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IJPP.book Page 17 Friday, January 4, 2008 1:32 PM

IJPP 2008, 16: 17–22 © 2008 The Authors Received April 23, 2007 Accepted July 18, 2007 DOI 10.1211/ijpp.16.1.0004 ISSN 0961-7671

Create Consultancy, Glasgow, Scotland

Development, implementation and evaluation of a pilot project to deliver interventions on alcohol issues in community pharmacies Niamh Fitzgerald, Dorothy J McCaig, Hazel Watson, David Thomson and Derek C Stewart

Niamh Fitzgerald, director School of Pharmacy, The Robert Gordon University, Aberdeen, Scotland Niamh Fitzgerald, senior research fellow Dorothy J McCaig, senior lecturer Derek C Stewart, senior lecturer School of Nursing, Midwifery and Community Health, Glasgow Caledonian University, Glasgow, Scotland Hazel Watson, professor of nursing Community Pharmacy Development, NHS Greater Glasgow and Clyde, Glasgow, Scotland David Thomson, joint lead

Correspondence: Dr Derek Stewart, Senior Lecturer, School of Pharmacy, The Robert Gordon University, Schoolhill, Aberdeen AB10 1FR, Scotland, UK. E-mail: [email protected] Acknowledgements: We wish to thank the Alcohol Education and Research Council (AERC) for funding this research. Thanks also to the respondents and the following for their contribution: support staff at the School of Pharmacy, The Robert Gordon University and each of the participating pharmacies; Scott Bryson (NHS Greater Glasgow and Clyde); Dr Eileen Kaner (University of Newcastle upon Tyne); Professor Nick Heather (Northumbria University); Professor Ray Hodgeson (AERC); Joanne Winterbottom (Glasgow Council on Alcohol); Julie Dowds (Create Consultancy); Kathryn McGrory (Centre for Population Health); Joyce Craig (AERC); and NHS Greater Glasgow Audit Facilitators.

Abstract Objective The aim was to evaluate the feasibility and acceptability of the provision of brief interventions on alcohol misuse in community pharmacies. The objectives were to: train community pharmacists to initiate discussion of alcohol consumption with targeted pharmacy clients and screen, intervene or refer as appropriate; and to explore with pharmacists and clients the feasibility, acceptability and perceived value of screening and delivering the intervention. Setting Eight community pharmacies in Greater Glasgow. Method After a two-day training course for pharmacists (n = 9) and one day for pharmacy assistants (n = 13), the eight pharmacies recruited clients over 3 months. Standardised protocols were prepared to screen clients for hazardous or harmful drinking using the Fast Alcohol Screening Tool (FAST) and to guide the intervention. Clients were recruited from specific target groups and via posters highlighting the service. Following completion of the recruitment phase, pharmacists and clients were followed up by the research team, using a combination of focus groups and semi-structured telephone interviews. Key findings During the study period 70 clients were recruited, 30 screened as drinking hazardously (42.9%) and 7 (10%) screened positive for harmful drinking. Interventions commonly included explanation of sensible drinking and units in clients’ preferred drinks (n = 33), feedback on screening and risks to health (n = 27) and discussion of pros and cons of current drinking pattern and link with presenting issue (n = 23). Of the 40 clients agreeing to be followed up, 19 could be contacted and most were generally positive about the experience. On follow-up the pharmacists were positive and felt the project worthwhile and, importantly, noted no strong negative reactions from clients. Conclusion This project has been successful in training community pharmacists to discuss alcohol with 70 clients. Further work is required to test the generalisability of our findings and to measure the impact on alcohol consumption.

