The current and potential role of community pharmacy in asset-based approaches to health and wellbeing: a qualitative study.

Background Asset-based approaches seek to positively mobilise the strengths, capabilities, and resources of individuals and communities. To date, limited consideration has been given to the potential value of this approach in relation to community pharmacy practice, yet this is important and timely given community pharmacy's expanding role and contribution to public health initiatives. Objectives This qualitative study aimed to explore the current and potential role of community pharmacy in asset-based approaches. Methods Fifteen semi-structured telephone interviews were undertaken with community pharmacists and project leads, and public health policy and strategic leads in the UK. Transcripts were analysed using simultaneous inductive open and deductive coding using an applied Theory of Change as an illustrative lens. Results The shift towards patient-facing roles in community pharmacy was felt to offer expanded relational opportunities to engage and collaborate with individuals, communities, and other stakeholders. However, only a small number of respondents described examples of systemic asset-based working within the pharmacy sector. The adoption of asset-based approaches was challenged or enabled by several factors including the availability of protected time/resources, workplace and organisational culture/values, strategic leadership, commissioning, and funding arrangements. Conclusions The study provides valuable insights into the potential for community pharmacy, a previously unconsidered sector, to further adopt and contribute to asset-based approaches and play a more central role in the improvement of public health and reduction of health inequalities.

Extending the scope of community pharmacists' practice to patients requiring urgent care - An evaluation of a training programme using the Theoretical Domains Framework.

Redesigned health systems could meet the rising demand for healthcare, with community pharmacy currently an underused resource for the treatment and management of patients requiring urgent care. This study aimed to investigate whether a training intervention delivered over 2 days to community pharmacists resulted in behaviour and practice change. Validated measures of psychological motivation and capability factors relevant to understanding behaviour and behaviour change were collected 1 week before, 1 week after and 2 months after training in a non-controlled before and after study design. Two targeted behaviours of the intervention were the primary outcome measures: taking a structured history and applying clinical examination techniques to patients requiring urgent care. Secondary outcomes measured participants' reported patient management behaviours to investigate possible bridging of gaps in the health system. Training was provided in 14 locations in the UK to 258 community pharmacists, with data collection occurring from July 2015 to September 2016. In total, 81 participants completed all three rounds of data collection (31.4%). Findings suggest that 1-week post-training significant changes in psychological capability had taken place, and that these were sustained 2 months later: of the eight domains influencing behaviour and stimulating behaviour change, knowledge, skills, professional role, beliefs about capabilities and goals all increased significantly between T1 and T2, and T1 and T3 (all p < 0.0001). At T3, participants were more likely to have taken a structured history than performed a clinical examination, and reported both managing patients themselves and changing referral practices to other healthcare providers. Participants reported workload and the need for liability insurance as structural and contextual barriers to implementation. While findings suggest the potential to transform models of care through training to extend community pharmacists' practice these barriers to successful implementation of the urgent care service would need to be addressed if this service is rolled out nationally.

Self-care of long-term conditions: patients' perspectives and their (limited) use of community pharmacies.

Background Self-care support is an 'inseparable' component of quality healthcare for long-term conditions (LTCs). Evidence of how patients view and use community pharmacy (CP) to engage in self-care of LTCs is limited. Objective To explore patients' perspectives of engaging in self-care and use of CP for self-care support. Setting England and Scotland. Method Qualitative design employing semi-structured interviews. LTCs patients were recruited via general practitioners (GPs) and CPs. Interviews were conducted between May 2013 and June 2014; they were audio-recorded, transcribed verbatim and analysed thematically. Results Twenty-four participants were interviewed. Three main themes emerged: engaging in self-care, resources for self-care support and (limited) use of community pharmacy. Participants' LTC 'lived experience' showed that self-care was integral to daily living from being diagnosed to long-term maintenance of health/wellbeing; self-care engagement was very personal and diverse and was based on beliefs and experiences. Healthcare professionals were viewed as providing information which was considered passive and insufficient in helping behavioural change. Non-healthcare sources (family, carers, friends, internet) were important in filling active support gaps, particularly lifestyle management. Participants' use of, and identified need for, community pharmacy as a resource for self-care support of LTCs was limited and primarily focussed on medicines supply. There was low awareness and visibility of CPs' potential roles and capability. Conclusion CP needs to reflect on patients' low awareness of its expertise and services to contribute to self-care support of LTCs. Rethinking how interventions are designed and 'marketed'; incorporation of patients' perspectives and collaboration with others, particularly GPs, could prove beneficial.

