Pharmacy’s main demographic holds the key to community healthcare, writes Janet Doyle
Given the majority of pharmacy’s customers are women, and they often hold the key to the health of others, such as family members and even colleagues, it makes sense that pharmacy captures the hearts and minds of its female customers. But doing this well means grasping that their health concerns may change and some areas that should be a concern—such as heart health—may get overlooked.
To gain an understanding of women’s health issues, not-for-profit advocacy group, Jean Hailes for Women’s Health, conducts annual women’s health surveys.
According to 2018 Women’s Health Survey, women said they want more information on:
- weight management;
- healthy eating/nutrition;
- mental and emotional health; and
With respect to physical health:
- 8% of women described their current weight as overweight or obese;
- 5% of women reported drinking alcohol daily;
- 4% of women described their overall health as very good or excellent; and
- 3% reported doing at least two hours of moderate physical activity per week.
With regards to mental health:
- almost half of the women (46.1%) who responded to the survey had been diagnosed with depression or anxiety by a doctor or psychologist;
- two-thirds of women (66.9%) reported feeling nervous, anxious or on edge in the last four weeks; and
- more than a third of women (34.3%) reported not getting time to themselves on a weekly basis.
About their health needs:
- more than one-in-four women have discussed or need to discuss with their doctor a lack of interest in sex in the past 12 months; and
- almost one-in-four (23.9%) said they could not afford to see a health professional when they needed one.
According to Dr Amanda Newman, a specialist women’s GP at Jean Hailes for Women’s Health, pharmacists can assist women not only by focusing on their key health concerns, but by using their drug expertise to position themselves as women’s health champions.
“For example, ensure women have up-to-date knowledge about menopausal hormone therapy,” Dr Newman told the AJP.
Similarly, a pharmacist might be able to give advice around pain and sex, she said, ensuring women only buy good quality lubricants and follow safe cleansing practices (she cited an example of a young woman with a vulva burn due to using apple cider vinegar). Pharmacists are also well placed to give advice about pelvic floor physiotherapy—including for men and women buying continence products.
Newman also said pharmacists can help plug the knowledge gaps around preventive health concerns, including vaccinations, “especially those not given in schools or child health centres”.
In their dealings with patients, Newman stressed that pharmacists must provide information that is unbiased, including information available on posters and in-store materials, as well as websites.
She said pharmacists have a key advantage in that they are accessible and approachable—pharmacy does well as a profession if it communicates well, particularly with its female customers.
Samantha Kourtis, proprietor of award-winning Charnwood Capital Chemist, in the ACT, agreed and said pharmacy benefited from having a demographic that many pharmacists can relate to.
“We are fortunate in that our workforce reflects the fact that majority of our consumers are predominantly women—so we should be able to look after them,” Kourtis told the AJP.
“People in general are working more, and there is less support around so I think women are bearing the brunt of this. I am also seeing a growing demand for preventative health and I think this is because I am in a lower socioeconomic area and a lot of the people I see can’t afford to get sick so wellness is their number one priority.”
Kourtis added that she sees a growing demand for help with mental health issues which “I’m happy to assume is because we are seen as a source of advice and support without judgement”. Likewise, she sees people wanting non-judgemental support for dealing with issues associated chronic pain and conditions such as endometriosis.
But she also questions whether pharmacy is doing enough for women and heart health.
“We know highest volume items on the PBS include cardiovascular medication and that this is often a silent killer for women. Are we really talking to these women who are carers for others enough about their own health?”
Weight management, cancer, reproductive and mental health are areas which women say they are worried about; but one issue that needs more attention is heart health. The lack of interest in heart health could be due to stereotypes about heart attacks, said Julie Anne Mitchell, director of Prevention at the Heart Foundation.
“How often do you see a woman suffering a heart attack in movies and TV shows? It’s always a man clutching his chest and falling to the ground,” Mitchell told the AJP.
In fact, while women may experience chest pain, not all will. Women need to know that the onset of a heart attack can also be signalled by pain in the jaw, back or neck; shortness of breath; nausea; vomiting and cold sweats; overwhelming fatigue or anxiety; lethargy and loss of appetite, Mitchell said.
