Introduction
The pharmacist is well positioned to improve population health.
Until now, increased impact of pharmacists has been based on the expansion of patient services rather than guided by a population approach to
health. To increase their effectiveness and breadth of impact, pharmacists
would benefit from applying the five core competencies of public health (social and behavioral science, health policy and administration, epidemiology,
biostatistics, and environmental health sciences) to the practice of pharmacy. This article aims to explain how each of the core competencies applies to
pharmacy practice and how pharmacists might apply public health skills in
a more specific manner.
Compared with pharmacy and other medical disciplines, public health has the key feature of focus on the
health of a population of people. A population is a group
of people with some shared characteristic. The population may be considered as the individuals frequenting
one’s pharmacy, the population from which those individuals came, or everyone in the community regardless
of their relationship with a specific pharmacy.
By definition, populations have shared social and environmental influences. These influences may be positive, but frequently populations have influences such as
poverty, weak social support, unsafe communities, poor literacy, or lack of insurance, and each of these can impinge on individual behavior. With skills in behavioral
science, pharmacists can better understand the communities in which they work and develop more empathic
approaches for targeting factors that could improve
medication use in their communities. Pharmacists can
address social and behavioral issues in the community
by being culturally competent, promoting diversity in
the pharmacy workforce, and providing assistance to
uninsured patients.
Health screening is another example of public health
outreach of pharmacists. Screenings can and should be
targeted to unique needs of a community; an example is
screening for human immunodeficiency virus (HIV) in
communities with a high incidence of HIV infections.
A public health perspective prioritizes policies that are
in the best interests of the greatest number of members
of a population, with particular concern for vulnerable
members of the group. For example, pharmacists are the
first people to notice when patients fail to pick up their
medications. The primary reason for failing to pick up
medications is often financial hardship, not irresponsibility. By understanding who these patients are and
knowing the broader determinants of nonadherence,
pharmacists are well positioned to advocate for these
vulnerable people within their health-system population. Pharmacists can also leverage their influence to
enhance services for such patients through legislative or
economic means.
The voice of the pharmacist is greatly magnified
when members of the profession collaborate with other
health care professionals to advocate their positions.
By
working closely with other professions on advocacy, the
pharmacists’ message is strengthened and the pharmacist is seen as an essential part of the public health team. From a microlevel perspective, pharmacists are becoming key players in patient-centered medical homes
and in accountable care organizations. From a macrolevel perspective, pharmacists have much to contribute to public policy debates by providing legislators and
regulators with background data, testimony, or feedback. For example, on October 1, 2013, California Governor Jerry Brown signed SB 493, affording pharmacists
provider status.This will help address the shortage of
primary care providers by expanding the scope of services that can now be covered by pharmacists. This new
opportunity was achieved by the informed advocacy of
pharmacists who understand health policy. Pharmacists
need to participate actively in community and national
health organizations, and to do so they need a grasp of
health policy that incorporates pharmacy into a broad
health sciences framework.
3. Epidemiology
Epidemiology asks key questions about diseases in the
target population: what is the disease, who has it, where
is it found, when does it appear, and why might this be
so? With public health problems such as prescription
drug abuse or increased rates of diabetes, pharmacists
have a unique role in understanding the epidemiology
of these problems. Many pharmacists have access to prescription data or pharmacy-related information about
their patients. Pharmacists tend to use these databases
for quality review or to improve marketing of pharmacy
services. Why not also query such databases to determine the unique characteristics of one’s own patient
population and thereby better understand the determinants of local community health? Clinical practitioners,
including pharmacists, can use their observations and
personal experience to develop hypotheses that could be
explored using the tools of epidemiology. For example,
one might be able to identify trends in medication use
and determine common characteristics of those uses.
Data will then inform the development of programs and
assist in prioritizing and delivering new interventions.
4. Bio-statistics
Pharmacies are located in communities where few other
health care options are available. In communities of all
types, community pharmacies are the most accessible
health care setting. These factors make them natural sentinel sites for population trends. Pharmacists can assist
in tasks of many types, including reporting of adverse
drug reactions and observing prescribing trends.
For example, a vigilant young pharmacist working
in the Indian Health Service in Montana took note of
increased prescription of inhaled beta-2 agonists for patients with asthma. Using basic skills in biostatistics, he
was able to determine that local children had an asthma
rate twice the national average. A pharmacist equipped with skills in biostatistics such as comparing mean differences and disaggregating
data by demographic characteristics is well prepared
to explore trends observed, thus allowing new interventions to be proposed. Claims data are available to pharmacists to evaluate medication dispensing patterns,
perform cost analyses, and determine community-level
usage trends in a population of patients. This application of biostatistics to answer epidemiologic questions
pertinent to pharmacy led to development of the discipline of pharmacoepidemiology.
5. Environmental health sciences
Environmental health sciences cover a wide range of
issues, from natural disasters to the impact on human
health of hazardous materials in the environment. The
latter area in particular stands at the interface of chemistry and human behavior. Some examples include the
exposure of sanitation workers to a wide variety of hazardous materials and the risks to the health of health
care workers who handle radiation or chemotherapy.
We know of a hospital pharmacy department in a
major health care system that has developed a systemwide policy to avoid unintentional exposure to all hazardous substances. Any community may face problems
with water pollution, hazardous substance disposal,
or waste management. These are all opportunities for
pharmacists to apply their pharmaceutical knowledge
to environmental health issues.
Also important in community planning is creating
an environment that enables people to choose healthy
behaviors. Pharmacies could contribute indirectly to
chronic disease prevention by choosing to prioritize
the sale of health-enhancing products and not stocking
products with known health hazards, including alcohol
and tobacco products.
Conclusion
Progress in public health and pharmacy requires integration of public health competencies into practice;
public health should not be viewed as a separate responsibility with which to task pharmacists. Pharmacy is ideally suited to contribute to population health in unique
and valuable ways. To achieve this contribution, pharmacists need training in the five core competencies of
public health.
As a multidisciplinary field, public health can also
benefit from the participation of pharmacy. A preferred
future involves enhancing the skills of practicing pharmacists so they can apply public health in their practice.
Some pharmacists might even choose to pursue public
health as a career. Both of these approaches have the potential to expand the scope of influence of pharmacists,
increase their credibility, and improve the health of populations they serve.
Source:
Mark A. Strand, PhD, is Associate Professor, Pharmacy Practice, Master of Public
Health Program; Donald R. Miller, PharmD, is Chair and Professor of Pharmacy
Practice, College of Pharmacy, Nursing,
and Allied Sciences, North Dakota State
University, Fargo.
Correspondence: Mark A. Strand, PhD,
Pharmacy Practice, Master of Public Health
Program, College of Pharmacy, Nursing,
and Allied Sciences, North Dakota State
University, 118L Sudro Hall, Fargo, ND
58101. Fax: 701-231-7606. E-mail: Mark.
Strand@ndsu.edu
Disclosure: The authors are contributors to
the Public Health Certificate Module mentioned in this article. They declare no conflicts of interest or financial interests in any
other product or service mentioned in this
article, including grants, employment, gifts,
stock holdings, or honoraria.
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