Equipping community pharmacy workers as agents for health behaviour change: developing and testing a theory-based smoking cessation intervention

Barriers to smoking interventions in community healthcare settings: a scoping review

Smoking is one of the major causes of preventable death and is considered the greatest threat to global public health. While the prevalence of smoking has decreased, population growth has led to an increase in the absolute number of smokers. There are many proven smoking cessation interventions available to support smokers in their quit attempts. Most people who smoke, however, underutilize the treatments available to them. This scoping review aimed to identify the current barriers experienced by all stakeholders (smokers, service providers and policymakers) to existing evidence-based smoking cessation interventions in community healthcare settings. Five electronic databases (CINAHL, Ovid MEDLINE, PsycINFO, Scopus and Web of Science) were searched for relevant literature. A total of 40 eligible articles from different countries published between 2015 and 2022 were included in the review and content analysis carried out to identify the key barriers to smoking cessation interventions. Seven key themes were found to be common to all stakeholders: (i) literacy, (ii) competing demands and priorities, (iii) time, (iv) access to product, (v) access to service, (vi) workforce and (vii) motivation/readiness. These themes were mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. This study presents the effect the barriers within these themes have on current smoking cessation services and highlights priorities for future interventions.

Closing the Tobacco Treatment Gap: A Qualitative Study of Tobacco Cessation Service Implementation in Community Pharmacies

Tobacco use remains a leading preventable cause of morbidity and mortality, with pharmacotherapy and counseling recognized as effective cessation aids. Yet, the potential role of pharmacists and pharmacy technicians in tobacco cessation services is underutilized. This study explores the integration of such services in community pharmacies, identifying facilitators and barriers to their implementation. A qualitative study was conducted across seven community pharmacies in California that were affiliated with the Community Pharmacy Enhanced Services Network. Participants included 22 pharmacists and 26 pharmacy technicians/clerks who completed tobacco cessation training. Data were collected through semi-structured interviews, focusing on experiences with implementing cessation services. The analysis was guided by Rogers' Diffusion of Innovations Theory. MAXQDA software was used for data management and thematic analysis. Sixteen pharmacy personnel participated in the study, highlighting key themes around the integration of cessation services. Compatibility with existing workflows, the importance of staff buy-in, and the crucial role of pharmacy technicians emerged as significant facilitators. Challenges included the complexity of billing for services, software limitations for documenting tobacco use and cessation interventions, and gaps in training for handling complex patient cases. Despite these barriers, pharmacies successfully initiated cessation services, with variations in service delivery and follow-up practices. Community pharmacies represent viable settings for delivering tobacco cessation services, with pharmacists and technicians playing pivotal roles. However, systemic changes are needed to address challenges related to billing, documentation, and training. Enhancing the integration of cessation services in community pharmacies could significantly impact public health by increasing access to effective cessation support.

Effectiveness of behavior change interventions for smoking cessation among expectant and new fathers: findings from a systematic review

BACKGROUND

Smoking cessation during pregnancy and the postpartum period by both women and their partners offers multiple health benefits. However, compared to pregnant/postpartum women, their partners are less likely to actively seek smoking cessation services. There is an increased recognition about the importance of tailored approaches to smoking cessation for expectant and new fathers. While Behavior Change Interventions (BCIs) are a promising approach for smoking cessation interventions, evidence on effectiveness exclusively among expectant and new fathers are fragmented and does not allow for many firm conclusions to be drawn.

METHODS

We conducted a systematic review on effectiveness of BCIs on smoking cessation outcomes of expectant and new fathers both through individual and/or couple-based interventions. Peer reviewed articles were identified from eight databases without any date or language restriction.Two independent reviewers screened studies for relevance, assessed methodological quality of relevant studies, and extracted data from studies using a predeveloped data extraction sheet.

RESULTS

We retrieved 1222 studies, of which 39 were considered for full text screening after reviewing the titles and abstracts. An additional eight studies were identified from reviewing the reference list of review articles picked up by the databases search. A total of nine Randomised Control Trials were included in the study. Six studies targeted expectant/new fathers, two targeted couples and one primarily targeted women with an intervention component to men. While the follow-up measurements for men varied across studies, the majority reported biochemically verified quit rates at 6 months. Most of the interventions showed positive effects on cessation outcomes. BCI were heterogenous across studies. Findings are suggestive of gender targeted interventions being more likely to have positive cessation outcomes.

