ASHP InterSections ASHP InterSections

June 1, 2010

Bringing Pharmacists’ Services to Rural Africa

Getting Started

Imbi Ichile, Pharm.D.

When I first got to South Africa, I was very excited, but I also had to establish myself and my credentials. There was some skepticism about a pharmacist coming from the U.S. and coming through a pharmaceutical company residency program. I had to let them know I was there as a professional, and that I wasn’t going to push anything on them.

Cultural barriers were also a consideration. I had heard that I’d be in competition with traditional healers, but actually, I found there was a lot of camaraderie between traditional and mainstream healers. They do training back and forth. There’s a high level of cultural sensitivity involved. You can’t go in and say, “That’s wrong; this is right.” It’s more about how you work your pharmacy expertise into what their beliefs are. You get better results that way.

Finding New Opportunities

The residency required me to be quite creative, as I had to tailor the work to each site. In South Africa, I focused on patient education. You have to be licensed to dispense there, and I was not licensed, so that allowed me to focus on areas that pharmacists didn’t usually focus on. For example, in a 4,000-bed hospital, there were only nine pharmacists, so they had to get patients in and out. Educating patients and creating things like drug information centers were not a priority, so that was where I saw an opportunity.

In Lesotho, I trained pharmacy assistants and technicians. The Senkatana Center, which is a health clinic that only treats HIV patients, had a team of pharmacy assistants led by a pharmacy technician. I did a whole set of training modules, from basic drug delivery to adverse reactions to information on HIV disease states and how the virus affects CD4 cells. They all got certificates at the end. It was fulfilling for them and for me.

Reaching Out via Health Fair

One event stands out for me: We put together a full-service health fair during the South African Pharmacy Council’s National Pharmacy Week. Practitioners would usually just go around to the different wards in the hospitals and provide information based on the year’s theme. This time, the services came to the people in a rural area. Government, local hospitals, community-based organizations, and private entities all partnered together. We were able to offer more than 500 rural-area residents all kinds of services, including mental health, social services, pediatric care, and blood pressure and blood glucose monitoring. There was a fully stocked pharmacy, and there were five medical rooms for doctors to see patients. There were a number of diagnoses that the patients would not have otherwise gotten because they didn’t have access to care where they lived.

A New Way of Thinking

%%sidebar%% I found during my time in South Africa and Lesotho that the residents have a communal way of addressing issues. The community-based organizations that exist there offer all kinds of services, from health care to food and income-generating activities that help build independence and financial freedom. Their whole approach seems to be to embrace the HIV/AIDS community. For example, I saw a campaign with the tagline “I love you, positive or negative.” That was profound to me. We could learn from these health care providers how to structure our programs and policies to be more embracing, and how we can bring more people into care.

The most rewarding thing about the residency experience was the feedback I received. People there show a great amount of appreciation for things that we might consider small. The experience has also changed my perspective on what people can do, and have a desire to do, in that part of the world. A little bit of thought goes a long way there, and there’s a lot of encouragement to keep the program going. 

Pharmacists Adopt Simple Tobacco-Cessation Tools

ROUGHLY ONE IN FIVE ADULTS in the U.S. uses tobacco products, according to the Centers for Disease Control and Prevention. That figure represents a tremendous opportunity for pharmacists to provide tobacco cessation counseling that can save lives, an opportunity not lost on the profession as a whole.

Karen S. Hudmon, Dr.Ph.

Indeed, roughly 85 percent of pharmacy schools train their students in techniques to help patients stop using tobacco products through Rx for Change, a shared curriculum being disseminated by the University of California-San Francisco Schools of Pharmacy and Medicine and promoted by the ASHP-supported Pharmacy Partnership for Tobacco Cessation (PPTC).

Initiating the Discussion
One of the most useful techniques featured in Rx for Change is a brief intervention called Ask-Advise-Refer (AAR). Using this intervention, pharmacists can ask patients about tobacco use, advise them to quit, and refer them to 1-800-QUIT NOW, a national quitline that connects to counselors located in each patient’s state.

“In many cases, it’s unrealistic for pharmacists to provide comprehensive counseling, from start to finish, so we are also promoting an approach where the pharmacist is the initiator of the quitting process,” said Frank M. Vitale, M.A., national director of PPTC and senior lecturer, pharmaceutical sciences, University of Pittsburgh School of Pharmacy.

“Most people have no idea how to quit,” Vitale adds. “They don’t understand that it’s more than just making yourself stop. So, pharmacists’ referring is a huge intervention because it gets people thinking about actual steps to take.”

