Practices, barriers and facilitators to the delivery of pretravel health services by community pharmacists: A scoping review using the theoretical domains framework

BACKGROUND

The involvement of community pharmacists (CPs) in the provision of pretravel health services is increasing due to the increase in international travelers, the increased risk of travel-related diseases, and the expansion of pharmacists' scope of practice in some countries. In order to improve the quality and effectiveness of pretravel health care provided by CPs, a greater understanding of the practices, barriers, and facilitators is required.

OBJECTIVE

This scoping review aimed to identify and describe existing studies on pretravel health services provided by CPs, and the barriers, and facilitators.

METHODS

The PubMed, Science Direct, Scopus, and Web of Science databases were searched for pertinent studies from their inception to February 2023. A manual search was also conducted of prominent travel medicine journals, Google Scholar, and the reference lists of the included studies. Potential barriers and facilitators were mapped to the 14 domains of the Theoretical Domains Framework (TDF).

RESULTS

There were twelve studies included in the review. Pretravel health advice was the most prevalent form of pretravel health services. Within ten domains of the TDF, various factors that either facilitate or impede the provision of pretravel health services by CPs were identified.

CONCLUSION

The provision of pretravel health services by CPs may be affected by a number of practitioner and organizational factors. The provision of pretravel health services can be facilitated by informational resources, training and education in travel medicine, and collaboration amongst healthcare providers.

Community-Based Pharmacy Travel Health Service Pilot Impact on Participant Understanding and Satisfaction

BACKGROUND

Increased rates of international travel have led to a higher demand for healthcare professionals to provide travel health services. Community-based pharmacists are capable of meeting this need.

OBJECTIVE

This study evaluates the impact of pharmacists providing travel health services in a community-based pharmacy on participant understanding and satisfaction of travel education and preparation.

METHOD

A trained pharmacist met with participants to review their medical history, travel itinerary, and provide education. Indicated immunizations were administered and the participant's primary care provider was contacted if prescription medications were warranted. A questionnaire was administered before and after the travel health consultation assessing participants perceived understanding of travel health information, satisfaction, and perceived monetary value of the service. Data were collected by 5-point Likert-scale responses, with 5 equivalent to strongly agree. Wilcoxon signed-rank test and descriptive statistics were used for evaluation. Participants were included if they had international travel planned within 12 weeks of the consultation.

RESULTS

A total of 12 participants were included. Participant understanding significantly increased for all 5 survey items relating to travel health information with a p value < 0.05 for each item. The largest change was for how to find medical help during international travel (medians and IQR were 3(2-3), and 5(5-5) for pre-and post-consultation, respectively, p = 0.003). Participant satisfaction questions received a median response of 5. Participants' perceived monetary value of the service was a median of $50 (IQR $50-50).

CONCLUSION

Pharmacist-led travel health consultations improved participant understanding of travel health information and was of perceived value.

Types and outcomes of pharmacist-managed travel health services: A systematic review

BACKGROUND AND AIM

Pharmacists have an important role in providing travel health services and medications to travelers. However, given the limited literature on this topic, the aim of this study is to systematically review the types and outcomes of pharmacist-managed travel health services.

METHODS

A comprehensive literature search was performed in four electronic databases, namely Scopus, Web of Science, PubMed and ProQuest to identify studies published in English from 1999 to July 2022. The inclusion criteria included the studies that reported an experience of providing dedicated travel health services by pharmacists and reported the outcomes and/or evaluation of these travel health services.

RESULTS

Nine studies were identified from the literature and included in the review. The pharmacists have provided a wide range of general and specialized travel health services including pre-travel risk assessment, routine and travel-related vaccination service, prescribing or recommending medications for travel-related illnesses, counseling and travel health advice. Overall, 94-100% of the patients were satisfied or very satisfied with pharmacist-managed travel health services. In addition, a good acceptance rate of pharmacist recommendations for vaccines and travel-related mediations was reported with most studies reporting an overall acceptance rate of ≥75% (acceptance rate range: 48%-94.2%). In addition, high rates of acceptance of other nonpharmacological advices were noted.

