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Involving the public and other stakeholders in development and evaluation of a community pharmacy alcohol screening and brief advice service
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Original Research
Involving the public and other stakeholders in development and evaluation of a community pharmacy alcohol screening and brief advice service J. Krska a,*, A.J. Mackridge b a
Medway School of Pharmacy, The Universities of Greenwich and Kent, Chatham Maritime, Kent ME4 4TB, UK School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK
b
article info
abstract
Article history:
Objectives: To explore the views of community pharmacy staff, the general public and other
Received 19 April 2013
stakeholders towards pharmacy-based alcohol screening and advice services.
Received in revised form 14 October 2013 Accepted 1 November 2013 Available online 6 April 2014
To involve all relevant stakeholders in designing an acceptable and feasible pharmacybased alcohol screening and advice service. To evaluate a pilot service from the user perspective. Study design: Mixed methods study involving a range of populations, designed to explore multiple perspectives and enable triangulation of results, to develop an optimal service
Keywords:
design, prior to service commissioning.
Alcohol
Methods: Telephone interviews were conducted with relevant stakeholders and a street
Screening
survey undertaken with the public to explore views on the desirability and feasibility of
Community pharmacy
pharmacy-based alcohol services. Following this, a stakeholder working group was held,
General public
involving a nominal group technique, to develop and refine the service design. Finally a pilot service was evaluated from the user perspective through telephone interviews and direct observations by a trained researcher. Results: All stakeholder groups (pharmacy staff, public, commissioners, alcohol treatment service staff) viewed pharmacy-based alcohol screening services as acceptable and feasible with the potential for integration and/or combination with existing public health services. Privacy was the main concern of the public, but 80% were comfortable discussing alcohol in a pharmacy. These views were not influenced by drinking status age or gender, but people recruited in areas of high deprivation were more likely to accept a pro-active approach or alcohol-related advice from a pharmacist than those from areas of low deprivation. Stakeholder groups were in agreement on the acceptability of a pharmacy screening service, but alcohol treatment service staff viewed direct referral to alcohol support services less beneficial than other stakeholders. Posters in pharmacies and GP surgeries were viewed as most likely to encourage uptake of screening. Involvement of non-pharmacist pharmacy staff was seen as essential.
* Corresponding author. Tel.: þ44 01634 202950. E-mail address: [email protected] (J. Krska). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.11.001
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The working group considered accessibility of pharmacies as the key facilitator for alcohol services, but agreed that an optimal service must ensure that poor pharmacy environment did not create a potential barrier, that clear information about the service’s availability was necessary. Plus good use of quiet areas. Use of AUDIT-C as a prescreening tool by pharmacy staff, followed when appropriate by completion of full AUDIT by the pharmacist in a private room/quiet area was agreed as optimal to ensure accessibility plus privacy. Direct referral was viewed as desirable. Five pharmacies piloted this service for two months and recruited 164 people for alcohol screening, of whom 113 were low risk (AUDIT score 0e7), 24 increasing risk (8e19) and 28 high risk/possibly dependent drinkers (20 or above). Observations showed that pharmacy support staff were involved in proactively approaching customers, that 20 of the 72 customers observed (28%) during two hours in each pharmacy were invited for screening and that 14 (19%) accepted screening. Promotion of the service was variable dependent on company policies, but was shown to have a positive effect, as two of the ten service users interviewed requested screening. The environment was judged suitable for alcohol services in all pharmacies, but some quiet areas were not audibly discrete. Ten service users interviewed all considered the experience positive and all would recommend the service, but most wanted the service to be delivered in a private area. Conclusion: The methodology enabled the development of pharmacy-based alcohol screening to be assessed for acceptability and feasibility from multiple perspectives, prior to full service commissioning. Results suggest that the pharmacy environment and concerns about privacy need to be recognized as potential barriers to service delivery. Good promotion is required to maximize service uptake and pharmacy staff need to be involved in both this and in service delivery. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The public health role of community pharmacies is encouraged by government,1 but current perceptions of both the public and practitioners may be barriers to such development.2e4 There is limited recognition among the general public of pharmacies as a source of public health advice,3e5 with participants in one survey indicating that reducing alcohol use was the least appropriate public health issue in which pharmacy should be involved.4 However pharmacies’ accessibility and frequent use by people in all degrees of health provide unique opportunities to deliver interventions to individuals not presently engaged with other health services. Some exploratory work has been undertaken on the provision of alcohol screening and brief advice or interventions in UK community pharmacies,6e10 and a further controlled trial is currently underway.11 A systematic review and a survey of Scottish pharmacists found factors limiting the uptake of these services included difficulties in identifying, approaching, and engaging customers on alcohol consumption.10,12 Subsequent work in England showed that training improved pharmacy staff attitudes towards risky drinkers and increased recruitment into services,13 and that users of pharmacies viewed alcohol services positively.7 This survey of pharmacy customers found 52% to be risky drinkers,7 whereas a larger study in New Zealand found a rate of approximately 30%,14 nevertheless both studies demonstrate the potential for pharmacy screening to identify considerable numbers of people who could potentially benefit.
Pharmacy-based alcohol services have been established or commissioned in many areas of the UK, but vary considerably in their design and have been subject to little evaluation. An example is the inclusion of alcohol interventions within the concept of Healthy Living Pharmacies,15 initially developed in Portsmouth. In a seven-month period here, over 3500 pharmacy customers in 37 pharmacies used scratch cards to assess their drinking risk, of whom 1784 received brief advice, plus a leaflet and 830 received more in-depth guidance.16 Although evidence of effectiveness is still lacking, commissioners view pharmacy-based alcohol screening and advice as a potentially important addition to existing service provision17,18 Indeed, national guidance recommends all primary healthcare professionals should provide such services opportunistically.19 In North West England, where there is a high rate of alcohol-related deaths,20 one Primary Care Trust (PCT) commissioned pharmacy alcohol services in 2007 and, by 2011, over 70% of the community pharmacies in this PCT were screening customers for risky drinking.21 However, no evaluation of this service was undertaken and, given the paucity of evidence for the acceptability of the service, prior to commissioning a similar service in another part of the North West, the PCT judged it essential to involve relevant stakeholders in service development, to ensure that services were desirable, feasible and acceptable. The authors therefore set out to develop a novel methodology for involving stakeholders in designing this pharmacy service. No previous work appears to have involved stakeholders directly in developing a pharmacy service.
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Table 1 e Study participants. Study stage Stage 1
Stage 2
Stage 3
Stakeholder group
Method of involvement
Number
Pharmacists
Interview
5
Pharmacy staff
Interview
4
Other stakeholders General public
Interview Street survey
Pharmacists
Working group
3
General public Other stakeholders
Working group Working group
3 2
Pharmacies
Pilot service provision
5
Users of pharmacy screening
Telephone interviews
10
Objectives: 1. To explore the views of community pharmacy staff, the general public and other stakeholders towards pharmacybased alcohol screening and advisory services; 2. To involve all relevant stakeholders in designing acceptable and feasible pharmacy-based alcohol screening and advisory services; and 3. To evaluate a pilot pharmacy-based alcohol screening and advisory service from multiple perspectives.
