Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: A qualitative study

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This study aimed to explore the communication barriers faced by pharmacists when managing patients with hypertension in a primary care team. Methods Twelve pharmacists working in five government primary care clinics were interviewed by a researcher using a topic guide. The interviews were audio-recorded, transcribed verbatim and subjected to thematic analysis. Results Pharmacists’ management of patients with hypertension was found to be affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and doctors, and doctors and patients. Barriers to communication between pharmacists and patients include language barrier, physical disabilities, medication brand changes, and specific challenges faced during video consultations. Barriers to communication between pharmacists and doctors include lack of access to patient information across institutions on the electronic medical records (EMR), inadequate and inappropriate documentation by doctors, and disruptive and ineffective phone calls by pharmacists to doctors. Barriers to communication between doctors and patients had a spillover effect on pharmacists; these barriers included language barrier, patients not discussing medication nonadherence with doctors, and conflicting advice given by doctors and pharmacists. Conclusions The communication barriers pharmacists faced when managing patients with hypertension involved multiple stakeholders. Many of the challenges resulted in patients having difficulty understanding and adhering to their management plan. Effective interventions to foster stronger interprofessional relationships and create a conducive platform of communication should be developed to address these communication barriers. Barriers Hypertension Communication Pharmacists Multi-disciplinary team Primary care Figures Figure 1 Background Hypertension is on the rise in Singapore and across the world ( 1 , 2 ), and primary care pharmacists in Singapore play an important role in the management of patients with hypertension. The latest National Population Health Survey conducted in 2019/2020 found that 1 in 3 (35.5%) Singaporean adults (aged 18–74) has hypertension, of whom nearly half of them have never been diagnosed, and among those who have been diagnosed and are on treatment, 2 out of 3 are poorly controlled ( 2 ). Despite the availability of effective blood pressure-lowering medications and the evidence of lifestyle modifications in reducing blood pressure, implementation of clinical evidence in real-world clinical practice remains challenging ( 3 , 4 ). This poses a significant burden of disease and care, as hypertension, if uncontrolled, can result in complications such as coronary artery disease, stroke, and chronic kidney disease ( 5 ). This will affect the quality of life of patients and their caregivers and impose a significant healthcare cost and burden on the health system ( 6 ). Currently, most patients with hypertension in Singapore (84%) are managed in the primary care setting, with the remaining patients being managed at specialist outpatient clinics in hospitals. Most patients (50.5%) seek care at government primary-care clinics (or polyclinics), while 33.5% of patients seek care from over 2000 private general practitioners ( 2 ). Hypertension care in the 23 polyclinics in Singapore is provided by multidisciplinary teams (MDTs), of which primary care pharmacists are an integral part ( 7 ). The practice of pharmacists is evolving as more pharmacists become incorporated into primary care teams, with a transition from dispensing medications to playing a more collaborative and patient-centred role ( 8 ). Increasingly, pharmacists play multiple roles in hypertension care, including providing medication and lifestyle counselling, picking up and addressing nonadherence, and facilitating home blood pressure monitoring ( 9 ); and pharmacist interventions have been shown to improve blood pressure control ( 10 ). The role that primary care pharmacists play often requires them to interact not only with patients but also with other healthcare professionals ( 11 ). Studies have identified several challenges faced by pharmacists when interacting with their healthcare colleagues. One commonly faced barrier was “medical dominance”, as defined by the Health Sociology Review as the occurrence of doctors “exerting sovereign power over other professions such as nursing” ( 12 ), thus undermining and restricting the roles of pharmacists ( 13 ). Lack of clarity regarding a pharmacist’s role and responsibilities by other healthcare professionals also led to underutilisation of their services ( 14 ). Studies have also shown that some doctors show a lack of respect towards pharmacists, resulting in pharmacists avoiding interacting with doctors ( 15 , 16 ). Often, even trying to reach doctors proved to be challenging for pharmacists ( 17 ). The pharmacists in Singapore’s polyclinics work in dynamic multidisciplinary teams to deliver care for a large number of patients who come from diverse socioeconomic, cultural and language backgrounds. Pharmacists work in a setting where one pharmacist will interact with multiple doctors who each have different communication and documentation styles. Furthermore, less than half of Singapore’s population (48.3%) uses English as their most frequently spoken language, and many other languages are spoken in this multiracial country, including Mandarin, Chinese dialects, Malay, Tamil, and other languages ( 18 ). However, very few studies have been conducted locally to explore the communication challenges faced by primary care pharmacists in managing patients with hypertension. We conducted a qualitative study exploring challenges faced by pharmacists when managing patients with hypertension in a Singapore public primary healthcare setting. ‘Communication barriers’ emerged as the main overarching theme. Therefore, this paper aimed to explore the communication barriers faced by primary care pharmacists when managing patients with hypertension in Singapore. By identifying these barriers, interventions can be developed to fill the gaps and address the unmet needs. The findings will be relevant to pharmacists who work in a team and manage patients with diverse backgrounds and to decision makers who are planning for healthcare interventions to improve hypertension care. Methods Study Design This study utilised a qualitative methodology consisting of individual in-depth interviews (IDIs), as it allowed us to inquire and delve into the views and experiences of primary care pharmacists concerning the management of patients with hypertension as encountered in their local practices ( 19 ). Setting The public healthcare system in Singapore is grouped into three clusters based on geographical location, with SingHealth Polyclinics managing patients in the eastern region of Singapore ( 20 ). The study was conducted among primary care pharmacists involved in managing patients with hypertension across five SingHealth Polyclinics in Singapore. The five selected Polyclinics were distributed across various locations in the eastern region of Singapore and had different patient population profiles (age, socioeconomic status, education level and health literacy). Care was also taken to ensure that a spectrum of practice experience was represented. Participants, recruitment, sampling We identified pharmacists at SingHealth Polyclinics who were involved in the care of patients with hypertension for at least six months. We purposively sampled pharmacists of different levels of seniority with varying years of experience practising in primary care. In addition, a pattern of snowball sampling developed as the participants named other pharmacists whom they felt would provide additional insights. Sample size was determined by data saturation whereby interviews were stopped when no new ‘views’, ’experiences’, or ‘challenges’ emerged from the interviews and data analysis. Data collection The researchers of this study are RT, NCJ, AK and OSP. RT is a medical student; NCJ is a professor and clinician who specialises in family medicine; AK is a research fellow with a PhD degree in health communication; and OSP is a senior pharmacist working in a SingHealth Polyclinic. Before commencing the IDIs, an interview topic guide was developed based on a literature review, clinical knowledge and research experience (Table 1 ). All interviews were carried out by NCJ, who had 20 years of experience conducting qualitative research. We avoided, whenever possible, selecting participants who were close acquaintances or colleagues of NCJ to minimise potential participant response bias. Prior to the interviews, the researchers gave the study information sheet and explained to the participants the aims of the study and the research method before informed consent was obtained from the participants. RT took detailed field notes that were used as discussion and comparison pointers with NCJ after the interviews, as well as for data analysis later. No repeat interviews were conducted. From March to October 2022, twelve 40–60 minute IDIs were conducted. Data collection was stopped when data saturation had been reached. All IDIs were audio-recorded and transcribed verbatim, after which they were checked for accuracy and used as data for analysis. Table 1 Study interview topic guide 1. Can you tell me about the patient profile at your polyclinic? a. Age group, ethnicity, education level, disease severity, health-seeking behaviour 2. How do patients with hypertension first present in your clinic? 3. Do you use any clinical practice guideline to guide your hypertension management? a. If yes, which guideline and why b. What do you think about the guideline? Useful or not? Why? 4. What is your approach to treating hypertension? a. Probe: Nonpharmacological – diet, exercise (be specific) b. Probe: Medications – which category, order of starting, mono- or dual therapy, how and when to step up 5. What are the challenges you face when managing patients with hypertension? a. Probe: Patient factor: Nonadherence to treatment/lifestyle modifications, communication barriers etc. b. Probe: Pharmacist factor: Knowledge and skills, keeping updated with latest evidence, Communication with other healthcare professionals etc. c. Disease factor: Diagnosis of different categories of hypertension (e.g. white-coat, masked, nocturnal, nondipper, morning surge), etc. d. System factor: Use of electronic medical records for patients with hypertension, PTEC, interprofessional care delivery, etc. 6. Can you suggest ways to improve the current management of hypertension? a. Probe: Change in current hypertension care delivery? Training? Technology? b. Probe: Do you need any support to provide better care for your patients 7. Do you have anything else to share with me? Data analysis After transcription and checking, the transcripts were imported into NVivo computer-assisted qualitative data analysis software for data management and thematic analysis. Initially, two researchers each analysed one transcript independently. Codes (short phrase labels) were assigned to specific data sections that represented their significance (open coding). Subsequently, the researchers used their developed codes to code one more transcript each. The coding was then compared for inter-researcher consistency. Any differences were resolved by discussion until an agreement was reached on the list of codes. This list was then reviewed, and the codes were grouped together to form categories (axial coding). These categories were further reviewed in terms of relation, and underlying themes were created to reflect the meaning of the data. This coding framework was then used to code data from the remaining transcripts ( 21 ). The remaining transcripts were distributed among three researchers (RT, NCJ, AK) and coded individually. New codes that emerged during analysis were added to the list upon consultation with the other researchers, while those that were not relevant were removed. The coding framework was continually relooked, and codes were rearranged into different or new categories as deemed appropriate through discussion among the researchers. In alignment with the comparative case approach, which used assorted forms of data ( 22 ), field notes taken during the interviews were also reviewed and included in the analysis