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Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe
Accepted Manuscript Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe Noreen Dadirai Mdege, Tafadzwa Chevo, Paul Toner PII:
S1551-7411(15)00270-3
DOI:
10.1016/j.sapharm.2015.11.010
Reference:
RSAP 681
To appear in:
Research in Social & Administrative Pharmacy
Received Date: 19 November 2015 Accepted Date: 20 November 2015
Please cite this article as: Mdege ND, Chevo T, Toner P, Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe, Research in Social & Administrative Pharmacy (2015), doi: 10.1016/j.sapharm.2015.11.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe
Noreen Dadirai Mdege,* [email protected]
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Mental Health and Addiction Research Group, Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
Tafadzwa Chevo
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[email protected]
Paul Toner [email protected]
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Department of Sociology, University of Zimbabwe, Harare, Zimbabwe
Mental Health and Addiction Research Group, Department of Health Sciences, University of
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*Corresponding author
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York, Heslington, York YO10 5DD, UK
ACCEPTED MANUSCRIPT ABSTRACT
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Background: There is increasing recognition of the potential significant contribution that
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pharmacy personnel can make to improve the public’s health. However, there is an
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evidence gap in developing countries on the public health role of pharmacy personnel.
5
Objectives: This study aimed to explore the current public health activities that pharmacy
6
professionals in Zimbabwe are currently involved in, and the potential of expanding this
7
role.
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Methods: The study utilised individual, face-to-face, semi-structured qualitative interviews
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with 9 key informants. The sample reflected the diversity of pharmacy practice groups and
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levels as well as professional experience, and included a representative from a patient
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group, and a non-pharmacist national level public health expert. Data collection and analysis
12
was an iterative process informed both by the currently available literature on the topic, as
13
well as themes emerging from the data. Framework analysis was utilised with two
14
independent analyses performed.
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Key findings: There was a general consensus among participants that pharmacy practice in
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Zimbabwe was mainly focused on curative services, with very limited involvement in public
17
health oriented activities. The following were identified as pharmacists’ current public
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health activities: supply chain management of pharmaceutical products, provision of
19
medications and other pharmaceutical products to patients, therapy monitoring,
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identification and monitoring of chronic illnesses, information provision and training of
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pharmacists. Nevertheless, there were concerns regarding the quality of some of these
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services, and lack of consistency in provision across pharmacies. Other potential areas for
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pharmacists’ public health practice were identified as emergency response, drug abuse,
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ACCEPTED MANUSCRIPT addressing social determinants of health particularly promoting healthy lifestyles, applied
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health research, counterfeit and substandard medicines, and advocacy.
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Conclusions: There is a perceived potential for Zimbabwean pharmacists to become more
4
involved in public health oriented services. However, concerns regarding the quality of
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services and lack of consistency in provision need to be addressed.
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Keywords: Pharmacist; Pharmacy practice; Public health; Zimbabwe; Qualitative interview
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ACCEPTED MANUSCRIPT INTRODUCTION
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There is increasing recognition by a number of countries and by agencies such as the World
3
Health Organization (WHO) and the International Pharmaceutical Federation (FIP), of the
4
potential significant contribution that pharmacies and pharmacy personnel can make to
5
improve the public’s health.1-3 Large numbers of people visit pharmacies both in good and in
6
poor health, including individuals that may not have contact with any other healthcare
7
setting including primary healthcare.4,5 These encounters present an opportunity to deliver
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public health interventions. In addition, pharmacies can be more accessible compared with
9
other healthcare settings as no appointment is needed for advice, and many pharmacies
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operate extended hours.4,6
11
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Public health interventions that can be delivered within pharmacy settings are wide, ranging
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and include smoking cessation services, sexual health services, healthy eating and lifestyle
14
advice, immunisation and vaccination services, prevention and management of unhealthy
15
alcohol use and problem drug use, chronic disease prevention and management, infection
16
control and prevention, minor ailment schemes and emergency preparedness.6,7 Some
17
reviews of evidence have supported the notion that well trained pharmacists and other
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pharmacy personnel (such as pharmacy technicians and dispensary assistants) can
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effectively deliver a number of these interventions such as smoking cessation and chronic
20
disease prevention and management.8-10
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The public health role of pharmacists and other pharmacy personnel is continually evolving.
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This calls for continuous generation and evaluation of new evidence on the feasibility,
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acceptability, effectiveness and cost-effectiveness of new interventions and services. In Page 3 of 25
ACCEPTED MANUSCRIPT addition, most of what is known about the public health role of pharmacy staff is from
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studies conducted in developed countries, with a clear evidence gap in developing
3
countries.9,11 To address the developing country evidence gap, this study aimed to explore
4
the perceptions of current and potential public health involvement of pharmacists in
5
Zimbabwe through semi-structured qualitative interviews with key informants.
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6 METHODS
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The study utilised individual, face-to-face, semi-structured qualitative interviews with key
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informants (hereafter referred to as participants).
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10 Participant selection
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Participants were purposively selected to reflect the diversity of pharmacy practice groups
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and levels (i.e. private or public sector pharmacy; community or hospital pharmacy; policy
14
level, regulatory level, practice level, teaching or research pharmacists), as well as
15
professional experience. A member of a patient group, and a national level public health
16
expert were also included. Potential participants were identified through a number of
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pharmacy professional groups: the Pharmaceutical Society of Zimbabwe; Pharmacist Council
18
of Zimbabwe; Retail Pharmacist Association of Zimbabwe; and the Research Pharmacists
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Association of Zimbabwe. Policy level participants were identified from the Directorate of
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Pharmacy Services (Ministry of Health and Child Welfare) and the Public Health Advisory
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Board. Pharmacists involved in teaching were identified from the School of Pharmacy,
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University of Zimbabwe. A patient group representative was identified from the Chronic
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Therapy Association of Zimbabwe.
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ACCEPTED MANUSCRIPT Initial contact with potential participants was by telephone or e-mail. The telephone
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conversation and e-mail provided participants with information about the study, with
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assurance that all information would be anonymized and treated confidentially. They were
4
informed of what their participation would involve, that participation was voluntary, and
5
that the qualitative interviews would be audio-recorded with their consent. Participants
6
contacted by telephone provided verbal consent, and for those contacted by e-mail, their
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indicated willingness to participate was considered as implicit consent. After consenting,
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participants were contacted either by telephone or e-mail to arrange an individual face-to-
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face qualitative interview.
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10 Sample
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Nine participants, representing different sectors and levels of pharmacy practice, as well as
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a wide range of professional experience and knowledge, were interviewed (Table 1).
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Although there were nine participants, it was possible for one participant to represent more
15
than one sector and level of pharmacy practice as shown in Table 1. In addition, Table 1 also
16
shows the participants’ current main areas and levels of practice on which purposive
17
sampling was based. It was possible that individuals would have past experience, or were
18
currently involved to some extent, in other areas or levels. For example a community
19
pharmacist could have worked as a hospital pharmacist in the past, and vice versa. Table 1
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does not include the genders and ages of the respondents for confidentiality reasons.
