Table 1

Factors influencing pharmacists’ self-care and compliance advice for common infections and antimicrobial stewardship (AMS) initiatives

Theoretical Domains Framework domainGiving self-care adviceGiving antibiotic compliance adviceParticipating in AMS initiatives
1KnowledgePharmacists report being knowledgeable in giving self-care advice.Pharmacists are knowledgeable on what drugs to take for a particular illness/condition.
‘I think doctors are brilliant at conditions, we’re the best at the drugs. So we know what should be prescribed when, and we can try and minimise as much as we can.’ Pharmacist 4, Gloucestershire.
Pharmacists understand that misuse of antibiotics can lead to resistance. Pharmacy staff also understand that misuse of antibiotics can lead to the return of infections.
Pharmacists lacked awareness of AMS initiatives and knowledge of what AMS is.
‘I’ve heard the term but to be honest I couldn’t recall a campaign going on at the moment, no.’ Pharmacist 15, Birmingham (Talking about antimicrobial stewardship).
2SkillsPharmacists report being skilled in giving self-care advice.Pharmacists report being skilled in giving compliance advice.This domain was not relevant in this context.
3Professional role and identityExamining patients is not part of the pharmacists’ role. Pharmacists reported that being unable to examine patients can make it difficult to give correct advice.
we always have to double check because we have no equipment in pharmacy to assess their breathing. I guess obviously that comes with training, so I don’t expect to just have a stethoscope and listen to customers. But if a pharmacy can, if a pharmacist can do that, it would be a bonus to our profession and to the service that we can give.’ Pharmacist 7, Gloucestershire.
Pharmacists believe an integral part of their role is to provide self-care advice for all common ailments.
It is unclear whether it is the pharmacist’s role to query the appropriateness of antibiotic prescriptions.
‘If a doctor’s decided that person needs an antibiotic, then I would be on a sticky wicket questioning that really. That’s outside of my authority as a pharmacist.’ Pharmacist 25, Wales.
‘in terms of where I see community pharmacy fitting in is where we do a clinical check on a prescription, it is our duty to decide whether or not it is clinically suitable or clinically appropriate for the patient to take the medication that we’re checking…’ Pharmacist 15, Birmingham.
4Beliefs about capabilitiesPharmacists are confident in their ability to give self-care advice.Pharmacists are confident in their ability to give compliance advice.This domain was not relevant in this context.
5OptimismPharmacists were optimistic that giving self-care advice can impact antimicrobial resistance (AMR).Pharmacists were optimistic that ensuring compliance can impact AMR.Pharmacists were optimistic that giving self-care advice and ensuring compliance can impact AMR.
6Beliefs about consequencesOne pharmacist highlighted the danger of missing something urgent that requires further medical attention if a culture of self-care is adopted.
‘If they keep on doing self care, actually, it actually prevents them to actually go to see the doctors if it’s something quite urgent.’ Pharmacist 10, Wales.
Pharmacists believe that patients don’t understand and don’t remember their compliance advice and therefore believe compliance is poor.
‘…And sometimes we find that they don’t come back to complete their course, or those that come back and say they probably don’t need the second bottle…’ Pharmacist 6, Gloucestershire.
There were no emerging themes within this domain.
7ReinforcementA few general practitioners (GPs) and stakeholders believe that pharmacists are financially motivated.
‘They’re not doing it for the love of the profession or the love of helping people get better, they’re doing it because they’re going to make money at the end of the day.’ Stakeholder 9.
Pharmacists reported not being financially motivated.
‘So, I’ve always said to anyone who works in there. Yes we have to make money but, we’re not unethically making money so, actually, if that product is not suitable for that person we won’t sell them. So, and that’s how it works.’ Pharmacist 2, Gloucestershire.
There were no emerging themes within this domain.There were no emerging themes within this domain.
8IntentionsPharmacists reported intentions to offer self-care advice to everyone presenting with symptoms or purchasing an over-the-counter medication.