Introduction There is increasing concern among health professionals, social care professionals and policy makers at the rising level of alcohol consumption in the UK and the overwhelming evidence of the negative impact of excessive alcohol consumption on health. Excessive alcohol consumption is associated with an increased risk of a wide range of illnesses that collectively contribute substantially to the morbidity and mortality of the population as a whole.1–4 The numbers of men and women drinking in excess of daily and weekly limits are increasing, as is binge drinking.4 Tackling alcohol misuse is therefore a key national priority area evidenced by the publication of many strategic policy documents.5,6 These place emphasis on a proactive anticipatory care approach, aiming to help individuals to identify at an early stage circumstances that may have a negative impact, and supporting them to develop strategies to avoid them or reduce their effects. There are national evidence-based clinical guidelines relating to the management of alcohol misuse.7,8 Scottish Intercollegiate Guidelines Network (SIGN) Guideline 74 defines hazardous drinking as the regular consumption of over 5 units per day for men and 3 for women, which contrasts with harmful drinking, a pattern of drinking that causes damage to

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The International Journal of Pharmacy Practice, February 2008

physical or mental health.7 This guideline is a national evidence-based clinical pathway covering all aspects of the management of hazardous drinking in primary care. There is strong evidence that short discussions or ‘brief interventions’ on alcohol, delivered in primary care settings, are both effective and cost-effective for hazardous and harmful drinkers.7,9 Typically the ‘brief intervention’ lasts between 5 and 20 minutes, sometimes with one short follow-up contact. The goal is to provide individuals with the tools to facilitate changes in attitudes and behaviours. The intervention uses a motivational approach and includes elements of: feedback about personal risk; emphasis on personal responsibility; advice to cut down or abstain; options for altering drinking patterns; empathetic interviewing and self-efficacy.7 The World Health Organization has produced a manual for primary care workers to deliver such interventions to those with alcohol-related problems.10 A meta-analysis of 19 randomised trials of reduction of alcohol consumption by brief interventions in primary care demonstrated a positive benefit in terms of reduction at 6 and 12 months.11 In addition brief interventions are heavily recommended in the SIGN guideline.7 The only published community pharmacy involvement in brief interventions for alcohol to date appears to be restricted to one community pharmacy.12 This lack of involvement is surprising given the recognised role and track record of community pharmacists’ involvement in public health.13 The argument for pharmacy involvement in addressing alcohol issues is strong, since an estimated 600 000 people visit a community pharmacy in Scotland each day, a walk-in facility accessed without an appointment, and 95% of the population does so at least once each year.9 Community pharmacies may well be the first port of call for clients with symptoms such as sleeping difficulties or feeling generally run-down, which can be alcohol related. Such clients may be reluctant to seek help elsewhere unless the condition has further deteriorated. There is considerable potential, therefore, for community pharmacists to contribute to changing the culture of hazardous drinking in the UK, by regularly and routinely enquiring about alcohol consumption as a potential contributory factor in these conditions. In addition, pharmacies are accessed by those seeking emergency hormonal contraception. Excessive alcohol consumption has been linked to the practice of unsafe sex,14 and a higher incidence of sexually transmitted infections, but current practice guidelines on the supply of emergency hormonal contraception in community pharmacies do not include guidance on addressing alcohol consumption.15 Finally, there is strong evidence of pharmacist intervention and positive outcomes in community pharmacy-based smoking cessation, using a motivational interviewing approach which is key to ‘brief interventions’.16 In the absence of previous work in this field, the aim of this project was to evaluate the feasibility and acceptability of the provision of brief interventions on alcohol in community pharmacies. The objectives were to: establish a pilot project in which trained community pharmacists initiate discussion of alcohol consumption with targeted pharmacy clients and screen, intervene or refer as appropriate; and to explore, with pharmacists and clients, the feasibility, acceptability and perceived value, and identify markers of good practice and formulate recommendations for future practice.