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Table 1: Participant Characteristics Pharmacy practice group
Level
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Sector (private/
Private
Public
Community
Hospital
Teaching
Policy
and
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public)
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Research
R1
R4
R5
R6
R8 R9
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R7
Public
Patient
Health
Group
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R3
Practice
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R2
Regulatory
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Data Collection and analysis
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Data collection and analysis was an iterative process informed both by the extant literature
3
and by themes emerging from the data.12
4 Data collection
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Individual, face-to-face, semi-structured qualitative interviews were conducted between
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February and March 2012. The qualitative interviews explored four areas: 1) the current
8
public health activities that pharmacy professionals practicing in Zimbabwe are involved in;
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2) additional public health activities that pharmacy professionals practicing in Zimbabwe
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could be involved in; 3) establishing the determinants of pharmacists’ public health
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activities; and 4) perceptions of what the current public health priorities for pharmacy in
12
Zimbabwe should be and why (Appendix). All interviews were conducted by a researcher
13
with experience working as a pharmacist at a public hospital, within the retail sector as well
14
as the teaching and research sector in Zimbabwe. A topic guide was used for all interviews to
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promote consistency. However, any new insights from each interview fed into further
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development of the guide to inform subsequent data collection. All interviews were audio-
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recorded upon consent from each of the interviewees.
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Data Analysis
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The interviews were transcribed and imported into QSR NVivo 10 for the management and
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analysis of data. Data from the qualitative interviews were analysed and interpreted within a
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thematic framework using themes drawn from literature as well as themes emerging from
23
the data.12 This allowed the exploration of issues of interest as well as for new issues to
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emerge from the data. Two researchers independently performed a thematic analysis on all
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transcripts, using a coding framework that was agreed upon through discussion.
3 RESULTS
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The current paper reports the findings from two of the four focus areas (Appendix Questions
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#1-5): 1) the current public health activities that pharmacy professionals practicing in
7
Zimbabwe are involved in; and 2) additional public health activities that pharmacy
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professionals practicing in Zimbabwe could be involved in. The findings from the other two
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focus areas specified under the data collection section are to reported separately. The
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characteristics of the respondents are presented in Table 1.
11 Overview
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Eleven themes were identified in total, 6 for perceptions of pharmacists’ current
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involvement in public health activities and 5 for perceptions of potential future involvement.
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Perceptions of pharmacists’ current involvement in public health activities
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There was a general consensus among all 9 participants that pharmacy practice in Zimbabwe
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was mainly focused on curative services, and that there were not many public health
19
oriented activities being carried out by pharmacists.
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“The face of pharmacy here is retail and it is mostly curative...... In Zimbabwe at the
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moment, it is actually a little bit worrying that we, for a long time, have not really
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engaged with public health, we are much more into the curative; that is our focus. So
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when looking broader in terms of health promotion and understanding that it is Page 8 of 25
ACCEPTED MANUSCRIPT about wellness, we have really been lagging behind. People have been more into
2
managing prescriptions, managing patient care, but we really have not had a wide
3
role in terms of the public health aspect........ The traditional pharmacist here is still
4
quite happy taking in the prescriptions, dispensing the prescriptions, and counselling
5
the patient.”(R1)
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“I am not confident enough to say that locally we have contributed much in terms of
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the public health concept. Participation in public health has been minimal. We do not
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do much such that the public has no appreciation of what we can do...... Our main
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participation is in treatment, basically because the pharmacist is much more
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accessible and not because the public appreciates what the pharmacist can do....”
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(R2)
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“...........as you know, pharmacy in Zimbabwe is mainly curative...... Pharmacists are
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always inclined to the curative aspects of healthcare” (R3)
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The following were identified as current public health activities carried out by pharmacists:
18
supply chain management of pharmaceutical products, provision of medications and other
19
pharmaceutical products to patients, therapy monitoring, identification and monitoring of
20
chronic illnesses, information provision and training of pharmacists. These will be discussed
21
below.
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ACCEPTED MANUSCRIPT Supply chain management of pharmaceutical products
2
The Zimbabwean pharmacists have retained their main role as custodians of medicines and
3
other pharmaceutical products. This role was however mostly associated with pharmacists
4
practising in public sector facilities (such as government and mission hospitals), the National
5
Pharmaceutical Company of Zimbabwe (NatPharm) which is the national drug supplier
6
responsible for supplying pharmaceutical products to government health facilities, and other
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multilateral or non-governmental organizations that work very closely with the Ministry of
8
Health and Child Welfare (MoHCW) and NatPharm.
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“If you are talking about public sector pharmacists, it is mainly about supply chain
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management, getting the right medication of the right quantity and right quality to
12
the right place at the right time and right price. For rural districts, pharmacists
13
become part of the district health team: seeing patients directly and also managing
14
the supply of medicines to health clinics within the district” (R4)
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“....in the hospital, it is mainly supply chain management really.....” (R5)
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“For non-governmental organizations such as UNICEF for example, we have pharmacists whose responsibility is supply chain management of pharmaceutical products in general, or for specific products such as ARVs (antiretroviral
21
drugs)......from quantification, purchasing and making sure that the products go
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wherever they are supposed to go....working very closely with MoHCW, NatPharm
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etc.” (R3)
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Provision of medications and other pharmaceutical products to patients
2
For pharmacists working in retail, community and government health facilities, provision of
3
pharmaceutical products to patients who need them and provision of advice to their clients
4
on health problems were also viewed as public health activities.
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5
“If you are talking about the retail sector or community pharmacies, they are often
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the first port of call for a wide range of ailments, for example pain, or ailments that
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patients just see for themselves such as skin problems or dietary issues; prescription
9
filling and re-fills for chronic illnesses; and also provision of medicines which are not
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available in the public sector for example for HIV sometimes.”(R4)
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“....we also fill patient prescriptions that come from the different wards in the
13
hospital, and try our best to ensure that each ward and every patient have the
14
medications and other products that they need......for example, today, we have a
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request for magnesium sulphate from a ward, we do not have enough, that is why I
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am making all these phone calls to make sure we get it from somewhere by the end
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of the day.”(R5)
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It was also reported that pharmacists are involved in a number of initiatives to promote
20
equitable access to pharmaceutical products and pharmacy services. These initiatives
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include a ‘bonding’ period for pharmacists, soon after completing their pharmacy training,
22
within which they have to work in government health facilities. In addition, there are also a
23
number of initiatives in partnership with multilateral organizations which aim to encourage
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pharmacists to work or provide pharmacy services in underserved areas through incentives
2
or improving working environments.
3 Therapy monitoring
5
Some pharmacists, particularly in public hospitals, are also engaged in therapeutic drug
6
monitoring.
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4
7
“If you are talking about public sector pharmacists, from time to time you hear them
9
also talking about monitoring of therapy for those who feel that they can, and
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depending on infrastructure and equipment availability.” (R4)
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Identification and monitoring of chronic illnesses
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Almost all participants mentioned that some pharmacies provided services aimed at
14
identification and monitoring of chronic illnesses. However there was a feeling that most
15
members of the general public were not aware of these provisions within pharmacies. In
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addition some participants questioned the quality of these services and expressed concerns
17
about the lack of regulation or standards to guide how these services were provided.
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“Some retail and community pharmacists do BP (blood pressure) checks, sugar levels,
cholesterol checks..... Maybe I need to clarify and say you can have these services,
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but I do not think the pharmacist is really doing pharmacy practice... I think
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pharmacists do not go into discussions with the patient in terms of the patient’s BMI
23
(body mass index), BP or sugar level and what it actually means.” (R1)
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“I am sure if you talk to the general public, they will actually be surprised that all
2
these services are available in pharmacies.” (R2)
3 “…there is no regulation, guidance or even standards for these services. So they are
5
provided in a haphazard manner. Some do it some don’t; and there is no proper
6
training. So you can’t tell whether the quality is good or bad.” (R6)
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7 Information provision
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Pharmacists were also regarded as one of the main sources of information on medication
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and other health issues.
