Embedding Preventive Cardiac Screening in Supermarkets: A Qualitative Study of Stakeholder Perspectives on Atrial Fibrillation Detection

Embedding Preventive Cardiac Screening in Supermarkets: A Qualitative Study of Stakeholder Perspectives on Atrial Fibrillation Detection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Embedding Preventive Cardiac Screening in Supermarkets: A Qualitative Study of Stakeholder Perspectives on Atrial Fibrillation Detection Robyn R. Lotto, Emma Johnston Smith, Lis Neubeck, Peter E Penson, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6682804/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Atrial fibrillation (AF) often remains undetected due to its asymptomatic nature and limited screening opportunities outside clinical settings. Expanding screening beyond traditional healthcare environments is crucial for improving early detection and outcomes. This study explores the feasibility and acceptability of supermarket-based AF screening from the perspectives of pharmacists and store managers involved in the initiative. Methods: A qualitative study was conducted using semi-structured interviews with pharmacists (n=4), pharmacy technicians (n=4), and store managers (n=7) from four supermarket-based pharmacies in the United Kingdom. Data were analysed using Braun and Clarke’s thematic analysis framework to identify key themes and patterns. Findings: Three key themes were identified: (1) Perceptions of involvement – Participants supported the initiative as an extension of pharmacists’ preventive healthcare role and a civic contribution by supermarkets. (2) Operational successes and challenges – Effective communication facilitated success, but logistical issues such as environmental noise, inconsistent staff communication, and lack of training in pulse assessment were highlighted. (3) Implementation considerations – Suggestions included automating follow-up processes, providing structured training for pharmacists, and ensuring free access to maintain health equity and engagement. Conclusions: Supermarket-based AF screening was viewed as feasible and valuable, with minimal disruption to store operations and positive engagement from staff and customers. Addressing logistical barriers and strengthening pharmacist training are critical for broader implementation. The findings highlight the potential for supermarkets to serve as community health hubs, increasing public access to cardiovascular screening and contributing to early detection and management of chronic conditions. Expanding such models could reduce healthcare inequities and improve population-level health outcomes. Atrial fibrillation screening pharmacists supermarkets public health early detection health inequalities Figures Figure 1 Background Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia globally, with recent estimated overall lifetime risk of approximately 30%. (1) AF significantly increases the risk of adverse cardiovascular events, including a five-fold increase in stroke incidence, (2, 3) a two-fold increase in myocardial infarction, and a heightened likelihood of heart failure.(4) Furthermore, AF has been associated with cognitive decline and dementia, independent of other vascular risk factors. (5) Despite its serious health implications, AF frequently remains undiagnosed due to its asymptomatic presentation and the lack of routine screening in traditional clinical settings, with up to one-third of AF cases identified after a stroke or other major cardiovascular event.(6) Expanding AF screening beyond conventional healthcare environments is therefore essential for improving early detection and reducing the associated health burden,(4) as well as impacting healthcare costs. (7) Screening for AF can be broadly classified into four main approaches: consumer-led, incidental, opportunistic and systematic screening. Consumer-led screening uses personal devices like wearable ECGs and smartphone apps to detect irregular heart rhythms without direct medical oversight. Whilst it has potential to uncover undiagnosed AF, evidence for stroke reduction through this approach remains limited, with the need to integrate consumer-led detection into clinical pathways to ensure accurate diagnosis and appropriate treatment.(8, 9) Incidental screening refers to the identification of AF during medical care for unrelated conditions, such as when an irregular pulse is noted during a routine clinical examination or electrocardiography.(10, 11) Systematic screening, in contrast, involves proactively inviting specific populations at higher risk of AF, such as older adults or individuals with cardiovascular risk factors, to undergo screening.(12) This has demonstrated higher detection rates but requires greater organisational resources and infrastructure. Opportunistic screening represents an extension of these approaches, targeting populations outside traditional healthcare settings, such as pharmacies, care homes, and public events.(13) Studies have demonstrated the effectiveness of these community-based screening in increasing detection rates and improving early management of AF.(6) In particular, pharmacy-based screening has been effective due to the accessibility of pharmacists and the established trust within these communities.(14) Supermarket-based opportunistic screening offers a further extension of this model, leveraging high footfall and regular customer engagement to provide a low-barrier method of detection. (15) Embedding ECGs into supermarket trolley handles represents an innovative approach to AF screening during routine shopping, with the potential to reach underserved populations, particularly those who face barriers to accessing traditional healthcare services. (16) Research has shown that individuals from lower socioeconomic backgrounds and minority ethnic groups are less likely to engage with preventive healthcare but are more likely to experience adverse outcomes from AF.(17) By embedding AF detection into routine shopping, this approach could increase early detection rates and improve health equity. (15) This study investigates the feasibility and acceptability of supermarket-based AF screening, focusing on the perspectives of pharmacists and store managers involved in its implementation. Understanding the experiences and insights of staff directly involved in the process is essential for optimising the operational efficiency of the programme and identifying potential barriers to wider adoption. The findings will inform the development of sustainable models for community-based AF screening and contribute to the growing evidence base on the role of non-clinical settings in cardiovascular health promotion. Aim To understand the views of supermarket-based pharmacists and store managers about the merits of embedding pulse sensors in the handles of supermarket trolleys to enable the detection of AF. Study Design This study employed a qualitative design to explore the feasibility and acceptability of supermarket-based AF screening to gain in-depth insights into the experiences and perceptions of pharmacists and store managers. Semi-structured interviews were conducted with a purposive sample of participants from four supermarket locations where a feasibility study had been undertaken. (15) Data were transcribed verbatim and analysed using Braun and Clarke’s (18) thematic analysis framework, which facilitated the identification of patterns and themes. This design enabled a comprehensive understanding of the operational, logistical, and social factors influencing the implementation of supermarket-based AF screening. Sample Pharmacists and store managers from each of the four supermarkets were invited to participate in a qualitative interview. Store managers were defined as any manager with responsibility for managing the store during the study period. Pharmacists were defined as General Pharmaceutical Council (GPhC) registered pharmacists. Store pharmacists were trained to assess pulse rhythm and provided with information regarding the project by the project lead but it was subsequently clear that pharmacists were regularly required to move between stores to cover sickness. This meant that on some occasions the pharmacists on duty were unfamiliar with the study and their role. Support was provided by the project team and the pharmacy technicians. It therefore seemed reasonable to explore the views of the technicians. Eligibility criteria All participants were able to provide written informed consent and devote time to attend the interview. The exclusion criteria included previous participation in the study in the event of a store manager or pharmacist transferring to a neighbouring store during the study period, and absence from the store during recruitment times. Recruitment A purposive sample including store managers, GPhC registered pharmacy technicians and pharmacists working in the supermarket during the study period (08-2021 to 04-2022) were recruited. The overall supermarket manager was responsible for identifying staff with responsibility for store management during the study and the pharmacists were identified centrally through Lloyds chemist. Fifteen participants including pharmacists (n=4), pharmacy technicians (n=4) and store managers (n=7) were recruited from across the four stores. All participants had been directly involved in the SHOPS-AF study, (15) either as the duty manager during data collection periods, or as the pharmacist reviewing participants who presented with an irregular heart rate or pharmacy technicians who were present during the study. Ethics Ethical approval and sponsorship were granted by Liverpool John Moores University's University Research Ethics Committee (21/NAH/001). All eligible participants received information about the study outlining the purpose, potential risks and implications of participation with written informed consent obtained. Analysis Thematic analysis using the qualitative data generated from the interviews with pharmacists, pharmacy technicians and store managers were independently analysed by two members of the research team (RL, IJ) adopting Braun and Clarke’s framework for thematic analysis. (18) NVivo software was used to organize and code the data. Findings The findings are presented generically across three themes: ‘ perceptions on involvement’ , highlighting the participants varying perception of the concept; ‘ operational successes and challenges , identifying things that worked well and what was problematic, and how processes were implemented to fit into