Sequential screening for diabetes—evaluation of a campaign in Swiss community pharmacies

Assessment of community pharmacy professionals' willingness, involvement, beliefs, and barriers to offer health promotion services: a cross-sectional study

INTRODUCTION

The role of community pharmacy professionals has been expanded to patient care and health promotion service globally. However, in Ethiopia, there is a scanty of data on the issue, although the country is dealing with a double burden of non-communicable and communicable diseases.

OBJECTIVES

This study aimed to assess community pharmacy professionals' willingness, involvement, beliefs, and barriers to offer extended services for health promotion in Injibara town, Amhara, Ethiopia.

METHODS

A cross-sectional study was conducted among licensed and registered community pharmacy professionals working in Injibara town from June 25 to July 10, 2022. A structured self-administered questionnaire was used to collect data. The data were presented using descriptive statistics. The data were analyzed using STATA version 16 software.

RESULTS

A total of 24 community pharmacy professionals were involved in the study, with a response rate of 92.3%. Approximately 91.7% of them were involved in health promotional services. Of them, 54.1% were willing and strongly believed that their involvement in health promotion services would have a positive impact on promoting health. A total of 60.9% of the community pharmacy professionals reported that they were very involved in family planning and alcohol consumption counseling. Different barriers to not providing health promotion services were also cited.

CONCLUSIONS

Majority of community pharmacy professionals in this study is involved in health promotional services but there are also barriers on their involvement. Therefore, governmental strategies to overcome the barriers that hamper their involvement should be designed.

Compliance of the POCT method with the fully automated method for HbA1c determination

Previous research suggests that point-of-care (POCT) determination of glycated hemoglobin (HbA1c) is a diagnostic test that can be an adequate alternative to measuring HbA1c in the laboratory. The main goal of this study was to examine the analytical characteristics of the novel INCLIX POCT method for HbA1c determination in order to test its performance before introducing this method into routine use. HbA1c is measured in a duplicate in 44 EDTA blood samples parallel on INCLIX POCT device (Sugitech, Inc.) and using automated turbidimetric immunoinhibition test on Olympus AU400 (Beckman Coulter). The within run imprecision was 7.58%, between runs imprecision was 6.63% and 6.22%, and day-to-day imprecision was 8.80% and 7.51%. Total laboratory imprecision was in agreement with those stated by the manufacturer. A statistically significant Pearson correlation coefficient was calculated (r = 0.871, P < 0.01; linear R2 = 0.757). Using Deming regression analysis, the following equation was obtained: y = - 1.80 + 1.304x. Our results indicate statistically significant correlation, linear relationship, and a significant degree of compatibility between the two analyzed methods. However, the negative bias of the HbA1c values determined on the POCT analyzer compared to the Olympus AU400 was confirmed, highlighting the need to standardize the INCLIX method.

A new Brazilian regional scenario of Type 2 diabetes risk in the next ten years

AIMS

According to a recent national diabetes screening performed by our group in 2018, 18.4% of the Brazilians were found to have high blood glucose. The objective of the present study was to estimate the risk of developing type 2 DM (T2DM) in the next ten years in Brazilian population.

METHODS

A cross-sectional study was carried out in community pharmacies across Brazil, in 2018, where pharmacists applied the FINDRISC questionnaire to estimate the population's risk of developing T2DM within a ten-year period.

RESULTS

The study included 977 pharmacists from 345 municipalities distributed across the five geographical regions of Brazil. Of the 17,580 people evaluated, the South region was found to have the highest frequency (59.6%) among people at very low and/or low risk of developing T2DM, while the North region, the most underserved, presented the highest and/or very highest T2DM risk (24.1%). The factors that mostly and importantly impacted these regional differences were body mass index; the highest daily consumption of vegetables and fruits; history of high blood glucose and family history of T1DM/T2DM.

CONCLUSION

These results showed an impressive change of direction concerning diabetes numbers between the most underserved region in public health care and one of the most developed and best organized regions concerning health assistance, the North and the South, respectively.

Pharmacy-based screening to detect persons at elevated risk of type 2 diabetes: a cost-utility analysis

Background

Early identification of people at elevated risk of type 2 diabetes (T2D) is an important step in preventing or delaying its onset. Pharmacies can serve as a significant channel to reach these people. This study aimed to assess the potential health economic impact of screening and recruitment services in pharmacies in referring people to preventive interventions.

Methods

A decision analytic model was constructed to perform a cost-utility analysis of the expected national health economic consequences (in terms of costs and quality-adjusted life years, QALYs) of a hypothetical pharmacy-based service where people screened and recruited through pharmacies would participate in a digital lifestyle program. Cost-effectiveness was considered in terms of net monetary benefit (NMB). In addition, social return on investment (SROI) was calculated as the ratio of the intervention and recruitment costs and the net present value of expected savings. Payback time was the time taken to reach the break-even point in savings. In the base scenario, a 20-year time horizon was applied. Probabilistic and deterministic sensitivity analyses were applied to study robustness of the results.

Results

In the base scenario, the expected savings from the pharmacy-based screening and recruitment among the reached target cohort were 255.3 m€ (95% CI − 185.2 m€ to 717.2 m€) in pharmacy visiting population meaning 1412€ (95% CI − 1024€ to 3967€) expected savings per person. Additionally, 7032 QALYs (95% CI − 1344 to 16,143) were gained on the population level. The intervention had an NMB of 3358€ (95% CI − 1397€ to 8431€) using a cost-effectiveness threshold of 50,000 €/QALY. The initial costs were 122.2 m€ with an SROI of 2.09€ (95% CI − 1.52€ to 5.88€). The expected payback time was 10 and 8 years for women and men, respectively. Results were most sensitive for changes in effectiveness of the intervention and selected discount rate.