Methods The study was conducted in Sefton PCT, an area with a population of around 280,000 in North West England, in three stages. Details of participants in all stages are shown in Table 1.
2 150
Selection and recruitment details From 7 pharmacies, selected by PCT commissioners as current providers of public health services, invited by letter Employed by the pharmacies and identified by the pharmacists involved in Stage 1 From 10 identified by PCT commissioners, invited by letter 358 approached face-to-face, near to 5 pharmacies All 5 stage 1 participants, plus 2 LPC representatives, invited by letter Recruited face-to-face following survey in Stage 1 The 2 Stage 1 participants, plus 3 further stakeholders, identified by PCT commissioners, invited by letter All Stage 1 participants, plus two additional pharmacies, invited by letter Recruited from 4 of the 5 pharmacies following screening, by provision of invitation letter
from each pharmacy where the pharmacist agreed to interview.
Stage 2 e service design A working group comprising representatives from all participant groups in Stage 1 plus PCT commissioners was convened. Invitations were sent by letter to pharmacist and other stakeholders who participated in Stage 1 interviews, plus two other pharmacists from the Local Pharmaceutical Committee (LPC, LPC representing local pharmacy contractors) and two additional stakeholders. Members of the public were invited following completion of the street survey. Results from Stage 1 were presented and a modified nominal group technique23 was used to enable participants to rank the main barriers, facilitators, opportunities and promotional methods. Results from this were used to facilitate further discussion, focussed through an exemplar service descriptor from an existing service,21 which was modified and further developed by the group to use as the basis for a pilot service.
Stage 1 e professional and public perspectives Stage 3 e pilot study PCT commissioners identified seven pharmacists who had previously delivered public health services, located in areas of both high and low deprivation, and ten other local professional stakeholders with roles relevant to alcohol. All were invited, by letter, to participate in a semi-structured telephone interview covering the acceptability and feasibility of a pharmacy alcohol screening service, plus practicalities, including signposting and referral. A questionnaire to obtain views of the general public who use alcohol was designed, including closed and open questions. This incorporated an initial screening question about alcohol use and the FAST screening tool22 (used in previous pharmacy studies) to assess risk and sought views on pharmacy alcohol screening, possible services, promotion and facilitators and barriers to a service. It was used in opportunistic face-to-face interviews to survey a target of 150 individuals, recruited in street locations approximately 50 m
The service designed through the working group was implemented in a two-month pilot, incorporating several key elements identified and considered essential in Stage 2. Six community pharmacies were invited to participate, four Stage 1 participants, one invited to Stage 1 and one who expressed interest to PCT commissioners. Pharmacists and other staff from all six pharmacies attended a 2-hour training event, facilitated by Sefton Alcohol Treatment and Interventions Nursing Service (SATINS). Training covered alcohol-related illness, units, local alcohol services and referral mechanisms and the use of standard screening tools to categorize drinking and appropriate action to take. How to identify and approach potential service users was discussed, but this training did not cover delivery of behavioural interventions. All attendees were provided with screening tools, literature and details of free electronic training, specifically designed for pharmacy
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Table 2 e Quotes illustrating views on pharmacy alcohol services obtained from a range of stakeholders, including the public. Interviews with stakeholders and survey with the public (Stage 1) ‘How it is presented e.g. I’d be more likely to take advice from guidance not authoritative instructions’ ‘I have a reasonable understanding of alcohol related illness and would be able to recognize this’ ‘Privacy would be a big issue. I would not speak to a pharmacist about personal matters over the counter. I would not like others to be able to hear what should be a private discussion. I would use this facility if there was a private room.’ ‘Are pharmacists qualified? e they are there to give prescriptions out’ ‘If it’s an overall health check and you’re checking, you know, obesity, you know smoking cessation, high blood pressure, you know just a general, everything e then people will find that far less intimidating so the barriers don’t go up.’ ‘I’d be quite happy to do it if the person asked. I wouldn’t like to ask people, but if someone came in and asked for help I would rather do it that way’ ‘They’re busy anyway, pharmacists, so if the girls and other members of staff can train up, then I think that would take the workload off the pharmacist.’ ‘If we were running a promotion programme then it wouldn’t seem like you were picking on individual people e if you were saying it to everybody people wouldn’t get as offended if it was a general ‘do you know we’re running an alcohol screening service at the moment for all our customers’.’
staff covering the provision of brief advice, which they were encouraged to complete prior to the commencement of the pilot. During the pilot, three observations were conducted by a trained researcher in each of the pharmacies. Observation 1 was covert and assessed, from a potential user perspective, promotional materials displayed, verbal promotion by pharmacy staff and visibility of consultation room(s) and quiet area(s) within the pharmacy. Immediately following observation 1, the researcher de-briefed staff on the findings and obtained consent for subsequent overt observations. Observation 2, carried out at an agreed time, examined pharmacy layout further and explored potential facilitators and barriers to the service through observation of workload and processes over a two-hour period in each pharmacy. Observation 3, carried out at a time selected by the observer with no prior warning, consisted of a further two hours in each pharmacy where opportunities for service delivery were identified through observation of interactions between pharmacy staff and customers at the pharmacy counter. Discussions in private areas or the consultation room were not observed. Data were gathered on the number of persons using the pharmacy, the main purpose of their visit and the frequency of screening offered. Data were gathered during the first 30 min of each observation were discarded to allow staff to become accustomed to the observer’s presence. Pharmacy staff collected data on: number of customers offered screening, screening scores and interventions offered. After each screening, pharmacy staff offered customers a letter inviting participation in a telephone interview with a researcher. The letter was accompanied by an information sheet, consent form and contact details form for return direct to the research team. Interviews sought customer views on the pharmacy environment and experiences of consultations.
Data analysis Stage 1 and 3 interviews were digitally recorded and transcribed verbatim, then thematically analysed using NVivo.
Female member of the public (low deprivation) Female member of the public (low deprivation) Female member of the public (high deprivation)
Male member of the public (high deprivation) Non-pharmacy stakeholder
Pharmacy support staff Pharmacy support staff Pharmacist
Field notes taken during the direct observations in Stage 3 were also analysed thematically. Quantitative data from the surveys were analysed using SPSS and sub-group comparisons made using chi-squared tests. Data from interviews and surveys were triangulated to compare and contrast different perspectives.
