Tourist travel is on the rise and, despite recent economic

Transcription

1 99 ORIGINAL ARTICLE Are Pharmacists Ready for a Greater Role in Travel Health? An Evaluation of the Knowledge and Confidence in Providing Travel Health Advice of Pharmacists Practicing in a Community Pharmacy Chain in Alberta, Canada Christina S. Bascom, BSc Pharm, DTM, Meagen M. Rosenthal, MA, PhD, and Sherilyn K.D. Houle, BSP, PhD Travel Health Network, St Albert, Alberta, Canada; Department of Administrative Pharmacy, The University of Mississippi, Oxford, Mississippi, USA; School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada DOI: /jtm Background. Patients often consult community pharmacists for medication needs related to travel, but little is known of pharmacists knowledge and readiness to provide this care. The aim of this study was to evaluate pharmacists knowledge in travel health, and to assess their confidence in providing travel-related advice to patients. Methods. A web-based survey was developed and distributed to 84 pharmacists practicing in a mid-size pharmacy chain in Alberta, Canada. The survey included knowledge and confidence assessment components. To assess knowledge, pharmacists were provided two cases, along with multiple-choice questions examining pre-travel risk assessment, and advice on travel at altitude, vaccines, malaria, travelers diarrhea, and other potential travel health risks. Confidence was assessed by asking respondents to report their level of confidence in answering each knowledge assessment question and providing travel advice overall, using a 5-point Likert scale. Respondents were also asked to indicate preferred means for receiving additional training in travel health. Results. A total of 53 pharmacists responded to the survey, with a response rate of 63%. Most (61%) indicated that they had some level of training in travel health and 69% counseled on travel health more than once a month. Only one respondent correctly answered all six questions in the knowledge assessment section. The mean knowledge score (proportion of correct answers, unaided) for the group was 27%. However, the majority (66%) felt confident that they would know where to seek the information required to answer the questions. Overall confidence in this group of pharmacists was determined to be low, with only 21% of respondents reporting that they felt highly confident in providing travel health advice. Conclusions. Travel health is becoming an increasingly common topic of discussion between patients and pharmacists. This study suggests that pharmacists baseline knowledge of travel health may be incomplete, affecting their confidence in providing this advice. Undergraduate and continuing education training programs must expand travel health curricula to meet this growing need. Tourist travel is on the rise and, despite recent economic setbacks, continues to grow. In 2013, over 1 billion international tourist arrivals were reported worldwide, with an increase of 4% to 4.5% expected in Since 2008, pharmacists in Alberta, Canada, have been eligible to obtain authorization to administer drugs and vaccines by injection, and to initiate drug therapy. 2 These legislative abilities present an opportunity Corresponding Author: Sherilyn Houle, BSP, PhD, School of Pharmacy, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada. sherilyn.houle@uwaterloo.ca for pharmacists to play a larger role in the provision of preventive care for travelers in community pharmacies or travel clinics. Interest in providing travel consultations by pharmacists in Alberta is evidenced by the opening of a number of pharmacist-directed travel clinics, and the designation of 48 pharmacies in Alberta as Yellow Fever Vaccination Centres by the Public Health Agency of Canada as of May Travelers often neglect to seek pre-travel advice because of a lack of perceived risk regarding their destination, or an inability to obtain appointments from existing travel clinics, which are often overwhelmed. 4 6 Pharmacists are easily accessible, have long hours of operation, and have a high level of public trust; 2014 International Society of Travel Medicine, Journal of Travel Medicine 2015; Volume 22 (Issue 2):

2 100 Bascom et al. therefore, a greater role for pharmacists has the potential to increase the frequency and quality of pre-travel advice sought out by travelers Pharmacist-provided travel advice has been well received by patients 7 and has also been demonstrated to be clinically effective. A recent study found that more appropriate evidence-based recommendations on prophylactic antibiotics for travelers diarrhea, anti-malarials, and vaccines were provided, and the proportion of patients actually receiving the recommended therapy was higher, among patients cared for by a pharmacist specialist in travel health versus usual primary care providers, even with access to the same clinical resources. 7 While previous research has found care provided by pharmacists with a specialty practice in travel health to be effective and well received by patients, other work suggests that generalist pharmacists may have knowledge deficiencies preventing a more effective provision of these services in the community. 12,13 For example, while a study of pharmacists in Portugal found a positive correlation among younger age, recent graduation from pharmacy school, and the number of correct responses on a knowledge assessment questionnaire, it ultimately found that pharmacists lack knowledge in important areas related to travel health, including malaria and vaccines. 