Conclusions

T2D screening and recruitment to prevention programs conducted via pharmacies was a dominant option providing both cost savings and QALY gains. The highest savings can be potentially reached by targeting recruitment at men at elevated risk of T2D.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06948-6.

Experience of point-of-care HbA1c testing in the English National Health Service Diabetes Prevention Programme: an observational study

INTRODUCTION

To report the observations of point-of-care (POC) glycated hemoglobin (HbA1c) testing in people with non-diabetic hyperglycemia (NDH; HbA1c 42-47 mmol/mol (6.0%-6.4%)), applied in community settings, within the English National Health Service Diabetes Prevention Programme (NHS DPP).

RESEARCH DESIGN AND METHODS

A service evaluation assessing prospectively collected national service-level data from the NHS DPP, using data from the first referral received in June 2016-October 2018. Individuals were referred to the NHS DPP with a laboratory-measured HbA1c in the NDH range and had a repeat HbA1c measured at first attendance of the program using one of three POC devices: DCA Vantage, Afinion or A1C Now+. Differences between the referral and POC HbA1c and the SD of the POC HbA1c were calculated. The factors associated with the difference in HbA1c and the association between POC HbA1c result and subsequent attendance of the NHS DPP were also evaluated.

RESULTS

Data from 73 703 participants demonstrated a significant mean difference between the referral and POC HbA1c of -2.48 mmol/mol (-0.23%) (t=157, p<0.001) with significant differences in the mean difference between devices (F(2, 73 700)=738, p<0.001). The SD of POC HbA1c was 4.46 mmol/mol (0.41%) with significant differences in SDs between devices (F(2, 73 700)=1542, p<0.001). Participants who were older, from more deprived areas and from Asian, black and mixed ethnic groups were associated with smaller HbA1c differences. Normoglycemic POC HbA1c versus NDH POC HbA1c values were associated with lower subsequent attendance at behavioral interventions (58% vs 67%, p<0.001).

CONCLUSION

POC HbA1c testing in community settings was associated with significantly lower HbA1c values when compared with laboratory-measured referrals. Acknowledging effects of regression to the mean, we found that these differences were also associated with POC method, location, individual patient factors and time between measurements. Compared with POC HbA1c values in the NDH range, normoglycemic POC HbA1c values were associated with lower subsequent intervention attendance.

Prevalence of people at risk of developing type 2 diabetes mellitus and the involvement of community pharmacies in a national screening campaign: a pioneer action in Brazil

BACKGROUND

Brazil is one of top 10 countries with the highest number of people with diabetes mellitus (DM), affecting 16.8 million peoples. It is estimated that 7.7 million people (20-79 years) in the country have not yet been diagnosed, representing an under-diagnosis rate of 46.0%. Herein we aimed to screen people for high blood glucose or risk for developing type 2 DM (T2DM) through community pharmacies in Brazil.

METHODS

A cross-sectional study was carried out in November 2018, involving 977 pharmacists from 345 municipalities in Brazil. The study evaluated people between 20 and 79 years old without a previous diagnosis of DM. Glycemia was considered high when its value was ≥ 100 mg/dL fasting and ≥ 140 mg/dL in a casual feeding state. The FINDRISC (Finnish Diabetes Risk Score) was used to estimate the risk for developing T2DM. The prevalence of high blood glucose was estimated and the associated factors were obtained using Poisson's multivariate analysis with robust variance.

RESULTS

During the national screening campaign, 17,580 people were tested with the majority of the consultations (78.2%) being carried out in private pharmacies. The population was composed mainly of women (59.5%) and people aged between 20 and 45 years (47.9%). The frequency of participants with high blood glucose was 18.4% (95% CI 17.9-19.0). Considering the FINDRISC, 22.7% of people had a high or very high risk for T2DM. The risk factors associated with high blood glucose were: Body Mass Index > 25 kg/m2, abdominal circumference > 94 cm for men and > 80 cm for women; education level below 15 years of study, no daily intake of vegetables and fruits; previous diagnosis of arterial hypertension; history of high blood glucose and family history of DM.

CONCLUSIONS

This is the largest screening study that evaluated the frequency of high blood glucose and its associated factors in a population without a previous diagnosis ever performed in community pharmacies in Brazil. These results may help to improve public health policies and reinforce the role of pharmacists in screening and education actions aimed at this undiagnosed population in a continent-size country such as Brazil.

Opportunistic screening for type 2 diabetes in community pharmacies. Results from a region-wide experience in Italy

Background and aims

Given the paucity of symptoms in the early stages of type 2 diabetes, its diagnosis is often made when complications have already arisen. Although systematic population-based screening is not recommended, there is room to experience new strategies for improving early diagnosis of the disease in high risk subjects. We report the results of an opportunistic screening for diabetes, implemented in the setting of community pharmacies.

Methods and results

To identify people at high risk to develop diabetes, pharmacists were trained to administer FINDRISC questionnaire to overweight, diabetes-free customers aged 45 or more. Each interviewee was followed for 365 days, searching in the administrative database whether he/she had a glycaemic or HbA1c test, or a diabetologists consultation, and to detect any new diagnosis of diabetes defined by either a prescription of any anti-hyperglycaemic drug, or the enrolment in the register of patients, or a hospital discharge with a diagnosis of diabetes.