Methods All pharmacies in Greater Glasgow (n = 222) were informed of the study. From the 17 that were interested, a purposive sample of eight was selected on the basis of availability for training and to include maximum possible variation in terms of pharmacy type, deprivation index, location and local level of hospital admissions for alcohol misuse. Only pharmacies that had a ‘counselling area’ (a separate, enclosed space or room dedicated to patient/client consultations) were permitted to take part. A description of pharmacies involved is provided in Table 1. A two-day training course was provided for the pharmacists (n = 9) to prepare them to be able to screen clients for hazardous drinking and to intervene appropriately, where indicated, using the brief intervention framework. The training covered problem alcohol use in Scotland, attitudes to alcohol use, drinking guidelines, screening tools, motivational interviewing and brief intervention, how and where to refer clients and the study protocol. Thirteen medicine counter assistants also participated in a day of training to enable them to correctly identify possible clients for referral to the pharmacists to take part in the study. Post training, staff in the eight pharmacies were asked to recruit clients over the period from the middle of July to October, 2005. Standardised protocols were prepared to screen clients for hazardous drinking using FAST (the Fast Alcohol Screening Tool17) and to guide the intervention. FAST is a four-item questionnaire that is recommended in the SIGN guideline and has been used and validated in several primary and secondary care settings.17 Clients were recruited by pharmacy staff from four specific target groups as well as through posters (inviting the public to enquire about alcohol issues and highlighting the expertise available in the pharmacy) in pharmacies. The four target groups were chosen to include clients who reported health needs or issues in which alcohol consumption could be a contributory factor, and who would not generally be attending their medical practice in relation to the reported problem. These were clients seeking: emergency hormonal contraception; advice or products to address sleep difficulties; advice or products to address fatigue/lethargy/a feeling of being ‘run-down’; and advice or products to aid with smoking cessation/reduction. Clients who presented in one of the target groups, or who enquired about the project (because of the posters on display in the pharmacy) were given the opportunity to have a discussion with the pharmacist. The pharmacist then explained the nature of the research, and the potential relevance to the client’s presenting issue, and sought full informed consent. Clients who consented were then taken through the FAST screening process by the pharmacists and provided with a brief intervention as necessary. The reasons for their recruitment, result of screening and details of the ensuing discussion were recorded by the pharmacists on protocols which were then returned to the research team. Clients were also asked if they were happy to be followed up by telephone and, if so, they provided their name and contact details. On completion of the recruitment phase, two group interviews and a one-to-one interview were carried out with six of


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Table 1

Profile of participating pharmacies and pharmacists

Code

Pharmacist profile

Ae Be Cf D E F G Hf

SIMDa decile

Alcohol admissionsb

How busy?c

Description

M/F

First year on registerd

1 6 1 1 2 6 9 1

1473 368 2408 1991 1206 590 340 2408

250/350 70/130 150/250 420/620 200/400 180/300 100/200 300/500

Multiple Independent, rural village Independent, deprived urban area Independent in a health centre; few over-the-counter sales Independent, counselling room Independent in self-contained community, elderly clients Multiple Independent, deprived urban area, counselling room

M M F F Fg F F M

1989 1994 1998 1983 2005 2002 2003 1989

Scottish Index of Multiple Deprivation 2004 decile, 1 = highest deprivation; 10 = least deprivation. Hospital admissions for alcohol misuse – rate per 100 000 population: 1999–2002 c Pharmacists’ estimates of number of prescription items on quietest day/busiest day. d The Royal Pharmaceutical Society of Great Britain’s Register of Pharmaceutical Chemists. e These two statistics, A and B, are based on information for datazones from www.sns.gov.uk. f Pharmacies C and H were located on the same street and were linked such that the pharmacists in each pharmacy also worked at the other one. g Two pharmacists (E1 and E2) were trained from this pharmacy. E2 who implemented the project is described here. a

b

the eight participating pharmacists. In addition, one-to-one telephone interviews of between 5 and 16 minutes were carried out with 19 clients who had agreed to be followed up, and explored clients’ views on the acceptability and value of the project. A current FAST score was also recorded at follow-up with clients. All follow-up interviews were recorded electronically. Data from pharmacist and client follow-up were transcribed in full, and thematic analysis was carried out in relation to the key areas of interest, that is, feasibility, barriers/helping factors, acceptability and perceived effectiveness. The framework approach to data analysis was considered more suitable than other approaches (e.g. grounded theory), as the research started deductively from preset objectives and more structured data generation.18 Analysis was undertaken by one of the authors, NF, and all emerging themes and illustrative quotes were discussed and finalised by two authors, NF and DS. Data from questionnaires were analysed using descriptive statistics. This research was approved by the Research Ethics Committee of the Primary Care Division of NHS Greater Glasgow and Clyde. Signed, informed consent was obtained from all research participants including pharmacists and clients.