13 As described in the knowledge translation literature, a component in the successful integration of knowledge into practice is practitioner confidence. 14 As such, the primary aim of this study was to examine both pharmacists knowledge in travel health and their confidence in providing this advice to patients within the Alberta context. A secondary aim, anticipating the identification of knowledge and confidence deficiencies, was to identify pharmacists preferred means for obtaining education on travel health. The findings of this study will be used to develop knowledge translation strategies to improve the provision of travel advice by pharmacists. Method Questionnaire The investigators created a web-based questionnaire to assess community pharmacists general knowledge of travel health, as well as their confidence in applying that knowledge. An was distributed to all pharmacists of a mid-sized pharmacy chain in Alberta. This included a letter explaining the study and inviting their participation, along with a link to the survey. The pharmacists were encouraged to provide their answers within a 2-week timeframe, and one reminder was sent 5 days prior to the deadline. The pharmacists level of knowledge was assessed using two cases outlining common, yet somewhat complicated, travel health scenarios. The cases were designed to assess knowledge of travelers diarrhea, altitude sickness, malaria, vaccinations, and other preventable health risks. The respondents were encouraged to assume that the case subjects were in front of them, and to answer the questions without consulting any reference material. Each case was followed by three multiple-choice questions, each with five possible answers and a sixth option indicating that the respondent would need to consult a reference. Questions on traffic and personal safety, cruise travel, diving, and management of preexisting medical conditions were not included to keep the questionnaire brief and relevant to questions asked of a typical community pharmacist. The respondents were also asked to rate their level of confidence in answering each question, and to provide an overall assessment of their confidence in providing travel health advice along a 5-point Likert scale. Finally, respondents were provided with a list of potential learning programs or support services and asked to score each based on its perceived value in improving their level of knowledge and confidence in providing travel advice. These services ranged from self-study and online continuing education (CE) courses to formal training programs with a residential (on campus/in person) component. Each question was carefully created using a number of travel health references (Centers for Disease Control and Prevention, 15 the World Health Organization, 16 Travax UK, 17 and the National Travel Health Network and Centre 18 ). Questions were created by a practicing community pharmacist completing a Diploma in Travel Medicine from the Royal College of Physicians and Surgeons of Glasgow, 19 and were reviewed by pharmacist, physician, and qualitative research experts for comprehensiveness and accuracy. As this was a small-scale study intended to serve as a pilot to a larger evaluation, questions were not tested prior to circulation. Study Population The survey was distributed to 84 full-time pharmacists practicing within a community setting, employed by the same pharmacy chain in Alberta, Canada. The chain s pharmacies are generally located in urban centers, and are geographically spread across the province. Data Analysis Answers to the cases multiple-choice questions were scored as correct or incorrect. Each question was designed to have only one correct answer. Pharmacists also had the option of selecting I don t know, I would have to look this up, which was scored as an incorrect answer for the purpose of the analysis. Pharmacists confidence scores for each of the knowledge questions and for overall confidence in sourcing travel health information and providing travel advice unaided were calculated by determining the median score across all the respondents. The results of the preferences for training and support services were first recoded by truncating the ends of the Likert scale. Items 1 and 2 were combined into a less important category and items 4 and 5 were combined into a more important category. Item

3 Community Pharmacists Knowledge and Confidence in Providing Travel Health Advice remained as the neutral category. These results were analyzed using a frequency count (ie, number of more important, less important, and neutral responses), represented proportionally to improve interpretability. All results are presented descriptively. Ethical Approval The study was completed as part of a Diploma in Travel Medicine through the Royal College of Physicians and Surgeons of Glasgow. According to the College, formal ethics approval was not required for completion of this study, but respondents were informed that the information collected was for research purposes and would be presented in aggregate form, and that they could decline to complete the survey at any time. Results Of the 84 pharmacists invited to participate, 53 completed the questionnaire, resulting in a 63% response rate. The respondents had been in practice for an average (±SD) of 9.94± 9.23 years. Complete characteristics of the responding pharmacists are presented in Table 1. Knowledge Assessment The results of the two cases are presented in Appendix S1, Supporting Information with the online version of the article. Bold italicized type indicates