process to help in comprehension and clarification of the data. Data analysis was conducted from both clinical (RT and NCJ) and nonclinical (AK) perspectives. After all twelve transcripts were coded, the findings were presented to the fourth researcher (OSP) for review. OSP, who is a pharmacist, helped provide further contextualised interpretation of the data from the perspective of a primary care pharmacist. To improve the credibility of the analysis, the research team caried out regular reflection and discussion on potential biases that the researchers might harbour due to their backgrounds. Results A total of 12 pharmacists participated in the study. Table 2 shows the participants’ demographic data. The initial research question was to broadly explore the challenges and barriers faced by primary care pharmacists in the management of patients with hypertension. However, one recurrent theme emerged very strongly across all five polyclinics: communication. With different stakeholders involved in the management of patients with hypertension, pharmacists were affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and doctors, and doctors and patients. Figure 1 illustrates the barriers that surfaced at each interaction. Table 2 Demographic profile of participants Characteristics Number (n = 12) % Mean ± SD (Range) Age 39.5 ± 9.5 years (26–61 years) Sex Female 7 58.3 Male 5 41.7 Years of experience 14.1 ± 9.78 years (2–35 years) Polyclinic C1 2 16.7 C2 3 25 C3 2 16.7 C4 3 25 C5 2 16.7 Between pharmacists and patients Pharmacists interacted with patients in the setting of medication dispensing, counselling and reconciliation. Challenges emerged during these interactions that impacted the pharmacist’s management of patients with hypertension. Language barrier. Language was a commonly raised factor. As a multiracial society, Singapore is home to many different ethnicities that speak varying languages; hence, language barriers emerged between pharmacy staff and patients, and this affected their ability to counsel patients appropriately. As put across by one pharmacist, Because many times they (patients) will tell us things like, ‘Oh, because when I got the medicine, I got it from a Malay speaking staff and I’m a Chinese and I don’t understand their English’ − 39yo Pharmacist, 15 years’ experience, Polyclinic C4 One pharmacist also pointed out that pharmacy staff would turn to other staff in the polyclinic to help with translation. This highlighted the issue of accuracy of translation, as medical and drug-related counselling has to be as accurate as possible to prevent medication errors and patient misconceptions. For example, we only have one or two Tamil-speaking staff; if this one patient only speaks Tamil, we may actually approach cross-domain staff who are Tamil-speaking to help us with the translation. However, we have to be more careful, because sometimes when they help us to translate, we do not know whether they actually translated it correctly or not. − 38yo Pharmacist, 15 years’ experience, Polyclinic C2 Patients with physical disabilities. Many pharmacists mentioned that a number of patients with hypertension they encountered had disabilities that made communication more challenging. Deficits in patients’ memory, hearing, and vision caused patient counselling to become more time-consuming and at times ineffective. I would say it happens mainly to the very old elderly or maybe they might have Alzheimer’s or dementia or poor memory. That kind of patient, we will need more time. They tend to forget what the doctor said, so they need more time to counsel. − 30yo Pharmacist, 2 years’ experience, Polyclinic C1 However, there can be patients who wear hearing aids; they may not be able to hear us properly. So I tend to write (the instructions) for them, if there's a need to. − 26yo Pharmacist, 2 years’ experience, Polyclinic C2 Medication brand changes. According to the pharmacists, medication brand changes were a common occurrence that made communication with patients even more arduous. Owing to polyclinic policy and partially due to supply chain disruptions during the COVID-19 pandemic, medications stocked in the pharmacy underwent brand changes regularly. When asked how frequently these medication brand changes occurred, one pharmacist replied, It can be every few months, every 3–4 months. − 49yo Pharmacist, 27 years’ experience, Polyclinic C5 The participants reported that with every change in medication brand, they would have to spend more time devising methods to communicate the brand change to patients clearly and took longer for patient counselling as well. Given the already existing time constraint, frequent medication brand changes proved to be very challenging. One pharmacist remarked that they had to perform the following additional tasks with every medication brand change: So in our clinic, actually we print out a list of new drugs with their drug images and we show the patient, ‘this is the new drug you're going to take, and the old one looks like this, the new drug looks like this, they're different.’ If the patient does not understand, we ask them to take a picture, then go back, tell your children that these are different and so on. In addition, then occasionally, we will write for them: ‘This is new.’ And for medications that are new and we know patients will get confused very easily, we will put a label, we will say: ‘this is a change in packaging’ on the label so that whoever is handling that medication for the patients actually know that this medication is a new packaging. − 61yo Pharmacist, 35 years’ experience, Polyclinic C5 As put across by another pharmacist, Oh, we will definitely have to spend a longer time, but there's no other way. − 49yo Pharmacist, 27 years’ experience, Polyclinic C5 Even after all these additional efforts put in by the pharmacists, patients would still be confused by medication brand changes. This negated the pharmacists’ previous efforts, affected patient nonadherence, and further increased the workload for the pharmacists and doctors who had to re-explain the brand changes. However, sometimes even though we do the counselling and put the ‘change in brand’ sticker, patients are still a bit dubious if they forget about the verbal counselling part. Upon going home, they say: ‘What is this sticker for?’ If they are illiterate, they do not understand the languages that is pasted on the sticker itself, so they will actually just leave the whole pack of medications there and they don’t take them. They will wait until the next visit when they come back and show it to the doctor, ‘oh this one I did not take because I do not know what it is for.’ − 38yo Pharmacist, 15 years’ experience, Polyclinic C2 Use of video consultation. Video consultations are becoming increasingly popular in Singapore, but pharmacists also raised unique barriers that emerged from them. It was noted that many patients struggled with the usage of technology required for video consultations and that communication over a virtual means was more challenging than face-to-face consultations. We have to be a bit more thorough to ensure that they actually capture the information, especially if there're changes to the medicines itself. So we may take more time for video consult compared to the usual face-to-face consult. − 26yo Pharmacist, 2 years’ experience, Polyclinic C2 They (patients) are not so IT-savvy and they prefer not to use the V-con (video consultation) because they do not know how to use it. In addition, they do not want to trouble their caregivers, or their family members to help them with the setting up and things like that. − 38yo Pharmacist, 15 years’ experience, Polyclinic C2 Between pharmacists and doctors The pharmacists interacted with doctors regularly when managing patients with hypertension; this occurred in both directions, either from doctors to pharmacists or from pharmacists to doctors. From doctors to pharmacists When doctors made prescriptions or referred patients to pharmacists for medication counselling or reconciliation, they communicated this information to the pharmacists via documentation on electronic medical records (EMRs). Barriers arose from this mode of communication in two ways: lack of EMR integration across institutions and inadequate and inappropriate documentation. Lack of access to patient medication information across institutions. Currently, in Singapore, different public healthcare clusters utilise different EMR platforms. The pharmacists highlighted that they encountered difficulty trying to harmonise a patient’s medications across different healthcare institutions due to the lack of integration of EMRs. When looking for existing or new prescriptions from doctors in other healthcare clusters, pharmacists had to access NEHR (National Electronic Health Record Singapore), which is a completely different portal from SingHealth’s in-house EMR platform. SCM is Singhealth cluster’s EMR platform. Then, when you want to find information from other health clusters, you cannot get the information. I mean when patient tell you ‘I recently visited Tan Tock Seng Hospital (TTSH), Khoo Teck Puat Hospital (KTPH)’ OK, you look into NEHR, you see maybe TTSH's records there, NHG's (Healthcare group under which TTSH and KTPH fall) records; useful, but still not fully encompassing all the records in Singapore. KTPH I think it uses a different system again that may not even file their medication list. − 36yo Pharmacist, 10 years’ experience, Polyclinic C3 Inadequate and inappropriate documentation by doctors. After making changes or cancellations of medications, some doctors did not document these changes clearly on the EMR. This made it challenging for pharmacists, as they needed to verify the new list of medications or dosages by calling the doctors; this delayed the process of medication review and dispensing. Because some of the hospitals' discharge summaries, especially for those patients who were recently hospitalised, they do not tend to indicate the medication changes. Therefore, it is difficult for us to verify whether the medicine should be continued or discontinued. So if there's no proper indications, it is a bit hard for us to decide. So we may take more time to actually go through the records. − 26yo Pharmacist, 2 years’ experience, Polyclinic C2 Beyond delaying medication review and dispensing, this inadequate documentation also led to conflicting advice given to the patient by the pharmacist and the doctor. Because sometimes there might be a lapse, like for example, the doctor told the patient this thing, then after when we counsel the medication to them then they will say but just now the doctor said otherwise. However, the doctor did not document this information in the clinical documents. Therefore, when I checked as a pharmacist, there was no mention anything like to stop for one day, for example. − 30yo Pharmacist, 2 years’ experience, Polyclinic C1 In addition to inadequate documentation, the doctors sometimes made mistakes in their documentation on the EMR; this added to the pharmacists’ workload and impacted their roles in medication counselling and dispensing. For instance, some doctors inappropriately documented that their patients needed medication counselling due to their practice of copying and pasting from previous medication instructions in the EMR. This resulted in pharmacists having to routinely reassess their referred patients for the need for medication counselling. We will not conduct medication counselling to all the patients who are referred by doctors - we will assess. If let’s say there is no change, no new issue, then we will still send back to our PT (pharmacy technician) to dispense. (These inappropriate documentations arise as) Sometimes they (the doctors) forget, they just copy from the previous (entry). So the previous instructions, they forget to delete. − 39yo Pharmacist, 12 years’ experience, Polyclinic C1 From pharmacists to doctors Phone calls are disruptive and ineffective. In the polyclinic, the pharmacist carries out an ‘intervention’ when they identify an error in the doctor’s prescription. The pharmacists would contact and clarify with the doctors before making the appropriate changes; this is often done via a telephone call. The participants expressed that the phone calls frequently disrupted the doctor’s consultation with a patient; this resulted in the doctor’s delay in picking up the call or acting on the prescription error. With such delays, patients experienced longer waiting times and developed greater dissatisfaction. From the patient’s perspective, the pharmacy staff kept them from leaving the clinic. Therefore, pharmacy staff received the brunt of patient complaints instead of doctors. Because sometimes the doctors are seeing patients when the pharmacist calls for intervention. So it may take some time for us to get through to the doctors. − 26yo Pharmacist, 2 years’ experience, Polyclinic C2 Because we are the end point, patients will usually tend to blame us (for the delay). Therefore, our colleagues will feel down, and it may affect our pharmacy staff morale. − 30yo Pharmacist, 2 years’ experience, Polyclinic C1 Sometimes it can be stressful if the patient is in a rush. They're pressing for an answer or they might even say, ‘You do not have to check, you just give me the medicine. I know what to do.’ And it is definitely not safe. − 29yo Pharmacist, 5 years’ experience, Polyclinic C4 Continual disruptions to doctors’ consultations affected the relationship between pharmacists and doctors. This was perceived to be a pertinent problem in a setting where teamwork is essential for a multidisciplinary team to treat patients with hypertension. Even though how busy you (doctors) are, try to understand that we (pharmacists) actually do not call you (doctors) for the sake of calling. We do not want to disturb anybody, actually we don’t want to call doctors, we hate to call doctors. [laughter] However, because we have a reason to call you, so maybe just be nicer, try to understand us, why we actually call you. − 49yo Pharmacist, 27 years’ experience, Polyclinic C5 Between doctors and patients The pharmacists highlighted that they were also impacted by the barriers that emerged from communication between doctors and patients. These manifested in a ‘spill-over’ effect, where issues arising from communication between doctors and patients ultimately affected the communication between pharmacists and patients. Language barrier. Pharmacists had to conduct more patient counselling if language barriers during doctor‒patient consultations left gaps in the patient’s knowledge. While some pharmacists saw this as part of their role in the multidisciplinary team, others viewed it as an additional burden that added to their already heavy workload. As one pharmacist pointed out, Like a Chinese patient sees an Indian doctor, for example. There is a language barrier; they don’t understand, they couldn’t request for a Chinese doctor and so they may not understand what the doctor is trying to say. In the end, they come to the pharmacy, and they found out they are getting one additional medicine. They will ask ‘why am I taking a new medicine?’ − 30yo Pharmacist, 2 years’ experience, Polyclinic C1 Patients did not discuss medication nonadherence with doctors Similarly, when doctors were unable to pick up medication nonadherence, there was an impact on the pharmacist’s workload and decision making. On top of their existing workload, pharmacists had to elicit the reasons for nonadherence, revert to the doctor for discussion regarding management options, and advise patients on the importance of adherence. When the patient actually tells us that oh, actually, these medications I am not taking at all. Then, I say, you did not tell the doctor in the consult room? No, I did not tell the doctor. Then, we need to communicate to the doctors. Then, we have to reinforce again that no you cannot self-titrate or self-adjust your dose. − 38yo Pharmacist, 15 years’ experience, Polyclinic C2 I'm not sure what happened there in the consultation room. Sometimes they are not so forthcoming. Yeah, so when they come down to the pharmacy, then they tell us there are other problems which they did not tell the doctor. These medications could be expensive, he cannot afford or he thinks that his conditions are controlled. So we will document on the thing. We will also discuss this with the doctor. − 61yo Pharmacist, 35 years’ experience, Polyclinic C5 Conflict ing advice given by doctors. When pharmacists communicated with patients, another barrier emerged when conflicting advice had been given to the patient by the doctor. This led to patients becoming nonreceptive to pharmacists’ counselling or even distrusting them. Sometimes it’s just a very simple thing like whether this medication can be taken in the morning or night. Just a very simple question. Maybe the doctors did mention it’s better to take at night. Then when they come to me, maybe due to the compliance issue, I would suggest that this medication actually can be taken in the morning together with as your other medication because they tend to forget to take it at night. So for them, they will like, ‘No, the doctor says must take at night’. So yes there is some argument there. − 39yo Pharmacist, 12 years’ experience, Polyclinic C1 On top of this, many pharmacists expressed that patients trusted doctors more than pharmacists. This compounded the effect of conflicting advice, with patients becoming shut-off to pharmacists instead of considering the advice given. It is not really whether we are saying the right thing, we're not saying on the same page and patients feel the difference. Patients think ‘Wow you're telling me one thing, the doctor is telling me another thing, you being the pharmacists, I think you're not good enough to tell me what I should do.’ − 61yo Pharmacist, 35 years’ experience, Polyclinic C5 Discussion This study uncovered the barriers primary care pharmacists in Singapore face in the management of patients with hypertension, with a focus on the challenges arising from communication and documentation. The findings highlighted that pharmacists face difficulties in communicating with both patients and doctors and that doctor‒patient communication also has an effect on pharmacists’ management. Team-based care is a promising advancement that taps into the expertise of various healthcare professionals to better control patients’ hypertension ( 23 ). However, working in a team requires good communication between all parties, and this study highlighted several gaps in communication that need to be addressed. This study identified language as a pertinent barrier that hindered effective communication with and management of patients with hypertension faced by pharmacists. With less than half of Singapore’s population (48.3%) using English as their most frequently spoken language, it is expected that healthcare professionals will meet patients with whom they do not share a spoken language. A study performed among patients in Malaysia, a neighbouring country that also has a multiracial population, reported that nearly all participants felt that the way to improve patient‒physician communication was for physicians to have the capability to speak the local languages ( 24 ). The impact of language barriers has been well documented and includes reducing both patients’ and healthcare professionals’ satisfaction, decreasing the quality of healthcare provided and patient safety, and increasing waiting times for patients while affecting the workflow for healthcare professionals ( 25 – 27 ). When a healthcare professional and patient lack a common language, initiating the process of shared decision-making, exchanging accurate information, and presenting treatment options can become exceedingly challenging ( 28 ). This study also surfaced the impact of medication brand changes on pharmacists’ management of patients with hypertension. Participants mentioned that due to global supply chain disruptions during the COVID-19 pandemic, the procurement of medications proved to be more challenging, and frequent medication brand changes resulted. However, even after the COVID-19 pandemic, many participants felt that medication brand changes were still a regular occurrence, with some participants pointing to fair trade policies as a cause. Existing interventions for each medication brand change were reported as too time-consuming and ineffective, with many patients still being confused about the changes. There have been few studies on this topic; one study conducted in Sweden ( 29 ) found similar challenges faced by pharmacists in terms of generic drug substitution. The study reported that many pharmacists were concerned that their patients would not understand the medication substitutions, leading to disruption of treatment or double medication. This suggests that the challenges faced with regard to medication brand changes are widely held and that interventions should be devised to counter this pertinent problem. The Swedish study further surfaced that elderly individuals, who often face a higher degree of polypharmacy (concurrent use of multiple medications commonly defined as five or more), can be a particularly vulnerable group. As Singapore faces an ageing population and with most patients taking chronic hypertension medications being elderly, more emphasis should be placed on addressing the barriers created by frequent medication brand changes. Furthermore, the participants in the Swedish study expressed doubts regarding the actual long-term cost savings for society that are expected from drug brand substitutions. They raised concerns that any potential savings could be offset by the overall rise in medical expenses caused by decreased adherence to medications and the heightened confusion experienced by patients. This was similarly raised in our study, where many pharmacists expressed that even after spending more time and resources trying to help patients understand the medication brand changes, many patients would still be confused. This resulted in decreased medication adherence and increased workload for pharmacists and doctors, who had to perform extensive medication reconciliation and counselling in subsequent clinic follow-ups. This study also raised certain barriers in communication between pharmacists and doctors, which posed challenges in managing patients with hypertension by pharmacists. One commonly identified barrier was the difficulty pharmacists faced in reaching doctors. Studies conducted in the West also pointed out the struggles pharmacists faced in communicating directly with primary care physicians ( 17 , 30 ). Notably, many of the pharmacists in the West felt that a main barrier to communication was the fact that they were not located in the same building as the doctors. The pharmacists from these studies postulated that working in the same physical location would greatly improve communication between doctors and pharmacists. In Singapore’s polyclinics, doctors and pharmacists work in the same polyclinic, and yet all the participants in our study agreed that getting through to doctors proved to be challenging. Working in the same clinic has overcome the challenge of dealing with “go-betweens” when trying to contact doctors, such as having to navigate clinic answering systems or leaving a message with clinic nurses or receptionists ( 30 ), but certain barriers to communication still remain. Pharmacists still raised the concern that physicians would often not respond to their phone calls, a difficulty that has been highlighted in other studies as well ( 17 , 31 ). Participants in our study reported that this difficulty in communication translated into longer waiting times for patients, who often became irritable and confrontational to pharmacy staff. This negatively impacted pharmacy staff morale and hindered their workflow. Furthermore, phone calls from pharmacists to doctors often disrupted doctors’ consultations. Pharmacists felt that this annoyed the doctors, resulting in some doctors being rude to the pharmacists. Naturally, this put a strain on the pharmacist-doctor relationship and negatively affected team-based care. As one study in Canada reported, doctors and pharmacists both felt that nurturing a healthy pharmacist-doctor relationship is important and that this relationship can further improve pharmacist-doctor communication ( 17 ). Thus, one can observe a negative cycle in our study, where the existing means for communication between pharmacists and doctors led to tension between both parties, which further strained the pharmacist-doctor relationship. This study also highlighted that barriers emerged when doctors tried to communicate certain information to pharmacists. Similar to a study conducted in the United States ( 30 ), our study surfaced that the main