COMMUNITY PHARMACY
Engaging Students in Wellness and Disease Prevention Services
Audra S. Anderson, PharmD* and Jean-Venable R. Goode, PharmD
School of Pharmacy, Virginia Commonwealth University
Pharmacy education has traditionally focused on medications and treatment of disease. However, as an
accessible health care professional, pharmacists can influence healthy behaviors in their patients. En-
couraging/promoting healthier lifestyles in the United States is essential because the leading causes of
mortality are tobacco use, poor nutrition, and inactivity. In order to prepare pharmacists for this role,
student pharmacists must be taught how to implement and deliver wellness and prevention services.
Community advanced pharmacy practice experiences (APPEs) occur at an ideal point in the curriculum
to engage students in these activities. This article provides preceptors with guidance and tools for
restructuring the community APPE at their sites to incorporate wellness and disease prevention activities.
Keywords: wellness, disease prevention, health promotion, advanced pharmacy practice experiences, community
pharmacy
INTRODUCTION
Much of the morbidity and mortality associated with
chronic disease in the United States could be prevented
though lifestyle and behavioral changes. Although the
leading causes of death in the United States are heart
disease and cancer, the actual leading causes of mortality
are tobacco use, poor nutrition, and inactivity.
1
Tradition-
ally, pharmacy education has focused on medications and
the treatment of disease. However, as accessible health-
care professionals, pharmacists are in an ideal position to
make an impact on patients’ behaviors. Furthermore,
pharmacists have been identified as key healthcare pro-
fessionals to help the nation meet the goals of Healthy
People
2
010.
2-
4
Healthy People 2010 is a document re-
flecting the nation’s health goals for reducing significant
preventable threats to public health. There are 2 overarch-
ing goals, which are to increase the quality and years of
life of Americans and to eliminate health disparities.2 In
order to accomplish these goals, as a profession, pharma-
cists will need to be prepared to deliver wellness and
disease prevention services.
The Center for Advancement of Pharmaceutical Ed-
ucation (CAPE) recently revised the educational out-
comes for colleges and schools of pharmacy.
5
The
advisory panel identified public health as a major area
for improvement and expansion in pharmacy education,
including teaching students strategies for promoting
health improvement, wellness, and disease prevention
to patients, communities, and at-risk populations, in col-
laboration with other health care providers. Community
advanced pharmacy practice experiences (APPE’s) are
ideal areas of the curriculum for offering these learning
experiences for students. Therefore, preceptors may need
to restructure APPE learning activities to provide oppor-
tunities for students to gain knowledge about wellness and
disease prevention. This article will provide preceptors
with ideas for incorporating wellness and disease preven-
tion into student learning experiences.
ESTABLISHING A WELLNESS AND
DISEASE PREVENTION FOUNDATION
Community practitioners should prepare for teaching
wellness and disease prevention by building a basic foun-
dation. The basic foundation for preceptors recommended
by these authors includes the following:
(1) Creating a model of wellness and disease pre-
vention in the advanced practice setting. This
means being a role model for students by hav-
ing at least one active service relating to well-
ness or disease prevention in the practice.
(2) Providing students with pertinent literature
about wellness, disease prevention, and health
promotion and addressing these issues either
during daily activities or during discussion
sessions.2-4,
6
-9
From the foundation, preceptors can build on stu-
dent’s knowledge using several different approaches in
their practice. These include students actively participat-
ing in the practice’s wellness and disease prevention
Corresponding Author: Jean-Venable R. Goode, PharmD.
Address: VCU School of Pharmacy, PO Box 9
8
05
3
3,
Richmond, VA 23298-0533. Tel: 804-828-3865.
Fax: 804-828-8359. E-mail: jrgoode@vcu.edu
*Dr. Anderson’s current affiliation is Ukrop’s Pharmacy,
Richmond, Va.
American Journal of Pharmaceutical Education 2006;
7
0 (2) Article 40.
1
activities, creating new wellness and disease prevention
activities for the practice, creating tools and educational
materials, discussing pertinent wellness and disease pre-
vention literature, writing newsletters or articles about
wellness and disease prevention, marketing wellness
and disease prevention services, and assessing outcomes
of the programs and services (Figure 1). Ideally, students
should be involved in a range of activities and discussions
about wellness and disease prevention throughout an ad-
vanced practice experience. Activities do not have to be
complicated; however, depending on the activity, it may
take more preceptor time, either through direct supervi-
sion or reviewing and revising the materials students cre-
ate. Preceptors will need to consider their ability to
supervise and provide guidance and teaching as they de-
sign activities and learning experiences around wellness
and disease prevention. The following sections will focus
on how to incorporate these approaches using several
wellness and disease prevention strategies.