the correct response. The mean (±SD) proportion of correct answers across all the case study questions was 27.4% ± 14.8%. Only one respondent answered all six questions correctly. The pharmacists scored most favorably on the questions assessing knowledge of pre-travel assessment (98% correct responses) and travelers diarrhea (40%). The pharmacists scored most poorly on the questions testing the knowledge of vaccines (4%) and traveling at altitude (2%). Overall, the option I don t know was chosen 33% of the time, and an incorrect answer was chosen 39% of the time. Confidence Assessment The pharmacists confidence in answering the knowledge assessment questions was highest for pre-travel assessment (median score 4), followed by travelers diarrhea, vaccines, and malaria (median score 3), and lowest for traveling at altitude and other health risks (median score 2). The pharmacists generally lacked confidence in providing travel health advice unaided, with only 21% feeling confident, 8% feeling not confident, and the majority of respondents feeling neutral regarding their overall confidence. While the pharmacists appeared to lack confidence in answering questions unaided, 66% of respondents reported feeling confident regarding sourcing travel health information if they needed to look up an answer. Table 1 Characteristics of survey respondents Characteristic n (%) Years in practice 0 5 years 20 (38%) 6 10years 14 (26%) years 8 (15%) 16 or more years 11 (21%) Practice authorizations obtained Additional prescribing authorization 2 (4%) Authorization to administer injections 40 (75%) Training in travel health (select all that apply)* No training 23 (43%) Self-study 16 (30%) Online continuing education 11 (21%) Live continuing education or distance learning 8(15%) program with a residential component Frequency of providing any travel medicine counseling (including travelers diarrhea, vaccines, etc.) Daily 2 (4%) At least once per week 11 (21%) At least once per month 24 (45%) Less than once per month 13 (25%) Rarely 3 (6%) *Percentages may not sum to 100% because multiple responses could be selected per respondent. Figure 1 Respondents reported value of various educational options for improving knowledge and confidence in travel medicine. Training and Support The majority of pharmacists scored each educational program or support tool as being of high value in improving their knowledge, as shown in Figure 1. An online/live medical support program, with a score of 65%, was felt to be the most valuable in improving the overall confidence and knowledge of the pharmacists surveyed, followed by an online CE course of more than 8 hours duration, distance learning with a residential component, self-study, and live CE programs. Discussion Community pharmacists are often asked to provide travel advice to patients. However, our survey demonstrates a knowledge gap, showing that pharmacist

4 102 Bascom et al. respondents have low confidence in providing this type of care. With international travel gaining in popularity and pharmacists scopes of practice expanding toward conducting medication assessments, administering injections, and prescribing drug therapy, travel health represents a potential opportunity for pharmacists to provide a valuable service for patients. To take advantage of this opportunity, obtaining training and support via online or live channels for consulting travel health experts, online CE, and formal distance learning programs with a residential component are the preferred means for developing competence to provide travel health consultations. The demand for pharmacist-provided travel advice observed in our study appears consistent with previous work conducted in Switzerland and in Portugal. For example, our survey found that 65% of respondents counseled patients on travel-related topics more than once per month, compared to 64% of Swiss pharmacists. 12 In addition, few pharmacists in our study had obtained any formal training in travel health, but the majority (57%) had obtained some learning, including self-study. This is consistent with the work of Teodósio et al. in Portugal, finding that 78% of respondents reported that they made an effort to stay informed on the subject. 13 This may be a result of pharmacists general interest in travel health, a need to meet the demand for this information by community pharmacy patients, or a combination of both. Results from the clinical knowledge questions were also similar to those from previous studies. Vaccine knowledge, for example, was generally low, with only 4% of Alberta respondents answering a question related to rabies vaccination correctly compared to 8% of Portuguese respondents correctly answering a question related to yellow fever. 13 However, pharmacists performed better on questions related to the treatment of travelers diarrhea in both studies. This may be a consequence of the historical scope of practice of pharmacists and the advice most commonly sought in community pharmacies. Travelers diarrhea is often treatable using non-prescription products under the advice of a pharmacist, whereas only recently have pharmacists been authorized to administer injections in a number of jurisdictions. 