LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF PHARMACY
DEPARTMENT OF DRUG TECHNOLOGY AND SOCIAL PHARMACY
NATALI BABAEV
HYPERTENSION PATIENT PERCEPTION AND EXPERIENCE OF PHARMACIST ROLE IN HEALTH PROMOTION IN ISRAEL
Master‘s Thesis
Thesis Supervisor: PhD Jurgita Daukšiene
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF PHARMACY
DEPARTMENT OF DRUG TECHNOLOGY AND SOCIAL PHARMACY
APPROVED by
Dean of the faculty of Pharmacy Prof. Ramunė Morkūnienė
HYPERTENSION PATIENT PERCEPTION AND EXPERIENCE OF PHARMACIST ROLE IN HEALTH PROMOTION IN ISRAEL
Master Thesis
Thesis Supervisor PhD Jurgita Dauksiene
Reviewer The thesis performed by
Name, Surname, signature Natali Babaev
KAUNAS‚ 2018
TABLE OF CONTENTS
SUMMARY ………...4
KEYWORDS………...8
ABBREVIATIONS………....9
INTRODUCATIONS………...10
AIM AND TASK………...11
1. LITERATURE REVIEW………..………...12
1.1 The benefits and aim of Health Promotion …………..………...….12
1.2 Community pharmacy…..……….13
1.3. High Blood Pressure………..………....15
2. MATERIAL AND METHOD………...23
2.1 Research organization………....23
2.2 Setting and sample………...23
2.3 Data collection………....26 2.4 Study questionnaire………... 26 2.5 Data analysis………..26 3. RESULTS……….……28 4. DISCUSSION………..38 5. CONCLUSION………40 6. RECOMMENDATION……….……..41 7. REFERENCES……….…....42 8. APPENDIX………...………...…46 3
SUMMARY
My name is Natali Babaev, I am a master student at the pharmacy faculty. I chose to do my thesis at drug technology and social pharmacy department under the supervision of PhD Jurgita Dauksiene.
Aim. This study was aimed to assess hypertension patient's perception and experience of pharmacist role in health promotion in Israel.
Background. Hypertension is defined as either a sustained systolic blood pressure or greater than 140 mm Hg or a sustained diastolic blood pressure of greater than 90 mm Hg. Prevention is an important object in which the pharmacists should take a part. Pharmacists are as healthcare professionals who practice in pharmacy, the field of health sciences focusing on safe and effective medication use. Pharmacists have been identified as being well-placed to perform a health promotion role. Health promotion has defined by the “World Health organization” (WHO) as a process that gives people the ability to increase the control and to improve their health. In this study I would like to determine the perception and experience of hypertensive patients from the pharmacists' role in health promotion in Israel, as there seems to be a gap around this topic in Israel.
Method. Data were collected by cross- sectional survey. A method of the questionnaire was chosen. Only hypertensive patients who enter pharmacy shop, and agreed to participate in the study, answered the questions in a face to face interview. The pharmacy shop is located in "Ashdod", my home city.
157 questionnaire had to be asked within 30 days, between the 7th of May, 2017 until the 6th if June, 2017, but only 125 patients agreed to participate in the survey.
Questions about the sources of information, the role of the pharmacist and health promotion in cardiovascular disease patients were included.
Results. The results of my study have shown that most of the respondents (75.2%) obtain the information about the disease from the doctor, while only 1.6% obtains it from the pharmacist. The majority of the respondents (72.0%) answered that they obtain their information about the medication from the doctor, while only 17.6% obtains it from the pharmacist. Most of the patients (66.4%) always feel totally comfortable to ask the pharmacist for an advice. Most of the respondents (76.8%) indicated that the pharmacist always acts politely with them when they come to the pharmacy. 74.4% of the participants indicated that the pharmacist at the pharmacy
never monitor their blood pressure, and 64.0% of them pointed that the pharmacists never gives them a lifestyle advices, at the pharmacy. On the one hand, when the patients were asked how important it is in their opinion to take care of salt use, 74.4% knows that it is very much important. On the other hand, only 9.6% of them do not use salt at all. Majority of the respondents (76.0%) think that the pharmacists are health professionals who know a lot about drugs.
Discussion. Our findings suggest that Israelis hypertensive patients has the knowledge of how important it is to avoid salt use, avoid smoking cigarette, promote physical activity and keeping a diet. But it is also seen that there is a gap between their knowledge and their everyday behavior. It means that some changes should take place, and the pharmacists have been identified as being well-placed to perform this health promotion role.
SANTRAUKA
Farmacijos specialisto svarba skatinant sveiką gyvenseną hipertenziją turinčių pacientų tarpe Izraelyje.
Natali Babaev, magistro baigiamasis darbas (mokslinis vadovas dr. Jurgita Daukšienė 2016/2018 mokslo metai. Darbas atliktas Lietuvos sveikatos mokslų universiteto Vaistų technologijos ir socialinės farmacijos katedroje.
Tikslas. Šio tyrimo tikslas buvo įvertinti farmacijos specialisto svarbą skatinant sveiką gyvenseną hipertenziją turinčių pacientų tarpe Izraelyje.
Aktualumas. Pasaulio sveikatos organizacijos teigimu (PSO)- sveikatos skatinimas yra procesas, kuris suteikia žmonėms galimybę didinti kontrolę ir gerinti jų sveikatą. Ši sritis yra ypač svarbi pacientams, sergatiems lėtinėmis ligomis. Šiame tyrime norėčiau nustatyti pacientų, kurie serga hipertenzija, suvokimą ir patirtį, susijusią su vaistininkų vaidmeniu sveikatos stiprinimui Izraelyje.
Metodas. Duomenys buvo surinkti atliekant skerspjūvio tyrimą. Parinktas klausimyno metodas. Tik hipertenzija sergantiems pacientams, kurie įeina į vaistinės parduotuvę ir sutiko dalyvauti tyrime, atsakė į klausimus interviu akis į akį . Vaistinės parduotuvė yra "Ašdodas", mano gimtajame mieste. Klausimynas sutarytas iš atskirų blokų apie apie informacijos šaltinius, vaistininko vaidmenį ir sveikatos skatinimą pacientams, sergantiems širdies ir kraujagyslių ligomis.