practice; and ‘ implementation considerations’ , where participants identified areas that would require consideration should the pilot be extended (see Figure 1). Perceptions on involvement The concept of the programme was universally applauded, with the interviewees also highlighting a general acceptance and engagement by shoppers. I thought it was a really good idea, and I was surprised how many people came and picked up on it. So yeah, it’s really good….. D1 The preventative nature of the study was highlighted as particularly important by the pharmacists, with the study aims perceived as fitting clearly within their role remit. taking a treatment style to a preventative style… looking at the community and preventing anything before it causes any ill health to that patient or extra load on the NHS…it really contributes significantly to again in general the wellbeing of the population. P1 Managers suggested the innovation was a civic duty (M1) owed by the supermarkets to their local community, stressing the importance of community engagement. This is a really good way of supporting the community. It’s really important. M1 With a high prevalence of heart disease within the geographical area, it was perhaps unsurprising that several participants had been personally affected, or knew someone, who had developed cardiovascular disease. We had a colleague who died over at ***** . He had a massive heart attack. They managed to raise money for a defib over there after that. M2 From a practical perspective, the study had little impact on pre-existing duties and responsibilities. Although the pharmacy could be busy, the pharmacists and dispensers felt that the requirements of the checks did not take long, and with relatively low numbers of people identified with suspected AF, had little impact on standard duties. I haven't seen load of patients, because it’s only flagged for the occasional patient. And when I've had to see that patient, it’s been, five minutes, 10 minutes where, we’ve done an assessment ……I wouldn’t say it’s impacting me too much in terms of workload P2 For most managers, the impact of the screening on the business was negligible, It didn’t really impact on us at all. To be honest, most of the time I wouldn’t have known that they were even here. M6 This was in part due to the self-contained, independent nature of the pharmacy units. We deal with their cash and such like, but they are self-contained. We don’t have anything to do with the pharmacy aspect at all. M7 . Operational Successes and Challenges The interview participants were asked to discuss what they felt had worked well. Effective communication was seen as key to success; ensuring that the process was clear to all involved and preventing undue anxiety should an irregular heart rate be identified. it’s just making sure that the communication is, consistent… to make sure we don’t raise anxiety and to make sure the people understand that this is what we’re out to find, and if you do, if we do find it, it’s not the end of the world basically, P1 Most of the problems highlighted by store managers appeared to arise from logistical issues arising from poor communication. On occasions, this meant that even though the regional management team were aware of the study, the supermarket staff were not always expecting the study team. it was a bit of a comms failure. Two sites knew and the others didn’t, so we found when they [research team] landed. We had to check they were kosher and then it came up on our activity app, so that confirmed things M2 Arriving in a clinical uniform helped, and was perceived as key, not only in terms of making them identifiable to staff, but also in demonstrating the authenticity of the innovation. The study staff were seen as an indispensable part of the process. Having them here all in uniform, that was really good because it made it look really professional. And they were smart, and it looked like it was something, you know, real rather than anything else. So, that was really, really helpful. M3 Pharmacists highlighted more practical issues, particularly around busy environments and noise. Clinical rooms were generally very small, and often constructed with temporary walls and no ceiling, meaning that the sounds from the hustle and bustle of the supermarket could not be escaped. In terms of a manual assessment of AF, it’s been a bit more tricky in terms of verifying what the monitors picked up in the first place, just with general surroundings, obviously, in a consultation room, it’s a bit noisy and you’re trying to sort of focus on pulse rates. P2 Furthermore, it was highlighted that manual assessment of AF is not taught as standard to pharmacists. However, in the last few years, the clinical content of MPharm degree programmes has substantially increased recently, as pharmacists qualifying from 2026 will be prescribers at the point of registration. This is likely to impact on clinical skills. In addition, frequent transfer of staff between sites/stores to cover short term absence meant that some staff arrived at a study site with little knowledge of the study and requirements. A broad training package would therefore be a requirement to rolling out the programme. and…but I think if you went to the general Pharmacist population, I’m not sure many would…it’s not something you get trained to do as part of it so, I think that, as long as there was a training package and an awareness of what to look for. P1 A general concern expressed was that of the impact on the shopper, and how an unexpected finding of AF would be managed. I think sometimes what didn’t help on the negative side was, people have come to do their shopping, and just agreed to do a survey of where they thought nothing was bad and then, when they presented the Pharmacy, they were quite anxious going “Oh my God, I've just been told I’ve, I might have Atrial Fibrillation”. P3 Pharmacists felt that they were ideally positioned to support patients who were identified with an irregular heart rhythm, with communication being an integral part of their role. we’re trained in face-to-face communication and body language…... A lot of them were accepting, but there were some that were anxious and concerned that it was almost like they’ve found a life changing thing, which to some people, that’s a nightmare……it’s sometimes difficult to transfer that message. P1 This evaluation was undertaken during the COVID-19 pandemic, although not during a period of lockdown. The impact of this on the study was highlighted, in particular in relation to staffing. Well we usually have 3 or 4 of us around. Problem at the moment is we have around 10-12 colleagues off self-isolating. M4 Similarly, pharmacists found themselves transferred to other stores, and with an increased use of locums. This meant that staff on duty may not have received the training that was provided or have been aware of the study. Yes, staffing has been a bit of an issue, and our regular pharmacist hasn’t been in so we’ve been relying on locums. M3 Considerations for Broader Implementation The main issue with expanding the innovation across supermarkets was perceived to be trained personnel, with the role of the research assistants on the ground seen as indispensable in the success of the study. I’m not sure that we would have the skills or time to be able to take over some of those extra jobs, so it would really have to be something that was automated. M5 Suggestions for the expansion of the programme included the need to replace fleets of trolleys with study trolleys, with greater reliance on technology to redirect the shopper to the pharmacy should an irregular HR be identified. Operationally it worked really well as it was, but that wouldn’t work long term. If you replaced my whole fleet of trolleys then the shoppers would have to use the device. We could add something at the till to redirect them to pharmacy…. or a QR code on each trolley so they can download their readings. M1 The demographics of the target population were identified as potentially problematic in relation to a move towards a technological solution, with the older generation perceived as less tech savvy, but at higher intrinsic risk of having AF. Yeah, of course, and I guess, you know, often it’s the older generation as well who don’t, which I guess would make things quite difficult. But I think the younger generation are more intrigued by technology in that way and would probably be really, really interested. M2 Similar concerns were highlighted by the Pharmacists This has only worked because, someone’s been there to guide them to the Pharmacy and I suppose it’s, when you take that away, how, how’s it going to work. P4 Ensuring that shoppers who were flagged up as potentially having AF sought help and were followed up was perceived as key to successfully rolling out the programme. whereas a lot of people might pick it up, it might tell them they've got AF and they’ll just walk out and go, and it’s getting that footfall through to make sure it is followed up, I think that’s the key. P1 More generally, the risk of commercialising the programme was highlighted, with both pharmacists and technicians expressing concern over potential charges and the resulting impact on uptake, as has happened for other screening services offered within pharmacies. most of them are paid for, like blood pressure, the blood glucose, you’ve got to pay for it. The only time you get it is the online doctor for your pill, or fat loss. I feel sorry for them, because a lot of them are old and they’re like, ‘£8.50!’ D1 In addition, many appreciated the influence of deprivation, with those least able to afford access to screening and monitoring such as blood pressure or glucose checks, often those most in need. I guess we’ve got all the issues with deprivation as well, haven’t we, in terms of your poorer patients are the ones who are most likely to have a problem. D2 Reflecting on the experience of being a participation site, pharmacists and technicians highlighted the positive impact on job satisfaction: first being able to offer free screening thereby creating opportunities to engage with regular customers; and second getting to hear about the outcomes to participants, both in terms of screening, but also follow up. … Yeah, it is, yeah. And some of them are regulars, and I was like, ‘Oh hi, Mr So-and-So’, so they felt comfortable and … so yeah, it’s really good. D1 it was just a standard Pharmacy service, we would refer on and then not really know what happens to that patient, because there’s no feedback mechanism, whereas this is a more rounded service as it were. P1 Discussion This study highlights the feasibility and acceptability of supermarket-based AF screening, supported by pharmacists, pharmacy technicians, and store managers. Supermarkets were seen as promising community health hubs, enhancing access to cardiovascular care. Three key themes were identified: perceptions on involvement where engagement with the initiative was widely viewed as part of pharmacists' public health role; operational challenges included issues such as noise and training gaps; and implementation needs including structured training, automated follow-up, and equitable access. The findings support the growing role of pharmacists in preventive care and to inform future community-based screening strategies. Pharmacists are increasingly recognised as key contributors to CVD management due to their accessibility and expertise in medication management, patient education, and lifestyle counselling. ( 19 – 21 ) Their involvement in preventive care has been shown to improve health outcomes, particularly in managing hypertension, diabetes, and dyslipidaemia, ( 20 ) as well as AF. ( 22 ) This has gradually been expanded into supermarket settings, where it presents a valuable opportunity to enhance public health by increasing access to early detection and health interventions. As of March 2022, the UK housed 14,370 registered pharmacy premises, with around 40% operated by larger entities, including supermarket chains. ( 23 ) Pharmacy-led health interventions can offer structured support that helps eliminate common implementation challenges, such as environmental constraints and staff training needs. By leveraging the established trust in pharmacists’ roles within healthcare, these initiatives are well positioned to create supportive frameworks that directly address and mitigate these barriers. ( 24 , 25 ) Recent prescribing guidelines and healthcare policies in the UK increasingly direct the public toward community pharmacies for treatment of minor conditions and access to prescription medications. Under initiatives such as Pharmacy First, ( 26 ) pharmacists are now empowered to offer clinical advice and prescribe for common ailments like sore throats, urinary tract infections, and earaches without the need for a GP appointment. This shift aims to reduce pressure on general practice, improve access to timely care, and make better use of pharmacists’ clinical expertise, positioning pharmacies as accessible front-line healthcare providers within local communities. Technological advancements present opportunities to enhance the efficiency and scalability of these interventions. Digital tools such as automated notifications, QR code-based referral systems, and electronic health records could streamline processes and improve follow-up care. ( 27 ) However, digital literacy, particularly among older adults, remains a challenge. ( 28 ) A hybrid model combining automated systems with personalised support could help to address this issue and ensure that interventions remain accessible to all demographic groups. Ensuring equitable access to these services is essential to maximising the public health impact. Supermarket-based health interventions have the potential to reach underserved populations, thereby reducing health disparities. ( 29 , 30 ) Access to preventive health services, including screening programs, is notably lower among underserved populations with barriers such as transportation difficulties, financial constraints, and long waiting lists disproportionately affecting these individuals. ( 31 ) Paid screening services have been linked to lower uptake rates among low-income populations. ( 32 ) Fostering a culture of innovation and providing sustainable funding models are essential to support the adoption of digital health technologies while ensuring equitable access. ( 33 ) Furthermore, aligning healthcare policies to respond to patient priorities and integrating user-centred design in digital health initiatives can enhance the scalability and effectiveness of interventions. Strong partnerships among stakeholders, scalable technologies, and policy alignment are critical components in overcoming barriers to technology dissemination and adoption. ( 34 ) Effective implementation will require strategic coordination between public health authorities, retailers, and pharmacy professionals to establish clear guidelines and funding mechanisms. Collaborative partnerships will be essential to scaling these interventions effectively and aligning them with broader public health objectives. Follow-up via primary or secondary care to confirm AF diagnosis and initiation of treatment, where appropriate is essential. Integrating supermarket-based screening initiatives into existing health strategies could enhance early detection and management of CVD, contributing to improved population health outcomes. ( 32 ) Recommendations Supermarket based AF screening is a feasible means of identifying people with asymptomatic AF which is valued and acceptable by participants and supermarket and pharmacy staff. However, the transient nature of the in-store pharmacists increases the training needs and may limit a pharmacy’s ability to deliver a screening service as part of their routine practice. Upskilling pharmacy technicians may provide a more realistic and sustainable service model. Alternatively, an adjunctive mobile service delivered solely by advanced healthcare staff with immediate clinical review for those identified as experiencing AF may provide an effective one-stop AF model of care that negates the need for hospital referral. Conclusions Supermarket managers, pharmacists, and pharmacy technicians evaluated the project positively, with minimal impact on workload. However, concerns were raised about staffing capacity to manage trolleys and guide shoppers to the pharmacy for follow-up, highlighting the need for practical adjustments. Training gaps were also noted, as pharmacist turnover and reliance on locums meant that pharmacy technicians and the research team often provided guidance. Involving a broader pharmacy team was recommended to ensure continuity and effective response when AF was identified. Both pharmacy and supermarket staff supported the service, viewing it as part of the supermarket's civic duty and an extension of the pharmacist’s public health role. Integrating pharmacist-led health interventions into supermarkets offers a promising strategy to improve health outcomes and prevent cardiovascular diseases. Addressing challenges related to staffing, training, infrastructure, and equitable access will be key to the successful implementation and sustainability of these initiatives. Declarations Abbreviations Not applicable Ethics approval and consent to participate Ethical approval and sponsorship were granted by Liverpool John Moores University's University Research Ethics Committee (21/NAH/001). All eligible participants received information about the study outlining the purpose, potential risks and implications of participation with written informed consent obtained. Consent for publication Consent for publication granted by all authors Authors contributions RL, IJ, LN, PP,AS, GL, DL, EJS - conception and design of the project RL data acquisition RL and IJ reviewed transcripts RL, IJ, LN, PP,AS, GL, DL, EJS - supported analysis RL drafted main manuscript text RL, IJ, LN, PP,AS, GL, DL, EJS - reviewed and corrected manuscript RL, IJ, LN, PP,AS, GL, DL, EJS - reviewed submitted version Acknowledgements We would like to thank Bristol Myers Squibb for funding the project. We would also like to acknowledge the support of Sainsbury’s supermarkets who allowed us to use the stores to recruit participants. Finally, we would like to thank Lloyds Pharmacy whose pharmacists contributed to the project both in terms of their time and professional expertise. Funding The authors would like to thank Bristol Myers Squibb for their financial support (funding number REQ-0000022262), which has enabled this novel study to be undertaken. Dataset The datasets generated and analysed during the current study are not publicly available as consent was not sought for public sharing. Conflicts of interest Robyn R Lotto is a co-applicant on the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research & Innovation programme. Deirdre A. Lane received investigator‐initiated educational grants from Bristol‐Myers Squibb and Pfizer; all outside the submitted work. She is a co-applicant on the AFFIRMO project on multimorbidity in AF (Grant Agreement No. 899871), ARISTOTELES project on artificial intelligence for management of chronic long-term conditions (Grant Agreement No. 101080189), and the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research & Innovation programme. Gregory Lip is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and Co-Principal Investigator of the AFFIRMO project on multimorbidity in AF, funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 899871. References Vinter N, Cordsen P, Johnsen SP, Staerk L, Benjamin EJ, Frost L, et al. Temporal trends in lifetime risks of atrial fibrillation and its complications between 2000 and 2022: Danish, nationwide, population based cohort study. BMJ. 2024;385:e077209. Odutayo A, Wong CX, Hsiao AJ, Hopewell S, Altman DG, Emdin CA. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and meta-analysis. bmj. 2016;354. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. stroke. 1991;22(8):983-8. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. Kalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: a meta-analysis. Annals of internal medicine. 2013;158(5_Part_1):338-46. Freedman B, Potpara TS, Lip GY. Stroke prevention in atrial fibrillation. The Lancet. 2016;388(10046):806-17. Burdett P, Lip GY. Targeted vs. full population screening costs for incident atrial fibrillation and AF-related stroke for a healthy population aged 65 years in the United Kingdom. European Heart Journal-Quality of Care and Clinical Outcomes. 2022;8(8):892-8. Brandes A, Stavrakis S, Freedman B, Antoniou S, Boriani G, Camm AJ, et al. Consumer-led screening for atrial fibrillation: frontier review of the AF-SCREEN international collaboration. Circulation. 2022;146(19):1461-74. Boriani G, Schnabel RB, Healey JS, Lopes RD, Verbiest-van Gurp N, Lobban T, et al. Consumer-led screening for atrial fibrillation using consumer-facing wearables, devices and apps: a survey of health care professionals by AF-SCREEN international collaboration. European journal of internal medicine. 