Attitude and Barriers of Community Pharmacists Towards Cancer Health Promotion: A Systematic Review

Background and Aim Over 8 million deaths occurred from cancer worldwide in 2013. As a result, it moved from the third major cause of death to the second major cause after cardiovascular diseases [1]. It is estimated that by 2030, approximately 26 million new cancer cases and 17 million cancer deaths will occur globally [2]. Evidence from studies suggests that health promotion improves quality of life and demonstrated several positive outcomes for cancer patients and survivors [3] such as a decrease in mortality rates among women with breast cancer [4], improvement in the emotional state and quality of life among cancer patients [5]. The World Health Organization (WHO) has continually advocated the involvement of pharmacists in health promotion campaigns to raise awareness on health issues and disease prevention [6]. Abstract


Background and Aim
Over 8 million deaths occurred from cancer worldwide in 2013. As a result, it moved from the third major cause of death to the second major cause after cardiovascular diseases [1]. It is estimated that by 2030, approximately 26 million new cancer cases and 17 million cancer deaths will occur globally [2].
Evidence from studies suggests that health promotion improves quality of life and demonstrated several positive outcomes for cancer patients and survivors [3] such as a decrease in mortality rates among women with breast cancer [4], improvement in the emotional state and quality of life among cancer patients [5]. The World Health Organization (WHO) has continually advocated the involvement of pharmacists in health promotion campaigns to raise awareness on health issues and disease prevention [6]. about cancer diseases [10]. To achieve this, our aim was to conduct a systematic review that analyses attitude and barriers of community pharmacist towards cancer health promotion.

Information Source and Search Strategy
The literature search included studies from the following electronic bibliographic databases: EMBASE (Ovid), CINAHL (EBSCOhost) and MEDLINE (EBSCOhost). The search period was from 2005 to July 2017.
The Embase search strategy (Appendix1) combined keywords such as cancer, community pharmacist, attitude, barriers, and health promotion. The keywords were combined using Boolean terms, medical subject headings, and truncation. This search strategy was adopted for other database searches. Additional search from reference lists of articles selected for full-text review yielded no results.
The review was planned and carried out using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist [11]. The protocol was registered with PROSPERO with registration number: CRD42017074328.

Screening and Extraction Process
All records were exported to and pooled in EndNote X7.0.2 software. Duplicates were identified and deleted using this reference management software. The title and abstract of the remaining articles were screened independently by two reviewers.
A standard table was used to extract data from the selected studies [12][13][14] and was later cross-checked for accuracy by a third reviewer. Data extracted included; lead author, year, country of study, sample description, type of cancer, duration of the study, study design, sample size, and conclusion.

Results
The database search yielded 323 records. Duplicates identified were deleted (n = 57). A total of 266 were screened on title and abstract. Irrelevant articles were excluded (n = 259). Relevant records (n = 17) were read fully and (n = 5) were considered eligible based on the set inclusion criteria. A flow chart summarising the selection procedure is shown in Figure 1.

Characteristics of the Selected Studies
The selected studies were conducted between the year 2010 and 2016 ( Table 2). One of the studies were conducted in Africa (Tanzania) and four of the studies in the Middle East (Qatar, Malaysia, United Arab Emirate (UAE), Jordan). Data were obtained from community pharmacists except in one study that the data include other health care personnel [15]. All the studies were descriptive cross-sectional using researcher designed questionnaires. The type of cancers in the selected studies was Breast cancer. The sample size ranged between 35 [10] and 1000 [9].

Quality Assessment of the Selected Studies
The quality of the selected studies was assessed using a quality assessment tool (9). Score from 0% -33.9% is regarded as weak, 34% -66.9% is regarded as moderate and 67% -100% is regarded as strong. Based on this assessment tool, the quality level of all the selected studies was strong.

Attitudes towards cancer health promotion
Although attitudes towards cancer health promotion varied among community pharmacists in the selected studies, studies done in the Middle East reported Health personnel in all Professionals had good knowledge and attitudes towards natural antioxidants but practice was not good. There was a significant difference in knowledge between professionals, whereby pharmacist were found to have highest knowledge. The results indicated that most pharmacists were not involved in any breast cancer health promotion, the majority were interested in educating patients about breast cancer. However, low breast cancer knowledge in addition to other identified barriers can prevent actualizing pharmacist's role in breast cancer education. Knowledge deficit pertaining to breast cancer risk factors and screening guidelines exist and might limit active enrolment of community pharmacists in patient education services. Therefore, pharmacists are encouraged to improve their breast cancer information regarding early detection and screening in order to be good educators to the public. Barriers in community pharmacy settings may limit proper counselling and education for women in community. These barriers should be managed to allow effective pharmacist interaction and education. Few community pharmacists are engaged in breast cancer health promotion activities, the majority of pharmacists view breast cancer health promotion as a part of their responsibility. However, low breast cancer knowledge in addition to other identified barriers can prevent actualizing pharmacists' role in breast cancer health promotion.