Results Stage 1 The survey target of 150 members of the public was achieved by approaching 358 people, 122 of 232 approached in areas of high deprivation (52.6%) and 28 of 136 in affluent areas (20.6%), giving an overall response rate of 41%. Most were aged either 16e35 years (40%) or 36e65 years (56%) and 63 (42%) were male. Approximately half the participants (80; 53.3%) were classed as low risk drinkers (<3) using FAST, 58 (42%) were increasing risk (3þ), while 12 did not complete FAST. The majority (116; 77.3%) had visited a pharmacy in the past 12 months. Of the pharmacy users, 46 (40%) were male and 43 (37%) were increasing risk drinkers. The latter had accessed a variety of pharmacy services in the previous six months, including prescription dispensing (25; 58%), over-the-counter medicine purchase (21; 49%) and smoking cessation support (11; 26%). Survey participants were positive about pharmacy-based alcohol services, with 80% (120) being comfortable or very comfortable discussing alcohol with a pharmacist, which was similar to the proportion comfortable discussing smoking (127; 85%) or diet (120; 80%). The services perceived to be a good idea by the highest proportions of respondents were: supporting people to reduce drinking (138; 92%), written advice (136; 91%), providing information about other services (135; 90%) and referral into other services (134; 89%). Fewer viewed providing medicines (117; 78%) and verbal advice (117;
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78%) as a good idea. Age, gender and drinking status showed no influence on these views. Eleven stakeholders were interviewed comprising: five pharmacists, four pharmacy support staff, an alcohol service manager and a representative of the local Alcohol Harm Reduction Strategy Group. These interviewees mirrored survey findings, considering that alcohol screening and advisory services would complement services such as smoking cessation support or NHS Health Checks, and could be incorporated into these. Pharmacy support staff felt that providing these additional services added to their job satisfaction, therefore welcomed alcohol-related services. Additional suggestions included joining local public health campaigns when the public may be more receptive and population-wide screening. However, the alcohol service manager suggested that interventions should be minimal, with signposting to specialist services being preferred, because of lower motivation in referred patients resulting in poorer treatment outcomes compared to self-referrals. In contrast, most pharmacy staff viewed direct referral, as opposed to signposting, into specialist support services as an important option, considering it essential to avoid duplication of effort and minimize the possibility of losing at risk individuals. Most survey participants (127; 85%) were happy or not concerned about a pharmacist providing advice about safer alcohol consumption if requested, while 99 (66.0%) felt similarly about pharmacists proactively raising the topic. These views were not dependent on gender, age or drinking status, however significantly (P < 0.001) more people recruited in affluent areas than in deprived areas were unhappy about pharmacists either proactively raising safer alcohol consumption (17/28; 61% vs 34/122; 28%) or giving advice (10/28; 36% vs 11/122; 9%). In contrast, most pharmacists and pharmacy staff were uncomfortable with pro-actively raising the subject of alcohol, preferring to respond to customer requests (Table 2). A small number of survey respondents and some pharmacists’ concerns centred more on the manner of the interaction, rather than the initiator of the discussion (Table 2). The most common factors identified by survey respondents as important in influencing use of pharmacy alcohol services were: privacy (144; 96%), confidentiality (141; 94%), friendly pharmacist (143; 95%) and staff (129; 86%), plus training (123; 82%). Most concerns related to fear of conversations being overheard, rather than disclosure of personal information by pharmacy staff (Table 1). Pharmacist interviewees raised the need for adequate private facilities and agreed that the open pharmacy environment was a possible limit to providing alcohol services (Table 1). A substantial proportion of the public also considered waiting times (120; 80%) and general busyness of the pharmacy (102; 68%) were important issues and both pharmacists and their staff highlighted concerns about pharmacist workload (Table 1), indicating the need for counter staff to be involved in providing screening. Stakeholders, pharmacists and the public all considered training as essential, to ensure adequate knowledge, and also to ensure pharmacy was integrated with wider service provision. The public considered that individuals would be able to recognize their need for advice on alcohol and one pharmacist
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viewed this as likely in some individuals. Some pharmacy staff interviewed felt that marketing of pharmacy alcohol services would require tailoring to reach different sociodemographic groups. All participant groups considered that services required promotion using a mixture of methods. The options most favoured by the public were posters in GP surgeries (129; 86%) or pharmacy windows (114; 76%). Fewer considered it likely they would respond to advertising in places where alcohol was sold, regardless of their drinking status (Fig. 1).
Stage 2 Nine participants attended the working group: three members of the public (one of whom was a volunteer in alcohol services), three community pharmacists (one involved in Stage 1 and two from the LPC), and a health promotion officer from the PCT plus a health services researcher with extensive experience of alcohol studies and the PCT alcohol services commissioner. Three members of the research team acted as moderators. The group discussed the barriers to pharmacy alcohol services derived from Stage 1 and developed a modified list, then ranked their importance. The pharmacy environment was viewed as the key barrier, which the group felt encompassed appropriate use of private space, business, which could affect service availability and visibility of information on how to access the service. Staff confidence was also ranked highly, and the need for appropriate training, which should encompass learning how to create opportunities to proactively raise the topic with customers. Public perceptions of pharmacy role were also viewed as important as was lack of awareness of services, hence the need for high visibility of information. The key facilitator was accessibility without appointment, with availability of quiet or private areas, long opening hours, convenient location and promotional materials also seen as important. The accessibility and use of pharmacies by all sectors of the public was perceived as enabling a wide reach and that targeting of specific populations which reduced this reach may be undesirable. The
Fig. 1 e General public views on acceptable methods of promoting pharmacy alcohol services by drinking status, as assessed by FAST score.
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working group concurred with public views that posters and leaflets were needed to promote pharmacy alcohol services, but that they should be appropriate to the target audience. Additionally, it was felt that promotion should clearly identify where in the pharmacy to go for the service and who to talk to or ask for. The group reviewed options for screening tools: FAST, AUDIT24 and the scratch cards used elsewhere.16 AUDIT was agreed to be most suitable for the pharmacy setting, with FAST viewed as more intrusive and complex. It was agreed that a prescreen by pharmacy support staff was feasible, in a quiet part of the main pharmacy environment, using AUDITC,25 followed, as appropriate, by referral to the pharmacist to enable completion of the remaining AUDIT questions in the private consultation area, resulting in minimal duplication. Direct referral to support services was agreed as essential to minimize potential loss to follow-up if customers were referred instead to their GP.
Stage 3 The pilot service included key elements agreed by the working group: staff should design and use their own pharmacy-specific promotional materials and methods to supplement standard materials; no specific groups to be targeted, with selection left to individual pharmacy teams; involvement of pharmacy support staff, using AUDIT-C as a prescreen; discussion of full AUDIT score to take place in private area, with pharmacist; and direct referral to the local alcohol treatment service (SATINS). Of the six pharmacies from which staff attended training, five participated in the pilot, four independent and one multiple, all in areas of high deprivation, one dropping out due to inconvenient timing. Observation 1 found clear information about the service displayed in the window and inside three pharmacies: one promoted the service intermittently on a display screen, one had a display board and the third a large home-produced poster on ‘Alcohol Awareness Week’. The remaining two pharmacies had unit calculators/leaflet displays on the counter, but posters were displayed only in the consultation room, in compliance with company policies. Observation 2 noted that there were sometimes insufficient staff to provide alcohol screening, but that a variety of methods were used to approach customers. The size and layout of the pharmacies were considered suitable for providing services, each having a good-sized private consultation room, although one was not audibly discrete. Divider screens/booths were present in three pharmacies, but the areas they afforded were also not audibly discrete. A total of 72 customers used one of the five pharmacies during the 10 h of observation 3, the majority (44; 61%) of whom presented a prescription for dispensing. Counter staff spoke to 60 (83%) of the 72 customers, 20 (28%) were offered screening, of whom 14 (19%) accepted it. Six screenings were
Table 3 e Quotes illustrating service user views of a pilot pharmacy alcohol service. Interviews with service users (Stage 3) ‘There were very sincere and very friendly, they don’t look down on people like ourselves. it should be available in every pharmacy so that people are aware about what alcohol actually does’ ‘There were no customers in so it wasn’t too bad but if it had have been busy I wouldn’t have done it..Just like err may be a private screened area just like you know like a photo booth style curtain or something just at the end of the counter e nothing more than that e I’m not talking about a private room or anything’ ‘The girl she offered me a leaflet or something to fill out...like a survey. they were fine it wasn’t forceful or anything like, no, they were just all friendly e it went quite well’ ‘Just keep it the way it is right and privacy and kept in the same kind of consultation room it’ll be alright.’ ‘I think things like that like are good like I say, I’ve learned more about it just through taking part in a questionnaire in just a few minutes, so I think it’s a good idea.’
