Exploring the evidence and transferability of pharmacy-based public health services for cardiovascular disease prevention across Europe : an investigation study in the UK and Greece

Peletidi, Aliki (2018) Exploring the evidence and transferability of pharmacy-based public health services for cardiovascular disease prevention across Europe : an investigation study in the UK and Greece. (PhD thesis), Kingston University, .


Cardiovascular disease (CVD) is the main cause of death globally, associated with 31% of all deaths. CVD prevention is therefore of great importance. In primary care, pharmacists are the most suitable healthcare professionals (HCPs) to screen, educate and prevent CVD among the general public. This pharmacy practice-bases thesis aimed to investigate the potential role of community pharmacists in the prevention of CVD in Greece, using the UK as a reference country. The UK was chosen for its wealth of experience in delivering pharmacy-led public health services related to CVD with high success rates, while Greece was chosen for convenience, due to the researcher's local knowledge and network. The thesis is divided into four studies, using both qualitative and quantitative research methods, due to their respective strengths. In the first study, structured interviews were conducted with 40 community pharmacists - 20 in London and Surrey (UK) and 20 in Athens, Thessaloniki and Patras (Greece), - to identify their needs, facilitators and barriers about their role in CVD prevention. Pharmacists in the UK were found to use a patient-centred approach, while Greek pharmacists used a paternalistic one. Nevertheless, the majority found it difficult to initiate a consultation. Both UK and Greek pharmacists thought that there is a need for a structured policy in delivering public health interventions. Greek pharmacists emphasised the need to expand their role in early screening and prevention of CVD, with a focus on weight management (WM) to help their clients/patients reduce their CVD risk. For this reason, structured interviews were conducted with 15 UK WM services providers (pharmacists and pharmacy staff) to explore their views and experience of their role in the service, as well as to identify the structure and training requirements for the service. Service providers emphasised that obesity is a difficult topic to talk about and they found it hard to start a conversation about it, even if they had received training to facilitate this role. It was clear that further training in order for service providers to feel more comfortable in approaching and communicating with people and an increase in the public's awareness of the pharmacy-led WM service is needed so as to ensure the service's sustainability. The third study of this thesis aimed to identify and explore Greek pharmacists' current knowledge and educational needs, as well as their training preferences to offer a WM service. Patras was the chosen Greek city for its convenience. Initially, structured interviews with 26 pharmacists were undertaken, followed by a pre-training quiz consisting of 14 questions investigating knowledge on guidance, causes and facts about obesity. The second phase comprised training design and delivery. The training used an experiential learning method, thus used role playing and included not only the clinical aspects of obesity and WM, but also focused on how to approach and motivate people. The last phase dealt with training evaluation, which included the perceived rating of knowledge and confidence levels pre- and post-training, and a post-training quiz (the same as the pre-training quiz). Through the training, participating pharmacists significantly improved their perceived knowledge and confidence-level (P-value<0.001) This was also reflected in the mean total knowledge quiz score, which was 6.38 pre-training, compared to 11.92 post-training (P-value<0.001). The last part of the thesis was a 'before and after' study. A 10-week WM programme was developed, delivered and evaluated with both programme providers and receivers. The programme included the following measuring parameters: self-reported height, weight, body mass index (BMI), waist circumference (WC), blood pressure (BP), heart rate (HR), AUDIT-C score and Mediterranean diet score. Additionally, it offered a structured approach supplemented with structured materials that were provided to both programme providers and receivers. The primary aim of the programme was a minimum of a 5% weight reduction of the initial weight, while the secondary outcomes were a reduction in participants' BMI, WC, BP, AUDIT-C score and an increase in the Mediterranean diet score and an improvement is physical activity levels. The sample size was calculated (n=96) based on the mean BMI for a Greek male and female individual, and the standard deviation (SD) of weight at baseline of 14Kg. Nearly every participant, 97.4% (n=114), achieved the programme's aim, losing at least 5% of their initial weight. The mean percentage of total weight loss of the the 117 participants at the 10th week was 8.97% (SD 2.65), and the t-test showed statistically significant results (P-value < 0.001; 95% CI [8.48, 9.45]. A significant reduction in the waist to height ratio (WHtR) was observed in both male (P-value=0.004) and female (P-value<0.001) participants. The participants' BP and AUDIT-C score and physical activity levels significantly improved (P-value <0.001), as well as their Mediterranean diet score. The thesis is unique, in that it is the first time that the role of Greek pharmacists in CVD prevention has been explored. It proposed a model for effectively delivering public health services in Greece. This study adds to the evidence in relation to pharmacists' CVD role in public health with outcomes that superseded other pharmacy-led WM programmes. It also provides the first evidence that Greek pharmacists have the potential to play an important role within primary healthcare and that after training they are able to provide public health services for both the public's benefit and their clinical role enhancement.

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