Reducing corticosteroid phobia in pharmacy staff and parents of children with atopic dermatitis.

Background Besides physicians, pharmacy staff has an important role to inform patients on appropriate medication use. However, they might also experience corticophobia themselves, affecting patient counseling and subsequently patient's disease management. Objective Implementation of an intervention for pharmacy staff to improve knowledge and stimulate positive perceptions towards TCS use, in order to reduce corticophobia in pharmacy staff and parents of young AD patients. Setting Nine community pharmacies in the Netherlands. Method We developed an intervention consisting of education of pharmacy staff followed by counseling of parents. The intervention was implemented in pharmacies and intervention effectiveness was studied using a pre-post design with an intervention period of 3 months. At baseline and follow-up (3 months), pharmacy staff and parents completed a questionnaire. Main outcome measure Corticophobia, both beliefs and worries, measured with the TOPICOP questionnaire. Higher scores indicate a more negative attitude. Result Baseline and follow-up data were available for 19 pharmacy staff members and 48 parents who attended a counseling session in the pharmacy. In both groups there was as decrease in negative beliefs and worries towards TCS (p < 0.05). Mean total TOPICOP scores decreased from 42 to 35% and from 33 to 25% for parents and pharmacy staff respectively. Conclusion Our results show the prevalence of corticophobia among parents. Education of pharmacy staff and targeted patient counseling seems to be effective in reducing corticophobia.

Impact of the COVID-19 epidemic on the provision of pharmaceutical care in community pharmacies.

BACKGROUND: Community pharmacists and their teams are easy accessible healthcare providers with an important role in primary care. As a consequence of the COVID-19 epidemic, (pharmaceutical) care and specifically communication between patients and healthcare providers is compromised. OBJECTIVE: To describe the impact of the COVID-19 epidemic on the provision of pharmaceutical care in the Netherlands. METHODS: A cross-sectional study with an online questionnaire was sent to community pharmacies in the Netherlands. The questionnaire covered the following main topics: changes in pharmacy setting and logistic procedures, communication about medication and baseline characteristics. RESULTS: Pharmacies implemented hygiene measures and minimized direct patient-provider contact, e.g. by delivering medication at home to a wider range of patients (47.0%), temporarily not conducting medication reviews (55.8%) and only performing inhalation instructions via telephone (22.3%). Only a small number of pharmacies used telepharmacy, such as video calling during patient education and counseling. A total of 76.7% of the participants expressed concerns towards the pharmaceutical care for vulnerable patients. CONCLUSIONS: Our results show considerable impact of the COVID-19 epidemic on both logistic procedures and services regarding patient education and counseling. Pharmacies should be stimulated to implement telepharmacy or remote service to optimally support patients during the COVID-19 epidemic.

Optimizing pharmaceutical care for pediatric patients with dermatitis: perspectives of parents and pharmacy staff.

Background Atopic dermatitis affects 10-20% of the children worldwide. Unfortunately not all patients who receive treatment have optimal treatment outcomes. Objective To assess the view of parents and pharmacy staff in order to optimize pharmaceutical care for young atopic dermatitis patients. Setting Community pharmacies in the Netherlands. Method We first held an expert panel meeting to determine experts' views on treatment of atopic dermatitis and their suggestions for areas of improvement. This input was used to develop the interview guide. We conducted telephone interviews with parents of children (aged 0-12 years) with atopic dermatitis and face-to-face interviews with pharmacy staff members. All interviews were audiotaped and transcribed verbatim. Transcripts were coded using qualitative data analysis software. Codes were used to identify themes. Main outcome measure Perspectives of parents of young atopic dermatitis patients and pharmacy staff about treatment. Results We interviewed 29 parents and 18 pharmacy staff members. Many parents mentioned fear of steroid adverse effects, with intentional nonadherence as a consequence, and difficulties with the application of topical treatment. Pharmacy employees also mentioned to encounter these issues. Some employees themselves expressed concerns towards use of steroids. Most parents were satisfied with the information they received; however, they need more practical lifestyle advices, e.g. about bathing or clothing. Both pharmacists and pharmacy technicians mentioned that technicians often lack knowledge to support patients optimally in correct medication use. Conclusion Parents' perceptions about topical corticosteroids might negatively influence treatment outcomes. Pharmacy staff has an important role to inform parents of children with eczema on the appropriate use of topical corticosteroids and emollients. Counseling should not be influenced by their own prejudices about topical corticosteroids. Close collaboration between primary care providers should ensure that parents receive uniform messages.

