A total of 23 participants (87% male) from both government (Govt) and non-government (NonGovt) policy sectors were interviewed via phone (78%) or in face-face interviews. Of these, almost 65% had pharmacy qualifications and most 16 (70%) participants were from the central region (Riyadh, capital city). Ten (44%) participants were recruited from academia (Public Universities), nine (39%) were from government health sectors and four (17%) were recruited from the private sector (i.e. community pharmacy CEOs and private companies). The government employees included representatives from the MoH, the Saudi Food and Drug Authority (SFDA), the King Fahad Medical City (KFMC) and the Ministry of National Guard Health Affairs (NGHA). Interviews lasted between 24-50 minutes with a median length of 35 minutes. Participant characteristics are shown in Table 1 below. All interview records were clearly audible; thus, no repeat interviews were required.
Table 1. Participants characteristics
Characteristics
|
Variables
|
n=23 (%)
|
Gender
|
Male
|
20 (87)
|
Female
|
3 (13)
|
Age Bracket (Years)
|
30-39
|
11 (48)
|
40-49
|
6 (26)
|
50-59
|
4 (17)
|
60-69
|
2 (9)
|
Experience Level (Years)
|
≤5
|
7 (30)
|
6-10
|
2 (9)
|
11-15
|
3 (13)
|
16-20
|
4 (17)
|
>20
|
7 (30)
|
Workplace location (city)
|
Riyadh
|
16 (70)
|
Dammam
|
3 (13)
|
Al-Qassim
|
2 (9)
|
Jeddah
|
1 (4)
|
Tabuk
|
1 (4)
|
Professional Background
|
Medicine
|
6 (26)#
|
Pharmacy
|
15 (65)*
|
Public Health
|
2 (9)
|
Academic Qualifications
|
Bachelor
|
7 (30)
|
Master
|
6 (26)
|
Doctor of Philosophy (PhD)
|
10 (44)
|
# 4 physicians were specialised in public and community health. *One pharmacist had a Master of Public Health.
Four themes emerged from the data analysis: 1) Future pharmacy CVD health service models, 2) Demonstrable outcomes, 3) Professional engagement and advocacy and 4) Implementability. Each theme is described below along with illustrative verbatim quotes (and participants details i.e. gender, age bracket, Govt/NonGovt sector).
During interviews, participants referred to both primary and secondary CVD risk prevention services. They also discussed a range of recent public health initiatives implemented by the MoH and SFDA in the context of CVD (tabulated in Appendix C).This discussion resulted from the interview guide, where the question about current initiatives was placed at the beginning of the interview, as an ice-breaker and to create the setting for the topic of focus.
Similarly, when asked about current pharmacist-supported roles in CVD prevention, participants were aware of and highlighted several roles/services such as patient education, medication management and monitoring that were currently offered to some extent by clinical pharmacists in some tertiary hospital outpatient clinics. Apart from roles in CVD, diabetes patient education and blood pressure monitoring were mentioned as services known to be offered in a few community pharmacies (e.g. big chain pharmacies in large metropolitan cities) in Saudi Arabia. While the provision of these pharmacy services has had recent approval from the MoH, participants acknowledged that their current availability is very limited.
Theme 1: Future pharmacy CVD health service models
One of the main aims of the study was to obtain a clear picture about the pharmacy health services model that participants envisaged if they supported the notion of pharmacist provided CVD risk prevention/management services. Of foremost importance is the finding that all participants supported pharmacy preventive health services and indicated that as policymakers they had a general expectation that community pharmacists are capable of running CVD risk screening services.
CVD health service roles
Specific public health roles that pharmacists could provide described by participants included: 1) health screening and 2) primary (health education on risk factors, identifying individual risk factors) and 3) secondary prevention (patient education on medications, adherence, lifestyle modifications for those with established CVD).
1. Health screening
While some participants supported the notion of POCT, others thought simple, fast and uncomplicated screening services i.e. questionnaire-based risk assessment only, utilising smart technology (applications) in community pharmacy might work better and more readily accepted by the public.
“I expect them [community pharmacists] to do just the screening services [e.g. POCT and BP check] or provide advice regarding dietary habits, exercise, smoking, and other health promotion and preventive advice. They can discover some cases during the screening. They will have a system connected, to advise patients to go to the nearest PHC [primary healthcare centre] … (Pt1, M, 40-49, Govt.)
2. Primary prevention
Most participants suggested pharmacists could adopt active primary prevention screening roles such as assessing patients’ risk factors, providing targeted CVD education and referral. A few participants preferred a more minimalist approach, where pharmacists simply provided consumers with information leaflets or brochures, and if needed referred them to a physician or other HCPs for further investigations and education, without spending time for risk assessment or patient education.