2020;82:97-104. Kalarus Z, Mairesse GH, Sokal A, Boriani G, Średniawa B, Casado-Arroyo R, et al. Searching for atrial fibrillation: looking harder, looking longer, and in increasingly sophisticated ways. An EHRA position paper. Europace. 2023;25(1):185-98. Mairesse G, Moran P, van Gelder I, Elsner C, Rosenqvist M, Mant J, et al. Screening for atrial fibrillation. Europace. 2017. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation. 2015;131(25):2176-84. Lowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation. Thrombosis and haemostasis. 2013;110(08):213-22. Valliant SN, Burbage SC, Pathak S, Urick BY. Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm. 2022;28(1):85-90. Jones ID, Lane DA, Lotto RR, Oxborough D, Neubeck L, Penson PE, et al. Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF) using sensors embedded in the handles of supermarket trolleys: A feasibility study. American Heart Journal. 2024;271:164-77. Jones ID, Lane DA, Lotto RR, Oxborough D, Neubeck L, Penson PE, et al. Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF): A mixed methods feasibility study protocol. Journal of Personalized Medicine. 2022;12(4):578. Essien UR, Holmes DN, Jackson LR, Fonarow GC, Mahaffey KW, Reiffel JA, et al. Association of race/ethnicity with oral anticoagulant use in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. JAMA cardiology. 2018;3(12):1174-82. Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. Handbook of Research Methods in Health Social Sciences. 2019:843-60. Santschi V, Chiolero A, Paradis G, Colosimo AL, Burnand B. Pharmacist interventions to improve cardiovascular disease risk factors in diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes care. 2012;35(12):2706-17. Cheema E, Sutcliffe P, Singer DR. The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta‐analysis of randomized controlled trials. British journal of clinical pharmacology. 2014;78(6):1238-47. Rattanavipanon W, Chaiyasothi T, Puchsaka P, Mungkornkaew R, Nathisuwan S, Veettil SK, et al. Effects of pharmacist interventions on cardiovascular risk factors and outcomes: An umbrella review of meta-analysis of randomized controlled trials. British Journal of Clinical Pharmacology. 2022;88(7):3064-77. Ritchie LA, Penson PE, Akpan A, Lip GY, Lane DA. Integrated care for atrial fibrillation management: the role of the pharmacist. The American Journal of Medicine. 2022;135(12):1410-26. Christie&Co. Pharmacy Market Review 2022. Available at: https://www.christie.com/news-resources/press-releases/report-launch-pharmacy-market-review-2022/2022 [Accessed 15 April 2025] Milosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients’ medication adherence and other health outcomes: a systematic review. International Journal of Pharmacy Practice. 2018;26(5):387-97. Ahmed A, Guo P, Jalal Z. A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation. International Journal of Clinical Pharmacy. 2023;45(2):320-9. NHSEngland. Pharmacy First Available at: https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-services/pharmacy-first/2024 [Accessed 10 March 2025] Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ digital medicine. 2020;3(1):17. Mitzner TL, Savla J, Boot WR, Sharit J, Charness N, Czaja SJ, et al. Technology adoption by older adults: Findings from the PRISM trial. The Gerontologist. 2019;59(1):34-44. Pringle JL, Boyer A, Conklin MH, McCullough JW, Aldridge A. The Pennsylvania Project: pharmacist intervention improved medication adherence and reduced health care costs. Health Affairs. 2014;33(8):1444-52. Boyer B, Huber K, Zimlichman E, Saunders R, McClellan M, Kahn C, et al. Advancing the future of equitable access to health care: recommendations from international health care leaders. Health Affairs Scholar. 2024;2(8). Sakellariou D, Rotarou ES. Access to healthcare for men and women with disabilities in the UK: secondary analysis of cross-sectional data. BMJ Open. 2017;7(8):e016614. Escaron AL, Meinen AM, Nitzke SA, Martinez-Donate AP. Supermarket and grocery store–based interventions to promote healthful food choices and eating practices: a systematic review. Preventing chronic disease. 2013;10:E50. Ahmad B, Landes D, Moffatt S. Dental Public Health In Action: Barriers to oral healthcare provision for older people in residential and nursing care homes: A mixed method evaluation and strategy development in County Durham, North East England. Community dental health. 2018. Aug;35(03):136-9. Phillips KA, Marshall DA, Adler L, Figueroa J, Haeder SF, Hamad R, et al. Ten health policy challenges for the next 10 years. Health Affairs Scholar. 2023;1(1). Additional Declarations Competing interest reported. Robyn R Lotto is a co-applicant on the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research & Innovation programme. Deirdre A. Lane received investigator‐initiated educational grants from Bristol‐Myers Squibb and Pfizer; all outside the submitted work. She is a co-applicant on the AFFIRMO project on multimorbidity in AF (Grant Agreement No. 899871), ARISTOTELES project on artificial intelligence for management of chronic long-term conditions (Grant Agreement No. 101080189), and the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research & Innovation programme. Gregory Lip is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and Co-Principal Investigator of the AFFIRMO project on multimorbidity in AF, funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 899871. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 23 Jun, 2025 Editor assigned by journal 16 Jun, 2025 Editor invited by journal 28 May, 2025 Submission checks completed at journal 27 May, 2025 First submitted to journal 27 May, 2025 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6682804","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475524449,"identity":"6a0daa73-60aa-4eb8-99eb-f6282208af27","order_by":0,"name":"Robyn R. Lotto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYLCCByCCvbnBAMpnJqwlgcFAgoHnIMlaJBIbYHz8WswbeB8wJFT8qeOXfNhQdLONQZ6/gcfYAJ8WmQPsBgwJZwwkJGcnNhjntjEYzjjAY5yAT4sEAxsDQ2KbgYTBbYgWxg0MPMYHiNNy8yBYiz0JWm4wgrUkgrTgdxgzG8OBhDPGkjN7gA7LOSeRPOMwWzFe70uwtzE++FAhx8/PfviYcU6ZjW1/e/NmCXxaQHEAczmbAcihxEQkQvcDEhSPglEwCkbBCAIAq0w7FZ/7LlkAAAAASUVORK5CYII=","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":true,"prefix":"","firstName":"Robyn","middleName":"R.","lastName":"Lotto","suffix":""},{"id":475524450,"identity":"3ee7c599-544d-4c56-a78a-d09209bd114a","order_by":1,"name":"Emma Johnston Smith","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"Johnston","lastName":"Smith","suffix":""},{"id":475524452,"identity":"af0dd6de-aa67-4aaa-8092-b63afb72678a","order_by":2,"name":"Lis Neubeck","email":"","orcid":"","institution":"Edinburgh Napier University","correspondingAuthor":false,"prefix":"","firstName":"Lis","middleName":"","lastName":"Neubeck","suffix":""},{"id":475524453,"identity":"e2196f8a-d1b7-4868-b210-0a532568d839","order_by":3,"name":"Peter E Penson","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"E","lastName":"Penson","suffix":""},{"id":475524454,"identity":"cc685a6d-9337-4782-9fd3-0916b83dd9e5","order_by":4,"name":"Andy Shaw","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Andy","middleName":"","lastName":"Shaw","suffix":""},{"id":475524455,"identity":"1429be4c-64a2-4716-8f01-0a53051ef588","order_by":5,"name":"Gregory Y.H. Lip","email":"","orcid":"","institution":"University of Liverpool","correspondingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"Y.H.","lastName":"Lip","suffix":""},{"id":475524456,"identity":"b34ab8a4-1f2f-40a1-bd85-7ed8c9be9de2","order_by":6,"name":"Ian D. Jones","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"D.","lastName":"Jones","suffix":""},{"id":475524457,"identity":"88c441ca-a733-4a8a-86c5-dd2f60a06237","order_by":7,"name":"Deirdre Lane","email":"","orcid":"","institution":"University of Liverpool","correspondingAuthor":false,"prefix":"","firstName":"Deirdre","middleName":"","lastName":"Lane","suffix":""}],"badges":[],"createdAt":"2025-05-16 17:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6682804/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6682804/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85642854,"identity":"9556fb23-1389-47ca-9d74-dc4c134dd8ab","added_by":"auto","created_at":"2025-06-30 08:04:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":168053,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003esummary of findings\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6682804/v1/5c36333809258cc741427af3.png"},{"id":85644463,"identity":"2389590e-cebb-4538-8690-eb2ad37b5de5","added_by":"auto","created_at":"2025-06-30 08:12:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":680745,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6682804/v1/87ae6171-a6c0-4365-8b57-270077cb41a9.pdf"}],"financialInterests":"Competing interest reported. Robyn R Lotto is a co-applicant on the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research \u0026 Innovation programme.\n\nDeirdre A. Lane received investigator‐initiated educational grants from Bristol‐Myers Squibb and Pfizer; all outside the submitted work. She is a co-applicant on the AFFIRMO project on multimorbidity in AF (Grant Agreement No. 899871), ARISTOTELES project on artificial intelligence for management of chronic long-term conditions (Grant Agreement No. 101080189), and the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research \u0026 Innovation programme.\nGregory Lip is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and Co-Principal Investigator of the AFFIRMO project on multimorbidity in AF, funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 899871.","formattedTitle":"Embedding Preventive Cardiac Screening in Supermarkets: A Qualitative Study of Stakeholder Perspectives on Atrial Fibrillation Detection","fulltext":[{"header":"Background","content":"\u003cp\u003eAtrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia globally, with recent estimated overall lifetime risk of approximately 30%. (1) AF significantly increases the risk of adverse cardiovascular events, including a five-fold increase in stroke incidence, (2, 3)\u0026nbsp; a two-fold increase in myocardial infarction, and a heightened likelihood of heart failure.(4) Furthermore, AF has been associated with cognitive decline and dementia, independent of other vascular risk factors. (5)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite its serious health implications, AF frequently remains undiagnosed due to its asymptomatic presentation and the lack of routine screening in traditional clinical settings, with up to one-third of AF cases identified after a stroke or other major cardiovascular event.