Ask, advise and refer: Hypothesis generation to promote a brief tobacco-cessation intervention in community pharmacies

Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis

BACKGROUND

Very brief advice (VBA; ≤ 3 min) on quitting is practical and scalable during brief medical interactions with patients who smoke. This study aims to synthesize the effectiveness of VBA for smoking cessation and summarize the implementation strategies.

METHODS

We searched randomized controlled trials aiming at tobacco abstinence and comparing VBA versus no smoking advice or no contact from Medline, Embase, CINAHL, Cochrane Library, PsycInfo databases, six Chinese databases, two trial registries ClinicalTrials.gov and WHO-ICTRP from inception to September 30, 2023. Grading of Recommendations, Assessment, Development, and Evaluations framework was used to assess the certainty of the evidence of the meta-analytic findings. The outcomes were self-reported long-term tobacco abstinence at least 6 months after treatment initiation, earlier than 6 months after treatment initiation, and quit attempts. Effect sizes were computed as risk ratio (RR) with 95% CI using frequentist random-effect models.

DATA SYNTHESIS

Thirteen randomized controlled trials from 15 articles (n = 26,437) were included. There was moderate-certainty evidence that VBA significantly increased self-reported tobacco abstinence at ≥ 6 months in the adjusted model (adjusted risk ratio ARR 1.17, 95% CI: 1.07-1.27) compared with controls. The sensitivity analysis showed similar results when abstinence was verified by biochemical validation (n = 6 studies, RR 1.53, 95% CI 0.98-2.40). There was high-certainty evidence that VBA significantly increased abstinence at < 6 months (ARR 1.22, 95% CI: 1.01-1.47). Evidence of effect on quit attempts (ARR 1.03, 95% CI 0.97-1.08) was of very low certainty.

DISCUSSION

VBA delivered in a clinical setting is effective in increasing self-reported tobacco abstinence, which provides support for wider adoption in clinical practice.

Reaching adults who smoke cigarettes in rural Appalachia: Rationale, design & analysis plan for a mixed-methods study disseminating pharmacy-delivered cessation treatment

INTRODUCTION

Unlike other U.S. geographical regions, cigarette smoking prevalence remains stagnant in rural Appalachia. One avenue for reaching rural residents with evidence-based smoking cessation treatments could be utilizing community pharmacists. This paper describes the design, rationale, and analysis plan for a mixed-method study that will determine combinations of cessation treatment components that can be integrated within community pharmacies in rural Appalachia. The aim is to quantify the individual and synergistic effects of five highly disseminable and sustainable cessation components in a factorial experiment.

METHODS

This sequential, mixed-method research design, based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, will use a randomized controlled trial with a 25 fully crossed factorial design (32 treatment combinations) to test, alone and in combination, the most effective evidence-based cessation components: (1) QuitAid (yes vs. no) (2) tobacco quit line (yes vs. no) (3) SmokefreeTXT (yes vs. no) (4) combination NRT lozenge + NRT patch (vs. NRT patch alone), and (5) eight weeks of NRT (vs. standard four weeks).

RESULTS

Logistic regression will model abstinence at six-months, including indicators for the five treatment factors and all two-way interactions between the treatment factors. Demographic and smoking history variables will be considered to assess potential effect modification. Poisson regression will model quit attempts and percent of adherence to treatment components as secondary outcomes.

CONCLUSION

This study will provide foundational evidence on how community pharmacies in medically underserved, rural regions can be leveraged to increase utilization of existing evidence-based tobacco cessation resources for treating tobacco dependence.

CLINICAL TRIALS

NCT05660525.