way doctors relayed information to pharmacists was via electronic medical records (EMR) instead of directly over the phone. This means of communication posed a challenge when doctors made inadequate and inappropriate documentation on the EMR. As pointed out by another study, pharmacists mentioned that their conversations with patients were frequently restricted due to inadequate details regarding patient medical conditions, reasons for prescribed medications, and doctors' treatment strategies ( 31 ). Should pharmacists need clarification regarding doctors’ documentation, they would have to call the doctors, leading to the many challenges raised above. Finally, our study also pointed out that challenges faced in communication between doctors and patients posed barriers to pharmacists’ management of patients with hypertension. This was observed in two main ways. The first was that doctors sometimes did not elicit patients’ nonadherence to medications. The phenomenon where patients only reveal their difficulties with medication adherence to pharmacists and not doctors has been highlighted in other studies ( 31 , 32 ). A systemic review conducted on communication between patients and healthcare professionals revealed that patients might choose not to disclose nonadherence to their doctors out of fear that the doctor might react negatively ( 32 ). When our study participants were asked why patients tend not to reveal their medication nonadherence to doctors, some posited that language barriers may have affected doctor‒patient communication. This resulted in a “spill-over effect”, where lapses in communication translated into more work for the pharmacists who already faced time constraints. Some pharmacists in our study felt that this negatively impacted the care they could provide for their patients, while others viewed this as an important part of their role in the multidisciplinary team as a “safety net”. Another barrier faced would be when doctors provide conflicting advice to patients compared to the advice pharmacists provide to patients. The pharmacists highlighted that the advice they provide was tailored to the patients’ context to best achieve medication adherence. However, many participants reported that patients tend to trust doctors more than pharmacists and would not even consider the advice given by pharmacists. This raises the issue of trust that patients place in different healthcare professionals. A study in the United Arab Emirates also pointed out that patients tend not to be receptive to the input of pharmacists when compared to that of physicians ( 33 ). This limited the role a pharmacist can play in a multidisciplinary team and compromised patient care. More research should be conducted on the underlying beliefs and assumptions the public has of allied healthcare professionals, and interventions should be developed to counter any misconceptions to provide the best multidisciplinary care for all patients. Conclusions This study highlights several barriers to communication that pharmacists face when managing patients with hypertension while working in a multidisciplinary team. Communication between pharmacists and patients can be challenging due to patient factors (language barrier and physical disabilities) and clinic factors (medication brand changes, use of video consultations). Barriers to communication between pharmacists and doctors include the existing means of pharmacist intervention (phone calls) being disruptive and ineffective and the prevalence of inadequate and inappropriate documentation on the EMR by doctors. Finally, barriers arising from doctor‒patient communication also impact pharmacists, including when patients do not discuss medication nonadherence with doctors and when conflicting advice is given by doctors. These barriers may have a significant impact on patient safety and healthcare professional satisfaction. Thus, future research should look into ways to address these challenges. The interventions developed need to involve all stakeholders, including pharmacists, doctors, and patients. Declarations Ethics approval and consent to participate This study received ethics approval from the SingHealth Centralised Institutional Review Board (CIRB Ref No: 2022/2168). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants involved in the study. Consent for publication Not applicable as our study contains no identifiable information or images. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to participant and patient confidentiality. Competing interests The authors declare that they have no competing interests. Funding This research was funded by SingHealth AM General Fund (14/FY2021/G2/01-A167), SingHealth Polyclinics, and Duke-NUS Medical School. The funding bodies had no influence on the design of the study, on the collection, analysis or interpretation of the data or on writing the manuscript. Authors' contributions CJN conceived the study, conducted the interviews, analysed the data, and critically reviewed the manuscript. RT took field notes during the interviews, checked the transcripts, analysed the data, drafted and revised the manuscript. AK analysed the data and critically reviewed the manuscript. SPO interpreted the data and critically reviewed the manuscript. All authors approved the final manuscript. Acknowledgements We would like to acknowledge the following for their help: Prof Vikki Entwistle, Chair in Health Services Research and Philosophy at University of Aberdeen, for feedback on the manuscript; all clinics and participants who participated in the study. References Zhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet. 2021;398(10304):957–80. Ministry of Health Singapore. National Population Health Survey 2020 (Household Interview and Health Examination) [Internet]. 2020 [cited 2023 Apr 11]. Available from: https://www.moh.gov.sg/docs/librariesprovider5/default-document-library/nphs-2020-survey-report.pdf . Khatib R, Schwalm JD, Yusuf S, Haynes RB, McKee M, Khan M, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS ONE. 2014;9(1):e84238. Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in Blood Pressure Control Among US Adults With Hypertension, 1999–2000 to 2017–2018. JAMA. 2020;324(12):1190. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75(6):1334–57. Wang G, Grosse SD, Schooley MW. Conducting Research on the Economics of Hypertension to Improve Cardiovascular Health. Am J Prev Med. 2017;53(6 Suppl 2):115–7. Ministry of Health S. Primary Healthcare Services [Internet]. 2022 [cited 2023 Apr 11]. 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Taylor SP, Nicolle C, Maguire M. Cross-cultural communication barriers in health care. Nurs Standard. 2013;27(31):35–43. Suurmond J, Seeleman C. Shared decision-making in an intercultural context. Patient Educ Couns. 2006;60(2):253–9. Olsson E, Kälvemark Sporrong S. Pharmacists’ experiences and attitudes regarding generic drugs and generic substitution: two sides of the coin. Int J Pharm Pract. 2012;20(6):377–83. Curran GM, Freeman PR, Martin BC, Teeter BS, Drummond KL, Bradley K, et al. Communication between pharmacists and primary care physicians in the midst of a U.S. opioid crisis. Res Social Administrative Pharm. 2019;15(8):974–85. Tarn DM, Paterniti DA, Wenger NS, Williams BR, Chewning BA. Older patient, physician and pharmacist perspectives about community pharmacists’ roles. Int J Pharm Pract. 2012;20(5):285–93. Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expect. 2004;7(3):235–45. Hasan S, Stewart K, Chapman CB, Kong DCM. Physicians’ perspectives of pharmacist-physician collaboration in the United Arab Emirates: Findings from an exploratory study. J Interprof Care. 2018;32(5):566–74. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Mar, 2024 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 26 Nov, 2023 Reviews received at journal 20 Nov, 2023 Reviewers agreed at journal 15 Nov, 2023 Reviewers invited by journal 15 Nov, 2023 Editor invited by journal 04 Oct, 2023 Editor assigned by journal 04 Oct, 2023 Submission checks completed at journal 01 Oct, 2023 First submitted to journal 18 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3364572","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":237147390,"identity":"697b014a-10c9-49bd-b880-959a40b072d7","order_by":0,"name":"Reuben Tan","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Reuben","middleName":"","lastName":"Tan","suffix":""},{"id":237147391,"identity":"69aea824-31f1-451e-8980-7ca797d70983","order_by":1,"name":"Ariffin Kawaja","email":"","orcid":"","institution":"SingHealth Polyclinics","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ariffin","middleName":"","lastName":"Kawaja","suffix":""},{"id":237147392,"identity":"fa09f525-8a5b-4b48-a969-53c107e70cd5","order_by":2,"name":"Swee Phaik Ooi","email":"","orcid":"","institution":"SingHealth Polyclinics","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Swee","middleName":"Phaik","lastName":"Ooi","suffix":""},{"id":237147393,"identity":"2905b9cf-1717-456e-b6a1-4ae012997c3b","order_by":3,"name":"Chirk Jenn Ng","email":"data:image/png;base64,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","orcid":"","institution":"SingHealth Polyclinics","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Chirk","middleName":"Jenn","lastName":"Ng","suffix":""}],"badges":[],"createdAt":"2023-09-18 04:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3364572/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3364572/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-024-02349-w","type":"published","date":"2024-03-27T15:01:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44208913,"identity":"e0943601-d894-4ce4-9068-541d188c8acb","added_by":"auto","created_at":"2023-10-06 20:34:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":181896,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCommunication barriers faced by primary care pharmacists in the management of patients with hypertension\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3364572/v1/9ef7aea929054223b4bfb18e.png"},{"id":53870085,"identity":"17ec8b69-c39e-4559-a41c-84227dd70604","added_by":"auto","created_at":"2024-04-01 15:12:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":619261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3364572/v1/26590389-a583-4e83-b490-0f1b10b12474.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eHypertension is on the rise in Singapore and across the world (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and primary care pharmacists in Singapore play an important role in the management of patients with hypertension. The latest National Population Health Survey conducted in 2019/2020 found that 1 in 3 (35.5%) Singaporean adults (aged 18\u0026ndash;74) has hypertension, of whom nearly half of them have never been diagnosed, and among those who have been diagnosed and are on treatment, 2 out of 3 are poorly controlled (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite the availability of effective blood pressure-lowering medications and the evidence of lifestyle modifications in reducing blood pressure, implementation of clinical evidence in real-world clinical practice remains challenging (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This poses a significant burden of disease and care, as hypertension, if uncontrolled, can result in complications such as coronary artery disease, stroke, and chronic kidney disease (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This will affect the quality of life of patients and their caregivers and impose a significant healthcare cost and burden on the health system (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrently, most patients with hypertension in Singapore (84%) are managed in the primary care setting, with the remaining patients being managed at specialist outpatient clinics in hospitals. Most patients (50.5%) seek care at government primary-care clinics (or polyclinics), while 33.5% of patients seek care from over 2000 private general practitioners (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Hypertension care in the 23 polyclinics in Singapore is provided by multidisciplinary teams (MDTs), of which primary care pharmacists are an integral part (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The practice of pharmacists is evolving as more pharmacists become incorporated into primary care teams, with a transition from dispensing