Community pharmacists in Montreal (Quebec, Canada) and surrounding areas perceive their potential role in health promotion and prevention as very significant, particularly in smoking cessation, screening for hypertension, diabetes and dyslipidemia, and counseling on sexual health. However, there is a wide gap between their ideal and actual levels of involvement. Most pharmacists believe they should be very involved in screening for hypertension (81.8%), diabetes (76.0%) and dyslipidemia (56.9%); in fact, though, only a minority is very involved (44.5%, 34.8% and 6.5%, respectively). Health-promotion and preventive services in pharmacy are provided largely by pharmacists and, to a lesser extent, by nurses and technical assistants. In fact, more than half of surveyed pharmacists reported that a nurse was present in their pharmacy. The services consist mainly of distributing written information, providing counseling when dispensing medications and referring patients to external resources. When offered, such services are provided relatively often and usually take 10 minutes or less. There are several barriers that limit pharmacists' involvement in health promotion and prevention, including lack of time, lack of coordination with other health care professionals, lack of staff or resources, lack of financial compensation, and lack of clinical tools.
Similarly to the present study, the results of a cross-sectional mail survey of community pharmacists in British Columbia published in 1994 showed that pharmacists are mostly involved in activities directly related to the dispensing or selling of medications and have less intense involvement in health education and disease prevention [2]. A 1996 cross-sectional mail survey of community pharmacists practicing in the province of Quebec found that, although only few pharmacists reported routinely performing prevention activities, over 90% believed that integrating prevention into their practices was important [1]. Similarly, a Web-based survey of pharmacists across Canada reported that, although pharmacists currently spend most of their time on dispensing duties, over 60% believed it was time to assume new responsibilities, and more than 70% wanted to expand their roles in various fields including public health outreach (e.g. working with communities and patients to focus on health promotion, disease prevention and chronic disease management) within five years [20]. Finally, a recent systematic review on the beliefs and attitudes of pharmacists regarding pharmaceutical public health showed that, although most view public-health services as important and part of their role, various organizational barriers limit their involvement [21]. These results confirm the profession's widespread acceptance of community pharmacists' changing role from traditional dispensing duties to greater involvement in health promotion and prevention and its understanding of the importance of providing these services.
Evidently, pharmacists and the population at large would welcome greater involvement of community pharmacies in health-promotion and preventive services [21, 22]. Our results suggest that the development of future public-health programs in community pharmacy should focus on the continuity of care, maximizing the expertise of other health care professionals who may be present in the pharmacy, and overcoming organizational barriers. Such programs need to be well integrated within the primary-care system through effective communication and collaboration with other health care providers, and they should be supported by clinical tools, such as collective prescriptions, to optimize the contribution of pharmacists.
In a study evaluating the impact of a community pharmacy-based smoking cessation program in Northern Ireland, the involvement of pharmacies was especially low: only 19% of recruited pharmacies enrolled the required number of patients to participate in the study [7]. This is in line with the results of the present study, suggesting that although pharmacists may envision an ideal level of involvement in health-promotion and preventive services, this vision is often not translated into their actual practice. In formal clinical trials where the level of involvement of pharmacists in specific public-health activities may be considered as ideal, beneficial impacts have been identified, namely in the area of smoking cessation [6, 7], hypertension [9, 10], dyslipidemia [9], diabetes [8, 9], and sexual health [11]. Integrating primary-care pharmacists and pharmacies into public-health programs should be considered a valuable option for optimizing population health. It is therefore crucial to better understand the barriers and facilitators of greater involvement of pharmacists in public health activities.
Similarly again to our results, studies have identified key barriers to the involvement of community pharmacists in health promotion and prevention. They include the lack of time, insufficient human resources, difficult access to patients' physicians, lack of skills and/or instrumentation, lack of compensation for prevention acts, and lack of space [1, 23–25]. Other factors limiting the provision of such activities in current practice that were found in the literature but did not stand out in our study include the general public's lack of awareness of pharmacy's role in health promotion and prevention, lack of access to the full patient record, confidentiality concerns, and defensive or uncooperative patients [23–26]. It is therefore to be expected that overcoming these barriers will require reorganizing not only community-pharmacy practice but also the health care system in order to better integrate pharmacists into the provision of preventive services. This reorganization will doubtless require agreement, commitment and engagement by all pharmacy stakeholders in addition to financial investments.
Two studies have identified facilitators of practice change in community pharmacy [27, 28]. These factors included government policy; remuneration for service delivery; communication and teamwork; leadership; task delegation; external support or assistance; reorganization of the structure and function of the pharmacy; professional satisfaction or competitiveness; communication and collaboration with physicians; and patient expectations regarding the services to be offered. Future public-health programs in community pharmacy will also need to consider these factors in order to facilitate practice change.
This study has some limitations. No data were collected regarding non-respondents; it is therefore possible that the pharmacists who returned the completed questionnaire are more motivated or interested than the non-respondents are and that involvement in health promotion and prevention may thus have been overestimated. A social-desirability bias may also have contributed to overestimate the ideal and actual prevention practices. Finally, the length of the questionnaire may have contributed to reduce the response rate. Nonetheless, despite random sampling and the absence of any telephone contact, the response rate was relatively high. Moreover, comparison with statistics compiled by the OPQ on gender and pharmacist status showed that our sample was representative of community pharmacists working in Quebec.
