Towards equity: a qualitative exploration of the implementation and impact of a digital educational intervention for pharmacy professionals in England
Patients belonging to marginalised (medically under-served) groups experience problems with medicines (i.e. non-adherence, side effects) and poorer health outcomes largely due to inequitable access to healthcare (arising from poor governance, cultural exclusion etc.). In order to promote service equity and outcomes for patients, the focus of this paper is to explore the implementation and impact of a new co-produced digital educational intervention on one National Health Service (NHS) funded community pharmacy medicines management service.
Semi-structured interviews with a total of 32 participants. This included a purposive sample of 22 community pharmacy professionals, (16 pharmacists and 6 pharmacy support staff) all who offered the medicine management service. In order to obtain a fuller picture of the barriers to learning, five professionals who were unable to complete the learning were also included. Ten patients (from a marginalised group) who had received the service (as a result of the digital educational intervention) were also interviewed. Drawing on an interpretative analysis, Normalisation Process Theory (NPT) was used as a theoretical framework.
Three themes are explored. The first is how the digital learning intervention was implemented and applied. Despite being well received, pharmacists found it challenging completing and cascading the learning due to organisational constraints (e.g. lack of time, workload). Using the four NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) the second theme exposes the impact of the learning and the organisational process of ‘normalisation’. Professional reflective accounts revealed instances where inequitable access to health services were evident. Those completing the intervention felt more aware, capable and better equipped to engage with the needs of patients who were from a marginalised group. Operationally there was minimal structural change in service delivery constraining translation of learning to practice. The impact on patients, explored in our final theme, revealed that they experience significant disadvantage and problems with their medicines. The medication review was welcomed and the discussion with the pharmacist was helpful in addressing their medicine-related concerns.
The co-produced digital educational intervention increases pharmacy professionals’ awareness and motivation to engage with marginalised groups. However structural barriers often hindered translation into practice. Patients reported significant health and medicine challenges that were going unnoticed. They welcomed the additional support the medication review offered. Policy makers and employers should better enable and facilitate ways for pharmacy professionals to better engage with marginalised groups. The impact of the educational intervention on patients’ health and medicines management could be substantial if supported and promoted effectively.
KeywordsCommunity pharmacy Co-production Digital learning Medically under-served groups Medicines use reviews (MURs) Normalisation process theory (NPT)
Medicines Use Review
Normalisation Process Theory
Examples of communities or groups that could be medically under-served
• People with disability i.e., people with physical disability (e.g., a person in a wheelchair); people with visual impairment (Partially sighted/blind); people with hearing impairments (deaf) people with learning impairment (e.g., Downs syndrome, autism etc.)
• People from Black, Asian and Minority Ethnic (BAME) communities
• People who are homebound, from rural communities
• People from Gypsy, Roma and Traveller (GRT) communities
• People who are homeless or have no fixed address
• People who are refugees or are seeking asylum
• People from the lesbian, gay, bisexual and transgender, queer (LGBTQ) communities
• People with mental health illness and stigmatised medical conditions (e.g., acquired immune deficiency syndrome (AIDS), epilepsy)
• Older people, particularly with multiple morbidities and medicines
• Young people (specifically men aged 18–25)
• People from a low socio-economic status, long-term unemployed, low levels of health literacy
• People with speech disorders (e.g., stutter) or language disorders e.g., from brain injury (stroke, dementia)
• People experiencing substance misuse (e.g. alcohol, illicit drug dependency)
• People who have experienced domestic/physical abuse
• People who are sex workers
• People in prison or those who are known to have been in prison
Internationally, there is growing global interest in reforming primary care systems that seek to improve health equity . Health educators have sought to reframe social determinants of health so they are seen less as “facts to be known” and more as “conditions to be challenged and changed” . Included in this movement is health professional cultural competence training which has unfortunately shown limited impact beyond increasing knowledge and improving attitudes . As such, there are now moves to teach the subject in a more nuanced way, moving away from pedagogic approaches of cultural competency towards a dynamic model that utilises frameworks of structural competency and critical consciousness [19, 20]. One limitation however, is that existing inequity reduction frameworks and models lack important guidance to organisations for the practical implementation of translating ambitions and macro policies into guided day-to-day action for frontline health professionals .