Male service user 10
Male service user 2
Female service user 6
Male service user 4
Female service user 7
conducted in a consultation room, six behind a screen or divider and two at the counter. In total 164 screenings were carried out over the twomonth period (range 6e59 per pharmacy): 113 (69%) were categorized as low risk (AUDIT score 0e7), 24 (15%) increasing risk (8e15), 19 (12%) high risk (16e19) and 9 (5%) possibly dependent (20 or more). All nine with scores of 20 or higher were offered referral to specialist services, together with one high risk customer. Six of these stated they were already receiving help, but only one of the remaining four accepted referral. Ten service users were interviewed; five male and five female, who had attended four different pharmacies. In eight of those interviewed, pharmacy staff proactively raised the topic of alcohol, but two requested screening on seeing the pharmacy’s promotional material. All interviewees had positive views of the service and reported professional staff attitudes, with no sense of being pressurized (Table 3). None of the interviewees raised confidentiality as a concern, but most mentioned privacy. Several viewed screening at the counter as acceptable, but only when no other customers were present, most feeling that they would wish to use the consultation room if the pharmacy was busy. All stated they would recommend the service.
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Discussion The method developed enabled a wide range of stakeholders, including members of the public, to be involved in developing a pharmacy-based service. The use of a short pilot enabled testing of the acceptability of several key desirable features of the service, while direct observations assessed the implementation of several of these features. The learning from this study enabled the subsequent commissioning of a service, which incorporated further specific evaluation of bespoke training on approaching potential customers and different promotional methods.17,26 Furthermore the method of direct observation developed here was subsequently used in a wider evaluation of service in other areas.17 All aspects of the development method provided valuable insights which informed commissioning. Both the stakeholder interviews and the working group proved useful in identifying the key elements of the service which needed attention, in particular the pharmacy environment, involvement of pharmacy support staff and need for appropriate promotion. Observations in all the pharmacies taking part in the pilot study enabled the environment and opportunities for service delivery to be assessed, with these data being fed back to all pharmacists. Support staff were clearly involved in recruiting customers to and delivering the service, but opportunities to engage customers were not always maximized. The public survey indicated that risky drinkers used pharmacies for a variety of services, supporting the view of stakeholders that alcohol screening could usefully link to existing pharmacy services. A variety of promotional methods were observed, but these were limited in some cases by company policies, despite their obvious effectiveness, as shown by two of the ten service users interviewed. The working group considered that pharmacies provide a unique opportunity for the public to proactively seek an assessment of their drinking by a health professional in a community setting and the public survey highlighted promotional methods most likely to succeed. Making the initial approach is a potential barrier to providing alcohol screening,27 hence the use of promotional materials in community pharmacies to encourage the public to request screening is worthy of more rigorous study.
Limitations While the authors included key relevant stakeholders, no GPs agreed to interview. Recruitment of the general public proved difficult in affluent areas, and participants from these areas had less positive views on pharmacy staff broaching the subject of alcohol. Also no pharmacy located in an affluent area was recruited to the pilot study. As involvement in the pilot required agreement to direct observations, pharmacies were invited to join the study based on the personal knowledge of PCT commissioners, with no intention to be representative of different types of pharmacies. While our initial plan was that Stage 1 participants would also take part in Stages 2 and 3, individual pharmacists dropped out, so were replaced. Our study was small scale and did not assess efficacy or effectiveness of pharmacy interventions, for which larger, controlled studies are needed.
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Conclusion The methodology enabled the development of pharmacybased alcohol screening to be assessed for acceptability and feasibility from multiple perspectives, prior to full service commissioning. Results suggest that the pharmacy environment and concerns about privacy need to be recognized as potential barriers to service delivery. Good promotion is required to maximize service uptake and pharmacy staff need to be involved in both this and in service delivery.
Author statements Acknowledgements The authors are grateful to Julia Taylor who carried out the surveys and assisted with the stakeholder workshop and to Matthew Brown who conducted the pharmacy observations.
Ethical approval Approval was granted from Liverpool John Moores University research ethics committee to conduct this work (reference number: 09/PBS/021) and Sefton PCT research governance committee.
Funding This work was funded by Liverpool John Moores University Institute for Health Research and Sefton PCT.
Competing interests None declared.
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project to deliver interventions on alcohol issues in community pharmacies. Int J Pharm Pract 2008;16:17e22. Dhital R, Whittlesea CM, Norman IJ, Milligan P. Community pharmacy service users’ views and perceptions of alcohol screening and brief intervention. Drug Alcohol Rev 2010;29:596e602. Goodall T, Dawson P. A feasibility study: the role of community pharmacists in the identification and treatment of hazardous drinking. Leeds Primary Care Trust. Available at: http://www. alcoholpolicy.net/2007/08/a-feasibility-s.html; 2006 (accessed 8 April 2013). Watson MC, Stewart DC, Inch J, Jaffray M, Duncan E, Afolabi E. Screening and brief interventions for alcohol misuse in the community pharmacy setting: a pilot study. Available at: http:// www.cso.scot.nhs.uk/Publications/ExecSumms/JuneJuly11/ WatsonPH.pdf (accessed 8 April 2013). McCaig D, Fitzgerald N, Stewart D. Provision of advice on alcohol use in community pharmacy: a cross-sectional survey of pharmacists’ practice, knowledge, views and confidence. Int J Pharm Pract 2011;19:171e8. Dhital R, Norman I, Whittlesea CM, McCambridge J. Effectiveness of alcohol brief intervention delivered by community pharmacists: study protocol of a two-arm randomised controlled trial. BMC Public Health 2013;13:152. Watson MC, Blenkinsopp A. The feasibility of providing community pharmacy based services for alcohol misuse. Int J Pharm Pract 2009;17:199e205. Dhital R, Whittlesea CM, Milligan P, Khan NS, Norman IJ. The impact of training and delivering alcohol brief intervention on the knowledge and attitudes of community pharmacists: a before and after study. Drug Alcohol Rev 2012;32(2):147e56. Sheridan J, Stewart J, Smart R, McCormick R. Risky drinking among community pharmacy customers in New Zealand and their attitudes towards pharmacist screening and brief interventions. Drug Alcohol Rev 2012;31:56e63. National Pharmacy Association. 2011 healthy living pharmacy: overview. Available at: http://www.npa.co.uk/Documents/ HLP/HLP_overview_12.11.pdf (accessed 19 February 2013). Bowhill J, Bowhill S, Evans D, Holden M, Nazar Z, Portlock J. An interim report on the outcomes from the Portsmouth Health Living Pharmacy initiative. Available at: http://www. portsmouth.nhs.uk/Downloads/General%20Documents/ Portsmouth%20HLP%20interim%20outcomes.pdf; 2010 (accessed 8 April 2013).
