The management of paediatric asthma in the community pharmacy setting

Abstract

Introduction: Literature from around the world suggests that paediatric asthma care is not in line with guidelines and inhaler technique, adherence, asthma management knowledge and written asthma action plan ownership are suboptimal. Thus there is a need for multiple primary care professionals to be involved in paediatric asthma management. Community pharmacists are in an ideal position to address the issues in paediatric asthma stated above therefore this thesis sought to strengthen and improve the current role of community pharmacists in managing paediatric asthma patients within primary care. (Chapter 1) Aim 1: To better understand the status of paediatric asthma management in the Australian and U.S.A community pharmacy setting and to identify the educational needs of community pharmacists in relation to paediatric asthma management. To achieve this aim, a cross-sectional observational study was implemented by recruiting community pharmacists across Sydney metropolitan, Australia and southeast Michigan, U.S.A. Enrolled pharmacists completed a structured, self-reported questionnaire, assessing information on four general domains related to paediatric asthma management: (1) counselling strategies/practices following the dispensing of new asthma medicines and confidence around the use of inhaled corticosteroids; (2) confidence and frequency of use of communication and self-management strategies; (3) attitudes and barriers to the appropriate delivery of education and counseling (4) guideline awareness/use and continuing education. Community pharmacists in both Australia and the U.S.A reported confidence in general communication skills, while a lower proportion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen, decision-making and reviewing short-term and long-term goals with the patient and carer. Community pharmacists in both Australia and the U.S.A were not engaging in paediatric asthma continuing education and most were not using national guidelines to inform their practice. (Chapter 2) Aim 2: To gain a deeper understanding of the perception community pharmacists have of their current role, awareness, practices, interactions and needs in relation to paediatric asthma. Qualitative interviews were conducted with a convenience sample of 23 community pharmacists practising across southeast Michigan in order to address this aim. Interviews were audiotaped and transcribed verbatim, and transcripts were thematically analysed. Upon analysis of the qualitative interviews with pharmacists it was found that pharmacists do not believe their primary role is to engage patients in education and skills training on paediatric asthma self-management, but rather to supply medicine. Although most v pharmacists chose to communicate and provide patient-education, they tended to only engage in these activities if they had time or if requested by the patient/carer. Pharmacists were aware of the areas of suboptimal asthma self-management in children and reported interest in expanding their current role to include paediatric asthma counselling and education. However, numerous challenges and barriers have been identified that prevent pharmacists from delivering optimal education to carers and children with asthma. These included lack of time and reimbursement, challenges in managing the affordability of medicines and lack of a collaborative partnership with doctors in their pharmacy practice. Pharmacists also expressed the view that paediatric asthma continuing education programs are not readily available. (Chapter 3) Aim 3: To identify the needs of carers in terms of managing their child’s asthma, and explore the experiences and perceptions of carers of children with asthma with regards to the community pharmacist. An observational, cross-sectional study design was implemented. This involved the completion of a self-administered questionnaire by carers of children with asthma. Community pharmacists were the sole recruiters of study participants and were responsible for asking carers, who consented to participate, to complete the study questionnaire while waiting in the community pharmacy. Data relating to 3 domains were collected: 1. Child’s asthma status including; asthma control using the validated Childhood Asthma Control Test, emergency service utilisation, days missed from school/childcare, Written Asthma Action Plan possession and prescribed asthma medicines, 2. Carer related outcomes including; days missed from work due to their child’s asthma and carer asthma knowledge using a validated Parental Asthma Knowledge Questionnaire tool, and 3. Pharmacist-Carer interactions: satisfaction with pharmacist, communication/education around paediatric asthma management using an adaptation of the patient satisfaction with pharmacy services questionnaire. The results identified that a high proportion of carers in this study reported that their child had poorly controlled asthma, and less than half possessed a written asthma action plan. Carers missed an average of 1.96 days (s.e.m; ±0.31) of paid work over a 6-month period so that they could manage their child’s uncontrolled asthma. The asthma knowledge of carers was suboptimal particularly regarding the management of an acute attack of asthma and asthma maintenance treatment. Finally, almost all carers reported satisfaction with their pharmacist’s services. However given the status of asthma control and carer knowledge, perhaps this positive relationship is being underutilised. (Chapter 3) Aim 4: To develop an evidence-based paediatric asthma communication and education program for community pharmacists, to test the feasibility of the new program for pharmacy and to explore the impact of the program on pharmacists’ communication skills and asthma vi related practices over time. The feasibility of the newly developed