CONCLUSION

Pharmacists with training in travel medicine have successfully provided a wide range of general and specialized travel health services. Most travelers were highly satisfied with the pharmacy-based travel health services and accepted the pharmacist recommendations.

Use of research evidence varied in efforts to expand specific pharmacist autonomous prescriptive authority: an evaluation and recommendations to increase research utilization

BACKGROUND

An expanding body of literature shows that pharmacists' interventions improve health outcomes and are cost-saving. However, diverse state regulations of pharmacists' scope of practice create a discrepancy between what pharmacists are trained to do and what they legally can do. This study investigated how stakeholders utilized research evidence when developing expanded scope of practice policies in their respective states.

METHODS

Using autonomous pharmacist prescriptive authority as a surrogate for general pharmacist scope of practice, a general policy document analysis was performed to understand the scope of practice landscape for pharmacists across the United States. Next, semi-structured interviews with policy-makers and pharmacy advocates were conducted to explore how the identified states in the policy document analysis utilized evidence during the policy-making process. Investigators analysed findings from the transcribed interviews through application of the SPIRIT Action Framework. Resulting codes were summarized across themes, and recommendations to researchers about increasing utilization of research evidence were crafted.

RESULTS

Sixteen states with 27 autonomous pharmacist prescriptive authority policies were identified. Public health need and safety considerations motivated evidence engagement, while key considerations dictating utilization of research included perceptions of research, access to resources and experts, and the successful implementation of similar policy. Research evidence helped to advocate for and set terms for pharmacist prescribing. Barriers to research utilization include stakeholder opposition to pharmacist prescribing, inability to interpret research, and a lack of relevant evidence. Recommendations for researchers include investigating specific metrics to evaluate scope of practice policy, developing relationships between policy-makers and researchers, and leveraging pharmacy practice stakeholders.

CONCLUSIONS

Overall, alignment of researcher goals and legislative priorities, coupled with timely communication, may help to increase research evidence engagement in pharmacist scope of practice policy. By addressing these factors regarding research engagement identified in this study, researchers can increase evidence-based scope of practice, which can help to improve patient outcomes, contain costs, and provide pharmacists with the legal infrastructure to practise at the top of their license.

Expanding pharmacists' roles: Pharmacists' perspectives on barriers and facilitators to collaborative practice

OBJECTIVE

The pharmacy profession is shifting from transactional dispensing of medication to a more comprehensive, patient-centered model of care. Collaborative practice agreements (CPAs) extend the role of a pharmacist to initiate, monitor, modify, and discontinue drug therapies and provide other clinical services. Although collaborative practice has been shown to improve health system efficiency and patient outcomes, little is known about how pharmacists perceive CPAs. To explore pharmacists' perspectives of CPAs, including barriers and facilitators to CPA implementation.

METHODS

Semistructured key informant interviews were used to elicit information from licensed pharmacists practicing in a variety of settings in Arizona. Thematic analysis was used to identify key qualitative themes.

RESULTS

Seventeen interviews of pharmacists with (n = 11, 64.7%) and without (n = 6, 35.3%) CPAs were conducted in April-May 2019. The pharmacists saw their role in CPAs as supportive, filling a care gap for overburdened providers. A heightened sense of job satisfaction was reported owing to increased pharmacist autonomy, application of advanced knowledge and clinical skills, and ability to have a positive impact on patients' health. Challenges to the implementation of CPAs included liability and billing issues, logistic concerns, some experiences with provider hesitancy, and lack of information and resources to establish and maintain a CPA. The barriers could be overcome with conscious team-building efforts to establish trust and prove the worth of pharmacists in health care teams; strategic engagement of stakeholders in the development of CPAs, including billing and legal departments; and mentorship in the CPA creation process.

CONCLUSIONS

The pharmacists in this study enjoyed practicing collaboratively and had overall positive perceptions of CPAs. As health worker shortages become more dire and pharmacy practice evolves to expand the role of pharmacists in providing direct patient care, CPAs will be an important tool for restructuring care tasks within health systems.