(6) Expanding AF screening beyond conventional healthcare environments is therefore essential for improving early detection and reducing the associated health burden,(4) as well as impacting healthcare costs. (7)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScreening for AF can be broadly classified into four main approaches: consumer-led, incidental, opportunistic and systematic screening. Consumer-led screening uses personal devices like wearable ECGs and smartphone apps to detect irregular heart rhythms without direct medical oversight. Whilst it has potential to uncover undiagnosed AF, evidence for stroke reduction through this approach remains limited, with the need to integrate consumer-led detection into clinical pathways to ensure accurate diagnosis and appropriate treatment.(8, 9) Incidental screening refers to the identification of AF during medical care for unrelated conditions, such as when an irregular pulse is noted during a routine clinical examination or electrocardiography.(10, 11) Systematic screening, in contrast, involves proactively inviting specific populations at higher risk of AF, such as older adults or individuals with cardiovascular risk factors, to undergo screening.(12) This has demonstrated higher detection rates but requires greater organisational resources and infrastructure. Opportunistic screening represents an extension of these approaches, targeting populations outside traditional healthcare settings, such as pharmacies, care homes, and public events.(13)\u0026nbsp; Studies have demonstrated the effectiveness of these community-based screening in increasing detection rates and improving early management of AF.(6) In particular, pharmacy-based screening has been effective due to the accessibility of pharmacists and the established trust within these communities.(14) Supermarket-based opportunistic screening offers a further extension of this model, leveraging high footfall and regular customer engagement to provide a low-barrier method of detection. (15)\u003c/p\u003e\n\u003cp\u003eEmbedding ECGs into supermarket trolley handles represents an innovative approach to AF screening during routine shopping, with the potential to reach underserved populations, particularly those who face barriers to accessing traditional healthcare services. (16) Research has shown that individuals from lower socioeconomic backgrounds and minority ethnic groups are less likely to engage with preventive healthcare but are more likely to experience adverse outcomes from AF.(17)\u0026nbsp; By embedding AF detection into routine shopping, this approach could increase early detection rates and improve health equity. (15)\u003c/p\u003e\n\u003cp\u003eThis study investigates the feasibility and acceptability of supermarket-based AF screening, focusing on the perspectives of pharmacists and store managers involved in its implementation. Understanding the experiences and insights of staff directly involved in the process is essential for optimising the operational efficiency of the programme and identifying potential barriers to wider adoption. The findings will inform the development of sustainable models for community-based AF screening and contribute to the growing evidence base on the role of non-clinical settings in cardiovascular health promotion.\u003c/p\u003e\n\u003ch1\u003eAim\u0026nbsp;\u003c/h1\u003e\n\u003cp\u003eTo understand the views of supermarket-based pharmacists and store managers about the merits of embedding pulse sensors in the handles of supermarket trolleys to enable the detection of AF.\u003c/p\u003e\n\u003ch1\u003eStudy Design\u003c/h1\u003e\n\u003cp\u003eThis study employed a qualitative design to explore the feasibility and acceptability of supermarket-based AF screening to gain in-depth insights into the experiences and perceptions of pharmacists and store managers. Semi-structured interviews were conducted with a purposive sample of participants from four supermarket locations where a feasibility study had been undertaken. (15) Data were transcribed verbatim and analysed using Braun and Clarke’s (18) thematic analysis framework, which facilitated the identification of patterns and themes. This design enabled a comprehensive understanding of the operational, logistical, and social factors influencing the implementation of supermarket-based AF screening.\u003c/p\u003e\n\u003ch2\u003eSample\u003c/h2\u003e\n\u003cp\u003ePharmacists and store managers from each of the four supermarkets were invited to participate in a qualitative interview. Store managers were defined as any manager with responsibility for managing the store during the study period. Pharmacists were defined as General Pharmaceutical Council (GPhC) registered pharmacists. Store pharmacists were trained to assess pulse rhythm and provided with information regarding the project by the project lead but it was subsequently clear that pharmacists were regularly required to move between stores to cover sickness. This meant that on some occasions the pharmacists on duty were unfamiliar with the study and their role. Support was provided by the project team and the pharmacy technicians. It therefore seemed reasonable to explore the views of the technicians.\u003c/p\u003e\n\u003ch2\u003eEligibility criteria\u003c/h2\u003e\n\u003cp\u003eAll participants were able to provide written informed consent and devote time to attend the interview. The exclusion criteria included previous participation in the study in the event of a store manager or pharmacist transferring to a neighbouring store during the study period, and absence from the store during recruitment times.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eRecruitment\u003c/h2\u003e\n\u003cp\u003eA purposive sample including store managers, GPhC registered pharmacy technicians and pharmacists working in the supermarket during the study period (08-2021 to 04-2022) were recruited. The overall supermarket manager was responsible for identifying staff with responsibility for store management during the study and the pharmacists were identified centrally through Lloyds chemist. \u0026nbsp;Fifteen participants including pharmacists (n=4), pharmacy technicians (n=4) and store managers (n=7) were recruited from across the four stores. All participants had been directly involved in the SHOPS-AF study, (15) either as the duty manager during data collection periods, or as the pharmacist reviewing participants who presented with an irregular heart rate or pharmacy technicians who were present during the study.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthics\u003c/h2\u003e\n\u003cp\u003eEthical approval and sponsorship were granted by Liverpool John Moores University's University Research Ethics Committee (21/NAH/001). All eligible participants received information about the study outlining the purpose, potential risks and implications of participation with written informed consent obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThematic analysis using the qualitative data generated from the interviews with pharmacists, pharmacy technicians and store managers were independently analysed by two members of the research team (RL, IJ) adopting Braun and Clarke’s framework for thematic analysis. (18) NVivo software was used to organize and code the data.\u003c/p\u003e\n\u003ch1\u003eFindings\u003c/h1\u003e\n\u003cp\u003eThe findings are presented generically across three themes: ‘\u003cem\u003eperceptions on involvement’\u003c/em\u003e, highlighting the participants varying perception of the concept; ‘\u003cem\u003eoperational successes and challenges\u003c/em\u003e, identifying things that worked well and what was problematic, and how processes were implemented to fit into practice; and ‘\u003cem\u003eimplementation considerations’\u003c/em\u003e, where participants identified areas that would require consideration should the pilot be extended (see Figure 1).\u003c/p\u003e\n\u003ch2\u003ePerceptions on involvement\u003c/h2\u003e\n\u003cp\u003eThe concept of the programme was universally applauded, with the interviewees also highlighting a general acceptance and engagement by shoppers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI thought it was a really good idea, and I was surprised how many people came and picked up on it. \u0026nbsp;So yeah, it’s really good….. \u0026nbsp;D1\u003c/p\u003e\n\u003cp\u003eThe preventative nature of the study was highlighted as particularly important by the pharmacists, with the study aims perceived as fitting clearly within their role remit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003etaking a treatment style to a preventative style… looking at the community and preventing anything before it causes any ill health to that patient or extra load on the NHS…it really contributes significantly to again in general the wellbeing of the population. P1\u003c/p\u003e\n\u003cp\u003eManagers suggested the innovation was a \u003cem\u003ecivic duty\u003c/em\u003e (M1) owed by the supermarkets to their local community, stressing the importance of community engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis is a really good way of supporting the community. It’s really important. \u0026nbsp;M1\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith a high prevalence of heart disease within the geographical area, it was perhaps unsurprising that several participants had been personally affected, or knew someone, who had developed cardiovascular disease.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe had a colleague who died over at \u0026nbsp;***** . He had a massive heart attack. They managed to raise money for a defib over there after that. \u0026nbsp;M2\u003c/p\u003e\n\u003cp\u003eFrom a practical perspective, the study had little impact on pre-existing duties and responsibilities. Although the pharmacy could be busy, the pharmacists and dispensers felt that the requirements of the checks did not take long, and with relatively low numbers of people identified with suspected AF, had little impact on standard duties.