Implementing Brief Tobacco Cessation Interventions in Community Pharmacies: An Application of Rogers’ Diffusion of Innovations Theory

Pharmacists, as highly accessible members of the healthcare team, have considerable potential to address tobacco use among patients. However, while published data suggest that pharmacists are effective in helping patients quit, barriers exist to routine implementation of cessation services in community pharmacy settings. Within the context of a randomized trial (n = 64 pharmacies), surveys were administered over a period of 6 months to assess pharmacists’ perceptions of factors associated with the implementation of “Ask-Advise-Refer”, a brief intervention approach that facilitates patient referrals to the tobacco quitline. Study measures, grounded in Rogers’ Diffusion of Innovations Theory, assessed pharmacists’ perceptions of implementation facilitators and barriers, perceptions of intervention materials provided, and perceived efforts and personal success in implementing Ask-Advise-Refer at 6-months follow-up. Findings indicate that while the brief intervention approach was not difficult to understand or implement, integration into normal workflows presents greater challenges and is associated with overall confidence and implementation success. Lack of time was the most significant barrier to routine implementation. Most (90.6%) believed that community pharmacies should be active in promoting tobacco quitlines. Study results can inform future development of systems-based approaches that lead to broad-scale adoption of brief interventions, including but not limited to tobacco cessation, in pharmacy settings.

Barriers to the Provision of Preventive Care to People Living with Mental Health Conditions: Self-Report by Staff Working in an Australian Community Managed Organisation

People living with mental health conditions experience a reduced life expectancy largely due to a higher prevalence of chronic diseases. Addressing health risk behaviours, including tobacco smoking, inadequate nutrition, harmful alcohol consumption, and physical inactivity (SNAP), through the provision of preventive care, is recommended to reduce this burden. Community Managed Organisations (CMOs) may play an important role in providing preventive care to consumers with mental health conditions, however, few studies have examined preventive care provision in CMO settings; and no studies have comprehensively assessed barriers to the provision of this care using a tool such as the Theoretical Domains Framework (TDF). To fill this research gap, we conducted an online survey among staff (N = 190) from one CMO in Australia to (1) identify barriers to preventive care provision (ask, advise, assist, connect) to address SNAP behaviours among consumers; and (2) explore associations between barriers and preventive care provision. Results demonstrate that while staff reported knowing how to provide preventive care and believed it would positively impact consumers; barriers including confidence in providing this care and consumer uptake of referrals, were identified. Further research among multiple CMOs is needed to identify care provision and associated barriers in the sector more widely.

Raising awareness of pre-conception care in community pharmacies: a feasibility study

Background

There is growing evidence to support the introduction of pre-conception interventions to optimise the health of mothers and their future children. At present, there is poor awareness regarding the importance of pre-conception care (PCC) amongst healthcare professionals and couples planning a pregnancy. Community pharmacies are ideally placed to reach a range of prospective couples planning a pregnancy and could effectively provide information about PCC.

Methods

This study assessed feasibility of an intervention to raise awareness of PCC in community pharmacies in Northern Ireland over 3 months. Inclusion criteria: women of childbearing age (16–45 years) engaging with services at participating pharmacies. Study resources: campaign posters, information cards, crib sheets for pharmacy staff. A mixed methods approach was employed, including, brief information provision for women, record of staff interactions with customers, customer feedback cards and qualitative interviews with pharmacy staff. Descriptive statistics assessed distribution of study resources and staff interviews were analysed using a thematic analysis framework.

Results

There were eight participating pharmacies, three of which consented to post-study interviews. Three pharmacies chose not to deliver the planned intervention. Distribution of campaign cards (n = 456) varied (0–86%). Analysis of customer feedback cards (n = 9) demonstrated that the majority of respondents were happy to receive information on pre-conception health. Of the women who responded to this question (n = 8), all were ‘extremely likely’ or ‘likely’ to act on the information provided. Four main themes emerged from analysis of staff interviews: (1) training and experience in providing health advice, (2) intervention resources, (3) understanding the aims of the intervention, (4) perceived value of the intervention. Barriers to intervention delivery included non-engagement from pharmacies and need for additional training of staff.

Conclusions

An intervention to raise awareness of PCC within a community pharmacy setting was feasible and acceptable to both women and staff in participating pharmacies. This study indicates that a number of factors must be considered to enhance implementation and effectiveness of PCC interventions in this setting. In particular, better understanding of non-engagement, provision of adequate training and support for staff, and exploring incentives for pharmacies to prioritise PCC.

