Brazilian pharmacists’ perspectives on continuing education for diabetes management

Brazilian pharmacists’ perspectives on continuing education for diabetes management

Available online at Currents in Pharmacy Teaching and Learning 7 (2015) 536–540 Short communication http://www.pharmacyteachi...

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Available online at

Currents in Pharmacy Teaching and Learning 7 (2015) 536–540

Short communication

Brazilian pharmacists’ perspectives on continuing education for diabetes management Yardlee S. Kauffman, PharmD, MPHa,*, Natalie Capozzolo, PharmDb, Scott Drab, PharmDc, Alana DeLoge, MPH, MAd, Claudio José de Freitas Brandão, MSe, Randall Smith, PhDc a

Department of Pharmacy and Pharmacy Administration, University of the Sciences, Philadelphia College of Pharmacy, Philadelphia, PA b CVS Pharmacy, Myrtle Beach, SC c Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA d Linguistics Department, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA e Hematology & Hemotherapy Center, Hospital Aliança and Edgard Santos General Hospital, Salvador, Bahia, Brazil

Abstract Background: Pharmacists in low- to middle-income countries often lack opportunities to develop and apply clinical pharmacy skills in real-world settings. The benefit of a diabetes continuing education program (DM Educates) has not been assessed in Brazil and may prove convenient and cost-effective for pharmacists to develop diabetes management skills. Objective: To identify if Brazilian pharmacists and student pharmacists would participate in DM Educates, utilize skills gained in practice, and identify modifications to DM Educates that better meet the needs of these health care professionals. Methods: Three focus groups of pharmacists and student pharmacists (N ¼ 19) were conducted in Brazil. Participants watched a module of DM Educates with visuals in English and audio in Brazilian Portuguese. Participants were asked about program value and barriers to its use and implementation in Brazil. Results: Four main themes emerged: Pharmacists struggle with expanding their clinical role and knowledge base, pharmacists value programs like DM Educates to acquire knowledge about diabetes care, cultural adaptations are necessary to improve program applicability, and program content should be available through different modalities. Conclusions: This study suggests that Brazilian pharmacists and student pharmacists want to provide clinical services to patients with diabetes, but they lack access to current drug information and have limited training to execute care. Continuing education programming like DM Educates enables pharmacists in other countries to engage in clinical training. Partnerships with U.S. institutions that provide educational programming could serve to establish clinical pharmacy education in countries that lack supporting infrastructure as long as program accessibility is convenient and culturally appropriate. r 2015 Elsevier Inc. All rights reserved.

Keywords: Brazil; Diabetes mellitus; Pharmacists; Continuing education

Introduction * Corresponding author: Yardlee S. Kauffman, PharmD, MPH, University of the Sciences, Philadelphia College of Pharmacy, 600S. 43rd Street, Philadelphia, PA 19104 E-mail: [email protected], [email protected] com 1877-1297/r 2015 Elsevier Inc. All rights reserved.

Pharmacists have been recognized for providing evidence-based care for patients,1 with many studies demonstrating their positive impact on clinical and economic outcomes.2–4 Clinical pharmacists’ value has been illustrated in high-income countries, but in middle- to low-income

