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A national survey exploring oral healthcare service provision across Australian community pharmacies.

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Manuscript ID Article Type:

Date Submitted by the Author:

Complete List of Authors:

28-May-2017 Freeman, Christopher ; The University of Queensland, School of Pharmacy Abdullah, Nabilah ; The University of Queensland, School of Pharmacy Ford, Pauline; University of Queensland Taing, Meng-Wong; The University of Queensland, School of Pharmacy Health services research Dentistry and oral medicine

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Keywords:

Research

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Secondary Subject Heading:

bmjopen-2017-017940

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Primary Subject Heading:

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Pharmacy, oral health services, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

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A national survey exploring oral healthcare service provision across Australian community pharmacies Christopher R. Freemana, Nabilah Abdullaha, Pauline J. Fordb, Meng-Wong Tainga a

School of Pharmacy, bSchool of Dentistry, The University of Queensland, Australia

Correspondence Dr Meng-Wong Taing, School of Pharmacy, The University of Queensland, Pharmacy Australia Centre of Excellence, Level 6, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia. E-mail: [email protected] Ph: +61-73346 1988

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Abstract

Objectives: This study investigated pharmacists’ and pharmacy assistants’ current practices and perspectives with regard to oral healthcare provision across Australian community pharmacies.

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Design: Cross-sectional study.

Participants: Pharmacists and pharmacy assistants working within 1000 randomly selected Australian community pharmacies (for each cohort) were contacted by telephone. A questionnaire for each cohort was developed, and was administered by online or postal means. Pearson’s Chisquared test was used to examine relationships between categorical variables.

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Results: The overall response rate was 58.5% (644/1100) for the pharmacist cohort and 28% (280/1000) for the pharmacy assistant cohort. This represents pharmacy staff responses from 803 community pharmacies across Australia (approximately 14.6%, 803/5500 of community pharmacies nationally). Overall, the majority of pharmacists (80.2%; 516/644) and pharmacy assistants (83.6%; 234/280) reported providing oral health advice/consultations to health consumers up to five times each week. More than half of community pharmacists and pharmacy assistants were involved in identifying signs and symptoms for oral health problems; and the majority believed health consumers were receptive to receiving oral health advice. Additionally, more than 80% of pharmacists and 60% of pharmacy assistants viewed extended oral health care roles positively and supported integrating them within their workplace; extended roles include provision of early intervention, prevention and referral oral healthcare services. The most commonly reported barriers to enhance pharmacy staff involvement in oral healthcare within Australian community pharmacies include lack of knowledge, ongoing training and resources to assist practice.

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Conclusions: This study highlights that Australian pharmacists have an important role in oral health, and provides evidence supporting the need for growing partnerships/collaborations between pharmacy and dental healthcare professionals and organisations to develop, implement and evaluate evidence-based resources, interventions and services to deliver improved and responsive oral healthcare within Australian communities.

Keywords Pharmacy, pharmacist, pharmacy assistant, oral healthcare services.

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Strengths and limitations of this study •

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This study describes oral health services provided by Australian pharmacy staff, and explores

attitudes towards implementation of early intervention, prevention and referral oral health services in community pharmacies. The sample size for this study included data from 644 pharmacists and 280 pharmacy assistants which captures a range of Australian pharmacist and pharmacy assistant responses. Responses were self-reported and may be subject to respondent recall and social desirability bias.

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Introduction Good oral health is essential for quality of life and for general health.[1] It can be defined as being free from any disease or disorder limiting an individual’s ability and capacity in biting, chewing, speaking, smiling and psychosocial wellbeing.[1] Oral disease is a considerable burden to the community with oral healthcare costs ranking as the second most expensive disease group in Australia.[2] Almost all Australians experience an oral or dental problem in their lives and expenditure in Australia on dental health services (excluding hospitals) was $8.7 billion in 2012-13, equivalent to approximately 6.5% of total national health expenditure.[2] Poor oral health is associated with complex interactions between individual, structural, social and economic factors. These include geographic, cultural and financial access issues and individual health behaviours.[3]

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In the majority of cases, the high cost of oral healthcare can be avoided by effective prevention strategies.[1, 4] In Australia, potentially preventable oral conditions include tooth decay, gum disease and oral cancer.[5] Disadvantaged members of the community including low-income earners, the elderly and remote/rural and regional residents are less likely to receive preventive care services and are at higher risk of poor oral health compared to the general population.[3] The World Health Organisation, International Association for Dental Research, and World Dental Federation have established Global Oral Health Goals intended to provide a framework and guide health policy makers at the national, regional and local levels regarding standards for oral health. Two objectives from this proposal advocate integration of non-dental health care providers for oral health promotion and surveillance of oral diseases and disorders.[6] Numerous initiatives have been developed to support non-dental practitioner involvement in oral healthcare promotion, many of which centre around provision of early intervention, prevention and referral to oral healthcare services.[7-10] There are limited studies reporting community pharmacy involvement or participation in the provision of any early intervention, prevention and referral oral health services.