Evaluating the feasibility of pharmacist-facilitated tobacco cessation interventions in independent community pharmacies in rural Appalachia

BACKGROUND

Smoking rates in the United States are the highest in underserved rural regions. Thus, more points of contact are needed to link smokers to evidence-based cessation programs.

OBJECTIVES

The purpose of this study was to conduct an evaluation to determine the feasibility, acceptability, and interest among rural pharmacists in implementing a pharmacist-facilitated smoking cessation program in independent community pharmacies in rural Appalachian communities in Virginia, North Carolina, Tennessee, and West Virginia.

METHODS

This study utilized a complementary sequential mixed-methods approach to explore independent community pharmacists and technicians' experiences and beliefs about implementing a tobacco cessation program in their pharmacy.

RESULTS

There were 49 pharmacists or technicians who completed the survey and 7 pharmacists who participated in the interviews. Four main findings emerged from the data: 1) pharmacies can help fill the gap in tobacco cessation services in rural communities, 2) under current practice, tobacco cessation resources when offered by independent community pharmacies are not always formalized, 3) there are known barriers, such as reimbursing for services, that need to be addressed to provide tobacco cessation in an independent pharmacy setting, and 4) the Ask-Advise-Connect model is a feasible tobacco cessation approach in a pharmacy.

CONCLUSION

Although pharmacists may be ideally situated to build capacity for smoking cessation in rural areas, smoking cessation interventions need to use existing approaches that compensate pharmacists for their time spent counseling patients. Furthermore, simple documentation and billing systems are needed to maximize utilization of tobacco cessation products and services provided in the pharmacy.

Factors influencing patient participation in medication counseling at the community pharmacy: A systematic review

BACKGROUND

Findings document that patient participation in pharmacy encounters is associated with favorable outcomes. However, there is a need to understand factors that may enhance or hinder patient engagement and pharmacist counseling behaviors during their medication discussions. This review aims to: (1) identify barriers and facilitators for patient engagement in pharmacy consultations, (2) explore the relationship between patient factors (such as demographics and communication behavior) and subsequent pharmacist counseling behavior.

METHODS

A systematic review of literature using PRISMA guidelines examined studies published in English addressing influences on patient participation and the relationship between patient factors and pharmacist counseling behavior. Four databases were used - PubMed, CINAHL, PsycINFO, and Scopus. Findings were framed thematically within the constructs of Street's Linguistic Model of Patient Participation in Care (LM).

FINDINGS

Fifty studies from 1983 to 2019, including 37 using self-reported data, were identified. Patient involvement in patient-pharmacist communication was influenced by enabling factors such as patient knowledge, communication skills, and pharmacy environment. Predisposing factors for participation ranged from patients' beliefs and past experiences to demographic characteristics such as gender and age. Pharmacists' participative behavior with patients was positively associated with patients' engagement and perceived patient cues in the conversation.

CONCLUSION

This systematic review identified predictors of patients' engagement in pharmacy encounters drawing on LM framework. Various predisposing factors, enabling factors, and pharmacist' responses impacted patients' willingness to actively participate in medication counseling at community pharmacies. Equally important, studies documented considerable impact by patients on pharmacists' counseling behavior. Pharmacy encounters should no longer be viewed as controlled simply by pharmacists' expertise and agendas. Patient characteristics and factors such as patient question-asking and expectations also appear to be associated with and influence patient-pharmacist interpersonal communication. Additional research needs to address the identified facilitators and barriers to enhance patient participation and pharmacist counseling behavior.

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.

Models for pharmacist-delivered tobacco cessation services: a systematic review

OBJECTIVES

To summarize delivery models of pharmacist-led tobacco cessation services.

DATA SOURCES

Studies published from July 1, 2003, to April 1, 2019, describing pharmacist-led tobacco cessation services in the United States were identified via PubMed/MEDLINE and EBSCO searches.

STUDY SELECTION

Studies were considered for inclusion if they met the following criteria: population, patients 18 years of age and older using tobacco products; intervention, pharmacist-led tobacco cessation services; comparator, not required; and outcome, tobacco cessation. We used a web-based tool, Rayyan QCRI, to assist with study selection.