medications to playing a more collaborative and patient-centred role (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Increasingly, pharmacists play multiple roles in hypertension care, including providing medication and lifestyle counselling, picking up and addressing nonadherence, and facilitating home blood pressure monitoring (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e); and pharmacist interventions have been shown to improve blood pressure control (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe role that primary care pharmacists play often requires them to interact not only with patients but also with other healthcare professionals (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Studies have identified several challenges faced by pharmacists when interacting with their healthcare colleagues. One commonly faced barrier was \u0026ldquo;medical dominance\u0026rdquo;, as defined by the Health Sociology Review as the occurrence of doctors \u0026ldquo;exerting sovereign power over other professions such as nursing\u0026rdquo; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), thus undermining and restricting the roles of pharmacists (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Lack of clarity regarding a pharmacist\u0026rsquo;s role and responsibilities by other healthcare professionals also led to underutilisation of their services (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Studies have also shown that some doctors show a lack of respect towards pharmacists, resulting in pharmacists avoiding interacting with doctors (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Often, even trying to reach doctors proved to be challenging for pharmacists (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe pharmacists in Singapore\u0026rsquo;s polyclinics work in dynamic multidisciplinary teams to deliver care for a large number of patients who come from diverse socioeconomic, cultural and language backgrounds. Pharmacists work in a setting where one pharmacist will interact with multiple doctors who each have different communication and documentation styles. Furthermore, less than half of Singapore\u0026rsquo;s population (48.3%) uses English as their most frequently spoken language, and many other languages are spoken in this multiracial country, including Mandarin, Chinese dialects, Malay, Tamil, and other languages (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, very few studies have been conducted locally to explore the communication challenges faced by primary care pharmacists in managing patients with hypertension.\u003c/p\u003e \u003cp\u003eWe conducted a qualitative study exploring challenges faced by pharmacists when managing patients with hypertension in a Singapore public primary healthcare setting. \u0026lsquo;Communication barriers\u0026rsquo; emerged as the main overarching theme. Therefore, this paper aimed to explore the communication barriers faced by primary care pharmacists when managing patients with hypertension in Singapore. By identifying these barriers, interventions can be developed to fill the gaps and address the unmet needs. The findings will be relevant to pharmacists who work in a team and manage patients with diverse backgrounds and to decision makers who are planning for healthcare interventions to improve hypertension care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study utilised a qualitative methodology consisting of individual in-depth interviews (IDIs), as it allowed us to inquire and delve into the views and experiences of primary care pharmacists concerning the management of patients with hypertension as encountered in their local practices (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe public healthcare system in Singapore is grouped into three clusters based on geographical location, with SingHealth Polyclinics managing patients in the eastern region of Singapore (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The study was conducted among primary care pharmacists involved in managing patients with hypertension across five SingHealth Polyclinics in Singapore. The five selected Polyclinics were distributed across various locations in the eastern region of Singapore and had different patient population profiles (age, socioeconomic status, education level and health literacy). Care was also taken to ensure that a spectrum of practice experience was represented.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants, recruitment, sampling\u003c/h2\u003e \u003cp\u003eWe identified pharmacists at SingHealth Polyclinics who were involved in the care of patients with hypertension for at least six months. We purposively sampled pharmacists of different levels of seniority with varying years of experience practising in primary care. In addition, a pattern of snowball sampling developed as the participants named other pharmacists whom they felt would provide additional insights. Sample size was determined by data saturation whereby interviews were stopped when no new \u0026lsquo;views\u0026rsquo;, \u0026rsquo;experiences\u0026rsquo;, or \u0026lsquo;challenges\u0026rsquo; emerged from the interviews and data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe researchers of this study are RT, NCJ, AK and OSP. RT is a medical student; NCJ is a professor and clinician who specialises in family medicine; AK is a research fellow with a PhD degree in health communication; and OSP is a senior pharmacist working in a SingHealth Polyclinic.\u003c/p\u003e \u003cp\u003eBefore commencing the IDIs, an interview topic guide was developed based on a literature review, clinical knowledge and research experience (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All interviews were carried out by NCJ, who had 20 years of experience conducting qualitative research. We avoided, whenever possible, selecting participants who were close acquaintances or colleagues of NCJ to minimise potential participant response bias. Prior to the interviews, the researchers gave the study information sheet and explained to the participants the aims of the study and the research method before informed consent was obtained from the participants. RT took detailed field notes that were used as discussion and comparison pointers with NCJ after the interviews, as well as for data analysis later. No repeat interviews were conducted. From March to October 2022, twelve 40\u0026ndash;60 minute IDIs were conducted. Data collection was stopped when data saturation had been reached. All IDIs were audio-recorded and transcribed verbatim, after which they were checked for accuracy and used as data for analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy interview topic guide\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Can you tell me about the patient profile at your polyclinic?\u003c/p\u003e \u003cp\u003ea. Age group, ethnicity, education level, disease severity, health-seeking behaviour\u003c/p\u003e \u003cp\u003e2. How do patients with hypertension first present in your clinic?\u003c/p\u003e \u003cp\u003e3. Do you use any clinical practice guideline to guide your hypertension management?\u003c/p\u003e \u003cp\u003ea. If yes, which guideline and why\u003c/p\u003e \u003cp\u003eb. What do you think about the guideline? Useful or not? Why?\u003c/p\u003e \u003cp\u003e4. What is your approach to treating hypertension?\u003c/p\u003e \u003cp\u003ea. Probe: Nonpharmacological \u0026ndash; diet, exercise (be specific)\u003c/p\u003e \u003cp\u003eb. Probe: Medications \u0026ndash; which category, order of starting, mono- or dual therapy, how and when to step up\u003c/p\u003e \u003cp\u003e5. What are the challenges you face when managing patients with hypertension?\u003c/p\u003e \u003cp\u003ea. Probe: Patient factor: Nonadherence to treatment/lifestyle modifications, communication barriers etc.\u003c/p\u003e \u003cp\u003eb. Probe: Pharmacist factor: Knowledge and skills, keeping updated with latest evidence, Communication with other healthcare professionals etc.\u003c/p\u003e \u003cp\u003ec. Disease factor: Diagnosis of different categories of hypertension (e.g. white-coat, masked, nocturnal, nondipper, morning surge), etc.\u003c/p\u003e \u003cp\u003ed. System factor: Use of electronic medical records for patients with hypertension, PTEC, interprofessional care delivery, etc.\u003c/p\u003e \u003cp\u003e6. Can you suggest ways to improve the current management of hypertension?\u003c/p\u003e \u003cp\u003ea. Probe: Change in current hypertension care delivery? Training? Technology?\u003c/p\u003e \u003cp\u003eb. Probe: Do you need any support to provide better care for your patients\u003c/p\u003e \u003cp\u003e7. Do you have anything else to share with me?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAfter transcription and checking, the transcripts were imported into NVivo computer-assisted qualitative data analysis software for data management and thematic analysis. Initially, two researchers each analysed one transcript independently. Codes (short phrase labels) were assigned to specific data sections that represented their significance (open coding). Subsequently, the researchers used their developed codes to code one more transcript each. The coding was then compared for inter-researcher consistency. Any differences were resolved by discussion until an agreement was reached on the list of codes. This list was then reviewed, and the codes were grouped together to form categories (axial coding). These categories were further reviewed in terms of relation, and underlying themes were created to reflect the meaning of the data. This coding framework was then used to code data from the remaining transcripts (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe remaining transcripts were distributed among three researchers (RT, NCJ, AK) and coded individually. New codes that emerged during analysis were added to the list upon consultation with the other researchers, while those that were not relevant were removed. The coding framework was continually relooked, and codes were rearranged into different or new categories as deemed appropriate through discussion among the researchers. In alignment with the comparative case approach, which used assorted forms of data (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), field notes taken during the interviews were also reviewed and included in the analysis process to help in comprehension and clarification of the data.\u003c/p\u003e \u003cp\u003eData analysis was conducted from both clinical (RT and NCJ) and nonclinical (AK) perspectives. After all twelve transcripts were coded, the findings were presented to the fourth researcher (OSP) for review. OSP, who is a pharmacist, helped provide further contextualised interpretation of the data from the perspective of a primary care pharmacist. To improve the credibility of the analysis, the research team caried out regular reflection and discussion on potential biases that the researchers might harbour due to their backgrounds.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 12 pharmacists participated in the study. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the participants\u0026rsquo; demographic data.\u003c/p\u003e \u003cp\u003eThe initial research question was to broadly explore the challenges and barriers faced by primary care pharmacists in the management of patients with hypertension. However, one recurrent theme emerged very strongly across all five polyclinics: communication.\u003c/p\u003e \u003cp\u003eWith different stakeholders involved in the management of patients with hypertension, pharmacists were affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and doctors, and doctors and patients. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the barriers that surfaced at each interaction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic profile of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 years (26\u0026ndash;61 years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.78 years (2\u0026ndash;35 years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyclinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBetween pharmacists and patients\u003c/h2\u003e \u003cp\u003ePharmacists interacted with patients in the setting of medication dispensing, counselling and reconciliation. Challenges emerged during these interactions that impacted the pharmacist\u0026rsquo;s management of patients with hypertension.