Hospital and health-system pharmacists have unique opportunities to help change the tobacco-related behaviors of patients within their care, according to Karen S. Hudmon, associate professor in the Department of Pharmacy Practice at Purdue University, Indianapolis. Hudmon, along with her colleagues at UCSF, developed the Rx for Change curriculum.

“Any pharmacist who has contact with the patient has an opportunity,” she said. “Tobacco use should be addressed with all patients, including, but not limited to, cardiac patients, pulmonary patients, cancer patients, pregnant women, patients with mental illness, and patients undergoing surgery.”

Hudmon noted that hearing about tobacco cessation from a pharmacist reinforces what physicians have already tried to impart. “Studies show that people are more likely to quit when they hear the message through multiple providers,” she said.

A Touchy Subject
One of the challenges of using AAR is getting through the first step—asking a patient if he or she smokes or uses tobacco.

“In clinics, nurses tend to ask because it’s a routine part of their job,” said Alan J. Zillich, Pharm.D., associate professor in the Department of Pharmacy Practice at Purdue and research scientist at the Roudebush Veterans Administration Medical Center in Indianapolis. “But it’s not something that pharmacists have traditionally done, so there isn’t necessarily a routine for incorporating it into our patient interactions.”

Sometimes, the ability to conduct outreach comes down to a simple matter of personal comfort. “There’s a reluctance particular to community pharmacy when it comes to asking people about their tobacco use,” said Zillich. “But if you don’t ask, you can’t help patients quit.”

The approach should always be respectful of the patient, said Hudmon. “Before asking questions about smoking or imparting advice, ask for permission to do so. ‘Do you mind if I ask you a few questions?’ and ‘May I tell you what concerns me [about your smoking]?’ ”

Vitale added that pharmacists often have a ready-made reason for asking: namely, drug interactions. “In training students and clinicians, we provide them with a list of medications known to interact with smoking,” he said. “If a patient is taking a medication that is on the list, that’s a perfect opportunity to start the conversation.”

Vitale, who has counseled more than 15,000 patients about smoking cessation, said that he finds a common theme among tobacco users. “You discover very quickly that most smokers hate it and want to stop,” he said. “But many have that little voice that wants them to find an excuse to continue. If you, as a health professional, don’t say anything, you could be providing them with that excuse to continue.”

In Support of Collaborative Practice

Henri R. Manasse, Jr., Ph.D., Sc.D.

Henri R. Manasse, Jr., Ph.D., Sc.D.

IN THIS ERA OF HEALTH CARE REFORM, advanced pharmacy practice, and enhanced public focus on medication safety and efficacy, you might think that health care professionals would be on the same page in our approaches to team-based, quality patient care. Unfortunately, in the case of the American Medical Association (AMA), you would be wrong.

The AMA recently released its “Scope of Practice [SOP] Data Series: Pharmacists.” This members-only document seeks to define, describe, and prescribe the scope of pharmacy practice. And it does so using erroneous information, false statements, and pure errors of fact about pharmacists’ education, training, and scopes of practice.

It is a troubling look into the way that the AMA perceives today’s pharmacist—a point of view that is clearly out of the mainstream of contemporary practice. The SOP is devoid of what prominent national boards and regulatory bodies such as the Institute of Medicine, the National Quality Forum, the American Board of Internal Medicine, and many others are saying about the importance of collaborative care.

It is clear from the document that the AMA is concerned about the way that medication therapy management (MTM) and collaborative practice agreements are evolving. Pharmacists in hospitals and health systems and nurse practitioners are moving into areas of practice traditionally handled by physicians. But it is an evolution created by need. Drug misadventures are a reality.

With more than 18,000 FDA-approved chemical entities and dosage forms on the market and a practice model that allows any physician to prescribe any medication at any time, there has never been a more urgent need for medication experts. Pharmacists who practice in hospitals and health systems are those experts.

The current state of practice, including a greater demand for pharmacists’ clinical skills and a growing number of new practitioners seeking pharmacy residencies, further bears out the need for pharmacists’ medication management services in the context of team-based care.

Instead, even though collaborative drug therapy management is currently authorized in 45 states, the AMA has chosen to use their policy document to raise fears in the reader that pharmacists aren’t competent to conduct MTM.

ASHP will not passively stand by and allow this publication to go unanswered. I recently sent a letter to AMA Executive Vice President and Chief Executive Officer Michael D. Maves, M.D., M.B.A., in which I laid out the inaccuracies and untrue representations in the SOP and asked the AMA to retract the document or, at minimum, correct it.

In this new world of patient care, it will take every health profession working together to ensure that patients receive the safest, most effective care. Pharmacists are a critical component of that care delivery model, and ASHP continually stands at the ready to promote the importance of collaborative practice.

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