“I think pharmacists shouldn’t be providing the health promotion advice. I think he is representing a point of contact; so, he is the most accessible person, he does the screening, probably can give the patient a brochure or something and then direct them to somebody who is willing to spend time to give him more advice about the health style, which is usually health educators job.” (Pt15, M, 40-49, Govt.)
3. Secondary prevention services
Most participants saw merit in pharmacist-provided medication therapy management (MTM) and other medication review services for patients who may already be diagnosed with/prescribed medication for CVD (i.e. secondary prevention) [Note: MTM is a service in which a pharmacist conducts a medication use intreview with patients on polypharmacy/long term medication use to help optimise regimens for safety and efficay [25, 26]]. In fact, some participants suggested that MTM services in patients not yet diagnosed with CVD could be used as an opportunity to undertake CVD risk screening.
“Medication therapy management (MTM)…. Give people an opportunity to be screened by a point of care machine that gives you the result in a minute for HbA1c, fasting blood glucose or blood pressure…. So, you could screen a lot of people in no time….” (Pt7, M, 30-39, Govt.)
However, a few participants were reticent to have community pharmacists involved in CVD management aspects.
“….. In general, they can provide counselling and educate, but management is a red line.” (Pt21, M, 50-59, Govt.)
Pragmatic factors
In the operationalisation of such models, however, participants emphasised that professional boundaries needed to be maintained and respected for patient safety.
“……it seems like the roles of different health professionals in Saudi Arabia are not very clear and the majority of providing health services are focused on physicians which I think is not the right way currently…” (Pt23, F, 30-39, Govt.)
Most favoured a collaborative doctor-pharmacist model where consumers at risk could be referred (perhaps via a connected system with primary healthcare centres) by a pharmacist provider with a written report or risk assessment sheet to either primary care physicians, specialists, another HCP, emergency department/s or even government-maintained hotline support numbers to contact for further help. Pharmacist referral straight on to a specialist was suggested to ease the process of these services, which could be favoured by health consumers. Medical oversight and collaboration around pharmacist provided services were seen as mandatory elements by many participants. Some participants specified the direction that patient care pathways need to take in such collaborative models, as well as the tasks that different professionals should perform. Participants highlighted the need for legislative changes to allow for CVD risk prevention collaborative physician-pharmacist service implementation (e.g. POCT and Blood Pressure (BP) check for risk screening and management).
“If we say how we can improve collaboration, so this can go through enforcement by law. This is number one. Number two is doing workshops and orientation and mixing people and creating a model that people will follow.” (Pt15, M, 40-49, Govt.)
“...So, if we said the pharmacist will be responsible for prevention, the next step has to be referring to a specialised physician. If you make a screening system that’s too long for the patient, the patient will hate it. So, if you say primary care physician then specialist, that would be okay. If you say pharmacist then specialised physician, that would be okay. But pharmacist then primary care physician then specialised physician, patient won’t use that model.” (Pt15, M, 40-49, Govt.)
“... So, once a patient is seen in the pharmacy and the problem is identified, then the pharmacist needs to send a letter stating what he/she has found and his/her recommendations to the primary care provider. A copy of the pharmacist report shall be given to the patient as well. So, I’m talking here also about medication therapy management side intervention in case of uncontrolled chronic conditions, but that may work for CVD risk assessment.” (Pt2, M, 30-39, Govt.)
The most common future CVD preventive service models in community pharmacy as envisaged by most participants are summarised in Figure 1. Distilling participant descriptions of preferred service models clearly illustrated three potential levels of pharmacists’ involvement.
Participants recommended that a culturally appropriate screening and risk assessment protocol and supporting tools needed to be developed to maximise service practicality and result in reliable outcomes. These recommendations were made as several participants were aware of tools developed through epidemiological research in other countries with available screening tools (e.g. English) that have not been validated in the Arabic language or with Saudi people. Other pragmatic suggestions for pharmacist provided CVD risk prevention/management services related to the physical practice environment. Appropriate service area design (private, comfortable physical space), and access to patient electronic medical records in community pharmacies were two factors recommended to facilitate pharmacist-led interventions.
“We need to reallocate, adapt, modify, translate, and validate those screening tools in order to make them suitable for our country.” (Pt20, M, 50-59, Govt.)
“…if pharmacies can provide such services, there should be a space [a private area in the pharmacy] provided where the pharmacist can sit down with the patient, take the vital parameters… then see what medications the case is taking and sit and discuss management with him or her and to follow up.”(Pt13, M, 60-69, NonGovt.)