How do community pharmacists conceptualise and operationalise self-care support of long-term conditions (LTCs)? An English cross-sectional survey.

OBJECTIVES: To explore community pharmacists' contributions to self-care support of long-term conditions by; investigating their conceptual understanding of self-care principles; identifying self-care support activities they considered important and their engagement in them; and examining barriers and enablers. METHODS: A questionnaire was developed using existing literature and qualitative interviews, piloted and distributed online to a random sample of 10 000 community pharmacists in England between August and November 2014. The questionnaire contained sections addressing the above objectives. Data were analysed using descriptive statistics; free text comments were analysed using content analysis. KEY FINDINGS: A total of 609 responses were received; 334 completed all sections of the survey. Responses to statements exploring conceptual understanding showed that respondents were more likely to agree with self-care principles about patients taking responsibility and being more actively involved in their health and care; they agreed less with self-care principles promoting patient autonomy and independence. Respondents considered medicines-related self-care support activities as a lead role for community pharmacy, which they said they engaged in regularly. Whilst many agreed that other self-care support activities such as supporting self-monitoring and collaborative care planning were important, they indicated only limited engagement. Respondents identified access to patient records and availability of private consultation rooms as their main barriers and enablers, respectively; working relationship with GPs and skill-mix in community pharmacy were viewed as both barriers and enablers. CONCLUSIONS: Community pharmacists in this study conceptualised and operationalised self-care support of long-term conditions (LTCs) from a narrow, medicines-focussed perspective, rather than from a multifaceted, patient-focussed perspective. A concerted and coherent strategy that builds on the strengths, and tackles the identified barriers is needed if community pharmacy is to improve contributions to self-care support of LTCs.

The national consultation skills for pharmacy practice program in England.

BACKGROUND: Pharmacy professionals are playing an increasing role in caring for patients, yet evidence has shown their consultation skills are lacking. OBJECTIVE: This article aims to discuss the need to enhance pharmacy professionals' (pharmacists and pharmacy technicians) consultation skills in England and describe the development of a national consultation skills training program to meet these needs. METHODS: The Centre for Pharmacy Postgraduate Education led on a project to create a consultation skills training program for all pharmacy professionals across England. The program embedded a set of consultation skills practice standards developed by a large task and finish group consisting of pharmacy professionals of varying roles from the National Health Service, private pharmacy organizations and academia. KEY FINDINGS: A Consultation Skills for Pharmacy Practice (CSfPP) training program, consisting of a distance learning workbook and website, was produced and disseminated to all registered pharmacy professionals in England, in March 2014. CONCLUSIONS: The first consultation skills training program of its kind was created that aimed to address the growing need to improve the consultations skills of pharmacy professionals in England. Future work will examine the reception of the CSfPP among pharmacy professionals and the impact it has on their practice.

A qualitative study exploring community pharmacists' awareness of, and contribution to, self-care support in the management of long-term conditions in the United Kingdom.

BACKGROUND: Self-care support refers to activities aimed at educating, training and empowering patients with skills and ability to manage [and monitor] their long-term conditions (LTCs). While self-care support by health care professionals has emerged as a distinct concept in the management of LTCs, evidence of community pharmacy's contribution is sparse. OBJECTIVE: The aim was to explore community pharmacy's contribution to self-care support of LTCs. The objectives were to explore how community pharmacists conceptualize self-care support of LTCs and how they operationalize the core elements of this in their practice. METHODS: Semi-structured interviews were conducted with community pharmacists in England (n = 12) and Scotland (n = 12). A framework consisting of the core elements of self-care support (information and advice; skills training and support; technology; support networks; and collaborative care planning) was developed from the literature and was used to structure the interviews and analysis. Analysis was done thematically using the interpretative phenomenological analysis technique. RESULTS: The three main themes that emerged were conceptualization; operationalization of the core elements; and barriers to providing self-care support. Participants conceptualized self-care of LTCs as patients taking responsibility for their own health, performing activities that improved their LTCs and that enabled them to become more independent in managing their LTCs. Their views on self-care support did not reflect this conceptual understanding but was described primarily as providing patients with information and advice rather than actively supporting them. Participants' views of operationalizing the core elements of self-care support was found to be medicines focused, opportunistic and dependent on the services they provided, rather than being patient-centered and proactive. The barriers to providing self-care support of LTCs in community pharmacy were described as priority accorded to dispensing activities, the structure of the community pharmacy contract, lack of incentives to provide self-care support and patients' expectations and lack of awareness of community pharmacy's role in LTCs management. CONCLUSION: Community pharmacists' theoretical understanding of self-care was not reflected in the ways that they portrayed their contributions to self-care support. The current ways in which community pharmacy delivers its services for patient care may need to be re-configured in order to fit into the holistic self-care support paradigm.