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“Pharmacists are more accessible and affordable. Patients cannot afford to go and
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see their doctor very often. Pharmacists are therefore a main source of information
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in terms of illness, life-style changes, medication and adherence to medication.” (R7)
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However, there was a view that information provision by pharmacists was mainly centred on
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medication use in relation to dispensing.
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beyond that.” (R2)
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“We provide information to patients. But like I said earlier, it is mainly to do with the medications that the patient is taking, nothing more. It is in rare occasions that we go
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Training of pharmacists
2
The training of pharmacists was considered as an important public health activity carried out
3
particularly by Universities. This was seen as a significant contribution public health with
4
regards to addressing the shortage of human resources for health.
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“From the academic sector, well, producing pharmacists with a diverse range of
7
expertise including distribution or public health directly, manufacturing, retail sector
8
etc; we contribute to public health in that way also.” (R4)
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A number of potential areas where pharmacists could have a public health impact were
12
identified. These include emergency response, drug abuse, addressing social determinants of
13
health particularly promoting healthy lifestyles, applied health research, counterfeit and
14
substandard medicines, and advocacy.
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Emergency response
17
Two participants perceived pharmacists’ participation in emergency response teams as a
18
potential contribution to public health in the future. Although pharmacists currently
19
sometimes participate in emergency response as part of emergency response teams, some
20
participants suggested that this was not an automatic and established role; pharmacists took
21
up this role only when requested.
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“In the community, in terms of disease outbreaks, or abuse, drug abuse, we have not
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really found a niche, but that is where we could be making an impact.” (R2) Page 14 of 25
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“Although in terms of the recent cholera outbreak, we were forced to come in and
3
we were actually doing patient education and distributing medicines. But this role
4
isn’t routine.” (R1)
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Promoting healthy lifestyles
7
All participants viewed the pharmacist as well placed for healthy lifestyle promotion.
“If we can talk to the patients that we see in our pharmacies about healthy lifestyles,
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that would go a long way. You see, many patients that we see could really benefit
11
health-wise from adopting a healthy lifestyle. Some conditions that many patients
12
are on medication for could be due to their lifestyle or behaviour.” (R7)
Within this theme there was recognition that non-communicable diseases are on the rise in
15
Zimbabwe, and there was need for increased attention to underlying behavioural causes of
16
non-communicable diseases such as exercise, diet, excessive alcohol consumption, tobacco
17
use, and problem drug use.
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“…a focus on other determinants of disease. For example tackling non-communicable diseases which are on the rise: obesity, diabetes, smoking, alcohol abuse, things like that.”(R1)
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Applied health research related to pharmacy practice and public health
2
Applied health research related to pharmacy practice and public health was seen as an area
3
that needed to be promoted and strengthened among the pharmacy profession.
4 “We need pharmacists to engage in applied health research relevant to pharmacy
6
practice and public health. We do some of this in school and University. However, a
7
lot of data is collected in the pharmacies on a daily basis but it’s never used. We
8
could be learning a lot on how to improve pharmacy services, or even on prescribing
9
trends and practices. The Directorate of Pharmaceutical Services sometimes does
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surveys. Most research on pharmacy issues is by doctors. Just a few pharmacists are
11
engaged in research. We need to change how research is perceived among
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pharmacists.”(R8)
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Related to the issues of applied health research was the need for a patient database of
15
anonymised pharmacy records containing comprehensive observational patient data on
16
aspects related to their pharmaceutical care. This was viewed as a potentially very valuable
17
tool for researchers and clinicians in a broad range of areas including pharmacoepidemiology
18
and pharmacoeconomics.
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Counterfeit and substandard medicines
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The illegal sell of medicines, and counterfeit and substandard medicines was identified as a
22
growing public health problem for which pharmacists had a part to play in addressing.
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ACCEPTED MANUSCRIPT “The selling of counterfeit medicines and substandard medicines in the streets. I
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believe it is our duty as pharmacists, through the MCAZ to address this problem and
3
protect the public. You find medicines on display along the streets, exposed. And
4
people will be buying them. Who knows how long that drug has been there on the
5
street, and what sort of quality it is?” (R3)
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“Pharmacists should be vigilant about the illegal sale of medicines. Some of them are
8
fake. That is another way that pharmacists can directly contribute to public health”
9
(R7)
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10 Advocacy
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Two participants highlighted the need for Zimbabwean pharmacists to be effective
13
advocates, both for public health and the pharmacy profession. They highlighted the lack of
14
participation of pharmacists on national level matters that could impact on public health and
15
pharmacy practice as demonstrated by the following quote:
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“We need to be able to speak more and be useful to our community. We are very
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reactive to policy. For the past 2 years there has been movement from different stakeholders, to review the Public Health Act and Health Professions Act. We have tried to bring pharmacists together to do that work. We have struggled seriously. We
21
have done some work on the Public Health Act, but it’s basically the work of about 4
22
people who have contributed representing pharmacy…..in a country with about I
23
think 400 pharmacists. For the Health Professions Act, it’s also mostly 4 people
24
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that is when people start crying. ‘Why were we not included?’ ‘Why were we not
2
consulted?’”(R2)
3 DISCUSSION
5
From the current public health activities by pharmacy professionals reported by the key
6
informants interviewed, it is clear that the pharmacist’s public health role in Zimbabwe is
7
centred on the use and supply of medicines. This finding is consistent with those of other
8
studies on the topic.4,13 A systematic review by Eades, Ferguson and O’Carroll reported that
9
pharmacy staff considered the public health role as secondary to medicine related roles.4
10
However, the study findings also highlight acknowledgement that the pharmacist’s public
11
health role in Zimbabwe can potentially go beyond this traditional role to include the
12
promotion of healthy lifestyles.
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4
As highlighted earlier, healthy lifestyle oriented public health interventions that can be
15
delivered by pharmacists or within pharmacy settings are wide ranging: from smoking
16
cessation, interventions for unhealthy alcohol use or problem drug use, through to healthy
17
eating and weight management.7 Other roles include chronic disease management (e.g.
18
clinics for blood pressure, cholesterol, diabetes, asthma), infection control and prevention
19
(e.g. vaccinations for seasonal flu, HPV, hepatitis B; and screening for chlamydia and
20
hepatitis), emergency response and management of minor ailments.4,7 Some pharmacies in
21
Zimbabwe are providing some of these services, particularly chronic disease management.
22
Nevertheless, findings from the current study highlight concerns regarding the quality of
23
these services, and lack of consistency in provision across pharmacies. There is therefore
24
need for support and training, defining the minimum standards for provision of each of
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these services, as well as monitoring and evaluation of practice. With the wide range of
2
activities, it could also be beneficial to identify priority areas to focus on which could be
3
reviewed periodically.
4 Evidence that pharmacists can provide such services effectively is currently limited to a few
6
interventions such as smoking cessation.6 Where evidence exists, it is often generated within
7
developed country context (such as the UK and USA)9-11; hence there could be questions
8
around the applicability and transferability of this evidence to developing country contexts
9
such as Zimbabwe.11 A recent systematic review by Pande and colleagues identified only
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twelve developing country studies comparing pharmacist-provided non-dispensing services
11
(such as lifestyle modification interventions, counselling and patient education) versus usual
12
care.11 Pharmacist-provided services targeting patients resulted in small improvements of
13
clinical outcomes such as blood pressure, blood glucose, blood cholesterol, asthma, health
14
service utilisation (such as rate of hospitalisation and general practice and emergency room
15
visits), and quality of life.11 This demonstrates the potential of pharmacists to deliver such
16
interventions effectively. However more evidence needs to be generated before the findings
17
can be generalized.