Out of 5977 interviewees, 53% were at risk of developing diabetes. An elevated FINDRISC score was associated with higher age, lower education, and living alone. Excluding the number of cases expected, based on the incidence rate of diabetes in the population, 51 new cases were identified, one every 117 interviews. FINDRISC score, being a male and living alone were significantly associated with the diagnosis.

Conclusions

The implementation of a community pharmacy-based screening programme can contribute to reduce the burden of the disease, particularly focusing on people at higher risk, such as the elderly and the socially vulnerable.

Middle-aged Health Checks Program Outputs in Non-communicable Diseases Screening in Iran

Background

The aim of the present study is identifying the outputs of middle-aged health checks program (MAHCP) in Isfahan province in central of Islamic Republic of Iran.

Methods

This is a cross-sectional study. During 30 months, from March 2014 to September 2016, 30-59 years old females and males were screened for abdominal obesity, overweight, obesity, physical inactivity, dyslipidemia, hypertension, diabetes, and also breast, skin, cervix, colorectal, and prostate cancers in all health houses, health posts, and health centers in the province. Based on the data bank of the family health office of the health center of Isfahan province, we estimated the outputs of MAHCP.

Results

The utilization rate of MAHCP was 0.39-273.06 per 1000 middle-aged population (MAP). The utilization rate in 2015 was higher for women (43.02-273.06 per 1000 MAP), particularly in rural areas (273.06 per 1000 MAP). The case detection rate of physical inactivity was 26.40-498.6, abdominal obesity was 16.50-428.38, overweight was 38.73-365.59, obesity was 3.30-261.99, and body mass index (BMI) ≥25 was 63.21-593.41 per 1000 MAP. Also dyslipidemia was 21.51-171.62, hypertension was12.33-53.88, and diabetes mellitus was 10.71 - 36.99 per 1000 MAP. Cancers detection rate in women included: breast cancers (99.52-330.32), skin (14.24-245.52), cervix (11.94-87.43), and colorectal (0-47.4) per 100,000 MAP. Cancer detection rate in men included: skin (0-59.18), colorectal (0-80.06), and prostate (0-42.03) per 100,000 MAP.

Conclusions

The MAHCP utilization rate in both the genders, particularly in men, was lower than it had been expected.

Quality Control of Norwegian Pharmacy HbA1c Testing: A Modest Beginning

BACKGROUND

Many pharmacy services involve laboratory testing using point-of-care (POC) instruments. Our aim was to describe the implementation of quality control of the HbA1c POC instruments and investigate the performance in internal quality control (IQC) and external quality control (EQA) for HbA1c POC instruments in Norwegian community pharmacies.

METHODS

Two project pharmacists from each of 11 pharmacies participated in a training program covering capillary blood sampling, how to use the POC HbA1c instrument (DCA Vantage) and IQC and EQA. The pharmacies were enrolled in an EQA program for HbA1c, and their performance was compared with that of general practitioners' (GP) offices.

RESULTS

Two of 89 (2.2%) IQC measurements were outside the acceptance interval. Seven out of 11 pharmacies sent in results in EQA in all the three surveys during six months. Two pharmacies did not analyze the control material in any of the surveys, one pharmacy analyzed the control material in one of the surveys, and one pharmacy analyzed two of the surveys. Of these pharmacies, 56-100% obtained "very good" evaluation for trueness and 71-100% obtained "very good" evaluation for precision. The corresponding numbers for GP offices were 75-87% for trueness and 84-94% for precision. No pharmacies obtained a "poor" evaluation.

CONCLUSIONS

Norwegian community pharmacies can perform IQC and EQA on a HbA1c POC instrument, and the performance is comparable with that of GP offices. The compliance in the EQA surveys was modest, but the duration of the study and participation in the EQA program was probably too short to implement all the new procedures for all pharmacies.

Risk assessment and HbA1c measurement in Norwegian community pharmacies to identify people with undiagnosed type 2 diabetes - A feasibility study

OBJECTIVES

Determine the feasibility of using a diabetes risk assessment tool followed by HbA1c-measurement in a community-pharmacy setting in Norway.

METHODS

In this longitudinal study two pharmacists in each of three community pharmacies were trained to perform risk assessments, HbA1c-measurements and counselling. Pharmacy customers who were > 18 years old and could understand and speak Norwegian or English were recruited in the pharmacies during a two-months-period. Information about the service was presented in local newspapers, social media, leaflets and posters at the pharmacy. Customers wishing to participate contacted the pharmacy staff. Participants completed a validated diabetes risk test and a background questionnaire including a validated instrument for self-rated health. A HbA1c measurement was performed for individuals with a moderate to high risk of developing diabetes. If HbA1c ≥ 6.5% they were recommended to visit their general practitioner for follow-up. The pharmacies performed internal and external quality control of the HbA1c instrument.

RESULTS

Of the 211 included participants 97 (46%) were > 50 years old. HbA1c was measured for the 47 participants (22%) with high risk. Thirty-two (15%) had HbA1c values < 5.7%, twelve (5.4%) had values between 5.7%-6.4%, and three (1.4%) had an HbA1c ≥ 6.5%. Two participants with HbA1 ≥ 6.5% were diagnosed with diabetes by their general practitioner. The third was lost to follow-up. Results from internal and external quality control for HbA1c were within set limits.

CONCLUSION

The pharmacists were able to perform the risk assessment and measurement of HbA1c, and pharmacy customers were willing to participate. The HbA1c measurements fulfilled the requirements for analytical quality. Thus, it is feasible to implement this service in community pharmacies in Norway. In a large-scale study the inclusion criteria should be increased to 45 years in accordance with the population the risk test has been validated for.