\u003c/p\u003e\n\u003cp\u003eI haven't seen load of patients, because it’s only flagged for the occasional patient. And when I've had to see that patient, it’s been, five minutes, 10 minutes where, we’ve done an assessment ……I wouldn’t say it’s impacting me too much in terms of workload \u0026nbsp;P2\u003c/p\u003e\n\u003cp\u003eFor most managers, the impact of the screening on the business was negligible,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt didn’t really impact on us at all. \u0026nbsp;To be honest, most of the time I wouldn’t have known that they were even here. M6\u003c/p\u003e\n\u003cp\u003eThis was in part due to the self-contained, independent nature of the pharmacy units.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe deal with their cash and such like, but they are self-contained. We don’t have anything to do with the pharmacy aspect at all. M7\u003c/p\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003ch2\u003eOperational Successes and Challenges\u003c/h2\u003e\n\u003cp\u003eThe interview participants were asked to discuss what they felt had worked well. Effective communication was seen as key to success; ensuring that the process was clear to all involved and preventing undue anxiety should an irregular heart rate be identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eit’s just making sure that the communication is, consistent… to make sure we don’t raise anxiety and to make sure the people understand that this is what we’re out to find, and if you do, if we do find it, it’s not the end of the world basically, P1\u003c/p\u003e\n\u003cp\u003eMost of the problems highlighted by store managers appeared to arise from logistical issues arising from poor communication. On occasions, this meant that even though the regional management team were aware of the study, the supermarket staff were not always expecting the study team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;it was a bit of a comms failure. Two sites knew and the others didn’t, so we found when they [research team] landed. We had to check they were kosher and then it came up on our activity app, so that confirmed things M2\u003c/p\u003e\n\u003cp\u003eArriving in a clinical uniform helped, and was perceived as key, not only in terms of making them identifiable to staff, but also in demonstrating the authenticity of the innovation. The study staff were seen as an indispensable part of the process.\u003c/p\u003e\n\u003cp\u003eHaving them here all in uniform, that was really good because it made it look really professional. \u0026nbsp;And they were smart, and it looked like it was something, you know, real rather than anything else. \u0026nbsp;So, that was really, really helpful. \u0026nbsp;M3\u003c/p\u003e\n\u003cp\u003ePharmacists highlighted more practical issues, particularly around busy environments and noise. Clinical rooms were generally very small, and often constructed with temporary walls and no ceiling, meaning that the sounds from the hustle and bustle of the supermarket could not be escaped.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of a manual assessment of AF, it’s been a bit more tricky in terms of verifying what the monitors picked up in the first place, just with general surroundings, obviously, in a consultation room, it’s a bit noisy and you’re trying to sort of focus on pulse rates. P2\u003c/p\u003e\n\u003cp\u003eFurthermore, it was highlighted that manual assessment of AF is not taught as standard to pharmacists. However, in the last few years, the clinical content of MPharm degree programmes has substantially increased recently, as pharmacists qualifying from 2026 will be prescribers at the point of registration. This is likely to impact on clinical skills. In addition, frequent transfer of staff between sites/stores to cover short term absence meant that some staff arrived at a study site with little knowledge of the study and requirements. A broad training package would therefore be a requirement to rolling out the programme.\u003c/p\u003e\n\u003cp\u003eand…but I think if you went to the general Pharmacist population, I’m not sure many would…it’s not something you get trained to do as part of it so, I think that, as long as there was a training package and an awareness of what to look for. P1\u003c/p\u003e\n\u003cp\u003eA general concern expressed was that of the impact on the shopper, and how an unexpected finding of AF would be managed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI think sometimes what didn’t help on the negative side was, people have come to do their shopping, and just agreed to do a survey of where they thought nothing was bad and then, when they presented the Pharmacy, they were quite anxious going “Oh my God, I've just been told I’ve, I might have Atrial Fibrillation”. P3\u003c/p\u003e\n\u003cp\u003ePharmacists felt that they were ideally positioned to support patients who were identified with an irregular heart rhythm, with communication being an integral part of their role.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ewe’re trained in face-to-face communication and body language…... A lot of them were accepting, but there were some that were anxious and concerned that it was almost like they’ve found a life changing thing, which to some people, that’s a nightmare……it’s sometimes difficult to transfer that message. P1\u003c/p\u003e\n\u003cp\u003eThis evaluation was undertaken during the COVID-19 pandemic, although not during a period of lockdown. The impact of this on the study was highlighted, in particular in relation to staffing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWell we usually have 3 or 4 of us around. Problem at the moment is we have around 10-12 colleagues off self-isolating. M4\u003c/p\u003e\n\u003cp\u003eSimilarly, pharmacists found themselves transferred to other stores, and with an increased use of locums. This meant that staff on duty may not have received the training that was provided or have been aware of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYes, staffing has been a bit of an issue, and our regular pharmacist hasn’t been in so we’ve been relying on locums. M3\u003c/p\u003e\n\u003ch2\u003eConsiderations for Broader Implementation\u003c/h2\u003e\n\u003cp\u003eThe main issue with expanding the innovation across supermarkets was perceived to be trained personnel, with the role of the research assistants on the ground seen as indispensable in the success of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI’m not sure that we would have the skills or time to be able to take over some of those extra jobs, so it would really have to be something that was automated. \u0026nbsp; M5\u003c/p\u003e\n\u003cp\u003eSuggestions for the expansion of the programme included the need to replace fleets of trolleys with study trolleys, with greater reliance on technology to redirect the shopper to the pharmacy should an irregular HR be identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOperationally it worked really well as it was, but that wouldn’t work long term. If you replaced my whole fleet of trolleys then the shoppers would have to use the device. We could add something at the till to redirect them to pharmacy…. or a QR code on each trolley so they can download their readings. M1\u003c/p\u003e\n\u003cp\u003eThe demographics of the target population were identified as potentially problematic in relation to a move towards a technological solution, with the older generation perceived as less tech savvy, but at higher intrinsic risk of having AF.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYeah, of course, and I guess, you know, often it’s the older generation as well who don’t, which I guess would make things quite difficult. \u0026nbsp;But I think the younger generation are more intrigued by technology in that way and would probably be really, really interested. M2\u003c/p\u003e\n\u003cp\u003eSimilar concerns were highlighted by the Pharmacists\u003c/p\u003e\n\u003cp\u003eThis has only worked because, someone’s been there to guide them to the Pharmacy and I suppose it’s, when you take that away, how, how’s it going to work. P4\u003c/p\u003e\n\u003cp\u003eEnsuring that shoppers who were flagged up as potentially having AF sought help and were followed up was perceived as key to successfully rolling out the programme.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ewhereas a lot of people might pick it up, it might tell them they've got AF and they’ll just walk out and go, and it’s getting that footfall through to make sure it is followed up, I think that’s the key. P1\u003c/p\u003e\n\u003cp\u003eMore generally, the risk of commercialising the programme was highlighted, with both pharmacists and technicians expressing concern over potential charges and the resulting impact on uptake, as has happened for other screening services offered within pharmacies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emost of them are paid for, like blood pressure, the blood glucose, you’ve got to pay for it. The only time you get it is the online doctor for your pill, or fat loss. \u0026nbsp;I feel sorry for them, because a lot of them are old and they’re like, ‘£8.50!’ D1\u003c/p\u003e\n\u003cp\u003eIn addition, many appreciated the influence of deprivation, with those least able to afford access to screening and monitoring such as blood pressure or glucose checks, often those most in need.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI guess we’ve got all the issues with deprivation as well, haven’t we, in terms of your poorer patients are the ones who are most likely to have a problem. D2\u003c/p\u003e\n\u003cp\u003eReflecting on the experience of being a participation site, pharmacists and technicians highlighted the positive impact on job satisfaction: first being able to offer free screening thereby creating opportunities to engage with regular customers; and second getting to hear about the outcomes to participants, both in terms of screening, but also follow up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e… Yeah, it is, yeah. \u0026nbsp;And some of them are regulars, and I was like, ‘Oh hi, Mr So-and-So’, so they felt comfortable and … so yeah, it’s really good. D1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;it was just a standard Pharmacy service, we would refer on and then not really know what happens to that patient, because there’s no feedback mechanism, whereas this is a more rounded service as it were. P1\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the feasibility and acceptability of supermarket-based AF screening, supported by pharmacists, pharmacy technicians, and store managers. Supermarkets were seen as promising community health hubs, enhancing access to cardiovascular care. Three key themes were identified: perceptions on involvement where engagement with the initiative was widely viewed as part of pharmacists' public health role; operational challenges included issues such as noise and training gaps; and implementation needs including structured training, automated follow-up, and equitable access. The findings support the growing role of pharmacists in preventive care and to inform future community-based screening strategies.