DATA EXTRACTION

We used a data extraction tool to collect article reference, study design, primary and secondary objectives, brief description of intervention, pharmacologic interventions, service model, business model, method to measure tobacco cessation, tobacco cessation rates, and other comments.

RESULTS

A total of 16 articles were incorporated into this review. Most studies included were observational (87.5%). The pharmacy settings included ambulatory care (68.8%), community (25%), and managed care (6.3%). Service models described most frequently followed an appointment-based, individual, face-to-face session between the patient and pharmacist. Business models included grant funding (12.5%), fee-for-service (6.3%), value-based (6.3%), and free services (6.3%), but most studies (56.3%) did not address reimbursement. Cessation rates ranged from 3.98% to 77.14% and were predominantly measured through self-report (62.5%). The timing of follow-up varied from 1 to 6 months after program completion, but in some articles was not reported (37.5%).

CONCLUSION

Pharmacists currently manage tobacco cessation services via an assortment of methods and can successfully assist patients in achieving abstinence. Gaps in the literature necessitate further guidance on consistent outcomes reporting, impact of service model on tobacco cessation, and economic data of business models. The profession will benefit from such information to further expand the pharmacists' role within tobacco cessation services.

A pilot study of Counsel to Quit®: Evaluating an Ask Advise Refer (AAR)-based tobacco cessation training for medical and mental healthcare providers

INTRODUCTION

Despite tobacco use as the largest preventable cause of premature death in the US, many healthcare providers continue to lack the knowledge and confidence in employing the Ask, Advise, Refer (AAR) model in tobacco cessation treatment delivery. This pilot study evaluated the feasibility and effectiveness of a novel AAR-styled training program, Counsel to Quit®, across a range of healthcare providers and disciplines (i.e., medical, mental health, other). The Counsel to Quit® training program primarily targeted publically-funded settings that serve communities with high smoking rates.

METHODS

Pre- and post-training surveys were administered to medical, mental health, and other professionals (N = 297) to evaluate the effectiveness of the 60-90 minute Counsel to Quit® counselor training program for improving confidence in the ability to discuss approved tobacco cessation interventions and address the current state of knowledge about the role of electronic cigarettes in tobacco cessation. The trainings were held across 14 different non-profit institutional settings in Chicago, IL.

RESULTS

The Counsel to Quit® program improved AAR beliefs, the confidence and ability to discuss smoking cessation, and knowledge on the role of electronic cigarettes in tobacco cessation among medical, mental health, and other providers (ps < .001). Interactions showed that Counsel to Quit® improved medical provider confidence in referring patients for smoking cessation the most (p < .001), and also improved mental health providers belief in the importance of tobacco cessation for preventative care the most (ps < .05).

CONCLUSIONS

Counsel to Quit® is a feasible and effective training for improving AAR beliefs across multiple healthcare provider domains and at different types of publicly-funded healthcare institutions. Further, this training increased provider preparedness to discuss the lack of evidence for e-cigarette use as a form of tobacco cessation.

Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women

BACKGROUND

Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians. We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally competent approach, developed collaboratively with AMS.

METHOD

The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.'s "Behaviour Change Wheel" guide.

RESULTS

Targets identified for health provider behaviour change included the following: capability (psychological capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation (optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring consultations using a flipchart and prompts. Education and training were selected as the main intervention functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints, bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded with videos to improve patients' capability, opportunity and motivation.

CONCLUSIONS

The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services in how to implement culturally competent evidence-based practice including counselling and nicotine replacement therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at systemic, provider, community and individual levels. This process was therefore important for defining the design and intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.

The power of the patient question: A secret shopper study

OBJECTIVES

To examine the effect of one standardized patient question on the length, number and type of new topics pharmacists addressed. To explore how community pharmacists counsel secret shoppers on two types of over-the-counter (OTC) medications-ibuprofen (IB) and emergency contraceptives (EC).