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countries that struggle with outdated pharmacy curricula, dilapidated health care infrastructures, and shortages of practicing pharmacists, the role of a clinical pharmacist has yet to be fully recognized.5,6 In Brazil, approximately 11.9 million citizens aged 20–79 years old have diabetes mellitus,7 with an additional five million cases expected by 2030.8 Knowledgeable clinicians who can care for this growing population segment are needed. With the aid of continuing education resources, clinical pharmacists could fill this gap while enhancing their professional role and offsetting the workload burden experienced by other clinicians.1 Particularly in Brazil, opportunities for continuing education are limited and are not mandatory to practice as a pharmacist. Individuals pursuing a pharmacy degree complete a five-year program resulting in a generalist pharmacy degree. While training activities involving patient care were introduced in 1997, such activities represent only 5% of the total curriculum hours, with the majority of coursework focusing on pharmacology, clinical analysis, and parenteral nutrition. Consequently, many pharmacists are employed in industry, clinical analysis laboratories, hospital pharmacies, and hospital pharmacy administration.6 DM Educates, an online continuing education program created by the University of Pittsburgh School of Pharmacy, is designed to provide health care professionals with a multidisciplinary approach to comprehensive diabetes management.9 The program contains a collection of 12 modules, delivered through video lecture by a multidisciplinary group of faculty. Lectures are available via the internet and are synchronized with PowerPoint slides. Learning is also facilitated through active learning experiences and post-module self-assessment questions. Some course modules incorporate supplemental learning activities provided through links outside the delivered lecture. An example activity is a step-by-step instructional video on the use of insulin delivery systems. At the end of each module section, a self-assessment test provides ten multiple-choice questions that are randomly selected by the program from a pool of at least 30 questions, so that learners receive unique examinations. Module topics focus on pharmacotherapy, nutrition, exercise, mental health, health promotion, and cultural competency. DM Educates has been implemented in over 85 colleges and universities and has assisted the educational needs of over 10,000 pharmacists, but it has not been explored in middle- to low-income countries.10 The purpose of this study was to describe the perspectives of Brazilian pharmacists and student pharmacists to determine how they would use this tool and what program adaptations would serve to meet their educational needs. Methods Setting This qualitative study was conducted between May 2011 and June 2011 in the city of Salvador, Brazil, at Hospital Aliança and the Regional Council of Pharmacy of Bahia.


Participant recruitment Eligible participants included adults who were licensed pharmacists or student pharmacists in Brazil with no previous exposure to DM Educates. Participants were recruited from universities, local hospitals, and the Center of Diabetes and Endocrinology of Bahia (CEDEBA) and were contacted via telephone and in person by coordinators from local health centers and from the Regional Council of Pharmacy of Bahia. The primary role of participating pharmacists in their respective job positions was related to medication dispensing. Each participant who completed the study received US $100 as compensation for three hours of participation. Data collection The Institutional Review Board at the University of Pittsburgh reviewed and approved the study prior to data collection. Participants provided verbal informed consent at the beginning of each focus group. The investigators sought to recruit eight to ten participants for each focus group, anticipating that six to eight individuals would participate based on dropout rates reported in the literature.11 A trained focus group facilitator fluent in Brazilian Portuguese conducted each focus group. Interview questions were designed for the study and are shown in Table 1. The facilitator did not present personal views during data collection. An interview guide was used to provide consistency among interviews, and probing questions were asked as needed when the interviewer needed to clarify participants’ answers. Participants were shown a DM Educates module (i.e., oral antihyperglycemic agents), with visual content in English and audio content in Brazilian Portuguese, followed by a question-and-answer period. Data analysis Each focus group was audio recorded and transcribed from Brazilian Portuguese to English by a reputable Table 1 Focus group questions What did you think about this video? Would you watch/participate in these modules?  If yes, why do you think that?  If no, why not? What would motivate you to participate? PROBE: If continuing education is not a requirement for your job, would you use the program for the purposes of your own education? How would you like to see these modules delivered to you? What challenges would you see in implementing this program? Do you see yourself using the information presented in this program in your profession?  If yes, why do you think that?  If no, why do you think that? What do you think is the best way to advertise this program?