Results Client recruitment and screening

Seventy clients were recruited. Most clients (n = 46, 66%) were female. Of the 70 clients: 19 (27%) were seeking smokingcessation advice; 13 (19%) asked about posters/displays; 12 (17%) were feeling run-down/tired/lethargic or seeking a tonic/multivitamin/herbal remedy; 4 (6%) were seeking sleep aids; 2 (3%) emergency hormonal contraception; and 20 other/not recorded by pharmacists.

Of these 70: 30 (43%) were drinking hazardously (3–6 on FAST); and 7 (10%) were assessed as drinking harmfully (scoring 7 or more on FAST according to Hodgson R, personal communication). The frequency and nature of the interventions provided to clients following screening is described in Table 2. Forty clients in total agreed to be followed up, including 25 who had screened as hazardous or harmful drinkers. The average times per consultation were 9 minutes with clients in the non-hazardous/harmful drinking category (n = 29) and 12 minutes with those in the hazardous or harmful drinking categories (n = 30). The average for clients in the harmful drinking category was 16 minutes (n = 7).

Table 2 Number of clients screened as hazardous/harmful drinkers and interventions delivered by pharmacists Intervention

Hazardous Harmful (n = 30) (n = 7)

Feedback on screening and risks to health Explanation of sensible drinking and units in clients’ preferred drink(s) Discussion of pros and cons of current drinking pattern and link with presenting issue Discussion of options for cutting down Recommended to seek further advice Literature: Unit Calculator Wheel Literature: Alcofacts leaflet Literature: So You Want to Cut Down booklet Literature: Alcohol Support Services contacts No intervention recorded

22 (73%) 25 (83%)

5 (71%) 5 (71%)

18 (60%)

5 (71%)

16 (53%) 0 18 (60%) 12 (40%) 15 (50%) 1 (3%) 3 (10%)

5 (71%) 1 (14%)a 2 (29%) 1 (14%) 4 (57%) 0 1 (14%)

a

This client was referred to their GP. Other referral options given but not used by the pharmacists were the local community addiction team, Glasgow Council on Alcohol or Alcoholics Anonymous.


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Pharmacies recorded a further 39 clients who refused to take part, citing reasons including not drinking alcohol and insufficient time to participate, although it was clear that not all refusals were recorded.

Pharmacist follow-up results

Pharmacists reported no major problems such as aggression or strong negative reactions when recruiting clients. A number of possible explanations for the lack of negativity were given. “I think intuition. You’re not going to ask, I mean your sixth sense says ‘I’m not going to ask this person who’s going to clout me over the head’.” (pharmacist D) “I think probably most of them [the clients who took part] know myself and the staff so I think they were comfortable with us discussing it.” (pharmacist A)

Although none reacted badly, a mixed picture emerges as to how willing clients were to engage. It is not possible to get a clear sense of what proportion of people who were asked to take part actually agreed or refused to do so. “Although people were really interested [in our display of alcohol bottles] and asked ‘are you giving away free drink or something?’, in terms of people wanting to discuss what they drank it was one extreme to the other.” (pharmacist F) “The only people who . . . who were maybe a bit shocked [to be asked about their drinking] were older people, pensioners.” (pharmacist H)

Pharmacists reported difficulty in providing the service to as many clients as initially envisaged (40 clients in the hazardous/harmful drinking category each over 3 months), most commonly due to workload. Several commented that recruitment was facilitated by posters/displays, and focusing on clients attending the pharmacy as part of a smoking-cessation programme. Pharmacists felt that clients found their involvement in the project valuable. In particular, they commented that clients were previously unaware of some of the information and advice. “I’d say people aren’t used to being asked about their drinking habits and I think there is a lot of information you can actually provide for people. I think a lot of people were surprised as well at the sensible drinking limits . . . didn’t really think too much about binge drinking as being a problem.” (pharmacist C)