We’d always make sure that any OTC sale, general sale list included, we would still check through WWHAM and make sure it is appropriate.’ Pharmacist 20, Wales.
Pharmacists discourage visiting the GP and try and promote self-care as much as possible.
‘I try as much as possible to stop that happening and saying, there’s no point going to the doctors for this you just need to manage it, symptom control it and in a period of five to seven, ten days you’ll probably feel a lot better.’ Pharmacist 23, Wales.
Pharmacists intend to give compliance advice with every antibiotic prescription.Pharmacists had no intentions to conduct AMS within the foreseeable future.
9GoalsA pharmacist’s main goal is to help their patients recover.
‘it’s caring for the patient. If we can give them advice and help them feel better then that’s our aim.’ Pharmacist 11, Birmingham.
There were no emerging themes within this domain.There were no emerging themes within this domain.
10Memory, attention and decision-makingPharmacists reported that they do not find it difficult in most instances to determine if a person needs an antibiotic or not.
Sometimes you can tell, like for example, if they’ve tried medicines or something for a duration of a so called infection. It’s more than like … You can generally tell when someone needs antibiotics so yeah. You can generally spot it, yeah.’ Pharmacist 22, Birmingham.
Pharmacists did report that it can be more difficult to decide whether a child or an elderly person needs to be referred to the GP or not.
‘Sometimes it can get very tricky. Especially with a young child at times, because obviously the child can’t explain their symptoms to you, so you’re relying on the mother to tell you everything… It’s when they’re elderly or really little, or a child, then it’s really hard.’ Pharmacist 19, Birmingham.
Pharmacists will refer patients to the GP if they are unsure whether the infection is viral or bacterial, or they feel that they can’t help the patient.
if there’s something there we can’t treat over-the-counter then we would refer it but we never would say that you need antibiotics, you just have something that needs to be looked into.’ Pharmacist 10, Wales.
Pharmacists reported not always asking for the diagnosis when giving compliance advice.
‘I probably wouldn’t, no, because we don’t, unless they’re obviously coughing or told us what it is, we wouldn’t necessarily know what those antibiotics are for.’ Pharmacist 8, Gloucestershire.
Pharmacists report giving compliance advice habitually with every antibiotic prescription.
Some pharmacists said that if they see several prescriptions over a short period of time for the same patient it will trigger them to have a discussion with that patient about potential resistance.
‘if I notice that we’re getting regular prescriptions or we’re getting prescriptions from regular customers I will intervene sometimes and talk to them,’ Pharmacist 8, Gloucestershire.
Some pharmacists were unaware of the link between giving self-care and compliance advice with tackling AMR.
‘I am not thinking, oh this is helping antimicrobial resistance, I’ll be thinking that, well, there’s no point them trying to get antibiotics for this because it’s just a viral infection, a cold, the, and they’re going to get better anyway.’ Pharmacist 11, Birmingham.
11Environmental context and resourcesPharmacists identified that pharmacy staff are more likely to deal with patients looking for advice for respiritory tract infection or urinary tract infections than pharmacists, particularly in large pharmacies.
‘…what you’ll find is the interaction with the pharmacist isn’t always the, is not probably the most common interaction that the patient has in the community pharmacy, it’s more normal with the healthcare assistant on the counter.’ Pharmacist 15, Birmingham.
Pharmacists report that during busy times advice is given over the counter instead of in the consultation room, therefore affecting the quality of the advice given.
‘…the time engaged with customers where you get a chance to actually counsel and go through what they’re taking, why they’re taking it, how to take, it’s, is very restricted. So you find that you’re not giving that pharmaceutical advice that you’d like to give in a way that you’d want to give it. So I think it’s not reinforced to the customer as best as it can be.’ Pharmacist 14, Birmingham.
Some pharmacists were concerned that misinformation is given to patients from untrained and inexperienced pharmacy staff.
if the assistant doesn’t feel confident then, and you’ll see it with newer assistants, then they’re likely to just say, go to the doctor, which is obviously not a good thing.’ Pharmacist 11, Birmingham.
