General demographics and participants experiences
A total of 26 physicians from public hospitals and primary healthcare centres in Saudi Arabia were interviewed either face-face (n=22) in clinics or workplaces or via phone (n=4). The interviews ranged between 24-52 minutes in duration. Almost half of the participants were Saudi citizens (50%) and most were male (96%). Only two participants who were known to the primary researcher were recruited within the convenience sampling approach, others were recruited using the ‘hands-off’ or snowballing methods. More details about participants demographics are highlighted in Table 2 below. All interview records were clearly audible, and no repeat interviews were required.
In general, the frequently observed CVD risk factors reported by participants included diabetes, hypertension, smoking, obesity, physical inactivity and dyslipidaemia. Screening for CVD risk and/or risk factors was not considered routine practice in Saudi Arabia, apart from some health promotion advice during a typical physician clinic consult, along with point-of-care testing during public health awareness campaigns by physicians and nurses. Most physicians were not aware of any standardised Saudi guidelines for CVD risk screening and management, hence the guidelines they followed varied.
Most participants stated routine clinical investigations based on presented symptoms were mainly followed to assess and manage CVD risks and complications.
“We [physicians] are following the American Diabetes Association [guidelines] for treating our patients. There is a separate section for treating and controlling the other factors to prevent cardiovascular disease….” (Dr14, 5 years)
“To be honest, I do not use any screening guidelines or tool for CVD risk, I know there are international guidelines, but I am not aware of any local Saudi guidelines.” (Dr20, 2 years)
The analysis yielded four key themes: physicians’ perception of pharmacists’ role, perception of critical success factors, suggested models of care and healthcare system reform.
Table 2. Participants Characteristics
CHARACTERISTICS
|
VARIABLES
|
N=26 (100%)
|
GENDER
|
Male
|
25 (96)
|
AGE (YEARS)
|
25-34
|
10 (38)
|
35-44
|
9 (35)
|
45-54
|
4 (15)
|
55-64
|
1 (4)
|
≥ 65
|
2 (8)
|
EXPERIENCE (YEARS)
|
< 2
|
2 (8)
|
2-5
|
8 (30)
|
6-10
|
8 (30)
|
11-15
|
1 (4)
|
16-20
|
2 (8)
|
21-25
|
2 (8)
|
> 25
|
3 (12)
|
SPECIALITY/WORKPLACE*
|
Cardiology
|
7 (27)
|
Internal Medicine
|
9 (35)
|
Emergency Medicine
|
4 (15)
|
Primary Care
|
6 (23)
|
NATIONALITY
|
Saudi
|
13 (50)
|
Sudanese
|
3 (12)
|
Yemeni
|
3 (12)
|
Egyptian
|
2 (8)
|
Syrian
|
1 (4)
|
American
|
1 (4)
|
Indian
|
1 (4)
|
Jordanian
|
1 (4)
|
Palestinian
|
1 (4)
|
WORKPLACE CITY
|
Najran (Southern region)
|
14 (54)
|
Riyadh (Central region)
|
9 (35)
|
Dammam and Qatif (Eastern province)
|
2 (8)
|
Jeddah (Western region)
|
1 (4)
|
*(Note: these specialty areas were how participants referred to themselves when asked their specialisation/or work unit).
Theme 1: Physicians’ perception of pharmacists’ role
Physicians’ perceptions of pharmacists’ roles were based on current experience and in their discussions, they also raised potential future roles relevant to the research question.
Current pharmacist roles
Most participants perceived that pharmacist’s roles in Saudi Arabia were limited to medication supply, while a few participants noted that some pharmacists participate in health promotion campaigns. Several participants were also aware of patient education programs for people with chronic diseases, including diabetes and hypertension being provided in a few community pharmacies.
“In Saudi Arabia, the role of the pharmacist is restricted to dispensing medications prescribed by the doctors.” (Dr1, 2 years)
“They [community pharmacists] sometimes check and screen blood pressure on the machine, but I don't think they do an official referral to doctors….” (Dr17, 6 years)
“You know some pharmacies such as X and Y [big chain pharmacies] have already started providing initial health education sessions on specific topics such as hypertension and diabetes in a few community pharmacies……” (Dr2, 2 years)
Future pharmacist roles
Most participants were positive and supported future CVD risk screening and management services in community pharmacy and many lauded the novelty and potential utility of such models. They pointed to advantages of community pharmacy such as long opening hours, easy accessibility and frequent consumer contact, compared with hospitals and primary healthcare centres, as reasons for their support.
“They [community pharmacists] can do these screening services because there are some pharmacies open 24 hours, in the health centre there is limited opening time but, in the pharmacy, people can go there any time to check, so it is good.” (Dr13, 22 years)
“They [the public] will love it because from our experience in the campaign, even the pharmacist inside the pharmacy, they measure the blood pressure, height, and weight. The people like it very much and they ask for it. When we are inside the campaign, you cannot imagine the number of people in queue just to measure their blood pressure….” (Dr8, 35 years)
Some participants commented on the wider patient catchment that such pharmacy models could service thereby increasing the chance of identifying those at CVD risk in a timely manner.