Although reactions were positive, pharmacists were unsure as to the impact on clients’ drinking behaviour. “Not everyone was really wanting to cut down even though they knew they were drinking more than was recommended. But I mean everyone I think learned something from it.” (pharmacist F)

Pharmacists felt that clients were generally honest about their consumption. “I definitely found everybody quite honest and open and I think people especially with all this publicity about pharmacies people do sort of see you as a health professional.” (pharmacist E2)

Client follow-up results

Of the 40 clients who agreed to participate in the follow-up, only 19 were contacted, despite repeated attempts. Nine of these screened as drinking hazardously at the time of the original intervention. Most reported being happy to have taken part and were generally positive about the experience. Some found it valuable as they were not previously aware of the sensible drinking guidelines. “I actually found it quite interesting. I’m not a great drinker, well I wouldn’t think so anyway, maybe a bottle of wine at the weekend . . . and that would last me the whole night and that would be me once a week. But I found it really interesting when she said that was actually coming under hazardous drinking.” (client D5)

Some commented on the non-judgemental style of the pharmacists and some that they knew the pharmacist and that this made it easier. Also mentioned were the clear explanations given and the privacy available in the pharmacy. A small number expressed less-positive reactions and, significantly, all of these had initially screened as hazardous or harmful drinkers. “I would say it would be worthwhile to other people but I didn’t really find it worthwhile. I don’t feel I’ve got a problem with alcohol.” (client G5)

Clients were asked for their views on the implementation of alcohol screening and interventions in community pharmacies in the future. In general, clients felt that it was a good idea because many people were not aware of how much they were drinking. The importance of privacy was referred to by more than one client.

Discussion This is the first research that has studied the feasibility of providing screening and interventions with hazardous or harmful drinkers in a number of community pharmacies. This study showed that the provision of screening and brief interventions in community pharmacies is feasible and acceptable to both clients and pharmacists. In summary, following training, community pharmacists conducted a short discussion about alcohol with 70 clients including screening using the Fast Alcohol Screening Tool. Where clients screened as drinking hazardously or harmfully, the pharmacists provided a brief intervention including advice about sensible drinking guidelines and alcohol units, appropriate literature and options for cutting down consumption. Follow-up data from pharmacists and clients indicate support for the service from both perspectives, although there were reservations around the best method of client recruitment and impact on drinking. As this research was planned as a feasibility study, it was important that those pharmacies that took part fulfilled the inclusion criteria. While the range of pharmacies that were selected encompassed urban, rural, small and large chains and a range of deprivation scores, it is not known whether they were representative of community pharmacies, thereby limiting