Rezultatai. Mano tyrimo rezultatai parodė, kad dauguma respondentų (75,2%) iš gydytojo gauna informaciją apie ligą, o iš vaistininko - tik 1,6%. Dauguma respondentų (72,0%) atsakė, kad gauna informaciją apie vaistus iš gydytojo, o tik 17,6% gauna iš vaistininko. Daugelis pacientų (66,4%) visada jaučiasi visiškai patogiai paprašydami vaistininko patarimo. Dauguma respondentų (76,8%) nurodė, kad vaistininkas visada mandagiai elgiasi, kai pacientas atvyksta į vaistinę. 74,4% dalyvių nurodė, kad vaistinėje niekada nepatikrina kraujo spūdžio, ir 64,0% iš jų nurodė, kad vaistinėse vaistininkai niekada nesuteikia jiems patarimų dėl gyvenimo būdo. Viena vertus, kai pacientų buvo paklausta, kaip svarbu rūpintis druskos vartojamu, 74,4% žino, kad tai labai svarbu. Kita vertus, tik 9,6% iš jų druskos nenaudoja. Dauguma respondentų (76,0%) mano, kad vaistininkai yra sveikatos priežiūros specialistai, kurie daug žino apie vaistus.
Išvados. Hipertenziją sergantys pacientai nurodė, kad žino, kaip svarbu išvengti druskos vartojimo, išvengti cigarečių rūkymo , skatinti fizinį aktyvumą ir
palaikyti mitybą. Tačiau pastebėta, kad tarp jų žinių ir jų kasdienio elgesio yra atotrūkis. Tai reiškia, kad kai kurie pokyčiai turėtų vykti, o vaistininkai galėtų jiems padėti skatinant sveiką gyvenseną, nes pacientų buvo pripažinti tinkamais atlikti šį vaidmenį.
KEYWORDS
Pharmacist - A pharmacist is a health care professional who cooperates with, consults with, and sometimes advises the licensed practitioner concerning drugs.
Pharmacy- Pharmacy is the science and technique of preparing and dispensing drugs and medicines. It is a health profession that links the health sciences with the chemical sciences and aims to ensure the safe and effective use of pharmaceutical drugs.
Hypertension- Also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. Hypertension defined as a blood pressure ≥ (systolic/ diastolic) 140/90mmHg.
Heath promotion- Defined by the WHO as the process of enabling people to increase control over and to improve their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions.
WHO- the World Health Organization is a specialized agency of the United Nations that is concerned with international public health.
Community pharmacist- Community pharmacists are the health professionals most accessible to the public. They supply medicines in accordance with a prescription or, when legally permitted, sell them without a prescription.
Blood pressure- Blood pressure is the force exerted by the blood against the walls of blood vessels, and the magnitude of this force depends on the cardiac output and the resistance of the blood vessels.
Perception- Combined sensations with past experiences. The way the patients interpret the pharmacist's health care.
Experience- A particular incident, feeling, etc. , that the patient has undergone with the pharmacist's attitude and health care.
ABBREVIATION
CP- Community pharmacy HP- Health promotion Q- Questionnaire BP- Blood pressure HT- HypertensionWHO- World Health Organization CBP- Clinic blood pressure measurements HBP- Home blood pressure measurements GP- General Practitioner
SBP- Systolic blood pressure DBP- Diastolic blood pressure CVD- Cardiovascular disease
INTRODUCTION
WHO defined health promotion as the process of enabling people to increase control over, and to improve their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions.
Most countries come across unprecedented social alternation as a result of population growth and urbanization together with environmental and other changes. For this reason, there is an instant need to orient health system more over health promotion and to assemble their capacity to promote health.
Community pharmacists are the health professionals most accessible to the public, who counsel, dispense and manage the patient's care plan; therefore they have an excellent setting for health promotion in the community [5, 26].
Eventually, reasons such as poverty, destitution, poor living conditions, lack of education, etc. contribute to disease and death, therefore health promotion, which is about facilitating people to take control over their health and its determinants, and so improve their health, incudes interference at the personal, organizational, social and political level to moderate accommodation conductive to upgrading or protecting health [20].
This research is aimed to assess hypertensive patients' perception and experience of the pharmacist role in health promotion in Israel, in order to find out what is the opinion of the people in this area, because no previous researches from this type have been done in Israel.
The results of this research will demonstrate whether there is a necessity for an improvement in health promotion among the pharmacists in Israel, following the role of the pharmacist in health promotion and the goals of health promotion.
AIM AND TASKS
The aim:
To assess Hypertension patients perception and experience of pharmacist role in health promotion in Israel
The research tasks:
1) To identify the sources of information the hypertensive patients obtain about the disease, the medications and the blood pressure measurement device.
2) To assess the perception and experience of hypertensive patients from the pharmacist's role.
3) To evaluate hypertensive patient's knowledge of non-healthy behavior risks to hypertension.
1. LITERATURE REVIEW
1.1The benefits and aim of Health Promotion
Health promotion has defined by the "World Health organization" (WHO) as the process of giving people the ability to increase the control and to improve their health [1]
.
Health promotion takes highly comprehensive approach to promote health by involving various players and focusing on multi sectorial approaches [20].Health promotion facilitates to diminish excess mortality, handling the leading risk factors and underlying determinants of health, helps intensify sustainable health systems, and site health at the middle of the broad development agenda. It has the ability in the prevention and control of both chronic and communicable diseases, especially among poor and marginalized groups.
Health promotion has an important role in caring healthy public policies and health-supportive environments, intensifying positive social conditions and personal skills, and providing healthy lifestyle [1].