\u003c/p\u003e \u003cp\u003ePharmacists are increasingly recognised as key contributors to CVD management due to their accessibility and expertise in medication management, patient education, and lifestyle counselling. (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Their involvement in preventive care has been shown to improve health outcomes, particularly in managing hypertension, diabetes, and dyslipidaemia, (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) as well as AF. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) This has gradually been expanded into supermarket settings, where it presents a valuable opportunity to enhance public health by increasing access to early detection and health interventions. As of March 2022, the UK housed 14,370 registered pharmacy premises, with around 40% operated by larger entities, including supermarket chains. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePharmacy-led health interventions can offer structured support that helps eliminate common implementation challenges, such as environmental constraints and staff training needs. By leveraging the established trust in pharmacists\u0026rsquo; roles within healthcare, these initiatives are well positioned to create supportive frameworks that directly address and mitigate these barriers. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Recent prescribing guidelines and healthcare policies in the UK increasingly direct the public toward community pharmacies for treatment of minor conditions and access to prescription medications. Under initiatives such as Pharmacy First, (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) pharmacists are now empowered to offer clinical advice and prescribe for common ailments like sore throats, urinary tract infections, and earaches without the need for a GP appointment. This shift aims to reduce pressure on general practice, improve access to timely care, and make better use of pharmacists\u0026rsquo; clinical expertise, positioning pharmacies as accessible front-line healthcare providers within local communities.\u003c/p\u003e \u003cp\u003eTechnological advancements present opportunities to enhance the efficiency and scalability of these interventions. Digital tools such as automated notifications, QR code-based referral systems, and electronic health records could streamline processes and improve follow-up care. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) However, digital literacy, particularly among older adults, remains a challenge. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) A hybrid model combining automated systems with personalised support could help to address this issue and ensure that interventions remain accessible to all demographic groups.\u003c/p\u003e \u003cp\u003eEnsuring equitable access to these services is essential to maximising the public health impact. Supermarket-based health interventions have the potential to reach underserved populations, thereby reducing health disparities. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) Access to preventive health services, including screening programs, is notably lower among underserved populations with barriers such as transportation difficulties, financial constraints, and long waiting lists disproportionately affecting these individuals. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Paid screening services have been linked to lower uptake rates among low-income populations. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Fostering a culture of innovation and providing sustainable funding models are essential to support the adoption of digital health technologies while ensuring equitable access. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFurthermore, aligning healthcare policies to respond to patient priorities and integrating user-centred design in digital health initiatives can enhance the scalability and effectiveness of interventions. Strong partnerships among stakeholders, scalable technologies, and policy alignment are critical components in overcoming barriers to technology dissemination and adoption. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Effective implementation will require strategic coordination between public health authorities, retailers, and pharmacy professionals to establish clear guidelines and funding mechanisms. Collaborative partnerships will be essential to scaling these interventions effectively and aligning them with broader public health objectives. Follow-up via primary or secondary care to confirm AF diagnosis and initiation of treatment, where appropriate is essential. Integrating supermarket-based screening initiatives into existing health strategies could enhance early detection and management of CVD, contributing to improved population health outcomes. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eSupermarket based AF screening is a feasible means of identifying people with asymptomatic AF which is valued and acceptable by participants and supermarket and pharmacy staff. However, the transient nature of the in-store pharmacists increases the training needs and may limit a pharmacy\u0026rsquo;s ability to deliver a screening service as part of their routine practice. Upskilling pharmacy technicians may provide a more realistic and sustainable service model. Alternatively, an adjunctive mobile service delivered solely by advanced healthcare staff with immediate clinical review for those identified as experiencing AF may provide an effective one-stop AF model of care that negates the need for hospital referral.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSupermarket managers, pharmacists, and pharmacy technicians evaluated the project positively, with minimal impact on workload. However, concerns were raised about staffing capacity to manage trolleys and guide shoppers to the pharmacy for follow-up, highlighting the need for practical adjustments. Training gaps were also noted, as pharmacist turnover and reliance on locums meant that pharmacy technicians and the research team often provided guidance. Involving a broader pharmacy team was recommended to ensure continuity and effective response when AF was identified. Both pharmacy and supermarket staff supported the service, viewing it as part of the supermarket's civic duty and an extension of the pharmacist\u0026rsquo;s public health role. Integrating pharmacist-led health interventions into supermarkets offers a promising strategy to improve health outcomes and prevent cardiovascular diseases. Addressing challenges related to staffing, training, infrastructure, and equitable access will be key to the successful implementation and sustainability of these initiatives.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAbbreviations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval and sponsorship were granted by Liverpool John Moores University's University Research Ethics Committee (21/NAH/001). All eligible participants received information about the study outlining the purpose, potential risks and implications of participation with written informed consent obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication granted by all authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRL, IJ, LN, PP,AS, GL, DL, EJS - conception and design of the project\u003c/p\u003e\n\u003cp\u003eRL data acquisition \u003c/p\u003e\n\u003cp\u003eRL and IJ reviewed transcripts\u003c/p\u003e\n\u003cp\u003eRL, IJ, LN, PP,AS, GL, DL, EJS - supported analysis\u003c/p\u003e\n\u003cp\u003eRL drafted main manuscript text \u003c/p\u003e\n\u003cp\u003eRL, IJ, LN, PP,AS, GL, DL, EJS - reviewed and corrected manuscript\u003c/p\u003e\n\u003cp\u003eRL, IJ, LN, PP,AS, GL, DL, EJS - reviewed submitted version\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Bristol Myers Squibb for funding the project. We would also like to acknowledge the support of Sainsbury’s supermarkets who allowed us to use the stores to recruit participants. Finally, we would like to thank Lloyds Pharmacy whose pharmacists contributed to the project both in terms of their time and professional expertise. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Bristol Myers Squibb for their financial support (funding number REQ-0000022262), which has enabled this novel study to be undertaken. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDataset\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available as consent was not sought for public sharing. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRobyn R Lotto \u003c/strong\u003eis a co-applicant on the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research \u0026amp; Innovation programme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeirdre A. Lane\u003c/strong\u003e received investigator‐initiated educational grants from Bristol‐Myers Squibb and Pfizer; all outside the submitted work. She is a co-applicant on the AFFIRMO project on multimorbidity in AF (Grant Agreement No. 899871), ARISTOTELES project on artificial intelligence for management of chronic long-term conditions (Grant Agreement No. 101080189), and the TARGET project on digital twins for personalised management of atrial fibrillation and stroke (Grant Agreement No. 101136244), all of which are funded by the European Union Horizon Europe Research \u0026amp; Innovation programme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGregory Lip\u003c/strong\u003e is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator and Co-Principal Investigator of the AFFIRMO project on multimorbidity in AF, funded by the European Union’s Horizon 2020 research and innovation program under grant agreement No. 899871.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVinter N, Cordsen P, Johnsen SP, Staerk L, Benjamin EJ, Frost L, et al. Temporal trends in lifetime risks of atrial fibrillation and its complications between 2000 and 2022: Danish, nationwide, population based cohort study. BMJ. 2024;385:e077209.\u003c/li\u003e\n \u003cli\u003eOdutayo A, Wong CX, Hsiao AJ, Hopewell S, Altman DG, Emdin CA. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and meta-analysis. bmj. 2016;354.