17. Gray NJ, Wilson SE, Cook PA, Mackridge AJ, Blenkinsopp A, Prescott J, Stokes LC, Morleo MJ, Heim D, Krska J, Stafford L. Understanding and optimising an identification/brief advice (IBA) service about alcohol in the community pharmacy setting. Final report. Liverpool PCT. Available at:, https://clok.uclan.ac.uk/ 5972/; 2012 (accessed 8 April 2013). 18. Davies J, Gill J, Crisp M, Taylor D. Pan-London Pharmacy alcohol awareness campaign. report. University College London. Available at:, http://ranzetta.typepad.com/files/pharmacy_ london_pilot_report-ucl-scratchards.pdf; 2013. 19. National Institute for Health and Clinical Excellence. Alcoholuse disorders: preventing harmful drinking. PH24. London: NICE. Available at: http://guidance.nice.org.uk/PH24; 2010 (accessed 8 April 2013). 20. North West Public Health Observatory. Local alcohol profiles for England. Online tool. Available at: http://www.nwph.net/ alcohol/lape/ (accessed 8 April 2013). 21. NHS Wirral January 2011 pharmaceutical needs assessment. Available at: http://www.wirral.nhs.uk/document_uploads/ Medicines-Mgt/WirralPNAIssue1Jan11.pdf (accessed 19 February 2013). 22. Hodgson R, Alwyn T, John B, Thom B, Smith A. The FAST alcohol screening tool. Alcohol Alcohol 2002;37:61e6. 23. Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The Nominal Group Technique: a research tool for general practice? Fam Pract 1993;10:76e81. 24. Babor TF, de la Fuente JR, Saunders J, Grant M. The alcohol use disorders identification test: guidelines for use in primary health care. World Health Organisation, PSA/92.4. Available at:, http://whqlibdoc.who.int/hq/1992/WHO_PSA_92.4.pdf; 1992 (accessed 8 April 2013). 25. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Arch Intern Med 1998;158(16):1789e95. 26. Krska J, Stokes E, Penson P, Mackridge AJ. Training needs of pharmacy staff providing an alcohol screening service. Presented at International Network for Brief Interventions on Alcohol and other Drugs (INEBRIA); 2012. 27. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health 2011;33(3):412e21.
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Original Research
Involving the public and other stakeholders in development and evaluation of a community pharmacy alcohol screening and brief advice service J. Krska a,*, A.J. Mackridge b a
Medway School of Pharmacy, The Universities of Greenwich and Kent, Chatham Maritime, Kent ME4 4TB, UK School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom Street, Liverpool L3 3AF, UK
b
article info
abstract
Article history:
Objectives: To explore the views of community pharmacy staff, the general public and other
Received 19 April 2013
stakeholders towards pharmacy-based alcohol screening and advice services.
Received in revised form 14 October 2013 Accepted 1 November 2013 Available online 6 April 2014
To involve all relevant stakeholders in designing an acceptable and feasible pharmacybased alcohol screening and advice service. To evaluate a pilot service from the user perspective. Study design: Mixed methods study involving a range of populations, designed to explore multiple perspectives and enable triangulation of results, to develop an optimal service
Keywords:
design, prior to service commissioning.
Alcohol
Methods: Telephone interviews were conducted with relevant stakeholders and a street
Screening
survey undertaken with the public to explore views on the desirability and feasibility of
Community pharmacy
pharmacy-based alcohol services. Following this, a stakeholder working group was held,
General public
involving a nominal group technique, to develop and refine the service design. Finally a pilot service was evaluated from the user perspective through telephone interviews and direct observations by a trained researcher. Results: All stakeholder groups (pharmacy staff, public, commissioners, alcohol treatment service staff) viewed pharmacy-based alcohol screening services as acceptable and feasible with the potential for integration and/or combination with existing public health services. Privacy was the main concern of the public, but 80% were comfortable discussing alcohol in a pharmacy. These views were not influenced by drinking status age or gender, but people recruited in areas of high deprivation were more likely to accept a pro-active approach or alcohol-related advice from a pharmacist than those from areas of low deprivation. Stakeholder groups were in agreement on the acceptability of a pharmacy screening service, but alcohol treatment service staff viewed direct referral to alcohol support services less beneficial than other stakeholders. Posters in pharmacies and GP surgeries were viewed as most likely to encourage uptake of screening. Involvement of non-pharmacist pharmacy staff was seen as essential.
* Corresponding author. Tel.: þ44 01634 202950. E-mail address: [email protected] (J. Krska). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.11.001
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The working group considered accessibility of pharmacies as the key facilitator for alcohol services, but agreed that an optimal service must ensure that poor pharmacy environment did not create a potential barrier, that clear information about the service’s availability was necessary. Plus good use of quiet areas. Use of AUDIT-C as a prescreening tool by pharmacy staff, followed when appropriate by completion of full AUDIT by the pharmacist in a private room/quiet area was agreed as optimal to ensure accessibility plus privacy. Direct referral was viewed as desirable. Five pharmacies piloted this service for two months and recruited 164 people for alcohol screening, of whom 113 were low risk (AUDIT score 0e7), 24 increasing risk (8e19) and 28 high risk/possibly dependent drinkers (20 or above). Observations showed that pharmacy support staff were involved in proactively approaching customers, that 20 of the 72 customers observed (28%) during two hours in each pharmacy were invited for screening and that 14 (19%) accepted screening. Promotion of the service was variable dependent on company policies, but was shown to have a positive effect, as two of the ten service users interviewed requested screening. The environment was judged suitable for alcohol services in all pharmacies, but some quiet areas were not audibly discrete. Ten service users interviewed all considered the experience positive and all would recommend the service, but most wanted the service to be delivered in a private area. Conclusion: The methodology enabled the development of pharmacy-based alcohol screening to be assessed for acceptability and feasibility from multiple perspectives, prior to full service commissioning. Results suggest that the pharmacy environment and concerns about privacy need to be recognized as potential barriers to service delivery. Good promotion is required to maximize service uptake and pharmacy staff need to be involved in both this and in service delivery. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The public health role of community pharmacies is encouraged by government,1 but current perceptions of both the public and practitioners may be barriers to such development.2e4 There is limited recognition among the general public of pharmacies as a source of public health advice,3e5 with participants in one survey indicating that reducing alcohol use was the least appropriate public health issue in which pharmacy should be involved.4 However pharmacies’ accessibility and frequent use by people in all degrees of health provide unique opportunities to deliver interventions to individuals not presently engaged with other health services. Some exploratory work has been undertaken on the provision of alcohol screening and brief advice or interventions in UK community pharmacies,6e10 and a further controlled trial is currently underway.11 A systematic review and a survey of Scottish pharmacists found factors limiting the uptake of these services included difficulties in identifying, approaching, and engaging customers on alcohol consumption.10,12 Subsequent work in England showed that training improved pharmacy staff attitudes towards risky drinkers and increased recruitment into services,13 and that users of pharmacies viewed alcohol services positively.7 This survey of pharmacy customers found 52% to be risky drinkers,7 whereas a larger study in New Zealand found a rate of approximately 30%,14 nevertheless both studies demonstrate the potential for pharmacy screening to identify considerable numbers of people who could potentially benefit.