Travel Medicine Curricula across Canadian Pharmacy Programs and Alignment with Scope of Practice

Limited research exists on pharmacy students’ training in travel medicine, and how this aligns with scope of practice. This research aimed to detail travel medicine education across pharmacy programs in Canada and map this against the scope of practice for pharmacists in each university’s jurisdiction. A survey based on the International Society of Travel Medicine’s Body of Knowledge was developed and distributed to all Canadian undergraduate pharmacy schools to identify topic areas taught, teaching modalities utilized, and knowledge assessment performed. Educational data was collected and analyzed descriptively, and compared to pharmacists’ scope of practice in the province in which each university is located. Training provided to students varied significantly across universities and topic areas, with topics amenable to self-care (e.g., traveller’s diarrhea and insect bite prevention) or also encountered outside of the travel context (e.g., sexually transmitted infections) taught more regularly than travel-specific topics (e.g., dengue and altitude illness). No apparent relationship was observed between a program’s curriculum and their provincial scope of practice. For example, training in vaccine-preventable diseases did not necessarily align with scope related to vaccine administration. Alignment of education to current and future scope will best equip new practitioners to provide care to travelling patients.

Development and Testing of a Clinical Practice Framework for Pharmacists to Assess Patients' Travel-Related Risks: The 5W Approach to Travel Risk Identification

Objective: To assist with identifying patients who may be managed by pharmacists without additional travel medicine training, versus those who may benefit from referral, we developed and validated a clinical practice framework. This framework was then piloted in eight pharmacies in Ontario, Canada, from March to August 2019. Methods: A panel of experts, comprised of physicians and pharmacists from Ontario, Canada, holding a Certificate in Travel Health^TM from the International Society of Travel Medicine was recruited. This panel participated electronically in the development of the framework in three stages: (1) Sharing their current approach when performing information gathering and assessing risk in a traveling patient; (2) judging of items collated from all panellists on the basis of how essential they are to a risk assessment; and (3) validation of items deemed essential by the panel using the Item and Average Content Validity Index. The framework was then released to community pharmacies, where pharmacists that self-identified as beginners to travel medicine completed pre- and post-test phase surveys to determine the utility of the framework. Key Findings: A total of 64 items for consideration were deemed essential enough to proceed to content validation, organized into 5 ‘W’ domains: Who, What, Where, When, and Why. Each item was ranked by the experts according to its relevancy, resulting in an Average-Content Validity Index of 0.91. The resulting framework was titled “The 5W Approach to Travel Risk Identification.” This clinical practice framework is the first published assessment tool for travel medicine tailored for pharmacy’s scope of practice that has been content validated. Pharmacists reported that the framework is simple to use and provides structure for interactions with travelling patients. However, it may not be as beneficial for those with a higher level of travel medicine expertise than the average pharmacist. Conclusion: The 5W Approach tool allows pharmacists inexperienced in travel medicine to collect information when required to use their professional judgement when assessing traveling patients as either high-risk (requiring a referral to a travel medicine specialist) or low-risk. With the aim of supporting pharmacists to be more confident in caring for traveling patients and increasing their involvement in travel medicine, future research will test this framework for feasibility in Canadian community pharmacy practice.

Community-Based Pharmacy Practice Innovation and the Role of the Community-Based Pharmacist Practitioner in the United States

Community-based pharmacy practice is evolving from a focus on product preparation and dispensing to becoming a health care destination within the four walls of the traditional community-based pharmacy. Furthermore, community-based pharmacy practice is expanding beyond the four walls of the traditional community-based pharmacy to provide care to patients where they need it. Pharmacists involved in this transition are community-based pharmacist practitioners who are primarily involved in leading and advancing team-based patient care services in communities to improve the patient health. This paper will review community-based pharmacy practice innovations and the role of the community-based pharmacist practitioner in the United States.

Travel health-related activities and services provided by community pharmacies in Selangor, Malaysia: A cross-sectional analysis

BACKGROUND

Millions of tourists visit Malaysia annually while a large number of Malaysians travel overseas. Taking care of travellers' healthcare needs is important aspect of the healthcare system. Community pharmacies are ideally positioned to provide travel health-related services. However, studies are lacking in this area. Therefore, this study aims to explore the nature and type of travel health-related services provided by Malaysian community pharmacies.