Health promotion is not just about changing lifestyle, it is also not only about providing information. It includes the authorization of people to have increased control over and to improve their health, as well as providing services that improve the health of individuals and communities. Pharmacists should work for health gaining and not only for lifestyle changes, so that the aim would be to improve the health of the patients which they are in contact with [5].
Fig.1. The two levels which are proposed to health promotion, created by the author according to the following guidelines [5].
Figure 1 shows two main levels which introduce how to reach health promotion with the help of a pharmacist.
The first level for all pharmacists
• The first level centralized on the pharmacists heartening healthy behavior. Such as using leaflets to highlight health issues, respond to requests for advice and providing simple health promotion advices when giving out prescriptions, making sales and advising about treating symptoms. The second level for those who wished to specialize
• In the second level pharmacists search opportunities to promote health
In order to attain these aims, WHO applies health promotion techniques to health and related social systems, and to a variety of risk factors, diseases and health issues, as well as oral health. Carrying out health promotion in frame where people live, work, learn and play is a creative and effective way of improving health and quality of life [1].
1.2Community pharmacy
Community pharmacists are the health professionals most accessible to the public. They supply medicines with prescription or when legally permitted, without a prescription. Except ensuring a precise supply of products, their activity is also to cover counseling the patients at the time of prescription and non-prescription drug distribution, drug information to health professionals, patients and the general public, and taking part in health promotion programs.
Table 1. The main activities of community pharmacist, created by the author according to the following guidelines [2].
Description Activity
The pharmacist ensuring the legality, safety and appropriateness of the prescription order, as well as checks the patient medication, ensures that the quantities of medication are distributed precisely, and decides if the medication should be given to the patient.
Processing of prescription
The pharmacist asked to collect and combine information about the patient’s drug history, make sure that the patient understand the intended dosage regimen and the way of administration, and advises the patient of drug-related precautions, in some countries the pharmacist may monitor and evaluate the therapeutic effect. Care of
patients or clinical pharmacy
The pharmacist can take a part in the monitoring of drug use, such as in practice research projects, and programs to analyze prescriptions for the supervision of adverse drug reactions. Monitoring
of drug use
Table 1 extension: The main activities of community pharmacist, created by the author according to the following guidelines [2].
Description
Activity
Pharmacists everywhere continue to prepare medicines at the pharmacy. This enables them to adjust the formulation of a medicine to the specific case of the patient.
Extemporaneous preparation and small scale manufacture of medicines
Some countries are in favor of the pharmacist to supply traditional medicines and homeopathic prescriptions.
Traditional and alternative medicines
The pharmacist receives requests from members of the public for an advice about the symptoms appeared when indicated, if the symptoms are not so severe, the pharmacist may recommend for a non-prescription medicine, with advice to consult with the medical practitioner if the symptoms continue for more than a few days. Another option is just giving an advice without medicinal supply.
Responding to symptoms of minor illnesses
The pharmacist can compile and maintain information on all medicines, and particularly on newly introduced medicines, provide this information as necessary to other health care professionals and to patients, and use it in promoting the rational use of drugs, by providing advice and explanations to physicians and to members of the public.
Informing health care professionals and the public
The pharmacist can participate in health promotion programs, locally and nationally, in different health-related topics, as well as on drug-related topics, topics related with other health problems as tuberculosis, leprosy, and family planning. Health
promotion
In only few countries, the pharmacist can advise and provide service to residual homes for elderly patients, and long term patients.
Domiciliary services
Pharmacists supply animal medicines and medicated animal feeds.
Agricultural& veterinary
Table 1, describes the main activities of community pharmacists. All the activities should be carried out, even though some might be more important than the others, in order to follow health promotion attitude.
Community pharmacy has a meaningful accessibility to health service. Patients tend to visit the community pharmacy more often than their general practitioner (GP), especially if it is a refill of chronic prescribed medicines. As a result there is a need to more fully utilize the pharmacists experience and accessibility, working towards the provision of team- based approaches to patient care [3].
Early Canadian experience attempting to apply pharmacogenetics service in community pharmacy was shared in Buenos Aires, Argentina. John Papastergiou of the University of Waterloo explained how pharmacists may identify significant drug therapy problems using buccal swabs (is a way to collect DNA from the cells on the inside of a person's cheek) and DNA analysis. In the experiment forty patients participated. The mean age was 60.2 years, and the mean of chronic medicines administered was 6.2. The pharmacists recorded 55.6% ineffective therapy, 18.5% needed to be guided for initiative therapy, and 25.9% of adverse reaction. An average 1.62 drug therapy problems were identified per patient. 60.9% were recommended for a change in therapy. The aim was to help pharmacists, no matter where they live and work, in the delivering of medicines, health products and services that will improve medicine use and the patients' health care [4, 34].
1.3. The hypertension problem worldwide
Hypertension (Defined as a blood pressure ≥ (systolic/ diastolic) 140/90mmHg) is a common disease all over the world and defined as an important public health problem.
It is a significant risk factor and powerful predictor of cardiovascular morbidity and mortality which is improved after treatment. Hypertension may farther lead to a stroke, congestive cardiac failure and other causes of mortality, but this it preventable if the blood pressure is controlled [6].
Table 2. Classification of office blood pressure levels [24]. Diastolic(mmHg)ª Systolic(mmHg)ª Category <80 And <120 Optimal 80-84 And/or 120-129 Normal 85-89 And/or 130-139 High normal 90-99 And/or 140-159 Grade 1 hypertension 100-109 And/ or 160-179 Grade 2 hypertension ≥110 And/or ≥180 Grade 3 hypertension <90 And ≥140 Isolated systolic blood pressure
Table 2, shows the classification of BP levels. Treatment guidelines are different among the countries. In United States treatment should be begin with an SBP or DBP of 140 or 90 mmHg, respectively. In the presence of CVD, renal disease, treatment is recommended for a BP 130/85 mm Hg [7].
When we talk about mortality, high blood pressure is estimated to more than 5.8% of total deaths, 1.9% of life years are lost due to the disease and 1.4% disability adjusted life years all over the world. But it seems to be more dramatic in the formerly socialist economic countries (fig.3) [19].