According to the Australian Bureau of Statistics’ causes of death data, 8076 women died from heart disease in 2017. This equates to 22 women every single day, and is almost three times the number of women who died from breast cancer.
Mitchell stressed as one of the most accessible and trusted health professionals, pharmacists are in a prime position to support and educate their female customers about the risk of heart disease.
“One thing they can do is simply talk to women about heart disease, and then use this opportunity to correct some of the common misconceptions—particularly the notion that heart disease only affects men and chest pain is the only warning sign of a heart attack.”
Although, men and women commonly experience chest pain during a heart attack, women are more likely to experience non-chest-pain symptoms, like pain in their arm neck or back, nauseousness or breathlessness.
“As women are less likely to expect to be affected by a heart attack, pharmacists are well placed to emphasise to women that it’s even more important for them respond to these warning signs and call Triple Zero—because the sooner a person receives treatment, the less damage to heart muscle is done. Too many women decide to wait or call a friend, fearful they are making a fuss. But if it turns out to be a false alarm, this is better than risking heart-muscle damage.”
Mitchell said as women often make it a priority to look after other’s health first—all too often they fail to make their own health a priority.
A 2014 Heart Foundation survey of 504 heart attack survivors showed that women were slower than men to seek help about when they have symptoms of a potential heart attack, and more likely to tell a friend or family member than to call Triple Zero.
In terms of looking after their heart, the best thing women can do is have a healthy lifestyle, said Mitchell. This includes being smoke-free; achieving and maintaining a healthy weight; monitoring blood pressure and cholesterol; being physically active; and enjoying a variety of nutritious foods.
“We also strongly encourage women to see their GP for a heart health check, which will help determine their risk of developing heart disease and having a heart attack. This is recommended if you are older than 45 or 35 for Aboriginal and Torres Strait Islander women.”
Importantly, it is vital that as many people as possible know what to do in the advent of a suspected heart attack, Mitchell said.
“The Heart Foundation would like all people to know the warning signs of a heart attack, but the only people who can confirm a heart attack are paramedics and hospital emergency room personnel. If people present to pharmacy staff saying they think they are having a heart attack, it is important they call triple zero without delay. Treatment can start over the phone and maximise the chances of saving the victim’s life. If you are unsure, call triple zero anyway—it’s better to be safe than sorry.”
Last year TerryWhite Chemmart and the Heart Foundation teamed up to offer free blood pressure checks instore around the country. This partnership aimed to raise awareness of high blood pressure as a leading risk factor for heart disease and stroke. The campaign ran throughout October 2018, and saw more than 10,000 Australians participate, with more than 1000 referred onto their local GP after receiving high blood pressure readings.
Although, it is important to talk women about the importance of caring for their heart at any life-stage; at a population level, this risk increases significantly around menopause, Mitchell told the AJP.
“It is not clear why women tend to get heart disease at a later age than men, although it is thought that a fall in women’s oestrogen levels, as well as other changes that occur around this time, may be part of the reason.
“Hormone Replacement Therapy (HRT), which includes oestrogen replacement, has been used for many years to treat short-term menopausal symptoms. In some women, depending on their GP’s advice, HRT has also been used after menopause for those with osteoporosis. There has been a lot of research into the effects of HRT on the development of heart disease; based on this research, the Heart Foundation does not recommend HRT in the treatment or prevention of heart disease. Before commencing HRT, women should discuss the risks and benefits of the therapy with their GP.” (For more on osteoporosis see page ####).
Mitchell stressed that any time that lends itself to a productive discussion heart health is invaluable. Although, it would make good sense to talk about heart health in conjunction with an activity related to a risk factor. For example, when taking a patient’s blood pressure, a pharmacist could mention that hypertension is a risk factor for heart disease, and uncontrolled high blood pressure can lead to a heart attack or stroke. If that patient is a woman, the pharmacist might also steer the discussion towards the link between pre-eclampsia in pregnancy and future heart issues.
Heart disease-risk associated with pregnancy has until recently been poorly acknowledged, researched and understood, but Mitchell said we now know pregnancy can be the ultimate cardiac stress test.