Recognizing and Addressing Limited PHarmaceutical literacy: Development of the RALPH interview guide.

BACKGROUND: In the context of medication use, pharmaceutical literacy skills are crucial for appropriate and safe use of medication. Recognition of patients with inadequate pharmaceutical literacy in daily pharmacy practice is difficult. No instrument is yet available to support pharmacists herein. The aim of this study was therefore to develop an interview guide for pharmacists to Recognize and Address Limited PHarmaceutical literacy (RALPH). METHODS: The RALPH interview guide was constructed in three phases: (1) development including a literature search, expert group discussion, and feasibility test with 15 patients; (2) pilot-test with 421 patients throughout 30 community pharmacies, and (3) final test with 508 patients to optimize the interview guide. RESULTS: The development phase resulted in a first interview guide comprising 15 questions: seven in the functional domain (understanding instructions), four in the communicative domain (finding and understanding medication information) and four in the critical domain (critically analyzing medication information). This version was pilot-tested in 30 pharmacies, with 147 patients during medication reviews and another 274 patients were interviewed while waiting to collect their medication. This test phase led to removal of questions that proved difficult to interpret and to rephrasing some questions. The second version including 11 questions was tested by 109 pharmacists trainees with 508 patients, resulting in the final RALPH interview guide comprising 10 questions, all directly linked to the patient's own medication: three in the functional, three in the communicative and four in the critical domain. Besides instructions on how to use the interview guide, recommendations are provided for pharmacists on how to support patients with limited pharmaceutical literacy skills. CONCLUSIONS: The practice-based RALPH interview guide supports pharmacists in recognizing patients with limited pharmaceutical literacy. With this insight, pharmacists can tailor their medication counseling to patients' pharmaceutical literacy level to better support patients in their medication use.

Recognizing pharmaceutical illiteracy in community pharmacy: Agreement between a practice-based interview guide and questionnaire based assessment.

BACKGROUND: Patients with limited pharmaceutical literacy are at increased risk of drug-related problems. Recognizing these patients in daily practice is difficult. The Recognition and Addressing of Limited Pharmaceutical Literacy (RALPH) interview guide was developed as practical set of questions to recognize patients with limited pharmaceutical literacy in daily pharmacy practice. OBJECTIVE: To compare agreement between pharmaceutical literacy measured with the RALPH guide and a validated general health literacy questionnaire. In addition, we provide insight into patients' pharmaceutical literacy using the RALPH interview guide. METHODS: Structured face-to-face interviews with patients who visited a community pharmacy to fill a prescription for themselves were conducted. The interview included the RALPH guide as well as the Functional Communicative Critical Health Literacy (FCCHL) questionnaire to measure general health literacy. Functional, communicative and critical skills were measured and agreement between two methods was calculated. RESULTS: Data were collected from 508 patients. Patients with limited pharmaceutical literacy, indicated by the RALPH questions, also had a lower general health literacy level according to FCCHL scores. Agreement between the RALPH guide and FCCHL questionnaire was moderate (∼60%) for the three health literacy domains. Most patients (>90%) had correct understanding of frequency and timing of medication use, but 25% did not understand warnings or precautions correctly. Finding understandable information (39%), assessing information applicability (50%) and reliability (64%) were mentioned as difficult by patients. CONCLUSION: Patients experienced difficulties with more complex skills, e.g. interpretation of warnings or precautions when using a medicine, finding and analyzing medication information. Whereas the FCCHL questionnaire is useful to assess general health literacy, the RALPH interview guide provides insight in the level of skills needed for good medication use and is more suitable for use in a medication specific context such as community pharmacy. Context specific assessment of skills is important to provide tailored pharmaceutical care.