METHODS

25 pharmacists from 7 independent, midwestern community pharmacies consented to have secret shoppers purchase an OTC medication and to have their consultations audio-recorded. Following standardized scenarios, 5 secret shoppers audio-recorded 73 encounters. At the end of 36 encounters secret shoppers asked one standard question, "What else should I know before taking this product?" Role Theory informed the study design with apriori hypotheses that topics assessed, topics discussed, and consultation length would vary by the OTC medication (IB or EC) and whether secret shoppers asked a question. Audio-recording coding had high inter-rater reliability (kappa=0.94).

RESULTS

Length of encounter was significantly associated with patients asking the question (p<0.05), but not type of OTC medication. On average 1.22 new topics were discussed with a patient question. New topics included information about safe and efficacious use of the OTC's.

CONCLUSION

Results highlight the importance of encouraging patients to ask pharmacists their questions about OTC products for safe use and thorough consultations.

Describing the role of Australian community pharmacists in oral healthcare

OBJECTIVES

To investigate community pharmacist's attitudes, beliefs and practices towards oral health in the Australian setting, describe the frequency and nature of consumer enquiries relating to oral health, and gain insight regarding smoking cessation support for people experiencing oral health problems.

METHODS

An online questionnaire was developed based on previous research, validated to ensure accuracy and reliability, and convenience sampling used to advertise across major pharmacy organisational websites and newsletters to maximise community pharmacist responses.

KEY FINDINGS

One hundred and forty-four valid community pharmacist responses were descriptively analysed. The majority of pharmacists (93%) believed it was their role to deliver oral health advice in the community and almost all (97%) pharmacists believed further education would benefit their practice. The top four consumer enquiries pharmacists reported confidence in handling related to analgesic medication to relieve oral-related pain (95.8%), mouth ulcers (95.1%), oral thrush (94.4%) and toothache (93.8%); and the most frequently reported consumer enquires were those where the majority of pharmacists reported high confidence in handling. A small proportion of pharmacists (8%) always enquired about patient smoking status, and nearly all pharmacists (97%) desired further education and training to benefit their practice in oral healthcare.

CONCLUSION

This study highlights that Australian pharmacists have an important role in oral health and there is opportunity to enhance this role, and address risk factors such as smoking with further training, support and education. The findings from this study can guide future research into the development of appropriate training programmes, standards, and best oral healthcare practices for Australian pharmacists.

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.

Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives

BACKGROUND

Community pharmacists play a vital part in reconciling medications for patients transitioning from hospital to community care, yet their roles have not been fully examined in the extant literature.

OBJECTIVES

The objectives of this study were to: 1) examine the barriers and facilitators community pharmacists face when reconciling medications for recently discharged patients; and 2) identify pharmacists' preferred content and modes of information transfer regarding updated medication information for recently discharged patients.

METHODS

Community pharmacists were purposively and conveniently sampled from the Wisconsin (U.S. state) pharmacist-based research network, Pharmacy Practice Enhancement and Action Research Link (PEARL Rx). Community pharmacists were interviewed face-to-face, and transcriptions from audio recordings were analyzed using directed content analysis. The Theory of Planned Behavior (TPB) guided the development of questions for the semi-structured interviews.

RESULTS

Interviewed community pharmacists (N = 10) described the medication reconciliation process to be difficult and time-consuming for recently discharged patients. In the context of the TPB, more barriers than facilitators of reconciling medications were revealed. Themes were categorized as organizational and individual-level themes. Major organizational-level factors affecting the medication reconciliation process included: pharmacy resources, discharge communication, and hospital resources. Major individual-level factors affecting the medication reconciliation process included: pharmacists' perceived responsibility, relationships, patient perception of pharmacist, and patient characteristics. Interviewed pharmacists consistently responded that several pieces of information items would be helpful when reconciling medications for recently discharged patients, including the hospital medication discharge list and stop-orders for discontinued medications.

CONCLUSIONS

The TPB was useful for identifying barriers and facilitators of medication reconciliation for recently discharged patients from community pharmacists' perspectives. The elucidation of these specific facilitators and barriers suggest promising avenues for future research interventions to improve exchange of medication information between the community pharmacy, hospitals, and patients.