With this in mind, we draw on Normalisation Process Theory (NPT) to investigate the impact of a novel digital educational intervention (e-learning resource) to improve access in one NHS-funded community pharmacy service known as ‘Medicines Use Reviews’ (MURs). Co-production is an equal partnership (through the sharing of power) between service providers and service users (or other members of the community), where both parties make substantial resource contributions . This concept has been shown to produce positive patient outcomes . Moreover, on-line educational tools have also been shown to support professional learning and bring practice improvements [24, 25]. This study explores the implementation and impact of a novel co-produced digital educational intervention to promote service equity and outcomes for patients. Through this, we extend the debate on how difficult new patterns of behaviour are normalised in existing cultures of practices, processes and policies, as well as investigate the regulative and organisational elements that contribute to resistance .
Medicine Use Reviews (MURs)
In light of the growing evidence suggesting patients experience significant problems taking medicines , concerns over medicine wastage, and adverse effects due to inappropriate polypharmacy , the United Kingdom (UK) Department of Health commissioned a national ‘Medicine Use Review’ (MUR) service in 2005. This was to be delivered from pharmacies as an optional ‘advanced service’ to support patient understanding and adherence to therapy . The service is currently offered in approximately 90% of pharmacies and is free to patients. It is organised as an annual, one-to-one patient-pharmacist consultation aiming to resolve medicine adherence-related problems, address medicine-related concerns and to reduce avoidable waste. At the time, this move was based on emerging international evidence that pharmacist-led medication review models were feasible , and effective at improving medication adherence and health outcomes [31, 32]. There was also a willingness of the pharmacy profession to extend the pharmacists’ role beyond dispensing and information-giving, towards health promotion, prescribing and supporting medicine-use .
The implementation of MURs into pharmacist routines and practices however, has not been straight-forward. Questions have been raised over the variability in service delivery [34, 35]. With little formal monitoring or supervision, concerns have been expressed over the value to patients  and whether MURs are being targeted to “local needs and patient priorities”  leading to measures to phase out the service. One cause of these problems is the way pharmacies are remunerated for MURs. The NHS offers contractors a fee of £28 for each review performed, with the total number each pharmacy can claim subject to a cap of 400 annually. This cap, however, appears to have created a target-driven organisation culture [34, 35] in which contractors strive to claim as many reviews as allowed. There have been no requirements or incentives for pharmacists to recruit vulnerable patients from marginalised or medically under-served groups. With vulnerable patients from these groups likely to be in more need of support, there is scope for an intervention that raises awareness and engagement with people who may benefit the most. With over 3 million MURs conducted annually, we hypothesised that a co-produced digital educational intervention could be well placed to improve the provision of MURs to marginalised, medically under-served groups.
Co-produced digital learning intervention
Discovering and understanding under-served communities,
Exploring the medicine experiences and needs of patients who are under-served,
Effectively interacting and engaging patients who are under-served.
In order to engage the learner in interactive learning, each resource consists of a mixture of multimedia elements (i.e., audio, images, activities and illustrative videos) and represents approximately 15–20 min of learning activity. The first resource was co-developed following the revelation that there is low levels of knowledge among pharmacy professionals of who is ‘medically under-served’. The second sought to cultivate empathy and to better understand the lived experiences of such patients. The last resource, provided the learner with steps on how they could empower patients to take up the offer of an MUR. The resource is freely accessible online and can be accessed through our dedicated website found at:
Normalisation process theory (NPT)
Normalization process theory (NPT) is a widely used theoretical framework and was used in this study to identify, characterise and explain key mechanisms that facilitate or inhibit the embedding or normalisation of the complex intervention; it has been used widely to explore the implementation of new technologies or new processes in health care settings . The theory proposes that “material practices become routinely embedded in social contexts as the result of people working, individually and collectively, to implement them” . NPT offer a generalisable framework that can be applied across settings with opportunities for incremental knowledge gain over time . One of the key strengths of the NPT is that it highlights potential social, cultural and organisational barriers to implementation, compared with more individualistic approaches such as the theory of planned behaviour . A qualitative systematic review by McEvoy et al.  of studies applying the NPT framework to research implementation processes suggested healthcare researchers had positive responses and outcomes to the theory. In the pharmacy context NPT has been useful to examine experiences of delivering community pharmacy service to support adherence and self-management in chronic heart failure .
Coherence (sense-making work)
e.g. shared understanding
Cognitive participation (relational work)
e.g. defining procedures
Collective action (operational work)
e.g. allocation of work
Reflexive monitoring (appraisal work)
e.g. determining effectiveness
This qualitative study is part of a larger appraisal of the co-produced digital educational intervention carried out between April 2016 and March 2019 . The appraisal included a before / after survey study which was undertaken in community pharmacies located in Nottinghamshire, England. The embedded qualitative study aimed to develop an in-depth understanding of professionals’ situated practices, cultural context and organisational facilitators and constraints within which the digital educational intervention was implemented. All pharmacies in the Nottinghamshire area (n = 237) were approached. Pharmacy staff who were actively involved in the MUR service were invited to take part in the survey study. ‘Active involvement’ was defined as being involved with the process of identifying, inviting or undertaking MURs on a day-to-day basis. Survey responses were received from 122 pharmacies (involving 149 staff). At 3 months 62 participants had reported accessing and completing the e-learning.
