An exploration of factors affecting the use of community pharmacy services by South Asians in ...

441 Pages·2014·3.77 MB·English

De Montfort University

An exploration of factors affecting the use of
community pharmacy services by South
Asians in Leicester

Neena Lakhani

Submitted in partial fulfilment of the requirements of
De Montfort University for the award of Doctor of Philosophy

Volume 1: Thesis

January 2012
ABSTRACT
Understanding the philosophy of a different culture and integrating this understanding into
the provision of pharmaceutical care is challenging and complex. This thesis argues the
importance for community pharmacists to acknowledge that culture, religion, family and
community dynamics can impact on patients’ health, health seeking behaviour and
medicines adherence. The perceptions of members of the South Asian1 population, general
practitioners, and community pharmacists about how these factors are viewed in relation to
community pharmacy services were explored in this study. It was conducted in Leicester
City, which has a South Asian minority ethnic population of more than 25%. Participants’
views of the role of extended community pharmacy services in the wider government agenda
were explored. South Asians attitudes to healthcare, self care and the management of
minor ailments were discussed.

A qualitative methodology approach was adopted, which used constructivist and interpretive
principles. Data collection for the study was conducted in two phases. In Phase 1, one to
one semi-structured interviews were conducted separately with six local GPs and five
community pharmacists from both ‘white’ (European) and South Asian backgrounds. In
Phase 2, six gender specific focus groups were convened comprising of fifty five participants
in total from the Sikh, Moslem and Hindu communities. Bi-lingual community workers were
used in this study which allowed a more ‘sensitive’ exploration of the sociological aspects of
health seeking behaviour and the impact of ‘cultural’ influences on medicines adherence.

The need for ‘cultural competence’ of community pharmacists is discussed as one of the
major contributions to the evidence base for pharmacy practice. Such initiatives would
require pharmacists to acquire more effective consultation skills in the first instance.
South Asians expressed views that community pharmacists need to be more
knowledgeable, responsive and flexible in their professional practice by assessing their
pharmaceutical needs and being aware of particular cultural sensitivities when planning their
services in line with the new pharmaceutical contract. More specifically, South Asian
participants illustrated the need for community pharmacists and their staff to be more
‘culturally knowledgeable’ about the communities in which they practice. It is argued that the
provision of a more culturally sensitive and pro-active service is needed to develop a better
patient-practitioner professional relationship that promotes trust. South Asians illustrated
how certain behavioural, religious and cultural beliefs impact on medicines adherence, such
as compliance issues whilst on holiday to their homeland, the impact of religious pilgrimage

1 The term South Asian refers to people whose origins can be traced to the Indian sub-continent comprising of Pakistan, India,
Sri Lanka and Bangladesh
and fasts. Many South Asian participants had limited understanding about ‘generic’
medicines and considered these to be ‘inferior’ or ‘less effective’ than ‘branded’ medication.
Participants’ views of ‘sharing’ of medicines and medicines waste were also illustrated.
Factors such as ‘stress’, ‘fate’ and ‘karma’ and their impact on health of the participants were
discussed. Many of these factors could not be solely attributable to a South Asian ‘culture’.
However, the findings illustrate a need for a Medicines Use Review (MUR) service to include
more ‘targeted’ exploration of medicines adherence and medicines optimisation for this
population. The findings also highlighted why South Asians rarely consult the community
pharmacist about sensitive or stigmatised issues such as depression, and how some
conditions and symptoms were perceived to have negative impact on the ‘social acceptance’
of South Asian individuals within their own communities. South Asians suggested that
community pharmacists needed to be more pro-active and ‘responsive’ to their
pharmaceutical needs and respect confidentiality through use of private consultation areas
for routine counselling, health promotion and medicines information.

All participants endorsed a need for more ‘professional’ recognition of the pharmacist not
only as an autonomous health care professional, but as one integral to providing NHS
services relating to medicines and public health. The findings illustrated a lack of
professional collaboration between community pharmacists and GPs, confounded by
community pharmacists being ‘subordinate’ to GPs and portraying more of a ‘shopkeeper’
image. South Asians were well informed about the lack of shared medical records and relied
heavily on a doctor’s definitive ‘diagnosis’ for somatic symptoms related common ailments.