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translating company. Qualitative analysis was performed to identify emerging themes using an inductive approach.12 An inductive approach means that the themes identified are strongly linked to the data themselves and may have little resemblance to the specific questions that were asked to participants. Three investigators (Y.K., N.C., and A.D.) read the transcripts independently for understanding of content. Data were reviewed line by line and passages of text were labeled with a code to help catalog key concepts. The coding structure evolved inductively as text segments were compared with text segments that had been assigned the same code previously. As text segments were compared, each coder decided if the same concept was reflected.13,14 For example, “Technological Barrier” abbreviated as “TBarrier” was defined as “a participant cites an issue with available technology as a limitation to DM Educates use” and was applied accordingly. If new text segments did not align with the code definition, a new code was created. Apart from independent coding, the investigators met regularly to discuss codes and emergent themes and discussed gaps or inconsistencies in analysis. The coded text was grouped into categories to identify major themes. This served as a quality check in order to improve the trustworthiness of the data.15

Results Three focus groups were conducted with a total of 19 participants. The majority of participants were female (79%). Ten participants were pharmacists, while the remaining participants were students at local universities in Salvador. The majority of pharmacists practiced in a hospital setting. Demographic data are presented in Table 2. Thematic analysis of the interview transcripts identified four common themes. Theme 1: Pharmacy practitioners struggle with expanding their clinical role and knowledge base.

Table 2 Baseline characteristics of focus group participants Baseline characteristics

N ¼ 19

Female (n, %) Pharmacists (n, %) Student pharmacists (n, %)

15 (79) 10 (52.6) 9 (47.3)

Student pharmacist university (n, %) Universidade Salvador Universidade Federal da Bahia

n¼9 5 (55.5) 4 (44.4)

Pharmacist practice setting (n, %) Hospital Aliança Hospital Português da Bahia—Salvador Hospital Espanol Hospital Ana Nery Hematology and Hemotherapy Foundation of Bahia Unknown

n 2 1 2 1 2 2

¼ 10 (20) (10) (20) (10 (20) (20)

Participants expressed that updated drug information resources are difficult to obtain, making it a challenge to remain current with new information. For example, one pharmacist stated, “We see the difficulty that we as pharmacists have (accessing new clinical information). I am amazed to see we do not know what’s useful and what isn’t. We are so ineffective in this regard.” Another pharmacist commented, “It’s difficult to obtain knowledge about new drugs,” while a student stated, “We have no supply of specialists in diabetes like this program is offering,” suggesting that opportunities to participate and develop into a clinical pharmacist with expertise in diabetes care are lacking.” All participants agreed that participation in DM Educates would help to address their educational needs and could facilitate the development of relationships with other health care providers. A pharmacist expressed, “This information is important even in interactions with a professional from another field…contact with the doctor is not as easy to make as contact with a patient.” Participants agreed that this knowledge could be used to assist providers who take care of patients with diabetes. Theme 2: Pharmacists value education programs like DM Educates to acquire knowledge in diabetes care. Participants thought that use of DM Educates would improve their diabetes knowledge, help them apply this knowledge in their professional roles, and ultimately improve patient care. Overall, participants felt that DM Educates is an opportunity for professional growth. For example, one pharmacist commented, “I think it (DM Educates) is a growth opportunity, a chance to change. A career pharmacist must never stop learning. He must be well-informed about drugs.” A student confirmed his dedication to lifelong learning by stating, “I see this (DM Educates) as an opportunity for us (pharmacy professionals) to delve deeper into the coursework we saw (learned) at the university, which we will use throughout our lives.” Another pharmacist suggested that DM Educates is a useful reference to acquire more knowledge—“This is a very practical way to obtain the information and from there on you have a basis for study.” In addition to obtaining diabetes knowledge, it would also facilitate a change in daily practice. For example, a student expressed, “I think I could put the knowledge absorbed from the program (DM Educates) into practice in order to help people who interact with me in my professional field,” and a pharmacist stated, “I can see myself doing this (applying this information) with the group of patients we have. This is a tool that I see myself putting into practice, for the benefit of all patients.” Theme 3: Adaptations related to cultural needs are necessary to improve program applicability. Participants identified that the language would be an important obstacle to overcome. For example, one pharmacist commented, “The actual lesson is taught in Portuguese and they also have text in English…but if there is somebody speaking in English and the text is in English, the language becomes a handicap.” Inapplicability of some drug