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLanguage barrier.\u003c/b\u003e Language was a commonly raised factor. As a multiracial society, Singapore is home to many different ethnicities that speak varying languages; hence, language barriers emerged between pharmacy staff and patients, and this affected their ability to counsel patients appropriately. As put across by one pharmacist,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause many times they (patients) will tell us things like, \u0026lsquo;Oh, because when I got the medicine, I got it from a Malay speaking staff and I\u0026rsquo;m a Chinese and I don\u0026rsquo;t understand their English\u0026rsquo;\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;39yo Pharmacist, 15 years\u0026rsquo; experience, Polyclinic C4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne pharmacist also pointed out that pharmacy staff would turn to other staff in the polyclinic to help with translation. This highlighted the issue of accuracy of translation, as medical and drug-related counselling has to be as accurate as possible to prevent medication errors and patient misconceptions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor example, we only have one or two Tamil-speaking staff; if this one patient only speaks Tamil, we may actually approach cross-domain staff who are Tamil-speaking to help us with the translation. However, we have to be more careful, because sometimes when they help us to translate, we do not know whether they actually translated it correctly or not.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;38yo Pharmacist, 15 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients with physical disabilities.\u003c/b\u003e Many pharmacists mentioned that a number of patients with hypertension they encountered had disabilities that made communication more challenging. Deficits in patients\u0026rsquo; memory, hearing, and vision caused patient counselling to become more time-consuming and at times ineffective.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI would say it happens mainly to the very old elderly or maybe they might have Alzheimer\u0026rsquo;s or dementia or poor memory. That kind of patient, we will need more time. They tend to forget what the doctor said, so they need more time to counsel.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;30yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e\u003cp\u003eHowever, there can be patients who wear hearing aids; they may not be able to hear us properly. So I tend to write (the instructions) for them, if there's a need to.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;26yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eMedication brand changes.\u003c/b\u003e According to the pharmacists, medication brand changes were a common occurrence that made communication with patients even more arduous. Owing to polyclinic policy and partially due to supply chain disruptions during the COVID-19 pandemic, medications stocked in the pharmacy underwent brand changes regularly. When asked how frequently these medication brand changes occurred, one pharmacist replied,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt can be every few months, every 3\u0026ndash;4 months.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;49yo Pharmacist, 27 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants reported that with every change in medication brand, they would have to spend more time devising methods to communicate the brand change to patients clearly and took longer for patient counselling as well. Given the already existing time constraint, frequent medication brand changes proved to be very challenging. One pharmacist remarked that they had to perform the following additional tasks with every medication brand change:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo in our clinic, actually we print out a list of new drugs with their drug images and we show the patient, \u0026lsquo;this is the new drug you're going to take, and the old one looks like this, the new drug looks like this, they're different.\u0026rsquo; If the patient does not understand, we ask them to take a picture, then go back, tell your children that these are different and so on. In addition, then occasionally, we will write for them: \u0026lsquo;This is new.\u0026rsquo; And for medications that are new and we know patients will get confused very easily, we will put a label, we will say: \u0026lsquo;this is a change in packaging\u0026rsquo; on the label so that whoever is handling that medication for the patients actually know that this medication is a new packaging.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;61yo Pharmacist, 35 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs put across by another pharmacist,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOh, we will definitely have to spend a longer time, but there's no other way.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;49yo Pharmacist, 27 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEven after all these additional efforts put in by the pharmacists, patients would still be confused by medication brand changes. This negated the pharmacists\u0026rsquo; previous efforts, affected patient nonadherence, and further increased the workload for the pharmacists and doctors who had to re-explain the brand changes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHowever, sometimes even though we do the counselling and put the \u0026lsquo;change in brand\u0026rsquo; sticker, patients are still a bit dubious if they forget about the verbal counselling part. Upon going home, they say: \u0026lsquo;What is this sticker for?\u0026rsquo; If they are illiterate, they do not understand the languages that is pasted on the sticker itself, so they will actually just leave the whole pack of medications there and they don\u0026rsquo;t take them. They will wait until the next visit when they come back and show it to the doctor, \u0026lsquo;oh this one I did not take because I do not know what it is for.\u0026rsquo;\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;38yo Pharmacist, 15 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eUse of video consultation.\u003c/b\u003e Video consultations are becoming increasingly popular in Singapore, but pharmacists also raised unique barriers that emerged from them. It was noted that many patients struggled with the usage of technology required for video consultations and that communication over a virtual means was more challenging than face-to-face consultations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe have to be a bit more thorough to ensure that they actually capture the information, especially if there're changes to the medicines itself. So we may take more time for video consult compared to the usual face-to-face consult.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;26yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003cp\u003eThey (patients) are not so IT-savvy and they prefer not to use the V-con (video consultation) because they do not know how to use it. In addition, they do not want to trouble their caregivers, or their family members to help them with the setting up and things like that.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;38yo Pharmacist, 15 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBetween pharmacists and doctors\u003c/h3\u003e\n\u003cp\u003eThe pharmacists interacted with doctors regularly when managing patients with hypertension; this occurred in both directions, either from doctors to pharmacists or from pharmacists to doctors.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFrom doctors to pharmacists\u003c/h2\u003e \u003cp\u003eWhen doctors made prescriptions or referred patients to pharmacists for medication counselling or reconciliation, they communicated this information to the pharmacists via documentation on electronic medical records (EMRs). Barriers arose from this mode of communication in two ways: lack of EMR integration across institutions and inadequate and inappropriate documentation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLack of access to patient medication information across institutions.\u003c/b\u003e Currently, in Singapore, different public healthcare clusters utilise different EMR platforms. The pharmacists highlighted that they encountered difficulty trying to harmonise a patient\u0026rsquo;s medications across different healthcare institutions due to the lack of integration of EMRs. When looking for existing or new prescriptions from doctors in other healthcare clusters, pharmacists had to access NEHR (National Electronic Health Record Singapore), which is a completely different portal from SingHealth\u0026rsquo;s in-house EMR platform.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSCM is Singhealth cluster\u0026rsquo;s EMR platform. Then, when you want to find information from other health clusters, you cannot get the information. I mean when patient tell you \u0026lsquo;I recently visited Tan Tock Seng Hospital (TTSH), Khoo Teck Puat Hospital (KTPH)\u0026rsquo; OK, you look into NEHR, you see maybe TTSH's records there, NHG's (Healthcare group under which TTSH and KTPH fall) records; useful, but still not fully encompassing all the records in Singapore. KTPH I think it uses a different system again that may not even file their medication list.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;36yo Pharmacist, 10 years\u0026rsquo; experience, Polyclinic C3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eInadequate and inappropriate documentation by doctors.\u003c/b\u003e After making changes or cancellations of medications, some doctors did not document these changes clearly on the EMR. This made it challenging for pharmacists, as they needed to verify the new list of medications or dosages by calling the doctors; this delayed the process of medication review and dispensing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause some of the hospitals' discharge summaries, especially for those patients who were recently hospitalised, they do not tend to indicate the medication changes. Therefore, it is difficult for us to verify whether the medicine should be continued or discontinued. So if there's no proper indications, it is a bit hard for us to decide. So we may take more time to actually go through the records.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;26yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBeyond delaying medication review and dispensing, this inadequate documentation also led to conflicting advice given to the patient by the pharmacist and the doctor.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause sometimes there might be a lapse, like for example, the doctor told the patient this thing, then after when we counsel the medication to them then they will say but just now the doctor said otherwise. However, the doctor did not document this information in the clinical documents. Therefore, when I checked as a pharmacist, there was no mention anything like to stop for one day, for example.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;30yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to inadequate documentation, the doctors sometimes made mistakes in their documentation on the EMR; this added to the pharmacists\u0026rsquo; workload and impacted their roles in medication counselling and dispensing. For instance, some doctors inappropriately documented that their patients needed medication counselling due to their practice of copying and pasting from previous medication instructions in the EMR. This resulted in pharmacists having to routinely reassess their referred patients for the need for medication counselling.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe will not conduct medication counselling to all the patients who are referred by doctors - we will assess. If let\u0026rsquo;s say there is no change, no new issue, then we will still send back to our PT (pharmacy technician) to dispense. (These inappropriate documentations arise as) Sometimes they (the doctors) forget, they just copy from the previous (entry). So the previous instructions, they forget to delete.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;39yo Pharmacist, 12 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFrom pharmacists to doctors\u003c/h2\u003e \u003cp\u003e\u003cb\u003ePhone calls are disruptive and ineffective.