Attention-Deficit/Hyperactivity Disorder Medication Use in Adolescents: The Patient's Perspective.

PURPOSE: The purpose of the study was to gain more insight into the attitudes of adolescents using medication for attention-deficit/hyperactivity disorder (ADHD). METHODS: A cross-sectional study among adolescents (aged 12-18 years) who filled at least two prescriptions for ADHD medication in the preceding year was conducted. Adolescents were invited to fill in an online questionnaire containing questions on sociodemographics, health status, illness perceptions, medication adherence, and medication beliefs. RESULTS: We invited 1,200 adolescents of whom 181 adolescents (122 males, mean age 14.2 ± 1.7 years) completed the online questionnaire. They mostly used methylphenidate (n = 167; 92%) as a pharmacological treatment for ADHD. Half of the study population (n = 93; 51%) experienced side effects, such as decreased appetite and sleep problems. Most participants (n = 150; 83%) had an indifferent attitude (perceived low necessity and low concerns) toward their ADHD medication. More than half of the study population (n = 111; 61%) reported to be nonadherent based on the Medication Adherence Report Scale. The highest score of the Brief Illness Perception Questionnaire was on "treatment control," suggesting that adolescents do think their medication is effective, despite their indifferent drug attitude. CONCLUSIONS: Most adolescents using ADHD medication had an indifferent attitude toward their medication and reported low adherence rates. These findings should be taken into account when treating adolescents with ADHD; regular counseling and monitoring of the pharmacological treatment might be useful to optimize treatment.

Availability of information on renal function in Dutch community pharmacies.

Background Early detection and monitoring of impaired renal function may prevent drug related problems. Objective To assess the availability of information on patient's renal function in Dutch community pharmacies, for patients using medication that might need monitoring in case of renal impairment. Methods Per pharmacy, 25 patients aged ≥65 years using at least one drug that requires monitoring, were randomly selected from the pharmacy information system. For these patients, information on renal function [estimated glomerular filtration rate (eGFR)], was obtained from the pharmacy information system. When absent, this information was obtained from the general practitioner (GP). Results Data were collected for 1632 patients. For 1201 patients (74 %) eGFR values were not directly available in the pharmacy, for another 194 patients (12 %) the eGFR value was not up-to-date. For 1082 patients information could be obtained from the GP, resulting in 942 additional recent eGFR values. Finally, recent information on renal function was available for 72 % (n = 1179) of selected patients. Conclusion In patients using drugs that require renal monitoring, information on renal function is often unknown in the pharmacy. For the majority of patients this information can be retrieved from the GP.

"These patients look lost" - Community pharmacy staff's identification and support of patients with limited health literacy.

OBJECTIVE: To date, routine use of health literacy assessment in clinical settings is limited. The objective of this study was to explore if community pharmacy staff can identify patients with limited health literacy, how they identify patients and how they support patients to improve medication use. In addition, perceived barriers in providing care for patients with limited health literacy were assessed. METHODS: Structured face-to-face interviews with pharmacy staff were performed in 27 community pharmacies. Questions concerned pharmacy staff's experiences with limited health literacy during their work, e.g. recognition of patients, communication strategies and possible interventions for this patient group to improve medication use. KEY FINDINGS: Results from 74 interviews were included for analysis. Sixty-eight interviewees (92%) mentioned to identify patients with limited health literacy during their work, mostly based on intuition. Suggested strategies to improve medication use included tailored education and information, intensive support or use of aids such as a multidose drug dispensing system. Pharmacy staff indicated lack of time as a barrier to provide tailored pharmaceutical care. CONCLUSIONS: Most participants mentioned to recognize patients with limited health literacy merely on intuition or based on certain patient characteristics. Thus, an unknown number of patients with limited health literacy might be missed. This underlines the need to create more awareness of health literacy among pharmacy professionals. Moreover, training of pharmacy staff and use of aids to identify limited health literacy may help to identify more patients who need additional counselling.

Quality of pharmaceutical care at the pharmacy counter: patients' experiences versus video observation.

