmacists function as extensions of their patients, defending their rights and providing them with the space to make decisions about their health or lifestyle.

Patients need and desire self-empowerment. Therefore, ethics is not about obeying rules or following a code of ethics. Bringing the human touch to patient-pharmacist interactions by respecting the rights of patients is a development which needs to occur within the pharmacy profession. There are many dramatic changes within health care expected in the field of pharmacogenetics alone. The confusion and complexity surrounding issues such as these has already culminated in an excellent report by the Nuffield Foundation focusing on areas such as information, equity, control and resource implications. Professor Agius impressed upon participants that pharmacists’ skills as patient advocates will be required to support patients’ decisions about their treatment options. Pharmacy input is essential to increase public education, awareness and understanding of pharmacogenetics.

Evaluation of patient counselling in US pharmacies: effect of pharmacist characteristics, pharmacy conditions and regulation

The quality of patient counselling in the US is lower in busy chain stores which do not have private areas in states where the legal requirements to counsel are not stringent. US states with a longer tradition of regulation over counselling standards have impacted positively on patients’ access to counselling by pharmacists. These were the findings of a study conducted by Bonnie Svarstad, professor of social pharmacy, University of Wisconsin-Madison, US. She investigated the interaction between pharmacist characteristics (age, education, etc), pharmacy conditions (ownership, design, workload, etc) and regulatory effects (standards, monitoring and enforcement of regulations, etc), on counselling rates in 384 randomly selected independent pharmacies and chain stores in 44 US states.

In the US, counselling is a legal requirement in many states. In 1990, Congress passed a law requiring pharmacists to counsel Medicaid patients presenting a new prescription. By 1993, 38 states extended this mandate to counsel or “offer to counsel” all patients with a new prescription. With 72 per cent of US pharmacy schools offering some communications training, it was evident that policy-makers and educators were fostering and encouraging this role. However, despite this, international research has consistently showed poor counselling rates among their samples.

Although there may be different reasons for this based on health systems, culture, etc, using a “mystery shopper” methodology, Professor Svarstad and her team discovered that only 44 per cent of medicines were handed out by pharmacists, with assistants handing out 51 per cent, even though this is against the law in the US. Although approximately 90 per cent of patients were provided with a medication leaflet, verbal information was only provided in around 42 to 48 per cent of interactions.

Pharmacists mainly concentrated on closed questions which did not enable “patients” to expand on their own understanding. Independent owners were more likely to hand out medicines and counsel at around 60 per cent. However pharmacy chains were more likely to substitute assistants and undertake less counselling — at rates of between 39 and 49 per cent. Although it was hypothesised that the busier the pharmacy, the less the verbal counselling activity, results showed that the difference in numbers between high and low customer flow is impacting on the quality of patient care significantly, with a fall from 63 to 27 per cent at quiet and busy times, respectively. Those who had a private area were more likely to counsel and it could not be ascertained from the results whether this was because the private area offered the opportunity to counsel or the pharmacy had a private area because it reflected the pharmacist’s commitment to counselling. Younger pharmacists were not more likely to counsel than older ones despite training. However, when they did counsel, they were more likely to provide fuller information on side effects, interactions etc, and not just repeat information from the drug label. Professor Svarstad went on to highlight the “extraordinary variation in standards” between the chains. She stated that all chains were not alike, with counselling rates varying from 11 per cent in the poorest performers to 80 to 90 per cent in the better performers.

She asked participants whether we are experiencing a “corporation effect” within pharmacy and what would be the impact of this. Were there no studies published due to lack of funding, or were researchers anxious about taking on the corporate giants in pharmacy if they had negative results and maybe would not be allowed to publish them? Professor Svarstad called on participants to undertake more research into issues such as regulation monitoring, enforcement methods, corporate culture/ideology and corporate policies on hiring and training of staff. She concluded by stating that pharmacists’ performance “is clearly not just about their education as undergraduates, but also where they work”.