Participants also mentioned the potential benefits that would likely accrue from the recently launched pharmacy initiative, the “Wasfaty Scheme” [a governmental funded initiative that is gradually being rolled out to electronically connect assigned community pharmacies and public primary healthcare centres or hospitals for e-scripts [27]]. It was suggested that the system be utilised for preventive services by supporting assigned community pharmacies to offer CVD risk prevention services.
“Wasfaty is already applied and available in some pharmacy mainly in the Eastern region of Saudi and across other regions of the country….” (Pt12, M, 30-39, NonGovt.)
“In the new model of care, we have different changes that will happen in the system…. So, one of these changes, which we have just started, is that any patient in primary care centres now will get the prescription and he can go to any private pharmacy to take those medications and how about if we advise those assigned pharmacies to do part of the education and screening services…. We should plan to add these screening services as roles for them.” (Pt1, M, 40-49, Govt.)
Theme 2: Demonstrable outcomes
Most participants highlighted that any future community pharmacy CVD risk prevention/management studies needed to be supported by ‘evidence’ before implementation policies could be launched. Sources of such ‘evidence’ mentioned included systematic literature reviews (global literature) and local demonstration projects.
“… I suggest that the pilot study be done in different socioeconomic levels of the community …. it should be diverse; it should take sample size from different levels of the society.” (Pt6, M, 40-49, Govt.)
These projects would need to be shown to have concrete evidence of benefit. Benefits sought were demonstrable high-level outcomes such as risk exposure reduction, lowered mortality and hospital admission rates or cost savings, clinical outcomes and patient reported benefits/satisfaction. A strong health services understanding in our participant group was also evident as they suggested that well worked out processes/documentation methods would be needed to collect data and build the evidence for the benefits of pharmacist-delivered preventive services, given that clinical documentation was not a current strength in the Saudi community pharmacy sector.
“You can document your success in such initiatives or such intervention by following up with patients who were exposed to such services for years and see what impact that has on their clotting time, on their A1C, on their blood pressure readings. And you can link the reduction to detect a decline in the number of mortalities, of case fatalities or number of hospitalizations in the future….” (Pt10, M, 30-39, Govt.)
Participants understood that the collection of such evidence would take time and were careful to differentiate between short ( e.g. changes in Haemoglobin A1C (HbA1c), BP, cholesterol level) and long-term (reduction in national annual CVD-related hospital admissions and lowered CVD related mortality) benefits expected from such services.
In identifying cost as a key indicator, many participants mentioned the need to use digital health innovations, such as screening applications. They believed that using such technologies could expedite the process for both patient/provider and render it more cost effective. All participants envisioned the long-term savings likely to ensue from these programs and saw expenditure allocation to preventive health as a long-term investment.
“….. from a commercial view, each $1 spent now in the prevention will save $7 in ten or twenty years in the future for the general cost of the healthcare system and other financial expenses made into healthcare or activation of population….” (Pt1, M, 40-49, Govt.)
“Well, if you decrease the number of people who had the complications, then that will cost the health system less in the future, and that will lead to less hiring of people to take care of complications and less expenditure on treatment of these complications.” (Pt15, M, 40-49, Govt.)
Whilst the participants clearly outlined the need for accumulating evidence supporting pharmacy CVD risk prevention/management services, they were not clear about who would do this research and how it might be funded.
Theme 3: Professional engagement and advocacy
Professional organisations were mentioned as salient foci for the development of pharmacy services but were described as ‘inactive’ in the Saudi pharmacy profession. Participants recommended that a collection of professional not-for-profit or private organisations should be actively engaged to provide recommendations for pharmacy practice advancement. Collaboration between pharmacy professional bodies and other medical or specialised bodies to develop new patient care models was also seen as essential. Health services models for pharmacy implementation would need stakeholder impetus for sustainability, where the stakeholder body was seen to represent pharmacy educators, private pharmacy business owners, medical professionals, clinical experts and consumers.
“… I think our professional bodies are still evolving…. What I recommend is an inter-professional model meaning that a professional organization such as the Saudi Pharmacy Association…. They should collaborate with different medical professional bodies such as the Saudi Society of Management of hypertension…and public societies…. advocating for the public. I think this will be more fruitful….” (Pt10, M, 30-39, Govt.)
“Well, it requires people in academia, people like us in NGOs, it requires influencers in the community and it requires many sessions of collaboration and workshops to get people who are in the seat of decision making to loosen to the subject matter experts to see the value added in all of the things they want to do.” (Pt13, M, 60-69, NonGovt.)