INTRODUCTION: Consumer Quality Index questionnaires are used to assess quality of care from patients' experiences. OBJECTIVE: To provide insight into the agreement about quality of pharmaceutical care, measured both by a patient questionnaire and video observations. METHODS: Pharmaceutical encounters in four pharmacies were video-recorded. Patients completed a questionnaire based upon the Consumer Quality Index Pharmaceutical Care after the encounter containing questions about patients' experiences regarding information provision, medication counseling, and pharmacy staff's communication style. An observation protocol was used to code the recorded encounters. Agreement between video observation and patients' experiences was calculated. RESULTS: In total, 109 encounters were included for analysis. For the domains "medication counseling" and "communication style", agreement between patients' experiences and observations was very high (>90%). Less agreement (45%) was found for "information provision", which was rated more positive by patients compared to the observations, especially for the topic, encouragement of patients' questioning behavior. CONCLUSION: A questionnaire is useful to assess the quality of medication counseling and pharmacy staff's communication style, but might be less suitable to evaluate information provision and pharmacy staff's encouragement of patients' questioning behavior. Although patients may believe that they have received all necessary information to use their new medicine, some information on specific instructions was not addressed during the encounter. When using questionnaires to get insight into information provision, observations of encounters are very informative to validate the patient questionnaires and make necessary adjustments.

Patient-provider communication about medication use at the community pharmacy counter.

OBJECTIVE: The objectives of this study were to, first, describe the information exchanged between pharmacy staff and patients about prescribed medication at the community pharmacy counter, and second, to investigate to what extent this met professional medication counselling guidelines. METHODS: Pharmaceutical encounters were videotaped in four community pharmacies in the Netherlands. Patients were included if they collected a prescription for their own use. An observation protocol, including the MEDICODE checklist, was used to analyse the video recordings. A distinction was made between first and repeat prescriptions. KEY FINDINGS: One hundred fifty-three encounters were videotaped. When dispensing first prescriptions, pharmacy staff provided most information on instructions how to use the medication (83.3%), form of the medication (71.4%) and treatment duration (42.9%). Topics for repeat prescriptions (such as the effects of the medication and the incidence of observed adverse effects) were rarely discussed. Pharmacy staff rarely encouraged patients to ask questions. CONCLUSIONS: Pharmacy staff members provided little medication-related information at the counter, especially for repeat prescriptions, did not encourage active patient participation, and thereby did not adhere to the guidelines of their professional organisation. Further research is needed to understand the reasons for this.

"I just forget to take it": asthma self-management needs and preferences in adolescents.

BACKGROUND: Medication adherence rates often decline as children become teenagers. Effective adherence-enhancing interventions for adolescents are lacking. The objective of this study was to assess adolescent asthmatics needs and preferences regarding medication counseling and support, with focus on new media. METHODS: Three focus groups including 21 asthmatic adolescents recruited from both primary and secondary care were held to explore needs and preferences regarding asthma-self management. Questions concerned adherence behavior and needs and preferences in adherence support with focus on new media (mobile technology, social media, health games). RESULTS: Forgetting was mentioned as major reason for not using medication as prescribed. Adolescents also mentioned lack of perceived need or beneficial effects. Parents mainly play a role in reminding to take medication and collecting refills. The suggested strategies to support self-management included smartphone applications with a reminder function and easy access to online information. Participants were positive about sharing of experiences with other teenagers. CONCLUSION: Forgetfulness is a major reason for non-adherence in adolescents. Furthermore, our results suggest use of peer support may be helpful in promoting good medication use. Future interventions should be aimed at providing practical reminders and should be modifiable to individual preferences.

Health literacy among pharmacy visitors in the Netherlands.

