Description of the condition
Pharmacists are the third largest regulated healthcare professional group in the world (Chan 2006), with community pharmacy the most common discipline represented. Community pharmacies have been identified as an easily accessible and cost-effective platform for delivering health care worldwide (DOH 2005; WHO 1998). For example, in England there are over 12,000 community pharmacies; crucially, 99% of the population – even those living in deprived areas – can access a pharmacy within a 20 minute drive (DOH 2008). In Australia, over 90% of the population visit a pharmacist over the course of a year (Benrimoj 2004). Similarly, in low- and middle-income countries pharmacies are often seen as ‘a first point of call’ for advice on symptoms and for early diagnosis of illness (Smith 2009).
In view of the wide accessibility of community pharmacists, the role has undergone rapid expansion in recent years (WHO 2006). In addition to dispensing and medication-linked services, pharmacies are now required to give advice on public health priorities, including modification of health behaviour to minimise risk of disease and to promote a healthy lifestyle (DOH 2005). Smoking cessation was one of the earlier behaviour change tasks given to pharmacists in the UK, and now others have been added such as improving general lifestyle behaviours, increasing uptake of screening and giving sexual health advice (RPSGB 1996). To address the needs of this changing role and to maintain high standards, international guidance for good pharmacy practice has been published which stresses health promotion as one of six components which contribute to the health improvement of individuals that access community pharmacy services (WHO 2011).
However, despite this potential, the evidence base underpinning these wider health promotion tasks is currently relatively poor, both for effective methods of changing professional practice and to evaluate the health gains that could result from these changes. Research evidence suggests that whilst pharmacists and consumers hold positive attitudes to pharmacist involvement in public health, pharmacist confidence is currently low and additional training needs are perceived (Eades 2011).
Systematic reviews examining behaviour change interventions by clinical topic have thus far been limited by small numbers of poor quality studies (Gordon 2011; Sinclair 2004; Watson 2006), suggesting that a broad overview of studies of health promotion interventions in pharmacies is needed both to inform current pharmacy practice and to identify areas for future research.
Description of the intervention
The World Health Organization defines health promotion as "the process of enabling people to increase control over, and to improve, their health". The idea of health promotion moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions (WHO 2009). Interventions that target a specific aspect of lifestyle, such as smoking cessation, or that address wider aspects of clinical management, such as overweight and obesity or type 2 diabetes mellitus, therefore fall within this definition.
Interventions to address these broad health promotion and behaviour change tasks amongst people attending community pharmacies may be directed at pharmacy staff, their clients (or patients), or at both groups. The types of intervention may vary from educational programmes (Sarayani 2012), to specific training in particular behavioural issues, such as readiness to change behaviour (Sinclair 1998). Other interventions target management of medical conditions by patients, for example monitoring blood pressure (Fikri-Benbrahim 2012) or managing asthma (Armour 2007). These types of interventions go well beyond the traditional remit of pharmacy workers, which conventionally focused on the dispensing and management of medicines.
Previous Cochrane reviews (Nkansah 2010; Pande 2013) have examined non-dispensing services in pharmacies; however, these have still had a strong focus on medications, including ‘medication reviews’ or medication therapy management interventions. Such interventions provide person-centred care and consider the medication regimen, including issues of adherence. To avoid overlap with previous work, we will exclude any purely medication-related interventions in this review. We will also exclude studies that only use behavioural techniques to address adherence to medication.
How the intervention might work
The way in which health promotion and behaviour change interventions work within community pharmacy is likely to be dependent on the theoretical basis for the intervention and the behaviour change techniques they use (Michie 2008). For example, interventions may aim to increase self efficacy in performing a behaviour that promotes health, or may examine ways of overcoming barriers to performing that behaviour. The behavioural theory underpinning interventions and the mechanisms by which community pharmacy interventions might work have not previously been studied in detail. However, an understanding of the mechanisms by which health behaviour change is achieved in successful community pharmacy interventions, and the behaviour change theories used, will be important in designing more effective interventions, both for existing clinical areas and to support the expansion of the role of the pharmacist in the future.
The current review will therefore seek to identify which underpinning theories and behaviour change techniques are most effective in achieving health behaviour change in a community pharmacy setting. We aim to identify generic methods that could be used to inform development of any health promotion intervention in a community pharmacy setting.
Most interventions involve training the pharmacist or pharmacy worker; however, evidence is sparse regarding the best methods of training pharmacists in health behaviour change techniques. Even if pharmacists and pharmacy staff can be trained effectively and can deliver the intervention with fidelity, there still remains the question of whether clients (or patients) follow the given advice and, further, whether this results in meaningful improvements in health and well-being. There has been no previous comprehensive review of the effectiveness of community pharmacy staff as agents for health behaviour change (Anderson 2003). It is important to consider the complete pathway from intervention to effects on health outcomes. Hence we will examine study outcomes related both to the professional behaviour of pharmacy staff and to health promotion in their clients.
Why it is important to do this review
This review is important because pharmacists worldwide are increasingly taking on health promotion as part of their rapidly expanding role in delivery of primary health care. However research evidence supporting the use of pharmacists as agents for changing health behaviours is sparse, and thus the best ways of enabling pharmacists to perform this new role and the magnitude of the health benefits that might accrue for their patients are both uncertain. Similar uncertainty surrounds the optimum structure of pharmacy-based health promotion interventions and their costs. This review aims to address gaps in existing knowledge, highlighting ways in which current clinical practice can be improved and suggesting areas where further research is needed.
We will examine all relevant studies where pharmacists or pharmacy staff (pharmacy technicians, pharmacy assistants) deliver an intervention to improve the health behaviour of people attending community pharmacies. The review will study the impact of the intervention on changing professional practice and effecting health behaviour change in patients or members of the public (collectively called 'clients (patients)' here). We shall also collate evidence on the methods of training pharmacists and pharmacy staff and will consider whether any specific approaches are associated with greater effectiveness in changing professional behaviour or patient-based outcomes.
The review will include high-, middle- and low-income country settings and will consider whether effectiveness differs by country income group. Pharmacies provide an existing health infrastructure with a client base, supply chains and trained health professionals in countries where other forms of primary care are poorly developed. Evidence to support expansion of their clinical role in low- and middle-income countries could be important in planning use of healthcare resources globally.
The review will also evaluate whether effectiveness of interventions varies by ethnicity or by the extent of the adverse health behaviour (e.g. number of cigarettes smoked per day), as it is important to understand whether a ‘one size fits all’ approach is effective, or whether there is evidence of differential effectiveness of the intervention in people with particular characteristics. For example, in asthma self management there is evidence that culturally specific interventions for different ethnic groups are more effective than generic programmes (Bailey 2009). Thus, this review will consider whether there is likely to be a benefit in stratifying people for targeted health promotion interventions in a community pharmacy setting.
The review will also evaluate whether the type of pharmacy worker delivering the intervention has an impact on the effectiveness of the intervention (e.g. pharmacist versus pharmacist assistant). A previous review has stressed the importance of training of facilitators for the effectiveness of self-management education programmes for chronic conditions (Foster 2007). Thus the current review will evaluate whether the level of qualification and experience of the pharmacy worker has an impact on the effectiveness of the intervention on clients'/patients’ behaviour change and health outcomes.