CONCLUSIONS

This systematic review found limited evidence supporting the effectiveness of BCI among expectant and new fathers, although the majority of studies show positive effects of these interventions on smoking cessation outcomes. There remains a need for more research targeted at expectant and new fathers. Further, there is a need to identify how smoking cessation service delivery can better address the needs of (all) gender(s) during pregnancy.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model

BACKGROUND

The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation.

OBJECTIVE(S)

To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change.

METHODS

An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed.

RESULTS

Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change.

CONCLUSIONS

Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

STOP- a training intervention to optimise treatment for smoking cessation in community pharmacies: cluster randomised controlled trial

BACKGROUND

Community pharmacies serve people with high levels of tobacco-related illness, but throughput in NHS Stop Smoking Services in pharmacies remains relatively low. We investigated the effectiveness of a complex intervention to increase service uptake and retention.

METHODS

We randomised 60 pharmacies in England and Wales to the STOP intervention or usual practice in a pragmatic, parallel-group, controlled trial over 11 months. Smokers were blind to the allocation. The intervention was theory-based consultation skills training for pharmacy staff with environmental prompts (badges, calendars and behavioural cues). The primary outcome was the number of smokers attending an initial consultation and setting a quit date.

RESULTS

The intervention made no significant difference in setting a quit date, retention or quit rate. A total of 631 adult smokers (service users) enrolled and set a quit date in intervention pharmacies compared to 641 in usual practice pharmacies, a rate ratio of 0.75 (95% CI 0.46 to 1.23) adjusted for site and number of prescriptions. A total of 432 (68%) service users were retained at 4 weeks in intervention and 500 (78%) in usual practice pharmacies (odds ratio 0.80, 0.41 to 1.55). A total of 265 (42%) service users quit smoking at 4 weeks in intervention and 276 (43%) in usual practice pharmacies (0.96, 0.65 to 1.43). The pharmacy staff were positive about the intervention with 90% (56/62) stating that it had improved their skills. Sixty-eight per cent would strongly recommend the training to others although there was no difference in self-efficacy for service delivery between arms. Seventy of 131 (53%) service users did not complete the 6-month follow-up assessment. However, 55/61 (90%) service users who completed follow-up were satisfied or very satisfied with the service. All usual practice arm service users (n = 33) and all but one in the intervention arm (n = 27) would recommend the service to smokers.

CONCLUSIONS

We found high levels of retention and acceptable quit rates in the NHS pharmacy stop smoking service. Despite pharmacy staff providing positive feedback on the STOP intervention, it made no difference to service throughput. Thus, other factors may currently limit service capacity to help smokers to quit.

TRIAL REGISTRATION

ISRCTN, ISRCTN16351033 . Retrospectively registered.

A Pragmatic Pilot Cluster-Randomized Study of Tobacco Screening and Smoking Cessation Program for Community Pharmacies in Japan: FINE Program

Objectives

To investigate the effectiveness of a smoking cessation program (FINE program) in community pharmacies.

Methods

A cluster-randomized controlled trial was conducted in 11 community pharmacies in Japan. The participants were randomly assigned to a pharmacist-led structured smoking cessation program (intervention group) or pharmacist-led usual care (control group). The intervention group was followed up over the telephone on the third day of smoking cessation, and ongoing follow-up and advice were provided according to the original smoking cessation guidebook developed for the current study based on a behavioral change approach. The control group received brief advice and ready-made pamphlets on smoking cessation from pharmacists upon their visit to these community pharmacies. The primary outcome was continued smoking cessation as determined by self-reporting and carbon monoxide monitoring with a microsmokerlyzer after 3 months.

Results

Five hundred and seventy-two smokers who met the eligibility criteria visited the pharmacies included in the study. Of these individuals, 24 patients agreed to participate in the study. The quit rates were 45.5% and 18.2% in the intervention and control groups, respectively (P = 0.380, effect size = 0.60).

Conclusion

Based on the effect size values, the FINE program may be effective to some extent, but the difference was not significant. We speculate that this is related to the small sample size due to difficulty in recruiting. Further studies with an effective recruitment method and larger sample sizes are needed to accurately verify the effectiveness of this program.

Improving outpatient medication counselling in hospital pharmacy settings: a behavioral analysis using the theoretical domains framework and behavior change wheel

Background:

Despite the importance of medication counselling for patients, it is common knowledge that it is often sub-optimally carried out by pharmacy staff. While some interventions have been designed to help improve counselling, no study till date has used the Capability Opportunity and Motivation behavior model (COM-B) or Theoretical Domains Framework (TDF) as a basis for identifying evidence-based intervention strategies to improve medication counselling.