METHODS

A survey was carried out at 135 community pharmacies in nine districts of Selangor, Malaysia, from November 2017 to February 2018, using a self-administered standardized questionnaire.

RESULTS

The majority (n = 95, 85%) of community pharmacies reported to have provided services to both international travellers and outbound Malaysian travellers. The common healthcare services provided to international travellers were monitoring of chronic diseases including hypertension and diabetes, and advice on minor ailments, supplements and medical devices. The key health services provided to outbound Malaysian travellers were advice on vaccination requirements, better management of chronic diseases and necessary medications to manage illness during travel. Most of the respondents supported the provision of travel health-related services through the community pharmacies.

CONCLUSION

The study findings showed that Malaysian community pharmacies provided several travel health-related services to both international and Malaysian outbound travellers. Pharmacists in Malaysia are ideally positioned to have an increased role in travel medicine. They have the training to advise on complex medication issues especially with regard to interactions and polypharmacy. However, further training and courses should be provided that are tailored specifically for the needs of this professional group.

Pharmacy Travel Health Services in Canada: Experience of Early Adopters

Since 2007, community pharmacists in Canada have become increasingly involved in delivering Travel Health services, including the recommendation and administration of vaccines. This qualitative scoping survey examines some of the activities and opinions of those early pharmacist adopters delivering these services. A Survey Monkey free text questionnaire was emailed to pharmacists who were involved in delivering travel medicine services. 21 pharmacists responding represented seven Canadian provinces. Only 5 pharmacists estimated that they were seeing five or more patients a week on average. Amongst the challenges they faced the most quoted was lack of time when running a busy pharmacy (62%) a lack of prescribing authority, (52%), and lack of access to public health vaccines (52%). ‘Word of mouth’ was widely quoted as a means of developing the service, indicating a good patient satisfaction. Also expressed were the advantages of convenience in terms of being a ‘one stop shop’, ease of billing to insurance companies and convenient appointment times. There are a number of challenges which are still to be faced which may be resolved by further legislation allowing access to public health vaccines and more widespread prescribing rights. The relatively low level of consultations reported by some is of concern if those pharmacists are to maintain competence.

Uptake of Travel Health Services by Community Pharmacies and Patients Following Pharmacist Immunization Scope Expansion in Ontario, Canada

In December 2016, pharmacists in Ontario, Canada with authorization to administer injections saw an expansion in their scope from a restriction to the influenza vaccination only to now including an additional 13 vaccine-preventable diseases, largely those related to travel. It was uncertain whether this change in scope would see sufficient uptake, or translate to a corresponding expansion in other travel health service offerings from community pharmacies. In October/November 2017 a survey was conducted of all licensed community pharmacists in Ontario, followed by semi-structured interviews with 6 survey respondents in June 2018. A web-based survey of members of the public from a single region of the province was also conducted in September 2018 to assess uptake of expanded vaccination services. Broad variability in uptake of these services was noted, ranging from the dispensing of travel-related medications and vaccinations only through to vaccine administration and prescribing under medical directive; however, uptake was generally at the lower end of this spectrum. This was evidenced by 94% of pharmacists reporting administering fewer than 10 travel vaccinations per month, fewer than 10% of patients reporting receiving a travel vaccine administered by a pharmacist, and a maximum of 30 pharmacies (of nearly 6000 in the province) designated to provide yellow fever vaccinations. Fewer than 1 in 3 pharmacists reported performing some form of pre-travel consultation in their practice, often limited to low-risk cases only. Barriers and facilitators reported were similar for these services as they were for other non-dispensing services, including insufficient time to integrate the service into their workload, perceived lack of knowledge and confidence in travel health, and low patient awareness of these new services available to them through community pharmacies.

