Introduction

Cardiovascular diseases (CVDs) are a group of non-communicable diseases of the heart and blood vessels [1]. CVDs are a leading cause of mortality globally. Approximately 31% of global mortality was attributed to CVDs in 2012, and 33% affected population was below 70 years of age, thus imposing suffering and economic difficulties, particularly in low- and middle-income countries, which carry the highest CVD burden [2]. Over the past two decades, a substantial decline in mortality was realised in High-Income Countries (HICs) through improved prevention and treatment strategies. Contrarily, low- and middle-income countries suffer the most CVD burden with rates twice as much as the HICs in recent years [2]. The World Health Organisation has warned of a projected global mortality increase of 27% by 2030, suggesting immense strain on health systems. Lesotho is a Sub-Saharan African country and is classified under low- and middle-income countries [3]. The country is faced with a growing burden of CVDs which are leading cause of mortality among non-communicable diseases. Between 1990 and 2015, Lesotho experienced over 60% increase in CVD burden [4]. In 2016, the country reported 32% of total mortality due to non-communicable diseases, with CVDs contributing 44% of total non-communicable disease-related deaths [5]. Moreover, in 2019, 45% overall non-communicable disease-related mortality was reported, which represented a 13% increase in three years (2016–2019) [6]. The increase in disease occurrences put a significant strain on healthcare systems and a subsequent poor health outcomes [7]. It is thus imperative that effective strategies to prevention and control of CVDs should be a priority in Lesotho.

Management of CVDs includes detection, screening, treatment, and providing palliative care for the people who need it [8]. Effective strategies to reduce the burden of CVDs can be classified into population-wide interventions to reduce overall risk factor exposure, individual approaches to modify risk factors for high-risk individuals, and treatment of CVD events with the last two being applicable for the primary healthcare setting [2]. At the primary healthcare, a further three stages have been proposed to manage CVDs namely: primary prevention, secondary prevention and early detection [2]. Cardiovascular diseases are highly preventable. The impact of CVDs can be minimized by addressing identifiable and modifiable risk factors such as the use of tobacco, addressing unhealthy diets and obesity, physical inactivity, and the harmful use of alcohol. The outcomes of these risk factors may present in patients as noticeable signs (e.g., high blood glucose, high blood lipids, high blood pressure, overweight and obesity) that can be measured and identified early at primary healthcare facilities. While various healthcare providers have a crucial role to play in mitigating the burden of CVDs at primary healthcare, community pharmacists are easily accessible health professionals and are well positioned to identify "at-risk" patients through medication regimes given their locality.

Community pharmacies are an essential part of primary healthcare. They are located at the heart of communities, and are the first point of contact for many [9]. Community pharmacists can provide both effective population-based and individualized primary healthcare services. The effectiveness of community pharmacist’ roles in primary healthcare interventions is demonstrated in smoking cessation programs, health promotion, and medication therapy management and adherence services [10–15]. Thus, community pharmacy presents an opportunity in primary healthcare setting for effective prevention and control of CVDs. The practice of community pharmacy was rare in Lesotho until late 2000 after the first batch of Bachelor of Pharmacy (BPharm) students graduated from the National University of Lesotho, the only University that produces pharmacists in the country [16]. To date, the country produces around 40 graduates annually, thus suggesting pharmacists as one of the abundant and sustainable health professions in Lesotho [17].

In response to the global agenda to reduce CVD-related mortalities, Lesotho has developed the National Health Policy and the National Health Strategic Plan [18]. The National Health Policy takes into consideration the United Nations sustainable development goals and aims to achieve sustainable development goal 3, and delivery of quality healthcare services to achieve universal health coverage objectives by 2030. To strengthen the country’s response to the prevention and control of non-communicable diseases such as CVDs, Lesotho has proposed the mobilization of human, financial and technical resources through a multi-sectoral inclusive primary healthcare model [7]. The proposed structure presents an opportunity to expand the roles of untapped healthcare resources such as community pharmacists to increase primary healthcare services to achieve better healthcare for all. The government of Lesotho recognizes community pharmacies as an important part of the private-for-profit healthcare system that provides care and medicines [19]. However, there is a paucity of local research on community pharmacists’ role in preventing and controlling non-communicable diseases, particularly CVDs. An understanding of Lesotho community pharmacist’s role in preventing and controlling CVDs is important to policymakers, civil societies, and patients to enable informed decision making in developing effective strategies to prevent and control CVDs. The current study is part of a large mixed method study that seeks to develop a conceptual framework for the integration of community pharmacist in primary healthcare model in Lesotho. The overarching aim of the study was to explore the Lesotho community pharmacist’s role in preventing and controlling CVDs. Specifically, the study seeks to answer the following research questions:

1. What are the roles of community pharmacists in the prevention and control of CVDs in Lesotho?
2. What are Lesotho community pharmacists’ perceived facilitators and barriers towards their contribution in preventing and controlling CVDs?

