Hearing Loss at the Pharmacy – A Qualitative Study of Pharmacists and Their Clients

According to the National Center for Health Statistics, 85% of adults in the US age 60 years and over use at least one prescription drug 1, with about 20% using at least five prescription drugs. 2 The numbers in the UK are similar. 3,4 A key role of the pharmacist is to support patients in their use of medicines. 5 This necessitates good communication, including communication with people with hearing loss. Bearing in mind that more than 40% of people over 50 years old have a hearing loss, with the number increasing to 70% among those over 70 years 6, we were interested in learning about the barriers and facilitators to communication perceived by pharmacists and the clients they serve so that interventions and education can be developed where needed.www.shutterstock.com. Pharmacy, pharmacists.Figure 1: Themes and subthemes extracted from the data. Pharmacy, pharmacists.This topic has not been widely investigated 7, although what research there is indicates that people with hearing loss encounter a variety of issues in pharmacy including being unable to hear their name being called when their prescription is ready; struggling to understand or misunderstanding the information provided; and perceiving pharmacists to be insensitive, unaware, or lacking in understanding of their difficulties. 8–11 Pharmacists are often aware of the negative impacts that hearing loss can have on communication in the pharmacy, that hearing loss can contribute to poor medication adherence, and that their clients may not be receiving optimal care as a result of communication barriers 12,13, however, despite pharmacists wanting more resources to support communication with people with hearing loss 14, little has been done to address the matter. Further, most of the studies examining the impact of hearing loss on pharmacy access have been conducted with people who are Deaf and use sign language. There is little information regarding the needs and perspectives of people with a hearing loss acquired later in life. 7,15 Given that inadequate communication could seriously impact the pharmaceutical care of older people with hearing loss, it is pertinent to take a closer look at the specific factors that facilitate and impede communication between these individuals and pharmacists, to identify possible solutions to these barriers and enable improved interactions. In addition, there are no studies in which an age-equivalent comparison group of people without hearing loss has been included to allow differentiation between communication issues in general, and communication issues directly resulting from hearing loss. With this in mind, and the awareness that COVID-19 mitigation effects such as face coverings and Perspex screens have detrimental effects on communication 16, we conducted a study in which we interviewed older people with and without age-related hearing loss regarding their experiences in community pharmacy and conducted focus groups with pharmacists, too. METHOD This project took place through the University of Manchester, UK. Ethical approval was obtained from the University of Manchester Research Ethics Committee (reference 2022-13524-22453). Data were collected between March and June 2022. We recruited 19 individuals (referred to below as clients) who said they routinely used community pharmacy from the study team’s personal and professional networks and University of Manchester research databases. All were over 50 years old. Sixteen had self-reported age-related hearing loss (mean age 73.4 years) and three had self-reported normal hearing (mean age 62 years). We also recruited eight community pharmacists via snowball sampling all of whom who practiced pharmacy in the UK. On average, they had been in practice for of 17.9 years. Semi-structured interviews were conducted with clients, and focus groups were conducted with all but one pharmacist, who took part in a one-on-one interview. Prior to each interview or focus group, participants provided information about their age, education, ethnicity, use of hearing aids, duration and severity of hearing loss, and general health (clients), or their occupational experience (pharmacists). Fourteen of the client interviews, the focus groups and the pharmacist interview were conducted using Zoom. The sessions were recorded from within the software with live captions were enabled when preferred. Two of the client interviews were conducted by telephone and recorded within Zoom. ANALYSIS Audio-recordings were transcribed verbatim. Thematic analysis using the framework method 17 was then used to extract themes and subthemes from the transcriptions. In the framework method, a set of codes organised into themes and subthemes are developed and used for data interpretation. The codes were used in NVivo 12 data management software to summarise the data into themes and subthemes. RESULTS Three primary themes and several subthemes associated with communication and access were identified from the across the transcripts. Each theme and its subcategories is shown in Figure 1 and discussed below. Theme 1: Grappling with the environment. This theme is about barriers to communication in the pharmacy setting, their impacts, and strategies used to address them. Both pharmacists and clients, regardless of their hearing status, reportedly were aware that communication in the pharmacy setting is impacted by noise, use of Perspex screens and face coverings, and lack of time. Pharmacists and clients appeared aware of the negative impacts of these communication barriers that -included embarrassment at asking for information to be repeated, a breach of if the pharmacist speaks loudly, and the mutual frustration of communication breakdowns. Both groups also alluded to use of a variety of strategies to cope. Some of those mentioned were positive (e.g. use of lipreading and requesting clarification using different vocabulary) and some were negative (e.g. pretending to hear). Theme 2: Promoting acknowledgment and inclusion of hearing loss in the pharmacy. This theme related to disclosure of hearing loss and supportive behaviours in the pharmacy setting. While some clients said they did not believe it was necessary to disclose their hearing loss, others were frustrated at the lack of awareness of the needs of people with hearing loss. Likewise, some pharmacists reported they were aware that some people with hearing loss were reluctant to disclose the matter, while others reported frustration at the consequences of hearing loss on communication. Both groups indicated that pharmacists should make it clear that they can, and want to, provide support for people with hearing loss in the pharmacy setting. Theme 3. Differing perceptions of patients and pharmacists about communication. This theme reflected the views expressed by patients and pharmacists regarding perceptions about communication and awareness of facilitators and barriers to communication. Clients often said they had little or no need to communicate with their pharmacist, while pharmacists felt communication was important; clients felt that pharmacists lacked awareness of how to communicate with people with hearing loss, while pharmacists reported knowing how to communicate but lacked training in how to implement what they knew; clients had strong views on the kinds of communication strategies pharmacists need to know, and pharmacists were keen to use technological solutions such as speech-to-text apps but said clients were not keen to engage with such technology. DISCUSSION The aim of this study was to learn about communication experiences in community pharmacy settings from the perspectives of pharmacists, and users of pharmacy with and without age-related hearing loss, within the context of COVID-19 mitigation measures (face coverings and Perspex screens). Interviews and focus groups were conducted and revealed a variety of similarities and differences between the perceptions of the groups of individuals. In terms of similarities, pharmacists and clients alike were aware of the specific barriers to communication in the pharmacy setting, which included noise, COVID-19 mitigation measures (face coverings and Perspex screens) and the time pressures faced by pharmacists. Regarding this latter point, clients felt this meant the pharmacists would be reluctant to engage in a conversation that might need repeating, while for pharmacists, time pressures meant they did not have time to take the patient to a quiet private space for a conversation. Pharmacists and clients alike were also cognizant of the fact that speaking loudly could lead to embarrassment and a lack of privacy among clients, and that pretending to hear was a strategy often used to avoid fuss and embarrassment. All groups were also in agreement that more could be done to signify that a pharmacy recognises the needs of those with hearing loss, and that it would be helpful if the presence of a hearing loss could be flagged in chart notes to avoid patients having to disclose it in the pharmacy setting. Opinions diverged on several topics. In particular, there was a perception among clients that their hearing loss is not relevant to the community pharmacy setting and thus there was no need to divulge their hearing loss to the pharmacist. This was because they saw the role of the pharmacist as the provider of prescriptions rather than as a health care professional who might provide other advice and services. On the contrary, pharmacists wanted their clients to tell them when they had a hearing loss so they knew to communicate differently. In a similar vein, clients perceived communication with their pharmacist to be unnecessary, while pharmacists wanted to ensure clear communication with their clients about medications. There was a feeling among clients that pharmacists did not appreciate the difficulties encountered by people with hearing loss, and that they do not know how best to communicate with a person with hearing loss. Pharmacists however, indicated that they were well aware of the needs of people with hearing loss but felt they, as pharmacists, needed training on how to implement solutions, and that their clients should play a role in facilitating this by better engaging with hearing technology and apps and disclosing their hearing needs more clearly. We conclude that future research should identify interventions to support the implementation of strategies/adaptations that are tailored to the needs of people with hearing loss and pharmacists in order to engender hearing-friendly community pharmacies and promote the safe use of medicines. This recommendation adds to recent calls for the inclusion of learning on communication and assistive technologies for older people with sensory impairment in training for pharmacy personnel at various levels. 18,19 Acknowledgements: This project received funding from -University of Manchester Research Institute UMRI as part of the Interdisciplinary Research Recovery Fund 2021-22. GS was supported by NIHR Manchester Biomedical Research Centre; CT by NIHR Applied Research Collaboration-Greater Manchester. We thank Ayaz Alam and Iqrah Mehdi for assisting with data collection.