“Applying the protocol only inside our hospitals, we will catch only the top of the iceberg of those having risk factors, but if we spread this [screening] protocol to other dimensions, such as community pharmacies, it will cover a new dimension of this target population; i.e. those having CVD risk factors.” (Dr8, 35 years)
In contrast, some participants did not believe that pharmacists had the ability to offer such services and appeared hesitant in accepting possible CVD risk screening in community pharmacies. In addition, a few physicians had unsupportive attitudes and expressed discomfort with the extension of pharmacist services into patient centred care. The commercial nature of pharmacy premises was perceived as an ethical barrier.
“I don’t think even they [community pharmacists] are up to the level that they have been educated to provide such education to the patients.” (Dr18, 37 years)
“At the beginning, I think they [community pharmacists] will find difficulties from the doctor to accept pharmacist to interfere in their job or in risk screening and management, but in the future if the point become accepted, this will be better.” (Dr5, 5 years)
“There is no communication between physicians and pharmacists. Physicians wouldn’t feel comfortable asking pharmacists. Most physicians would say who is the pharmacist ….” (Dr1, 2 years)
“…. this service needs legislation, rules and regulations to avoid possible commercial bias in community pharmacy.” (Dr8, 35 years)”
Theme 2: Perception of critical success factors
In talking about future services, many participants highlighted what, in their view, would be essential initial steps to ensure the success of future pharmacy services for CVD risk prevention and management.
Public acceptance and creating patients demand
Participants suggested that the public must be made aware of the availability and significance of pharmacy-based services to enhance acceptance and participation in these services. Initial resistance to consumer engagement with pharmacy services was predicted, but this may resolve as such services become more commonplace. In addition, it was suggested that role clarity of physicians and pharmacists’ tasks within these screening services might lead to more public acceptance and collaboration from physicians. Gender issues were also mentioned, given religious and social mores about gender segregation.
“There needs to be more education for the public to raise awareness of such services and clarify the service model to physicians and what are their roles.” (Dr7, 7 years)
“Initially you may struggle to get people acceptance and they will have to spend time, till they accept those services in the community pharmacy as they might prefer to receive such services from their GP.” (Dr21, 35 years)”
“I think if there is a good system to control this process, in other words, clear role for pharmacists and clear role for physicians and how they operate together to end up with management and reduction of cardiovascular diseases and risks….” (Dr19, 7 years)
“May be, here in Saudi Arabia, if the pharmacist is male and person is female, maybe it is difficult to check blood pressure, or she will not accept….” (Dr15, 6 years)
Resources and task planning
Clear service protocols, simple screening tools and guidelines were mentioned as important factors during the planning and implementing of such pharmacy services. Also, training for pharmacists for quality assurance was considered essential. Ministerial supervision from the Saudi MoH or other authorised bodies was mentioned frequently by participants. Participants commented about the need to modify pharmacy layout to better accommodate such services – for example the need for seating areas and private counselling areas were seen as important for patient comfort. Many participants suggested running service pilots in selected areas and if proven acceptable and effective, to then scale-up the provision nationally.
“…. If there is some supervision from the Ministry of Health or Saudi FDA on these pharmacies and their tools and their practice, it will be a very nice idea, I totally agree it will be a breakthrough.” (Dr8, 35 years)
“They [community pharmacists] have to change their way of dispensing …., for example in Europe, you will find that customer when he comes, he sits on a chair and then give his medication list. Then the pharmacist goes and collects it and sits with him, has a dialogue as a person to person while in our system, no, it is just like a supermarket…” (Dr18, 37 years)
“…. The bottom line, it is too early to implement it in pharmacy nationally and plans to do it should be done in small area to be measured and evaluated and shown effective results.” (Dr19, 7 years)
Legislation and incentivisation
From a system’s perspective, legalising the provision of pharmacy services by the MoH or other regulatory bodies was perceived to be a key facilitator, along with media support for successful pharmacy service pilots. Empowering allied HCPs in Saudi Arabia was recommended by some participants to enable provision of optimal collaborative patient care. Financial incentives and motivational rewards for pharmacists and pharmacy owners were suggested as essential for sustainability and quality of pharmacy-based services. This would enhance commitment to service quality by pharmacy owners and pharmacists, an essential first step for winning public trust.
“I think they [pharmacists] should have to get official legal support from Ministry of Health, also they [pharmacists] should have support from the media newspapers, and twitter, and once that just elicited even awareness for whole society….” (Dr23, 7 years)
“I think we should review the whole national program for empowering professionals, I would say empowering the pharmacist and empowering the nurse staff, empowering these hidden professionals, I mean, heroes of the health services.” (Dr8, 35 years)
“…. They [community pharmacists] could receive monetary incentives or any other kinds of overtime incentive.” (Dr2, 2 years)
“The owner of the pharmacies, those running the business of community pharmacies have to be motivated financially.” (Dr8, 35 years)
“I think it has to be supported by the government financially and legally.” (Dr17, 6 years)
Theme 3: Suggested models of care
Models of care suggested by participants included: 1) pharmacist delivered health education/health promotion (on lifestyle modification and CVD risk reduction) to improve health literacy, 2) point of care testing 3) medication review, 4) being part of the home care visit team - all with clear communication and collaboration with physicians. Care provision formats suggested by the participants included Internet and tele-consult models besides face to face models delivered in the community pharmacy setting.