20 Despite pharmacists relative confidence in providing advice on travelers diarrhea, our survey found that an approximately equal proportion of respondents recommended drug therapy in the form of Dukoral (oral inactivated Escherichia coli andvibrio cholerae vaccine, Crucell Vaccines Inc., Toronto, Ontario, Canada) prophylaxis for travel to India (42%) compared to those recommending oral rehydration solutions because of the often self-limiting nature of this condition (40%). Previous studies by Kodkani et al. and Teodósio et al. also found that pharmacists were generally more inclined to recommend drug treatment over non-drug measures such as water precautions and oral rehydration solutions for travelers diarrhea. 12,13 While not captured in this study, potential reasons for this tendency could be fear of complications and liability, pharmacy schools traditional focus on drug therapy options over non-pharmacologic management, or tendencies toward risk aversion. 21 Currently, travel consultations are provided largely through primary care physicians offices or nurse-led travel clinics. A study of Dutch travel nurses confidence in adopting a supplementary prescribing role found that while over three-quarters reported feeling confident to take on this role, 14% preferred restricted prescribing authorization or mandatory completion of additional education before prescribing, and 95% reported having at least one educational need, with pharmacology being the most commonly cited. 22 Three case-based questionnaire studies of primary care physicians suggest a wide variance in the quality of advice provided by physicians. A survey of Scottish physicians observed that 36% would offer the recommended malaria prophylaxis to a case patient traveling to Turkey. 23 A study of German and Swiss physicians asked respondents to provide advice for travel to Kenya and Thailand. 24 Less than one in three of respondents provided complete advice on malaria prevention, whereas 93% of Swiss respondents prescribed acceptable malaria medication for the case regarding travel to Kenya. Vaccination advice was correctly provided by 38% of German general practitioners versus 57% of Swiss general practitioners. A survey of French primary care physicians found similar variations related to providing advice on vaccinations and malaria prophylaxis to a pregnant patient, a diabetic patient, or a healthy male patient. 25 Nearly half of the respondents reported that they would seek expert advice before prescribing vaccinations or malaria prophylaxis for the pregnant patient (43% and 44%, respectively), whereas expert advice for the diabetic or healthy male patient would be sought by 22% to 28% of respondents. Based on the limited literature to date, nurses with a specialist practice in travel health appear to be more confident regarding their knowledge than general practitioners or the pharmacist respondents in our study. This is to be expected, given the frequent application of specialist travel nurses knowledge to patient care versus that of community pharmacists or primary care physicians with less frequent travel consultations. Highly variable knowledge assessment scores among primary care physicians and the pharmacists in our study suggest that all generalist practitioners may benefit from additional training or evidence-based algorithms with respect to making care decisions. The results of this study should be interpreted in light of a number of potential limitations. While the response rate for this survey was good, the population was limited to pharmacists from one medium-sized chain pharmacy. As such, these results may not be representative of those from other chains or all community pharmacists in Alberta. One must also consider the possibility that pharmacists opting not to complete the survey may differ from respondents in terms of knowledge in travel health or the confidence to have

5 Community Pharmacists Knowledge and Confidence in Providing Travel Health Advice 103 this knowledge evaluated by the survey. Pharmacists expanded scope of practice in Alberta including the ability to prescribe drugs and administer injections may also have influenced the responses observed. For example, pharmacists not entirely confident about the answer to a knowledge assessment question may have been more likely to select the option I don t know than to guess at an answer, since in practice they may be responsible for prescribing the drug or administering the vaccine in question and, therefore, directly liable for that patient s health outcome. In addition, the knowledge assessment questions were designed to cover topics across a range of difficulty, from common questions seen in practice (pre-travel assessment and travelers diarrhea) to more complex topics such as traveling at altitude and country-specific infectious disease risks. Travelers with complex itineraries may be more likely to be referred to a specialized travel health center than to be managed in a community pharmacy. Respondents to our survey were also asked not to consult any reference materials when, in practice, online and print resources would be readily available and likely extensively used. Furthermore, the use of a small number of very specific cases cannot be considered a comprehensive assessment of the respondents knowledge base. Given that the survey questions were not pilot tested, it is possible that modified wording of questions for clarity or a larger number of cases addressing other travel concerns such as jetlag or non-pharmacologic infection prevention practices would have provided a broader or more accurate assessment. Finally, as this study was limited to a community pharmacy chain, the results cannot be generalized across all pharmacists, particularly those with specialty practices in travel health or infectious diseases. Community pharmacy-based travel clinics provide an opportunity for practice expansion and