Hypertension is the most common risk factor for cardiovascular disease, but during the last 30 years it seems that the treatment has dramatically improved, and leading to a decrease in the mortality due to stroke and coronary heart disease [7]. According to a report published in 2014 in Israel by the "Ministry of Health", it appeared that heart diseases are in the second place of the 10 main causes of death; however the first place is occupied be cancer [21].
Fig. 2. The main cause of death in 2017 worldwide [25].
Figure 2, summarizes the ten main causes for death worldwide in 2017. The most popular cause is a heart disease.
Limited data exist about the prevalence of hypertension, and the BP values are different around the European countries. But overall the prevalence appears to be around 30-45% in the general population, which increases with the increase of the age [8].
Fig.3. World map showing the global distribution of CVD mortality [22].
Figure 3, is the world map shows the distribution of cardiovascular diseases mortality. Asia, china, and other socialist economic countries have the highest distribution. Israel is marked with a green color, which shows the lowest distribution.
Israel
Fig.4. Hypertension risk factors, created by the author according to the following guidelines [9].
1.Age- The risk of developing high blood pressure increases with advancing
age. Usually it may appear in adults aged 60 or more in 64.9% of the cases in United States. After reaching the age of 50 the systolic blood pressure (SBP) tend to rise, while the diastolic blood (DBP) pressure tends to drop. Before 50 years SBP and DBP raise equally.
2.Gender- Until 45 years, men are at higher risk to develop HT, from 45-64
years the risk is equal for both genders, but above 65 years, women are at higher risk. For women who take oral contraceptives, HT is 2 to 3 times more common, especially obese or older women. (fig.5)
3.Race/Ethnicity- Black population develop HT at younger age in comparison
to white population; additionally their blood pressure is less well-controlled. As a result in black people CVD as stroke, heart diseases are more popular than in white people.
4.Geography- The southeastern United States has a higher prevalence of high
blood pressure and stroke among both blacks and whites.
5.Children and Adolescents- Data indicate that SBP and DBP levels increased
significantly among children of all age, race and gender, probably due to the increase of overweight children.
risk
factors
Age
Geography
Race/Ethnici
ty
Children and
Adolescents
Gender
18Other risk factors are a family history of the disease and chronic stress [9]. Fig. 5. Top 10 causes of death among women and men [23].
Figure 5, Shows the main ten diseases among women and men. Both genders are in equal risk of death among heart diseases.
The primary urgent steps for the prevention of hypertension are weight control, exercise, and reduce salt and alcohol intake [10]. Regular physical activity is considered a cornerstone in the prevention and management of hypertension. Epidemiological studies indicate that greater physical activity or fitness is related to a lower blood pressure, and meta-analysis of randomized controlled trials have shown that chronic dynamic aerobic endurance training may result in decreasing BP [11].
Despite patient self-management is defined as a key component and strategy for the management of hypertension, studies have shown poor understanding of the condition and the role of treatment among hypertensive patients [12].
Pharmacists are an essential part in the health care team, and because they are the most accessible health care professionals in the community, they are in a good position to detect chronic diseases and to identify unhealthy life styles. Community pharmacists may also reduce risk factors by consulting for weight and diet management, exercise and smoking.
Pharmacists have the knowledge which should be explained to the patients for understanding the danger of chronic disease and the importance of a treatment [13].
The topic is highly investigated from many points of view in different countries. We chose to explore in Israel, my home country, and concentrate on the experience and perception of pharmacist role in health promotion.
Mehos, Joseph and others in 2012 published a Controlled study evaluating the impact of pharmacist-initiated home blood pressure monitoring and intervention on blood pressure controls and other criteria. Subjects were 36 patients with uncontrolled stage 1 or 2 hypertension. Eighteen subjects received home blood pressure monitors, a diary, and instructions to measure blood pressure twice every morning. Eighteen control patients did not receive home monitors or pharmacist intervention. 6 month later the data suggest that the combination of pharmacist intervention with home monitoring can improve blood pressure control in patients with uncontrolled hypertension [14].
Another research article which published in 2012 in Japan was done in order to investigate the status of Japanese pharmacists' awareness and attitude toward home blood pressure measurement (HBP) and at the pharmacy (CBP). Of the 708 community pharmacists and 117 hospital pharmacists, more than 90% answered that HBP is equally or more important than CBP. More than 70% of community pharmacy and about half of hospital pharmacist recommended HBP measurement to hypertensive patients. However, the recognition and knowledge of the JSH (Japanese Society of Hypertension) guidelines criteria for hypertension were insufficient [15].
A study which has been done in 2006 in Kuwait University by a pharmacy faculty. The purpose was to determine the types of devices for self-monitoring of blood pressure available to consumers in Kuwait and the pharmacists’ knowledge and level of information provided to consumers when purchasing such devices. Data was collected from pharmacists at the 174 community pharmacies via face-to-face structured interview of the respondents at their work sites. Of the 174 pharmacists, 173 (99.4%) claimed to offer or provide advice to clients at the time of purchasing devices, 117 (67.1%) of them stating that they did so even if the patients did not ask. There is a need for improvement of community pharmacists’ competence in supporting patients and in providing them with information regarding devices for measuring blood pressure in Kuwait [16].
Second study from Kuwait, Primary Health Care, Hadiya Clinic, was done in 2009 in order to estimate the compliance rate, associated factors, status of blood pressure control and reasons for non-compliance among patients on treatment for hypertension. Out of 154 subjects recruited, 132 completed follow-up of 6 months, of whom 84 (64%) had uncontrolled(if the mean of three consecutive measures of systolic blood pressure was ≥140 mm Hg and /or mean diastolic blood pressure was ≥90 mmHg) hypertension. Seventeen percent of the uncontrolled hypertensives were non-compliant by pill count as compared to 2% of the controlled hypertensives.The compliance rate was 88.6%. The compliance rate was high in this study and was accompanied by inadequate blood pressure control among non-compliant subjects. Non- compliance was associated with lack of knowledge about hypertension [6].