STUDENT ACTIVITIES
Health Observances
The Office of Disease Prevention and Health Promo-
tion publishes a comprehensive calendar of national
health observances, eg, October is National Breast Cancer
Awareness Month.6 Most of the health observances have
websites with additional information and materials.
These materials are excellent resources for pharmacists
and students developing wellness and disease prevention
activities7 and can be used as a framework for many of
the student activities during an APPE. Students should
choose a health observance that interests them and that
will occur during their experience. The student should
develop an activity that can be accomplished during the
rotation and be incorporated into the practice site. For
example, during National Osteoporosis Awareness and
Prevention Month, when dispensing a prescription, the
student could counsel every female patient about the ap-
propriate amount of dietary calcium and/or supplemental
calcium. This would engage the student in health promo-
tion activities directly with the patient.
Another activity based on the national health observ-
ances includes the development of handouts and patient
education materials to be made available at the pharmacy.
For example, during National Stroke Awareness Month in
May, students could develop handouts and patient educa-
tion materials on the risk factors and signs and symptoms
of stroke, and measures patients can take to prevent strokes.
Students could also evaluate patient education materials
that could be used by the practice site. Evaluation should
Figure 1. Algorthim for engaging students in wellness and prevention.
American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.
2
include assessing the handout’s literacy level. If the prac-
tice site has a population of patients whose primary lan-
guage is not English, students should research the available
educational materials in other languages.
If the pharmacy has space, students could develop
a bulletin board or display with educational messages
and handouts for a national health observance. The phar-
macy could use these materials each year. If the pharmacy
does not have space for a bulletin board or display, stu-
dents could be involved in developing shelf-talkers or
posters to convey a message about a national health ob-
servance. For example, students could develop a message
around National SAFE KIDS Week that could be put on
the shelves displaying children’s products, toys, etc.
Students could also be involved in developing a pre-
sentation about a national health observance. The presen-
tation could be given in a meeting room or similar space at
the pharmacy or at a community center, church, civic
building, or library for various groups or associations. If
the pharmacy has a newsletter or if other community pub-
lications exist, a student activity could include developing
an article about the national health observance.
National health observances can also be used as a plat-
form for more advanced pharmacy activities such as risk
assessments, screenings, lifestyle counseling, immuniza-
tions, and targeted interventions. These activities will be
discussed later in the article.
Students do not have to focus on a national health
observance. Any of these activities could also center on
other health-related issues including seasonal concerns
(eg, sunscreen protection, allergies, bug bites, influenza)
or disease prevention topics (eg, diabetes mellitus,
obesity, depression).
Risk Assessment
If the practice site or state laws do not allow pharma-
cists to conduct health screenings, risk assessments are
another way to increase patient interaction and provide
patients with valuable information.
10,11 Risk assessments
may also be used in combination with screenings, such as
the Framingham Risk Assessment for which obtaining
cholesterol and blood pressure values are necessary. As
mentioned previously, risk assessments may be an activ-
ity related to a national health observance or a standalone
activity that is offered in the pharmacy.
Student activities can be related to designing and
implementing a new risk assessment program. Part of this
activity should include researching different risk assess-
ment tools for a specific disease state and choosing a risk
assessment tool that will be appropriate for the practice
site. Table 1 contains some resources for locating risk
assessments on the Internet. Some risk assessment tools
are available in paper format and others are available for
completion via the Internet. Once a risk assessment tool is
chosen, students should design an educational handout
with the risk assessment score and how to interpret the
patient’s risk. Preceptors should have the students de-
velop policies and procedures for the new risk assessment
program.
After designing and implementing the program or if
a risk assessment service is already in place at the practice
site, student activities should center around identifying
patients who should complete the risk assessment, per-
forming and documenting the actual risk assessment, pro-
viding patient counseling and education, recommending
lifestyle changes or preventative measures, referring to
other healthcare providers, and providing follow-up. To
enhance this activity, preceptors should have the student
present 1-2 patient cases from the risk assessments. The
case presentations can be brief but should address patient
demographics, pertinent information about the risk assess-
ment, plan, education and/or counseling, and follow-up.
Health Screenings
If the practice site and state laws permit pharmacists
to conduct health screenings, this is another way for stu-
dents to become involved in wellness and direct patient
care. Providing various screenings within the pharmacy
allows students to have extensive patient contact and will
assist in the development of their communication skills as
well.