improved patient access to care. As most travel health consultations do not require physical assessment or diagnostic skills and therapy consists largely of self-care and pharmacotherapy, pharmacists can readily provide these services for most patients within their scope of practice. Travel health may therefore be a suitable area for pharmacies to begin offering specialized clinical services. Our study suggests that community pharmacists have the interest and capability to provide care for patients seeking travel advice, but would benefit from additional training to address more complex scenarios. Additional training in travel health is required, in both undergraduate training programs and continuing professional development programs, to ensure competence, and confidence, in providing these services to patients. Currently, the American Pharmacists Association offers a 10-hour advanced competency training program in pharmacy-based delivery of travel health services using a blend of online and live components. 26 We therefore suggest that our study highlights the need for expansion of such programs outside of the United States, or a training and support program through the International Society of Travel Medicine tailored for community pharmacists to address these knowledge and confidence gaps with the goal of improving travelers access to pre-travel care. Declaration of Interests The authors state they have no conflicts of interest to declare. Supporting Information Supporting Information may be found in the online version of this article: Appendix S1. Pharmacist responses and answer key for knowledge assessment questions. References 1. World Tourism Organization (WTO). International tourism exceeds expectations with arrivals up by 52 million in Available at: press-release/ /international-tourism-exceedsexpectations-arrivals-52-million (Accessed 2014 Jun 4) 2. Government of Alberta. Health Professions Act: Pharmacists and Pharmacy Technicians Profession Regulation. Available at: (Accessed 2014 Jun 4) 3. Public Health Agency of Canada. Yellow fever vaccination centres in Canada: Alberta. Available at: (Accessed 2014 Jun 4) 4. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med 2004; 11: Toovey S, Jamieson A, Holloway M. Travelers knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport. J Travel Med 2004; 11: Van Herck K, Van Damme P, Castelli F, et al. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. J Travel Med 2004; 11: Durham MJ, Goad JA, Neinstein LS, Lou M. A comparison of pharmacist travel-health specialists versus primary care providers recommendations for travel-related medications, vaccinations and patient compliance in a college health setting. J Travel Med 2010; 18: Hind CA, Bond CM, Lee AJ, van Teijlingen ER. Needs assessment study for community pharmacy travel medicine services. J Travel Med 2008; 15: Hess KM, Dai C, Garner B, Law AV. Measuring outcomes of a pharmacist-run travel health clinic located in an independent community pharmacy. J Am Pharm Assoc 2010; 50: Ipsos Reid. With interprovincial working group seeking transformative and innovative healthcare sustainability, majority of Canadians support private sector pharmacies extending products and services into avenues of health care. Available at: (Accessed 2013 Jan 1). 11. Seed SM, Spooner LM, O Connor K, Abraham GM. A multidisciplinary approach in travel medicine: the pharmacist perspective. J Travel Med 2011; 18:

6 Houle SKD, Grindrod KA, Chatterley T, Tsuyuki RT. Publicly funded remuneration for the administration of injections by pharmacists: an international review. Can Pharm J 2013; 146: Rosenthal M, Austin Z, Tsuyuki RT. Are pharmacists the ultimate barrier to pharmacy practice change? Can Pharm J 2010; 143: Overbosch FW, Koeman SC, van den Hoek A, Sonder GJB. Dutch travel health nurses: prepared to prescribe? J Travel Med 2012; 19: Usherwood V, Usherwood TP. Survey of general practitioners advice for travellers to Turkey. J R Coll Gen Pract 1989; 39: Hatz C, Krause E, Grundmann H. Travel advice: a study among Swiss and German general practitioners. Trop Med Int Health 1997; 2: Piotte E, Bellanger AP, Piton G, et al. Pre-travel consultation: evaluation of primary care physician practice in the Franche-Comté region. J Travel Med 2013; 20: American Pharmacists Association. Pharmacy-based travel health services. Available at: pharmacy-based-travel-health-services. (Accessed 2014 Jul 30) The Farmácia Popular is located in central Macao. It started its service in 1895 (Qing Dynasty, 21st Year of Guangxu Emperor s reign). It is the oldest western pharmacy in Macao, and it was the first pharmacy to provide consultation by pharmacists from Portugal. Photo Credit: Eric Caumes. 12. Kodkani N, Jenkins JM, Hatz CF. Travel advice given by pharmacists. J Travel Med 1999; 6: Teodósio R, Gonçalves L, Imperatori E, Atouguia J. Pharmacists and travel advice for tropics in Lisbon (Portugal). J Travel Med 2006; 13: Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet 2003; 362: Centers for Disease Control and Prevention. Travelers health clinician information center. Available at: (Accessed 2014 Jun 4) 16. World Health Organization. International travel and health. Available at: (Accessed 2014 Jun 4) 17. TRAVAX. Available at: (Accessed 2014 Jun 4) 18. National Travel Health Network and Centre. Health professionals. Available at: index.htm. (Accessed 2014 Jun 4) 19. Royal College of Physicians and Surgeons of Glasgow. Travel medicine: about the faculty and travel medicine courses. Available at: (Accessed 2014 Jun 4) Bascom et al.