In 2013 a study was done, in order to determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care. A cluster randomized clinical trial of 450 adults with uncontrolled BP recruited from Minneapolis-St Paul, Minnesota, with 12 months of intervention and 6 months of post-intervention follow-up. According to the results, Compared with the usual care group(6-30.0%,12- 30.0%, 18-57.1%) , systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months(57.2%), at 12 months(57.2%), and at 18 months (71.8%) ; The same results were for diastolic BP [18].
To summarize, during our research, we found many articles and publications on different scientific websites. However not all articles were precise enough to our chosen topic. After an intensive research I shortened my research to five articles that are of best fit.
The pharmacist's role is crucial in giving important information to patients about how to manage their hypertension. This can be done by giving specific instructions on how to use the instruments and also an important part of drug management. According to the results of the researches which we mentioned, we have noticed an insufficiency in the information supplied to the patients for the improvement of their health and control.
Unfortunately, we could not find an article about the perception and experience from community pharmacy among hypertensive patients in Israel; hence, 21
we are choosing to do the research in Israel, and investigate the intervention of community pharmacy in hypertensive patient's daily life.
2. MATERIAL AND METHODS
2.1 Research organization
The quantitative method of a questionnaire was chosen to assess hypertensive patients' perception and experience of the pharmacist role in health promotion in Israel.
Ethics approval was granted by Bioethics Research Committee of Lithuanian University of Health and Sciences.
The prepared questionnaire is composed of 33 different questions and needed to be translated into Hebrew language for the Israelis patients.
2.2 Setting and Sample
This study was conducted during the year 2017 at selected pharmacy shop- "New pharm", located in Ashdod; The southern district of the country on the Mediterranean coast, with a population of 220,174 thousand. The pharmacy has approximately 2800 patients per month, 5 pharmacists and 1 assistant (helping with OTC medication). All the patients were asked to take part in a survey, and those who agreed, answered the questions. (The demographic characteristics of the sample are presented in Table 1.)
Scheme 1. Representative scheme of 3 random days, created by the author.
Out of the 157 number of patients calculated with the help of the sample size calculator, 80% agreed to take a part in answering the questionnaire. 80% represents 125 hypertensive patients.
79
Patients 112 Patients Patients 84
With prescriptio Without prescription 32 Patients (41%) 53 Patients (48%) Patients 35(42%) Cardio patients Other patients 49 Patients 59 Patients 47 Patients 9 Patients (26%) 16 Patients (31%) 12 Patients (40%) 12 Patients After an average 264 Patients Within 22/30 working days. Sample size calculator: 157 Patients 26 Patients 37 Patients 20 Patients 24
Fig. 6. The quantity of patients during 30 days.
Figure 6 illustrates the exact quantities of patients visiting our pharmacy of choice during 30 days in May and June 2017.
2.3 Data collection
Data were collected by cross-sectional survey, in a quite consultation room at the pharmacy, and questionnaires were read to the participants for responses in a face-to-face interview. The questions were asked from the patients on working days from Sunday until Thursday, during the morning (8:30-13:00) and the afternoon (15:00-18:30).This month included 2 holiday days ("Shavuot"). The patients were informed about the aim of the survey and about the confidentiality. All participants were assured that the questionnaire is anonymous and data will be used only for scientific purposes. The sign on the consent form was accepted as an indicator that a patient wishes to participate in a research. It took from 10 to 15 minutes for every participant to answer the questionnaire. All questionnaires were gathered. Overall 157 patients were asked to participate, but 125 agreed to answer. The rate of patient's participation was more than 80%.
2.4 Study questionnaire
The questionnaire included 33 questions divided into 4 parts: the first set of the questions are about the sources of information regarding the disease' the medications, blood pressure measurement device and the importance if lifestyle. The second set of questions is asking regarding the pharmacist, one part is about the general opinion of the patients about the pharmacist and the second part is about the communication of the patient with the pharmacist.
The third set consists of health promotion questions. On the one hand about patient's thoughts, but on the other hand about the habits.
The fourth and the last set of questions addressed socio-demographic factors like age, systolic and diastolic blood pressure, how long the patient has hypertension, whether the patient lives alone and whether is having a pet.
Most of the questions were closed, with proposed choices of answers with "tick" box possibility.
2.5 Data analysis
SPSS (version 22.0) was used for data analysis. Descriptive statistics such as frequencies, means and ranges were calculated to summarize the data. T-test (the t test
compares two averages / means and tells you if they are different from each other. The t test also tells you how significant the differences are) [30] was used to analyze the differences among the groups. Results were considered significant when the p-value was less than 0.05.
Table 3. Socio-demographic characteristics of the respondents (n=125)
Demographics N (%) Gender Male 55 44% Female 70 56% Age range <50 6 5% 50-70 67 53% >70 52 41% Family status Living alone 24 19% Having a pet 32 26%
Table 3 represents most of the demographic characteristics of the respondents. The results are summed in numbers and percentages.
3. RESULTS
3.1 Sources of information hypertensive patients obtain about the
disease, the medications and the blood pressure measurment device
. In this section we would like to discover what are the most excessible and reliable sources of infornation from patient's point of view. Each patient might choose only one option. The results of each question are illustrated by percentage.Figure 7. Sources of information the patient receives about the disease.
Figure 7 shows that 94 (75.2%) of the respondents reported that they obtain the information about the disease from the doctor, while only 2(1.6%) chose the pharmacist.
Figure 8. Sources of information the patient receives about the medications.
Figure 8 shows that 90 (72.0%) obtain the information about the mrdications from the doctor, 22 (17.6%) from the pharmacist, while only 4 (3.2%) this time from the nurse.
Figure 9. Sources of information the patient receives about blood pressure measurment device.
Figure 9 shows that when it was asked about the information obtained about the blood pressure measurment device, in this case 27 (21.6%) chose the doctor, 23 (18.4%) chose pharmacist, while the the highest number was for family/friends, 40 (32.0%).