This study draws on a total of 32 interviews including 22 pharmacy professionals (16 pharmacists and 6 dispensing staff) from the sample of pharmacy staff who agreed to participate in the survey study. Pharmacy professionals were purposefully selected reflecting variations in pharmacy ownership and employment role. In order to obtain a fuller picture of the barriers to learning, five professionals were selected who had been offered but unable to complete the digital educational intervention.
Ten patients were interviewed (who were identified as belonging to one or more medically under-served group(s)). Patients were recruited through 2 pharmacies by pharmacists who had completed the learning intervention. Once they had received their MUR from the pharmacist, the patient was then invited to the study. Patients and the recruiting pharmacy were offered a £25 High Street gift voucher as an inconvenience allowance. To avoid gift vouchers being used as incentives to take part in in an MUR, pharmacists were instructed to only invite patients to the study following their acceptance to have an MUR.
Qualitative, one-to-one, face-to-face semi-structured interviews were undertaken by AL. Patient / professional interviews lasted approximately 30–45 min and with the participants’ consent, were audio-recorded. Using NPT as a theoretical framework, we explored the impact of the e-learning on professional awareness, attitudes and behaviours engaging with and inviting people who were medically under-served. Professional motivation, barriers and facilitators to engage with the learning were also explored (see Table 2 in Appendix for topic guide). Patient interviews explored their health and illness, medicine-taking habits and experiences and personal value of the MUR. Their feelings about being approached for an MUR were also explored as well as thoughts on how healthcare professionals could better engage with, and improve services to, medically under-served groups (see Table 3 in Appendix for topic guide). Audio-recorded interviews were transcribed verbatim. Data were then imported into the qualitative analysis package NVivo  for coding using an interpretative analytical approach. The coding framework was developed through emerging themes as well as around the 4 NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring).
Implementation of the digital educational intervention
It’s extraordinarily difficult to find the time at work. There’s pressure to do 101 other things. I’m a travel health pharmacist, I do meningitis vaccines, I do flu vaccines, there’s a great pull on my time at work to do the actual training. (Pharmacist_Male_51yrs_Chain pharmacy).
We get a lot of e-learning and training here but myself I feel like I am always rushed to go through it as quickly as possible. … I feel I don’t want anyone to think I’m slacking, I feel I should be back on that counter. (Dispenser_Female_39yrs_Chain pharmacy).
Nobody else was interested in doing it I believe … I suspect it was a time element for them … (Pharmacist_Female_32yrs_Chain pharmacy).
I don’t know why we didn’t do it. It’s not something that was high on the list of things for them to do I guess … People who are old and been in the career for decades, change is hard. (Pharmacist_Male_46yrs_Independent pharmacy).
Impact of the learning: the process normalisation
Using the four NPT constructs, our second theme explores the process of normalisation and impact of the intervention on professional practice.
So obviously these are real people giving their experiences of MURs and their struggles, it sort of puts you in their shoes, so you can understand where they are coming from. You can identify exactly how they feel and how they are being under-served. (Pharmacist_Male_44yrs_Independent pharmacy).
I don’t think anyone would maliciously try and go out and say “You know what, I’m going to avoid that definitely”, but I think you kind of look at it and subconsciously avoid it. I think now it’s probably opened my eyes that these are the kind of people who are more in need of this service. They are the people I should actively try and target. (Pharmacist_Male_29yrs_Independent pharmacy).
I didn’t even realise that I had a bias even … so the e-learning for me was brilliant … it challenged my assumptions, my biases, my awareness of cultures, and not a one size fits all kind of umbrella. (Pharmacist_Male_35yrs_Chain pharmacy).
I don’t have the time to constantly search out vulnerable groups. Maybe that’s what we should be doing, but in the current climate, that’s an impossible thing to achieve. So, I’m going to go for the things that are contractually required of me to do because I’ve got enough on my plate already. (Pharmacist_Male_43yrs_Independent pharmacy).
Foreign people because there’s a bit of a language barrier, so it’s hard to explain it to them. And elderly, I guess, because they don’t really like to wait around, they are agitated … You can tell people who are a bit easier to approach than people who aren’t. (Dispenser_Female_36yrs_Independent pharmacy).