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Another concern raised was the lack of public awareness that pharmacists or pharmacies are
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a source of public health advice, which may result in low demand for such services. This is
21
consistent with findings from other studies that revealed a general lack of awareness of
22
pharmacy capacity and role in public health among the general public14; that most pharmacy
23
users did not expect public health advice from a pharmacist15,16; and that pharmacy users
24
did not often use pharmacies for general health advice as they perceived pharmacists as Page 19 of 25
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drug experts.4 This could be because they had never been offered or received a public health
2
service from a pharmacist. It is possible that these perceptions will change with the changing
3
role of a pharmacist. The views of pharmacy users on this issue are yet to be explored in
4
Zimbabwe.
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Major population level public health improvements are achieved through the use of
7
government level levers such as laws and regulations17. Other mechanisms include changes
8
in policy and institutional practices and standards. Pharmacists need to participate and be
9
strong advocates for public health and the pharmacy profession within the different forums
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where issues such as changes in laws and regulations relevant to public health and the
11
pharmacy profession are discussed. Advocacy may need recognition within pharmacy
12
training programmes as well as the pharmacist competency frameworks, as an essential
13
required competency for pharmacy practice.
14
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The current study focused on the perceptions of current and potential public health
16
involvement of pharmacists in Zimbabwe. Effective delivery of public health interventions
17
requires pharmacists and other pharmacy personnel to have a self-perception that public
18
health is a legitimate part of their role and that they have the skills and knowledge to
19
perform this responsibility well.4,18 It also requires therapeutic commitment, as well as easily
20
accessible sources of specialist support and advice.18,19 Research evidence has shown that
21
these attributes are important determinants of behaviour, as well as effective delivery of
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health interventions.19 There is need therefore to investigate the Zimbabwean pharmacists’
23
perceptions on public health role legitimacy and support, and assess their therapeutic
24
commitment and competencies in delivering different public health services. The
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perceptions of pharmacy service users on the pharmacy personnel’s public health role are
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also important to the success of the service and require investigation.4 In addition, there is
3
also a need to understand the current and potential barriers that pharmacists could face in
4
the provision of these services in Zimbabwe.
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5 Study strengths and limitations
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This study has a number of strengths. It is the first study to elicit pharmacists’ views on
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public health approaches in Zimbabwe. A range of stakeholder views were considered.
9
In addition, a rigorous methodological approach was used with two independent analyses
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performed.
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One of the limitations of the study is the small sample, which means the findings cannot be
13
interpreted as representative of divergent range of views from pharmacists. The study
14
provides an important first step but more in-depth studies required within each setting to
15
provide recommendations that are generalizable. The findings from the individual interviews
16
were not triangulated with other information. For example, views do not take account of
17
resources available for potential expansion of the pharmacist role.
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CONCLUSIONS
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There is a perceived potential for Zimbabwean pharmacists to become more involved in
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public health-oriented services. However, concerns regarding the quality of services and lack
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of consistency in provision need to be addressed.
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ACCEPTED MANUSCRIPT ACKNOWLEDGEMENTS AND FUNDING
2
This work was supported by an International Health Link Start-up Grant funded by the
3
Department for International Development (DFID) and the Department of Health (DH), and
4
jointly managed by the British Council and Tropical Health and Education Trust (THET). The
5
views expressed in this article are those of the authors and not necessarily those of the
6
Department for International Development (DFID), Department of Health (DH), British
7
Council or Tropical Health and Education Trust (THET). The funder had no role in the study
8
design, data collection, analysis or interpretation of the data, writing the manuscript, or the
9
decision to submit the paper for publication.
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REFERENCES
12
1.
14
Department of Health. Pharmacy in England: Building on Strengths—Delivering the Future. London: Department of Health; 2008.
2.
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Wiedenmayer K, Summers RS, Mackie CA, Gous AGS, Everard M, Tromp D. Developing pharmacy practice: a focus on patient care. Geneva, The Hague: World
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Health Organization, International Pharmaceutical Federation; 2006. 3.
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pharmacy: for pharmacists and pharmacy teams working in England and Wales.
19 20
Royal Pharmaceutical Society. Professional standards for public health practice for
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London: Royal Pharmaceutical Society; 2014.
4.
Eades CE, Ferguson JS, O'Carroll RE. Public health in community pharmacy: A
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systematic review of pharmacist and consumer views. BMC Public Health.
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2011;11:582.
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5.
Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev. 2008(1):CD003698. Page 22 of 25
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6.
Public Health England. Consolidating and developing the evidence base and research
2
for community pharmacy's contribution to public health: a progress report from Task
3
Group 3 of the Pharmacy and Public Health Forum. London: Public Health England;
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2013. 7.
6 7
Agomo CO. The role of community pharmacists in public health: a scoping review of literature. J Pharm Health Serv Res. 2012;3:25-33.
8.
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George PP, Molina JAD, Cheah J, Chan S-C, Lim B-P. The evolving role of the
community pharmacist in chronic disease management - a literature review. Ann
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Acad Med Singapore. 2010;39:861-867. 9.
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Mdege ND, Chindove S. Effectiveness of tobacco use cessation interventions
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delivered by pharmacy personnel: a systematic review. Res Social Adm Pharm.
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2014;10:21-44. 10.
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Saba M, Diep J, Saini B, Dhippayom T. Meta-analysis of the effectiveness of smoking
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cessation interventions in community pharmacy. J Clin Pharm Ther. 2014;39:240-247. 11.
Pande S, Hiller JE, Nkansah N, Bero L. The effect of pharmacist-provided nondispensing services on patient outcomes, health service utilisation and costs in low-
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and middle-income countries. Cochrane Database Syst Rev. 2013(2):CD010398. 12.
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Ritchie J, Spencer L. Qualitative Data Analysis for applied policy research. Abingdon: Routledge; 1994.
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Anderson C, Blenkinsopp A, Armstrong M. Pharmacists' percetions regarding thier
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contribution to improve the public's health: a systematic review of the United
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Kingdom and international literature 1990-2001. Int J Pharm Pract. 2003;11:111-120.
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14.
Krska J, Morecroft CW. Views of the general public on the role of pharmacy in public health. J Pharm Health Serv Res. 2010;1:33-38. Page 23 of 25
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an area of competition for Swedish pharmacies. Pharm Pract. 2008;6:74-78. 16.
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Sunderland B, Burrows S, Joyce A, McManus A, Maycock B. Rural pharmacy not delivering on its health promotion potential. Aust J Rural Health. 2006;14:116-119.
17.
6 7
Larsson E, Viberg N, Vernby A, Nordmark J, Stalsby-Lundborg C. Health information,
Palombi L, Kading M, Hayes CJ. The public health pharmacist and the role of the
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pharmacy curriculum: A call to action. Curr Pharm Teach Learn. 2013;5:477–482. 18.
Lauder W, Reynolds W, Smith A, Sharkey S. A comparison of therapeutic
commitment, role support, role competency and empathy in three cohorts of nursing
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students. J Psychiatr Ment Health Nurs. 2002;9:483-491. 19.
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Raistrick DS, Tober GW, Unsworth SL. Attitudes of healthcare professionals in a
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general hospital to patients with substance misuse disorders. J Subst Use.
12
2015;20:56-60.
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Appendix. Primary Questions Comprising the Interviews
2 1. What is the current public health role of pharmacists in Zimbabwe?