PURPOSE: Health literacy is defined as the ability to obtain, understand and apply information to make appropriate health decisions. Most health literacy research has been performed in the USA. Our objective was to study the prevalence of limited health literacy among adult pharmacy visitors in the Netherlands and to assess the association between health literacy and understanding of drug label information. METHODS: A cross-sectional study was performed in community pharmacies belonging to the Utrecht Pharmacy Practice network for Education and Research. Adult pharmacy visitors (aged ≥18 years) were approached in the pharmacy waiting area and invited for a brief interview including the newest vital sign, a validated health literacy assessment measure and questions about understanding of standard drug label instructions. RESULTS: A total of 984 pharmacy visitors were included in the study: 63% were women, mean age was 56 years and the majority was of native origin (84%). Based on newest vital sign scores, 52% had limited health literacy skills. Pharmacy visitors with limited health literacy skills had significantly lower understanding of drug label instructions (p < 0.001). CONCLUSION: Approximately half of the pharmacy visitors in this study had limited health literacy skills. These individuals experienced more difficulties understanding drug label instructions. These findings emphasize the need to identify patients with limited health literacy skills, as these patients might be at increased risk for drug-related problems caused by misunderstanding of information.

Medication adherence in adolescents in current practice: community pharmacy staff's opinions.

OBJECTIVE: To explore pharmacy staff's perspectives regarding medication use behaviour in adolescent patients. METHODS: Structured face-to-face interviews were conducted with 170 community pharmacy staff members. KEY FINDINGS: Medication-related problems in adolescents had been experienced by 80 respondents; non-adherence was frequently mentioned (n = 73). An important reason for medication-related problems in adolescents not being recognised was that prescriptions are often collected by the parents (with or without the teenager). Solutions suggested by the interviewees to improve adolescents' medication use behaviour included (improving) counselling with emphasis on necessity/benefits of medication (n = 130) and more direct contact with adolescents instead of parent(s) (n = 77). Use of digital media for educational purposes or reminder services was suggested to support medication use (n = 67). CONCLUSIONS: Almost half of pharmacy staff experienced problems related to medication use in adolescents. Pharmacy staff see a primary role for counselling on the benefits of therapy but foresee difficulties in obtaining direct contact with adolescents. Use of new media could be useful.

Adolescents' inhaled corticosteroid adherence: the importance of treatment perceptions and medication knowledge.

BACKGROUND: Studies measuring inhaled corticosteroid (ICS) adherence frequently report adherence rates below 50%. Although asthma is common in adolescents, few studies have explored determinants of ICS adherence in adolescents. The objective of this study was to examine adherence and related factors in adolescent ICS users. METHODS: Adolescent ICS users, aged 12-18 years, were randomly recruited from a sample of 94 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research to complete an online questionnaire. The survey contained questions on asthma control, self-reported adherence, medication beliefs and medication knowledge. Data were collected between April and August 2013. RESULTS: Complete questionnaire data were received from 182 adolescents of which 40% reported to be adherent. Approximately 40% of the participants perceived strong needs, whilst only 10% was highly concerned about adverse effects regarding their ICS use. Good adherence was significantly associated with asthma control (OR: 2.1, 95% CI: 1.1-4.1). Necessity beliefs and sufficient medication knowledge were associated with better adherence (p < 0.05). CONCLUSION: Our results suggest that by improving knowledge about asthma treatments and stimulating positive perceptions towards medicines, especially regarding the necessity of medication use, better adherence rates might be achieved.

The Utrecht Pharmacy Practice network for Education and Research: a network of community and hospital pharmacies in the Netherlands.

Practice-based networks can serve as effective mechanisms for the development of the profession of pharmacists, on the one hand by supporting student internships and on the other hand by collection of research data and implementation of research outcomes among public health practice settings. This paper presents the characteristics and benefits of the Utrecht Pharmacy Practice network for Education and Research, a practice based research network affiliated with the Department of Pharmaceutical Sciences of Utrecht University. Yearly, this network is used to realize approximately 600 student internships (in hospital and community pharmacies) and 20 research projects. To date, most research has been performed in community pharmacy and research questions frequently concerned prescribing behavior or adherence and subjects related to uptake of regulations in the pharmacy setting. Researchers gain access to different types of data from daily practice, pharmacists receive feedback on the functioning of their own pharmacy and students get in depth insight into pharmacy practice.

Problems experienced by older people when opening medicine packaging.