Because of the time constraints most community pharmacists will take the easier option … It’ll be somebody who’ll be compos mentis, not deaf and not challenging, just to fulfil the numbers. Are they realistically the people who need the time and advice? (Pharmacist_Male_52yrs_Chain pharmacy).
You find yourself under some tension because it’s about the pressure to find one [MUR] and not the pressure to support the patient. (Pharmacist_Male_43yrs_Locum).
It is difficult sometimes to pick apart the need to hit the targets rather than whether or not it’s the most appropriate patient to do an MUR on. (Dispenser_Female_30yrs_Chain pharmacy).
The problem with this pharmacy is 70–80% of our business is delivery, sometimes we might not see the person for 6, 7 or 8 months. (Pharmacist_Male_40yrs_Independent pharmacy).
It’s very difficult to see if somebody’s homeless … In my six years I’ve never seen a prescription where it says “no fixed abode”, so are you telling me that in six years having served thousands of patients, if not a million patients, I’ve never served a homeless person? (Pharmacist_Male_29yrs_Independent pharmacy).
If you had a choice of an easy patient and a not so easy one, what would you go for? That’s the reality and I’m sorry but that’s the basic truth. (Pharmacist_Female_59yrs_Independent pharmacy).
I had a patient who was Chinese and somehow through some sort of signing or whatever I was able to get my message across. Maybe I wouldn’t have tried that MUR before, but I thought “no, I’m going to do this” … Today a patient who I never realised had ADHD got quite enraged in the pharmacy … Maybe before I may have banned him … He got quite aggressive over a refund … I said “let’s go and have a chat, let’s go and have a bit of time out”. That actually turned into an MUR, and it was as a result of the e-learning because of me thinking “under-served”. (Pharmacist_Male_35yrs_Chain pharmacy).
I would have been wary of doing an MUR with somebody who’s deaf, and since then I’ve done 2 people who are deaf … I’ve got somebody else who’s with them to come in and they helped with lip reading … It takes a bit longer, but actually I can see this type of group benefitting because nobody really takes the time to speak to them. (Pharmacist_Male_51yrs_Chain pharmacy).
I was on heroin. People used to look at me and think “No not helping him”. I have been shunned from a few agencies. I’ve been shunned at hospital as well when they find out your background … They’ve made me feel it all, guilt. You’ve got yourself in that predicament … For years I didn’t go to the doctors … if I wanted medicine I could get it off the old boy down the street. I didn’t go and see the doctor because I was crucified for going in there. So, I ended up taking black market medication. (Patient_Male_44yrs_substance misuse).
I get confused as I’ve had a stroke … Sometimes, I know it sounds mad, I can’t be bothered because they’re too many … I’m blind as a bat so when reading them I’m not sure which ones I’m supposed to take, when I supposed to take or how I’m supposed to take it. (Patient_Female_58yrs_disability_homebound).
Found it a bit strange … I thought you always had that chat with the doctor and thought the pharmacist was there to just sort out your medication. (Patient_Female_52yrs_mental health illness).
I felt quite nervous because at that time I didn’t realise why they were calling me in and I was chosen randomly, it felt quiet obscure. (Patient_22yr_ undertaking gender transition and registered disabled).
She explained about the medicine, “are you OK now, how are you feeling?” She was nice, very nice. (Patient_Male_55yrs_Black community).
She told me I need to keep my blue inhaler with me at all times as I sounded chesty and wheezy and I have COPD. [Prior to that did you not keep your inhaler with you?] No, but will do now. (Patient_Male_44yrs_mental health illness).
She asked me if I wanted to ask any questions, but I didn’t feel like I had to, she covered all bases. She told me about my medications, told me when to take them, what I was to do if I took too many, an overdose, and things like that … I think it was to get me to understand what medication I was on and what they were for. (Patient_Female_39yrs_mental health illness).
Although their MURs were able to resolve some problems, it was acknowledged that further help including ‘outreach services’ were urgently needed and that ‘government cut-backs’ to local services meant there were fewer resources to meet patient needs.
This study adds to the debate on how equitable improvements to primary care services for vulnerable populations can be promoted . It explores the implementation of a new co-produced digital educational intervention to improve access, drawing in particular on NPT to understand how the intervention is enacted and embedded in practice. It also considers the impact of how the intervention and its implementation is experienced from the perspective of patients from the target population. Regarding the learning, pharmacists and their support staff reported several well documented barriers to learning. These were similar to those reported when undertaking continuing professional development (CPD) including not having time, lack of resources and interest . Incorporating CPD as a form of in situ workplace learning has been suggested to improve engagement and professional practice . However, our study suggests the perceived excessive workload within pharmacies, creates a barrier to undertaking new learning and constrains applying this knowledge in the workplace .