A key role that pharmacy professional bodies would need to undertake was to work out legal systems and professional indemnity for pharmacists venturing to the unchartered territory of preventive health service provision.
Theme 4: Implementability
Professional pharmacy governance Change in professional governance, workforce development, professional policies and guidelines was an issue stressed by most participants, given that most recognised the limited spectrum of services offered in only few community pharmacies currently.
1. Pharmacy careers and workforce
The need to enhance the profile of community pharmacy careers was highlighted by all participants, given that there was very little engagement in this role by local graduates. It was recognised that higher pay rates, paid leave provisions, job-security, professional development could lead to better retention in community pharmacy careers – and that these aspects should be internally regulated by the pharmacy industry. Many participants also posited that boosting professional service roles may be another way of ensuring job-satisfaction.
“We should change the theme/image in Saudi Arabia. This is currently very unattractive working place, like a supermarket, just selling products.... Also, the salary and incentives for the pharmacists themselves are low. Also, the job security, as community pharmacies are privately-owned and they care about financial profits. They are not willing to give high salary or vacations to pharmacists compared to the governmental sectors. So, there is a need to incentivise those pharmacists to attract them to provide services.” (Pt19, M, 30-39, Govt.)
Policies suggested by most participants that would be needed to underpin the widened pharmacy service scope included support for Saudization (local instead of expatriate workforce) and gender equity of community pharmacists. Mandating community pharmacy employment for at least 2 years post-graduation for local pharmacy graduates was suggested by a few participants, as it was felt that this may develop future (local) pharmacy graduates’ ongoing engagement with this career role.
“…We start now with Saudization …. and in my opinion, I see that community pharmacists are mostly expats so if they would be replaced by Saudi male and female pharmacists who will make a change in the way pharmacy is evolving...” (Pt3, M, 60-69, NonGovt.)
“It could be done in a way that in the first two years of graduates’ careers they have to work in a community pharmacy after graduation and before going to a secondary or tertiary hospital….” (Pt15, M, 40-49, Govt.)
2. Pharmacy curricula and ongoing education
Pharmacy curricula content and increased community pharmacy placements were suggested to motivate and equip local pharmacy graduates to work in community pharmacy; this was seen as particularly important for new entrants into the profession.
“… we might concentrate on fresh graduate students because those fresh graduate students have good knowledge and they are well trained and maybe offering those services will be run by them more than old pharmacists because attitude is difficult to change their practice....” (Pt19, M, 30-39, Govt.)
Participants also advocated for a better alignment between Saudi pharmacy curricula and pharmacy practice – with skills such as public health methods, patient psychology, communication and management lacking in the current highly clinical/scientific curricula. As such, it was believed preventive medicine content was under-emphasised in curricula where the focus remained on pharmacology and therapeutics.
“The medical/pharmacy education system is very much curative-oriented not preventive-oriented…. the medical or health education system does not focus on the social part or the social determinants of health and how to address those social determinants. These are very poorly addressed in our education….” (Pt20, M, 50-59, Govt.)
Training for pharmacists already in practice was recommended. It was suggested they would need skills in CVD risk screening and management services, and that such upskilling should be the remit of authorised bodies accredited and committed to providing continuing professional development (CPD). It was thought that such CPD needed to emphasise both clinical and communication skills.
“…give them enough training before they start the service. And this can be done either through the Saudi Commission, through universities, or through the Ministry of Health. There are several certifications they need to get.….” (Pt11, M, 30-39, Govt.)
“…. the training should focus on proper communication. I have to emphasise this many time because proper communication between the healthcare provider or the pharmacist and the patient is a cornerstone in providing this service and for it to work properly.” (Pt4, F, 40-49, Govt.)
3. Practice policies, standards and guidelines
Participants mentioned that at a policy level, the profession would need to build and support adherence to stringent quality control requirements for pharmacies accredited to provide services. Structurally, a common suggestion was to have a ministerial department appointment for program director that would oversee pharmacy delivered CVD risk prevention services. A few participants mentioned third party inspection and quality control certification bodies. A current lack of quality accreditation bodies/systems for community pharmacy practice was also seen as an issue that needed to be addressed; for example, through CBAHI (The Saudi Central Board for Accreditation of Healthcare Institutes) Surveyors.
“… the role of healthcare leader is to (a) standardise their work, (b) monitor the quality or output of their work, and (c) evaluate and compare between different sources of information or those of pharmacies with other members of healthcare team.” (Pt1, M, 40-49, Govt.)
“…… The Ministry of Health can have a contract with a third party who is going to assess the quality of services delivered by the pharmacies and then that would be connected with a reimbursement given to such services.” (Pt16, M, 30-39, Govt.)