4
2. What services are currently provided by pharmacists in Zimbabwe?
5
3. Of the services that Zimbabwean pharmacists currently provide, are there any that you could
7 8
categorize as public health activities?
4. Of the public health activities that you have mentioned, what is the current level of provision by pharmacists? Are all pharmacies and pharmacists providing these services?
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5. Besides the public health services that are already being provided by pharmacists, are there
10
any other public health services that you think pharmacists in Zimbabwe can potentially
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make a significant contribution to?
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6. What factors determine whether a pharmacist provides these public health services?
13
7. If you were to rank these current and potential public health services/activities beginning
14
with the most important that pharmacists should be providing, which ones would be your
15
top 5 priorities and why?
18 19 20
of these 5 priority public health services?
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8. What help or support do you think could be given to pharmacists to facilitate their provision
9. What help or support do you think could be given to pharmacists to help them in their public health role more broadly?
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ACCEPTED MANUSCRIPT Perceptions of current and potential public health involvement of pharmacists in Zimbabwe: findings from a qualitative study
Highlights: Pharmacists in Zimbabwe are currently involved in the following public health activities:
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supply chain management of pharmaceutical products, provision of medications and
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other pharmaceutical products to patients, therapy monitoring, identification and
monitoring of chronic illnesses, information provision and training of pharmacists. There are a number of public health areas where Zimbabwean pharmacists can
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potentially contribute to including: emergency response, drug abuse, addressing social determinants of health particularly promoting healthy lifestyles, applied health research, counterfeit and substandard medicines, and advocacy.
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There are concerns regarding the quality of these services and lack of consistency in
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provision across pharmacies that need to be addressed.
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S1551-7411(15)00270-3
DOI:
10.1016/j.sapharm.2015.11.010
Reference:
RSAP 681
To appear in:
Research in Social & Administrative Pharmacy
Received Date: 19 November 2015 Accepted Date: 20 November 2015
Please cite this article as: Mdege ND, Chevo T, Toner P, Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe, Research in Social & Administrative Pharmacy (2015), doi: 10.1016/j.sapharm.2015.11.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Perceptions of current and potential public health involvement of pharmacists in developing nations: The case of Zimbabwe
Noreen Dadirai Mdege,* [email protected]
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Mental Health and Addiction Research Group, Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
Tafadzwa Chevo
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[email protected]
Paul Toner [email protected]
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Department of Sociology, University of Zimbabwe, Harare, Zimbabwe
Mental Health and Addiction Research Group, Department of Health Sciences, University of
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*Corresponding author
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York, Heslington, York YO10 5DD, UK
ACCEPTED MANUSCRIPT ABSTRACT
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Background: There is increasing recognition of the potential significant contribution that
3
pharmacy personnel can make to improve the public’s health. However, there is an
4
evidence gap in developing countries on the public health role of pharmacy personnel.
5
Objectives: This study aimed to explore the current public health activities that pharmacy
6
professionals in Zimbabwe are currently involved in, and the potential of expanding this
7
role.
8
Methods: The study utilised individual, face-to-face, semi-structured qualitative interviews
9
with 9 key informants. The sample reflected the diversity of pharmacy practice groups and
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levels as well as professional experience, and included a representative from a patient
11
group, and a non-pharmacist national level public health expert. Data collection and analysis
12
was an iterative process informed both by the currently available literature on the topic, as
13
well as themes emerging from the data. Framework analysis was utilised with two
14
independent analyses performed.
15
Key findings: There was a general consensus among participants that pharmacy practice in
16
Zimbabwe was mainly focused on curative services, with very limited involvement in public
17
health oriented activities. The following were identified as pharmacists’ current public
18
health activities: supply chain management of pharmaceutical products, provision of
19
medications and other pharmaceutical products to patients, therapy monitoring,
20
identification and monitoring of chronic illnesses, information provision and training of
21
pharmacists. Nevertheless, there were concerns regarding the quality of some of these
22
services, and lack of consistency in provision across pharmacies. Other potential areas for
23
pharmacists’ public health practice were identified as emergency response, drug abuse,
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ACCEPTED MANUSCRIPT addressing social determinants of health particularly promoting healthy lifestyles, applied
2
health research, counterfeit and substandard medicines, and advocacy.
3
Conclusions: There is a perceived potential for Zimbabwean pharmacists to become more
4
involved in public health oriented services. However, concerns regarding the quality of
5
services and lack of consistency in provision need to be addressed.
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Keywords: Pharmacist; Pharmacy practice; Public health; Zimbabwe; Qualitative interview
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ACCEPTED MANUSCRIPT INTRODUCTION
2
There is increasing recognition by a number of countries and by agencies such as the World
3
Health Organization (WHO) and the International Pharmaceutical Federation (FIP), of the
4
potential significant contribution that pharmacies and pharmacy personnel can make to
5
improve the public’s health.1-3 Large numbers of people visit pharmacies both in good and in
6
poor health, including individuals that may not have contact with any other healthcare
7
setting including primary healthcare.4,5 These encounters present an opportunity to deliver
8
public health interventions. In addition, pharmacies can be more accessible compared with
9
other healthcare settings as no appointment is needed for advice, and many pharmacies
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operate extended hours.4,6
11
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Public health interventions that can be delivered within pharmacy settings are wide, ranging
13
and include smoking cessation services, sexual health services, healthy eating and lifestyle
14
advice, immunisation and vaccination services, prevention and management of unhealthy
15
alcohol use and problem drug use, chronic disease prevention and management, infection
16
control and prevention, minor ailment schemes and emergency preparedness.6,7 Some
17
reviews of evidence have supported the notion that well trained pharmacists and other
18
pharmacy personnel (such as pharmacy technicians and dispensary assistants) can
19
effectively deliver a number of these interventions such as smoking cessation and chronic
20
disease prevention and management.8-10
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The public health role of pharmacists and other pharmacy personnel is continually evolving.
23
This calls for continuous generation and evaluation of new evidence on the feasibility,
24
acceptability, effectiveness and cost-effectiveness of new interventions and services. In Page 3 of 25
ACCEPTED MANUSCRIPT addition, most of what is known about the public health role of pharmacy staff is from
2
studies conducted in developed countries, with a clear evidence gap in developing
3
countries.9,11 To address the developing country evidence gap, this study aimed to explore
4
the perceptions of current and potential public health involvement of pharmacists in
5
Zimbabwe through semi-structured qualitative interviews with key informants.
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6 METHODS
8
The study utilised individual, face-to-face, semi-structured qualitative interviews with key
9
informants (hereafter referred to as participants).
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10 Participant selection
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Participants were purposively selected to reflect the diversity of pharmacy practice groups
13
and levels (i.e. private or public sector pharmacy; community or hospital pharmacy; policy
14
level, regulatory level, practice level, teaching or research pharmacists), as well as
15
professional experience. A member of a patient group, and a national level public health
16
expert were also included. Potential participants were identified through a number of
17
pharmacy professional groups: the Pharmaceutical Society of Zimbabwe; Pharmacist Council
18
of Zimbabwe; Retail Pharmacist Association of Zimbabwe; and the Research Pharmacists
19
Association of Zimbabwe. Policy level participants were identified from the Directorate of
20
Pharmacy Services (Ministry of Health and Child Welfare) and the Public Health Advisory
21
Board. Pharmacists involved in teaching were identified from the School of Pharmacy,
22
University of Zimbabwe. A patient group representative was identified from the Chronic
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Therapy Association of Zimbabwe.
