key: cord-0961658-bbh8re9x
authors: Hope, Denise L; Day, Georgie; Clements, Joshua; Hattingh, H Laetitia
title: Australian community pharmacists’ perceptions of public health before the COVID-19 pandemic
date: 2021-03-24
journal: Int J Pharm Pract
DOI: 10.1093/ijpp/riaa010
sha: cc495127c48d95ed64339fac64f9743bf3a39d0d
doc_id: 961658
cord_uid: bbh8re9x

BACKGROUND: Consensus is lacking regarding delivery of public health services in community pharmacy. OBJECTIVE: The objective of this study was to explore pharmacists’ perspectives on public health initiatives in community practice. METHOD: Australian community pharmacists were randomly sampled to participate in face-to-face, semi-structured interviews to explore public health definitions and perceptions. KEY FINDINGS: Nine pharmacists participated early 2020, pre-COVID-19. Mean interview duration was 23 min. Results revealed little distinction between individual and public health services. Barriers to service provision were lack of time, remuneration, training, standards and privacy. Enablers opposed barriers, namely accessibility, improved funding, education, standardised services and consulting rooms. CONCLUSION: Improved clarity is required regarding the role that community pharmacists can assume in provision of public health.

Public health involves organised societal approaches to promote health, prevent disease and enhance longevity in individuals, communities and populations. [1] It is important for the effectiveness and efficiency of health system delivery. Consensus is lacking over the parameters of public health services, particularly involving the pharmacy profession.

The ambiguity of the definition of public health contributes to the difficulty in defining the role community pharmacists could play in public health. There is evidence of successful international community pharmacy driven public health initiatives, facilitated by the accessibility, proximity and availability of community pharmacists. [2, 3] Evolving pharmacists' roles in a changing practice landscape has facilitated provision of health screening, early intervention and treatment services to improve public health outcomes. Successful interventions include chlamydia [4] or Hepatitis C screening, [5] antimicrobial stewardship, [3] vaccine administration, [6] smoking cessation, [7] alcohol screening [8] and opioid replacement programs and disease control (e.g. obesity management, blood pressure screening, diabetes management). Consumers report mixed satisfaction with health interventions undertaken in community pharmacy. [9] Pharmacy public health initiatives may potentially reduce health care systems burden and generate cost savings. [3, 5, 7, 10] However, reported barriers to the implementation of public health interventions have included under-resourcing, skill shortages, insufficient capacity, poor morale, low pay, self-perceived competency, inadequate training, pharmacist's workload, lack of time, lack of space and lack of demand or awareness of services. [2, 10, 11] Given the recent expansion of pharmacists' roles, particularly in vaccine administration in Australia, it is timely to explore pharmacists' current perceptions of public health in community pharmacy. Recent Australian research has focused on extended pharmacy services, [9] which prompted exploring the role of community pharmacists in public health within an Australian context.

The overall aim of the study was to explore community pharmacists' perspectives on public health initiatives in community practice.

The exploratory study involved semi-structured interviews with community pharmacists in the Gold Coast area of Queensland, Australia. Institutional ethical clearance was received (HREC No. 2019/1014).

Community pharmacists were randomly sampled. Potential participants were telephoned, emailed study information and semi-structured interviews conducted face to face at participants' pharmacy sites. Consented interviews were audio recorded, [Distribution of personal protective equipment] "...so we are providing the alcohol, the masks." P5 "...a distribution opportunity that the government needs." P8

[Vaccination] "We potentially could be an enormous resource if we were to face an epidemic of some sort of virus in the world. If we were required to vaccinate the whole population... the current system probably would be stretched to the limit." P9 transcribed verbatim and de-identified transcripts quality checked by researchers.

The interview guide consisted of nine questions with prompts, asking about public health interventions in community pharmacy; pharmacists' perceptions about enablers and barriers to expansion of community pharmacists' public health role; and potential changes needed for expansion to occur. The interview guide was validated by two practising community pharmacists, whose data were excluded from analysis.

Thematic analyses were used to code and generate ideas, and themes that emerged included definitions, pharmacist roles, barriers and enablers to the provision of public health interventions. All team members reviewed the analysis.