South Asians pro-actively engaged with ‘community action’ based approaches in health
education and health promotion, and an opportunity for community pharmacists to become
more involved with social initiatives was inferred from the findings. Candid and animated
discussions explored their understanding of exercise as part of weight management and
their interpretation of effects of the use of herbal products, alternative practitioners and the
importance of collaboration with religious and community leaders in promoting medicines
adherence. Participants desired alternative communication methods other than leaflets
(translated or otherwise), including the use of audio-visual means and use of media.
Communication difficulties were still prevalent, and trained interpreters were rarely used.

By embracing some of these challenges, community pharmacists could enhance the value of
their services and provide a more meaningful, ‘culturally’ competent and responsive services
based on the needs of their local populations and nurture a better trusting and professional
relationship with their service users and healthcare colleagues.
DEDICATION

This thesis is dedicated to my wonderful
family

To my husband Bharat, and my daughters
Shrina and Ria
ACKNOWLEDGEMENTS

This thesis was possible due to the fact that I had an amazing group of people who guided
me through this enjoyable, memorable and at times, very challenging journey. They are my
research ‘family’ across three institutions De Montfort University (DMU), University Hospital
of Leicester NHS Trust (UHL) and University of Leicester (UoL).
First and foremost, my heartfelt thanks and gratitude to Professor Mark Johnson, my first
supervisor. Your guidance has been inspiring. Your belief that I was capable of producing
my own ‘kahani’ and that ‘nothing is impossible’ has finally made me complete this journey
after 10 years. This leg of the journey might have ended, but I hope it is the start of a whole
new cultural ‘safari’!
Secondly my thanks to Professor Larry Goodyer, my second supervisor, for his guidance
throughout this project, and also his support as Head of the Leicester School of Pharmacy.
There are other key colleagues who I would like to thank as they were pivotal to this project.
 Mr Peter Golightly, Director of the Trent Medicines Information Centre, UHL for
starting me on this journey.
 Dr Nichola Seare (formerly UoL), Professor Michael Aulton (formerly DMU) and
Professor David Upton (formerly DMU) as my initial supervisory team for Phase 1 of
this project.
 Mrs Ann-Marie Cannaby (formerly UHL) for her input to ensure rigour and neutrality
to Phase 1 data collection and analysis
 Professor Azhar Farooqi and Professor Robert McKinley for being part of my steering
group for Phase 1 and 3 of this project
 Mrs Davinder Nagra (DN) for moderating, interpreting and translating in Phase 2 of
my project and being part of my steering group for Phase 2 data analysis.
 Dr Kip Jones and Dr Asesha Morjaria-Keval for helping me ensure rigour and
neutrality aspects of the Phase 1 and Phase 2 data analysis
 My employer, De Montfort University for paying the annual PhD registration fees.
 To all the participants in my study: I am indebted to you all.
I would like to say a big thank you to Dr Diane Harris, Dr Tina Harris, Professor Judith
Tanner, (the late) Mrs Debra Khan and Dr Fenglin Guo for their moral support between
2007-2012; to Dr Piali Palit for being my ‘critical’ friend and reading the final versions of the
original thesis; and to the entire team at MSRC and the Leicester School of Pharmacy for
their patience and support.
Lastly to my wonderful family: Bharat, Shrina and Ria. I could not have done this without
you. You have been my light at the end of the tunnel. Thank you for picking me up at times
of ‘being in the wilderness’.
CONTENTS (VOLUME 1)

ABSTRACT

ACKNOWLEDGMENTS

LIST OF TABLES, FIGURES AND BOXES

CONTENTS OF APPENDICES (volume 2)

GLOSSARY

CHAPTER 1: INTRODUCTION AND BACKGROUND 1

Aims and intended outcomes 3

The setting for the study 10

The execution of the study 14

Organisation of the thesis 16

CHAPTER 2: DEFINITIONS AND POLICY CONTEXT 17

Section 2.1. Ethnicity, culture, race, diversity and health inequalities 18

Section 2.2. Review of key government policies underpinning the study 35

Section 2.3 Policy context for reformation in community pharmacy services 47

CHAPTER 3: LITERATURE REVIEW 57

Section 3.1 Literature search strategy 56

Section 3.2 Appraisal of the literature 65

Section 3.2.1 The use of community pharmacy services by the South Asian population 66

Section 3.2.2 Key studies underpinning the perceptions of community pharmacy 70
services in the UK

Section 3.2.3 The use of General Practitioner services by the South Asian population 90

Section 3.2.4 The health of ethnic minorities in UK: a literature appraisal of some key 96
reports
Section 3.2.5 Cultural influences on health seeking behaviour of South Asians 104