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information was identified as another issue. In particular, a student cited that the drug names that were in the used video were not recognizable. “The first challenge would be to adapt it (DM Educates) to Brazilian reality, for example the issues of names. We use the drug’s chemical name…not the brand name.” All participants agreed that language barriers and program content should be relevant to pharmacy practice in Brazil. Theme 4: Access to program content should be available through different modalities. Participants want to access the program in different ways including CD-ROM and public symposiums as technological barriers are a problem. For example, one pharmacist pointed out that access to the internet is difficult to get—“I work in rural areas, and it’s tough to get internet access.” Other pharmacists and students offered alternative suggestions to receive these materials in addition to the internet. Their comments included, “It’s better to get this material on a CD” and “I think (dissemination) via symposia would be an interesting way to do it because people are already interested in renewing and/or updating their knowledge. It would be a good means of dissemination.” Discussion These results demonstrate that participants value educational programming to strengthen their clinical knowledge of diabetes. Most participants recognize the growing need for competent clinicians in this area and view DM Educates as an opportunity to update their knowledge of medications and develop the skills that are necessary to assist other clinicians. Pharmacist training in Brazil does not emphasize direct patient care, favoring preparation of students for pharmaceutical industry, laboratory analysis, and hospital services.5 However, organizations such as the Regional Council of Pharmacy of Bahia are interested in expanding access to continuing education programs to enhance pharmacists’ knowledge and assist with clinical practice development.16 Other studies investigating the impact of diabetesfocused programs for pharmacists and students have concluded positive improvement in skills and knowledge of diabetes management.17–20 In particular, a diabetes certificate program noted improvements in patient education skills and student knowledge in comparison to those who were not involved in the program.17 In addition, an online program emphasizing diabetes medication therapy management (MTM) was associated with improvements in participants’ knowledge of how to perform MTM for patients with diabetes.18 Participants’ beliefs that they have control while performing MTM were also reported. Another example associated with improvements in student knowledge and skills was a specialty diabetes care course that incorporated active learning experiences.19 While DM Educates has already been used in many settings, exploring its use in Brazil may fill gaps in pharmacists’ and students’ educational needs.


Addressing language barriers and identifying effective delivery methods will be necessary to deliver programs such as DM Educates to pharmacists and other health care providers in countries like Brazil. It will be important to provide access to the material in a way that is accessible to all (e.g., in coursework or via CD) and ensure that drug names are consistent with those used in Brazil. To facilitate the implementation of DM Educates, developing partnerships with universities in the U.S. may create opportunities to share methods for establishing best practices and improving clinical training. An ideal strategy would be to implement it in the pharmacy curricula, providing students with a foundation for clinical management of diabetes and increased ability to translate this knowledge base to clinical practice. It will be necessary to ensure that language barriers have been removed and terminology has been changed to reflect the medical vernacular within the country. To prevent this from becoming an issue, DM Educates could be tested out in a small group of student pharmacists and pharmacists to ensure that the content is understood. Furthermore, this program highlights the multidisciplinary elements of diabetes care and could provide further guidance as to how to work in an interprofessional care team. This program could be implemented in other communities around the world as long as consistent access is ensured to participants. While these results are promising, further research should focus on the implementation and evaluation of this program to determine the impact on pharmacist knowledge and practice. Limitations While the program would be offered in Brazilian Portuguese, participants were shown a small portion of the course with the visual content delivered in English and the audio content delivered in Brazilian Portuguese during the focus groups. Participants’ understanding of how this program is delivered may have been misunderstood; consequently, other modifications may not have been identified. Also, the amount of the monetary incentive may have influenced individuals’ decision to enroll. In addition, community pharmacists were not represented in the data, and the results may not be generalizable to other areas in Brazil. Although the impact of DM Educates on pharmacists’ knowledge and patient outcomes was not formally evaluated in this study, these data help to bridge the gap in knowledge about pharmacists’ preferences for utilization of continuing education programs in Brazil. Conclusions This study suggests that Brazilian pharmacists and student pharmacists want to provide clinical pharmacy services to their patients with diabetes, but they lack access to resources and training to execute this care. Participants believe that educational programs like DM Educates could enhance their diabetes knowledge. However, access to