Objective:

To understand barriers/facilitators to optimal medication counselling by conducting a behavioral analysis using the COM-B model and TDF, and use the Behavior Change Wheel (BCW) as a basis for identifying evidence-based intervention strategies and policy categories that could be used to improve outpatient medication counselling by pharmacy staff in hospital settings located within Northwest Nigeria.

Methods:

Semi-structured interviews were used to collect data from 25 purposively sampled pharmacy staff working at eight major public hospitals, from January till March 2020. Data from the interviews were then transcribed and deductively coded using the COM-B model and TDF. These findings were then used to identify areas requiring change, as well as the intervention type and policy functions required to support these changes.

Results:

Findings from the behavioral analysis revealed shortfalls in pharmacy staff capability, opportunity and motivation with respect to outpatient medication counselling. To improve their counselling behaviors, change was identified as necessary in eight TDF domains namely ‘knowledge’, ‘interpersonal skills’, ‘memory’ ‘environmental context’, ‘social influences’, ‘intentions’, ‘reinforcement’ and ‘beliefs about capabilities’. Seven intervention functions including ‘education’, ‘training’, ‘modelling’, ‘enablement’ and ‘environmental restructuring’, in addition to three policy categories (‘guidelines’, ‘regulations’ and ‘environmental/social planning’) were also identified as relevant to future intervention design.

Conclusions:

Various factors were identified as affecting medication counselling by the pharmacy staff, with several of them requiring changes if counselling was to be improved upon. Multi-component interventions combining several of these intervention functions are recommended for hospital authorities and other relevant stakeholders to improve outpatient medication counselling.

A systematic review of interventions addressing limited health literacy to improve asthma self-management

Background

Supported asthma self-management improves health outcomes. However, people with limited health literacy, especially in lower-middle-income countries (LMICs), may need tailored interventions to enable them to realise the benefits. We aimed to assess the clinical effectiveness of asthma self-management interventions targeted at people with limited health literacy and to identify strategies associated with effective programmes.

Methods

Following Cochrane methodology, we searched ten databases (January 1990 – June 2018; updated October 2019), without language restriction. We included controlled experimental studies whose interventions targeted health literacy to improve asthma self-management. Selection of papers, extraction of data and quality assessment were done independently by two reviewers. The primary outcomes were clinical (asthma control) and implementation (adoption/adherence to intervention). Analysis was narrative.

Results

We screened 4318 titles and abstracts, reviewed 52 full-texts and included five trials. One trial was conducted in a LMIC. Risk of bias was low in one trial and high in the other four studies. Clinical outcomes were reported in two trials, both at high risk of bias: one of which reported a reduction in unscheduled care (number of visits in 6-month (SD); Intervention:0.9 (1.2) vs Control:1.8 (2.4), P = 0.001); the other showed no effect. None reported uptake or adherence to the intervention. Behavioural change strategies typically focused on improving an individual’s psychological and physical capacity to enact behaviour (eg, targeting asthma-related knowledge or comprehension). Only two interventions also targeted motivation; none sought to improve opportunity. Less than half of the interventions used specific self-management strategies (eg, written asthma action plan) with tailoring to limited health literacy status. Different approaches (eg, video-based and pictorial action plans) were used to provide education.

Conclusions

The paucity of studies and diversity of the interventions to support people with limited health literacy to self-manage their asthma meant that the impact on health outcomes remains unclear. Given the proportion of the global population who have limited health literacy skills, this is a research priority.

Protocol registration

PROSPERO CRD 42018118974

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Evaluating the effectiveness and cost-effectiveness of the Smoking Treatment Optimisation in Pharmacies (STOP) intervention: protocol for a cluster randomised controlled trial

BACKGROUND

NHS community pharmacies provide effective smoking cessation services; however, there is scope for increasing throughput and improving quit rates. This trial examines whether the Smoking Treatment Optimisation in Pharmacies (STOP) intervention can improve smoker engagement to increase service throughput, retention and quitting.

METHODS

This study is a pragmatic, cluster randomised controlled trial in 60 pharmacies in England and Wales. All workers in intervention pharmacies are offered STOP training while control pharmacies provide usual care. The STOP intervention, based on behavioural and organisational theories, comprises educational sessions for staff and environmental prompts in the pharmacy. Intervention fidelity is assessed by actors visiting pharmacies posing as smokers. The primary outcome is throughput, defined as the number of smokers who join the programme, set a firm quit date and undergo at least one stop smoking treatment session, and is measured using routinely collected data. Secondary outcomes include retention and quit rates at 4 weeks and continuous abstinence at 6 months verified by salivary cotinine. Cost-effectiveness is estimated using quality-adjusted life years and the probability that the intervention is effective at different levels of willingness to pay is calculated.