Generally, a woman’s blood volume increases by 30 to 50% over the course of her pregnancy. Labour and delivery exact a further toll on her body, producing abrupt changes in blood flow and blood pressure. This puts a lot of stress on a woman’s heart.
“A woman’s experience during pregnancy can also provide a unique window into her future heart health complications. If a woman has high blood pressure, pre-eclampsia or gestational diabetes while pregnant, she may be at higher risk of developing heart issues in the years ahead,” said Mitchell.
“For example, research is telling us that having pre-eclampsia while pregnant increases the chance four-fold of developing high blood pressure later in life, and increases the risk of developing cardiovascular disease by two to three times.”
To look after their hearts during pregnancy, women should maintain a healthy lifestyle and follow the advice of their obstetrician. And women with pre-existing heart conditions need extra care.
“Because of the increased cardiac demands during pregnancy and labour, it is important that any woman with a pre-existing heart condition is assessed by a cardiologist with expertise in maternal cardiology before becoming pregnant,” said Mitchell. “She may also need closer monitoring by a multidisciplinary healthcare team throughout her pregnancy.
“And very importantly, if a woman was diagnosed with high blood pressure, pre-eclampsia or gestational diabetes while pregnant, she and her doctors should be particularly vigilant about her heart health afterwards.”
But she points out the management of these conditions is often excellent during pregnancy—the Heart Foundation is concerned that both mothers and healthcare professionals stop thinking about it once the baby is born.
“A focus on maintaining good heart health and regular check-ups over the coming years is essential for these women’s long-term health and wellbeing.”
CEO of Cancer Council Australia Professor Sanchia Aranda said Australian pharmacies are great at promoting sun protection and quitting smoking, but there is also an opportunity for them to raise awareness of women’s cancers.
“For instance, pharmacies can encourage all women to be breast aware and report any changes in their breast shape, appearance or feel to their doctor. Women aged 50–74 are also encouraged to participate in breast screening every two years and women can also get checked from age 40. Cancer organisations like Cancer Council, Cancer Australia and the Cancer Institute NSW have some great content online that pharmacies can share on their local Facebook pages or instore to ensure their local communities are aware of the need to screen and get checked.”
Prof Aranda added there’s also the opportunity for pharmacy to promote the new cervical cancer screening program.
“Many Australian women may also not be aware that Australia transitioned to a new cervical screening program last year. Screening now starts at age 25 and uses a more sophisticated HPV test, which has replaced the old pap test. However, we know that many women might not be aware that they are due for their first HPV test two years after the last pap smear. Pharmacies can use their social media pages to encourage women to make sure they are up to date. Cancer Council has also created a great website, www.cervicalscreening.org.au, which includes answers to common questions, videos with experts and easy to understand explanations.”
With respect to women who have concerns about Hormone Replacement Therapy (HRT) and cancer risk, Prof Aranda said women should be helped to make informed choices.
“The evidence shows that HRT use is a risk factor for breast cancer, but, of course, it can also be a beneficial therapy for women experiencing the symptoms of menopause. Like any medical intervention that confers both benefit and risk, this is a clinical matter depending on an individual woman’s circumstances. Women with any concerns should discuss them with their doctor.”
Cancer Australia has published a summary guide to the evidence. (See https://canceraustralia.gov.au/publications-and-resources/position-statements/hormone-replacement-therapy-hrt-and-risk-breast-cancer)
Pharmacists can also draw attention to the impact of bowel cancer, in both women and men.
This is particularly important given a new report that predicts that the number of people dying from bowel cancer in Australia is expected to jump by as much as 60% in the coming decades.
The global study, published in the International Journal of Cancer predicts death rates from rectal cancer will increase in Australia by almost 59.2% in 16 years.
Meanwhile, the US will see a 28% jump and Ireland and Canada increases of 24%.
The underlying reasons for the rise in the high-income countries are “yet to be fully understood”, the authors said.
“Possible explanations are changes in the prevalence of risk factors such as increasing body weight and lower physical activity,” the researchers said.
They conclude the result is “worrisome” and warrants further research.
On the plus side, Australia’s rates of colon cancer are expected to fall by around 50% in the same period.