The findings from the four constructs of NPT framework revealed the complexity and extent to which the outcomes from the learning became normalised in practice. Under the coherence theme, the findings revealed there were improvements in awareness and better understanding of health inequities including how they occurred. However, cognitive participation and collective action remained limited due to organisational barriers and work place constraints. This hindered effective practice change to occur and to be sustained. When appraising their work (reflexive monitoring), most success was seen when pharmacists took it upon themselves to effect change; when this occurred, there was real potential for this to overcome the barriers to implementation and to achieve and maintain normalization. It could be that pharmacists who had been proactive, had positive attitudes to innovation or were, ‘early adopters’ . Others have described these pharmacists as engaging fully with training and learning activities, being receptive to innovative behaviours and welcoming greater autonomy . Nevertheless, effective ways to address inequity should seek to involve staff from all levels with equal motivation to participate in ‘readiness for change’ where these could contribute to improving practice .
Regarding the impact on patients, MURs were welcomed and the extra help and support these afforded were appreciated. In terms of Levesque et al.  model of conceptualising access, the learning had promoted abilities to perceive, seek, reach and engage with several medically under-served groups. It is well reported that people from these groups are more likely to manage health as a series of minor and major crises, rather than treating diseases as requiring maintenance and prevention . Where the intervention was successfully implemented and professional learning was successfully implemented, there was potential for patient benefit. In times where questions are being asked about whether MURs represent value for money, targeting MURs to marginalised or medically under-served groups could be a valuable step towards demonstrating their relevance within certain medically under-served groups. However, it is clear that further research is needed to address the structural inequities within the system.
Strengths and limitations
Whereas other studies using NPT have been criticised for not moving beyond a single stakeholder perspective , the present study used a range of stakeholders including patient, pharmacist and pharmacy support staff. These differing perspectives improved the credibility and transferability of the findings. Furthermore, in order to get a more balanced view, accounts were also taken from those who had not completed the digital educational resource. It is however not known what extent the digital learning accommodated for different learning preferences as this was beyond the scope of the present study.
Interventions can be applied at three levels: across the individual level that directly affect a patients’ social situation, at a health care organisational level aimed at professionals, and at a community or societal-level interventions, including social and political advocacy and research . We accept that the intervention focuses predominantly on supply-side determinants to access, with less attention to facilitating demand-side determinants. As O’Donnell  notes, demand-side and supply-side barriers should be addressed concurrently in order to tackle the problem of access. Further research is needed to explore strategies on how awareness of the benefits of an MUR can be better promoted to patients from diverse backgrounds. In addition, more investment is needed to develop novel equity interventions  and evaluate their impact on patient care.
Improving fairness, social justice and addressing inequitable access to health services features as a key priority for the UK NHS . However, health disparities are still evident resulting in vulnerable patients experiencing significant problems with their health and managing medicines . The co-produced digital educational intervention described in this paper aimed to support pharmacy teams to promote MURs to people medically under-served. Despite the significant challenges to implementing the learning, and normalising practice, patients from medically under-served backgrounds who were offered an MUR found this to be valuable and worthwhile.
We acknowledge and thank all the participants and organizations that took part in this study. We are also grateful to our Patient and Public Involvement (PPI) representatives Mahomed Khatri and Abida Malik.
AL is the Chief Investigator and made substantial contributions to the overall conception, development, and design of the study. JW, KP, JS, and CA provided guidance on the methodology and on the qualitative analyses. NG and SC were responsible for data collection, data input, data analysis and contributed to the write-up. They contributed to the logistical aspects of recruitment including advice on access to under-served communities, study administration, and conduct. All named authors contributed to editing and approved the final manuscript.
This study is funded by the Department of Health through the Health Education England (HEE) and National Institute for Health Research (NIHR) Integrated Clinical Academic (ICA) Programme (Grant number ICA-CL-2015-01-008).
Ethics approval and consent to participate
Ethical approval was received from East Midlands Research Ethics Committee (REC reference: Derby 16/EM/0237) on 15th July 2015, along with governance clearance through the NHS Health Research Authority (HRA) (Nottingham, UK).
Consent for publication
Written Informed consent was obtained from all individual participants included in the study.
The authors declare that they have no competing interests The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.
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