Figure 10. Sources of information the patient receives about the importance of lifestyle.
Figure 10 shows that in the question about the lifestyle information, it was found that 67 (53.6%) chose the doctor, while no one choose the pharmacist.
3.2 The perception and experience of hypertensive patients from the
pharmacist's role.
In this section the patients had to evaluate their opinion and to choose one option out of 4, "Never", "Rarely", "Usually", "Always". First part will be demonstrated using a table, ever as the second part using Bar graphs. The results of each question are illustrated by percentage.
Table 4. The role of the pharmacist
When I come to the pharmacist in the pharmacy…. % I feel totally comfortable to ask the pharmacist for an advice. -Never -Rarely -Usually -Always 3.2 11.2 19.2 66.4
The pharmacist gives me enough time to discuss my problems and listen to me carefully. -Never -Rarely -Usually -Always 4.8 14.4 20.0 60.8 I think that the pharmacist is rude to me.
-Never -Rarely -Usually -Always 90.4 7.2 1.6 0.8 The pharmacist is acting politely with me.
-Never -Rarely -Usually -Always 0.8 0.8 21.6 76.8 The pharmacist is monitoring my blood pressure.
-Never -Rarely -Usually -Always 74.4 16.8 8.0 0.8 The pharmacist gives me lifestyle advices.
-Never -Rarely -Usually -Always 64.0 24.0 8.8 3.2
Table 4 shows that 83 (66.4%) of the respondents always feel totally comfortable to ask the pharmacist for an advice. 76 (60.8%) think that always the pharmacist gives
them enough time to discuss their problems and listen to them carefully. 113 (90.4%) answered that the pharmacist never been rude to them, and 96 (76.8%) answered that they always feel the politeness of the pharmacist every time they come to the pharmacy. As soon as i asked if the pharmacist is monitoring respondent's blood pressure, 93 (74.4%) answered never. 80 (64.0%) answered that the pharmacist never gives them lifestyle advices, 30 (24.0%) answered that it happen rarely.
Figure 11. I think that the pharmacists are health professionals who know a lot about drugs.
Figure 11 shows that 95 (76.0%) always think that the pharmacists are health professionals who know a lot about drugs. 27 (21.6%) answered usually, 2 (1.6%) indicate never, and only 1 (0.8%) indicate rarely.
Figure 12. I think that the pharmacists are concerned with the health of the patients.
Figure 12 shows that majority 39 (31.2%) of the participants indicate that the pharmacists never are concerned with their health, 33 (26.4%) indicate that usually they are concerned, 27 (21.6%) rarely and 26 (20.8%) always concerned.
Figure 13. Do you discuss with the pharmacist about
About the question: do you discuss with the pharmacist about keeping a diet, about physical activity, about smoking or about salt consumption, announce that our respondents had different answers from "never" to "rarely" to "usually", to "always". The results of this adherence question shown in figure 13. It seems that most of the respondent never been asked about one of the questions.
3.3 Hypertensive patient's knowledge of non- healthy behavior risks
to hypertension.
In the last section we are comparing between patient's knowledge and the actual implementation on a regular bases. Right below each we added a table, to identify significant differences between the socio-demographic characteristics.
Figure 14. How important it is to take care of salt consumption, and do the respondents use salt.
Figure 14 shows from one side that 93 (74.4%) of the respondents think that salt consumption should be taken care very much, 18 (14.4%) some what, 11 (8.8%) undecided, and only 2 (1.6%) not really think so, and 1 (0.8%) think thank that salt consumption should not be taken care at all.
On the other side, out of all the respondents it seems that 48 (38.4%) use salt somewhat, 32 (25.6%) use salt very much, but only 12 (9.6%) do not use salt at all.
Table number 5. Correlation of patient's opinion about salt consumption promoting hypertension and socio-demographic characteristics. The table was arranged from the most insignificant to the most significant value (from the bottom to the top).
P-value T-value Std. Deviation Mean N Question 0.0108 P<0.05 2.5889 0.91490 1.6000 55 Male Your gender 0.624050 1.2429 70 Female 0.4059 P>0.05 -0.8339 0.62183 1.3333 52 ≤Monthly How often do
you visit the
doctor More than monthly 73 1.4521 0.88256
0.4884 P>0.05 0.6949 0.93250 1.5000 24 Yes Do you live alone No 101 1.3762 0.746340 0.6629 P>0.05 0.437 0.83434 1.4222 91 ≤160 Systolic blood pressure >160 34 1.3529 0.64584 0.9383 P>0.05 -0.0775 0.78536 1.3982 113 Monthly How often do you visit the
pharmacist More than monthly 12 1.4167 0.79296
0.9622 P>0.05 0.0475 0.85108 1.4043 47 <65 Age 0.74450 1.3974 78 >65 0.9999 P>0.05 0 0.73565 1.4000 35 Yes Do you have a pet No 90 1.4000 0.804480
Figure 15. Does smoking cigarette promote the risk of developing hypertension and do the respondents smoke.
According to figure 15, 71 (56.8%) of the participants chose "very much" in the question "do you think that smoking cigarette promotes the risk of developing 34
hypertension", 30 (24.0%) chose "undecided", 16 (12.8%) chose "somewhat", and 6 (4.8%) and 2 (1.6%) chose "not really" and "not at all", respectively.
For the question "do you smoke cigarette" 101 (80.8%) answered "not at all", and only few chose the rest options, as it is shows in this figure.
Table number 6. Correlation of patient's opinion about smoking cigarette promotes hypertension and socio-demographic characteristics. The table was arranged from the most insignificant to the most significant value (from the bottom to the top).