Barriers towards cancer health promotion
Perceived barriers for providing breast cancer health promotion reported in the selected studies were lack of breast cancer educational materials, lack of personnel, lack of public recognition of pharmacist's role, lack of time, lack of skills, lack of adequate knowledge, lack of direct profit, lack of training, lack of personnel, lack of budget and lack of reimbursement for such services. Only one study reported on gender barrier [10].

Summary
This review presents available evidence on attitudes and barriers towards cancer health promotion among community pharmacists. A study done by Murray and McMillan demonstrated that cancer remains the most feared disease in modern society [18]. Though the general public might be excused for their negative taught or attitude, one could assume that as a result of education, health professionals should have positive attitudes towards the disease.
The review shows that community pharmacists have a positive attitude toward breast cancer health promotion despite their actual poor involvement. Findings from the selected studies showed that community pharmacists hold a positive attitude because of their moderate to high level of knowledge on breast cancer. The selected study done in Tanzania showed that the majority of pharmacists had a positive attitude towards the use of antioxidants in cancer prevention due to their awareness about the usefulness of natural antioxidants [15].
Despite their low involvement in breast cancer health promotion activities, the majority of pharmacists were willing to be involved in educating their patients about breast cancer and viewed breast cancer health promotion as their responsibility. This goes in line with the findings which involved 485 community pharmacists in British Columbia concerning their level of participation in health education and disease prevention activities. It concluded that there is ample room for increasing pharmacist involvement in health education and disease prevention activities [19]. This means community pharmacists have the opportunity to improve upon their involvement in educating patients on cancer health promotion.
Majority of community pharmacists agreed that they should be involved in providing counseling, distributing breast cancer education materials, etc. as part of activities towards cancer health promotion. Counseling directed at behavioral and attitudinal change may produce greater changes than traditional educational approaches to health promotion, particularly when tailored to the individual's readiness to change [20]. Hence provision of counseling services by community pharmacist will improve cancer health promotion in the community.
One of the selected studies done in the United Arab Emirates (UAE) indicates lack of patient's awareness of the type of services that pharmacists can offer, the type of counseling and education pharmacists are capable of delivering influence their attitude towards breast cancer health activities [17]. A marketing perspective would presuppose that cancer health promotion services might not be provided very intermittently due to lack of demand for these services. If patients are aware of cancer health promotion services could be made, community pharmacists or providers would devote labor, technology, and other resources to the provision of the service. Marketing perspective postulate that demand for a service depends on personal expectations and knowledge of the service [21]. There is evidence that exists indicating lack of patient's awareness of the type of services that pharmacists can offer. A study by Gagnon indicated that patients ranked of most professional services given by a pharmacist less important on average than pharmacists did. It was suggested in the study that patients may have been uninformed about the given by pharmacists [22]. This suggests that community pharmacist must create awareness and educate patients on the importance of breast cancer. This will influence the attitude of community pharmacist on breast cancer health promotion.
In this review, major factors that were identified as perceived barriers to cancer health promotion were lack of time, lack of educational materials, lack of privacy, lack of training, lack of personnel, lack of patients' appreciation for the role of the pharmacist as a breast cancer health promoter, gender, lack of profit and lack of budget. Lack of time is a barrier that stands against   [23]. Community pharmacists in the selected studies perceived time as a barrier because of the lack of supporting staffs such as pharmacy technicians. This will interrupt their service delivery or daily activities if pharmacists are to provide breast cancer information to patients as their daily activities. The studies suggested for pharmacists to adequately provide breast cancer information to patients, without significant disruption to their daily activities, more pharmacy technicians need to be hired and better delineation should exist between the role of pharmacy technicians and that of pharmacists in this country. The study done in Qatar indicated that lack of demand of breast cancer health promotion by patients as a barrier can be bypassed by educating the public about the pharmacist's role in health promotion and encouraging pharmacists to promote their abilities in this area [16].
Various researchers have identified that patients who are educated regarding the possibilities of pharmaceutical care are interested in receiving it. They are satisfied with the care they receive (24)(25)(26) and they are willing to pay for this services (27). Even though patients may need further information relating to their prescriptions, they do not fully understand this expanded role for pharmacists and how important it is for them. This difference in expectations can lead to pharmacists thwarted by lack of interest when a patient visits the pharmacy or patients frustrated by pharmacists' lack of attention when dispensing a prescription or a patient visit to the shop. By increasing patient expectations for their services, pharmacists can create an increase in demand for cancer health promotion services.
Lack of educational material was also perceived as a barrier to breast cancer education by Pharmacists in the selected studies. For effective patient education, community pharmacists should be provided with necessary tools, such as printed material, which can be easily provided to the public in work settings [9]. The role of cancer health information is often underestimated. It has a potential power in challenging the public to seek protective health services. An essential aspect of health promotion is to obtain accurate information. Access to accurate health information is important for progress toward reducing morbidity and mortality resulting from these cancers. Several studies in the mass media suggest that the public uses educational materials such as leaflets, fact, sheets, posters, and videos among others as their main sources of health information [28][29]. Access to accurate health information is crucial in enabling individuals to protect themselves from risk factors for diseases and conditions and in keeping up to date of existing cancer examinations or tests. It was reported in one of the selected studies that, to overcoming all perceived barriers, attention should be given to the education of undergraduate pharmacy students to ensure that they are well prepared for breast cancer health promotion [16]. The duration and composition of pharmacy education differ among countries [30][31]. Even though the basic pharmaceutical courses are similar, the pharmaceutical care concept is different with regards to the practice applied in the country [32][33][34]. Also, health care needs and standards of practice vary among countries as  The action plan has four main areas of action namely quality assurance, academic and institutional capacity, competence, and vision for pharmacy education. The taskforce continuously monitors and disseminating evidence-based guidance and frameworks that facilitate the development of pharmacy education. This system in place will address or will be able to address this challenge or barrier.
Beshir and Hanipah [10] reported a lack of training as a major barrier that limits the involvement of community Pharmacists in breast cancer health promotion activities. Workplace training or learning plays an important part in the development of learners' attitudes, behaviors, and skills. The medical degree curriculum allows early integration of practice-based learning in the clinical environment [35]. Medical students are therefore exposed to the practice environment early in their career [36] through a range of clinical placements during undergraduate education or training [37]. The incorporation of practice-based training in the clinical setting from early on in the curriculum is an important part of a medical degree. The pharmacy profession is now clinical and patient-focused career but education and training have traditionally been very different from medicine. The pharmacy education and training require four years of training with relatively little practice exposure followed by 52 weeks of practice-based pre-registration training [38]. The pharmacy training may not prepare pharmacy graduates well for practice [39].
In conclusion, Results from this review indicate that most community pharmacists are not involved in cancer health promotion. Even though the majority are interested in educating patients particularly about breast cancer, there is low breast cancer knowledge in addition to other barriers that prevent the actualization of pharmacists' role in breast cancer health promotion. Therefore, further work should focus on evaluating community pharmacists' level of knowledge and educating them on general cancers to influence their involvement in cancer health promotion. Studies to overcome identified barriers should also be undertaken to help community pharmacist make an important contribution to cancer health promotion. Also, further studies should be undertaken to investigate barriers to general cancers and how to overcome them.

