The community pharmacist’s position and qualitative means to influence use of antibiotics

An exploration of patient needs for informed counselling and involved dialogue on antibiotics

Abstract

The overarching goal of this project was to leave no stone unturned in the global fight against antimicrobial resistance (AMR). The main drivers of AMR are misuse and overuse of antibiotics and new approaches to combat AMR development are urgently needed, particularly in the primary health care sector where most antibiotics are used. The community pharmacist (CP) is the primary healthcare’s final contact point to consult patients prescribed antibiotics and this thesis explores if and how the CP’s can influence the quality of information provided from prescriber through CP to patient. This project was therefore initiated to explore the CP’s position and qualitative means to influence the proper use of antibiotics. A series of focus group interviews were conducted with general practitioners (GPs), CPs and patients, respectively, using one interview guide taking the patient perspective on the qualities of the information chain from antibiotics prescriber to user. The transcript was analyzed using Malterud’s systematic text condensation. The qualitative insights from of Paper 1 and 2 were about patients' sources of information on antibiotics and AMR, patients' experiences from interactions with GPs and CPs, barriers to patient-oriented communication, information patients want from CPs, and how CPs can meet patients' request for a triangular dialogue (CP-patient - GP). These themes were compiled, and their key message fronted on the first page of a brochure which was used to guide an AD campaign (knowledge update) for CPs described in Paper 3. Paper 1 explored the level of patient knowledge of antibiotics and AMR, how patients accessed information and finally, how knowledge about antibiotics is communicated and perceived during interactions with their GPs and CPs. Paper 1 found that the quality of relational communication was central for achieving patient understanding from consultations on antibiotics and AMR. Skjervheim’s concept of triangular joint involvement in the "subject matter" (patient-CP-antibiotic prescription) was utilized as a theoretical framework to explore underlying structures and mechanisms concerning how to ensure the quality of dialogue about antibiotic prescriptions. Recognizing that medical consultations often involve participants (patients-GP/CP) on unequal footing, with varying opportunities to assert their perceptions of reality, there emerges a complex interplay of disempowerment and empowerment. Skuladottir & Halldorsdottir’s perspective was employed in this regard to gain deeper insight into the importance of empowering patients in their counseling. By using these frameworks, it became easier to understand the qualitative means available to CPs when meeting with patients. One specific recommendation from the patient focus group, which was partly agreed upon by the GP focus groups, was for CPs at pharmacies to initiate conversations with open-ended questions such as, “What information did your GP provide about this antibiotic?” This approach allows the CP to inform, confirm, correct, or supplement the information as necessary in a patient centered manner and in alignment with the theoretical frameworks. Paper 2 explored how positioning CPs in the health care hierarchy (GP-Patient-CP) can impact the triangular dialogue and proposed ways to improve the quality of counselling to secure proper antibiotic use. Through a CP positioning lens using Harré’s theoretical framework, it was shown in Paper 2 that patients experienced that they were best served when they were involved in triangular dialogue with GPs and CPs. Patients positioned CPs as the “GPs' extended arm”, acknowledging their role in enhancing the quality of the information chain following an antibiotic prescription, a perspective that may not necessarily align with CPs' point of views. To improve acknowledgment and maximize the potential of each other's roles and room of maneuver in patient antibiotic counseling, it is crucial for GPs and CPs to have a shared understanding of their respective tasks, duties, rights, and responsibilities. The first academic detailing (AD) campaign tailored CPs in Norway was designed based on qualitative insight from Paper 1 and 2, run with 86 one-on-one CP visits, evaluated, and reported in Paper 3. The AD campaign was evaluated for user satisfaction and willingness to change using validated questionnaires, PSAD (Provider Satisfaction with Academic Detailing) and DAVE (Detailer Assessment of Visit Effectiveness). To address a supplementary query concerning whether AD could be a preferred method for knowledge updates methods, a onesample t-test was used to compare the mean score from the survey data to the neutral reference midpoint with no preference either way. The AD campaign was found a significantly preferred knowledge update method and a suited tool to both update CPs knowledge on antibiotics and AMR and importantly to improve counselling practice in meeting the patient. Finally, the three papers were published separately and assembled to constitute an article-based PhD thesis using a mixed method embedded design. The thesis shows the importance of CP’s awareness towards patient empowerment dynamics and their own available qualitative means to involve and influence responsible antibiotics use. The thesis also emphasises the importance of improving interprofessional collaboration to mitigate the threat of AMR. An AD campaign tailored for this purpose, can be a significant improvement in this regard.