Hypothesis / aims of study
Urinary and fecal incontinence affects millions of people in the general population and people are often reluctant to disclose their symptoms, meaning that they are unable to access evidence-based strategies that can facilitate improvement (1). Pharmacies are ‘closer to home’ than most healthcare services. The majority (89%) of the population in England has access to a community pharmacy within a 20-minute walk, increasing to over 99% for those in areas of highest deprivation (2). Increasingly community pharmacy is being recognised as an intrinsic component of the healthcare pathway for a range of conditions. This is supported through accessibility to trained staff and private consultation space, and no requirement for appointment. Community pharmacies are perceived to be convenient and a less formal environment to other kinds of health services. Continence care is an area where there is an opportunity for innovation in community pharmacies to improve patient and service outcomes. This study describes the exploratory phases undertaken to underpin development of a novel Pharmacy Bladder and Bowel Service (PBBS) in the UK.
Study design, materials and methods
This study comprises three sub-studies which form the first phase of the Medical Research Council’s (MRC) Framework for Developing and Evaluating Complex Interventions (3).
Systematic review
A systematic review was undertaken using standard systematic review methods, to identify the empirical studies of continence interventions in community pharmacy, and to evaluate the effectiveness, safety, acceptability and key determinants of interventions. Medline, Embase, PsycINFO and CINAHL databases were searched and supplemented by grey literature (PROSPERO: CRD42022322558). Titles and abstracts were screened and following exclusions, full text screening was undertaken to identify studies for inclusion. Due to the heterogeneity of the studies, findings were reported narratively.
National community pharmacy survey
A cross-sectional study was undertaken to explore existing practice regarding continence provision in community pharmacies, and identify opportunities for further development and likely barriers. The online survey was conducted using the Qualtrics platform. The content was informed by the literature and the research team members’ expertise. The survey also explored previous continence-related training. The survey was disseminated through national pharmacy networks. Descriptive statistics were employed to summarise findings.
Qualitative stakeholder interviews
Semi-structured interviews were undertaken to explore stakeholders’ perspectives of the facilitators and barriers to the PBBS, enabling more in-depth exploration than the survey. Purposive sampling was used to identify and recruit participants from four stakeholder groups: community pharmacists, bladder and bowel service care staff, healthcare commissioners, and members of the public who represented potential service users, or their carers. Interviews were conducted using online platforms e.g. MS Teams, and transcribed verbatim. The transcripts were imported into the qualitative data analysis package, NVivo 12 QSR. Thematic analysis was undertaken.
Results
Systematic review
Four studies were included in the systematic review, demonstrating a paucity of evidence for this topic. The studies were conducted in Canada (n=2), Australia and the Netherlands. There was some evidence of the provision of self-help advice, staff knowledge and confidence in continence care, and acceptability to both pharmacy staff and consumers. Barriers to service provision included time constraints and inadequate funding for service provision. The studies were limited by small sample sizes and low follow-up rates.
National community pharmacy survey
The survey was completed by 30 respondents. Thirty community pharmacy personnel completed the survey, 22 qualified pharmacists and 8 in other roles such as Pharmacy Technician or Dispensing Staff. The majority (90%, n=27%) of respondents reported that continence care is a part of their role. Most (87%, n=26) were based in pharmacies that sold urinary incontinence products, while fewer (43%, n=13) sold faecal incontinence products. The respondents’ current provision of continence care and perception on future provision is presented in Figure 1. The key determinants of future continence service provision were access to a private consultation room (n=24), appropriate funding (n=21), adequate staffing (n=20) and access to training (n=20). Eight respondents reported undertaking training related to incontinence either during under- and/or post-graduate training or from commercial providers.
Stakeholder interviews
Qualitative interviews were undertaken with 27 individuals including community pharmacists (n=8), Bladder and Bowel Service staff (n=8), service users (n=8), and healthcare commissioners (n=3). Common themes were identified across all stakeholder groups regarding the implementation of a PBBS and included: additional training and resources, for example, information technology, private rooms, awareness raising materials supported by public awareness campaigns. Pharmacist and commissioner participants identified the need for service funding/reimbursement and policy development to underpin the implementation of PBBS. Potential service users and bladder and bowel care staff, who are most familiar with this patient group, highlighted the need for sensitivity and privacy, and recognised the benefit of increasing accessibility. Barriers to future PBBS delivery included staff capacity, scope of the role and embarrassment preventing symptom disclosure. A protocolised service, aligned with guidance and clear service specifications were highlighted as requirements for a PBBS development.
Interpretation of results
These results summarise the initial phase of the PRIME project, in accordance with the MRC complex intervention framework. This phase includes identification of the planned intervention, the PBBS, and evaluation and generation of evidence required for its development and future evaluation. Identification of current activity and key factors that will enable its feasible implementation in the current system and pathway, is critical to develop a service with the potential for successful implementation and impact. There is a paucity of research evidence, however the survey demonstrated that some pharmacies already provide some continence related practice. A clear appetite is evidenced to expand this provision, particularly where activity becomes more continence-specific by comparison with general lifestyle advice. ‘System’ factors such as funding models, ‘Provider’ factors such as training and facilities, and ‘Service User’ perspectives such as privacy and dignity are key. This study provides a robust evidence base for the Pharmacy Bladder and Bowel Service specification which will be Co-Produced in the next phase. Subsequent feasibility testing will precede clinical and cost-effectiveness evaluation in future studies in accordance with the further phases of the MRC framework.