Background: Pharmacy practice has evolved with ever-increasing roles in patient care and providing medicine use information to the community. Efficient public health care services encourage the rapid attainment of universal health coverage in developing countries.

Objective: This study was set to examine the role of health promotion activities in local community pharmacy practice.

Methods: A narrative overview of health promotion activities among Nigerian pharmacists was described and qualitative syntheses of the findings were obtained from government documents and published articles. An electronic search of the literature was conducted in Embase, Medline and CINAHL using keywords, truncations terms for adjacency search and a logical combination of these search terms.

Result: A survey of pharmacists’ participation in health promotion activities within two cities in Nigeria showed a 90% participation among respondents, irrespective of whether financial incentives or remunerations were paid for performing these activities or not. Community pharmacists in Nigeria offered free consultation services at various identified pharmacy outlets, making them readily accessible and well placed for achieving wider coverage among the public. Overall, they respondents showed willingness and a positive attitude in all domains of health promotion activities examined.

Conclusion: Community pharmacists now have the expanded and evolving roles of preventive and holistic care. The ease of access pharmacists have to patients, has positioned the profession towards the incorporation of advanced health promotion activities and involvement in various stages of awareness campaigns, especially in testing indicator sensitivity to specific targets set for community health in developing regions. The shortage of health care providers in public health facilities, especially in rural areas, could be leveraged by pharmacists who are adequately trained to educate or train the community towards a particular end or attaining set goals. Health promotion interventions driven by pharmacists, in addition to other health professionals, raise awareness levels about adverse effects of medicines and disease outbreaks. Active participation of community pharmacists in health promotion may serve as a needed link in the sustained global push towards providing increased access to essential medicines in developing communities and improving health coverage.

Keywords: public health, health promotion, health coverage, pharmacist, population health

Health promotion enables people to gain better control and improve their health and overall wellbeing.^1‒4 An important aspect of health promotion is community action and participation through health education which encourages socioeconomic and cultural activities, and improves environmental determinants of health. Diseases associated with lifestyle modifications like diabetes, and hypertension, have been on the increase with a lopsided ratio of population to healthcare staff.^5,6 The high demand of care staff underscores the need for a move towards preventive strategies and health promotion activities by pharmacists in communities. Through self-care advocacy, patients are becoming increasingly aware of various disease conditions which affects the quality of life and self-care management steps required to improve adherence or humanistic outcomes. Theoretically, potential gap exists between a healthy individual and that same person in a diseased state. Since pharmacists are located within the community, enlightenment programs on quality use of medicines would help in promoting individual behavior that may delay chronic or debilitating state development and reverse subsequent progression from infectious to virulent disease conditions. The community pharmacist role in community health promotion has not been fully incorporated in the primary health care (PHC) structure in Nigeria since its introduction in 1978 to address key health issues at the lowest level of care in the population. Health promotion for preventive, curative, and rehabilitative activities and care services has been encouraged by government through the regional health sectors.⁷ These health services combined with a service integration model (the process of including either the elements of one service or an entire service into an efficient functioning system), community mobilization and advocacy have been implemented to varying levels through the activities of international agencies, researchers and collaborators.^8‒11 However, the limited impact of these services are being felt by individuals in the community due to inadequate manpower or low numbers of healthcare professionals, poor funding for staff training and development, frail political will to implement health promotion guidelines in rural settings, meager inter-sectorial collaboration and sparse engagement between the local and state governments, among other key constraints.^9‒12 The PHC can provide a collaborative platform for deliberate planning which involves the patient, community health worker, nurse, pharmacist and physician or prescriber. In addition, engaging in talks with the Ministry of Health on ways to tap from the beneficent services offered by pharmacists would help in implementing health promotion strategies in Nigerian communities. Other stakeholders such as the Food and Drug regulatory body- NAFDAC, Consumer Protection Council, mega-distribution medicine centers, community pharmacies and Pharmaceutical Society of Nigeria, preventive care proactive health groups, and vaccination campaign clusters all need to be involved in crafting a viable strategy. The study, therefore, set out to examine and highlight some of the expanded roles of pharmacists in health promotion activities.