Barriers to promote cardiovascular health in community pharmacies: a systematic review

Community pharmacists play an important role in the provision of health promotion services, and community pharmacies are considered as a potentially ideal site for cardiovascular health promotion. Information based on a systematic review of barriers to promoting cardiovascular health in community pharmacy is currently lacking. We have sought to identify the most important barriers to cardiovascular health promotion in the community pharmacy. We have systematically searched PubMed and International Pharmaceutical Abstracts for a period of 15 years from 1 April 1998 to 1 April 2013, contacted subject experts and hand-searched bibliographies. We have included peer-reviewed articles, with English abstracts in the analysis, if they reported community pharmacists' perceptions of the barriers to cardiovascular health promotion activities in a community pharmacy setting. Two reviewers have independently extracted study characteristics and data. We identified 24 studies that satisfy the eligibility criteria. The main barriers to cardiovascular health promotion in the community pharmacy included pharmacist-related factors; practice site factors; financial factors; legal factors; and patient-related factors. This review will help to provide reliable evidence for health promotion practitioners of the barriers to promoting cardiovascular health in the community pharmacy setting. This knowledge is valuable for the improvement of cardiovascular health promotion in this setting and guiding future research.

Community pharmacy COPD services: what do researchers and policy makers need to know?

COPD is a leading cause of morbidity and mortality across the world and is responsible for a disproportionate use of health care resources. It is a progressive condition that is largely caused by smoking. Identification of early stage COPD provides an opportunity for interventions, such as smoking cessation, which prevent its progression. Once diagnosed, ongoing support services potentially provide an opportunity to assist the patient in managing their condition and working more closely with the rest of the primary care team. While there are a number of robust studies which have demonstrated the role which pharmacists could undertake to identify and prevent disease progression, adoption of such services is currently limited. As a service that would seem to be appropriate for adoption in all societies where smoking is prevalent, we have performed a review of reported approaches that have been used when setting up and evaluating such services, and therefore aim to inform researchers and policy makers in other countries on how best to proceed. Implementation science has been used to further contextualize the findings of the review in terms of components that are likely to enhance the likelihood of implementation. With reference to screening services, we have made clear recommendations as to the identification of patients, structure and smoking cessation elements of the program. Further work needs to be undertaken by policy makers to determine the approaches that can be used to motivate pharmacists to provide this service. In terms of ongoing support services, there is some evidence to suggest that these would be effective and cost-effective to the health service in which they are implemented. However, the capability, opportunity and motivation of pharmacists to provide these, more complex, services need to be the focus for researchers before implementation by policy makers.

Pharmacy Intervention to Improve HIV Testing Uptake Using a Comprehensive Health Screening Approach

OBJECTIVE

HIV testing is increasingly available, yet barriers to HIV testing persist for low-income black and Latino people, especially those who use illicit drugs. HIV exceptionalism, or the idea that a positive HIV diagnosis is drastically different from a diagnosis for any other disease, may influence HIV testing-related stigma, resulting in reduced willingness to undergo HIV testing. This pharmacy-based intervention combined HIV testing with less stigmatized chronic disease screening tests (e.g., blood pressure, glucose, and cholesterol) to equate the concept of an HIV diagnosis with other diagnoses.

METHODS

Three pharmacies located in low-income, minority neighborhoods in New York City were enrolled in an intervention to provide (1) HIV testing, chronic disease screening, and a healthy lifestyles video that normalized all screening tests and destigmatized HIV as a fatal disease (comprehensive arm); (2) HIV testing and the video (video arm); and (3) HIV testing only (control arm). Injection drug users (IDUs) and pharmacy staff recruited un- and underinsured pharmacy customers, IDUs, and IDU peers from 2010 to 2012. Participants in the control group were compared with those in the comprehensive and video intervention groups.

RESULTS

Participants in the comprehensive arm (prevalence ratio [PR] = 1.61, 95% confidence interval [CI] 1.03, 2.49, p=0.08) and the video arm (PR=1.59, 95% CI 1.00, 2.53, p=0.09) were marginally significantly more likely to receive an HIV test in the pharmacy compared with those in the control arm after adjustment.

CONCLUSIONS

These findings suggest that adoption of strategies that destigmatize and normalize HIV testing can improve uptake. Implementation of this strategy in low-access, minority communities with high HIV prevalence and among high-risk populations may help reduce racial/ethnic disparities in HIV.

Assessment of a screening protocol for type 2 diabetes in community pharmacy. The DiabNow Study

The aim of this study was to assess the performance and feasibility of a protocol for screening type 2 diabetes in community pharmacy. Performance was primarily assessed by measuring stakeholders' adherence (pharmacists, patients and physicians) to the protocol's components.

Australian community pharmacy services: a survey of what people with chronic conditions and their carers use versus what they consider important

OBJECTIVE

To explore the purpose/s for which people with chronic conditions and their carers use Australian community pharmacies, and compare this to what pharmacy services they consider important, from the perspectives of both consumers and pharmacists.

DESIGN

An exploratory study involving a survey, which asked participants to indicate the pharmacy services they had ever used, and rate the importance of 22 pharmacy services to them, or the person they care for, or for their consumers if a pharmacist.

SETTING

Four regions of Australia: Logan-Beaudesert and Mt Isa/North West region, Queensland, Northern Rivers, New South Wales, and the Greater Perth area, Western Australia.

PARTICIPANTS

Surveys were undertaken with 602 consumers and 91 community pharmacists.