\u003c/li\u003e\n \u003cli\u003eWolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. stroke. 1991;22(8):983-8.\u003c/li\u003e\n \u003cli\u003eBenjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics\u0026mdash;2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.\u003c/li\u003e\n \u003cli\u003eKalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: a meta-analysis. Annals of internal medicine. 2013;158(5_Part_1):338-46.\u003c/li\u003e\n \u003cli\u003eFreedman B, Potpara TS, Lip GY. Stroke prevention in atrial fibrillation. The Lancet. 2016;388(10046):806-17.\u003c/li\u003e\n \u003cli\u003eBurdett P, Lip GY. Targeted vs. full population screening costs for incident atrial fibrillation and AF-related stroke for a healthy population aged 65 years in the United Kingdom. European Heart Journal-Quality of Care and Clinical Outcomes. 2022;8(8):892-8.\u003c/li\u003e\n \u003cli\u003eBrandes A, Stavrakis S, Freedman B, Antoniou S, Boriani G, Camm AJ, et al. Consumer-led screening for atrial fibrillation: frontier review of the AF-SCREEN international collaboration. Circulation. 2022;146(19):1461-74.\u003c/li\u003e\n \u003cli\u003eBoriani G, Schnabel RB, Healey JS, Lopes RD, Verbiest-van Gurp N, Lobban T, et al. Consumer-led screening for atrial fibrillation using consumer-facing wearables, devices and apps: a survey of health care professionals by AF-SCREEN international collaboration. European journal of internal medicine. 2020;82:97-104.\u003c/li\u003e\n \u003cli\u003eKalarus Z, Mairesse GH, Sokal A, Boriani G, Średniawa B, Casado-Arroyo R, et al. Searching for atrial fibrillation: looking harder, looking longer, and in increasingly sophisticated ways. An EHRA position paper. Europace. 2023;25(1):185-98.\u003c/li\u003e\n \u003cli\u003eMairesse G, Moran P, van Gelder I, Elsner C, Rosenqvist M, Mant J, et al. Screening for atrial fibrillation. Europace. 2017.\u003c/li\u003e\n \u003cli\u003eSvennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation. 2015;131(25):2176-84.\u003c/li\u003e\n \u003cli\u003eLowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation. Thrombosis and haemostasis. 2013;110(08):213-22.\u003c/li\u003e\n \u003cli\u003eValliant SN, Burbage SC, Pathak S, Urick BY. Pharmacists as accessible health care providers: quantifying the opportunity. J Manag Care Spec Pharm. 2022;28(1):85-90.\u003c/li\u003e\n \u003cli\u003eJones ID, Lane DA, Lotto RR, Oxborough D, Neubeck L, Penson PE, et al. Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF) using sensors embedded in the handles of supermarket trolleys: A feasibility study. American Heart Journal. 2024;271:164-77.\u003c/li\u003e\n \u003cli\u003eJones ID, Lane DA, Lotto RR, Oxborough D, Neubeck L, Penson PE, et al. Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF): A mixed methods feasibility study protocol. Journal of Personalized Medicine. 2022;12(4):578.\u003c/li\u003e\n \u003cli\u003eEssien UR, Holmes DN, Jackson LR, Fonarow GC, Mahaffey KW, Reiffel JA, et al. Association of race/ethnicity with oral anticoagulant use in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. JAMA cardiology. 2018;3(12):1174-82.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V, Hayfield N, Terry G. Thematic analysis. Handbook of Research Methods in Health Social Sciences. 2019:843-60.\u003c/li\u003e\n \u003cli\u003eSantschi V, Chiolero A, Paradis G, Colosimo AL, Burnand B. Pharmacist interventions to improve cardiovascular disease risk factors in diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes care. 2012;35(12):2706-17.\u003c/li\u003e\n \u003cli\u003eCheema E, Sutcliffe P, Singer DR. The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta‐analysis of randomized controlled trials. British journal of clinical pharmacology. 2014;78(6):1238-47.\u003c/li\u003e\n \u003cli\u003eRattanavipanon W, Chaiyasothi T, Puchsaka P, Mungkornkaew R, Nathisuwan S, Veettil SK, et al. Effects of pharmacist interventions on cardiovascular risk factors and outcomes: An umbrella review of meta-analysis of randomized controlled trials. British Journal of Clinical Pharmacology. 2022;88(7):3064-77.\u003c/li\u003e\n \u003cli\u003eRitchie LA, Penson PE, Akpan A, Lip GY, Lane DA. Integrated care for atrial fibrillation management: the role of the pharmacist. The American Journal of Medicine. 2022;135(12):1410-26.\u003c/li\u003e\n \u003cli\u003eChristie\u0026amp;Co. Pharmacy Market Review 2022. Available at: https://www.christie.com/news-resources/press-releases/report-launch-pharmacy-market-review-2022/2022 [Accessed 15 April 2025]\u003c/li\u003e\n \u003cli\u003eMilosavljevic A, Aspden T, Harrison J. Community pharmacist-led interventions and their impact on patients\u0026rsquo; medication adherence and other health outcomes: a systematic review. International Journal of Pharmacy Practice. 2018;26(5):387-97.\u003c/li\u003e\n \u003cli\u003eAhmed A, Guo P, Jalal Z. A systematic review investigating the role and impact of pharmacist interventions in cardiac rehabilitation. International Journal of Clinical Pharmacy. 2023;45(2):320-9.\u003c/li\u003e\n \u003cli\u003eNHSEngland. Pharmacy First Available at: https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-services/pharmacy-first/2024 [Accessed 10 March 2025]\u003c/li\u003e\n \u003cli\u003eSutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ digital medicine. 2020;3(1):17.\u003c/li\u003e\n \u003cli\u003eMitzner TL, Savla J, Boot WR, Sharit J, Charness N, Czaja SJ, et al. Technology adoption by older adults: Findings from the PRISM trial. The Gerontologist. 2019;59(1):34-44.\u003c/li\u003e\n \u003cli\u003ePringle JL, Boyer A, Conklin MH, McCullough JW, Aldridge A. The Pennsylvania Project: pharmacist intervention improved medication adherence and reduced health care costs. Health Affairs. 2014;33(8):1444-52.\u003c/li\u003e\n \u003cli\u003eBoyer B, Huber K, Zimlichman E, Saunders R, McClellan M, Kahn C, et al. Advancing the future of equitable access to health care: recommendations from international health care leaders. Health Affairs Scholar. 2024;2(8).\u003c/li\u003e\n \u003cli\u003eSakellariou D, Rotarou ES. Access to healthcare for men and women with disabilities in the UK: secondary analysis of cross-sectional data. BMJ Open. 2017;7(8):e016614.\u003c/li\u003e\n \u003cli\u003eEscaron AL, Meinen AM, Nitzke SA, Martinez-Donate AP. Supermarket and grocery store\u0026ndash;based interventions to promote healthful food choices and eating practices: a systematic review. Preventing chronic disease. 2013;10:E50.\u003c/li\u003e\n \u003cli\u003eAhmad B, Landes D, Moffatt S. Dental Public Health In Action: Barriers to oral healthcare provision for older people in residential and nursing care homes: A mixed method evaluation and strategy development in County Durham, North East England. Community dental health. 2018. Aug;35(03):136-9.\u003c/li\u003e\n \u003cli\u003ePhillips KA, Marshall DA, Adler L, Figueroa J, Haeder SF, Hamad R, et al. Ten health policy challenges for the next 10 years. Health Affairs Scholar. 2023;1(1).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Atrial fibrillation, screening, pharmacists, supermarkets, public health, early detection, health inequalities","lastPublishedDoi":"10.21203/rs.3.rs-6682804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6682804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003cstrong\u003e\u003cbr\u003e\n \u003c/strong\u003eAtrial fibrillation (AF) often remains undetected due to its asymptomatic nature and limited screening opportunities outside clinical settings. Expanding screening beyond traditional healthcare environments is crucial for improving early detection and outcomes. This study explores the feasibility and acceptability of supermarket-based AF screening from the perspectives of pharmacists and store managers involved in the initiative.\u003c/p\u003e\n\u003cp\u003eMethods:\u003cbr\u003e\nA qualitative study was conducted using semi-structured interviews with pharmacists (n=4), pharmacy technicians (n=4), and store managers (n=7) from four supermarket-based pharmacies in the United Kingdom. Data were analysed using Braun and Clarke’s thematic analysis framework to identify key themes and patterns.\u003c/p\u003e\n\u003cp\u003eFindings:\u003cbr\u003e\nThree key themes were identified: (1) \u003cem\u003ePerceptions of involvement\u003c/em\u003e – Participants supported the initiative as an extension of pharmacists’ preventive healthcare role and a civic contribution by supermarkets. (2) \u003cem\u003eOperational successes and challenges\u003c/em\u003e – Effective communication facilitated success, but logistical issues such as environmental noise, inconsistent staff communication, and lack of training in pulse assessment were highlighted. (3) \u003cem\u003eImplementation considerations\u003c/em\u003e – Suggestions included automating follow-up processes, providing structured training for pharmacists, and ensuring free access to maintain health equity and engagement.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003cbr\u003e\nSupermarket-based AF screening was viewed as feasible and valuable, with minimal disruption to store operations and positive engagement from staff and customers. Addressing logistical barriers and strengthening pharmacist training are critical for broader implementation. The findings highlight the potential for supermarkets to serve as community health hubs, increasing public access to cardiovascular screening and contributing to early detection and management of chronic conditions. Expanding such models could reduce healthcare inequities and improve population-level health outcomes.\u003c/p\u003e","manuscriptTitle":"Embedding Preventive Cardiac Screening in Supermarkets: A Qualitative Study of Stakeholder Perspectives on Atrial Fibrillation Detection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:04:16","doi":"10.21203/rs.3.rs-6682804/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-06-23T07:31:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T18:22:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-28T07:10:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-27T18:44:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-27T18:43:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9994d9fc-b7f1-4759-bd40-da19189ec33e","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T08:04:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 08:04:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6682804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6682804","identity":"rs-6682804","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}