\u003c/b\u003e In the polyclinic, the pharmacist carries out an \u0026lsquo;intervention\u0026rsquo; when they identify an error in the doctor\u0026rsquo;s prescription. The pharmacists would contact and clarify with the doctors before making the appropriate changes; this is often done via a telephone call. The participants expressed that the phone calls frequently disrupted the doctor\u0026rsquo;s consultation with a patient; this resulted in the doctor\u0026rsquo;s delay in picking up the call or acting on the prescription error. With such delays, patients experienced longer waiting times and developed greater dissatisfaction. From the patient\u0026rsquo;s perspective, the pharmacy staff kept them from leaving the clinic. Therefore, pharmacy staff received the brunt of patient complaints instead of doctors.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBecause sometimes the doctors are seeing patients when the pharmacist calls for intervention. So it may take some time for us to get through to the doctors.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;26yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003cp\u003eBecause we are the end point, patients will usually tend to blame us (for the delay). Therefore, our colleagues will feel down, and it may affect our pharmacy staff morale.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;30yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e\u003cp\u003eSometimes it can be stressful if the patient is in a rush. They're pressing for an answer or they might even say, \u0026lsquo;You do not have to check, you just give me the medicine. I know what to do.\u0026rsquo; And it is definitely not safe.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;29yo Pharmacist, 5 years\u0026rsquo; experience, Polyclinic C4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eContinual disruptions to doctors\u0026rsquo; consultations affected the relationship between pharmacists and doctors. This was perceived to be a pertinent problem in a setting where teamwork is essential for a multidisciplinary team to treat patients with hypertension.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEven though how busy you (doctors) are, try to understand that we (pharmacists) actually do not call you (doctors) for the sake of calling. We do not want to disturb anybody, actually we don\u0026rsquo;t want to call doctors, we hate to call doctors. [laughter] However, because we have a reason to call you, so maybe just be nicer, try to understand us, why we actually call you.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;49yo Pharmacist, 27 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBetween doctors and patients\u003c/h2\u003e \u003cp\u003eThe pharmacists highlighted that they were also impacted by the barriers that emerged from communication between doctors and patients. These manifested in a \u0026lsquo;spill-over\u0026rsquo; effect, where issues arising from communication between doctors and patients ultimately affected the communication between pharmacists and patients.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLanguage barrier.\u003c/b\u003e Pharmacists had to conduct more patient counselling if language barriers during doctor‒patient consultations left gaps in the patient\u0026rsquo;s knowledge. While some pharmacists saw this as part of their role in the multidisciplinary team, others viewed it as an additional burden that added to their already heavy workload. As one pharmacist pointed out,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLike a Chinese patient sees an Indian doctor, for example. There is a language barrier; they don\u0026rsquo;t understand, they couldn\u0026rsquo;t request for a Chinese doctor and so they may not understand what the doctor is trying to say. In the end, they come to the pharmacy, and they found out they are getting one additional medicine. They will ask \u0026lsquo;why am I taking a new medicine?\u0026rsquo;\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;30yo Pharmacist, 2 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients did not discuss medication nonadherence with doctors\u003c/b\u003e Similarly, when doctors were unable to pick up medication nonadherence, there was an impact on the pharmacist\u0026rsquo;s workload and decision making. On top of their existing workload, pharmacists had to elicit the reasons for nonadherence, revert to the doctor for discussion regarding management options, and advise patients on the importance of adherence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen the patient actually tells us that oh, actually, these medications I am not taking at all. Then, I say, you did not tell the doctor in the consult room? No, I did not tell the doctor. Then, we need to communicate to the doctors. Then, we have to reinforce again that no you cannot self-titrate or self-adjust your dose.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;38yo Pharmacist, 15 years\u0026rsquo; experience, Polyclinic C2\u003c/p\u003e\u003cp\u003eI'm not sure what happened there in the consultation room. Sometimes they are not so forthcoming. Yeah, so when they come down to the pharmacy, then they tell us there are other problems which they did not tell the doctor. These medications could be expensive, he cannot afford or he thinks that his conditions are controlled. So we will document on the thing. We will also discuss this with the doctor.\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;61yo Pharmacist, 35 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict\u003c/strong\u003e \u003cp\u003e \u003cb\u003eing advice given by doctors.\u003c/b\u003e When pharmacists communicated with patients, another barrier emerged when conflicting advice had been given to the patient by the doctor. This led to patients becoming nonreceptive to pharmacists\u0026rsquo; counselling or even distrusting them.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSometimes it\u0026rsquo;s just a very simple thing like whether this medication can be taken in the morning or night. Just a very simple question. Maybe the doctors did mention it\u0026rsquo;s better to take at night. Then when they come to me, maybe due to the compliance issue, I would suggest that this medication actually can be taken in the morning together with as your other medication because they tend to forget to take it at night. So for them, they will like, \u0026lsquo;No, the doctor says must take at night\u0026rsquo;. So yes there is some argument there.\u003c/p\u003e \u003cp\u003e\u0026minus;\u0026thinsp;39yo Pharmacist, 12 years\u0026rsquo; experience, Polyclinic C1\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn top of this, many pharmacists expressed that patients trusted doctors more than pharmacists. This compounded the effect of conflicting advice, with patients becoming shut-off to pharmacists instead of considering the advice given.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt is not really whether we are saying the right thing, we're not saying on the same page and patients feel the difference. Patients think \u0026lsquo;Wow you're telling me one thing, the doctor is telling me another thing, you being the pharmacists, I think you're not good enough to tell me what I should do.\u0026rsquo;\u003c/p\u003e\u003cp\u003e\u0026minus;\u0026thinsp;61yo Pharmacist, 35 years\u0026rsquo; experience, Polyclinic C5\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study uncovered the barriers primary care pharmacists in Singapore face in the management of patients with hypertension, with a focus on the challenges arising from communication and documentation. The findings highlighted that pharmacists face difficulties in communicating with both patients and doctors and that doctor‒patient communication also has an effect on pharmacists\u0026rsquo; management. Team-based care is a promising advancement that taps into the expertise of various healthcare professionals to better control patients\u0026rsquo; hypertension (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, working in a team requires good communication between all parties, and this study highlighted several gaps in communication that need to be addressed.\u003c/p\u003e \u003cp\u003eThis study identified language as a pertinent barrier that hindered effective communication with and management of patients with hypertension faced by pharmacists. With less than half of Singapore\u0026rsquo;s population (48.3%) using English as their most frequently spoken language, it is expected that healthcare professionals will meet patients with whom they do not share a spoken language. A study performed among patients in Malaysia, a neighbouring country that also has a multiracial population, reported that nearly all participants felt that the way to improve patient‒physician communication was for physicians to have the capability to speak the local languages (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The impact of language barriers has been well documented and includes reducing both patients\u0026rsquo; and healthcare professionals\u0026rsquo; satisfaction, decreasing the quality of healthcare provided and patient safety, and increasing waiting times for patients while affecting the workflow for healthcare professionals (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). When a healthcare professional and patient lack a common language, initiating the process of shared decision-making, exchanging accurate information, and presenting treatment options can become exceedingly challenging (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study also surfaced the impact of medication brand changes on pharmacists\u0026rsquo; management of patients with hypertension. Participants mentioned that due to global supply chain disruptions during the COVID-19 pandemic, the procurement of medications proved to be more challenging, and frequent medication brand changes resulted. However, even after the COVID-19 pandemic, many participants felt that medication brand changes were still a regular occurrence, with some participants pointing to fair trade policies as a cause. Existing interventions for each medication brand change were reported as too time-consuming and ineffective, with many patients still being confused about the changes. There have been few studies on this topic; one study conducted in Sweden (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) found similar challenges faced by pharmacists in terms of generic drug substitution. The study reported that many pharmacists were concerned that their patients would not understand the medication substitutions, leading to disruption of treatment or double medication. This suggests that the challenges faced with regard to medication brand changes are widely held and that interventions should be devised to counter this pertinent problem. The Swedish study further surfaced that elderly individuals, who often face a higher degree of polypharmacy (concurrent use of multiple medications commonly defined as five or more), can be a particularly vulnerable group. As Singapore faces an ageing population and with most patients taking chronic hypertension medications being elderly, more emphasis should be placed on addressing the barriers created by frequent medication brand changes. Furthermore, the participants in the Swedish study expressed doubts regarding the actual long-term cost savings for society that are expected from drug brand substitutions. They raised concerns that any potential savings could be offset by the overall rise in medical expenses caused by decreased adherence to medications and the heightened confusion experienced by patients. This was similarly raised in our study, where many pharmacists expressed that even after spending more time and resources trying to help patients understand the medication brand changes, many patients would still be confused. This resulted in decreased medication adherence and increased workload for pharmacists and doctors, who had to perform extensive medication reconciliation and counselling in subsequent clinic follow-ups.