RESULTS

Community pharmacy is predominantly used to obtain advice about medication and whether a doctor's visit is necessary, as well as for monitoring and screening services. Pharmacy services that were patient centric were important, such as individualised medication advice and respectful care, as well as tools or procedures to facilitate streamlined medication access. Less important services included adult vaccinations and health and wellness programmes. Carers identified services that assisted them with their specific role/s to be important. Overall, community pharmacists had a good understanding of the services that were important to people with chronic conditions and their carers.

CONCLUSIONS

People with chronic conditions and their carers not only care about what services are delivered, but how they are delivered; they sought services that generally improved their access to medication and information, but in a way that was patient centred. Ultimately, pharmacists understood the importance of patient-centred care for people with chronic conditions and their carers, perhaps indicating a greater acceptance of integrating patient-centred care into their everyday practice.

Pharmaceutical services and health promotion: how far have we gone and how are we faring? Scientific output in pharmaceutical studies

The objective of this study was to investigate the scientific output on health promotion within the pharmaceutical field and its relation with the development of pharmaceutical services within health systems. A comprehensive review of published scientific articles from the Medline and Lilacs databases was carried out. The review comprised articles published until December 2011, and used combinations of the terms 'health promotion' or 'health education' and 'pharmacy', 'pharmacist' or 'pharmaceutical'. The articles were selected according to inclusion and exclusion criteria. A total of 170 full texts and 87 indexed abstracts were analyzed, evidencing that most described actions of health promotion in community pharmacies and other services. Following the Ottawa Charter, most of the studies dealt with new guidance of the service and the supply of pharmaceutical information and services. It was concluded that there is a lack of theoretical background on health promotion in the pharmaceutical field to sustain the professional education and practice required by the health system and the population.

The effectiveness of screening for diabetes and cardiovascular disease risk factors in a community pharmacy setting

Risk factors for cardiovascular disease including diabetes have seen a large rise in prevalence in recent years. This has prompted interest in prevention through the identifying individuals at risk of both diabetes and cardiovascular disease and has seen increased investment in screening interventions taking place in primary care. Community pharmacies have become increasingly involved in the provision of such interventions and this systematic review and meta-analysis aims to gather and analyse the existing literature assessing community pharmacy based screening for risk factors for diabetes and those with a high cardiovascular disease risk.

Methods

We conducted systematic searches of electronic databases using MeSH and free text terms from 1950 to March 2012. For our analysis two outcomes were assessed. They were the percentage of those screened who were referred for further assessment by primary care and the uptake of this referral.

Results

Sixteen studies fulfilled our inclusion criteria comprising 108,414 participants screened. There was significant heterogeneity for all included outcomes. Consequently we have not presented summary statistics and present forest plots with I² and p values to describe heterogeneity. We found that all included studies suffered from high rates of attrition between pharmacy screening and follow up. We have also identified a strong trend towards higher rates for referral in more recent studies.

Conclusions

Our results show that pharmacies are feasible sites for screening for diabetes and those at risk of cardiovascular disease. A significant number of previously unknown cases of cardiovascular disease risk factors such as hypertension, hypercholesterolemia and diabetes are identified, however a significant number of referred participants at high risk do not attend their practitioner for follow up. Research priorities should include methods of increasing uptake to follow up testing and early intervention, to maximise the efficacy of screening interventions based in community pharmacies.

Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults

BACKGROUND

Obesity is a global public health threat. The transtheoretical stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably. 

OBJECTIVES

To assess the effectiveness of dietary intervention or physical activity interventions, or both, and other interventions based on the transtheoretical model (TTM) stages of change (SOC) to produce sustainable (one year and longer) weight loss in overweight and obese adults.

SEARCH METHODS

Studies were obtained from searches of multiple electronic bibliographic databases. We searched The Cochrane Library, MEDLINE, EMBASE and PsycINFO. The date of the last search, for all databases, was 17 December 2013.

SELECTION CRITERIA

Trials were included if they fulfilled the criteria of randomised controlled clinical trials (RCTs) using the TTM SOC as a model, that is a theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical activity interventions, versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss, measured as change in weight or body mass index (BMI); participants were overweight or obese adults only; and the intervention was delivered by healthcare professionals or trained lay people at the hospital and community level, including at home.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data, assessed studies for risk of bias and evaluated overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). We resolved disagreements by discussion or consultation with a third party. A narrative, descriptive analysis was conducted for the systematic review.

MAIN RESULTS

A total of three studies met the inclusion criteria, allocating 2971 participants to the intervention and control groups. The total number of participants randomised to the intervention groups was 1467, whilst 1504 were randomised to the control groups. The length of intervention was 9, 12 and 24 months in the different trials. The use of TTM SOC in combination with diet or physical activity, or both, and other interventions in the included studies produced inconclusive evidence that TTM SOC interventions led to sustained weight loss (the mean difference between intervention and control groups varied from 2.1 kg to 0.2 kg at 24 months; 2971 participants; 3 trials; low quality evidence). Following application of TTM SOC there were improvements in physical activity and dietary habits, such as increased exercise duration and frequency, reduced dietary fat intake and increased fruit and vegetable consumption (very low quality evidence). Weight gain was reported as an adverse event in one of the included trials. None of the trials reported health-related quality of life, morbidity, or economic costs as outcomes. The small number of studies and their variable methodological quality limit the applicability of the findings to clinical practice. The main limitations include inadequate reporting of outcomes and the methods for allocation, randomisation and blinding; extensive use of self-reported measures to estimate the effects of interventions on a number of outcomes, including weight loss, dietary consumption and physical activity levels; and insufficient assessment of sustainability due to lack of post-intervention assessments.

