Study of knowledge, attitude and practice regarding patient education in hypertension among community pharmacists in China

Hypertension is the leading risk factor for cardiovascular diseases [1]. Hypertension management is essential for controlling disease advancement and promoting residents’ health. Patients’ better knowledge of hypertension can improve their compliance, and consequently, better compliance is conducive to controlling their blood pressure (BP) [2‐4]. Therefore, as an important part of hypertension management, patient education is worth of research. Patient education refers to increasing patients’ knowledge of disease through education, which can give patients a deeper understanding of the characteristics of the disease, discipline patients’ behavior, enhance clinical outcomes, or more specifically improve patients’ medication compliance and BP control effectively [5, 6]. The official guidelines for hypertension management of various countries have emphasized the importance of patient education to different degrees [7‐9]. For example, management of Arterial Hypertension in Adults issued by the French Society of Arterial Hypertension recommends that patients should conduct a consultation that specifically provides disease and treatment information before drug treatment [7]. Guidelines for Hypertension Education in China (GHEC) has directly clarified the content, methods and skills of patient education for medical staff [8]. The Canadian government has issued guidelines, stating that pharmacists should educate hyperation patients and their family members, which can significantly reduce systolic blood pressure (SBP) and diastolic blood pressure (DBP) [9].

Since there is still a gap between the awareness rate and control rate of hypertension patients in China and that of developed countries, focusing on the patient education conducted in community pharmacies is an important step in addressing the challenges brought by hypertension. According to the China Hypertension Survey, the crude prevalence rate of hypertension among residents aged over 18 from 2012 to 2015 was 27.9%, only 51.6% of the patients were aware of their health condition and 16.8% had their condition under control [10]. Although the awareness rate and control rate have been significantly increased, they remain lower than those in U.S. and Canadian, which are average of about 80% and 55%, respectively [11, 12]. In addition, there is lack of disease knowledge among Chinese hypertensive patients [13‐15]. Patient education conducted by community pharmacists is an effective way to ensure the hypertension management and enhance the awareness rate and control rate of patients. Several studies from different countries have shown that interventions implemented by community pharmacists can improve blood pressure control, with the most frequently implemented ones including patient education and counseling [16‐20]. In China, community pharmacies are the most convenient and accessible health care providers (HCPs) for the public due to their geographical proximity to communities and convenient transportation [21]. The focus of community pharmacists in China is gradually shifting from medicine selling to pharmaceutical services such as patient education [22]. They are expected to play an important role in hypertension management, especially in patient education. However, the hypertension management in Chinese communities mainly relies on hospitals and more attention has been paid to the medical staff [23]. But as many scholars emphasize to fully realize the importance of community pharmacists, various circles of society are actively exploring the patterns of hypertension management oriented to community pharmacies, such as the Cooperative Project for Hypertension Management in Pharmacy sponsored by the Chinese Stroke Society and supported by Pfizer [22, 24].

Only 2 studies have reported the positive effect of community pharmacists on hypertension management in China [25, 26]. The number of relevant studies is extremely limited. Also, there is a lack of empirical studies on the situation of hypertension patient education conducted by community pharmacists in China. The complicated and uncertain situation makes it difficult to put forward measures for Chinese community pharmacies to control hypertension. There is an urgent need to carry out research on community pharmacists to provide justifications for the formulation of improvement measures.

In order to fully utilize the role of community pharmacists, it is necessary to understand their current patient education service in hypertension to lay a foundation for improvement measures. This study evaluated the situation of patient education in hypertension conducted in Chinese community pharmacies based on the theory of knowledge, attitude and practice (KAP), and tried to improve their services from various aspects. The results will help to propose possible solutions to the existing problems and provide basis for the formation of supporting policies, thus improving the services and BP control of hypertensive patients to a certain extent. In addition, this study may provide reference for other developing countries, which is conducive to the joint effort to cope with the global burden caused by hypertension.

This study explored the situation of patient education in hypertension conducted by community pharmacists by understanding their levels of KAP. It was the first study to explore this issue based on the theory of KAP in China. We found that generally, the respondents were positive about their role in patient education, but they still need to be improved with regard to self-identity, knowledge and practice, which is consistent with the findings reported in other studies conducted in community pharmacists in China that they have positive attitudes but insufficient knowledge about their related duties [27, 42]. This study reflected the current services and revealed the problems of patient education conducted by community pharmacists, which was of vital significance for the later improvement measures.

Respondents generally agreed with the positive role of themselves and patient education, and about half of them fully agreed with this. However, compared to the recognition of the role of patient education, respondents were slightly less likely to recognize the role they play in patient education. This gap may be related to the lack of widespread clinical evidence and authoritative support for hypertension management conducted in Chinese community pharmacies. In China, there is good evidence only indicating that medical staff can achieve clinical effects in the hypertension management [43, 44]. The responsibilities and methods of medical staff to prevent and control hypertension are emphasized in Chinese official guidelines [8, 45, 46]. Those guidelines can be a reference but not a basis directly for community pharmacists, because of the differences in their working environment, responsibilities and limits of authority between community pharmacists and medical staff. It is difficult for community pharmacists to fully identify themselves in the absence of extensive evidence and authoritative support.

To help community pharmacists strengthen their career identity, researches and guidelines are needed to prioritize their responsibilities. It means that more Chinese local researches remain to be done to demonstrate the clinical effects of patient education conducted by community pharmacists. The importance and details of community pharmacists’ responsibilities should be emphasized in guidelines designed for Chinese community pharmacies. Based on international experience and domestic status，new guidelines should be formulated by authoritative institutions or associations as soon as possible. The role of pharmacists in improving patients’ compliance and outcomes and the detailed procedure of patient education have been pointed out by the American Society of Health-system Pharmacists [47]. Considering that drug dispensing is being separated from prescription and the orientation of community pharmacists remains unclarified in China, the new guidelines should accurately define the responsibilities, work processes and evaluation criteria of community pharmacists, and try to refine and standardize their work processes such as establishing health record, health education, follow-up and referral to hospitals.

