Pharmacists continue to protect communities during COVID-19

APhA–APRS

An opportunity to use and generate cross-disciplinary research

Carico Jr.

In late 2019, a novel coronavirus disease (COVID-19) was detected in Wuhan, China; the respiratory illness associated with this virus was named COVID-19.¹ This disease rapidly spread around the world. By July 2020, the disease had been detected in more than 200 countries, infected more than 10 million individuals, and contributed to more than 500,000 deaths.² The United States has been an area of particularly high disease burden, with more than 2.7 million cases and 120,000 deaths as of July 2020.³ The disease possesses epidemiologic characteristics that may frustrate containment efforts.

Each infected person may infect 2 additional people without mitigation measures; furthermore, patients may show symptoms in only half of cases and may be presymptomatic for up to 2 weeks.⁴ Thus, individuals are unlikely to know when they are carrying the disease and may spread the disease before showing symptoms. Unless and until a vaccine is produced, the public needs to take steps to minimize viral spread in the community.

Although the profession of pharmacy deals primarily with medication, pharmacists must now grapple with the fact that COVID-19 is a public health crisis that compels prevention, not treatment. Pending curative treatments or vaccines, pharmacists must dispense the best therapy: counseling that is likely to reinforce COVID-19 mitigation behaviors among patients.⁵ Pharmacists may find a natural route to these discussions by bringing up pharmacy services that may limit patient contact with pharmacies, such as 90-day refills and mail order services. From there, community pharmacists should remember that the profession has already been dispensing public health information on smoking cessation,⁶ lifestyle changes for the management of type 2 diabetes,⁷ and opioid overdose reversal.⁸ Absent educational interventions specific to COVID-19, the profession may instead rely on more general evidence-based tools and public health frameworks. This creates an opportunity to generate new research in public health pharmacy.

The potential role of one such communication framework, the Health Belief Model (HBM), in COVID-19 response has been explored elsewhere.⁹ In brief, the HBM is often deployed when population behavior needs to be altered in response to a health threat. It contextualizes behavior in terms of how the individual perceives the severity of the threat, their susceptibility to the threat, whether they feel empowered to meet the threat, and the benefits or barriers that they may encounter while meeting the threat. A coherent HBM-based communication intervention may use these constructs as a guide for a patient interview, with the pharmacist seeking to improve the patient’s ability to respond while reinforcing the salience of the threat.

Pharmacists may be more familiar with the Transtheoretical Model (TTM), which is routinely used in tobacco cessation.⁶ Generally, the TTM conceptualizes the patient as existing on a continuum of behavioral change, from the “don’t know/don’t care” of precontemplation through action and maintenance of the health behavior.¹⁰ TTM-based interventions are usually structured so that the patient, not the pharmacist, argues in favor of the healthy behavior. If the patient is listing reasons why they will not take on COVID-19 mitigation behaviors, the pharmacist is not having a productive conversation. Most importantly, community pharmacists should remember they have often been trained in guiding patients through difficult conversations using tools such as the TTM as a guide. Many, perhaps most, pharmacists have hands-on experience with frameworks such as these.

The previous frameworks do not strongly address group identity, which may be a key component of COVID-19 mitigation behaviors in the United States. A more straightforward communication framework may be the Theory of Planned Behavior (TPB), which holds that an individual’s intention to act is shaped by their attitudes toward the action, their perceived ability to act, and their perception of how others in their social group will perceive their actions (i.e., social norms). The TPB has been used to study pharmacist-patient interactions in opioid safety¹¹ and patients’ medication adherence behaviors.¹² The value of consciously addressing social norms in the context of COVID-19 is underscored by a recent article by Bavel and 41 other authors.¹³ This wide-scoping review contains many immediately actionable suggestions for anyone who wishes to communicate effectively regarding COVID-19 mitigation behaviors. The authors stated that one of the most effective ways to motivate behavior change is to showcase members of the patient’s community engaging in the desired behavior and being rewarded for doing so. Thus, even when not directly engaged with patients, pharmacists should be aware that their actions will have an impact on how others may implement COVID-19 mitigation behaviors: every action by visible community members, such as pharmacists, reinforces the behavior of others.

Pharmacists may not always be accustomed to guiding patients toward healthier behaviors. However, COVID-19 is one of the most urgent health crises of the last century, and the next steps will likely be rooted in the preventive measures of public health rather than the curative measures of health care. Many community pharmacists may not feel comfortable acting as advocates for healthy, mitigation-based behaviors. The profession should take an interdisciplinary approach, using insights from community health and social pharmacy research for evidence-based ways to communicate effectively. Our profession should not—and indeed, cannot—back down from the challenge that comes with helping our patients remain healthy in the face of the greatest health care challenge of this generation.

Biography

Ronald Carico Jr, PharmD, MPH, Clinical Pharmacist, Marshall Health, Huntington, WV