Background: Community pharmacists can partner in collaborative management of chronic diseases such as osteoporosis. However, in Malaysia, the involvement of community pharmacists in the provision of osteoporosis care is minimal. Objectives: To identify the barriers and facilitators faced by Malaysian community pharmacists in providing osteoporosis care. Methods: Semi-structured one-on-one interviews and focus groups discussions (in groups of 5 participants), were conducted from October 2013 to July 2014. Community pharmacists were purposively sampled based on their years of experience and place of work. One of three trained researchers interviewed the participants using a topic guide. Interviews were recorded and transcribed verbatim. Data were analysed thematically using an interpretative description approach. Results: Nineteen community pharmacists participated (one-on-one interviews=9, focus group discussions=10). None of the participants had directly provided pharmaceutical care to people with osteoporosis. The main barriers were lack of public awareness (n=17); lack of accurate screening tools for community pharmacists (n=16); lack of knowledge (n=13), time (n=6) and collaboration between pharmacists and doctors (n=14); and lack of support from the government and pharmaceutical society (n=11). The pharmacists wanted more public awareness campaigns on osteoporosis (n=17), more continuing education on osteoporosis (n=11), a simple unbiased osteoporosis management guideline (n=13), inter-professional collaboration (n=18), and reimbursement for osteoporosis care (n=8) to facilitate the provision of osteoporosis care. All participants had equally shared the same view on the barriers and facilitators to provide osteoporosis care. Conclusions: This study has provided an insight into the barriers and needs of community pharmacists to provide osteoporosis care. The findings may help to develop interventions in supporting community pharmacists to improve osteoporosis care in the community.

1. Nik Jah1, Pauline Siew Mei Lai1, Chirk Jenn Ng1, Lynne Emmerton2
1Department of Primary Care Medicine, University Malaya Primary Care Research Group
(UMPCRG), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
2 School of Pharmacy, Curtin University, GPO Box U1987, PerthWA 6845, Australia
Barriers and facilitators to community pharmacy
management of people with osteoporosis in
Malaysia: A qualitative study
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2. Introduction
• Osteoporosis has significant impact on healthcare costs and
quality of life1
• By the year 2050, almost 50% of hip fractures worldwide will
occur in Asia due to an increase of the elderly population2
• Untreated osteoporosis incurs significant costs to primary and
secondary care3
1. Cauley JA.(2013)The Journals Of Gerontology, 68(10):1243-51.
2. Cooper C, et.al (1992). Osteoporosis International, ;2(6):285-9
3. Harvey N, Dennison E, Cooper C. (2010) Nature reviews Rheumatology, 6(2):99-105.
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3. • Community pharmacists can play an important role in providing
pharmaceutical care4 (the responsible provision of drug therapy for
the purpose of achieving definite outcomes that improve a patient’s
health-related quality of life) for people with osteoporosis5
• However, amongst the models for collaborative disease state
management services published internationally, there is sparse
evidence regarding the role of community pharmacists in the
provision of osteoporosis care.
4. Hepler CD, et.al.(1990) American Journal Hosp Pharm, 47(3):533-43.
5. Summers KM, et.al.(2005). Annals of Pharmacotherapy, 39(2):243-8.
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4. Objective
• To explore barriers, facilitators and the scope of a
hypothetical osteoporosis management service by
community pharmacists in Malaysia, informing a
vision for developing this service.
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5. Methods
•Study design: Qualitative
•Setting : Kuala Lumpur, Malaysia
•Duration: October 2013 to July 2014
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6. Participants
• Included were
• Community pharmacists from independent and chain pharmacies
• Working full time (8 hours for 5 days/ week)
• Excluded were locums
• Purposive sampling and the snowballing method was
used
• Sample size: estimated 20 participants or until data
saturation occurred
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7. Procedure
Invitation was sent
to pharmacists
For those who agreed,
the participant
information sheet was
sent
Where feasible,
pharmacists were
allocated to FGDs/IDIs
at a convenient date &
time
FGDs/IDIs
recorded and
transcribed
verbatim
• Research instruments used: a topic guide and a baseline
demographic form
• Ethics approval obtained (MEC Ref. No : 1017.29)
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8. Analysed using thematic and interpretative descriptive(ID)
approach
1
• 4 researchers worked in pairs and coded 2 interviews line-by-line to develop an initial
list of nodes
2
• This framework was used to code another transcript
3
• Coding discrepancies were resolved by discussion
4
• Lists of nodes were used as the final coding framework
5
• New nodes emerging during coding were added to the list upon consultation with the
research team
6
• Lists of nodes were regrouped into larger categories as themes emerged from the
data
• Computer software NViVo 10 was used to manage the data
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9. Demographic characteristics of participants
Participants Age Gender Working
experience
(years)
Participants Age Gender Working
experience
(years)
P1 54 Female 23 P10 42 Female 3
P2 29 Male 1 P11 46 Female 13
P3 42 Female 16 P12 42 Male 10
P4 33 Male 3 P13 33 Female 7
P5 28 Female 2 P14 43 Male 15
P6 39 Female 1 P15 26 Male 1
P7 30 Male 3 P16 42 Female 1
P8 37 Female 11 P17 51 Female 13
P9 42 Male 13 P18 47 Female 10
P19 31 Female 1
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10. Results
Description of pharmaceutical care service
components
Barriers
Facilitators
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11. Description of pharmaceutical care service
components
• Most community pharmacists do not actively
provide pharmaceutical care for osteoporosis
• However, when requested by clients, they would
advise on
• Osteoporosis risks and prevention
• How to take their osteoporosis medications correctly
• Bone density screening
• The patient seeing a doctor if the patient was at high risk
for osteoporosis
“So far, we don’t really
have customers come to
the pharmacy and say “I
want to prevent
osteoporosis” but they
come and say “I want to
do blood sugar or
cholesterol screening ….”
