Aim
The aim of this study is to understand patients’, pharmacists’ and stakeholders’ perspectives on identifying the scope for developing a community pharmacist-led intervention to provide support and improve health outcomes for breast cancer survivors.
Objectives
The objectives are to explore the experiences and views of breast cancer survivors towards community pharmacy-based cancer services; to investigate community pharmacist’s views on the feasibility of introducing new services to meet breast cancer survivors’ care needs; and to explore the views of relevant stakeholders towards introducing new community pharmacy-based services for breast cancer survivors; including key considerations when developing a service proposal.
The outcomes of this research are expected to identify the opportunities for community pharmacists to better support breast cancer survivors throughout their treatment in primary care, and inform the development of future services in this sector through providing insights into unmet care needs, and how these can feasibly be addressed.
Study Design
The mixed methods design was selected due to the general lack of national literature on the scope of the community pharmacist role in breast cancer services. This resulted in the need to explore both the breadth and depth of the issue; an aim most appropriately addressed using mixed methods1. Firstly, the current treatment pathway of breast cancer survivors in primary care needed to be defined in order to establish where unmet care needs may exist. This issue lent itself well to a quantitative method exploring prescribing trends. Following the generation of a hypothesis, a deeper look into the issues raised and how community pharmacists could address these was required via qualitative methods.
Focus groups were selected as the most appropriate means of obtaining such data since they can often produce richer data than individual interviews. A natural conversational context is conducive to exploring participants’ experiences and perspectives and supporting the generation of ideas; it is therefore commonly adopted within health services and pharmacy research.
Firstly, survivor focus groups will explore their experiences and views of the breast cancer care received in the community. The group will consider how community pharmacists might address any unmet care needs and better support breast cancer survivors. Findings will then be followed up in a pharmacist focus group to explore attitudes, feasibility and other operational aspects of introducing a pharmacy-led service or intervention to address the issues raised. Finally, a stakeholder meeting will be convened to draw together various stakeholders’ perspectives of such a service, and discuss factors to consider when developing a service proposal or considering commissioning prospects. Telephone interviews will be used as an alternative if stakeholders cannot attend (Figure 1.).
Figure 1. Project overview
Recruitment
Survivor participants will be recruited through community pharmacies, which will be approached to display posters. Additionally, participating Boots Macmillan Information Pharmacists (BMIPs) will invite any eligible survivors accessing the BMIP service to participate. These breast cancer survivors will have previously identified themselves to the pharmacists as having breast cancer when seeking to access cancer-related support through this private service. Upon expressing interest in becoming involved in the study, potential survivor participants will be provided with a participant information sheet by the pharmacist (or a briefed member of the pharmacy team). The team member will then collect contact details accordingly to pass on to the research team.
Pharmacists and stakeholders will be identified through researcher’s personal contacts and snowballing. During the early stages of this research, informal meetings were arranged with several potential stakeholders including representatives from local pharmacy groups, pharmacy businesses and cancer charities, these people will be invited to participate, and asked to distribute an invitation to colleagues or other contacts who may be interested.
All participants will be provided with an information sheet at the point of recruitment. They will be briefed on the purpose of the study and the requirements of their involvement. It will be explained to the potential participant that entry into the study is entirely voluntary and that their treatment and care will not be affected by their decision. It will also be explained that they can withdraw at any time but attempts will be made to avoid this occurrence. In the event of their withdrawal, it will be explained that their data collected so far cannot be erased and we will seek consent to use the data in the final analyses where appropriate. Participants will be required to sign a consent form immediately prior to commencing the focus group, meeting or interview.
Inclusion criteria
Breast cancer survivors
- Able to give informed consent
- Able to understand or communicate in English
- Female
- Over 18 years of age
- Treated for breast cancer within primary care in England
- Minimum of two years since the first diagnosis of breast cancer was confirmed
- Living within (or able to easily travel to) the selected geographical areas of recruitment
Pharmacists
- Currently practising community pharmacy in England
Stakeholders
- Job or voluntary role relevant to the development of breast cancer services in community pharmacy in England
- (Self-defined) Knowledge of current practice regarding cancer services in primary care, specifically community pharmacy
Exclusion criteria
Breast cancer survivors
- Unable to give informed consent
- Unable to understand or communicate in English
- Male (Male breast cancer survivors will not be recruited since breast cancer is very rare in men)
- Under 18 years of age
- Received no treatment for breast cancer within primary care in England
- Less than two years since the first diagnosis of breast cancer was confirmed
- Not living within (or able to easily travel to) the selected geographical areas of recruitment
Pharmacists
- Not currently practising community pharmacy in England
Stakeholders
- No job or voluntary role relevant to the development of breast cancer services in community pharmacy in England
- No knowledge (self-defined or otherwise), of current practice regarding cancer services in primary care, specifically community pharmacy
Sample size
Being a qualitative study, an exact sample size has not been pre-determined and will vary depending on the results obtained. However, the focus groups and stakeholder meeting will contain 6-8 participants each since current literature considers this optimum within pharmacy practice research, allowing in-depth discussion whilst ensuring even inclusion of members.
In order to maximise representativeness, the study will take place at various different locations across England. Three different regions have been selected for the survivor recruitment: South Warwickshire, Lincolnshire and Nottinghamshire. The three regions of survivor recruitment were purposively sampled due to their high numbers of pharmacists with an active interest in improving cancer services, which is expected to maximise the opportunity to recruit. Initially, six pharmacies (multiples and independents) will be approached within each region; further pharmacies will be recruited as necessary depending on uptake and survivor recruitment rates. Pharmacies will be selected through existing professional contacts with pharmacists; snowballing, and through convenience sampling.
A focus group will be conducted within each of the three areas, and findings will be compared. If data saturation is not been reached; subsequent focus groups will be convened in additional regions as required.
The pharmacist focus group will be web-based and the stakeholder focus group will be held either Nottingham or an alternative convenient location. In total, there is expected to be approximately 18-24 participants of breast cancer survivors, 6-10 pharmacist participants and 6-8 stakeholder participants.
Data Collection
The survivor focus groups will be held first. Upon arriving at the focus group, breast cancer survivors will initially complete a short survey to establish participant demographics and treatment received. The focus groups will be digitally audio-recorded, and a researcher will take notes during the discussion to aid transcription.
Pharmacist focus groups will be web-based and will utilise AdobeConnect software, which can be logged into via a password-protected link. This will enable pharmacists from across the country to participate in the discussion. The exact content of the focus group will vary, but will essentially involve a presentation of findings from the pharmacist focus group, and an exploration of pharmacist views on these responses, including generating ideas on how a feasible pharmacy-based service might address issues raised. The interview schedule for the focus group will be written following analysis of survivor data.
Finally, a stakeholder meeting will be arranged in a location convenient for participants, such as at the University of Nottingham. For stakeholders unable to attend, the presentation slides will be sent via email, and the discussion will take place in the form of a telephone interview. The meeting schedule will be as follows:
Data Analysis
Survivor survey data will be analysed using descriptive statistics with Microsoft Excel 2010 or Stata SE 14 (Stata-Corp, Texas, USA, 2015). Survivor focus groups will be fully transcribed and analysed using thematic framework analysis with NVivo 11 software. The subsequent pharmacist focus group and stakeholder meeting will be guided according to the findings from the survivor data analysis and will be selectively transcribed as necessary (to record relevant data only) and likewise analysed by thematic framework analysis using NVivo 11.