Pharmacy-based alcohol services have been established or commissioned in many areas of the UK, but vary considerably in their design and have been subject to little evaluation. An example is the inclusion of alcohol interventions within the concept of Healthy Living Pharmacies,15 initially developed in Portsmouth. In a seven-month period here, over 3500 pharmacy customers in 37 pharmacies used scratch cards to assess their drinking risk, of whom 1784 received brief advice, plus a leaflet and 830 received more in-depth guidance.16 Although evidence of effectiveness is still lacking, commissioners view pharmacy-based alcohol screening and advice as a potentially important addition to existing service provision17,18 Indeed, national guidance recommends all primary healthcare professionals should provide such services opportunistically.19 In North West England, where there is a high rate of alcohol-related deaths,20 one Primary Care Trust (PCT) commissioned pharmacy alcohol services in 2007 and, by 2011, over 70% of the community pharmacies in this PCT were screening customers for risky drinking.21 However, no evaluation of this service was undertaken and, given the paucity of evidence for the acceptability of the service, prior to commissioning a similar service in another part of the North West, the PCT judged it essential to involve relevant stakeholders in service development, to ensure that services were desirable, feasible and acceptable. The authors therefore set out to develop a novel methodology for involving stakeholders in designing this pharmacy service. No previous work appears to have involved stakeholders directly in developing a pharmacy service.
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Table 1 e Study participants. Study stage Stage 1
Stage 2
Stage 3
Stakeholder group
Method of involvement
Number
Pharmacists
Interview
5
Pharmacy staff
Interview
4
Other stakeholders General public
Interview Street survey
Pharmacists
Working group
3
General public Other stakeholders
Working group Working group
3 2
Pharmacies
Pilot service provision
5
Users of pharmacy screening
Telephone interviews
10
Objectives: 1. To explore the views of community pharmacy staff, the general public and other stakeholders towards pharmacybased alcohol screening and advisory services; 2. To involve all relevant stakeholders in designing acceptable and feasible pharmacy-based alcohol screening and advisory services; and 3. To evaluate a pilot pharmacy-based alcohol screening and advisory service from multiple perspectives.
Methods The study was conducted in Sefton PCT, an area with a population of around 280,000 in North West England, in three stages. Details of participants in all stages are shown in Table 1.
2 150
Selection and recruitment details From 7 pharmacies, selected by PCT commissioners as current providers of public health services, invited by letter Employed by the pharmacies and identified by the pharmacists involved in Stage 1 From 10 identified by PCT commissioners, invited by letter 358 approached face-to-face, near to 5 pharmacies All 5 stage 1 participants, plus 2 LPC representatives, invited by letter Recruited face-to-face following survey in Stage 1 The 2 Stage 1 participants, plus 3 further stakeholders, identified by PCT commissioners, invited by letter All Stage 1 participants, plus two additional pharmacies, invited by letter Recruited from 4 of the 5 pharmacies following screening, by provision of invitation letter
from each pharmacy where the pharmacist agreed to interview.
Stage 2 e service design A working group comprising representatives from all participant groups in Stage 1 plus PCT commissioners was convened. Invitations were sent by letter to pharmacist and other stakeholders who participated in Stage 1 interviews, plus two other pharmacists from the Local Pharmaceutical Committee (LPC, LPC representing local pharmacy contractors) and two additional stakeholders. Members of the public were invited following completion of the street survey. Results from Stage 1 were presented and a modified nominal group technique23 was used to enable participants to rank the main barriers, facilitators, opportunities and promotional methods. Results from this were used to facilitate further discussion, focussed through an exemplar service descriptor from an existing service,21 which was modified and further developed by the group to use as the basis for a pilot service.
Stage 1 e professional and public perspectives Stage 3 e pilot study PCT commissioners identified seven pharmacists who had previously delivered public health services, located in areas of both high and low deprivation, and ten other local professional stakeholders with roles relevant to alcohol. All were invited, by letter, to participate in a semi-structured telephone interview covering the acceptability and feasibility of a pharmacy alcohol screening service, plus practicalities, including signposting and referral. A questionnaire to obtain views of the general public who use alcohol was designed, including closed and open questions. This incorporated an initial screening question about alcohol use and the FAST screening tool22 (used in previous pharmacy studies) to assess risk and sought views on pharmacy alcohol screening, possible services, promotion and facilitators and barriers to a service. It was used in opportunistic face-to-face interviews to survey a target of 150 individuals, recruited in street locations approximately 50 m
The service designed through the working group was implemented in a two-month pilot, incorporating several key elements identified and considered essential in Stage 2. Six community pharmacies were invited to participate, four Stage 1 participants, one invited to Stage 1 and one who expressed interest to PCT commissioners. Pharmacists and other staff from all six pharmacies attended a 2-hour training event, facilitated by Sefton Alcohol Treatment and Interventions Nursing Service (SATINS). Training covered alcohol-related illness, units, local alcohol services and referral mechanisms and the use of standard screening tools to categorize drinking and appropriate action to take. How to identify and approach potential service users was discussed, but this training did not cover delivery of behavioural interventions. All attendees were provided with screening tools, literature and details of free electronic training, specifically designed for pharmacy
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Table 2 e Quotes illustrating views on pharmacy alcohol services obtained from a range of stakeholders, including the public. Interviews with stakeholders and survey with the public (Stage 1) ‘How it is presented e.g. I’d be more likely to take advice from guidance not authoritative instructions’ ‘I have a reasonable understanding of alcohol related illness and would be able to recognize this’ ‘Privacy would be a big issue. I would not speak to a pharmacist about personal matters over the counter. I would not like others to be able to hear what should be a private discussion. I would use this facility if there was a private room.’ ‘Are pharmacists qualified? e they are there to give prescriptions out’ ‘If it’s an overall health check and you’re checking, you know, obesity, you know smoking cessation, high blood pressure, you know just a general, everything e then people will find that far less intimidating so the barriers don’t go up.’ ‘I’d be quite happy to do it if the person asked. I wouldn’t like to ask people, but if someone came in and asked for help I would rather do it that way’ ‘They’re busy anyway, pharmacists, so if the girls and other members of staff can train up, then I think that would take the workload off the pharmacist.’ ‘If we were running a promotion programme then it wouldn’t seem like you were picking on individual people e if you were saying it to everybody people wouldn’t get as offended if it was a general ‘do you know we’re running an alcohol screening service at the moment for all our customers’.’
staff covering the provision of brief advice, which they were encouraged to complete prior to the commencement of the pilot. During the pilot, three observations were conducted by a trained researcher in each of the pharmacies. Observation 1 was covert and assessed, from a potential user perspective, promotional materials displayed, verbal promotion by pharmacy staff and visibility of consultation room(s) and quiet area(s) within the pharmacy. Immediately following observation 1, the researcher de-briefed staff on the findings and obtained consent for subsequent overt observations. Observation 2, carried out at an agreed time, examined pharmacy layout further and explored potential facilitators and barriers to the service through observation of workload and processes over a two-hour period in each pharmacy. Observation 3, carried out at a time selected by the observer with no prior warning, consisted of a further two hours in each pharmacy where opportunities for service delivery were identified through observation of interactions between pharmacy staff and customers at the pharmacy counter. Discussions in private areas or the consultation room were not observed. Data were gathered on the number of persons using the pharmacy, the main purpose of their visit and the frequency of screening offered. Data were gathered during the first 30 min of each observation were discarded to allow staff to become accustomed to the observer’s presence. Pharmacy staff collected data on: number of customers offered screening, screening scores and interventions offered. After each screening, pharmacy staff offered customers a letter inviting participation in a telephone interview with a researcher. The letter was accompanied by an information sheet, consent form and contact details form for return direct to the research team. Interviews sought customer views on the pharmacy environment and experiences of consultations.