P11/F/46yo
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12. Barriers
Lack of public
awareness
Lack of an accurate
machine for
osteoporosis
screening at the
pharmacy
Lack of
collaboration
between
pharmacists and
doctors
Lack of
government
support
Pharmacists’ lack
of knowledge
Lack of time to
counsel about
bone health
Extrinsic factorsIntrinsic factors
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13. Intrinsic factors
“…I’m not that confident
because I do not have a big
picture of what osteoporosis
is all about: its treatment,
the apparatus used to screen
for Osteoporosis …. So, the
management part, I am not
that familiar.”
37yo female
• Lack of knowledge and time
• Not familiar with osteoporosis
• Perceived that osteoporosis is a complicated
disease, so they were not confident to advise
on osteoporosis
• Felt that the provision of pharmaceutical care
in osteoporosis would take a lot of time
• Need to allocated special time to provide
pharmaceutical care to osteoporosis patients
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14. Extrinsic factors
Lack of
government
support
Lack of
collaboration
between and
doctors and
pharmacists
Lack of
public
awareness
“…When we want to
discuss about bone health,
the client wants to see
some proof that they
have osteoporosis… but
we don’t have that
machine…”
P10/F/42yo
“…the problem with the
healthcare system …
pharmacists don’t receive
osteoporosis prescriptions
from doctors..”
P3/F/42yo
“… osteoporosis is not
something that I talk to
with my clients as there
is lack of public
campaigns by the
government …”
P17/F/51yo
“… osteoporosis is a
hidden health
condition,...not like
other conditions that
may have symptoms…”
P6/F/39yo
Lack of an
accurate
machine for
osteoporosis
screening at
the pharmacy
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15. Facilitators
Public health
campaign
Inter
Professional
collaboration
A
pharmaceutical
care plan on
osteoporosis
for community
pharmacy
Pharmacists
reimbursement
Continuing
education on
osteoporosis
“..keep on
educating
ourselves, new
knowledge on
osteoporosis”-
P9/M/42yo
“ we can’t work with
one hand,
collaborates with
doctors for DEXA
scan, a win-win
situation”
P7/ M/30yo
“if there is a
minimal fee
imposed compulsory
by government, it’s
a to boost our
image also.”
P19/F/31
“..if you have the booklet
or anything about
osteoporosis from
independent sources..”
P13/Female/ 33yo
“..the supports from the
government, create the
awareness in the public
…help us to reach the mass
public” –P9/M/42yo
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16. Discussion
• Findings show that Malaysian community pharmacists’ involvement in the
provision of pharmaceutical care for osteoporosis is minimal.
• Little demand for osteoporosis services from the public
• Deeply rooted in the traditional role of medication dispensing
• Only opportunistic counselling on osteoporosis prevention
( such as risk factors and lifestyle modification) were practiced
• Pharmacists associated clients’ lack of awareness with inadequate public
health campaigns.This is surprising when raising public awareness is indeed
a role for pharmacists, which may be achieved using posters and health
promotion initiatives in-store, and public health messages via the media. 16
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17. • Previous studies have shown that osteoporosis screening by community pharmacist
was well accepted by the public and other health care partners6
• However, osteoporosis screening tools (e.g. heel ultrasound) or stratification
algorithm (e.g. fracture risk assessment tool, FRAXTM ) must be based on device-
specific cut-offs that are validated in the populations for which they are intended to be
used7
• The Osteoporosis Self-Assessment Tool for Asians (OSTA) is a simple and cost-
effective risk-screening tool that has been validated for use in the Asian populations8
• Similar to published studies9,10, the adoption of pharmaceutical care elsewhere has
been challenged by lack of knowledge, time and incentives, and limited inter-
professional collaboration
6. Goode JV, et.al. JAPhA. 2004;44(2):152-60.
7.Thomsen K, et.al. 2015. Osteoporos International 2015.
8. Chaiyakunapruk N, et.al.2006.JAPhA. 2006;46(3):391-6.
9. Laliberte MC, et.al. 2012. BMC public health.12(1471-2458)
10.WibowoY, et.al.2010. Rural Remote Health.10(3):1400
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18. Limitations
• Small sample of participants may not be generalizable to all
community pharmacists, especially those from rural areas
• Commercially-sensitive issues could not be explored in this study,
and this is suggested for later research in developing
osteoporosis services or proposing a structure for remuneration.
• Participants may have given a socially desirable response to
some questions to impress the university-based research team.
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19. Conclusion
• The majority of identified barriers are similar to those reported from other studies
of pharmaceutical care implementation
• Although pharmaceutical care services for osteoporosis are underdeveloped in
Malaysia, this study suggests general support amongst community pharmacists
to meet the needs of the aging Asian population.
• Careful planning, incorporating client needs analysis, and involvement of
pharmacy professional bodies and doctors, is indicated in the further
development of osteoporosis care services in Malaysian pharmacies.
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20. Acknowledgements
•University of Malaya Postgraduate Research Grant,
UMPRG (grant no: PG010-2014A)
•Participants
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