Practitioner Asthma Communication and Education (PACE) for Pharmacy program was tested with 44 pharmacists practising in the Sydney metropolitan region. Pharmacists were trained in small groups in the PACE for Pharmacy program. Pharmacists’ confidence in using communication strategies pre- and post-workshop and self-reported behaviour change post workshop were evaluated. All 44 pharmacists attended the program and completed pre- and post-workshop questionnaires. The participants reported a high level of satisfaction and valued the interactive nature of the workshops. Following the PACE for Pharmacy program, pharmacists reported significantly higher levels in using the communication strategies, confidence in their application and their helpfulness. Pharmacists checked for written asthma action plan possession and inhaler device technique more regularly, and provided verbal instructions more frequently to paediatric asthma patients/carers at the initiation of a new medication. (Chapter 4) Following the feasibility study, the long-term impact of the PACE for Pharmacy program was evaluated through a parallel group, randomised, control versus intervention repeated measures study design, involving 40 control and 39 intervention pharmacists. Recruited pharmacists were assigned to the control or intervention group. Intervention group pharmacists were trained in the PACE for Pharmacy program, while control pharmacists continued with their regular practice. Both control group and intervention group pharmacists completed a selfadministered questionnaire upon initial enrolment into the study and 12 months later. This study identified that participation in the PACE for Pharmacy program was associated with significant improvements in intervention pharmacists’ self-reported scores, when compared with control, in the following areas; confidence and frequency of use of communication strategies, ability to reflect on the use/effectiveness of communication self-monitoring strategies, use of strategies when counselling on new medicines as well as confidence around monitoring/counselling on the use of inhaled corticosteroids. Improvements within these areas were sustained for at least 12 months. (Chapter 4) Aim 5: To gain an understanding of the educational/training needs of pharmacy students in relation to paediatric asthma. To achieve this aim the entire final year Bachelor of Pharmacy cohort was invited to participate in this study (212 pharmacy students). Students were asked to complete a structured, self-reported questionnaire to determine communication confidence, practices and attitudes in paediatric asthma management and multiple regression analyses were used to determine predictors towards pharmacy students’ confidence and use of communication/counselling strategies. Almost all (209) students completed the study vii questionnaire (98.6%). Most students reported confidence in forming an interactive conversation (54%), while 27% reported confidence in setting long-terms goals with patients/carers. Almost all (89%) students reported observing the patients’/carers’ behaviour as a cue for the effectiveness of their communication behaviour, while 75% reported reviewing key instructions about new medicines at the end of a consultation. Tertiary level training for pharmacy students enables the acquisition of generic communication skills. Integrating these skills within the therapeutic content may enhance the confidence levels of students when it comes to communicating about higher order self-management practices in paediatric asthma. (Chapter 5) Aim 6: To develop an evidence-based paediatric asthma communication and education program for pharmacy students and evaluate its impact on their communication skills and asthma related education practices. To address this aim a pre-post study was implemented. Pharmacy students were trained in the PACE for Pharmacy Students program. Students were asked to reflect on their encounters with paediatric asthma patients/carers during their clinical placements and to report on five domains pre and 1-month post completion of the PACE for Pharmacy student program. The first three domains related to their confidence, beliefs of the helpfulness and frequency of use of evidence-based communication strategies. The final two domains related to pharmacy students’ ability to self-reflect on the use of communication self-monitoring techniques and frequency of use of strategies when counselling on new asthma medicines. The mean pharmacy student self-reported scores for each item in domains 1–5 were calculated pre and 1-month post program completion and compared using a Paired Samples Student’s T -Test (significance 0.05, power 0.8). Pharmacy students (n=209) provided data pre and 1-month post participation in the PACE program. Pharmacy student self-reported data showed a statistically significant increase in confidence and frequency of use of evidence-based communication strategies, beliefs of the helpfulness of communication strategies, their ability to self-reflect on their use communication self-monitoring techniques and their frequency of use of strategies when counselling on new asthma medicines. The findings of this study support the value of integrating the evidence-based PACE program into the Pharmacy coursework. This may lead to an improvement in pharmacy students’ paediatric asthma related communication confidence and practices when they enter the workforce. (Chapter 5) Conclusion: The research within this thesis posits that an evidence-based communication and education program specifically tailored to focus on the needs of community pharmacists in viii paediatric asthma management, coupled with strategies to overcome barriers, can together support the development of a long-term pharmacist-patient relationship. This is essential for the achieving optimal management of a chronic disease like paediatric asthma. (Chapter 6)