It was mentioned that as you don’t need to book appointments with pharmacists it gives patients immediate access to a health care professional, unlike other primary care services.
‘The advantage is from a patient point of view, is they’ve kind of got a healthcare professional …on demand… They might never have walked into your pharmacy ever but they can walk in and access that self-care.’ Pharmacist 9, Wales.
Pharmacists do not know diagnoses without asking the patient. This makes it difficult for pharmacists to query accuracy and appropriateness of prescriptions with GPs.
‘…I don’t know what’s been diagnosed, obviously even with UTIs you’re guessing, but if it’s Trimethoprim or Nitrofurantoin you generally know. But… it’s hard for me to know if the doctor is being conscientious when I don’t know what’s being treated.’ Pharmacist 18, Wales.
AMR was described as not being promoted or advertised within community pharmacy settings.
‘We know about it, and I did my initial training in a hospital so, I know about what happens. But, in the community it’s not really, it’s not something that would be heavily advertised I would say.’ Pharmacist 2, Gloucestershire.
Some believe that AMR needs to be tackled across all sectors of healthcare and not just one sector of healthcare, for example, just primary care, or just GPs.
Pharmacists are generally unaware of any AMS going on within their Clinical Commissioning Group (CCG).
‘I can’t recall a particular campaign, I don’t think,’ Pharmacist 15, Birmingham.
Pharmacists in England reported not having much communication with their CCG.
‘because they haven’t really approached us in the pharmacy, so I would say it’s probably not very active…I don’t know what they do with the doctors though, because they haven’t informed us of anything.’ Pharmacist 19, Birmingham.
Pharmacists in Wales reported that their Health Boards are very proactive within community pharmacy.
‘They’re really proactive. You’ve got several health campaigns every couple of months. We get the leaflets, we get audits, whatever. It’s very proactive’ Pharmacist 20, Wales.
12Social influencePharmacists believe that patients are given unnecessary prescriptions from their GP as a result of patient expectations.
‘I think some GPs they even succumb to pressures with giving out a prescription for it. And then you see the patient and I don’t think they need that antibiotic.’ Pharmacist 13, Birmingham
Pharmacy staff have noticed that patients are disinterested in compliance advice and tend to be in a rush to go.
‘You can stay talking to them all day long and they don’t mind but sometimes, like I said, especially for antibiotics, they just want to go.’ Pharmacy staff, Gloucestershire.
Pharmacists believe that the general public finds it difficult to understand AMR and this prevents them from attempting to discuss it with them.
‘It’s, I think it’s very difficult for the public to get their head around.’ Pharmacist 5, Gloucestershire.
Pharmacists report that AMR is not something that is discussed frequently with colleagues.
‘It’s not something that we would probably discuss as such within the pharmacy, yeah.’ Pharmacist 1, Gloucestershire.
13EmotionThis domain was not relevant in this context.This domain was not relevant in this context.All pharmacists were concerned about AMR, only very few expressed fear as a response.
‘Because I am quite scared actually that…these antibiotics in the next 20 odd years they’re not going to be effective at all… So, yeah, that does frighten me a bit.’ Pharmacist 13, Birmingham.
14Behavioural regulationPharmacists receive informal feedback from regular customers on the advice they give and the products they recommend.
‘patients do sometimes come back and say, oh that worked really well’ Pharmacist 12, Gloucestershire.
There is not a way for pharmacists to find out if their advice was unhelpful.
‘Only if the patient really came in and told us about it, but no, there’s no way of finding out other than that.’ Pharmacist 21, Birmingham.
There were no emerging themes within this domain.A few pharmacists in Wales reported the effectiveness of audits on raising awareness of AMR and changing practice.
‘Well we had the audit so I think that raised a bit more awareness of possibly what you should be doing’ Pharmacist 23, Wales.