DISCUSSION

The trial will generate evidence to inform the public health smoking cessation strategy in England and Wales, and may help to shape service commissioning decisions. The STOP intervention model may help inform the undertaking of a range of health behaviour change tasks in community pharmacies.

TRIAL REGISTRATION

ClinicalTrials.gov, ISRCTN16351033. Retrospectively registered on 21 March 2017.

Evaluating NHS Stop Smoking Service engagement in community pharmacies using simulated smokers: fidelity assessment of a theory-based intervention

OBJECTIVES

Smokers are more likely to quit if they use the National Health Service (NHS) Stop Smoking Service (SSS). However, community pharmacies experience low service uptake. The Smoking Treatment Optimisation in Pharmacies (STOP) programme aims to address this problem by enhancing staff training using a theory-based intervention. In this study, we evaluated intervention fidelity using simulated smokers (actors) to assess smoker engagement and enactment of key intervention components by STOP trained staff.

DESIGN

An observational pilot study.

SETTINGS

Five community pharmacies in North East London with an NHS SSS.

METHODS

Six actors, representative of East London's population, were recruited and trained to complete intervention fidelity assessments. Consenting pharmacy staff from five participating pharmacies received STOP Intervention training. Four weeks after the staff training, the actors visited the participating pharmacies posing as smokers eligible for smoking cessation support. Engagement behaviour by pharmacy staff and enactment of intervention components was assessed using a scoring tool derived from the STOP logic model (scoring range of 0-36), and contemporaneous field notes taken by actors.

RESULTS

18 of 30 completed assessments were with STOP trained staff (10/18 were counter assistants). Mean score for smoker engagement was 24.4 (SD 9.0) points for trained and 16.9 (SD 7.8) for untrained staff, respectively. NHS SSS leaflets (27/30) were the most common smoking cessation materials seen on pharmacy visits. Most trained counter staff engaged with smokers using leaflets and a few proactively offered appointments with their cessation advisors. Appropriate use of body language was reported on 26/30 occasions alongside the use of key phrases from the STOP training session (n=8). Very few pharmacy staff wore STOP promotional badges (4/30).

CONCLUSIONS

STOP training may change client engagement behaviour in pharmacy staff and could improve the uptake of the NHS SSS. A cluster randomised controlled trial is currently in progress to evaluate its effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN16351033.

Determining counselling communication strategies associated with successful quits in the National Health Service community pharmacy Stop Smoking programme in East London: a focused ethnography using recorded consultations

OBJECTIVES

To determine communication strategies associated with smoking cessation in the National Health Service community pharmacy Stop Smoking programme.

SETTING

11 community pharmacies in three inner east London boroughs.

PARTICIPANTS

9 stop smoking advisers and 16 pairs of smokers who either quit or did not quit at 4 weeks, matched on gender, ethnicity, age and smoking intensity.

METHOD

1-3 audio-recorded consultations between an adviser and each pair member over 5-6 weeks were analysed using a mixed-method approach. First a content analysis was based on deductive coding drawn from a theme-oriented discourse analysis approach and the Roter Interaction Analysis System. Core themes were identified through this quantification to explore in detail the qualitative differences and similarities between quitters and non-quitters.

RESULTS

Quantitative analysis revealed advisers used a core set of counselling strategies that privileged the 'voice of medicine' and often omitted explicit motivational interviewing. Smokers tended to quit when these core strategies were augmented by supportive talk, clear permission for smokers to seek additional support from the adviser between consultations, encouragement for smokers to use willpower. The thematic analysis highlighted the choices made by advisers as to which strategies to adopt and the impacts on smokers. The first theme 'Negotiating the smoker-adviser relationship' referred to adviser judgements about the likelihood the smoker would quit. The second theme, 'Roles of the adviser and smoker in the quit attempt', focused on advisers' counselling strategies, while the third theme, 'Smoker and adviser misalignment on reasons for smoking, relapsing and quitting', concerned inconsistencies in the implementation of National Centre for Smoking Cessation and Training recommendations.

DISCUSSION

Advisers in community pharmacies should use the advantages of their familiarity with smokers to ensure appropriate delivery of patient-centred counselling strategies and reflect on the impact on their counselling of early judgements of smoker success.