Effectiveness of intervention to implement tobacco cessation counseling in community chain pharmacies

OBJECTIVES

To test the feasibility of implementing ask-advise-refer (AAR) tobacco cessation counseling approach in community chain pharmacies serving low socioeconomic areas and to assess the effectiveness of a multimodal intervention on short-term implementation of AAR.

DESIGN

Randomized controlled trial.

SETTING

South-central Wisconsin from July 2008 through March 2009.

PARTICIPANTS

Pharmacists and technicians from 16 community chain pharmacies.

INTERVENTION

Training to implement AAR, workflow integration recommendations, tobacco cessation poster to create awareness, and a support visit.

MAIN OUTCOME MEASURES

Number of pharmacy patrons asked about tobacco use, number of tobacco users advised to quit, number of tobacco users enrolled in the quit line, and number of quit line cards given.

RESULTS

As hypothesized, the multimodal intervention significantly predicted the number of patrons asked to quit (estimate 4.84, incidence rate ratio 127.2, P < 0.001), number of tobacco users advised to quit (2.12, 8.33, P < 0.01), number of tobacco users enrolled in the quit line (2.31, 10.13, P < 0.001), and number of quit line cards given (1.04, 2.82, P < 0.05).

CONCLUSION

This trial demonstrates the feasibility of implementing AAR in routine community pharmacy practice. This trial also supports the short-term effectiveness of the multimodal intervention in facilitating AAR in partnership with other public health systems. More research is needed to evaluate the generalizability, effectiveness, and sustainability of AAR, including factors influencing adoption and the impact on cessation.

A randomized trial evaluating 2 approaches for promoting pharmacy-based referrals to the tobacco quitline: methods and baseline findings

BACKGROUND

Despite the fact that individuals who smoke are at an increased risk for disease and therefore require frequent visits to pharmacies for medications, most community pharmacies do not integrate tobacco cessation activities into routine practice.

OBJECTIVE

The objective of this report is to describe the methods and baseline findings for a 2-state randomized trial evaluating 2 intervention approaches for increasing pharmacy-based referrals to their state's tobacco quitline.

METHODS

Participating community pharmacies in Connecticut (n=32) and Washington (n=32) were randomized to receive either (1) on-site education with an academic detailer, describing methods for implementing brief interventions with patients and providing referrals to the tobacco quitline or (2) quitline materials delivered by mail. Both interventions advocated for pharmacy personnel to ask about tobacco use, advise patients who smoke to quit, and refer patients to the tobacco quitline for additional assistance with quitting. Study outcome measures include the number of quitline registrants who are referred by pharmacies (before and during the intervention period), the number of quitline materials distributed to patients, and self-reported behavior of cessation counseling and quitline referrals, assessed using written surveys completed by pharmacy personnel (pharmacists, technicians).

RESULTS

Pharmacists (n=124) and pharmacy technicians (n=127), representing 64 participating pharmacies with equal numbers of retail chain and independently owned pharmacies, participated in the study. Most pharmacists (67%) and half of pharmacy technicians (50%) indicated that they were not at all familiar with the tobacco quitline. During the baseline (preintervention) monitoring period, the quitline registered 120 patients (18 in Connecticut and 102 in Washington) who reported that they heard about the quitline from a pharmacy.

CONCLUSION

Novel tobacco intervention approaches are needed to capitalize on the community pharmacy's frequent interface with tobacco users, and these approaches need to be evaluated to estimate their effectiveness. Widespread implementation of brief, yet feasible, pharmacy-based tobacco cessation efforts that generate referrals to a tobacco quitline could have a substantial impact on the prevalence of tobacco use.

Public health in community pharmacy: a systematic review of pharmacist and consumer views

Background

The increasing involvement of pharmacists in public health will require changes in the behaviour of both pharmacists and the general public. A great deal of research has shown that attitudes and beliefs are important determinants of behaviour. This review aims to examine the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health in order to inform how best to support and improve this service.