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ACCEPTED MANUSCRIPT Initial contact with potential participants was by telephone or e-mail. The telephone
2
conversation and e-mail provided participants with information about the study, with
3
assurance that all information would be anonymized and treated confidentially. They were
4
informed of what their participation would involve, that participation was voluntary, and
5
that the qualitative interviews would be audio-recorded with their consent. Participants
6
contacted by telephone provided verbal consent, and for those contacted by e-mail, their
7
indicated willingness to participate was considered as implicit consent. After consenting,
8
participants were contacted either by telephone or e-mail to arrange an individual face-to-
9
face qualitative interview.
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10 Sample
12
Nine participants, representing different sectors and levels of pharmacy practice, as well as
13
a wide range of professional experience and knowledge, were interviewed (Table 1).
14
Although there were nine participants, it was possible for one participant to represent more
15
than one sector and level of pharmacy practice as shown in Table 1. In addition, Table 1 also
16
shows the participants’ current main areas and levels of practice on which purposive
17
sampling was based. It was possible that individuals would have past experience, or were
18
currently involved to some extent, in other areas or levels. For example a community
19
pharmacist could have worked as a hospital pharmacist in the past, and vice versa. Table 1
20
does not include the genders and ages of the respondents for confidentiality reasons.
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Table 1: Participant Characteristics Pharmacy practice group
Level
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Sector (private/
Private
Public
Community
Hospital
Teaching
Policy
and
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public)
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Research
R1
R4
R5
R6
R8 R9
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R7
Public
Patient
Health
Group
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R3
Practice
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R2
Regulatory
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Data Collection and analysis
2
Data collection and analysis was an iterative process informed both by the extant literature
3
and by themes emerging from the data.12
4 Data collection
6
Individual, face-to-face, semi-structured qualitative interviews were conducted between
7
February and March 2012. The qualitative interviews explored four areas: 1) the current
8
public health activities that pharmacy professionals practicing in Zimbabwe are involved in;
9
2) additional public health activities that pharmacy professionals practicing in Zimbabwe
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could be involved in; 3) establishing the determinants of pharmacists’ public health
11
activities; and 4) perceptions of what the current public health priorities for pharmacy in
12
Zimbabwe should be and why (Appendix). All interviews were conducted by a researcher
13
with experience working as a pharmacist at a public hospital, within the retail sector as well
14
as the teaching and research sector in Zimbabwe. A topic guide was used for all interviews to
15
promote consistency. However, any new insights from each interview fed into further
16
development of the guide to inform subsequent data collection. All interviews were audio-
17
recorded upon consent from each of the interviewees.
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Data Analysis
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The interviews were transcribed and imported into QSR NVivo 10 for the management and
21
analysis of data. Data from the qualitative interviews were analysed and interpreted within a
22
thematic framework using themes drawn from literature as well as themes emerging from
23
the data.12 This allowed the exploration of issues of interest as well as for new issues to
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emerge from the data. Two researchers independently performed a thematic analysis on all
2
transcripts, using a coding framework that was agreed upon through discussion.
3 RESULTS
5
The current paper reports the findings from two of the four focus areas (Appendix Questions
6
#1-5): 1) the current public health activities that pharmacy professionals practicing in
7
Zimbabwe are involved in; and 2) additional public health activities that pharmacy
8
professionals practicing in Zimbabwe could be involved in. The findings from the other two
9
focus areas specified under the data collection section are to reported separately. The
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characteristics of the respondents are presented in Table 1.
11 Overview
13
Eleven themes were identified in total, 6 for perceptions of pharmacists’ current
14
involvement in public health activities and 5 for perceptions of potential future involvement.
15
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Perceptions of pharmacists’ current involvement in public health activities
17
There was a general consensus among all 9 participants that pharmacy practice in Zimbabwe
18
was mainly focused on curative services, and that there were not many public health
19
oriented activities being carried out by pharmacists.
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“The face of pharmacy here is retail and it is mostly curative...... In Zimbabwe at the
22
moment, it is actually a little bit worrying that we, for a long time, have not really
23
engaged with public health, we are much more into the curative; that is our focus. So
24
when looking broader in terms of health promotion and understanding that it is Page 8 of 25
ACCEPTED MANUSCRIPT about wellness, we have really been lagging behind. People have been more into
2
managing prescriptions, managing patient care, but we really have not had a wide
3
role in terms of the public health aspect........ The traditional pharmacist here is still
4
quite happy taking in the prescriptions, dispensing the prescriptions, and counselling
5
the patient.”(R1)
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“I am not confident enough to say that locally we have contributed much in terms of
8
the public health concept. Participation in public health has been minimal. We do not
9
do much such that the public has no appreciation of what we can do...... Our main
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participation is in treatment, basically because the pharmacist is much more
11
accessible and not because the public appreciates what the pharmacist can do....”
12
(R2)
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“...........as you know, pharmacy in Zimbabwe is mainly curative...... Pharmacists are
15
always inclined to the curative aspects of healthcare” (R3)
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The following were identified as current public health activities carried out by pharmacists:
18
supply chain management of pharmaceutical products, provision of medications and other
19
pharmaceutical products to patients, therapy monitoring, identification and monitoring of
20
chronic illnesses, information provision and training of pharmacists. These will be discussed
21
below.
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ACCEPTED MANUSCRIPT Supply chain management of pharmaceutical products
2
The Zimbabwean pharmacists have retained their main role as custodians of medicines and
3
other pharmaceutical products. This role was however mostly associated with pharmacists
4
practising in public sector facilities (such as government and mission hospitals), the National
5
Pharmaceutical Company of Zimbabwe (NatPharm) which is the national drug supplier
6
responsible for supplying pharmaceutical products to government health facilities, and other
7
multilateral or non-governmental organizations that work very closely with the Ministry of
8
Health and Child Welfare (MoHCW) and NatPharm.
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“If you are talking about public sector pharmacists, it is mainly about supply chain
11
management, getting the right medication of the right quantity and right quality to
12
the right place at the right time and right price. For rural districts, pharmacists
13
become part of the district health team: seeing patients directly and also managing
14
the supply of medicines to health clinics within the district” (R4)
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“....in the hospital, it is mainly supply chain management really.....” (R5)
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“For non-governmental organizations such as UNICEF for example, we have pharmacists whose responsibility is supply chain management of pharmaceutical products in general, or for specific products such as ARVs (antiretroviral
21
drugs)......from quantification, purchasing and making sure that the products go
22
wherever they are supposed to go....working very closely with MoHCW, NatPharm
23
etc.” (R3)
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Provision of medications and other pharmaceutical products to patients
2
For pharmacists working in retail, community and government health facilities, provision of
3
pharmaceutical products to patients who need them and provision of advice to their clients
4
on health problems were also viewed as public health activities.
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5
“If you are talking about the retail sector or community pharmacies, they are often
7
the first port of call for a wide range of ailments, for example pain, or ailments that
8
patients just see for themselves such as skin problems or dietary issues; prescription
9
filling and re-fills for chronic illnesses; and also provision of medicines which are not
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available in the public sector for example for HIV sometimes.”(R4)
11
“....we also fill patient prescriptions that come from the different wards in the
13
hospital, and try our best to ensure that each ward and every patient have the
14
medications and other products that they need......for example, today, we have a
15
request for magnesium sulphate from a ward, we do not have enough, that is why I
16
am making all these phone calls to make sure we get it from somewhere by the end
17
of the day.”(R5)
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It was also reported that pharmacists are involved in a number of initiatives to promote
20
equitable access to pharmaceutical products and pharmacy services. These initiatives
21
include a ‘bonding’ period for pharmacists, soon after completing their pharmacy training,
22
within which they have to work in government health facilities. In addition, there are also a
23
number of initiatives in partnership with multilateral organizations which aim to encourage
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pharmacists to work or provide pharmacy services in underserved areas through incentives
2
or improving working environments.