Pharmacy technicians' views of learning and practice implementation.

OBJECTIVE: Registered pharmacy technicians are a new group of regulated healthcare professionals in Great Britain, who fall under the same requirements for undertaking and recording of continuing professional development (CPD) as pharmacists. Little is known about this group of pharmacy professionals, their understanding of CPD and learning, or how they implement their learning into practice. This study aimed to address this. METHODS: A questionnaire was developed and sent to all 216 attendees of an interactive continuing education workshop provided in 12 different geographical locations in England. KEY FINDINGS: Over a third (n = 146; 67.6%) responded. The majority (94.5%) were female, aged between 40 and 49 years (43.8%), and had qualified less than 10 years ago (49.4%). Most worked in community (56.2%) or hospital (19.9%) pharmacy. When asked about whether they had implemented any of the workshop learning into practice, 84.2% ticked at least one option from a predetermined list, and 83.6% provided detailed descriptions of a situation, what they did and its outcome. These were grouped into two themes: people and places. Places referred to comments made about changes to systems, operations or equipment within the workplace; people concerned changes within respondents themselves or others, such as staff or customers. More than two-thirds (70.3%) had used their learning to create a CPD record, and those who had not (n = 43) gave lack of time but also lack of understanding as reasons. CONCLUSIONS: This study has provided detailed insights into pharmacy technicians' learning, reflection and practice implementation following an interactive workshop.

Hospital trust engagement with a new vocational learning programme for pharmacists and pharmacy technicians in England.

OBJECTIVES: This study aimed to explore hospital trusts' uptake of Learning@Lunch (L@L), a new vocational learning programme for hospital pharmacists and pharmacy technicians in acute and mental health trusts in England, recently introduced by the Centre for Pharmacy Postgraduate Education (CPPE). METHODS: The CPPE's ordering database for the first eight L@L modules, with addition of hospital trust and pharmacy characteristics, was analysed using SPSS, providing simple frequencies and chi2 cross-tabulations. KEY FINDINGS: The CPPE database contained data for 168 acute and 73 mental health trusts, about a third of each being foundation trusts. One-third (33.3%) of acute trusts were teaching, and the majority of them (91.1%) offered pre-registration places for 2009, the mean number being 3.39; only three mental health trusts offered places. L@L uptake by specialist and mental health trusts was lower than by those providing general services. Uptake was highest in the North and South, and lowest in London. Acute trusts with zero to two pre-registration places had a higher uptake than those offering three or more. CONCLUSIONS: Despite limitations of the database, analysis provides interesting insights into the uptake of this new learning programme, which are of interest to CPPE, as well as pharmacy academics and educationalists. L@L uptake by specialist and mental health trusts was significantly lower than that by acute trusts providing general services. Reasons for this need to be explored further to ensure that CPPE and other learning providers can meet the needs of hospital pharmacists and pharmacy technicians working in specialist areas, thus ensuring refresher training in core clinical areas.

Effects of fish meal replacement with full-fat soy meal on growth and tissue fatty acid composition in Atlantic cod (Gadus morhua).

Atlantic cod of initial mean weight approximately 220 g were fed a control diet and three diets in which fish meal (FM) was replaced with increasing levels of full-fat soybean meal (FFS) supplied at 12, 24, and 36% of dry diet, for 12 weeks. There were no significant differences in final weights, but the specific growth rate (SGR) was significantly higher in fish fed the control (FFS0) diet compared to fish fed the FFS12 and FFS36 diets, and the feed conversion ratio (FCR) was significantly lower in fish fed the FFS0 diet compared to the other three treatments. The fatty acid (FA) compositions of the cod muscle and liver were highly affected by dietary treatment, and linear relationships between dietary and tissue FA concentrations were shown for some of these. Moreover, selective utilization or accumulation in the tissues of specific FA was suggested by the results.

Support needs of supply nurses in rural and remote Queensland.