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In Australia there are approximately 5500 community pharmacies equitably distributed and highly accessible in metropolitan, suburban, rural and remote regions.[11] On average, each person in Australia visits a community pharmacy up to 14 times per year.[12, 13] Community pharmacy staff are trustworthy, knowledgeable and well respected healthcare professionals that play a critical role in delivering quality healthcare to people of all income levels and stages of life.[14] Services are generally provided without charge or need for an appointment and are usually in close proximity to people’s homes. Pharmacists and pharmacy assistants are often the first or only point of contact with a health professional particularly for disadvantaged population groups including the elderly, who frequently visit their pharmacy for general and medication related health advice.[15-17] Patients with chronic conditions (e.g. cardiovascular disease and diabetes) are also in regular contact with pharmacy staff for their prescriptions which presents an excellent opportunity to promote health advice through the common risk factor approach.[18, 19] Because community pharmacy staff are readily accessible in the community [11] and have established relationships with regular clients, they are ideally positioned to recognise and appropriately manage or refer a range of common oral health conditions for many population groups living in Australia. Community pharmacies may also logistically serve as ideal healthcare destinations to implement and deliver early intervention, prevention and referral oral health services to reduce the incidence of potentially preventable oral conditions including tooth decay, gum disease and oral cancer. Recent publications by the US Institute of Medicine and the Australian Dental Association (ADA) advocate for closer working

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relationships between non-dental healthcare professionals and the dental profession to build professional capabilities and undertake oral disease prevention, health promotion and screening to reduce oral health disparities within communities.[20, 21] In the last 20 years, the traditional role of pharmacists (i.e. dispensing and compounding medicines) has evolved to include a broader range of functions within primary health care.[22-24] International studies and reports recognise the potential to enhance the role of pharmacy staff in oral health, given they are regularly consulted for a variety of oral health related issues. [17, 25-27] Australian and international studies report pharmacy staff are eager to expand and undertake new roles in public health, expressed a strong interest in providing oral healthcare services to the community and viewed this role positively.[27-31] Our previous study reported that community pharmacists valued their role as oral health advisors and that both pharmacists and pharmacy assistants were involved in handling the majority of oral health related presentations in Australian community pharmacies. Nearly all pharmacists (97%) also desired further education and training to benefit their practice in oral healthcare. The aim of this present study was to extend the findings of our previous work to gain further insight and knowledge about oral healthcare service provision across Australian pharmacies. The specific objectives of this study were to:

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1) Identify services provided by Australian community pharmacy staff (pharmacists and pharmacy assistants) in oral healthcare and describe the range of over-the counter products stocked within Australian community pharmacies

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2) Evaluate Australian pharmacy staff attitudes and reported barriers towards provision of oral healthcare services and early intervention, prevention and referral to oral health services in Australian community pharmacies

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3) Determine pharmacy staff future training areas, further support required and preferences for training and;

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4) Assess for associations between staff characteristics and workplace/practice location variables with respect to oral health services/products provided, attitudes towards oral healthcare/preventive services and staff training preferences.

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Methods

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Development of pharmacy staff questionnaires

The questionnaires used in this study were based on the authors’ (MWT, CF, PF) discipline-specific knowledge and experience in oral healthcare; and national Australian questionnaires created by Hussainy et al (2015), however reflecting topics relating to provision of oral healthcare and promotion services. Two questionnaires, one for pharmacy assistants and one for pharmacists were developed and comprised of 4 sections to address the aims of this study. Section A comprised of items relating to participant demographics; section B asked questions relating to oral health services provided at the pharmacy; section C asked questions relating to staff attitudes for provision of oral healthcare and preventive services in pharmacy and section D enquired about staff regarding training areas/further support required. The questionnaire was piloted for content and face validity by pharmacy and dentistry university academics (n=2), pharmacists (n=5) and pharmacy assistants (n=5). Changes regarding 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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wording and formatting of questions were made and re-piloted with pharmacists (n=3) and pharmacy assistants (n=3). Suggested changes were incorporated into the final questionnaire prior to national dissemination (see Supplementary S1 for the questionnaires). Sample size calculation and randomisation From approximately 5500 Australian community pharmacies, for each pharmacist and pharmacy assistant questionnaire, a sample size of 360 pharmacies for each cohort would provide a target 5% margin of error for population percentage estimates with a level of 95% confidence. A minimum 40% response rate was assumed (based on previously used recruitment strategy by the authors[32]), therefore a randomised sample of 1000 Australian community pharmacies for each pharmacist and assistant cohort was selected (2000 pharmacies in total). An Australian pharmacy premises list obtained from pharmacy premises authorities from each Australian State/Territory was used to randomly select a proportional number of pharmacies (20%) from each State/Territory. Randomisation was performed using Excel 2013.