Methods

Five electronic databases were searched for articles published in English between 2001 and 2010. Titles and abstracts were screened by one researcher according to the inclusion criteria. Papers were included if they assessed pharmacy staff or consumer attitudes towards pharmaceutical public health. Full papers identified for inclusion were assessed by a second researcher and data were extracted by one researcher.

Results

From the 5628 papers identified, 63 studies in 67 papers were included. Pharmacy staff: Most pharmacists viewed public health services as important and part of their role but secondary to medicine related roles. Pharmacists' confidence in providing public health services was on the whole average to low. Time was consistently identified as a barrier to providing public health services. Lack of an adequate counselling space, lack of demand and expectation of a negative reaction from customers were also reported by some pharmacists as barriers. A need for further training was identified in relation to a number of public health services. Consumers: Most pharmacy users had never been offered public health services by their pharmacist and did not expect to be offered. Consumers viewed pharmacists as appropriate providers of public health advice but had mixed views on the pharmacists' ability to do this. Satisfaction was found to be high in those that had experienced pharmaceutical public health

Conclusions

There has been little change in customer and pharmacist attitudes since reviews conducted nearly 10 years previously. In order to improve the public health services provided in community pharmacy, training must aim to increase pharmacists' confidence in providing these services. Confident, well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health.

Mixed methods evaluation: pharmacists' experiences and beliefs toward an interactive communication approach to patient interactions

OBJECTIVE

To characterize pharmacists' experience and explore their beliefs toward an interactive communication technique, the three prime questions (3PQs),where pharmacists ask about patients' understanding of medication's purpose, directions, and monitoring.

METHODS

Mixed method design. Pharmacists were briefly trained and then integrated the 3PQs into their practice for two weeks. Pharmacists recorded their perceptions of patient interactions, completed a survey addressing self-efficacy and role beliefs toward the 3PQs, and participated in a focus group.

RESULTS

Eleven pharmacists participated and the 3PQs were used with 176 patients. Most interactions were under 5min. Pharmacists reported that questions about directions and monitoring were most effective in gathering new information with refills whereas medication purpose question was preferred for new fills. The majority of pharmacists were certain they could use the 3PQs and agreed it was their role. Five themes arose from the qualitative analysis: established communication routines, enhanced patient-pharmacist relationships, good medication history, tailoring of the 3PQs, and impact of pharmacy organization.

CONCLUSION

The 3PQs enabled pharmacists to briefly assess patient medication experiences and tailor education while fostering patient-centered relationships in pharmacy practice.

PRACTICE IMPLICATIONS

While the 3PQs may enhance pharmacists' patient assessment; integration may challenge pharmacists' work routine.

Tobacco users' perceptions of a brief tobacco cessation intervention in community pharmacies

OBJECTIVE

To explore factors affecting tobacco users' perceived appropriateness of a brief and proactive tobacco cessation counseling program, ask, advise, and refer (AAR), at community pharmacies.

DESIGN

Inductive thematic analysis.

SETTING

Southern Wisconsin during fall 2008.

PATIENTS

24 tobacco users who had recently received brief and proactive tobacco cessation counseling at a community pharmacy.

INTERVENTION

Semistructured telephone interviews conducted by primary author.

MAIN OUTCOME MEASURES

Perceptions of a brief and proactive tobacco cessation counseling program conducted at community pharmacies.

RESULTS

In conducting the thematic analysis, eight distinct themes were identified. Display of information and resources at pharmacies for use by tobacco users as needed was identified as the most predominant theme and was found to be most helpful by many respondents. Other themes identified in decreasing order of prevalence were: tobacco users' perceptions of the role of pharmacists in health care, tobacco users' belief that smoking could interact with a current medication or health condition, tobacco users' sensitivity toward their tobacco use behavior or being told what to do, nonconfrontational and friendly approach of pharmacists, tobacco users' readiness to quit at the time of AAR counseling, tobacco user initiation of tobacco use discussion, and tobacco users' belief that tobacco use is bad.

CONCLUSION

Overall, this qualitative investigation suggests that several factors might influence tobacco users' perceived appropriateness of AAR counseling at community pharmacies. AAR might be well received by tobacco users and pharmacy patrons as long as it is done in a professional and respectful manner.