Community pharmacy alcohol-related liver disease risk identification and linkage to care through development of a complex intervention

Abstract

Liver disease is one of the leading causes of premature mortality in the United Kingdom. Alcohol-related liver disease (ArLD) causes the majority of these deaths. Morbidity and mortality from ArLD can be reduced if it is diagnosed earlier. Earlier diagnosis can be achieved by testing for ArLD in people who are at risk of it due to their alcohol consumption. Local liver disease pathways exist to facilitate earlier diagnosis in primary care. There is a drive to widen their reach by using novel community settings to identify ArLD. Community pharmacies represent an accessible setting with evidence indicating harmful alcohol use can be identified by pharmacists through alcohol screening and brief intervention (SBI) services. This PhD explores the development of a complex intervention that can enable community pharmacy to utilise this accessibility and SBI experience to identify patients at risk of ArLD and link them with ArLD pathways of care. The work in this PhD is underpinned by the Medical Research Council guidance on complex intervention development and undertaken in four work packages.
Firstly, to gain understanding of context and the wider system, an interrupted time series study examined the effect of implementing a local liver disease pathway to identify ArLD (the Southampton primary care liver pathway - SLP) on referrals to secondary care. This found the SLP was associated with a statistically significant gradual reduction in referrals, demonstrating the potential impact of a community ArLD liver disease intervention and a method of evaluating such interventions.
Secondly, a review of existing evidence using a qualitative evidence synthesis of nine studies of SBI in community pharmacy was undertaken. This generated understanding of the barriers and facilitators experienced in the delivery of SBI so that these can be addressed in intervention design. Facilitators included non-confrontational communication skills, aligning SBI with existing pharmacy services and pharmacist role legitimacy. Barriers included multiple demands on staff time, a lack of staff experience with screening tools, and staff concerns of causing offence.
Thirdly, new primary research was conducted as semi-structured interviews with stakeholders (n=26). This explored perceptions of a role for community pharmacists in ArLD identification, perceived challenges to such a role, and potential features of the intervention. Stakeholders included patients with ArLD, members of the public, pharmacists and pharmacy assistants, hepatology professionals and general practitioners.
Finally, the intervention was designed and refined using theory and stakeholder review. The behaviour change wheel was applied to earlier findings to guide the design of the intervention. This was then refined through a co-design workshop with key stakeholders. The outcome of this work was 23 described key components and a structure of a community pharmacy complex intervention anticipated to have the best chance of being implementable and suitable for assessment in feasibility and pilot testing in future work.

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Identifiers

ORCID for Alexander Murray Smith: orcid.org/0000-0003-1190-0170

ORCID for Julie Parkes: orcid.org/0000-0002-6490-395X

ORCID for Kinda Ibrahim: orcid.org/0000-0001-5709-3867

ORCID for Ryan Buchanan: orcid.org/0000-0003-0850-5575

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