AUTHORS' CONCLUSIONS

The evidence to support the use of TTM SOC in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn. When combined with diet or physical activity, or both, and other interventions we found very low quality evidence that it might lead to better dietary and physical activity habits. This systematic review highlights the need for well-designed RCTs that apply the principles of the TTM SOC appropriately to produce conclusive evidence about the effect of TTM SOC lifestyle interventions on weight loss and other health outcomes.

Screening for major diseases in community pharmacies: a systematic review

OBJECTIVES

The aim of this systematic review was to assess the published evidence about the feasibility and acceptability of community pharmacy-based screening for major diseases.

METHOD

Studies published between January 1990 and August 2012 involving community pharmacy-based screening interventions, published in the English language, were identified from electronic databases. Reference lists of included studies were also searched.

KEY FINDINGS

Fifty studies (one randomised controlled trial, two cluster randomised studies, five non-randomised comparative studies and 42 uncontrolled studies) were included. The quality of most of these was assessed as poor. Screening was mostly opportunistic and screening tools included questionnaires or risk assessment forms, medical equipment to make physiological measurements, or a combination of both. Few studies assessed the accuracy of pharmacy-based screening tools. More than half of the screening interventions included an element of patient education. The proportion of screened individuals, identified with disease risk factors or the disease itself, ranged from 4% to 89%. Only 10 studies reported any economic information. Where assessed, patient satisfaction with pharmacy-based screening was high, but individuals who screened positive often did not follow pharmacist advice to seek further medical help.

CONCLUSION

Available evidence suggests that screening for some diseases in community pharmacies is feasible. More studies are needed to compare effectiveness and cost-effectiveness of pharmacy-based screening with screening by other providers. Strategies to improve screening participants' adherence to pharmacist advice also need to be explored. This systematic review will help to inform future studies wishing to develop community pharmacy-based screening interventions.

Preventive counselling for public health in pharmacies in South Germany

BACKGROUND

No overview of preventive health activities conducted by pharmacists in South Germany has been available until now. Moreover, little about the needs of the public is known with regard to pharmacy-based preventive services.

OBJECTIVES

To gain an overview of the preventive health services and campaigns carried out by pharmacists in the federal state of Bavaria, and to assess the interest of the public for pharmacy-based preventive care counselling.

SETTING

Pharmacies in the seven Bavarian administrative districts, South Germany.

METHODS

In September 2010, all 3,470 pharmacies in Bavaria were mailed a questionnaire concerning their preventive health activities. The pharmacists were given the opportunity to complete the questionnaire either online or to mail them in. To assess the needs of pharmacy-based preventive health services in the Bavarian population, customers of 50 pharmacies were invited to fill in an anonymous self-completion questionnaire in March 2011.

MAIN OUTCOME MEASURE

Relevant preventive health services which can be provided by pharmacists in order to meet the customers' needs.

RESULTS

519 of 3,470 pharmacies (15.0 %) took part in the survey. 60.5 % (n = 314) conducted at least one preventive health activity in the past and 51.6 % (n = 268) offering a disease prevention education event at least once a year. As a result of the pharmacists' survey, a ranking list of the most frequent preventive care activities was established. The projects conducted often lacked structured project schedules and evaluations. The survey assessing customer needs was completed by 1,808 customers in 49 of 50 community pharmacies. Pharmacists were identified as the preferred provider in 29 of the 31 preventive care services listed in the questionnaire. A ranking list with the top ten preventive subjects of highest interest was compiled.

CONCLUSIONS

Pharmacists are active in many different prevention subjects and there is a great interest in pharmacy-based preventive care counselling in the Bavarian population. Very few structured, well planned and evaluated preventive projects have been conducted in Bavarian community pharmacies. Further surveys are needed to analyse the benefit of pharmacy-based preventive care counselling for the Bavarian population.

Opportunistic screening and health promotion for type 2 diabetes: an expanding public health role for the community pharmacist

BACKGROUND

Early detection to identify people at risk of diabetes is an important approach to prevent or delay type 2 diabetes. This study aimed to implement the Diabetes Prevention Program in community pharmacy using a diabetes risk prediction tool.

METHODS

The program was conducted in seven pharmacies in Bangkok, Thailand. Participants were the pharmacy's clients aged ≥ 35 years without the history of diabetes. A validated risk prediction tool was used to assess individuals' diabetes risk. Educational information was offered to all participants. Those with a high risk score (≥ 9 out of 17) were offered a self-check of fasting capillary blood glucose (CBG). A referral was made for those with CBG ≥ 126 mg/dl.

RESULTS

During a 3-month service, 397 individuals participated in the program. Nearly half of the participants (49.4%) were at a high risk of diabetes (risk score: ≥ 9). Ninety five (48.5%) of these high risk individuals undertook fasting CBG. Elevated fasting CBG (≥ 126 mg/dl) was found in 12 persons (12.7%). Overall, two patients with diabetes were identified during the provision of the program.

CONCLUSIONS

The Diabetes Prevention Program in community pharmacies uncovered half of the clients who were at risk of diabetes and provided an opportunity for participants to learn more about the prevention of diabetes.

Screening and identifying diabetes in optometric practice: a prospective study

BACKGROUND

Unconventional settings, outside general medical practice, are an underutilised resource in the attempt to identify the large numbers of people with undiagnosed diabetes worldwide.

AIM

The study investigated the feasibility of using optometry practices (opticians) as a setting for a diabetes screening service.

DESIGN AND SETTING

Adults attending high street optometry practices in northern England who self-reported at least one risk factor for diabetes were offered a random capillary blood glucose (rCBG) test. Those with raised rCBG levels were asked to visit their GP for further investigations.