Section 3.2.6 Communication and health promotion for the South Asian population 114

Section 3.2.7 Professional collaboration 124
Summary of Chapter 3 132

CHAPTER 4: METHODOLOGY, METHODS AND DATA ANALYSIS 134

Section 4.1. The research methodology 136

Section 4. 2. The research strategy and design 147

Section 4. 3 157
Interviews with GPs and community pharmacists (Phase 1: 2001-2)

Focus group interviews with members of the South Asian community 1 6 5
(Phase 2 : 2002-3)

Section 4.4 Data analysis 174

Section 4. 5. Limitations of the research process 188

Summary of chapter 4 191

CHAPTER 5: Phase 1 FINDINGS AND DISCUSSION. 193
The views of general practitioners and community pharmacists

Section 5.1 Phase 1 Findings from GP interviews 196

Key findings from GP interviews 228

Section 5.2 Phase 1 Findings from community pharmacist interviews 230

Key findings from community pharmacist interviews 266

Section 5.3 Discussion of the findings from Phase 1 268

CHAPTER 6. Phase 2. FINDINGS AND DISCUSSION 276
The views of South Asian service users

Section 6.1 Phase 2 Findings of focus group interviews 278

Section 6.2 Confirmation of the findings 2008 334

Key findings of Phase 2 (2001-3) and re-confirmation exercise (2008) 339

Section 6.3 Discussion of the findings from Phase 2 focus group interviews 342

Section 6.3.1 Triangulation of findings with the study by Jesson et al (1994b) 343

Section 6.3.2 Discussion of the main findings 348

Section 6.3.3 The strengths and limitations of the study findings 374
Section 6.3.4 Reflection: How this research has changed my practice 376

Section 6.3.5 Recommendations for a minor ailments scheme for Leicester City 379

Section 6.3.6 Recommendations for further professional development, education and 382
research

CHAPTER 7: CONCLUSIONS 385

REFERENCES 390
LIST OF TABLES, FIGURES AND BOXES

Boxes
Box 1 Research aims and outcomes 3
Box 2 Cultural Factors that can influence the use of health services by 12
BME members of the population
Box 3 Examples of Patterns of ethnic health inequalities 23

Box 4 Factors that can influence the use of health services by BME 26
members of the population

Box 5 The main findings of the study by Jesson et al (1994b) 68
Box 6 A summary of the findings from the study by Hassell et al (2000b) 81
Box 7 Communication: Some of the recommendations from Szczepura et 123
al (2005)

Box 8 Important issues addressed in the research design of this study 147
Box 9 Broad ideas explored in Phase 1 interviews 160
Box 10 Areas explored in the focus group discussions 169
Box 11 Summary of the main stages of data analysis 176
Box 12 Objectives for GP and pharmacist interviews 195
Box 13 Key findings from GP interviews (Phase 1) 228

Box 14 Key Findings from the pharmacist interviews (Phase 1) 266
Box 15 Aims of Phase 2 focus group interviews 279
Box 16 Key findings of Phase 2 (2001-3) and re-confirmation exercise 339
(2008).
Box 17 Suggestions for the service components of a minor ailments 381
scheme for NHS Leicester City Primary Care Trust 2008
Figures
Figure 1 The PCTs with the largest ethnic minority populations in East 11
Midlands

Figure 2 The execution of the PhD study 15

Figure 3 An illustrative definition of ethnicity and key factors that contribute 22
to the concept of ethnicity

Figure 4 How new codes were applied to previously coded data 182

Figure 5 Synopsis of the findings of Phase 2 341

Tables
Table 1 Ethnicity in Leicester City (Census 2001) 12

Table 2 Religion in Leicester City (Census 2001) 13

Table 3 Comparing the concepts of race, culture and ethnicity 20
Table 4 Ascertaining the religious background of census participants 33
Table 5 Key policies on Health inequalities, NHS and community pharmacy 36
service reforms (1980-2010)
Table 6 Key words for searches of the published literature 60
Table 7 Results of published literature search pertaining to South Asians 61
and pharmacy services
Table 8 The ideal criteria used for inclusion of studies and reviews in the 64
literature review
Table 9 Key therapeutic risk areas* in the South Asian population 100
Table 10 The Mary Seacole Research Centre Social Action Model 153
Table 11 Data collection methods for the study 155
Table 12 Community centres identified for Phase 2 168