OBJECTIVE: The aim of this report is to discuss a needs analysis conducted with rural and remote nurses in Queensland undertaking supply of medications in public hospitals without a pharmacist. DESIGN: Survey questionnaire. METHODS: A questionnaire was faxed to 65 Queensland Health rural and remote hospitals using supply nurses. It contained six closed questions regarding previously identified medication 'supply' issues, and three open questions to determine additional information. RESULTS: Of the surveys, 42 (65%) were returned. Major areas of interest included a safety checklist for medication supply (90%, 38/42), more information on medication labelling requirements (83%, 35/42) and timing of medications with regard to food (86%, 36/42). Requirements for patient counselling, increased access to consumer medication information (CMI) (76%, 32/42), and resources regarding doses, indications, interactions and adverse effects also rated highly (73%, 31/42). Thirty-three supply nurses highlighted at least one issue in the open questions: more information on the legal requirements of repackaging medications (39%, 13/42), increased access to CMI and counselling tools (36%, 12/42) and an efficient stock control system (30%, 10/42). CONCLUSIONS: This report highlights the need to broaden current support services available to nurses undertaking the supply of medications. It is vital that support programs, and the laws and guidelines related to supplying medications in rural and remote hospitals, support health care professionals providing quality use of medicines (QUM) and reflect the realities of rural and remote health care.

Do rural consumers expect a prescription from their GP visit? Investigation of patients' expectations for a prescription and doctors' prescribing decisions in rural Australia.

OBJECTIVE: To assess patients' expectation for receiving a prescription and GPs' perceptions of patient expectation for a prescription. DESIGN: Matched questionnaire study completed by patients and GPs. SETTING: Seven general practices in rural Queensland, Australia. SUBJECTS: The subjects were 481 patients consulting 17 GPs. MAIN OUTCOME MEASURES: Patients' expectation for receiving a prescription and GPs' perceptions of patients' expectation. RESULTS: Ideal expectation (hope) for a prescription was expressed by 57% (274/481) of patients. Sixty-six per cent (313/481) thought it was likely that the doctor would actually give them a prescription. Doctors accurately predicted hope or lack of hope for a prescription in 65% (314/481) of consultations, but were inaccurate in 19% (93/481). A prescription was written in 55% of consultations. No increase in patients' expectation, doctors' perceptions of expectation, or decision to prescribe were detected for patients living a greater distance from the doctors. CONCLUSIONS: Rural patients demonstrated similar rates of hope for a prescription to those found in previous urban studies. Rural doctors seem to be similarly 'accurate' and 'inaccurate' in determining patients' expectations. Rates of prescribing were comparable to urban rates. Distance was not found to increase the level of patient expectation, affect the doctors' perception or to influence the decision to prescribe.

Influences on doctors' prescribing: is geographical remoteness a factor?

OBJECTIVE: To identify factors influencing the prescribing of medicines by general practitioners in rural and remote Australia. DESIGN: A qualitative study using a questionnaire to determine attitudes about prescribing, specific prescribing habits and comments on prescribing in 'rural practice'. SETTING: General practice in rural and remote Queensland. SUBJECTS: General practitioners practising in rural and remote settings in Queensland (n = 258). MAIN OUTCOME MEASURES: The factors perceived to influence the prescribing of medicines by medical practitioners in rural environments. RESULTS: A 58% response rate (n = 142) was achieved. Most respondents agreed that they prescribe differently in rural compared with city practice. The majority of respondents agreed that their prescribing was influenced by practice location, isolation of patient home location, limited diagnostic testing and increased drug monitoring. Location issues and other issues were more likely to be identified as 'influential' by the more isolated practitioners. Factors such as access to continuing medical education and specialists were confirmed as having an influence on prescribing. The prescribing of recently marketed drugs was more likely by doctors practising in less remote rural areas. CONCLUSION: Practising in rural and remote locations is perceived to have an effect on prescribing. These influences need to be considered when developing quality use of medicines policies and initiatives for these locations.

Culture of harpacticoid copepods: potential as live feed for rearing marine fish.

Copepods are useful as food for marine fish cultivation, in terms of both nutrition and ease of culture. Harpacticoid copepods are favoured over calanoids, since harpacticoids, as a result of their benthic habitat, can be reared at much higher densities. However, their benthic nature also makes mass culture difficult, since large surface areas must be provided. Within Harpacticoida, Tisbe spp. seem most useful, having high overall fecundity, and positive phototaxis of the nauplii. Harpacticoids can synthesise de novo several nutritionally important essential fatty acids (EFA), making them desirable as food for rearing marine fish. However, a diet rich in EFAs (e.g. animal derived feed) improves the productivity of copepod cultures, suggesting that the synthesis of EFA is rate-limiting for their reproduction. The nature of the substratum is also important in maintaining a good population, since harpacticoid biomass is more dependent on surface area than volume of a culture. Heterogeneous substrates can support large cultures because of their high surface area, but efficient cleaning methods are necessary. Frequent harvesting of populations will maintain good water quality and an overall low density of sexually mature copepods, raising naupliar productivity overall. Over-harvesting will naturally deplete the population. Harpacticoids are generally tolerant of environmental fluctuations but they do have temperature and salinity optima, and these will be species- and strain-dependent. Harpacticoid copepods are better food for fish larvae than Artemia, because of their ability to synthesise EFAs. The nauplii of harpacticoids are energetically poor but appear to have an appetite-stimulatory effect. Uneaten nauplii grow within the fish rearing tanks and graze on the walls, building up their own nutritional value and maintaining tank hygiene.