The study was a narrative overview of health promotion activities by pharmacists in developing nations. An electronic search of literature, from January 1985 to 31 December 2016, was conducted and relevant full articles were retrieved from Medline, Embase, and CINAHL, databases. Grey literature search was performed to retrieve any publications that met inclusion criteria using ISI® Web of Science and snowballing of references from previously identified papers along with hand searching. Relevant keywords and standard Boolean operator search terms were employed to perform adjacency search, truncations, and the combination of search terms with the links of “AND” and “OR” as required. Studies were delimited to pharmacists’ involvement in health promotion activities. Only articles published in the English Language and those that had clear methods or relevance to health promotion among healthcare professionals were considered for inclusion. Of the 96 articles found, 42 were eligible for the study, while 54 were excluded for lack of merit. The keywords used in the search were ‘health promotion’, ‘pharmacists’, ‘community’, ‘healthcare’, ‘health education’ and ‘Nigeria’.

Quality improvement in healthcare services and operational research on healthcare has evolved from the era of usual to value-based care services. The focus on value now optimizes the money spent and actual value added to patients receiving treatment. Exploring better ways of promoting quality improvement services in health care is important.^13‒16 On the other hand; improving patient outcomes is usually promoted with limited healthcare providers and pharmacists.¹⁷ Patients’ accessibility to community pharmacists has brought to the fore issues surrounding roles of a pharmacist in prevention initiatives and interventions. This is a trend in the positive direction among community pharmacists.^18,19 Health promotion activities by pharmacists include health education, behavioral and lifestyle modifications among patients. Providing care information about the available choices for disease prevention or management encourages positive behavioral change in care providers. This is not without information on policy areas that borders on health like good nutrition, physical exercise, and weight control, avoidance of overcrowding, medication use, good housing, and self-care, monitoring of illnesses, and working conditions. These activities empower individuals and communities to take responsibility for the control of modifiable determinants of health. Support, promotion, and diversification of these activities and maintaining them in a continuum as a process will sustain the positive outcomes and impacts in community health. These activities encourage people to move to a state of optimal health, which is a balance between physical, emotional, social, spiritual, and intellectual health.^20‒22

Community-based activities including vaccination, injury, or illness management specifically constitute the concept of health prevention. Whereas, the measurable improvements in individual or community health that are attributable to interventions carried out earlier account for health gain. A survey of pharmacists’ participation in health promotion activities in two cities in Nigeria showed 90% participation irrespective of whether provisions were made for reimbursement or not.^23,24 Health promotion activities encouraged by pharmacists over the years have continued to evolve from traditional provision of medicine information treatment of self-limiting conditions and management of chronic diseases. Other activities include, health education and advice, campaigns promoting lifestyle modifications and the collaborative interventions with other healthcare professionals. Some studies have focused on ways to improve promotional activities in community pharmacies.^25‒28 A study in Uganda showed that clients accessing injectable contraceptives in a community pharmacy were satisfied with the quality of care, excluding the cost of care.²⁹ In Canada, patients were satisfied with the general services provided by community pharmacists but did not consider domains of satisfaction.³⁰ A randomized controlled trial observed diabetes patients in Denmark and findings showed improvement in medicine therapy management and patients’ quality of life in community pharmacies.³¹ An evaluation of the effectiveness of pharmacists’ primary care consultations in a pre-post intervention study in Australia showed that patient satisfaction was established with pharmacists’ consultations and effective resolution of medicine therapy problems.³² A quasi-experimental study that considered health promotion in the United States of America (USA) indicated a decrease in hospital readmissions, reduction in medicine therapy problems, and improvement in care and patients’ quality of life.³³

A collaborative practice agreement in the USA enhanced community access to Lyme disease prophylaxis and reported high level of satisfaction for community pharmacy services rendered, though, relapses and major side effects were not recorded.³⁴ Another study in the USA showed that pharmacy-based cognitive memory screening and referrals yielded positive impact and suggested incorporation of core clinical services into community pharmacies.^35,36 An observational study in England on expanded practice status of pharmacists revealed that community pharmacists’ involvement in health care activities had improved vaccination rates with a high level of patients’ acceptability.³⁷ In addition, pharmacists’ interventions in communities had been found to improve patients’ knowledge and self-management of asthma,³⁸ improved adherence and glycemic control in diabetes patients,³⁹ and satisfaction with opioid substitution treatment.⁴⁰

