What is the aim of this review?
We aimed to find out whether interventions that support people to change health behaviours, and are delivered in community pharmacies, can change the way that pharmacy workers interact with pharmacy users and can improve health outcomes for those users.
Community pharmacies and their workers may have an important part to play in health promotion, and probably improve the health outcomes of pharmacy users slightly, at an acceptable cost and with no evidence of harm (adverse events may or may not have occurred, this is unclear as no adverse effects were reported by the studies).
What was studied in the review?
Community pharmacies are an easy place for many people to access healthcare advice. In the past this advice was limited to how best to take medicines, but, increasingly, community pharmacy workers are carrying out other activities, such as giving advice on healthy eating and management of long-term conditions. While some community pharmacy workers may offer the sale of products without a strong evidence-base, the professional guidance issued to pharmacists has attempted to reduce these transactions, and has placed more emphasis on developing evidence-based public health services. Many people find health-related lifestyle and self-management behaviours difficult. Pharmacies may be convenient for people to use, but it is important to understand whether health-promoting activities delivered in pharmacies are worthwhile and effective, so that those responsible for commissioning health care can decide whether it is worth spending resources to support them.
What are the main results of the review?
We identified 57 studies with a total of 16,220 participants that investigated the effects of health-promotion activities compared to normal treatment or no treatment. These were conducted across the world, 49 of them in high-income countries and eight in middle-income countries. Most studies (36/57) targeted both pharmacy workers and pharmacy users; eight were directed at pharmacy workers only, and 13 at pharmacy users only. The health areas most frequently studied were diabetes, hypertension, asthma and reduction of cardiovascular risk. The studies varied in quality. Some studies did not take enough precautions to stop the participants who should have received either no treatment or usual treatment (i.e. the control group) receiving parts of the intervention.
We found that pharmacy workers may be able to change their behaviour, for example improve their communication skills, to help people to manage their health conditions more effectively.
Overall these studies probably show a slight beneficial effect on pharmacy users' health-related behaviour, intermediate clinical outcomes (e.g. levels of cholesterol or glycated haemoglobin) and quality of life. No studies reported measuring pharmacy users' clinical events such as heart attacks or stroke. There was also no evidence of harm reported in any of the studies, but no studies reported measuring adverse events. Five out of seven studies that measured costs showed that health promotion delivered by pharmacy workers was cost effective.
These findings suggest that community pharmacy workers can probably slightly improve pharmacy users' health outcomes at a reasonable cost. The variety of studies includes different countries, conditions, interventions and outcomes, and suggests there is great interest in using the community pharmacy setting for workers to promote health-related behaviours. However, in order to make future studies easier to compare, there is a need for greater use of thorough, systematic approaches in the description of these interventions, use of a standardised set of outcomes, and for new studies to build on prior work.
How up to date is this review?
We searched for studies that had been published up to February 2018.
Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users.
Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.
Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.
To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.
We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.
We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.
We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.
We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities.
The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias.
Professional practice outcomes
We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology.
Pharmacy user outcomes
Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I2 = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I2 = 90%; 20 trials; 3971 participants; moderate-certainty evidence).
We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users.
Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I2= 82%; 10 trials, 2687 participants; moderate-certainty evidence).
No studies reported adverse events for either pharmacy workers or pharmacy users.
We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.