Doctors perceptions of the influences on their prescribing: a comparison of general practitioners based in rural and urban Australia.

OBJECTIVES: To compare and contrast the influences on prescribing perceived by general practitioners in an urban area of Queensland, Australia, to those perceived by general practitioners in rural Queensland. METHOD: An investigation was undertaken with a group of general practitioners in urban and rural locations of Australia. A self-administered questionnaire requested the doctors' demographic details and their opinions on statements about prescribing. They also reported their prescribing of six recently marketed drugs. RESULTS: One hundred and forty-two general practitioners from rural areas of Queensland (55% of the eligible population of these doctors) and one hundred and thirty-seven from the urban area (54% response) returned the surveys. The urban group were older and had more experience as general practitioners. Similarities and differences were detected between the two groups. The urban group considered that continuing medical education had a lesser influence on their prescribing than the rural group. The rural general practitioners were more likely than the urban doctors to agree that their information needs on prescribing were not being met in their practice, that their practice location had an effect on their prescribing (and also an effect on their prescribing of new drugs) as well as the remoteness of the patient's address having an effect. The rural doctors agreed more than the urban doctors that they try to avoid drugs requiring a significant amount of monitoring, reinforced by their agreement that they would be more likely to prescribe a newly marketed drug requiring less monitoring. When relating to whether the doctors in the two groups had reported initiating a supply of specific newly marketed drugs, independent of a specialist, rural general practitioners had initiated fewer of these selected new medicines. CONCLUSION: This study has highlighted some of the differences in perceptions of doctors on the influences on prescribing in rural relative to urban areas of Australia. An understanding of these perceptions will allow targeting and development of location-relevant prescribing interventions and messages.

A clinical audit of the prescribing of celecoxib and rofecoxib in Australian rural general practice.

AIMS: The new cyclooxygenase-2 (COX-2) selective inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx), have been widely prescribed since their launch. No reviews currently appear in the literature of prescribing patterns in Australia. This paper describes a self-audit of the clinical use of selective COX-2 inhibitor therapy undertaken with rural general practitioners (GPs) in Australia. METHODS: A structured audit form was developed and distributed to interested GPs. The form was self-administered and focused on issues about COX-2 inhibitors and the types of patients who were receiving them, e.g. indications, patient demographics, risk factors and drug interactions. RESULTS: A total of 627 patients were recruited (569 celecoxib and 58 rofecoxib). A range of doses was prescribed. Osteoarthritis was the most common indication (68.1%). Risk factors known for the nonselective nonsteroidal anti-inflammatory drugs were identified in 65.1% of patients, with the most common being advanced age, hypertension and previous peptic ulcer disease. Potential drug interactions were common. A variety of reasons for initiation of therapy was identified; these included perceived increased efficacy, safety and failure of other treatment. CONCLUSIONS: These results show that COX-2 inhibitors are being prescribed for patients with multiple risk factors that may place the patient at increased risk of adverse drug reactions to a COX-2 inhibitor. The perception of improved safety and efficacy was common and is of concern. Limitations of the study include the reliance on self-reporting.

Nonsteroidal anti-inflammatory drugs and potential risks in a convenience sample of general practitioners.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with significant morbidity and mortality. They remain widely prescribed. AIM: To describe current prescribing of non-COX-2 inhibitor NSAIDs. METHODS: Audit of a convenience sample of general practitioners. Individual and group results were fed back to individual GPs. RESULTS: Seventy-one GPs submitted 790 patients records. A wide range of NSAIDs was used. NSAIDs with a higher risk of gastrointestinal side effects were used in 30% of patients over 70 years. The most common risk factors for their use were age, cardiovascular disease and concomitant ACE inhibitor prescribing. Over 85% of participating doctors stated that feedback of these data would change their future use of NSAIDs. CONCLUSION: Patients are often exposed to the potential risks of NSAIDs.