Students can assist with implementing a specific type
of screening into the practice or they can improve and en-
hance an existing screening program. Screenings that can
be conducted within the community pharmacy include,
but are not limited to, blood pressure, blood glucose,
Table 1. Selected Patient Risk-Assessment Resources for Use in a Community Advanced Pharmacy Practice Experience
Risk Assessment Web Site
Health Check Tools www.nlm.nih.gov/medlineplus/interactivetools/
Interactive Health Tools www.brighamandwomens.org/healthinfor/healthTools.asp
Framingham CHD Risk Calculator hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype5pub
Men’s Health www.ncpanet.org/knowyourscore/assessment
Breast Cancer bcra.nci.nih.gov/brc/q1.htm
American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.
3
cholesterol, osteoporosis, Alzheimer’s disease, depres-
sion, metabolic syndrome, and body fat analysis.12-22
For a practice site that does not already have established
screenings in place, several steps may need to be taken.
Conducting non-invasive tests that do not require
a human specimen, such as blood pressure or osteoporosis
screening, have few or no regulations. Student activities
for implementing these types of screenings include the
development of screening forms, patient education materi-
als, and a general policy and procedures guide for the site.
Tests that require human specimens, such as blood
samples, are considered invasive and there are more strin-
gent regulations and requirements for conducting those
tests.
23 The Clinical Laboratory Improvement Act
(CLIA) of 1988 was enacted to assist in the standar-
dization of laboratory screening, personnel, and quality
control. There are varying levels of laboratory testing
based on the complexity of the test being performed. Most
pharmacy-based screenings, such as blood glucose or
cholesterol testing, are waived tests and are less regulated.
These tests require the site to have a certificate of waiver
from a local or regional Centers for Medicare and Med-
icaid Services (CMS) office and to agree to follow good
laboratory practices. To enroll in the CLIA program
a pharmacy must complete and submit CMS Form 116
for a Certificate of Waiver. A CLIA waiver is required to
allow pharmacy-based laboratory screenings. If there are
multiple screening sites, each site must have its own
CLIA waiver. Complete information regarding CLIA and
the waiver process is available at www.cms.hhs.gov/clia. A
full list of waived tests can be found at www.cms.hhs.gov/
clia/waivetbl . Students can learn about maintaining
a pharmacy-based laboratory including good laboratory
procedures, standard operating procedures, and quality
control. Along with obtaining the CLIA waiver for per-
forming screenings, pharmacies must also comply with
the universal precautions for blood-borne pathogens
regulations from the Occupational Safety and Health
Administration (OSHA). OSHA regulates worksite
safety and provides guidelines for protection, exposure
actions, and proper policies and procedures. Complete
information is available on the OSHA website at www.
osha.gov.
Another activity for students is researching the vari-
ous instruments and devices to perform screenings. For
example, there are numerous lipid analyzers available for
cholesterol screening. The most commonly used device is
the Cholestech LDX. Obtaining information such as cost,
supplies needed, and reliability of the instrument is im-
portant in selecting the appropriate device.
For practice sites that already have patient screenings
in place, students could assist with enhancing the current
program. Finding ways to increase the number of patients
that take advantage of the screening services is an impor-
tant task with which students could assist.
In addition to assisting with establishing and promot-
ing the screening program, students can participate in
administering the program, performing and documenting
screening tests, providing counseling and education, rec-
ommending lifestyle changes or preventative measures,
referring patients to other healthcare providers, and fol-
lowing up with patients to determine effectiveness/out-
comes of the program. Preceptors should have students
present 1-2 patient cases per week from the screening
program. Students should be able to justify the recom-
mendations made to their patients.
Involving students in planning and implementing
a screening service in a pharmacy practice provides them
with a unique and valuable experience, increased confi-
dence, and the skills and tools for developing their own
services and programs.
Specific Screenings
Students can be asked to lead a presentation and
discussion of particular diseases, prior to conducting
screenings. Providing appropriate and accurate patient
counseling requires knowledge of the current guidelines
and recommendations for the disease. For example,
reviewing the JNC 7 Guidelines and all available anti-
hypertensive medications with the student is a good
way to increase his/her knowledge and confidence rela-
ted to the screening and management of high blood
pressure. Also, instruction in the proper operation of
the equipment that will be used in the screening is impor-
tant prior to the students’ interaction with patients. For
example, prior to providing cholesterol screening, the
student should observe how to obtain the blood sample,
operate the lipid analyzer, and counsel the patient based
on the results. Patient education after a screening should
include discussing diet, exercise, and potential drug
therapy alternatives. Observing the preceptor screening
a patient and discussing the patient’s disease state will
help the student become confident in providing patient
care.