Data analysis Stage 1 and 3 interviews were digitally recorded and transcribed verbatim, then thematically analysed using NVivo.
Female member of the public (low deprivation) Female member of the public (low deprivation) Female member of the public (high deprivation)
Male member of the public (high deprivation) Non-pharmacy stakeholder
Pharmacy support staff Pharmacy support staff Pharmacist
Field notes taken during the direct observations in Stage 3 were also analysed thematically. Quantitative data from the surveys were analysed using SPSS and sub-group comparisons made using chi-squared tests. Data from interviews and surveys were triangulated to compare and contrast different perspectives.
Results Stage 1 The survey target of 150 members of the public was achieved by approaching 358 people, 122 of 232 approached in areas of high deprivation (52.6%) and 28 of 136 in affluent areas (20.6%), giving an overall response rate of 41%. Most were aged either 16e35 years (40%) or 36e65 years (56%) and 63 (42%) were male. Approximately half the participants (80; 53.3%) were classed as low risk drinkers (<3) using FAST, 58 (42%) were increasing risk (3þ), while 12 did not complete FAST. The majority (116; 77.3%) had visited a pharmacy in the past 12 months. Of the pharmacy users, 46 (40%) were male and 43 (37%) were increasing risk drinkers. The latter had accessed a variety of pharmacy services in the previous six months, including prescription dispensing (25; 58%), over-the-counter medicine purchase (21; 49%) and smoking cessation support (11; 26%). Survey participants were positive about pharmacy-based alcohol services, with 80% (120) being comfortable or very comfortable discussing alcohol with a pharmacist, which was similar to the proportion comfortable discussing smoking (127; 85%) or diet (120; 80%). The services perceived to be a good idea by the highest proportions of respondents were: supporting people to reduce drinking (138; 92%), written advice (136; 91%), providing information about other services (135; 90%) and referral into other services (134; 89%). Fewer viewed providing medicines (117; 78%) and verbal advice (117;
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78%) as a good idea. Age, gender and drinking status showed no influence on these views. Eleven stakeholders were interviewed comprising: five pharmacists, four pharmacy support staff, an alcohol service manager and a representative of the local Alcohol Harm Reduction Strategy Group. These interviewees mirrored survey findings, considering that alcohol screening and advisory services would complement services such as smoking cessation support or NHS Health Checks, and could be incorporated into these. Pharmacy support staff felt that providing these additional services added to their job satisfaction, therefore welcomed alcohol-related services. Additional suggestions included joining local public health campaigns when the public may be more receptive and population-wide screening. However, the alcohol service manager suggested that interventions should be minimal, with signposting to specialist services being preferred, because of lower motivation in referred patients resulting in poorer treatment outcomes compared to self-referrals. In contrast, most pharmacy staff viewed direct referral, as opposed to signposting, into specialist support services as an important option, considering it essential to avoid duplication of effort and minimize the possibility of losing at risk individuals. Most survey participants (127; 85%) were happy or not concerned about a pharmacist providing advice about safer alcohol consumption if requested, while 99 (66.0%) felt similarly about pharmacists proactively raising the topic. These views were not dependent on gender, age or drinking status, however significantly (P < 0.001) more people recruited in affluent areas than in deprived areas were unhappy about pharmacists either proactively raising safer alcohol consumption (17/28; 61% vs 34/122; 28%) or giving advice (10/28; 36% vs 11/122; 9%). In contrast, most pharmacists and pharmacy staff were uncomfortable with pro-actively raising the subject of alcohol, preferring to respond to customer requests (Table 2). A small number of survey respondents and some pharmacists’ concerns centred more on the manner of the interaction, rather than the initiator of the discussion (Table 2). The most common factors identified by survey respondents as important in influencing use of pharmacy alcohol services were: privacy (144; 96%), confidentiality (141; 94%), friendly pharmacist (143; 95%) and staff (129; 86%), plus training (123; 82%). Most concerns related to fear of conversations being overheard, rather than disclosure of personal information by pharmacy staff (Table 1). Pharmacist interviewees raised the need for adequate private facilities and agreed that the open pharmacy environment was a possible limit to providing alcohol services (Table 1). A substantial proportion of the public also considered waiting times (120; 80%) and general busyness of the pharmacy (102; 68%) were important issues and both pharmacists and their staff highlighted concerns about pharmacist workload (Table 1), indicating the need for counter staff to be involved in providing screening. Stakeholders, pharmacists and the public all considered training as essential, to ensure adequate knowledge, and also to ensure pharmacy was integrated with wider service provision. The public considered that individuals would be able to recognize their need for advice on alcohol and one pharmacist
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viewed this as likely in some individuals. Some pharmacy staff interviewed felt that marketing of pharmacy alcohol services would require tailoring to reach different sociodemographic groups. All participant groups considered that services required promotion using a mixture of methods. The options most favoured by the public were posters in GP surgeries (129; 86%) or pharmacy windows (114; 76%). Fewer considered it likely they would respond to advertising in places where alcohol was sold, regardless of their drinking status (Fig. 1).
Stage 2 Nine participants attended the working group: three members of the public (one of whom was a volunteer in alcohol services), three community pharmacists (one involved in Stage 1 and two from the LPC), and a health promotion officer from the PCT plus a health services researcher with extensive experience of alcohol studies and the PCT alcohol services commissioner. Three members of the research team acted as moderators. The group discussed the barriers to pharmacy alcohol services derived from Stage 1 and developed a modified list, then ranked their importance. The pharmacy environment was viewed as the key barrier, which the group felt encompassed appropriate use of private space, business, which could affect service availability and visibility of information on how to access the service. Staff confidence was also ranked highly, and the need for appropriate training, which should encompass learning how to create opportunities to proactively raise the topic with customers. Public perceptions of pharmacy role were also viewed as important as was lack of awareness of services, hence the need for high visibility of information. The key facilitator was accessibility without appointment, with availability of quiet or private areas, long opening hours, convenient location and promotional materials also seen as important. The accessibility and use of pharmacies by all sectors of the public was perceived as enabling a wide reach and that targeting of specific populations which reduced this reach may be undesirable. The
Fig. 1 e General public views on acceptable methods of promoting pharmacy alcohol services by drinking status, as assessed by FAST score.