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Participant recruitment

All 2000 pharmacies were telephoned and pharmacists and pharmacy assistants from each cohort (1000 pharmacies each), were invited to complete the questionnaire by online or postal means. Three followup reminders were made to participants via phone/email at two weekly intervals. Data collection occurred between June and September 2016. All participants received a $10 retail gift card upon completing the questionnaire to improve response rates. Data Analysis

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The questionnaire responses were descriptively analysed using Statistical Package for Social Sciences (SPSS v24) and Microsoft Excel 2013. Pearson’s Chi-squared test was used to determine significant relationships between categorical variables; the significance level was set at p 5 minutes Other (please specify):__________________

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22. When providing oral health advice/products, do you follow or refer to any resources/guidelines?

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Yes (please specify name of the guideline/resource):___________________________ No

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23. Generally, are patients receptive to receiving oral health advice from you? (Please select only one)

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Always Most of the time Sometimes Hardly ever Never (please give reason why):______________________________________________ Unsure I do not provide oral health advice to my patients

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Section C: Pharmacy assistant attitudes, preferences and opinions regarding oral healthcare provision

24. As a pharmacy assistant, I feel confident in my practice to identify signs and symptoms for:

Strongly Agree Mouth ulcers/lesions Pulpitis (inflammation of nerves, blood vessels and connective tissue inside a tooth) Gingivitis (mild gum infection) Periodontitis (serious gum infection) Oral abscesses (localisation of pus that can form inside teeth, gums or in bone of mouth) Alveolar osteitis (dry socket) Cracked, Fractured, Loose or Displaced Tooth Fragments and Restorations Orthodontic problems (irregularities in teeth and jaw) Ill-fitting or Loose Dentures Sinusitis (inflammation of sinuses) Injuries to the Mouth, Face and Jaws Acute Temporomandibular Joint (TMJ) Conditions Salivary Gland Obstruction or Infection Intra-oral Swellings and Abnormal Appearance Poor general oral hygiene practices Drug-related adverse oral events Oral thrush Dental erosion (acid erosion) Dentine hypersensitivity (sensitive teeth) Xerostomia (dry mouth) Halitosis (bad breathe) Bruxism (grinding/clenching teeth when asleep or awake) Trigeminal Neuralgia (trigeminal nerve disorder) Oral-health issues in pregnant women Oral-health issues in young children, toddlers and infants Other (please specify)____________

Agree

Disagree

Strongly Disagree

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25. We are interested in your opinions about different aspects of pharmacy practice in oral healthcare. Please choose an appropriate response for each item:

Strongly Agree

Agree

Neither agree or disagree

Disagree

Strongly Disagree

Pharmacy assistants have an important role to play in promoting oral healthcare in the community I am comfortable looking inside a patient’s mouth to identify/diagnose oral health issues Identifying/diagnosing oral health issues and making appropriate evidence-based product recommendations is part of my professional responsibility I would be interested in receiving further training to better identify/diagnose oral health issues and make appropriate evidence-based product recommendations for my patients Offering oral health care programs/services in pharmacies is a good use of time and money I would be interested in working collaboratively with other health care professionals in the local area to support better oral health for the community

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26. The following questions below refer to provision of ‘oral health assessment and preventive services’ in pharmacy. This includes but is not limited to performing oral health services such as: - Dental cavity risk assessments (determining the likelihood of caries and their progression in patients) - Screening and dental practitioner referral programs (e.g. ‘Lift the Lip program’ - Screening patient mouths to detect the presence of cavities and appropriately referring) - Fluoride varnish application (Applying fluoride varnish on patients teeth) - Patient education/ guidance to promote and maintain good oral health. Your pharmacy may not currently offer these oral health services. We are however, interested in your opinions regarding these services. Please choose an appropriate response for each item:

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Integrating oral health assessment and preventive services in community pharmacy is a good idea I would be interested in receiving further training to perform oral health assessment and preventive services in the community I would be interested in performing oral health assessment and preventive services in the community

