Public Health in Community Pharmacy Fiona Macfarlane BSc MPH Health Promotion Officer NHS Forth Valley Who I am What my role is – Supporting oral health improvement in NHS Forth Valley – Early Years, Schools, Vulnerable and Homelessness, Prisons, Workplace and Community settings Why research? – This research was conducted in part fulfilment of the Master of Public Health degree. Public Health in Community Pharmacy: The experiences and perceptions of Community Pharmacists in NHS Forth Valley involved in delivering an innovative oral health intervention with clients accessing substance misuse services.

Background Scottish Executive – Dental Action Plan (2005)1 NHS Forth Valley – Dental Health Strategy (2005)2 1 Year Pilot - Oral Health Initiative in Community Pharmacy (2007- 2008) Pilot Service Evaluation and Client Experiences The Scottish Executive. An Action Plan for Improving Oral Health and Modernising the NHS Dental Services in Scotland. Edinburgh: The Scottish Executive; 2005 NHS Forth Valley. Multi-agency and Dental Health Strategy for NHS Forth Valley. Stirling: NHS Forth Valley; 2005 Scottish Executive -Dental Action Plan – An Action Plan for Improving Oral Health and Modernising the NHS Dental Services in Scotland “ to develop and deliver oral health care preventative programmes for adults most in need … eg homeless and prisoners” Reducing oral health inequalities and improving oral health NHS FV Strategy – “to support health improvement around substance misuse” “develop programmes targeting vulnerable groups” “support community pharmacists in oral health improvement” Oral Health and Substance Misuse- Significantly higher prevalence of dental caries and periodontitis amongst the substance misuse clients than the general population. Social, economic, lifestyle and pharmacological factors contributing to poor oral health in this group. Consumption of high calorific food increases = magnified tooth decay and loss. Methadone doesn’t have the same analgesic properties and therefore clients experience toothache and pain after commencing methadone - Blame oral health status on substance misuse Study revealed that targeting oral health advice and education is appropriate for substance misuse and that dental health is the most commonly discussed problem and the one most would currently like support. Recovering substance misuse clients placed a great importance on health, particularly oral health and wanted to improve it.

Background Scottish Executive – Dental Action Plan (2005)1 NHS Forth Valley – Dental Health Strategy (2005)2 1 Year Pilot - Oral Health Initiative in Community Pharmacy (2007- 2008) Pilot Service Evaluation and Client Experiences 1 year pilot – development and agreement with Local Contractors Committee. Rolled out to Pharmacies in November 2007. Aim – to utilise the continued and frequent contact between community pharmacists and methadone treatment service users to improve oral health knowledge and oral health outcomes. Objectives – Promote oral health, provide information and practical materials, offer regular and consistent advice and support, maximise the role of pharmacists . 93% of pharmacies providing substance misuse services signed up to the intervention serving approximately 600 clients. Intervention – delivery of oral health packs 4 times per year (every 3months, in line with the recommendation to change toothbrush approx every 3 months). Providing toothbrush, toothpaste appropriate strength 1450ppmf, chewing gum with XYLITOL, grab bags with oral health messages and an information leaflet. Key oral health messages centred around these themes and were developed into the following messages Toothbrushing, Drinks, Snacks, Sugar Free Gum and Visiting the dentist - Brush your teeth twice a day the right way (spit don’t rinse, dry toothbrush, pea size of toothpaste) - Choose sugar free drinks and snacks between meals (water and milk, cut down on fizzy juice, choose sugar free, eat more fruit, vegetables, starchy carbohydrates and keep sweet /sugary food to mealtimes) - Chew sugar free gum after eating or drinking (Chew after eating or drinking, recommend chewing gum after taking methadone) Visit the dentist regularly (dependent on individual but generally 6 – 12 months)