3 Therapy monitoring
5
Some pharmacists, particularly in public hospitals, are also engaged in therapeutic drug
6
monitoring.
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4
7
“If you are talking about public sector pharmacists, from time to time you hear them
9
also talking about monitoring of therapy for those who feel that they can, and
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depending on infrastructure and equipment availability.” (R4)
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Identification and monitoring of chronic illnesses
13
Almost all participants mentioned that some pharmacies provided services aimed at
14
identification and monitoring of chronic illnesses. However there was a feeling that most
15
members of the general public were not aware of these provisions within pharmacies. In
16
addition some participants questioned the quality of these services and expressed concerns
17
about the lack of regulation or standards to guide how these services were provided.
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“Some retail and community pharmacists do BP (blood pressure) checks, sugar levels,
cholesterol checks..... Maybe I need to clarify and say you can have these services,
21
but I do not think the pharmacist is really doing pharmacy practice... I think
22
pharmacists do not go into discussions with the patient in terms of the patient’s BMI
23
(body mass index), BP or sugar level and what it actually means.” (R1)
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“I am sure if you talk to the general public, they will actually be surprised that all
2
these services are available in pharmacies.” (R2)
3 “…there is no regulation, guidance or even standards for these services. So they are
5
provided in a haphazard manner. Some do it some don’t; and there is no proper
6
training. So you can’t tell whether the quality is good or bad.” (R6)
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7 Information provision
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Pharmacists were also regarded as one of the main sources of information on medication
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and other health issues.
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“Pharmacists are more accessible and affordable. Patients cannot afford to go and
13
see their doctor very often. Pharmacists are therefore a main source of information
14
in terms of illness, life-style changes, medication and adherence to medication.” (R7)
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However, there was a view that information provision by pharmacists was mainly centred on
17
medication use in relation to dispensing.
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beyond that.” (R2)
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“We provide information to patients. But like I said earlier, it is mainly to do with the medications that the patient is taking, nothing more. It is in rare occasions that we go
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Training of pharmacists
2
The training of pharmacists was considered as an important public health activity carried out
3
particularly by Universities. This was seen as a significant contribution public health with
4
regards to addressing the shortage of human resources for health.
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5
“From the academic sector, well, producing pharmacists with a diverse range of
7
expertise including distribution or public health directly, manufacturing, retail sector
8
etc; we contribute to public health in that way also.” (R4)
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11
A number of potential areas where pharmacists could have a public health impact were
12
identified. These include emergency response, drug abuse, addressing social determinants of
13
health particularly promoting healthy lifestyles, applied health research, counterfeit and
14
substandard medicines, and advocacy.
15
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Emergency response
17
Two participants perceived pharmacists’ participation in emergency response teams as a
18
potential contribution to public health in the future. Although pharmacists currently
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sometimes participate in emergency response as part of emergency response teams, some
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participants suggested that this was not an automatic and established role; pharmacists took
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up this role only when requested.
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“In the community, in terms of disease outbreaks, or abuse, drug abuse, we have not
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really found a niche, but that is where we could be making an impact.” (R2) Page 14 of 25
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“Although in terms of the recent cholera outbreak, we were forced to come in and
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we were actually doing patient education and distributing medicines. But this role
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isn’t routine.” (R1)
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Promoting healthy lifestyles
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All participants viewed the pharmacist as well placed for healthy lifestyle promotion.
“If we can talk to the patients that we see in our pharmacies about healthy lifestyles,
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that would go a long way. You see, many patients that we see could really benefit
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health-wise from adopting a healthy lifestyle. Some conditions that many patients
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are on medication for could be due to their lifestyle or behaviour.” (R7)
Within this theme there was recognition that non-communicable diseases are on the rise in
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Zimbabwe, and there was need for increased attention to underlying behavioural causes of
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non-communicable diseases such as exercise, diet, excessive alcohol consumption, tobacco
17
use, and problem drug use.
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“…a focus on other determinants of disease. For example tackling non-communicable diseases which are on the rise: obesity, diabetes, smoking, alcohol abuse, things like that.”(R1)
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Applied health research related to pharmacy practice and public health
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Applied health research related to pharmacy practice and public health was seen as an area
3
that needed to be promoted and strengthened among the pharmacy profession.
4 “We need pharmacists to engage in applied health research relevant to pharmacy
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practice and public health. We do some of this in school and University. However, a
7
lot of data is collected in the pharmacies on a daily basis but it’s never used. We
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could be learning a lot on how to improve pharmacy services, or even on prescribing
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trends and practices. The Directorate of Pharmaceutical Services sometimes does
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surveys. Most research on pharmacy issues is by doctors. Just a few pharmacists are
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engaged in research. We need to change how research is perceived among
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pharmacists.”(R8)
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Related to the issues of applied health research was the need for a patient database of
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anonymised pharmacy records containing comprehensive observational patient data on
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aspects related to their pharmaceutical care. This was viewed as a potentially very valuable
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tool for researchers and clinicians in a broad range of areas including pharmacoepidemiology
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and pharmacoeconomics.
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Counterfeit and substandard medicines
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The illegal sell of medicines, and counterfeit and substandard medicines was identified as a
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growing public health problem for which pharmacists had a part to play in addressing.
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ACCEPTED MANUSCRIPT “The selling of counterfeit medicines and substandard medicines in the streets. I
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believe it is our duty as pharmacists, through the MCAZ to address this problem and
3
protect the public. You find medicines on display along the streets, exposed. And
4
people will be buying them. Who knows how long that drug has been there on the
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street, and what sort of quality it is?” (R3)
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“Pharmacists should be vigilant about the illegal sale of medicines. Some of them are
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fake. That is another way that pharmacists can directly contribute to public health”
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(R7)
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10 Advocacy
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Two participants highlighted the need for Zimbabwean pharmacists to be effective
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advocates, both for public health and the pharmacy profession. They highlighted the lack of
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participation of pharmacists on national level matters that could impact on public health and
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pharmacy practice as demonstrated by the following quote:
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“We need to be able to speak more and be useful to our community. We are very
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reactive to policy. For the past 2 years there has been movement from different stakeholders, to review the Public Health Act and Health Professions Act. We have tried to bring pharmacists together to do that work. We have struggled seriously. We
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have done some work on the Public Health Act, but it’s basically the work of about 4
22
people who have contributed representing pharmacy…..in a country with about I
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think 400 pharmacists. For the Health Professions Act, it’s also mostly 4 people
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that is when people start crying. ‘Why were we not included?’ ‘Why were we not
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consulted?’”(R2)
3 DISCUSSION
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From the current public health activities by pharmacy professionals reported by the key
6
informants interviewed, it is clear that the pharmacist’s public health role in Zimbabwe is
7
centred on the use and supply of medicines. This finding is consistent with those of other
8
studies on the topic.4,13 A systematic review by Eades, Ferguson and O’Carroll reported that
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pharmacy staff considered the public health role as secondary to medicine related roles.4
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However, the study findings also highlight acknowledgement that the pharmacist’s public
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health role in Zimbabwe can potentially go beyond this traditional role to include the
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promotion of healthy lifestyles.