Immunizations
Immunizations are another area of wellness and dis-
ease prevention that pharmacists can implement at their
practice site. Pharmacists have the authority to administer
immunizations in 44 states.24 Additionally, many col-
leges and schools of pharmacy have incorporated vaccine
science and vaccines into the curriculum; therefore, APPE
students will usually have some knowledge of immuniza-
tions. In 1997, the American Pharmacists Association’s
Board of Trustees adopted guidelines for pharmacy-based
American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.
4
immunization advocacy.25 The guidelines include 3 lev-
els: advocacy, facilitation, and administration. Activities
for students should be designed around these levels.
In states that do not allow pharmacist or student phar-
macist administration of immunizations, students should
be involved in recommending immunizations to at-risk
populations, educating patients about the vaccines, and
referring patients to an appropriate health care provider.
Additionally, students could research vaccine controver-
sies and create handouts for patients with the facts about
the vaccine controversy. Students could also research
anti-vaccine web sites so they have an understanding of
the information patients may be exposed to on the Inter-
net.
26 Students could be responsible for updating the phar-
macy’s staff on the frequently changing recommendations
regarding vaccines and for developing a vaccine record
card for patients.
If the pharmacy practice is active in the second level,
facilitation of immunizations (having another healthcare
professional administer vaccines at the site), students
could assist with screening patients for immunizations
and processing paperwork. Students could also be in-
volved with identifying at-risk patients, marketing the
service, and answering questions.
In states that allow pharmacists to administer immu-
nizations, students could assist with designing and imple-
menting a new program or enhancing an existing one.
For example, if the practice site offers only influenza
vaccinations during October and November, students
could design and implement a year-round immunization
program, identifying patients at risk for other diseases
for which immunizations are available such as tetanus-
diphtheria or pneumococcal vaccine. Students could
assist with the administration of vaccines if allowed by
state law.
Preventative Services
Another way to approach wellness and disease pre-
vention is to target patients based on their age. The US
Preventative Health Services Task Force has a guide to
preventative health services which is based on age and
gender.
27 In addition, several other organizations publish
preventative health checklists based on age and gender
including the American Academy of Family Physicians
(www.aafp.org), the American College of Physicians
(www.acponline.org), and the American College of
Obstetricians and Gynecologists (www.acog.com). Stu-
dents could use these checklists to design a preventative
services counseling program for the practice site. Ano-
ther exercise is to have the student assess the usability
of preventative health guidelines (ie, how difficult is it
to identify the services recommended and determine
how frequently they should be performed), and sug-
gest changes that would make the checklists easier to
use.
Lifestyle Counseling
Knowledge and training about educating patients on
proper lifestyle choices is one of the keys to actually
helping them make positive changes. Realizing each
patient’s specific situation and goals is essential in help-
ing them attain those goals. Additionally, it is important to
understand how patients make lifestyle changes. APPE
activities could include researching and learning about
the different theories addressing changing patient behav-
iors. Several models have been used by pharmacists in-
cluding the Health Belief Model, Fishbein-Ajzen Theory
of Reasoned Action, and the Transtheoretical Model.
28-30
Students should observe preceptors using these models
in patient counseling, and then employ them when
working with patients trying to make lifestyle changes.
Other techniques used for disease and wellness programs
that students should learn include conducting motiva-
tional interviewing and providing self-management
education.31
Smoking Cessation
Tobacco use is one of the leading causes of mortality
in the United States. Providing directed interventions to-
ward patients who use tobacco is another way pharmacists
and student pharmacists can become involved in wellness
and disease prevention in their practice.
Students could provide brief interventions with
patients, such as counseling them on the benefits of quit-
ting, or more detailed interventions as part of a com-
prehensive smoking cessation program that includes
conducting one-on-one counseling, making drug ther-
apy recommendations, and providing follow-up care/
counseling.32-34 Students could assist in the development
of forms describing the various nonprescription and pre-
scription smoking cessation products available and the
advantages and disadvantages, side effects, and cost of
each.35 Providing patients with detailed information re-
garding available pharmacotherapy can help them make
informed decisions. To assist in the implementation and
delivery of a smoking cessation program within the prac-
tice site, students could develop patient handouts, and
patient interview and documentation forms.32,33
Students could also participate in one-on-one patient
counseling sessions provided for patients. Additionally,
some smoking cessation programs may include group ed-
ucational sessions, students may be involved in creating
and/or teaching these sessions. Offering smoking cessation
therapy management and obtaining payment for the
services will give the student a valuable experience in the
American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.