Background Scottish Executive – Dental Action Plan (2005)1 NHS Forth Valley – Dental Health Strategy (2005)2 1 Year Pilot - Oral Health Initiative in Community Pharmacy (2007- 2008) Pilot Service Evaluation and Client Experiences Service and Client Evaluation – Conducted approximately 2 months following the delivery of the oral health materials, 4 times in the pilot year, 3 pharmacies involved in the evaluation (Falkirk, Clacks and Stirling). 70 clients seen during the evaluation (44 x 1, 19 x 2, 6 x 3 and 1 x 4) 1st Evaluation - 28% of clients recalled some advice ( not to rinse, brushing important), many didn’t remember what they were told. Brushing once a day common. The clients said that the intervention was a good idea – bringing oral health to people’s attention 2nd Evaluation – 51% of clients recalled some of the advice (mixture of clients brushing daily, majority twice a day) The second delivery emphasis was changed to the way to use toothpaste. More messages being recalled about toothbrushing advice - not rinsing with water, amount of toothpaste to use. Although knowledge was changing behaviours hadn’t changed for some and they recognised that by saying ‘ the message is brush twice a day bit I still brush once’. The clients reported the intervention ‘makes them more proactive to brush’ and that ‘they trust the pharmacist for advice’ 3rd Evaluation – The questions were amended to find out if the clients remembered how many important messages they had been told about, what they know about looking after your teeth and mouth, and what they know about using toothpaste. Message 1 – ‘Brush your teeth twice a day the right way’ was the most remembered message amongst the clients followed by ‘Chew sugar free gum after eating or drinking’. 85% of the clients knew important reasons for chewing sugar free gum. The clients expressed that the initiative was a good idea, as its not seen as a priority for people, good to be reminded. 4th Evaluation – 47% of clients said they could remember how many messages they had been told about, 53% of clients remembered being told about the best way to use toothpaste. 84% knew why it was important to chew sugar free gum Receiving health messages in the pharmacy was perceived as positive by the clients There were positive behaviour changes made by some of the clients since the project started – Some are cleaning their teeth more regularly, going to the dentist, others brushing now when they weren’t before

The experiences and perceptions of Community Pharmacists in NHS Forth Valley involved in delivering an innovative oral health intervention with clients accessing substance misuse services.

Objectives To explore the community pharmacists’ perceptions of their public health role in contributing to health improvement amongst substance misuse clients To identify factors that influence community pharmacists participation in public health interventions To explore the experiences of community pharmacists who delivered oral health interventions to substance misuse clients Literature review – Community Pharmacists, Public Health and Health Promotion Community Pharmacists Role in Substance Misuse Changing attitudes towards Substance Misuse clients and services Community Pharmacists as Dental Health Advisors

Objectives To investigate the perceptions and attitudes towards oral health improvement with substance misuse clients To determine if community pharmacists believe they can engage effectively with substance misuse clients to affect health behaviour and behaviour change related to oral health improvement To investigate if community pharmacists are appropriately placed to deliver oral health improvement with substance misuse Presenting the results of the last 4 objectives . Focussed on the intervention.

Method / Data Collection Qualitative Methodology Non random sampling Semi- structured interview schedule Face to face interviews Analysis and Interpretation Data transcription Thematic analysis and coding Ethical Approval University of Glasgow Faculty of Medicine Ethics Perceptions and experiences – Subjective accounts Theoretical approach – phenomenology – iterative process of data collection and analysis which identifies emerging themes from the data to understand and interpret the phenomenon Interpretation – the data was used to support theories and generate new theories. Adopted a systematic and rigorous approach to data analysis – transcripts analysed in line with the question pathway – assigned codes /categories to sections of data

Experiences and Perceptions Good Idea, Beneficial, Raised Awareness “A lot of them with regards to the oral health, you know, have mentioned about their teeth and they’ve had problems with, you know dental work and stuff so obviously the oral hygiene initiative is a good idea” Pharmacist 12 Overall the experiences and perceptions were positive – the pharmacists reported the intervention was a good idea, beneficial, and raised awareness Nearly ¾ reported that the initiative was a good idea. Though it was also acknowledged that a lot of the clients had been on methadone for a long time and that the intervention may be too late for some.

“I think…it may be of benefit [to] one of two cases out of the 6 in our particular case…” Pharmacist 13 “I think it just reminds them. I think they are all becoming a lot more aware of their oral health” Pharmacist 16 Thought to be beneficial for some clients however there will always be people in the population who are not influenced by health improvements Relationships – frequency of contact allows trust and relationships to develop “I think it’s well received, from my experience obviously when they are coming in everyday, most of them, we’ve got a good rapport with them so – and it builds up relationships” Pharmacist 4

Intervention / Service Delivery Easy to deliver and well organised “It is quite an easy way that it’s been set out. Its quite easy to give the information… simple and straight forward and not time consuming that’s the kind of things we need” Pharmacist 4 Practicability of delivery – Easy to deliver and Well organised,