Limitation
The search was done using three databases and did not include data from the grey literature. The search was limited to studies conducted from 2005 to July 2017 and studies reported in English. These can result in study selection bias. Questionnaires used in the studies were designed by the studies investigators, hence resulting in heterogeneous results which cannot be combined for metaanalysis or meta-synthesis. Again some of the studies were self-reported surveys; hence the responses may be limited by some data inaccuracies resulting from intentional deception, poor recall of information, acquiescence (tendency to agree), extremity (tendency to use extreme ratings), misunderstanding of the question and may be biased by an inclination to provide socially desirable responses. The use of convenience sample in some of the selected studies could also create a selection bias which limits the generalizability of results. In one study, the survey was translated to Arabic via native speakers who are also fluent English speakers but this can affect the results since it was not validated and also different people will have the different interpretation to issues.
The studies were carried out only in breast cancer hence cannot be generalised for the other cancers. The review was limited to five studies, hence regional or country studies will have to be carried out for indepth analysis or picture of the attitude and barriers of community pharmacists and ways to address it.

WHO: World Health Organisation
Declarations: None Ethics approval and consent to participate: Not applicable.

Consent for publication Not applicable
The authors declare that they have no financial and nonfinancial competing interests.

Funding
No financial support was sought in the production of this article.

Availability of data and materials
The datasets generated during the study are available in the figshare repository, https://figshare.com/s/a12a3cb18f1899c3fa53 Available data was presented in the main manuscript. No supplementary data was generated.

Authors' contributions
All authors have made significant contributions in obtaining and analysis of the data. KB and FO was involved in the data extraction and preparing the manuscript. FO and KB were involved in revising the manuscript critically for important intellectual content. Each author has performed sufficiently in the work and takes responsibility for appropriate portions of the content. AB was involved in reviewing the data and independently running the data extraction process. All authors have read and have given final approval of the study to be published.