RESULTS

Of 1909 adults attending practices for sight tests, 1303 (68.2%) reported risk factors for diabetes, of whom 1002 (76.9%) had rCBG measurements taken. Of these, 318 (31.7%) were found to have a rCBG level of ≥6.1 mmol/l, a level where further investigations are recommended by Diabetes UK; 1.6% of previously undiagnosed individuals were diagnosed with diabetes or pre-diabetes as a result of the service. Refining the number of risk factors for inclusion would have reduced those requiring screening by half and still have identified nearly 70% of the new cases of diabetes and pre-diabetes.

CONCLUSION

Screening in optometric practices provides an efficient opportunity to screen at-risk individuals who do not present to conventional medical services, and is acceptable and appropriate. Optometrists represent a skilled worldwide resource that could provide a screening service. This service could be transferable to other settings.

Ideal and actual involvement of community pharmacists in health promotion and prevention: a cross-sectional study in Quebec, Canada

Background

An increased interest is observed in broadening community pharmacists' role in public health. To date, little information has been gathered in Canada on community pharmacists' perceptions of their role in health promotion and prevention; however, such data are essential to the development of public-health programs in community pharmacy. A cross-sectional study was therefore conducted to explore the perceptions of community pharmacists in urban and semi-urban areas regarding their ideal and actual levels of involvement in providing health-promotion and prevention services and the barriers to such involvement.

Methods

Using a five-step modified Dillman's tailored design method, a questionnaire with 28 multiple-choice or open-ended questions (11 pages plus a cover letter) was mailed to a random sample of 1,250 pharmacists out of 1,887 community pharmacists practicing in Montreal (Quebec, Canada) and surrounding areas. It included questions on pharmacists' ideal level of involvement in providing health-promotion and preventive services; which services were actually offered in their pharmacy, the employees involved, the frequency, and duration of the services; the barriers to the provision of these services in community pharmacy; their opinion regarding the most appropriate health professionals to provide them; and the characteristics of pharmacists, pharmacies and their clientele.

Results

In all, 571 out of 1,234 (46.3%) eligible community pharmacists completed and returned the questionnaire. Most believed they should be very involved in health promotion and prevention, particularly in smoking cessation (84.3%); screening for hypertension (81.8%), diabetes (76.0%) and dyslipidemia (56.9%); and sexual health (61.7% to 89.1%); however, fewer respondents reported actually being very involved in providing such services (5.7% [lifestyle, including smoking cessation], 44.5%, 34.8%, 6.5% and 19.3%, respectively). The main barriers to the provision of these services in current practice were lack of: time (86.1%), coordination with other health care professionals (61.1%), staff or resources (57.2%), financial compensation (50.8%), and clinical tools (45.5%).

Conclusions

Although community pharmacists think they should play a significant role in health promotion and prevention, they recognize a wide gap between their ideal and actual levels of involvement. The efficient integration of primary-care pharmacists and pharmacies into public health cannot be envisioned without addressing important organizational barriers.

Transtheoretical model for dietary and physical exercise modification in weight loss management for overweight and obese adults

BACKGROUND

Obesity is a global public health threat. The transtheoretical model stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably. 

OBJECTIVES

To assess the effectiveness of dietary and physical activity interventions based on the transtheoretical model, to produce sustainable weight loss in overweight and obese adults.

SEARCH STRATEGY

Studies were obtained from searches of multiple electronic bibliographic databases. Date of last search for The Cochrane Library was issue 10, 2010, for MEDLINE Dezember 2010, for EMBASE January 2011 and for PSYCHINFO Januar 2011.

SELECTION CRITERIA

Trials were included if they fulfilled the following criteria: randomised controlled clinical trials using TTM SOC as a model, theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical exercise versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss; and participants were overweight or obese adults.

DATA COLLECTION AND ANALYSIS

Two researchers independently applied the inclusion criteria to the identified studies and assessed risk of bias. Disagreement was resolved by discussion or by intervention of a third party. Descriptive analysis was conducted for the review.

MAIN RESULTS

A total of five studies met the inclusion criteria and a total of 3910 participants were evaluated. The total number of participants randomised to intervention groups was 1834 and 2076 were randomised to control groups. Overall risk of bias was high. The trials varied in length of intervention from six weeks to 24 months, with a  median length of nine months. The intervention was found to have limited impact on weight loss (about 2 kg or less) and other outcome measures. There was no conclusive evidence for sustainable weight loss. However, TTM SOC and a combination of physical activity, diet and other interventions tended to produce significant outcomes (particularly change in physical activity and dietary intake). TTM SOC was used inconsistently as a theoretical framework for intervention in the trials. Death and weight gain are the two adverse events reported by the included trials. None of the trials reported health-related quality of life, morbidity, and costs as outcomes.

AUTHORS' CONCLUSIONS

TTM SOC and a combination of physical activity, diet and other interventions resulted in minimal weight loss, and there was no conclusive evidence for sustainable weight loss. The impact of TTM SOC as theoretical framework in weight loss management may depend on how it is used as a framework for intervention and in combination with other strategies like diet and physical activities.