February 2008, The International Journal of Pharmacy Practice

the generalisability of the findings. In addition, it may be that the pharmacists who took part were particularly interested in this field and hence more likely to recruit clients. Similarly, those clients participating in the study may not be typical of the general community pharmacy-attending population. Although there was attrition of clients between recruitment and follow-up, those who were followed up included both those who required no intervention and those who were screened as hazardous drinkers. The details of client recruitment provided only limited information on the profile of clients involved for two reasons. It is clear from the number of clients for whom a reason for recruitment was not recorded and from the discussions with pharmacists in follow-up interviews that a large number of clients were recruited informally by assistants or pharmacists without necessarily falling into the target groups. This raises an important issue for future recommendations on this kind of intervention in this setting. In addition, the amount of missing data was relatively large given the size of the study and the motivation of the pharmacists. This issue has important governance-related consequences if the study/service were to progress. Our study placed particular emphasis on training prior to implementation providing two days of in-depth training on a range of issues related to screening and brief interventions. Training needs and associated resources have to be fully considered as part of any plans to extend this pilot. The SIGN guideline describes the importance of training to deliver brief interventions and the need to research whether or not training can increase service availability.7 The method of recruitment in relation to alcohol is especially important and requires careful consideration due to the sensitive nature of the topic. In this study, clients were recruited from four target groups for whom alcohol may be a contributing factor to their presenting issue, and interestingly almost one-fifth were recruited by posters/displays in the pharmacies. A key factor that complicated recruitment when compared with other public health interventions was that clients were largely unaware that their current drinking behaviour was likely to be hazardous and so were less likely to self-refer. Also, a high proportion of hazardous drinkers are not detected by other health professionals so referral to pharmacists from this route is also unlikely.19 This differs from smokers or those who are obese who may self-refer or be referred by other health professionals. Nonetheless, the posters/ displays used in the pharmacies provided an opportunity to unobtrusively raise clients’ awareness and encourage self-referral, and appeared to work very well. These methods need further exploration. In addition, there are many conditions that require prescription treatment for which clients would be attending a community pharmacy, which can be adversely affected by alcohol (e.g. diabetes, heart disease); however, for this pilot study these clients were not directly targeted as it was felt that their drinking may be already addressed by their general practitioner (GP) practice. The evidence would suggest however that this is not routinely done and that as many as 98% of excessive drinkers presenting to primary care are being missed.19 An argument could therefore be made that future similar work by pharmacists would also target appropriate prescription clients.

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The proportion of clients screened as drinking hazardously in our study is higher than reported in population studies, where 14% of women and 28% of men have been found to be exceeding weekly limits.20 This comparison should be made with caution as our study was not designed to quantify hazardous drinking. In addition, there have been no officially published figures relating to daily limits, which relate more closely to the FAST screening tool used. The reasons for these high figures for hazardous drinking are unknown; however, it is possible to speculate. These high figures may be due to the study design and nature of the screening process. In particular, pharmacists were encouraged to ask clients to describe their drinking in their own words, and the pharmacists then calculated the number of alcohol units they were consuming and completed the screening tool. As the pharmacists were carefully trained, they may have more accurately estimated consumption than if the clients had completed the screening tools by themselves or had simply been asked how many units they drink. As it is common for clients (and professionals) to underestimate unit calculations, this may have led to higher figures.21 The high numbers of clients recruited and screened positive for intervention is of paramount importance. In our feasibility study, this equated to almost one previously unknown hazardous/harmful drinker every 2 weeks which, extrapolated across to larger numbers of community pharmacies, has the potential to make a substantial contribution to reducing health problems due to alcohol misuse. The methods of intervention used in this study were similar to those recommended in the SIGN guideline, and the pharmacists were trained to refer clients to other agencies as appropriate. Hence it is likely that the clients in this study received the same standard of care as they would if identified through other means. The philosophy of this service is clearly in line with the pharmaceutical public health element of the new community pharmacy contract and has the potential to make a significant contribution to anticipatory care. Further work is necessary to determine the best way to approach clients, that is, whether posters and leaflets advertising the service are sufficient or whether pharmacists should raise the issue specifically with certain groups, and if so, which groups. If this feasibility project is to be implemented into practice on a large scale, then we need to determine the views and attitudes of community pharmacists in Scotland in general towards working with clients with drinking issues. Importantly, any further expansion must include measures of outcomes in terms of client drinking knowledge and level of consumption, encompassing an evaluation of the economic implications. Focus also needs to be placed on researching the most appropriate method of delivering training and remuneration for the pharmacists providing the service. While this research was based in Scotland, there are clear messages on a national and international level. In conclusion, this project has demonstrated that it is feasible for trained community pharmacists to recruit, screen and intervene with clients on alcohol issues as recommended by SIGN 74. On follow-up, pharmacists and clients were generally positive, although there were some issues, mainly relating to client recruitment and potential impact on drinking.


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Further work is required to test the generalisability of our findings and to measure the impact of this kind of service on clients’ alcohol consumption.

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