Doing Qualitative Research

The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, suboptimal health literacy and lack of involvement in the treatment decision–making process), those that are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and those that are related to health care systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multifactorial. To assess general aspects of medication adherence using cardiovascular disease as an example, a MEDLINE-based literature search (January 1, 1990, through March 31, 2010) was conducted using the following search terms: cardiovascular disease, health literacy, medication adherence, and pharmacotherapy. Manual sorting of the 405 retrieved articles to exclude those that did not address cardiovascular disease, medication adherence, or health literacy in the abstract yielded 127 articles for review. Additional references were obtained from citations within the retrieved articles. This review surveys the findings of the identified articles and presents various strategies and resources for improving medication adherence.

Medication Adherence: WHO Cares?

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Qualitative Research: Data Collection, Analysis, and Management.

CONTEXT: Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes. METHODS: Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis. FINDINGS: From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context. CONCLUSIONS: We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change.

/pdf/uncovering-the-benefits-of-participatory-research-4569tmo8p0.pdf

Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice

Three Types of Interaction

Determinants of Health

Objectives
This study evaluated the barriers and facilitators that were experienced as pharmacists were integrated into 23 existing primary care teams located in urban and rural communities in Saskatchewan, Canada.

Methods
Qualitative design using data from one-on-one telephone interviews with pharmacists, physicians and nurse practitioners from the 23 teams that integrated a new pharmacist role. Four researchers from varied backgrounds used thematic analysis of the interview transcripts to determine key themes. The research team met on multiple occasions to agree on the key themes and received written feedback from an external auditor and two of the original interviewees.

Key findings
Seven key themes emerged describing the barriers and facilitators that the teams experienced during the pharmacist integration: (1) relationships, trust and respect; (2) pharmacist role definition; (3) orientation and support; (4) pharmacist personality and professional experience; (5) pharmacist presence and visibility; (6) resources and funding; and (7) value of the pharmacist role. Teams from urban and rural communities experienced some of these challenges in unique ways.

Conclusions
Primary care teams that integrated a pharmacist experienced several common barriers and facilitators. The negative impact of these barriers can be mitigated with effective planning and support that is individualized for the type of community where the team is located.

Integrating pharmacists into primary care teams: barriers and facilitators

Health systems are moving toward a more interprofessional approach to primary care This team-based paradigm has had a significant impact on the role of pharmacists within primary health care systems Within the past decade, nondispensing clinical pharmacists have been integrated into many Primary Care Trusts in the United Kingdom,1,2 primary care teams in North America3-5 and similar practice settings around the world6,7 Pharmacists bring value to these teams by improving medication use through individual patient assessments and population-based interventions, providing education and drug information to other team members and implementing system-level practice enhancements3

Pharmacists commonly encounter barriers to integrating into these primary care teams For example, many experience a lack of role clarity, and other team members’ expectations regarding the pharmacists’ responsibilities are frequently unclear4,8-11 In addition, patients often do not understand the role of the pharmacist in this setting9,10,12 Pharmacists are also typically unfamiliar with the roles of other team members,13 creating difficulties in collaborating successfully14-16 During the early stages, pharmacists often depend on other team members to assist in their integration, creating additional work for nurses and physicians17 Other frequently reported barriers include physician resistance, lack of pharmacist assertiveness, inadequate pharmacist support, lack of space and inadequate pharmacist training9-11,13,14,17-21

Many of these barriers to pharmacist integration can be minimized or avoided if pharmacists are prepared Unfortunately, recent evidence suggests that pharmacists often continue to make the same mistakes and struggle to integrate into these teams, despite the fact that these barriers are well documented in the literature22 The purpose of these guidelines is to provide recommendations that will assist pharmacists to successfully integrate into existing primary care teams

Guidelines for pharmacists integrating into primary care teams.

Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services. Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada. Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains. Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.

http://www.ruor.uottawa.ca/bitstream/10393/22956/1/Kennie-Kaulbach_Natalie_2012_Pharmacist_provision_of_primary_health_care.pdf

Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies

Background:Vision and action plans have been created to address the future of pharmacy and help pharmacists progress into expanded roles in order to provide more patient-centred care. To assess the...

Derek Jorgenson

Papers

Determinants of Health

Integrating pharmacists into primary care teams: barriers and facilitators

Guidelines for pharmacists integrating into primary care teams.

Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies

Practice Change Challenges and Priorities: A National Survey of Practising Pharmacists