Strongly Agree

Neither agree nor disagree

Agree

Disagree

Strongly Disagree

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Oral health assessment and preventive services would be useful in all communities Oral health assessment and preventive services would be more useful in disadvantaged communities (e.g. lower socioeconomic status)

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27. Please describe your thoughts regarding whether identifying/managing oral health presentations and providing additional oral health assessment and preventive services should be part of your professional scope of practice? (open question)


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28. What are the barriers to furthering your role in oral healthcare? (Mark all that apply) No anticipated barriers Lack of knowledge/training in this field Lack of staff training resources (eg. online training modules/programs, seminars) Lack of time to develop, implement, sustain oral health promotion programs/services Lack of oral health educational promotion materials for consumers (e.g. pamphlets, posters) Support from manager or pharmacy owner Personal costs associated with training in this field or implementing health promotion programs/services Lack of privacy/consultation rooms to support oral health care roles in pharmacy Lack of public interest Lack of personal interest Lack of remuneration Other_________________

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29. Are you aware of government dental funding schemes available to support dental care for patients? Yes (please describe):____________________ No

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30. Are you aware of public dental clinics and patient eligibility to use these clinics to support dental care for patients? Yes No

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31. What are your thoughts regarding fluoridation (adding fluoride) in Australian drinking water supplies? (Select only one) Should be continued as it is a safe, effective, efficient and socially equitable approach to prevention of caries Is not a safe population approach to the prevention of caries Not sure Other________________________

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Section D – Training areas and further support required 32. Which factors do you feel may improve the ability of pharmacies to promote better oral health in Australia? (Mark all that apply) Extra staff to provide appropriate advice, counselling and support to assist customers Private counselling/consultation to support oral health care roles in pharmacy Pharmacy-specific practice guidelines, decision support pathways, information and educational resources for oral health promotion/management of oral health issues Further training for pharmacy assistants Further training for pharmacists Payment for providing oral health advice Payment for provision of additional oral health assessment and preventive services in my pharmacy (e.g. screening for cavities in children, patient oral health assessment interviews and fluoride varnishing) Other (please specify):_________________________________________

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33. What format would you like to receive training about how to identify/diagnose and manage oral health problems? (Mark all that apply) Face to face Online Webinar Other (please specify):______________________________________ Would not like to receive training in this area

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34. What format would you like to receive training about providing oral health assessment and preventive services e.g. screening for cavities in children, patient oral health assessment interviews and fluoride varnishing? (Mark all that apply) Face to face Online Webinar Other (please specify):______________________________________ Would not like to receive training in this area

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35. In your opinion, when is information about oral health knowledge/training best delivered? (Mark ALL that apply)

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During my studies/training as a pharmacy assistant Continuing Professional Development Formal course Other (please describe):_______________________________________

36. Do you have any comments regarding oral health services in community pharmacies? (Open answer)


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If you would like to receive a $10 Coles/Myer gift card for completion of the survey, please enter your name and contact details (phone number/email) below: Name:_________________________________________________

Contact number/email:____________________________________

Postal Address:__________________________________________

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Thank you for participating in this survey.

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Supplementary S2. Proportion of community pharmacies (n = 803) stocking a range of oral healthcare products as reported by Australian pharmacists and pharmacy assistants Oral healthcare products stocked in community pharmacies

Response rate %

Oral hygiene products

99.6

Mouth sore/ulcer relief products

99.6

Oral-related pain/toothache relief products

99.1

Oral thrush treatments

98.9

Sensitive teeth toothpastes

98.1

Dry mouth products

98.1

Denture cleansing products

97.6

Denture adhesives

96.1

High fluoride dental care products

95.9

Mouth rinses (Alcohol containing/free antibacterial)

95.5

Chlorhexidine-based products (gels/mouth rinses)

92.3

Sugar-free confectionary/gum

87.1

Fluoride-based mouth rinses

69.9

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Naturally-based dental hygiene products

63.4

Orthodontic wax

52.9

Dentafix filling repair and cap repair products Recaldent® (CPP-ACP) based products Dentist in a Box® dental emergency kits

35.4

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8.3 7.7

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Supplementary S3. Pharmacist and pharmacy assistant reported factors and preferences for delivery of education resources Pharmacists

Pharmacy assistants

(n=644)

(n=280)

Factors that may improve the ability of pharmacies to promote better oral healthcare in Australia

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that may improve their ability to promote better oral healthcare


P value

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Further training for pharmacists

90.8% (585)

63.2% (177)