Abstract

Objective: The Sub-Saharan Africa region has the highest hypertension prevalence of 30% globally. Hypertension is a key driver of cardiovascular diseases such as stroke and ischaemic heart disease in the region.  In Zambia, for instance, hypertension accounted for an estimated 50% of cardiovascular diseases-related deaths in 2019. However, managing the condition remains a low priority, with inadequate hypertension screening and other cardiovascular risk factors prevention and management services at the primary healthcare level. Community pharmacists could help reduce the burden of hypertension and other cardiovascular risk factors such as diabetes and high cholesterol in such contexts. Therefore, this study aimed to explore the potential role of community pharmacists in hypertension and other cardiovascular risk factors prevention and management services in Zambia. Barriers and facilitators associated with delivering these services were explored.

Methods: An exploratory qualitative study with a constructivist approach was conducted. Purposeful and snowballing sampling were utilised to recruit participants: Ministry of Health policymakers (n=8), pharmacy academics (n=2), community pharmacists (n=22), nurses (n=4), and clinical officers (n=4) and focus group discussions with patients (n=24). Semi-structured interview and focus group guides were developed based on 1) the Consolidated Framework for Implementation Research (CFIR) version 2022, 2) gaps from a systematic review and 3) findings from the document analysis. Data collection was conducted in Lusaka Province and Ndola of the Copperbelt Province of Zambia. Interviews and focus group discussions were audio recorded and transcribed verbatim. Data was analysed using a framework analysis approach.

Results: The findings suggest that accessibility, early diagnosis, and short waiting times for patients were major facilitators to providing hypertension and other cardiovascular risk factors prevention and management services in community pharmacies. Providing these services in community pharmacies could also help decongest public (government) health facilities. Additionally, strengthening legislation and monitoring of community pharmacies, developing a standardised community pharmacy non-communicable diseases model of practice, specialist training, and enhancing public-private sector partnerships were notable facilitators.

Barriers to implementing hypertension and other cardiovascular risk factors included structural barriers (i.e. community pharmacy is delinked from the mainstream health system), lack of community pharmacy non-communicable diseases policies and regulations, lack of community pharmacists’ representation at policy development level, inadequate pharmacists’ practical exposure to glucose or high cholesterol testing, a lack of interest from pharmacy business owners, insufficient funding and implementation costs.  A lack of access to electronic patient medical records was also a significant barrier. For instance, none of the 22 community pharmacists interviewed had access to electronic patient medical records in their pharmacy.

Recommendations: Policymakers should consider linking the private community pharmacy sector to the mainstream referral health system. The implementation of an electronic interface to allow community pharmacists to access patients' medical records and connect with public health facilities to enhance collaboration between clinicians in hospitals/health centres to provide optimal patient care. For example, the implementation of electronic information systems, such as Smart Care, being rolled out in some public health facilities. Accrediting the National Health Insurance Management Authority (NHIMA) community pharmacies near public health facilities could reduce transport costs and challenges patients encounter to access NHIMA services in community pharmacies. Policymakers and pharmacy regulatory bodies should work towards creating policies and laws that support the expanded role of community pharmacists in reducing the burden of non-communicable diseases in Zambia.