5
delivery of wellness and disease prevention services within
a pharmacy practice.
Basic Nutrition and Exercise Counseling
A fundamental component of wellness and disease
prevention is good nutrition and adequate exercise. Stu-
dents should learn the basic nutrition and exercise infor-
mation needed for pharmacists to appropriately and
effectively counsel their patients regarding either pre-
vention or management of disease.
8-9 This topic is usually
not stressed in pharmacy curriculums and APPE’s pro-
vide an excellent forum for students to learn about nutri-
tion and exercise and practice their patient counseling
skills.
Preceptors can assign readings and have a topic
discussion about nutrition and exercise.
8-9 Students can
research and learn about the differences between fad
diets and create a chart for the pharmacy staff. Stu-
dents could also do this for vitamins and dietary sup-
plements.
Nutrition and exercise counseling can be incorporated
into patient counseling during risk assessment, disease
screening, and targeted intervention programs. Students
could be involved in developing, implementing, and mar-
keting a new patient care service for weight management or
starting a body composition screening service. Possible
activities would be similar to activities discussed in pre-
vious sections.
Targeted Interventions
Targeted intervention programs are programs designed
to focus on promoting wellness, disease prevention, and
healthy living for patients who already have a chronic
disease. As with the other areas of wellness, student
activities could include developing and implementing
the target intervention program, including writing poli-
cies and procedures, creating monitoring forms, and de-
veloping or evaluating existing patient educational
materials. For example, a targeted intervention program
for patients with diabetes might center on ensuring that
patients who have diabetes are receiving appropriate
medications such as ACE inhibitors or aspirin therapy.
36
Even though this is not really wellness, it is prevention of
future problems related to diabetes mellitus. A targeted
intervention program for patients with diabetes mellitus
could also include ensuring that these patients have access
to appropriate preventative services, such as annual
check-ups with a podiatrist and ophthalmologist and
bi-annual check-ups with a dentist.
Conducting targeted intervention provides students
with lessons in communicating with patients and pro-
viders, and in managing chronic diseases. Other activities
could include the preceptor conducting topic discussions
with the student that reinforce the student’s knowledge of
the pathophysiology and the pharmacologic and non-
pharmacologic (lifestyle modifications and preventative
measures) treatment of the disease. Students could be re-
quired to create a patient case and present all of this in-
formation to the preceptor, or ideally, the preceptor and
the student could discuss specific patients in the targeted
intervention program.
Targeted intervention programs can be used to assess
the outcomes of the practices’ patient care activities.
These outcomes can be used by the pharmacists to market
patient care services to self-insured employers or other
payors. This gives the preceptor another opportunity for
teaching APPE students. Students can be involved in the
process of organizing the outcomes for presentation and
developing materials for the meeting. Additionally, the
preceptor can engage the student in discussions about
compensation for patient care services.
Marketing
Acquiring a basic knowledge of marketing is impor-
tant for APPE students since effectively marketing a phar-
macy’s services to the appropriate patient population not
only increases the site’s revenue stream, it ensures that
patients are aware of the valuable and potentially life-
saving services offered. Students should be involved with
the marketing of any of the previously mentioned health
promotion programs and preventative services. Students
should be able to design marketing materials (signs, shelf
talkers, brochures, and patient handouts) including a plan
for how to inform patients about any new service or pro-
gram. Students could also develop a marketing strategy
that targets others such as caregivers, third-party payors,
and family members. Preceptors could assign readings
for students to learn more about marketing pharmacy
services.
37-39 Another valuable activity is to have stu-
dents participate in marketing the program to patients
directly. Preceptors should use this activity to have
discussion with the student about marketing, including
the difference between product and service marketing.
As another component, students could visit local physi-
cians and their practices to market new programs and
services.
Outcomes Assessment
All pharmacy services should be evaluated to determine
the outcomes and success of the program and then this in-
formation should be used for continuous quality improve-
ment. A learning activity for students could be designing an
evaluation process for the risk-assessment program or per-
forming evaluation activities such as tallying numbers of
patients, number at risk, and number of referrals. Students
could be involved with designing or researching available
American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.
6
evaluation tools for the program (eg, patient satisfaction
instruments).40,41
CONCLUSION
A community APPE provides an excellent opportunity
for developing and implementing wellness and disease pre-
vention activities. Additionally, preceptor involvement
with these activities provides a positive role model for
students. In turn, teaching and practicing wellness and dis-
ease prevention for the benefit of patients and student phar-
macists will help improve the professions’ capability of
making an impact on the health of the nation.
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