“Health literacy is the problem here in Saudi Arabia, you may need somebody in the community pharmacy to educate these people in the society with healthy lifestyle habits” (Dr21, 35 years)
“Pharmacists should have an effective role in the society by providing consultations to people through the internet on social media and or via the phone……” (Dr1, 2 years)
“It will be beneficial if they [community pharmacists] can do BP or BGL or lipid profile tests….” (Dr24, 1 year)
“As long as there’s a pharmacy clinic, patients would bring their medications whether vitamins, herbal medications or whatever and they [pharmacist] will ask how they [patients] them all and [explain] what are their [medications] benefits…. possible contradictions…….” (Dr1, 2 years)
“It [involving pharmacists within the home care visits team] will be better because they [pharmacists] could go and see how the patient is handling the drugs, how the patient is tolerating the drugs, is he compliant by tablet counting or whatever and is he taking the drugs on a proper time……” (Dr18, 37 years)
It was recognised that collaborative (physician-pharmacist) models were not yet the norm in Saudi Arabia. Most participants recommended enhanced collaboration of pharmacist with physicians with clear role definitions for pharmacists. The most common model suggested was a progressive stepped care collaborative service model (Figure 1). It was suggested that pharmacists risk assessment and education could lead to a pathway for targeted referrals to dietitians, primary and/or tertiary care physicians.
“… Pharmacist and doctor collaboration is still not well established in Saudi Arabia.” (Dr5, 5 years)
“… They [community pharmacists] will do screening or risk assessment, and what is the pathway after, for example, if GP diagnose a patient with diabetes, what is next? …. There should be clear in system, what they will do, and how can they handle it. I think it is doable and even time saving and will help us, and this is not that difficult things. It can be done even nationally.” (Dr23, 7 years)
“If there is good collaboration between pharmacists, general practitioners and cardiologists especially in the screening or risk factor assessment, this will limit costs by the government or by the people themselves….” (Dr5, 5 years)
While some participants expected community pharmacists to provide a full-service ranging from CVD risk screening, referral, patient’s education to those with long term conditions and follow ups, a few thought community pharmacists’ roles should be limited to point of care tests and patient education. Documentation during service provision was thought to be essential for quality assurance and improvement.
“There can be a simplified screening tool the pharmacists could use and once they see a mild-risk no need for referral, moderate-to-severe risk, he has to be referred. So that would ……save the time for doctors to see moderate-to-high risk rather than seeing only the mild patients.” (Dr17, 6 years)
“I think providing education to patients is enough for pharmacists. Because if you want to do the scoring, they [pharmacists] have to see the file, but usually no, especially in the community pharmacy…” (Dr18, 37 years)
“Pharmacists have to document everything to facilitate these services and that will help evaluating them.” (Dr22, 1.5 years)
Theme 4: Healthcare system reform
Participants noted several issues with the limited structure of the primary healthcare system. Most people lacked family physicians with the generic help seeking pattern for most issues being presentations at tertiary hospital – where medical care was publicly funded. Also, participants felt that community pharmacies operated separately from the public primary healthcare system. Thus, participants suggested that a system-wide linkage may improve the public perception of the importance of primary healthcare including their family physicians and pharmacists. For instance, to optimise patient a national electronic health record system was needed, it should be accessible to community pharmacists and other HCPs and used nationally with better patient record management and seamless transitions between health settings.
“Other point, our GP system is weak here in Saudi Arabia. There is no GP-patient connected directly to the consultant and specialists. There is no clear structure for GP in Saudi Arabia ….” (Dr23, 7 years)
“I think community pharmacy should be connected by a system to primary care centres and hospitals……” (Dr20, 2 years)
“They [policymakers] should reform the current health service situation towards a community-oriented health providing services. This means they should do some form of legislation for all health services…………….” (Dr8, 35 years)
“So, they [health consumers] tend not to go to the primary healthcare clinic anymore and I think that is an issue we are having with our health system.” (Dr20, 2 years)
“They [MOH] will do all of that with the national system connected by the Saudi ID. The United Health files.” (Dr12, 16 years)
Many participants suggested that given community pharmacies operated privately, there should be a public-private mixed model approach in Saudi healthcare system, which would also require system reform. Involving community pharmacies with publicly operated primary healthcare centres might increase the public awareness and enhance primary care service use in Saudi Arabia.
“That is what we are trying in PHCs [Primary Health Centres] to provide another model of care including the community and at least the whole community including all health services, all health providers including community pharmacies to be involved in a good well-built national protocol to deal with this as a national tragedy……...” (Dr8, 35 years)