Pharmacy-Based Travel Health Services in the United States

The aim of this paper is to review pharmacy laws and regulations, pharmacist training, clinic considerations, and patient care outcomes regarding pharmacy-based travel health services in the United States. Pharmacists and pharmacies in the United States are highly visible and accessible to the public, and have long been regarded as a source for immunization services. As international travel continues to increase and grow in popularity in this country, there is a pressing need for expanded access to preventative health services, including routine and travel vaccinations, as well as medications for prophylaxis or self-treatment of conditions that may be acquired overseas. In the United States, the scope of pharmacy practice continues to expand and incorporate these preventable health services to varying degrees on a state-by-state level. A literature review was undertaken to identify published articles on pharmacist- or pharmacy-based travel health services or care in the United States. The results of this paper show that pharmacists can help to increase access to and awareness of the need for these services to ensure that patients remain healthy while traveling abroad, and that they do not acquire a travel-related disease while on their trip. For those pharmacists interested in starting a travel health service, considerations should be made to ensure that they have the necessary training, education, and skill set in order to provide this specialty level of care, and that their practice setting is optimally designed to facilitate the service. While there is little published work available on pharmacy or pharmacist-provided travel health services in the United States, outcomes from published studies are positive, which further supports the role of the pharmacist in this setting.

Pharmacy-Based Travel Health Services: State Approaches to Prescriptive Authority

Pharmacists have provided travel health services in some capacity for more than 25 years. The ability of pharmacists to autonomously prescribe travel medications is growing. Three states (California, Idaho, and New Mexico) allow pharmacists to autonomously prescribe medications for international travel using the Centers for Disease Control and Prevention Yellow Book as a guide. Idaho also allows pharmacists to autonomously prescribe select medications appropriate to domestic travel (motion sickness prevention and Lyme disease prophylaxis), and Florida allows for the prescribing of drugs for motion sickness. Core elements from each state law including education, patient assessment, provider notification, and documentation are reviewed.

Pharmacy travel health services: current perspectives and future prospects

Rates of international travel are increasing annually, with particular growth observed in travel to Southeast Asia and to emerging economies. While all patients traveling across geographic regions are recommended to receive a pre-travel consultation to consider their individual risks, many do not, or receive care and recommendations that are not consistent with current evidence-based guidelines. As experts in drug therapy, and given the largely preventive nature of most travel health recommendations, pharmacists are well suited to help address this need. Pharmacists generally possess a high degree of knowledge and confidence with more commonly observed travel health topics in community practice such as travelers' diarrhea; however, training in more specialized travel health topics such as travel vaccinations and traveling at altitude has generally been lacking from pharmacy curricula. Pharmacists with an interest in providing pre-travel consultations are encouraged to pursue additional training in this specialty and to consider Certificate in Travel Health designation from the International Society of Travel Medicine. Future roles for pharmacists to include the prescribing of medications and vaccines for travel and the in-pharmacy administration of travel vaccinations may improve patient access to pre-travel consultations and recommended preventive measures, improving the health of travelers and potentially reducing the burden of communicable disease worldwide. Pharmacists providing travel care to patients are also reminded to consider noninfectious risks of illness and injury abroad and to counsel patients on strategies to minimize these risks in addition to providing drug and vaccine recommendations.

Clinical outcomes and satisfaction with a pharmacist-managed travel clinic in Alberta, Canada

BACKGROUND

In Alberta, Canada, authorized pharmacists may prescribe medications and vaccines and administer injections. Some have implemented travel clinics to meet the growing demand for pre-travel consultations. As a new service, the outcomes of independent pharmacist-performed pre-travel consultations is unknown.

METHODS

Chart review and post-travel surveys were performed among a convenience sample of patients presenting to a pharmacist-managed travel clinic for consultation. Data collected included patients' travel plans, recommendations for vaccines and other prescription and non-prescription drugs and adherence to these recommendations, satisfaction with the service, and health issues experienced during travel.

RESULTS

103 patients participated in the study. The overwhelming majority (79%) of recommended vaccinations were administered in clinic. The post-travel questionnaire was completed by 76% of patients, with 94% of these reporting being satisfied or very satisfied with the care received. Health issues during travel were infrequent, with gastrointestinal illness most common. Of those patients who experienced any health issue during their trip, 93% felt adequately prepared to manage the condition.

CONCLUSIONS

This study reports positive patient satisfaction and health status while travelling following a pharmacist-performed pre-travel consultation including authorization to prescribe and to administer vaccines. These results support the continued expansion of pharmacists' scope in this area.