“Not all of them [community pharmacies] are ready because up to now there are no standards of accreditation for community pharmacy. If they put accreditation standards and include it, most of them will be ready.” (Pt8, M, 50-59, Govt.)
Implementation vision
1. Scalability
Participants suggested that health services models constructed would need to be scalable. A popular idea was that utilising the bigger pharmacy chains as initial ‘test’ sites would allow a quick scale up, should the models have demonstrable positive outcomes and acceptability. It was also recognised that implementation may need to be incremental rather than nationwide rollout at one go. The initial implementation should take place in chain pharmacies, as they could be ready to provide such services as national implementation needs time. While it was suggested making such services mandatory for at least one every 50-community pharmacy within a chain pharmacy group, other community pharmacies were thought to implement some activities towards CVD risk prevention based on their capacity.
“…We would start with big chain pharmacies to provide those services like for example in Riyadh we have like 2 or 3 pharmacies that might want to start those services and start gradually and this eventually will end up with completing those services in all of those pharmacies ….” (Pt19, M, 30-39, Govt.)
“… I suggest that this be at least mandatory for chain pharmacies. For example, now XX chain pharmacy have almost 1000 pharmacy, we can make it mandatory that of every 50 pharmacies, at least one should provide screening. If they wish to increase this limit, it would be up to them, but this shall be the minimum.” (Pt8, M, 50-59, Govt.)
2. Affordability and access
Participants suggested health promotion/social marketing methods to enhance the public’s awareness of these services, using a range of marketing channels (social media, referrals (health professionals), word of mouth, television and radio). It was thought that such measures were especially important to create a reach for pharmacy services in rural areas - since access to physicians in such areas is limited. Public health activists, patients’ advocates, social media influencers and religion leaders were also suggested to be engaged to enhance awareness of these services.
“By educating the public through social media like WhatsApp…. and through television and radio….” (Pt14, M, 30-39, Govt.)
“….in rural areas, where there is a lack in number of physicians, pharmacists are well-trained and educated to provide the necessary preventative measures….” (Pt2, M, 30-39, Govt.)
“…. men of religion or leaders can help address the issue [CVD risk]. They can talk to people in mosques about the Islamic way of living as a good system or a good model to prevent those problems because our religion, Islam, is always in favour of prevention of CHD [Coronary Heart Disease]. This has to be utilised.” (Pt20, M, 50-59, Govt.)
Participants emphasised that incentives for service-provider pharmacists were required for the sustainability of such services. A reimbursement system via the government and/or health insurance companies was suggested (on a pay-for-performance basis). This, it was proposed, would keep the services affordable for patients.
“…. So, if you want to implement screening, then it has to be paid for either by the government or the insurance companies….” (Pt15, M, 40-49, Govt.)
“…. Cost affordability of the services will encourage patients to come and use these services….” (Pt15, M, 40-49, Govt.)
3. Service adoption
The participants mentioned that as public perception of community pharmacists was still centred around them being ‘products suppliers’, there may be hesitancy in engaging with pharmacy services. High-quality, standardised, ministry supported/accredited services, were likely to, over time, address consumer hesitancy in engaging with pharmacy services by accruing trust.
“…the most important aspects are quality standards that have to be met in screening to establish a very strong and trustworthy patient-pharmacist relationship and this will be established by more communication between the pharmacist and patients….” (Pt4, F, 40-49, Govt.)
“… many people look at pharmacies as a place where they go, buy things, and go out. They don’t think of pharmacies as healthcare facilities. This, I think, will be one of the limitations that will exist, initially at least. They need to readjust their way of thinking that pharmacists are just vendors….” (Pt2, M, 30-39, Govt.)
4. Health system changes
Most participants agreed that the Saudi primary healthcare system was still evolving. The system lacked current networking paths between community pharmacy and primary healthcare centres; these would need to be facilitated to implement pharmacy CVD risk prevention/management. Some physicians were thought to still be unaware of pharmacists’ role and ability in general and particularly community pharmacists, which may impact policy and regulations for pharmacy practice.
“Well, I think the primary healthcare system in Saudi Arabia is still fragmented….” (Pt10, M, 30-39, Govt.)
“……Currently, there is a complete lack of understanding and lack of knowledge among physicians and other healthcare professionals, to be honest, about the role of pharmacists in clinical and community settings….” (Pt2, M, 30-39, Govt.)
Finally, as the interview guide applied Donabedian’s model for service quality [24], which identifies three key elements of a high-quality health service (structures, processes and outcomes), the raw data were examined to see the extent to which participant discussions centred around these factors (Figure 2).