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Chronic obstructive pulmonary disease (COPD) is expected to be the third leading cause of death worldwide by 2030 and is currently the second leading cause of mortality in Nepal. In 2016, nearly one million Nepalese suffered from COPD; 16320 of whom died due to the consequences of this disease. While medication is an integral part of the effective management of COPD, more than 65% of Nepalese people living with it do not adhere to their prescribed medications. Preliminary studies conducted among Nepalese patients suggest that lack of understanding about COPD and medicines, and the higher cost and side effects of medicines, are common factors associated with non-adherence. Limited skills and resources among health care providers (HCPs) are other factors associated with suboptimal adherence. Nepal is a low- and middle-income country (LMIC) and has limited healthcare resources for the appropriate management of chronic diseases including COPD. Thus, it is crucial for Nepalese HCPs including pharmacists to understand how COPD is managed at the pharmacy level in a developed nation. Australia is one such example. This understanding may enable Nepalese pharmacists to develop customised strategies to promote medication adherence, and subsequently optimise outcomes for Nepalese people living with COPD. This study was intended to be conducted in two phases: phase I in Australia and phase II in Nepal. Phase I comprised a study that explored Australian pharmacists’ experiences of delivering care to people living with COPD, including their perspectives on potential barriers to treatment adherence and their strategies for improving it. The result of phase I was intended to be used to inform the development of an educational intervention for delivery in Nepal; the evaluation of which formed phase II of this research. To conduct phase II, findings from the phase I study involving Australian pharmacists was expected to inform research implications, in conjunction with published evidence collectively aimed to develop an educational intervention, to be delivered by the pharmacist, targeting Nepalese people living with COPD. A randomised control trial (RCT) design was planned to assess the effectiveness of the intervention. However, the international ii travel restrictions during the COVID-19 pandemic led to the cancellation of phase II of the study. For that reason, necessary changes were made, and the research project was extensively revised to adapt to the uncertainty with the pandemic and its implications on this research. In both Australia and Nepal, limited information exists on how pharmacists are providing services during the pandemic. Therefore, an assessment of the impact of the pandemic on the provision of pharmacy services for people living with COPD was urgently required. The revised aims guiding this thesis were: (i) evaluate the provision of Australian pharmacy services among COPD patients during the pandemic, (ii) validate a survey instrument to assess the provision of pharmacy services among COPD patients during the pandemic, and (iii) conduct a pilot study among Nepalese pharmacists to evaluate barriers to and strategies for providing care to COPD patients during the pandemic. An online and paper-based cross-sectional survey was conducted among Australian pharmacists and an online pilot-survey was conducted among Nepalese pharmacists. Firstly, a survey instrument customised to the pandemic response in the provision of COPD care was developed, distributed, and validated among Australian pharmacists. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to validate the survey instrument. A total of 335 Australian and 35 Nepalese pharmacists completed the 29-item and 12-item questionnaires respectively. Interrogation of the survey responses enabled the development and validation of a 16-item instrument that measures the impact of COVID-19 on Australian pharmacy services. Results from Australia identified significant changes in the day-to-day operation of community pharmacies, and subsequently in the delivery of services. For instance, there was a significant increase in the number of vaccinations that required the reallocation of staff to meet demand. Due to the limits on dispensing and sales of COPD medications, patients were only able to buy salbutamol inhalers for a limited period. Response to the pandemic preparedness and handling had some positive sides. For instance, the initiation of home medicine delivery services and telehealth services supported the continuity of treatment for patients. Despite the physical and mental stress and time constraints, pharmacists continued to deliver services crucial for optimising the health outcomes for patients with COPD. The findings from iii Nepal identified that pharmacists are having difficulty in providing care due to lack of resources and time constraints, alongside challenges in demonstrating inhaler technique to COPD patients. In summary, this research demonstrated that pharmacists express a desire to better support their patients particularly in the event of global health crises such as the COVID-19 pandemic. However, practical strategies to overcome the challenges pharmacists face in clinical settings are lacking. As the pandemic continues, it increases the burden on the health system and health care professionals, and subsequently impacts health service delivery. Some of the practices and policies executed by the Australian Government may have helped minimise the shortage of COPD medicines to a certain extent, but many respondents reported a medicine shortage in their pharmacy regardless. This study suggests that during the pandemic in Australia, pharmacists were working conscientiously to provide a variety of pharmacy services to people living with COPD. There is opportunity for improvement in the provision of pharmacy services that could help optimise outcomes for people living with COPD. Future research should focus on exploring ways to engage patients at the pharmacy level, thereby enhancing the provision of services that would optimise medication adherence. In addition, future studies should evaluate the effectiveness of pharmacy services during pandemics and/or natural disasters/emergencies. Lastly, while the intervention study could not be conducted in Nepal, the findings from Australia during and before COVID-19 can be a lesson and may be a step in the right direction toward optimising COPD care in Nepal. |