The low level of knowledge of respondents related to drug therapy, nutrient requirements, and complications with high expertise requirements was associated with insufficient effectiveness of continuing education. The study result showed that only 34.3% of respondents had studied GHEC and 28.7% of them had had relevant training experience and they even still had insufficient knowledge about hypertension, indicating that continuing education needs to be strengthened and improved in China. Continuing education refers to a structured educational activity designed to support the long-term development of pharmacists and/or pharmacy technicians to maintain and enhance their competence [48]. It has been proved effective in obtaining the knowledge of community pharmacists in hypertension management [49]. However, the majority of respondents have not been trained properly on patient education in hypertension, indicating that continuing education has failed to function effectively in China. The continuing professional development (CPD) model in the UK has provided a good example for China, which is equipped with a diversified and strict continuing education system to constantly update the knowledge of pharmacists. The Royal Society of Medicine provides corresponding development planning for the different needs of pharmacy students, new pharmacists and experienced pharmacists. And all the processes are recorded in CPD, which could by checked by the General Pharmaceutical Council irregularly. Those who fails will be disqualified from the Council [50]. In Chinese community pharmacies, community pharmacists consist of licensed pharmacists and general pharmaceutical technicians. Licensed pharmacists are certificated by the provincial medical products administrations for their continuing education, leading to the uneven educational levels between different regions and institutions, and the unsatisfied and diversified needs of licensed pharmacists [51]. General pharmaceutical technicians who receive continuing education more rely on independent participation in training. To improve the efficiency and effectiveness of continuing education in China, a unified certificate authority or standard should be set at the national level with the reference of the CPD model. In addition, education plans should be formulated according to the demands of community pharmacists on basic knowledge and practices at various stages. Under the rigid evaluation of their learning process and results, those who fail the evaluation will be rejected or prohibited from been registered as licensed pharmacists.

Programs on patient education required in the GHEC have not been well conducted by the respondents. As it was found in the research by Sima Garshasbi et al., the respondents were optimistic about patient education but not necessarily would they provide education services all the time [52]. Although all relevant programs have been implemented, there was still a general problem of low frequency of implementation in practice. Some of the items were conducted by only lower than 30% of respondents “always”, such as “explaining the damage to the target organ and clinical complications of hypertension to patients”, “explaining the management of hypertension complications to patients”, and “explaining the susceptible population of hypertension to patients”, etc. These items are all part of the content of health education for patients as stipulated in the GHEC. Only about 30% of the respondents have studied the GHEC and the subgroup analysis showed that whether or not the guideline had been read had little effect on the relevant practice of the community pharmacists interviewed. The dissemination in a limited range and the poor implement of the GHEC also reflected to some extent the weak willingness of respondents to conduct patient education, which hinders the relevant practice.

A study shows that the health care system in the UK would pay for the chronic diseases management provided by community pharmacists, which promotes the wide spread of services [53]. Therefore to promote the implementation of guidelines by community pharmacists, salary incentives can be tried to motivate them. In China, in order to establish a remuneration incentive system related to patient education in hypertension, it is necessary to first improve the continuing education system and formulate unified guidelines to ensure the community pharmacists’ service capacity and standardize their services. On the basis of this, a salary incentive system can be piloted in the chain community pharmacies equipped with the necessary premises, attached facilities and personnel. Those licensed pharmacists who are qualified for patient education are allowed to obtain reasonable and open remuneration according to their performance. Finally, relevant government departments can learn from the experience in the trial processes to improve the salary incentive system and expand the scope of the pilots. More qualified community pharmacists will be allowed to provide fee-based education services for hypertensive patients.

In order to promote the effectiveness of patient education conducted in Chinese community pharmacies, further research can be conducted from the perspective of the factors for services or the needs of hypertensive patients. The distinct economic levels and cultural characteristics in different regions and the low threshold for community pharmacists make the situation more complicated, with diversified factors affecting the service levels of community pharmacists. Analyzing whether and how those factors work is conducive to formulating targeted measures for various groups of community pharmacists. The research on the needs of hypertensive patients could help the skills and knowledge of community pharmacists to satisfy the needs of patients, thus improving the service effect.

This study has limitations in the questionnaire and samples. Since there is no standardized questionnaire for testing the KAP of community pharmacists on patient education in hypertension, this study used a self-designed questionnaire. In order to enhance the scientificity of questionnaire and reflect the reality of community pharmacists’ services effectively, researches based on the theory of KAP and guidelines for hypertension management were referred when the questionnaire was formulated and revised. And Delphi method was adopted to seek consultation from the experts. The result of the pre-investigation indicated that the questionnaire can be used to obtain valuable information about the characteristics, knowledge, attitude and practice of respondents. In terms of the samples, this study focused on the community pharmacies which provide hypertension management, therefore it may not represent all community pharmacists. But it was helpful to obtain more effective information such as the problems existing in the process of patient education.

The results showed that the service levels of hypertension patient education in Chinese community pharmacies remained to be improved. Community pharmacists held a positive attitude towards the patient education. But there were defects in their knowledge reserve, and at the same time, the GHEC have not been widely implemented in practice. In the future, more Chinese local researches and new guidelines are expected to emphasize the role of community pharmacists and instruct them in patient education. Departments responsible for community pharmacists should improve the continuing education system, and at the national level, certificate those pharmacists in a uniform way and meet their needs at different stages. On this basis, a salary incentive system could be established to try to spur the enthusiasm of community pharmacists.