For the current study, the preventive roles were community pharmacist’s services for patients with reported CVD risk factors such as hypertension, diabetes, and dyslipidaemia but without established CVDs. The control roles (contributions) were community pharmacist’s services for patients with reported established CVDs, while CVD patients are patients with both CVD risk factors and established CVDs.

Methods

Results

In total seventeen (n = 17) community pharmacists were invited to participate in the study. One pharmacist declined the invitation. Out of sixteen pharmacists who agreed to participate, only eleven were interviewed. The other five were not available for the interview. On average, the interview took 40 minutes, ranging from 27 to 60 minutes. Five females and six males had one to thirteen years of community pharmacy work experience. A total of nine (n = 9) respondents were working in community pharmacies in Maseru urban, one in Maseru rural and one from outside Maseru.

A total of five themes with their corresponding subthemes (for some) were identified from the transcripts after reiterative review of the identified codes, and they are 1) Current roles of community pharmacists, 2) Future role of community pharmacists, 3) Facilitators, 4) Barriers, and 5) Community pharmacists’ perceptions of their roles (Table 1).

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Table 1. Themes, sub-themes and generated codes in role of community pharmacists in preventing and controlling CVDs.

https://doi.org/10.1371/journal.pone.0301525.t001

Current roles of community pharmacists

A detailed account of the respondents’ quotes supporting the identified themes are represented in Table 2. The study findings showed that community pharmacists in Lesotho provide services daily to both patients with CVD risk factors and established CVDs, highlighting their potential contribution in primary and secondary prevention of CVDs (Table 2, 2.01, 2.03). The identified current roles were predominantly screening tests such as blood pressure tests, medication dispensing and counselling, lifestyle counselling such as diet modification, and referral of patients (Table 2, 2.01). Although less common, respondents mentioned that they provide other services such as patient follow up, keeping patient medical records, patient self-care advice, over the counter dispensing of supplements, CVD education, and medicine therapy management (Table 2, 2.02–2.06).

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Table 2. Community pharmacists’ interview excerpts.

https://doi.org/10.1371/journal.pone.0301525.t002

Discussion

To the best of the authors’ knowledge, this is the first study to report the role of community pharmacists in preventing and controlling CVDs in Lesotho. Lesotho is not an exception to the global burden of CVDs particularly in low- and middle-income countries. The country has seen a considerable increase in CVDs in the last two decades [4,6]. Thus, it is imperative that prevention and control of CVDs should be a priority in Lesotho’s health systems. With the rising morbidity rates, and shortage of skilled human resources in healthcare, community pharmacists stand an opportunity to become part of the proposed multi-sectoral model towards prevention of CVDs.

The study findings established that the pharmacists provide services to both patients with CVD risk factors (e.g., hypertension) and patients with established CVDs (e.g., heart failure). This suggests that contribute in primary and secondary prevention of CVDs, and detection of modifiable risk factors. Generally, the role of community pharmacists in CVD prevention and control involves the traditional medication dispensing, detection, and health promotion. Previous reviews have reported important clinical improvement of CVD risk factors following community pharmacist interventions. In a systematic review conducted by Chiazor, Evans [13], community pharmacist’s interventions on diabetes and hypertension revealed favourable clinical outcomes [13]. Similar findings reported substantial improvement on hypertension, diabetes, hyperlipidaemias, obesity, and smoking cessation following community pharmacists’ interventions [10–12,14,15]. The identified roles of community pharmacist suggest that they can provide expanded services and stand an opportunity to improve CVD burden in Lesotho. The effectiveness of the services opens room for future studies.

In health promotion, the most mentioned service was weight management counselling. However, patient adherence to weight loss programs were discouraged by affordability where patients could not afford the recommended eating habits against their willingness to change their lifestyles. In some instances, patients were not willing to receive counselling, but would prefer to get their medication and leave. This suggests that the lifestyle modification counselling services by a community pharmacist could only reach a few patients who were willing to receive or could afford such services. The reasons behind pharmacist perceived patients’ hesitation and lack of willingness to receive needs further investigation. On the same note, it was evident that the community pharmacist would initiate the lifestyle discussion on many occasions, posing the question of patients’ awareness of community pharmacist’s provision of service beyond medication dispensing. A similar finding was reported by Peletidi, Nabhani-Gebara [31] who established that Greek pharmacists adopted a paternalistic approach where pharmacists give instructions to the patients [31]. On the other hand, patients initiate lifestyle conversations in the United Kingdom (UK). There is a need to investigate patients’ views about the role of community pharmacists in preventing and controlling CVDs in Lesotho to better understand patients’ views of community pharmacy services. Nonetheless, one of the drivers of community pharmacist’s continued provision of services towards CVD patients was a good relationship with their patients and trust developed by patients towards pharmacists. There is evidence that the positive feedback the pharmacists receive from the patients was an important enabler. The variability in patients’ attitude towards community pharmacists’ services calls for future studies to establish patient’ perceptions of community pharmacist’s services in Lesotho. The quality of services provided by community pharmacists is evaluated based on the economic (cost implications), clinical (events that occur following disease occurrence or therapy), and humanistic (patient-centred outcomes including patient satisfaction, quality of life) outcomes (ECHO) model [32]. According to Theory of Planned Behaviour, patients’ behavioural beliefs and attitude hint their intention to utilise healthcare services, contributing towards positive or negative outcomes [33]. Thus, it is imperative to investigate patients’ perception of community pharmacists’ services in Lesotho to encourage patient-centred outcomes.