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As highlighted earlier, healthy lifestyle oriented public health interventions that can be
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delivered by pharmacists or within pharmacy settings are wide ranging: from smoking
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cessation, interventions for unhealthy alcohol use or problem drug use, through to healthy
17
eating and weight management.7 Other roles include chronic disease management (e.g.
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clinics for blood pressure, cholesterol, diabetes, asthma), infection control and prevention
19
(e.g. vaccinations for seasonal flu, HPV, hepatitis B; and screening for chlamydia and
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hepatitis), emergency response and management of minor ailments.4,7 Some pharmacies in
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Zimbabwe are providing some of these services, particularly chronic disease management.
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Nevertheless, findings from the current study highlight concerns regarding the quality of
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these services, and lack of consistency in provision across pharmacies. There is therefore
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need for support and training, defining the minimum standards for provision of each of
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these services, as well as monitoring and evaluation of practice. With the wide range of
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activities, it could also be beneficial to identify priority areas to focus on which could be
3
reviewed periodically.
4 Evidence that pharmacists can provide such services effectively is currently limited to a few
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interventions such as smoking cessation.6 Where evidence exists, it is often generated within
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developed country context (such as the UK and USA)9-11; hence there could be questions
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around the applicability and transferability of this evidence to developing country contexts
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such as Zimbabwe.11 A recent systematic review by Pande and colleagues identified only
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twelve developing country studies comparing pharmacist-provided non-dispensing services
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(such as lifestyle modification interventions, counselling and patient education) versus usual
12
care.11 Pharmacist-provided services targeting patients resulted in small improvements of
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clinical outcomes such as blood pressure, blood glucose, blood cholesterol, asthma, health
14
service utilisation (such as rate of hospitalisation and general practice and emergency room
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visits), and quality of life.11 This demonstrates the potential of pharmacists to deliver such
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interventions effectively. However more evidence needs to be generated before the findings
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can be generalized.
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Another concern raised was the lack of public awareness that pharmacists or pharmacies are
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a source of public health advice, which may result in low demand for such services. This is
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consistent with findings from other studies that revealed a general lack of awareness of
22
pharmacy capacity and role in public health among the general public14; that most pharmacy
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users did not expect public health advice from a pharmacist15,16; and that pharmacy users
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did not often use pharmacies for general health advice as they perceived pharmacists as Page 19 of 25
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drug experts.4 This could be because they had never been offered or received a public health
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service from a pharmacist. It is possible that these perceptions will change with the changing
3
role of a pharmacist. The views of pharmacy users on this issue are yet to be explored in
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Zimbabwe.
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Major population level public health improvements are achieved through the use of
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government level levers such as laws and regulations17. Other mechanisms include changes
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in policy and institutional practices and standards. Pharmacists need to participate and be
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strong advocates for public health and the pharmacy profession within the different forums
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where issues such as changes in laws and regulations relevant to public health and the
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pharmacy profession are discussed. Advocacy may need recognition within pharmacy
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training programmes as well as the pharmacist competency frameworks, as an essential
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required competency for pharmacy practice.
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The current study focused on the perceptions of current and potential public health
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involvement of pharmacists in Zimbabwe. Effective delivery of public health interventions
17
requires pharmacists and other pharmacy personnel to have a self-perception that public
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health is a legitimate part of their role and that they have the skills and knowledge to
19
perform this responsibility well.4,18 It also requires therapeutic commitment, as well as easily
20
accessible sources of specialist support and advice.18,19 Research evidence has shown that
21
these attributes are important determinants of behaviour, as well as effective delivery of
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health interventions.19 There is need therefore to investigate the Zimbabwean pharmacists’
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perceptions on public health role legitimacy and support, and assess their therapeutic
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commitment and competencies in delivering different public health services. The
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perceptions of pharmacy service users on the pharmacy personnel’s public health role are
2
also important to the success of the service and require investigation.4 In addition, there is
3
also a need to understand the current and potential barriers that pharmacists could face in
4
the provision of these services in Zimbabwe.
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This study has a number of strengths. It is the first study to elicit pharmacists’ views on
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public health approaches in Zimbabwe. A range of stakeholder views were considered.
9
In addition, a rigorous methodological approach was used with two independent analyses
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performed.
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One of the limitations of the study is the small sample, which means the findings cannot be
13
interpreted as representative of divergent range of views from pharmacists. The study
14
provides an important first step but more in-depth studies required within each setting to
15
provide recommendations that are generalizable. The findings from the individual interviews
16
were not triangulated with other information. For example, views do not take account of
17
resources available for potential expansion of the pharmacist role.
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CONCLUSIONS
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There is a perceived potential for Zimbabwean pharmacists to become more involved in
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public health-oriented services. However, concerns regarding the quality of services and lack
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of consistency in provision need to be addressed.
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ACCEPTED MANUSCRIPT ACKNOWLEDGEMENTS AND FUNDING
2
This work was supported by an International Health Link Start-up Grant funded by the
3
Department for International Development (DFID) and the Department of Health (DH), and
4
jointly managed by the British Council and Tropical Health and Education Trust (THET). The
5
views expressed in this article are those of the authors and not necessarily those of the
6
Department for International Development (DFID), Department of Health (DH), British
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Council or Tropical Health and Education Trust (THET). The funder had no role in the study
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design, data collection, analysis or interpretation of the data, writing the manuscript, or the
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decision to submit the paper for publication.
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REFERENCES
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Wiedenmayer K, Summers RS, Mackie CA, Gous AGS, Everard M, Tromp D. Developing pharmacy practice: a focus on patient care. Geneva, The Hague: World
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pharmacy: for pharmacists and pharmacy teams working in England and Wales.
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Royal Pharmaceutical Society. Professional standards for public health practice for
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Eades CE, Ferguson JS, O'Carroll RE. Public health in community pharmacy: A
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2011;11:582.
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Mdege ND, Chindove S. Effectiveness of tobacco use cessation interventions
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Appendix. Primary Questions Comprising the Interviews
2 1. What is the current public health role of pharmacists in Zimbabwe?
4
2. What services are currently provided by pharmacists in Zimbabwe?
5
3. Of the services that Zimbabwean pharmacists currently provide, are there any that you could
7 8
categorize as public health activities?
4. Of the public health activities that you have mentioned, what is the current level of provision by pharmacists? Are all pharmacies and pharmacists providing these services?
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5. Besides the public health services that are already being provided by pharmacists, are there
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any other public health services that you think pharmacists in Zimbabwe can potentially
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make a significant contribution to?
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6. What factors determine whether a pharmacist provides these public health services?
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7. If you were to rank these current and potential public health services/activities beginning
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with the most important that pharmacists should be providing, which ones would be your
15
top 5 priorities and why?
18 19 20
of these 5 priority public health services?
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8. What help or support do you think could be given to pharmacists to facilitate their provision
9. What help or support do you think could be given to pharmacists to help them in their public health role more broadly?
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ACCEPTED MANUSCRIPT Perceptions of current and potential public health involvement of pharmacists in Zimbabwe: findings from a qualitative study
Highlights: Pharmacists in Zimbabwe are currently involved in the following public health activities:
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supply chain management of pharmaceutical products, provision of medications and
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other pharmaceutical products to patients, therapy monitoring, identification and
monitoring of chronic illnesses, information provision and training of pharmacists. There are a number of public health areas where Zimbabwean pharmacists can
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potentially contribute to including: emergency response, drug abuse, addressing social determinants of health particularly promoting healthy lifestyles, applied health research, counterfeit and substandard medicines, and advocacy.
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provision across pharmacies that need to be addressed.
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