While the study aim was to interview a larger sample of pharmacists, recruitment slowed by February 2020, with spreading awareness of the novel coronavirus. Community pharmacists became increasingly unavailable for research. Data collection was suspended once the World Health Organization declared SARS-CoV-2 (COVID-19) 

Thirteen pharmacists were approached and nine (four females, five males) were interviewed in January and February 2020. Their roles were owners, managers and pharmacists in charge with practice experience ranging from 5 to more than 30 years. Six of the community pharmacies identified with three different banner groups, and the remainder were independent pharmacies. Mean interview duration was 23 min (minimum 15, maximum 42 min). Study results revealed a lack of consistency regarding the definition of public health initiatives in Australian community pharmacy, with limited focus on public health as organised societal efforts. Instead, participants mostly discussed individual patient screening services. Participant comments related to concepts of public health services and interventions in community pharmacy were critically analysed, clustered with similar ideas and presented on a continuum, from individual patient-centric to community-centric concepts, in Figure 1 .

Participants appeared to value aspects of public health that they were familiar with or participated in; most commonly primary health prevention measures (i.e. blood pressure monitoring), smoking cessation, needle and syringe programs and vaccination. All participants recognised pharmacist-administered vaccination as an important public health intervention. The success of Australian community pharmacy vaccine programs was viewed as a potential gateway to the expansion of public health services. In contrast, many participants expressed discomfort with sensitive or unfamiliar service topics, particularly alcohol or sexually transmitted infection screening and opioid replacement programs, with some identifying lack of training and awareness as contributing to their lack of confidence in these unfamiliar areas.

Participants identified barriers and facilitators to the delivery and expansion of public health initiatives, with exemplar interview quotes related to each summarised in Table 1 .

Participants expressed willingness to support programs perceived as beneficial, particularly if they minimally impacted pharmacy time or workload, such as needle and syringe programs. For more involved interventions, the main barriers to provision were lack of remuneration, time, training, standards and unsuitability of premises. While lack of familiarity and confidence were mentioned when discussing potential public health initiatives, they were not identified as possible barriers to expansion of services.

This study identified that community pharmacists' perceptions of public health revealed little distinction between individual and broader population-focused public health initiatives. Barriers to the provision of public health services identified in this study aligned with previous research. [2, 11] However, lack of confidence not being identified as a potential barrier in this study contrasted with previous research, in which pharmacist competency was identified as the primary barrier to public health role expansion. [10] The primary facilitators to expansion of public health initiatives mostly opposed the lack of resources identified as barriers. Enablers were pharmacists' accessibility; provision of funding and education; availability of private consultation rooms in pharmacies and professional standards. Perhaps identification of aspects of practice (e.g. funding, education) as either barriers or enablers was determined by the pharmacist's willingness and motivation to undertake an expanded role in public health, which somewhat reflects recent research. [9] The later interviews were conducted as COVID-19 awareness increased. Participants described pharmacists' potential role in the management of current or future pandemics, proposing that they could provide consumer education, personal protective equipment or implement mass vaccination measures. Pharmacist pandemic vaccination would be facilitated by community pharmacists' accessibility and proximity, aligning with previous research findings. [2, 3, 6] A study limitation was disruption of data collection by COVID-19, therefore data saturation could not be attained. The researchers intend to resume interviews once COVID-19 abates, to explore pharmacists' opinions following their pandemic experience.

This research highlighted the need for improved clarity of the role that community pharmacists can assume in provision of public health.

Supplementary data are available at International Journal of Pharmacy Practice online.

The report of the committee of inquiry into the future development of the public health function. London: The Stationery Office

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

Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: a narrative overview

Chlamydia screening interventions from community pharmacies: a systematic review

Pharmacists performing hepatitis C antibody point-of-care screening in a community pharmacy: a pilot project

Community pharmacy involvement in vaccine distribution and administration

Community pharmacy-delivered interventions for public health priorities: a systematic review of interventions for alcohol reduction, smoking cessation and weight management, including meta-analysis for smoking cessation

Drugs, sex. and alcohol? Extending the community pharmacist's public health role

Successful implementation and provision of enhanced and extended pharmacy services

Relationship between performance barriers and pharmacist competency towards the implementation of an expanded public health pharmacy role

Benefits and tensions in delivering public health in community pharmacies-a qualitative study of healthy living pharmacy staff champions

Thank you to the community pharmacists who participated in this research. The research team are grateful for the contributions of Kelly Meuleman, of the School of Pharmacy and Pharmacology, Griffith University and Helen Clifford and Anne Cowdry, of the Gold Coast Public Health Unit, Queensland Health.

Conceptualisation, DH and LH; Methodology, DH and LH; Investigation, JD and JC; Formal Analysis DH and LH; Writing -Original Draft Preparation, DH; Writing -Review and Editing LH; Funding Acquisition DH and LH. All authors have read and agreed to the published version.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This work was supported by funding from the School of Pharmacy and Pharmacology, Griffith University, Queensland, Australia.

None declared.