\u003c/p\u003e \u003cp\u003eThis study also raised certain barriers in communication between pharmacists and doctors, which posed challenges in managing patients with hypertension by pharmacists. One commonly identified barrier was the difficulty pharmacists faced in reaching doctors. Studies conducted in the West also pointed out the struggles pharmacists faced in communicating directly with primary care physicians (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Notably, many of the pharmacists in the West felt that a main barrier to communication was the fact that they were not located in the same building as the doctors. The pharmacists from these studies postulated that working in the same physical location would greatly improve communication between doctors and pharmacists. In Singapore\u0026rsquo;s polyclinics, doctors and pharmacists work in the same polyclinic, and yet all the participants in our study agreed that getting through to doctors proved to be challenging. Working in the same clinic has overcome the challenge of dealing with \u0026ldquo;go-betweens\u0026rdquo; when trying to contact doctors, such as having to navigate clinic answering systems or leaving a message with clinic nurses or receptionists (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), but certain barriers to communication still remain. Pharmacists still raised the concern that physicians would often not respond to their phone calls, a difficulty that has been highlighted in other studies as well (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Participants in our study reported that this difficulty in communication translated into longer waiting times for patients, who often became irritable and confrontational to pharmacy staff. This negatively impacted pharmacy staff morale and hindered their workflow. Furthermore, phone calls from pharmacists to doctors often disrupted doctors\u0026rsquo; consultations. Pharmacists felt that this annoyed the doctors, resulting in some doctors being rude to the pharmacists. Naturally, this put a strain on the pharmacist-doctor relationship and negatively affected team-based care. As one study in Canada reported, doctors and pharmacists both felt that nurturing a healthy pharmacist-doctor relationship is important and that this relationship can further improve pharmacist-doctor communication (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Thus, one can observe a negative cycle in our study, where the existing means for communication between pharmacists and doctors led to tension between both parties, which further strained the pharmacist-doctor relationship.\u003c/p\u003e \u003cp\u003eThis study also highlighted that barriers emerged when doctors tried to communicate certain information to pharmacists. Similar to a study conducted in the United States (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), our study surfaced that the main way doctors relayed information to pharmacists was via electronic medical records (EMR) instead of directly over the phone. This means of communication posed a challenge when doctors made inadequate and inappropriate documentation on the EMR. As pointed out by another study, pharmacists mentioned that their conversations with patients were frequently restricted due to inadequate details regarding patient medical conditions, reasons for prescribed medications, and doctors' treatment strategies (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Should pharmacists need clarification regarding doctors\u0026rsquo; documentation, they would have to call the doctors, leading to the many challenges raised above.\u003c/p\u003e \u003cp\u003eFinally, our study also pointed out that challenges faced in communication between doctors and patients posed barriers to pharmacists\u0026rsquo; management of patients with hypertension. This was observed in two main ways. The first was that doctors sometimes did not elicit patients\u0026rsquo; nonadherence to medications. The phenomenon where patients only reveal their difficulties with medication adherence to pharmacists and not doctors has been highlighted in other studies (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). A systemic review conducted on communication between patients and healthcare professionals revealed that patients might choose not to disclose nonadherence to their doctors out of fear that the doctor might react negatively (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). When our study participants were asked why patients tend not to reveal their medication nonadherence to doctors, some posited that language barriers may have affected doctor‒patient communication. This resulted in a \u0026ldquo;spill-over effect\u0026rdquo;, where lapses in communication translated into more work for the pharmacists who already faced time constraints. Some pharmacists in our study felt that this negatively impacted the care they could provide for their patients, while others viewed this as an important part of their role in the multidisciplinary team as a \u0026ldquo;safety net\u0026rdquo;.\u003c/p\u003e \u003cp\u003eAnother barrier faced would be when doctors provide conflicting advice to patients compared to the advice pharmacists provide to patients. The pharmacists highlighted that the advice they provide was tailored to the patients\u0026rsquo; context to best achieve medication adherence. However, many participants reported that patients tend to trust doctors more than pharmacists and would not even consider the advice given by pharmacists. This raises the issue of trust that patients place in different healthcare professionals. A study in the United Arab Emirates also pointed out that patients tend not to be receptive to the input of pharmacists when compared to that of physicians (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). This limited the role a pharmacist can play in a multidisciplinary team and compromised patient care. More research should be conducted on the underlying beliefs and assumptions the public has of allied healthcare professionals, and interventions should be developed to counter any misconceptions to provide the best multidisciplinary care for all patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights several barriers to communication that pharmacists face when managing patients with hypertension while working in a multidisciplinary team. Communication between pharmacists and patients can be challenging due to patient factors (language barrier and physical disabilities) and clinic factors (medication brand changes, use of video consultations). Barriers to communication between pharmacists and doctors include the existing means of pharmacist intervention (phone calls) being disruptive and ineffective and the prevalence of inadequate and inappropriate documentation on the EMR by doctors. Finally, barriers arising from doctor‒patient communication also impact pharmacists, including when patients do not discuss medication nonadherence with doctors and when conflicting advice is given by doctors. These barriers may have a significant impact on patient safety and healthcare professional satisfaction. Thus, future research should look into ways to address these challenges. The interventions developed need to involve all stakeholders, including pharmacists, doctors, and patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethics approval from the SingHealth Centralised Institutional Review Board (CIRB Ref No: 2022/2168). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable as our study contains no identifiable information or images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to participant and patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was funded by SingHealth AM General Fund (14/FY2021/G2/01-A167), SingHealth Polyclinics, and Duke-NUS Medical School. The funding bodies had no influence on the design of the study, on the collection, analysis or interpretation of the data or on writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCJN conceived the study, conducted the interviews, analysed the data, and critically reviewed the manuscript. RT took field notes during the interviews, checked the transcripts, analysed the data, drafted and revised the manuscript. AK analysed the data and critically reviewed the manuscript. SPO interpreted the data and critically reviewed the manuscript. All authors approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the following for their help: Prof Vikki Entwistle, Chair in Health Services Research and Philosophy at University of Aberdeen, for feedback on the manuscript; all clinics and participants who participated in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet. 2021;398(10304):957\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health Singapore. 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J Interprof Care. 2018;32(5):566\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Barriers, Hypertension, Communication, Pharmacists, Multi-disciplinary team, Primary care","lastPublishedDoi":"10.21203/rs.3.rs-3364572/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3364572/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAs primary care pharmacists take on an increasingly important and collaborative role in managing patients with chronic diseases, communication barriers with patients and healthcare colleagues have emerged. This study aimed to explore the communication barriers faced by pharmacists when managing patients with hypertension in a primary care team.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwelve pharmacists working in five government primary care clinics were interviewed by a researcher using a topic guide. The interviews were audio-recorded, transcribed verbatim and subjected to thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePharmacists\u0026rsquo; management of patients with hypertension was found to be affected by communication challenges at three different levels: between pharmacists and patients, pharmacists and doctors, and doctors and patients. Barriers to communication between pharmacists and patients include language barrier, physical disabilities, medication brand changes, and specific challenges faced during video consultations. Barriers to communication between pharmacists and doctors include lack of access to patient information across institutions on the electronic medical records (EMR), inadequate and inappropriate documentation by doctors, and disruptive and ineffective phone calls by pharmacists to doctors. Barriers to communication between doctors and patients had a spillover effect on pharmacists; these barriers included language barrier, patients not discussing medication nonadherence with doctors, and conflicting advice given by doctors and pharmacists.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe communication barriers pharmacists faced when managing patients with hypertension involved multiple stakeholders. Many of the challenges resulted in patients having difficulty understanding and adhering to their management plan. Effective interventions to foster stronger interprofessional relationships and create a conducive platform of communication should be developed to address these communication barriers.\u003c/p\u003e","manuscriptTitle":"Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-06 20:34:13","doi":"10.21203/rs.3.rs-3364572/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-11-27T04:58:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-20T15:45:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"490953f2-58e8-44ed-ae61-7825c7b6341c","date":"2023-11-15T15:23:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-11-15T13:54:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-10-04T06:35:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-04T05:56:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-01T07:30:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2023-09-18T04:38:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e29022b6-cc73-454d-bd01-6bdc5e224b09","owner":[],"postedDate":"October 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-01T15:11:52+00:00","versionOfRecord":{"articleIdentity":"rs-3364572","link":"https://doi.org/10.1186/s12875-024-02349-w","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2024-03-27 15:01:04","publishedOnDateReadable":"March 27th, 2024"},"versionCreatedAt":"2023-10-06 20:34:13","video":"","vorDoi":"10.1186/s12875-024-02349-w","vorDoiUrl":"https://doi.org/10.1186/s12875-024-02349-w","workflowStages":[]},"version":"v1","identity":"rs-3364572","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3364572","identity":"rs-3364572","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}