P-value T-value Std. Deviation Mean N Question 0.0077 P<0.05 -2.7093 1.01786 1.7345 113 Monthly How often do you visit the
pharmacist More than 12 2.5833 1.16450 monthly 0.0108 P<0.05 2.5882 1.15809 2.2000 35 Yes Do you have a pet No 90 1.6667 0.98300 0.0628 P>0.05 1.8776 1.21508 2.0426 47 <65 Age >65 78 1.6795 0.93272 0.485 P>0.05 0.7005 1.06585 1.8909 55 Male
Your gender Female 70 1.7571 1.05550
0.485 P>0.05 0.7005 1.06585 1.8909 55 Male Your gender 1.05550 1.7571 70 Female 0.7244 P>0.05 0.3534 1.05867 1.8627 52 ≤Monthly How often do
you visit the
doctor More than 73 1.7945 1.06665 monthly 0.7353 P>0.05 -0.3389 1.03209 1.7500 24 Yes Do you live alone No 101 1.8317 1.06836 35
Figure 16. Do you think that physical activity decreases the risk of developing hypertension, and do you do any physical activity.
Figure 16 shows that 61 (48.8%) "Very much" agreed that physical activity decreases the risk for hypertension, 43 (34.4%) think that "Some what", 16 (12.8%) "Undecided", and 4 (3.2%) and 1 (0.8%) are "Not really" and "Not at all, respectively. We may see that 41 (32.8%) and 27 (21.6%) "Some what" do physical activity and "Very much", respectively, while 27 (21.6%) and 24 (19.2%) "Not at all" and "Not really", respectively.
Table number 7. Correlation of patient's opinion about physical activity reduces the risk for hypertension and socio-demographic characteristics. The table was arranged from the highest insignificant to the lowest insignificant value (from bottom to top).
P-value T-value Std. Deviation Mean N Question 0.0967 P>0.05 1.6739 0.78668 1.8936 47 <65 Age 0.89890 1.6282 78 >65 0.1409 P>0.05 1.4819 0.98020 1.8627 52 ≤Monthly How often do
you visit the
doctor More than monthly 73 1.6301 0.77292
0.1515 P>0.05 -1.4431 0.78019 1.5000 24 Yes
Do you live alone
0.878680 1.7822 101 No 0.2999 P>0. 05 1.0411 0.943800 1.8571 35 Yes Do you have a pet No 90 1.6778 0.83232 0.5396 P>0.05 0.6151 0.89631 1.7818 55 Male Your gender 0.843440 1.6857 70 Female 0.7604 P>0.05 -0.3058 0.83793 1.7111 91 ≤160 Systolic blood pressure >160 34 1.7647 0.95533 0.9267 P>0.05 -0.0922 0.85824 1.7257 113 Monthly How often do you visit the
pharmacist More than monthly 12 1.7500 0.96531
Figure 17. Do you think that keeping a diet decreases the risk of developing hypertension, and do you keep a diet.
Figure 17 shows that 87 (69.6%) do think that keeping a diet decreases the risk for developing hypertension, 27 (21.6%) think that it "Some what" decreases, 9 (7.2%) are "Undecided" , and 2 (1.6%) "Not really". 47 (37.6%) do keep a diet "Some what", 41(32.8%) "Very much", 16 (12.8%) "Not at all", 13 (10.4%) "Not really", and lastly 8 (6.4%) are "Undecided".
Table number 8. Correlation of patient's opinion about keeping a diet reduces the risk for hypertension and socio-demographic characteristics. The table was arranged from the most insignificant to the most significant value (from the bottom to the top).
P-value T-value Std. Deviation Mean N Question 0.0058 P<0.05 2.8062 0.829990 1.6000 55 Male Your gender 0.52985 1.2571 70 Female 0.1161 P>0.05 -1.5825 0.54015 1.2941 52 ≤Monthly How often do
you visit the
doctor More than monthly 73 1.4932 0.78392
0.2025 P>0.05 1.2812 0.74811 1.5106 47 <65 Age 0.66111 1.3462 78 >65 0.387 P>0.05 -0.8681 0.64613 1.3778 91 ≤160 Systolic blood pressure >160 34 1.5000 0.82572 0.5613 P>0.05 -0.5825 0.63702 1.3333 24 Yes Do you live alone No 101 1.4257 0.71199 0.6251 P>0.05 0.4899 0.78000 1.4571 35 Yes Do you have a pet No 90 1.3889 0.66526 0.964 P>0.05 -0.0452 0.71511 1.4071 113 Monthly How often do you visit the
pharmacist More than monthly 12 1.4167 0.51493
4. DISCUSSION
In our study we detected HT patients' perception and experience of pharmacist role in health promotion in Israel. The main outcomes were associated with socio-demographic characteristics: gender, age, systolic blood pressure, having a pet, living alone, the frequency of visiting the doctor and the frequency of visiting the pharmacist.
Hypertensive patients obtain the information about the disease, medications and the importance of lifestyle mostly from the doctor. In my opinion it might happen due to the reason that doctors appear to be the primary candidate for patient's support, and so they are the first in providing the information to the patient. Another reason could be convenience, a quiet and private room that the doctor supplies to each patient, which grants patient's the possibility to ask questions without feeling pressure from other patients. As for the blood pressure measurement device, most answered friends/ family. Few of them explained that the reason of their previous background is due to a family member or a relative who had the disease before. The same problem is seen in Kuwait and in Poitou-Charentes where pharmacist should improve their role in providing information regarding devices for measuring BP [16]. These problems might occur due to a low confidence of the pharmacist in providing these services. Well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health [33]. Training and improving their knowledge might help [27]. Furthermore, Community pharmacists recognize by themselves a wide gap between their ideal and actual levels of involvement [17].
The assessment of the perception and experience of hypertensive patients from the pharmacist's role showed that most of the patients feel totally comfortable to ask the pharmacist for any advice, and in most of the cases the pharmacist dedicates enough time to discuss about patient's problems and listen to them carefully.