“It’s been, I think, very well organised… it’s been very straightforward and very easy to do… I think it’s been made very easy for me to do…” Pharmacist 13 Remuneration – The pharmacists are remunerated for providing the intervention. Service provision is influenced by time and remuneration however participation in the oral health intervention was not seen to be influenced by remuneration/ time Independent pharmacists may be feel the remuneration issue more than multiple chains. “it’s not my own shop but I believe [the company] are quite happy with that. They see the payments going through… yeah it seems reasonable the payment that we’re receiving but that’s not my first focus” Pharmacist 6 Repetitive - 3 pharmacists thought it was slightly repetitive for clients – “you’re giving them the same messages that they had the last time and then their enthusiasm weans a bit” Pharmacist 2 2 pharmacists mentioned wasting resources with reference to the oral health materials and money being spent on the client group

Engagement / Attitude Three quarters of pharmacists involved other staff in the delivery of the intervention Staff engagement was viewed positively by the pharmacists Mixed perceptions of client engagement It’s just a freebie? Nearly ¾ of the pharmacists had involved other staff members in the delivery of the intervention although some chose not to involve other staff members. “ I just found it easier and like I said I knew who I’d given it too… it was best if I just did it ‘cause then I knew it was done” Pharmacist 7 All of the staff involved. “I mean it is really just the … you know the counter assistants that have been involved … they would build up a good relationship with the clients” Pharmacist 9 Staff engagement was viewed positively by the pharmacists and it was commented that the pharmacy staff were able to deliver the advice in a less clinical and formal way. Perceptions of client engagement – Some positive and negative perceptions. It was felt that some of the clients listened to the advice though some appeared not to engage “ … I think that the message seemed to get through to them that if they did something to take care of their teeth then it could minimise the problems” Pharmacist 15 Despite the largely positive attitudes some pharmacists commented that it was just seen as a freebie “they are always quite positive about it but then they are getting something for free…” Pharmacist 1

Effectiveness Over half reported that the model was ‘effective’ or ‘very effective’ “They are guaranteed to come in for their methadone … utilising the pharmacists is the most effective way of doing it” Pharmacist 7 The remaining pharmacists reported that it was ‘fine’ “I think it has been a very effective model” Pharmacist 4

Impact on Client Attitudes and Behaviours Some perceived impact on client attitudes and behaviours “I think its had a good impact, I think it just remind them … they are more aware of their health and oral health especially… I think it’s had a positive impact definitely” Pharmacist 16

“… It did have an impact, I wouldn’t say it was enormous, probably I would say significant” Pharmacist 1 “Hopefully we’ve maybe changed some of their attitudes… sort of dispelled their theories on oral health and methadone… I think we must have made an impact” Pharmacist 10

“… they’ve been coming here for while so they’re like ‘oh yes, I don’t wet the toothbrush’ and you know it seems that they’re remembering what you’ve told them” Pharmacist 12 Dental Registration - 4 Pharmacists acknowledged that the intervention had influenced clients to seek dental appointments and registration “I’ve managed to get a couple of them registered with a dentist, which is positive” Pharmacist 16 “it has led to a lot of clients maybe seeking appointments with dentists you know, just thinking about their oral health, especially it’s maybe the last thing they come to although but everyone get the toothache and pain” Pharmacists 6 The overall perception was that there was some impact, but that the size and nature of the impact was unknown. Pharmacists reported that clients were asking for oral health materials leading them to believe that they were being used by clients.

Appropriateness All of the pharmacists believed they were appropriately placed to engage and deliver the oral health intervention Recurring themes Regular / frequent contact Existing relationship Accessibility of the pharmacy

“ We’re best placed really, if we are seeing them everyday “ We’re best placed really, if we are seeing them everyday. That’s really the only healthcare professional they’re going to be seeing on a regular basis” Pharmacist 4 “I think that this is more than appropriate … we’re a bit of continuity for them and we do see them most regularly…” Pharmacist 16 Utilising a similar model for other health topics - “I wouldn’t dismiss it as a route for using to pass on other health information messages” Pharmacist 15 “I think it would be quite useful for them” Pharmacist 10

Summary Good idea, beneficial, raised awareness and influenced the behaviours and attitudes of some clients Simple and straightforward to deliver, well organised and not time consuming Largely positive experiences of the intervention Community pharmacists feel appropriately placed to deliver the intervention Could be adopted to address other health issues with this client group

Contact Details Fiona Macfarlane Health Promotion Officer NHS Forth Valley Tel. 01786 442940 Email. Fiona.macfarlane2@nhs.net