Screening for type 2 diabetes and dysglycemia

Type 2 diabetes mellitus (T2DM) and dysglycemia (impaired glucose tolerance and/or impaired fasting glucose) are increasingly contributing to the global burden of diseases. The authors reviewed the published literature to critically evaluate the evidence on screening for both conditions and to identify the gaps in current understanding. Acceptable, relatively simple, and accurate tools can be used to screen for both T2DM and dysglycemia. Lifestyle modification and/or medication (e.g., metformin) are cost-effective in reducing the incidence of T2DM. However, their application is not yet routine practice. It is unclear whether diabetes-prevention strategies, which influence cardiovascular risk favorably, will also prevent diabetic vascular complications. Cardioprotective therapies, which are cost-effective in preventing complications in conventionally diagnosed T2DM, can be used in screen-detected diabetes, but the magnitude of their effects is unknown. Economic modeling suggests that screening for both T2DM and dysglycemia may be cost-effective, although empirical data on tangible benefits in preventing complications or death are lacking. Screening for T2DM is psychologically unharmful, but the specific impact of attributing the label of dysglycemia remains uncertain. Addressing these gaps will inform the development of a screening policy for T2DM and dysglycemia within a holistic diabetes prevention and control framework combining secondary and high-risk primary prevention strategies.

Economic analysis of the diabetes and hypertension screening collaboration between community pharmacies and a Thai government primary care unit

AIMS

To evaluate models for collaboration between community pharmacies and a government primary care unit (PCU) in carrying out a screening program for diabetes and hypertension.

METHODS

An action research was undertaken and a screening and referring protocol developed. Study sites were two community pharmacies (Model 1) and footpaths/streets and seven communities (Model 2) under supervision of PCU in the city of Maha Sarakham Province, Thailand. The Combined Model consisted of Models 1 and 2. Those eligible were aged 40 years and over, not known to have diabetes or hypertension. Activity based costing of three models was analyzed from the provider perspective.

RESULTS

The study involved 456 people during July-September 2007; 11 out of 51 attending pharmacies (21.6%) and 27 out of 405 attending the communities (6.6%) met criteria for referral to PCU for confirmatory diagnosis. Only six attended the PCU. Two of 456 (0.4%) were confirmed the diagnosis having hypertension, one was referred from a pharmacy (2%, 1/51) the other from a community (0.2%, 1/405). Model unit costs were US$ 11.2, 4.3 and 5.1 per screened person, respectively.

CONCLUSIONS

The results indicate a working model can identify people in the community requiring treatment of hypertension or diabetes. Pharmacy-based screening was more costly, but the success rate for referral was higher compared with a community-based service. More effort is needed to ensure referred patients attend the PCU.

Implementation of a method for glucose measurements in community pharmacies

Objectives

We aimed to implement a method for glucose measurements that could be used as a comparison method for asessing patients' self-monitoring of blood glucose. Further, we investigated whether pharmacies could achieve an analytical quality comparable to glucose measurements performed in general practice.

Methods

Sixteen Norwegian pharmacy employees were trained in glucose measurement, quality control and blood sampling. The comparison method, HemoCue Glucose 201+, was validated in four steps: (1) estimation of the variation between the HemoCue instruments to be used at the 16 pharmacies, (2) comparison between HemoCue results and a laboratory glucose method, (3) monitoring quality by internal quality controls and (4) an external quality-assessment scheme. The pharmacies' results of the external quality assessment were compared to those of 359 general practices.

Key findings

The coefficient of variation for HemoCue instruments was 6.1% at the low level and 1.7% at the normal and high levels. Bias was negligible at the normal level. The coefficients of variation for internal quality controls were 4.5, 1.5 and 1.2% for the low, normal and high levels, respectively. All pharmacies achieved good precision and acceptable or good trueness in the external quality assessment. The pharmacies exhibited significantly lower variation between sites (2.2 and 1.2%) than general practices (3.8 and 2.9%) on both external quality-assessment samples.

Conclusions

Given correct training and the establishment of a system of quality assurance, pharmacies are capable of obtaining glucose measurements that can be used as comparison measurements for controlling patients' meters. The pharmacies had external quality-assessment results comparable to general practice.

Identification of persons with dysglycemia: terminology and practical significance

Allocating scarce resources for dysglycemia intervention requires identification of persons who will benefit. Identification has two steps: screening followed by diagnosis. Lowering a screening test's cut-off score identifies more persons with dysglycemia, but causes more normoglycemic persons to receive diagnostic testing. Raising a test's cut-off score reduces needless diagnostic testing, but increases the number falsely identified as not having dysglycemia. With limited budgets for intervention, raising a screening test's cut-off score may be appropriate. With ample budgets, lowering the test's cut-off score may be appropriate. Screening tests are most efficient in populations with high prevalence of dysglycemia.

Change of body weight and lifestyle of persons at risk for diabetes after screening and counselling in pharmacies

OBJECTIVE

To investigate the effects of pharmacy based counselling on changes in lifestyle and body weight.

METHODS

Three months after screening a stratified sample of 3,800 randomly chosen overweight persons were addressed with questionnaires. Half a year and 1 year later the assessment was repeated. Standard counselling (SC; non-specific recommendations towards lifestyle), intensive counselling (IC; additional advice to reduce body weight) and counselling for persons at high risk for type 2 diabetes (HRC; recommendation to contact a physician) were compared.

RESULTS

All counselling groups (SC; n = 557, IC; n = 568, HRC; n = 245) showed significant weight loss three months after screening (0.6-1.9 kg). A further weight reduction was observed at 1 year follow up (1.1-2.4 kg). The HRC group showed a higher percentage of weight loss than the IC or SC group after 3 months (-2.25% vs. -1.20% and -0.67%; P < 0.001) and at 1 year of follow-up (-2.74% vs. -1.54% and -1.29%; P < 0.01). Lifestyle changes in physical activity and/or nutrition were reported by 81.2% in the HRC group, 74.1% in the IC group and 67.0% in the SC group.

CONCLUSION

Immediate counselling in community pharmacies after screening for type 2 diabetes can result in significant lifestyle changes and weight loss in overweight individuals.