The study found death rates for both colon and rectal cancer are expected to drop globally but the total number of deaths is expected to rise, due to population growth and ageing.
The numbers of deaths were predicted up to the year 2035 by taking a weighted average of the projected mortality rates and then applying the United Nations national population forecasts available for each country.
In Australia, participation in Bowel Cancer Screening Program remains alarmingly low, with some experts theorising that this is because people feel uncomfortable about the screening test, which requires a stool sample.
But according to Prof Aranda, evidence shows people are less squeamish about performing the immunochemical faecal occult blood (iFOBT) test once they actually do it.
“[They] see how easy it is and feel part of one of the most important public health programs in Australia’s history—the National Bowel Cancer Screening Program (NBCSP). [But] it is concerning that bowel cancer remains Australia’s second biggest cancer killer—particularly as most cases can be treated successfully if detected early. Australians eligible for bowel cancer screening will receive a free iFOBT in the mail—and pharmacists should encourage their customers to take part in the screening program when their kit arrives.”
Prof Aranda stressed that there is also some excellent material online that pharmacies can share on their own social media pages or in the pharmacies.
With respect to other cancers, pharmacy already helps people to quit smoking, but Prof Aranda said evidence for e-cigarettes as a smoking cessation tool are unsupported.
“There are studies that show people who might have quit have maintained their nicotine addiction through e-cigarettes and continue to use both; there is also disconcerting evidence of a major increase in e-cigarette use in young people, particularly in the US, and younger e-cigarette users go on to smoke tobacco than those who do not use e-cigarettes. There are also claims that e-cigarettes have helped people to quit, but they are individual testimonies not supported by population-level evidence. The key is to do more of what works, and pharmacy has an important role to play in supporting access to existing successful cessation programs via QUIT.”
For other cancers such as skin cancer, Prof Aranda said a major concern is young people.
“One of those factors is complacency, particularly among teens, which is why we encourage Australians to be aware of the risks of tanning and continue to call on the Federal Government to fund a national awareness campaign,” said Prof Aranda.
Another challenge is education around the common mistakes made when applying sun protection.
“Some common errors include not applying enough sunscreen (you need at least a teaspoon per limb), not reapplying every two hours and not using the product in conjunction with a hat, protective clothing, sunglasses and seeking shade. Sunscreens have certainly improved, but some Australians do mistakenly believe that an SPF50 means that they can spend longer out in the sun. Pharmacies can play a key role in making sure their customers know how much sunscreen to apply, reapply regularly, use it in conjunction with other sun protection measures and don’t over-estimate how much protection sunscreen provides.”
With respect to other ways to help people, Prof Aranda suggested pharmacies offer information about the support that is available for people—or carers—impacted by cancer.
“For instance, we have a support and information line, 13 11 20, that anyone affected by cancer can call to speak to a specially trained cancer nurse. Support services vary around the country, but also include things like transport to treatment, subsidised accommodation for those travelling for treatment, pro-bono legal and financial assistance and support groups. It would be great to see more pharmacies referring their customers to these services, so that more Australians know we are here for them when they need us most.
“Part of Cancer Council Australia’s strategic vision in the coming year is focusing on cancer inequalities. We already know that some sections of community experience worse cancer outcomes—including those living in regional and remote areas, Aboriginal and Torres Strait Islander people, and those who are socio-economically disadvantaged. Our focus this year is on identifying the reasons for this—in order to determine what action should be taken. One simple thing pharmacists can do to help address cancer disparities, is make sure those who are disadvantaged know about the support services that Cancer Council can provide.
“We have also recently released a draft Informed Financial Consent Standard for Health Professionals for public consultation (www.cancer.org.au/financialconsent). Pharmacists are also encouraged to help their clients understand what cancer costs to expect, and their different treatment and medication options. Pharmacists will also become aware if people with cancer are experiencing financial hardship through behaviours such as not filling prescriptions or having a prescription last longer than expected. Making sure patients who are in financial distress are aware of support services is important. Pharmacists can refer them to Cancer Council’s 13 11 20 support and information line to find out about the practical and financial support services we offer.”