OBJECTIVE: Medicine packages can cause problems in daily practice, especially among older people. This study aimed to investigate the prevalence of problems experienced by older people when opening medicine packaging and to investigate how patients manage these problems. METHODS: A convenience sample of 30 community pharmacies participated in this study. They selected a systematic sample of 30 patients over 65 years old with a recent omeprazole prescription, and a questionnaire was administered by telephone for at least 10 patients per pharmacy. KEY FINDINGS: A total of 317 patients completed the questionnaire. They received their omeprazole in a bottle (n = 179, 56.5%), push-through blister pack (n = 102, 32.2%) or peel-off blister pack (n = 36, 11.4%). Some 28.4% of all patients experienced one or more problems with opening their omeprazole packaging; most problems occurred with peel-off blisters (n = 24, 66.7% of all respondents using peel-off blisters), followed by push-through blisters (n = 34, 33.3%) and finally bottles (n = 32, 17.9%). The risk of experiencing problems with peel-off blisters and push-through blisters was higher [relative risk 3.7 (95% confidence interval 2.5-5.5) and 1.9 (1.2-2.8), respectively] than the risk of experiencing problems with opening bottles. Two-thirds of respondents reported management strategies for their problems. Most were found for problems opening bottles (n = 24, 75%), followed by push-through blisters (n = 24, 70.6%) and peel-off blisters (n = 14, 58.3%). CONCLUSIONS: One in four patients over 65 experienced difficulties opening their omeprazole packaging and not all of them reported a management strategy for their problems. Manufacturers are advised to pay more attention to the user-friendliness of product packaging. In addition, it is important that pharmacy staff clearly instruct patients on how to open their medicine packaging, or assist them in choosing the most appropriate packaging.

Pharmacy Technicians' Attention to Problems With Opening Medicine Packaging.

Background: Pharmacy technicians seem to be well equipped to engage in conversations with patients about their experiences and problems with medication, but it is unclear whether or not they systematically explain or demonstrate to patients how to use medication packaging. Objective: To explore to what extent pharmacy technicians identify problems with opening medicine packaging and how they assist patients in solving these problems. Methods: We conducted a cross-sectional study that comprised semistructured interviews, with 31 pharmacy technicians in 31 pharmacies, to assess the occurrence and type of difficulties with packagings and to suggest solutions. Results: All pharmacy technicians recognize the occurrence of packaging problems, though patients rarely report them at the pharmacy counter. Not all pharmacy technicians are familiar with opening all packaging forms, but they all describe ways to find out how to open them, which usually only happens after patients bring up problems. Solutions suggested by the pharmacy technicians include informing and counseling, changing or manipulating the packaging, and providing assisting tools. Conclusions: This study shows that although pharmacy technicians are aware that medication packaging can cause problems and are able to name or find out solutions to all these problems, there is no systematic attention for packaging at drug dispensation in most pharmacies. Discussing the handling of medication packaging should become a fixed part of drug dispensation counseling. Pharmacists should draw up working procedures to support pharmacy technicians in their counseling activities.

Patients' satisfaction with information and experiences with counseling on cardiovascular medication received at the pharmacy.

OBJECTIVE: To assess the extent to which patients feel they have received enough information on cardiovascular drugs and experienced counseling at the pharmacy. In addition, to identify factors that are predictors for patient satisfaction with the information received. METHODS: Fifteen community pharmacies participated. New and chronic users of cardiovascular medication received a questionnaire containing sociodemographic and health questions, a measure of satisfaction with information received (SIMS), beliefs about medication (BMQ), and frequency of pharmacy counseling. RESULTS: Of the 578 respondents, 335 (58%) indicated to be unsatisfied with the information received on 3 or more SIMS items. Patients' age, beliefs about medication, duration of cardiovascular treatment and use of antithrombotics predicted patients' satisfaction with information received. Two-thirds of patients reported 'never' to have experienced 5 of 8 counseling activities at the pharmacy. CONCLUSIONS: A considerable proportion of patients are unsatisfied with the information received on cardiovascular medication. The majority of patients have only received a limited scope of medication counseling at the pharmacy. PRACTICE IMPLICATIONS: Information and counseling should be tailored to patients' needs and concerns about cardiovascular medication and the experience patients already have with treatment. Pharmacists could enhance their role in supporting patients using cardiovascular medication.