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program material must be made convenient based on available resources. This online course could train these practitioners and students with minor adaptations, providing a foundation to build clinical pharmacist services to manage diabetes. Future research should concentrate on implementation of DM Educates. Acknowledgments We thank Ms. Vana Blanker for initiating contact with Dr. Claudio José de Freitas Brandão and the Regional Council of Pharmacy (Conselho Regional de Farmácia) of Bahia (CRF-BA) in Brazil, and we also thank Novo Nordisk for support with development of DM Educates. References 1. Giberson S, Yoder S, Lee MP. U.S. Public Health Service. Office of the Chief Pharmacist. Improving patient and health system outcomes through advanced pharmacy practice. A report to the U.S. Surgeon General. December 2011. 2. Smith M. Pharmacists’ role in improving diabetes medication management. J Diabets Sci Technol. 2009;3(1):175–179. 3. Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3): 52–60. 4. Johnson CL, Nicholas A, Divine H, Perrier DG, Blumenschein K, Steinke DT. Outcomes from DiabetesCARE: a pharmacistprovided diabetes management service. J Am Pharm Assoc. 2008;48(6):722–730. 5. Anderson S. The state of the world’s pharmacy: a portrait of the pharmacy profession. J Interprof Care. 2002;16(4):391–404. 6. Dewulf NLS, Troncon LEA. The invisible pharmacist. Am J Pharm Educ. 2009;73(4):2–3. 7. International Diabetes Federation. IDF diabetes atlas, 6th ed. Brussels, Belgium. 〈〉; 2013 Accessed May 15, 2015.

8. Shaw JE, Sicree RA, Zimmer PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4–14. 9. Hall DL, Drab SR, Campbell RK, Meyer SM, Smith RB. A web-based interprofessional diabetes education course. Am J Pharm Educ. 2007;71(5):Article 93. 10. DM Educates. Comprehensive diabetes management. 〈http://〉; Accessed May 15, 2015. 11. Krueger R. Focus Groups: A Practical Guide for Applied ResearchCalifornia: Sage Publications Ltd; 2000. 12. Braun V, Clark C. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 13. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes and theory. Health Serv Res. 2007;42(4):1758–1772. 14. Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contribution to outcomes research. Circulation. 2009;119(10):1442–1452. 15. Ulin R, Tolley EE. Qualitative data analysis. In: Ulin PR, Robinson ET, Tolley EE, eds. Qualitative Methods in Public Health: A Field Guide for Applied Research, 1st ed, San Francisco, CA: Jossey-Bass; 2005:139–174. 16. Conselho Regional de Farmácia CRF-BA. 〈http://www.crf-ba.〉; Accessed May 15, 2015. 17. Ryan GJ, Foster KT, Unterwagner W, Haomiao J. Impact of a diabetes certificate program on pharmacists’ diabetes care activities. Am J Pharm Educ. 2007;71(5):Article 84. 18. Battaglia JN, Kieser MA, Bruskiewitz RH, Pitterle ME, Thorpe JM. An online virtual-patient program to teach pharmacists and pharmacy students how to provide diabetesspecific medication therapy management. Am J Pharm Educ. 2012;76(7): Article 131. 19. Johnson J, Chesnut RJ, Tice BP. An advanced diabetes care course as a component of a diabetes concentration. Am J Pharm Educ. 2003;67(1):160–170. 20. Hsiang-Yin C, Tzung-Yi L, Wan-Tsui H, Chun-Jen C, Chi-Ming C. The short-term impact of a continuing education program on pharmacists’ knowledge and attitudes toward diabetes. Am J Pharm Educ. 2004;68(5):1–6.