A cross-sectional study in Quebec, Canada showed positive attitude of community pharmacists in health promotion especially in the area of health screening for hypertension, diabetes, dyslipidemia, smoking cessation, sexual health, infectious diseases control, and immunization.⁴¹ However, the limitations, which hinder their full involvement, included the limited interaction between pharmacists and other health professionals, no proper fees or reimbursement for services provided, policy-related issues with only non-maleficent legislation backing pharmacy practice, and the huge workload on the community pharmacists discourages participation in health promotion.⁴¹ These have contributed to the gap between their actual and ideal involvement in health promotion activities. Other studies suggested that pharmacists and the general population would welcome increased participation of community pharmacies in preventive healthcare services. This underscores the need for better utilization of community pharmacists’ services of other health care staff, and continuity of care in the planning, development, and execution of public health programs.^41‒43 Many published studies have shown a low level of pharmacists’ involvement in public health programs and activities which range from preventive or curative interventions to continuity of care. Therefore, there is the need for full integration of relevant public health courses and programs into pharmacy education and training. This will be invaluable in promoting community pharmacy health programs and improve population health.^44‒49

Some studies identified remuneration for service delivery, inter-professional communication, and collaboration with other healthcare givers, government policy, and patients’ expectations as the key facilitators of practice change in community pharmacies that could be explored in maximizing their input in present and future public health programs.^50,51 Other factors, which influence the implementation of health promotion activities by pharmacists, include community factors like religious believes cultural practices and gender. Non-availability of data or demographic information of the targeted population, poor communication between the media, schools and communities, and institutional factors were all considered as limitations.^52,53 To our knowledge, the first public healthcare facility in Nigeria was a dispensary established by Church Missionary Society at Obosi in Anambra State in 1880 followed by others in Onitsha and Ibadan. Subsequently, the take-off of Sacred Heart Hospital, as the first hospital established by Roman Catholic Mission in Nigeria in 1885 at Abeokuta Nigeria and St Margaret Hospital built in 1889 at Calabar, Nigeria.^54,55 Community pharmacy outlets in Nigeria today offer free consultation services, which make them readily accessible to the populace. They outlets serve as referral centers and carry out health improvement services, promotion of self-care, management of prescribed medicines, caregivers’ education, and targeted health promotion services among others.^56,57 Community pharmacies stock health promotion products for newborn, infants, children, adolescents, women, geriatrics, and the general population. They offer harm reduction services to injection drug users. In Canada, India, China, Australia, and Europe, community pharmacies are centers of opioid substitution therapy, human immune deficiency virus (HIV) and hepatitis prevention services.^58‒63 A quasi-experimental study conducted in various jurisdictions in Nigeria including Abuja, Kwara, Abia and Edo states indicated that community pharmacists serve as a bridge between patients and physicians and offer varying levels of maternal and child healthcare services. However, intervention on focused antenatal care produced significant improvement on their knowledge of the subject and services. Such intervention services could be improved upon to complement on already existing ones. More than 15% of the community pharmacists attend to between 5 and 10 pregnant women daily.⁶⁴ This shows that high population of pregnant women accesses the services of community pharmacists. In USA, for example, the Centers for Disease Control and Prevention (CDC) has reorganized the community pharmacists and incorporated active participation in disease management for many chronic diseases as part of their role in the health team among the elderly.

The team-based relationships with pharmacists and other strategic stakeholders is constantly developed by the CDC to improve population health.^65‒71 Policy makers in developing countries may follow a similar trend and promote discussions around major interventions or clinical trials which include pharmacists in health promotion activities that benefit the their citizens. In recent studies, Farquhar⁷² suggested targeted application of beneficial principles from community health promotion. Community organizing and educational programs by community pharmacists for specific populations should involve advocacy, activism, coalition building and leadership amidst a series of parallel synergistic regulatory changes from both local and national arms of policy and decision makers to evoke a successful behavior change.

The roles of community pharmacists have been evolving in the last few years century and have been greatly expanded with automated dispensing systems. Improving upon the current practice among community pharmacists in Nigeria requires readily and easily accessible healthcare providers in all pharmacy outlets which are evenly spread, in both urban and rural areas, within the community. The increasing need for quality healthcare services and the limited number of healthcare staff available, places a huge demand for preventive services, disease management and health promotion activities. Scaling up community pharmacists involvement with health promotion activities will help to accelerate universal health coverage while maintaining access to many public health services in the communities.

None.

Author declares that there is no conflict of interest.

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