While it was evident that dispensing of medication was a standard practice, other services such as screening were not provided by some of the facilities partly due to lack of screening equipment. Interestingly, most community pharmacists provided blood pressure screening. Only few respondents indicated that they provide other screening tests such as cholesterol. While limited provision of screening services could possibly be a result of lack of equipment, the absence of clear regulations and guidelines cannot be overlooked as a contributing factor for the lack of standardisation in provision of services at the community pharmacies. Nonetheless, the findings compare with practice in parts of Europe and Australia where counselling on lifestyle modification were the common health promotion activity [31,34].

Community pharmacists revealed that they work under challenging circumstances that hinder their practice scope. Firstly, the study established that patients do not return to the pharmacy after referral to the physicians. This possibly affect continuity of services and possibly the effectiveness of the services provided by community pharmacists due to patients’ loss to follow up. Additionally, this could suggest possible role conflicts and competition between community pharmacists and physicians. Secondly, the inter-professional relationship between community pharmacists and other healthcare professionals is not well understood. While some community pharmacists reported a good relationship with medical doctors, other community pharmacists expressed their frustration over poor communication with doctors due to lack of structured collaboration guidelines. According to World Health Organization [35], every person should receive quality healthcare services from anywhere [35]. The relationship between healthcare professionals involved in CVD care should be regulated to afford patients freedom to obtain healthcare services from anywhere they wish, without being forced to go to a certain pharmacy or clinic. Another barrier was the lack of support from the government. Community pharmacists believed that they could dedicate more time to delivering services to CVD patients should their services get a subvention from the government to pay off staff salaries and medication. Government support could potentially encourage more affordable services and broader utilisation by the public. There is need for standardisation of community pharmacy practice to support universal health coverage objectives. Generally, the barriers stem from legislation that does not provide clear community pharmacy guidelines of service.

Despite the challenges, community pharmacists believed that they have opportunity not only to improve their current services but to expand their services to include for instance, prescription which is normally reserved for medical profession. It is unclear what prompted this desire, which could see role conflicts between pharmacists and other healthcare professionals. Also, this view was echoed by respondents who indicated limited time and staff as barrier of service provision to CVD patients. Expanded services might worsen their current workload and promotes inefficiency. There is need to establish a clear structure of professions and their roles in the country that work collaboratively for improved health outcomes. Moreover, community pharmacists regarded themselves as confident in delivering health promotion activities. This contrasts with views of pharmacists in UK and Greece who expressed their lack of confidence in initiating lifestyle conversations with patients [31]. The perceived confidence might be encouraged by lack of reference point due to lack of guidelines. This further substantiate the need for standardisation of community pharmacy services.

The study had limitations. The results presented might not cover a full view of community pharmacists in Lesotho since all the community pharmacists, but one, were based in the capital city. Those based outside Maseru might share different opinions. Therefore, further research to include a larger representative sample that takes account of demographic factors. Nonetheless, the study provides in-depth views of community pharmacists about their role in preventing and controlling CVDs in Lesotho and adds to the current literature. The participants had a good gender representation of 5:6 females to males and a broad coverage of experience ranging from one to thirteen years. The findings built a foundation for future research and provides insights to healthcare policy makers regarding the role of community pharmacists in preventing and controlling CVDs in Lesotho. The authors are conducting a survey to a generalizable sample that includes other districts beyond the capital city (Maseru).

Conclusions

Lesotho community pharmacists can potentially improve CVD health outcomes at primary healthcare level through early detection of CVD risk factors, and health promotion services. They stand an opportunity to become part of primary healthcare structure in the management of CVDs. However, there is need for clear guidelines for standardised community pharmacy services and demarcation of the roles for healthcare professionals involved in CVD management. The study established that contact details obtained from the Ministry of Health of Lesotho had unreachable numbers and/or email databases. Further to that, the authors believe that there are more community pharmacies in Lesotho than found in the database since there are pharmacies on every corner as observed by the first author (NFM). It is possible that some pharmacies are not available in the database. Thus, the authors recommend regular update of community pharmacies’ database.

Acknowledgments

We give recognition to the University Library, University of KwaZulu-Natal, Durban, South Africa.