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working group concurred with public views that posters and leaflets were needed to promote pharmacy alcohol services, but that they should be appropriate to the target audience. Additionally, it was felt that promotion should clearly identify where in the pharmacy to go for the service and who to talk to or ask for. The group reviewed options for screening tools: FAST, AUDIT24 and the scratch cards used elsewhere.16 AUDIT was agreed to be most suitable for the pharmacy setting, with FAST viewed as more intrusive and complex. It was agreed that a prescreen by pharmacy support staff was feasible, in a quiet part of the main pharmacy environment, using AUDITC,25 followed, as appropriate, by referral to the pharmacist to enable completion of the remaining AUDIT questions in the private consultation area, resulting in minimal duplication. Direct referral to support services was agreed as essential to minimize potential loss to follow-up if customers were referred instead to their GP.
Stage 3 The pilot service included key elements agreed by the working group: staff should design and use their own pharmacy-specific promotional materials and methods to supplement standard materials; no specific groups to be targeted, with selection left to individual pharmacy teams; involvement of pharmacy support staff, using AUDIT-C as a prescreen; discussion of full AUDIT score to take place in private area, with pharmacist; and direct referral to the local alcohol treatment service (SATINS). Of the six pharmacies from which staff attended training, five participated in the pilot, four independent and one multiple, all in areas of high deprivation, one dropping out due to inconvenient timing. Observation 1 found clear information about the service displayed in the window and inside three pharmacies: one promoted the service intermittently on a display screen, one had a display board and the third a large home-produced poster on ‘Alcohol Awareness Week’. The remaining two pharmacies had unit calculators/leaflet displays on the counter, but posters were displayed only in the consultation room, in compliance with company policies. Observation 2 noted that there were sometimes insufficient staff to provide alcohol screening, but that a variety of methods were used to approach customers. The size and layout of the pharmacies were considered suitable for providing services, each having a good-sized private consultation room, although one was not audibly discrete. Divider screens/booths were present in three pharmacies, but the areas they afforded were also not audibly discrete. A total of 72 customers used one of the five pharmacies during the 10 h of observation 3, the majority (44; 61%) of whom presented a prescription for dispensing. Counter staff spoke to 60 (83%) of the 72 customers, 20 (28%) were offered screening, of whom 14 (19%) accepted it. Six screenings were
Table 3 e Quotes illustrating service user views of a pilot pharmacy alcohol service. Interviews with service users (Stage 3) ‘There were very sincere and very friendly, they don’t look down on people like ourselves. it should be available in every pharmacy so that people are aware about what alcohol actually does’ ‘There were no customers in so it wasn’t too bad but if it had have been busy I wouldn’t have done it..Just like err may be a private screened area just like you know like a photo booth style curtain or something just at the end of the counter e nothing more than that e I’m not talking about a private room or anything’ ‘The girl she offered me a leaflet or something to fill out...like a survey. they were fine it wasn’t forceful or anything like, no, they were just all friendly e it went quite well’ ‘Just keep it the way it is right and privacy and kept in the same kind of consultation room it’ll be alright.’ ‘I think things like that like are good like I say, I’ve learned more about it just through taking part in a questionnaire in just a few minutes, so I think it’s a good idea.’
Male service user 10
Male service user 2
Female service user 6
Male service user 4
Female service user 7
conducted in a consultation room, six behind a screen or divider and two at the counter. In total 164 screenings were carried out over the twomonth period (range 6e59 per pharmacy): 113 (69%) were categorized as low risk (AUDIT score 0e7), 24 (15%) increasing risk (8e15), 19 (12%) high risk (16e19) and 9 (5%) possibly dependent (20 or more). All nine with scores of 20 or higher were offered referral to specialist services, together with one high risk customer. Six of these stated they were already receiving help, but only one of the remaining four accepted referral. Ten service users were interviewed; five male and five female, who had attended four different pharmacies. In eight of those interviewed, pharmacy staff proactively raised the topic of alcohol, but two requested screening on seeing the pharmacy’s promotional material. All interviewees had positive views of the service and reported professional staff attitudes, with no sense of being pressurized (Table 3). None of the interviewees raised confidentiality as a concern, but most mentioned privacy. Several viewed screening at the counter as acceptable, but only when no other customers were present, most feeling that they would wish to use the consultation room if the pharmacy was busy. All stated they would recommend the service.
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Discussion The method developed enabled a wide range of stakeholders, including members of the public, to be involved in developing a pharmacy-based service. The use of a short pilot enabled testing of the acceptability of several key desirable features of the service, while direct observations assessed the implementation of several of these features. The learning from this study enabled the subsequent commissioning of a service, which incorporated further specific evaluation of bespoke training on approaching potential customers and different promotional methods.17,26 Furthermore the method of direct observation developed here was subsequently used in a wider evaluation of service in other areas.17 All aspects of the development method provided valuable insights which informed commissioning. Both the stakeholder interviews and the working group proved useful in identifying the key elements of the service which needed attention, in particular the pharmacy environment, involvement of pharmacy support staff and need for appropriate promotion. Observations in all the pharmacies taking part in the pilot study enabled the environment and opportunities for service delivery to be assessed, with these data being fed back to all pharmacists. Support staff were clearly involved in recruiting customers to and delivering the service, but opportunities to engage customers were not always maximized. The public survey indicated that risky drinkers used pharmacies for a variety of services, supporting the view of stakeholders that alcohol screening could usefully link to existing pharmacy services. A variety of promotional methods were observed, but these were limited in some cases by company policies, despite their obvious effectiveness, as shown by two of the ten service users interviewed. The working group considered that pharmacies provide a unique opportunity for the public to proactively seek an assessment of their drinking by a health professional in a community setting and the public survey highlighted promotional methods most likely to succeed. Making the initial approach is a potential barrier to providing alcohol screening,27 hence the use of promotional materials in community pharmacies to encourage the public to request screening is worthy of more rigorous study.
Limitations While the authors included key relevant stakeholders, no GPs agreed to interview. Recruitment of the general public proved difficult in affluent areas, and participants from these areas had less positive views on pharmacy staff broaching the subject of alcohol. Also no pharmacy located in an affluent area was recruited to the pilot study. As involvement in the pilot required agreement to direct observations, pharmacies were invited to join the study based on the personal knowledge of PCT commissioners, with no intention to be representative of different types of pharmacies. While our initial plan was that Stage 1 participants would also take part in Stages 2 and 3, individual pharmacists dropped out, so were replaced. Our study was small scale and did not assess efficacy or effectiveness of pharmacy interventions, for which larger, controlled studies are needed.
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Conclusion The methodology enabled the development of pharmacybased alcohol screening to be assessed for acceptability and feasibility from multiple perspectives, prior to full service commissioning. Results suggest that the pharmacy environment and concerns about privacy need to be recognized as potential barriers to service delivery. Good promotion is required to maximize service uptake and pharmacy staff need to be involved in both this and in service delivery.
Author statements Acknowledgements The authors are grateful to Julia Taylor who carried out the surveys and assisted with the stakeholder workshop and to Matthew Brown who conducted the pharmacy observations.
Ethical approval Approval was granted from Liverpool John Moores University research ethics committee to conduct this work (reference number: 09/PBS/021) and Sefton PCT research governance committee.
Funding This work was funded by Liverpool John Moores University Institute for Health Research and Sefton PCT.
Competing interests None declared.
references
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