It seems that the pharmacist almost never rude to the patients and are acting politely with them. In addition the pharmacist almost never monitors the blood pressure of the patients and in most of the cases, does not give lifestyle advices. In this section most of the respondents added orally that they do not see a reason for the pharmacist to share with them any lifestyle advices, or be interested with their blood pressure. Any
way we could not find any updated researches to prove the unsatisfied control of blood pressure in Israel as it is in US, Canada and other European countries [31, 32]. Most of the patients agreed that the pharmacist is a health professional who knows a lot about drugs, but are not enough concerned about the health of their patients. During the questioning experience I could notice that the returning customers tend to be asked by the pharmacist question about their health, and it seems like the pharmacists show some interest in their health, but new customers do not receive the same attention.
Almost all the patients do not discuss with the pharmacists about salt consumption, smoking cigarette, physical activity and keeping a diet, as well as in Kuwait. An improvement of community pharmacists' competence in supporting patients should be done as well as highlighting the role of the pharmacists as it is already done in the developing country Pakistan [16, 35].
Hypertensive patient's knowledge of non-healthy behavior risks of hypertension has shown that even though most of the respondents think that it is very important to take care of salt consumption, most of them still use salt. They explained that they can not give up on their favourite salty dishes
Most of the respondents think that smoking cigarette promotes the risk of developing HT, and in the same way most of them do not smoke cigarette.
Most of the respondents think that physical activity reduces the risk of developing HT, and it seems that most of the patients do any kind of physical activity.
And lastly, most of the respondents agreed that keeping a diet reduces the risk of developing HT, and most of them do keep a diet.
In this section it seems that there is a high understanding of the disease risk factors, but not that high action.
There seems to be a better overall awareness, treatment, and control of hypertension in the US [29] but not in France [27], Poland [28] and Canada [29], where BP goals and the lifestyle modifications are poorly known by the hypertensive patients.
5. CONCLUSION
1. According to the results of the survey from "New-pharm" community pharmacy in Ashdod, hypertensive patients in Israel have a wide spectrum of information sources about the disease, the medications and the blood pressure measurement device and even though pharmacists are in a good position in providing information to the patients, it seems that doctors are deeper involved in it.
2. Patient's understanding of pharmacist's role in health promotion must be corrected. Patients should use more often the services that community pharmacists can offer, but only after the pharmacists will follow their role in health promotion, to become more voluntary in the health of the patients, and show how interested they are in their patient's health.
3. Generally most of the hypertensive patients demonstrate knowledge about the importance of healthy behavior and the risk factors, but not everybody follow it and apply it in their everyday bases. Most of the respondents were women, is seems that women tend to visit the community pharmacy more often than men does; hence women demonstrate a higher knowledge than men (P<0.05).
6. RECOMMENDATION
After the literature review and results of the patient’s survey we recommend: To patients:
• Attempt to receive information about their disease and treatment also from the pharmacists as they are professionals in drugs field
• Try to find one pharmacy which fits the best for you in every way and get only their service in order to foster your relation with the pharmacist.
To community pharmacists:
• Promote and increase their intervention in the education and promotion to improve blood pressure control.
• Increase the adherence of the patient to the antihypertensive medication and reduce the systolic and diastolic blood pressure.
To health authorities:
• The role of the pharmacist should be promoted, and this currently unpaid role should be recognized by health authority for its potential contribution towards the health care of the population, and receive an appropriate funding.
• To create a courses for the patients about the risk factors of hypertension to increase their knowledge about the disease.
• To create a course for the patients about the role of community pharmacist in health promotion.
• Physician-pharmacist cooperation program for blood pressure control in patients with hypertension might be effective in Israel too as it is already in Japan [31].
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46
6. APPENDIX
Hypertension patient perception and experience of pharmacist role in
health promotion
1.Sources of information:
1. What sources did you obtain your information about:
Doctor Pharma cist Nurse Family/ Friends Books/ Internet The disease The medications
The blood pressure measurment device The importance of lifestyle
2. Pharmacist
2.1.
When i come to the pharmacist in the pharmacy...2.2 I think that the pharmacists...
Never Rarely Usually Always
I feel totally comfortable to ask the pharmacist for an advise
The pharmacist gives me enough time to discuss my problems and listen to me carefully
I think that the pharmacist is rude to me The pharmacist is acting politely with me The pharmacist is monitoring my blood pressure
The pharmacist gives me lifestyle advices
Never Rarely Usually Always
Are health professionals who know a lot about drugs
Are concerned with the health of the patients
Dear respondent.
Community pharmacists- are the health professionals most accessible to the public. They supply medicines in accordance with a prescription or, without a prescription. In addition, their professional activities also cover counselling of patients at the time of dispensing of prescription and non-prescription drugs.
My name is NataliBabaev, I am a 4th year pharmacy, master student.I would like to thank you for taking a part in my scientific research. Your opinion is very important in order to find the perception and experience of pharmacist role in health promotion. I would like to note that the questionnaire is anonymous andthe data will be used only for scientific purposes. Thank you for your time, if after completing the questionnaire you will have any additional questions, you may contact me at this number: 0523289097.
47
2.3.
Do you discuss with the pharmacist about:3. Health promotion
Question Very much Some what Undecided Not really Not at all
How important is it in your opinion to take care of salt use?
Do you think that smoking cigarette promotes the risk of developing hypertension?
Do you think that physical activity decreases the risk of developing hypertension ?
Do you agree that keeping a diet decreaces the risk of developing hypertention? Habit Very much Some what Undeci
ded Not really Not at all
Do you use salt?
Do you smoke cigarette?
Do you do any physical activity? Do you keep on diet?
4.Sociodemography
Thank you for your answers!
Never Rarely Usually Always
Salt consumption Smoking cigarette Physical activity Keeping a diet Diastolic blood pressure: ... (Write) Your gender Male Female
How old are you? ... (Write) Systolic blood pressure: ... (Write)
When were you diagnosed with hypertension?
<1 month 1 month- 1 year >1 year ago
How often do you visit a pharmacist for
any reason?
Daily Weekly Monthly
More than monthly
Do you have a pet? Yes No Do you live alone? Yes No
How often do you visit your doctor?
Daily Weekly Monthly
